Leprosy Mailing List – October 8, 2016
Ref.: (LML) The long war against M. Leprae
From: Joel Almeida, Bombay and London
Dear Pieter,
The WHO strategy for 2016-2020 has rightly emphasized the need for planning and sustainable financing.
In TB, sustainable financing was multiplied once a clear global plan was made, with a focus on the common vision. In leprosy we have a clear common vision: zero transmission, zero disability, zero discrimination. What are the steps that will carry us in that direction over the next 10 to 25 years? What is the scale of financing required? How do we attract the young professionals and workers needed to do the work and the research? We need to put aside past errors and enthuse the world with our plan.
Let's be bold about pursuing the vision. M. leprae is an arsonist which keeps setting human nerves on fire with inflammation. We cannot afford to dismiss the fire brigade. Patients cannot afford to rely on promises of services at the fire station. Instead, the fire brigade of skilled leprosy workers needs to reach patients near their homes. Skilled leprosy workers need to be mobile so that they can serve patients scattered over a large area. We need to treat the nerves of patients as if they are our own nerves, and be far more conscientious about protecting them.
Nor can we afford to keep neglecting polar lepromatous patients, who remain susceptible to re-infection after MDT. Otherwise they are condemned, through no fault of theirs, to becoming walking sources of M. leprae. It takes hundreds of thousands of newly detected tuberculoid or borderline patients to excrete as many M. leprae as one untreated - but reinfected - polar lepromatous patient. M. leprae survive for at least five months in the Indian shade. If they can re-infect one polar lepromatous patient, then these environmental M. leprae can outwit all our leprosy control efforts. Protecting one polar lepromatous patient against M. leprae is equivalent, in epidemiological terms, to protecting hundreds of thousands of other individuals. It takes relatively little to achieve this: skin smears to recognize polar lepromatous patients at diagnosis, and prolonged anti-microbial protection for them.
We have come a long way during the past year, with scientific errors steadily being replaced. Our vision is now expressed in clear, rational and objective terms: zero transmission, zero disability, zero discrimination. In the next few years we have a golden opportunity to keep improving the quality of our work, so that populations at risk of leprosy know that they are in safe professional hands. This means greater emphasis on a few key points:
1) Expressing the burden of leprosy in YLDs (years lived with disability)
This is the common global currency (prevalence of ALL persons disabled by leprosy x weights of disabilities). Populations at risk of other conditions benefit from this globally standardized measure. So should populations at risk of leprosy. Otherwise we place leprosy patients at a disadvantage compared to those afflicted by other conditions. It is an easily remedied form of discrimination. Current YLD estimates for leprosy appear way too low. That's because we have neglected key information, and largely abstained from the process of estimation. Once we record the prevalence of all persons disabled by leprosy, and describe the weight of those disabilities (physical, emotional and social) then the case for adequate financing will be transformed.
2) Funding population-based action research in a high endemic area
Here, every promising approach can be used in concert. This would be an all-out, no-expense-spared attempt to achieve our common vision. That is the most promising way of demonstrating what works.
That is also a way of attracting bright young talent into this war against an ancient foe. India has a huge number of highly trained but underemployed young professionals, and we need a programme to attract the best talent into this war. It would be good if ILEP members made the development and funding of human resources a priority, at least in India. We need to think about developing leaders for the long war ahead.
3) Responding to the observed doubling of incidence rate in India, of newly detected cases with visible deformities, since 2005.
This strongly suggests a doubling of the underlying incidence rate of leprosy in India. The visible deformities of leprosy are so characteristic, that even lay people recognize them (and unfortunately use them as the basis for discrimination). No special equipment is required, one needs only to open one's eyes to see the deformities.
By contrast, the new case detection rate can be doubled or halved at will by starting or stopping case-finding activities. That's because the majority of newly occurring cases heal themselves without any treatment. As the interval between case-finding surveys in increased, self-healing cases steadily disappear from the new case detection rate. This misleads us about the underlying incidence rate of leprosy. Instead, the incidence rate of newly detected cases with visible deformity is more reliable. That's because visible deformities persist.
The next time someone predicts the elimination of leprosy, or boasts about it, we can gently remind them that the incidence rate of newly detected cases with visible deformities has doubled in India, during the past decade. One has to be atop a very tall ivory tower to ignore this or brush it aside. Rhetoric about elimination serves only to eliminate leprosy services and financing. This exposes vulnerable patients to avoidable permanent damage, while repelling young talent.
Now that we have a clear, rational and objective common vision, we can plan and start attracting financing and people. These are necessary to better protect populations at risk of leprosy. Greetings to the many fine people who are making such a difference already.
Regards,
Joel
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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