Elimination is the zero incidence of the disease in some part of the world at a given time. ‘Global Disease Elimination and Eradication as Public Hea

Elimination is the zero incidence of the disease in some part of the world at a given time.  ‘Global Disease Elimination and Eradication as Public Health Strategies’ Interantional Concerence, Atlanta , February 1998.

From:  Porichha D., Bhubaneswar, Orissa , India

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Dear Salvatore,

 

Greetings from LEPRA Society , India .  I would like to  express some personal views  on the issue of “elimination” and state of cure etc. appearing in LML.  A few mails have referred to the leprosy elimination and related problems.  I would like to make few comments as my personal view.  The paper is a bit lengthy hence a copy of it is in attachment

 

First of all I appreciate Elizabeth ’s  interest of working with inmates of leprosy villages and expressing her keen observations (LML March 2^nd, 2009).  

 

Leprosy cases belong to two main groups.  One group suffered from the disease when effective treatment is available. They were treated early before the onset of disability and are completely cured.  With no continuing problem as disability, they are happy to accept the programme irrespective of the terms used.  They were also convinced of cure as signs and symptoms disappeared in most of the cases.  The  others are with crippling disability which they got prior to MDT or due to inaccessibility to the services.  They are unhappy with the programme. Most of them reside in the leprosy colonies. To them the state of cure after certain doses of MDT was not acceptable because symptoms continued after stoppage of treatment especially in persons with reaction and disability. Prevention of disabilities including prevention of worsening was in practice mostly in projects managed by reputed NGO groups and missionaries and was hardly visible as a programme component.  Hence there continued a feeling that their problems are not adequately taken care of.

 

I agree with Elizabeth ’s views that they are too much negative towards the programme and people involved.  Elimination or control has no meaning for them. She has only conveyed that with some concern and I agree with Prof Frankel (LML March 17^th, 2009) that she deserves appreciation. Any intervention in leprosy is incomplete without care, support and rehabilitation for people with disability including for those in colonies. It is probably time to defer issues like “final push”, ‘further reduction of PR’, ‘sustainability of elimination’ etc and divert resources for such activities.

 

The term ‘elimination’ which latter acquired the phrase ‘for public heath point of view’ remained debatable from the day it replaced the word ‘control’ in the leprosy programme. Prevalence below 1 per 10000, as a criterion for elimination was not readily accepted and there was reservation on the suitability of this criterion. Many suggested incidence rate as a better indicator for the purpose.

 

I agree with Prof. Frankel that target was described for elimination of disease as public health problem.  But according to internationally agreed definitions (as public health strategy) what was marketed as ‘elimination’ for wider global acceptance, is in reality a control strategy.  Moreover the definitions of control, elimination, eradication and extinction have been defined mostly to deal infectious diseases as public health problems (WHO sponsored International conference in Atlanta on the theme of ‘Global Disease elimination and eradication as Public Health Strategies’, February 1998).  Elimination was defined as the zero incidence of the disease in some part of the world at a given time while control is reduction of prevalence, incidence, morbidity or mortality to a locally acceptable level. Encouraging aspect is that this approach was highly effective in achieving the objective. But the two can not be taken interchangeably.  

 

The important risk of control is that as soon as the intervention is relaxed the disease is likely to come back.  This is the present apprehension with a considerable section of workers if not with all.  I feel this is also the focus of criticism, if I could understand the letter of Dr Bendick (LML March 7^th, 2009) and substantiating criteria are definition and approach.  This also relates to Dr Vijaykumaran’s letter (LML March 3^rd, 2009).  Before introduction of the term’ elimination’ the word control was used for control activities hence there was no objection. The definition with which the elimination activities started in reality, was that of control hence there is confusion or objection.  With whatever definition we have worked, the achievement is a high level of control.  Sustaining that, let us work some time actively for disability care and rehabilitation with the resources.

 

Please do not mind for a long letter.

Yours sincerely,

 

D Porichha,

Medical Coordinator,

LEPRA Society, Bhubaneswar , India