Leprosy Mailing List – April 18 , 2016
Ref.: (LML) Economics of leprosy control
From: Joel Almeida, Mumbai and London
Dear Pieter,
The Government of India is resuming more vigorous efforts to protect its people against M. leprae.
House-to-house case-finding surveys have been done in 50 districts with the highest incidence rate of leprosy. More districts are to be included. Such surveys, provided they are backed by skin smear examination and experienced paramedical workers, have the potential to detect polar lepromatous patients who still require MDT. Many polar lepromatous patients, after being released from MDT, migrate to urban areas to boost their income and escape from local ostracism. The others can still be found by house-to-house surveys in high-incidence districts.
Unprotected polar lepromatous patients (whether before treatment or after release from MDT) are the no. 1 source of M. leprae, according to current microbiological knowledge. Denying polar lepromatous patients MDT ensures a world full of M. leprae, not a world free from leprosy. Such lack of protection is cruel to the patients, but extremely favourable to M. leprae. As long as we deny polar lepromatous patients prolonged protection by MDT, even mass chemoprophylaxis is likely to be futile.
House-to-house case-finding uncovers many self-healing forms of leprosy too. In these individuals, the signs of leprosy indicate a successful immune response rather than bacterial proliferation. The more frequent and more intensive the surveys, the greater the chance of finding transient, self-healing cases. This accounts for the boost in incidence rate after the introduction of MDT, from about 500,000 cases a year in 1985, to about 800,000 cases a year in 2000. The subsequent progressive suppression of case-finding accounts for the drop in incidence rate to under 250,000 cases a year. Self-healing cases disappear from the incidence rate if surveys are suppressed. Therefore the new case detection rate is unreliable as an indicator of the trend in incidence rate. It can be doubled or halved at will, by starting or stopping case-finding surveys.
Visible deformity, by contrast, is not transient. The trend in the incidence rate of new cases with visible deformity, more reliably than the new case detection rate, indicates the trend in incidence rate of leprosy. The incidence rate of new cases with visible deformity has almost doubled in India since 2005-6, according to official Indian reports. This strongly suggests a near-doubling in the incidence rate of progressive forms of leprosy, in India, since 2005-6.
The Indian government has been pressed by civil society to wage a more intensive battle against M. leprae. A concerned citizen even took the government to the Supreme Court. The petition requested sufficient staffing for the leprosy programme. The programme had been battered by premature self-congratulation, loose claims about cost-effectiveness, and needless elimination of leprosy services. People affected by leprosy had inadequate services to begin with, and this needless assault on leprosy services left them completely vulnerable to visible deformity.
Cost-effectiveness is relevant mainly after effectiveness is well established, and after interventions are scaled up. Economies of scale transform costs. Our first responsibility is to protect people from disability. We are not in the business of saving money, but of saving people's limbs and eyes. That's why demonstration projects of highly effective interventions are so important.
The Governor of the Reserve Bank of India agrees with this viewpoint, which I had the good fortune to discuss with him in person. Spending on effective health programmes is investment, not expenditure. Deformed citizens lose not only their quality of life, but also a stream of future income, as well as costing the taxpayer a considerable sum for rehabilitation. It is better, for the economy, to invest in effective interventions, than to allow citizens to suffer deformity.
Whenever we enquire about the cost-effectiveness or cost-benefit of leprosy services, we need to compare it to the cost-benefit of armaments etc. Taxpayers fund a variety of activities which do little to save human beings from death or disability. Let not a blinkered view of cost-benefit stand in the way of protecting human beings.
We need to enlarge our vision beyond the premature, and temporary, self-congratulation that has so blighted leprosy work and financing. We need to devise demonstration projects where cost is no object. We need to demonstrate effectiveness first: how to save the limbs and eyes of human beings. Then we can analyse and streamline costs. The flow of financing, from taxpayers as well as noble-minded donors, will increase to match the opportunity of transforming human lives.
This happened in TB, where the global budget went from about a hundred million dollars per year in 1995 to several billion dollars per year by 2005. It would be good if we started batting more vigorously for the human beings at risk from leprosy. Then we can truly provide people with the leprosy services which will protect them against visible deformity, and perhaps even make a dent on the incidence rate of progressive forms of leprosy.
A positive sign is that we now speak of zero disability as our target. This is crystal clear and rational. Let's demonstrate how we achieve zero disability in projects, then scale it up. We need to develop systems that are demonstrably effective in the field, then funding will start to flow more readily.
Regards,
Joel Almeida
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
