Fw: Ref.: (LML) Why the world needs to focus on HD

 

Leprosy Mailing List – August 5,  2021

 

Ref.:  (LML) Why the world needs to focus on HD

 

From:  Joel Almeida, London and Mumbai

 

Dear Pieter and colleagues,

It is great that the world's attention increasingly is being focused on HD (leprosy).

The world faces many pressing problems. The HD bacillus is not the only enemy of humankind. The pandemic interrupted economic activity and even affluent people became eligible for financial handouts. Consequently, economies are limping. So why should the world focus on HD?

Because successful projects have demonstrated that the HD endemic can be quelled reasonably rapidly, by doing highly effective things. And because HD offers a unique opportunity for the world to affirm the inalienable dignity of every human being, as enshrined in the Universal Declaration of Human Rights (the world's humane response to the most egregious excesses of war).

Wherever LL patients were protected against reinfection, by prolonged anti-microbial protection, HD transmission declined relatively rapidly. This was true of even low income areas such as Karigiri (India) and Uele (DR Congo). Wherever mass multi-drug administration at intervals of less than a year was implemented in hyperendemic hot spots, HD transmission declined even more rapidly.

The world is capable of uniting against this terrible enemy, the HD bacillus. The exemplary projects in Shandong and FSM (Micronesia) were supported by the Sasakawa Health Foundation. The exemplary project in Karigiri (Schieffelin Leprosy Centre, India) was supported by American Leprosy Missions, The Leprosy Mission, & later WHO, the World Bank and Indian governments (national and state). Uele, in DR Congo, had a project that demonstrated rapid decline in incidence rate of MB (multibacillary) HD. At that time LL (lepromatous) patients were protected against reinfection by prolonged anti-microbial cover. The Uele project was supported by the Belgian Ministry of Co-operation and Fonds du Pere Damien (an organisation inspired by the example of Jozef de Veuster, also known as St. Damien of Molokai. He developed LL HD and died before reaching the age of 50. Today he is venerated by many for joining in the life of people who were shunned and feared by many, his noble service to them emphasising the inalienable dignity of every human being).

Shandong continued the successful approaches until near-zero transmission was achieved. A decline in incidence rate of about 20% per year was demonstrated. Karigiri and Uele achieved over 16%/year decline in incidence rate of LL or MB (multibacillary) HD. However, they then switched to only 12 months of treatment for even LL patients. Consequently, their earlier success was compromised. FSM discontinued mass multi-drug administration and withdrew prolonged anti-microbial protection of LL patients, prematurely. It consequently lost the earlier rapid decline in incidence rate of HD (over 40%/year). It is cheaper in the short run to withdraw highly effective approaches, and to permit covert reinfection in LL patients. However, anti-microbial neglect of LL patients is vastly more expensive in the long run, both financially and in terms of easily avoidable human suffering.

Salaunikhurd village in India offers a different kind of lesson. It was found to have an increase greater than 300% in new cases/year, within a short span of about 3 years. Great investigative work by the Indian government and WHO staff revealed that previously treated LL patients were in need of further anti-microbial protection. Also, skin camps with expert clinicians (even using telemedicine) and nasal smear or skin smear microscopy would have helped greatly in diagnosing previously untreated "de novo" LL patients. Such patients tend to show only subtle signs of HD. In Salaunikhurd, they clustered in families and remained undiagnosed because of only non-troublesome and subtle signs of HD. The bacilli turn genomically anergic LL patients into unwitting factories for concentrated viable bacilli. Anti-microbial neglect of LL patients after 12 months of MDT is epidemiologically disastrous. It also increases the incidence rate of excruciatingly painful ENL episodes among these patients, by several hundred percent. It seems wise and humane to prevent reinfection of LL patients in endemic areas by ensuring prolonged anti-microbial protection for them. 

We can succeed despite any past mistakes because we are open to learning from unexpected successes and unexpected failures alike. Although we may hold a range of opinions on various matters, we are united by a common enemy. That enemy is the HD bacillus. Widespread misunderstanding about HD aggravates its consequences. Our mission is very important. Therefore we need to look beyond whatever we have originated and instead promote whatever works best, regardless of its origin.

A wide range of sponsors can be enthused by exemplary projects. (I got an insight into this when serving as the consultant leprologist to the World Bank mission in the early 1990s, that co-designed the Indian National Leprosy Eradication Programme with the Indian government. The concessional finance that resulted was measured in tens of millions of dollars per year. I then went to work for the WHO's Global TB Programme, where global finances were stuck at about 100 m USD per year. Once the DOTS strategy was launched with its pilot projects demonstrating excellent quarterly outcomes, financial flows increased steadily to reach billions of USD per year). Money chases success. As we create dramatic successes and parade them before the world, financial flows will improve.

I had the privilege of working under a legendary Japanese public health physician at WHO. He emphasised the importance of devising counter-measures when faced with disappointing outcomes. That approach helped to limit discouragement, and repeatedly transformed unexpected failures into fairly consistent success. He transformed the global health situation and budgets in TB, and then went on to do the same in malaria. Those were no flukes. His approach worked. Based on those experiences, it seems likely that efforts against HD can be highly successful, and reasonably rapidly too. 

 

There is, however, an important contrast in approach between the TB and HD professional communities. In TB, patients died yet we strove to make them visible. In HD patients survive with sequelae, yet they have been excluded from registers and (in effect) made invisible. Consequently, TB work is well funded and HD work is not.

This is a good time for the world to focus on HD, and to unite against our common enemies, the HD bacillus and misinformation. We have a realistic chance of defeating the bacillus, averting a great deal of human suffering, and affirming the inalienable dignity of every human being.

Let's unite behind what demonstrably works, and keep creating success after success. Step by step, the whole world will join us. It is a good time to be focusing on HD.

Joel Almeida



PS Esteemed colleagues engaged in research have an important role. It is useful to observe that R&D budgets tend to form a roughly fixed percentage of the overall financial allocation to disease control efforts. In the early 1990s TB research was dying. Once the DOTS strategy was launched, TB control budgets expanded vastly. Then TB research budgets too expanded. That's how the world tends to work. To expand R&D budgets in HD, we could talk up successful HD control projects instead of talking them down. Then the whole financial cake is likely to expand, and the R&D slice too will expand. Proclaiming the impact of what has worked in no way diminishes the world's respect for R&D (from basic research through to operational research). Rather, it tends to expand the whole financial cake including the slice available for R&D.

 

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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