Conquering leprosy and guinea-worm disease [full issue]

Wtt-11'- ~ RLD ~ . I ~ ~ ~ ~ THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION In this issue Editorial Leprosy and guinea-worm disease 3 Hiroshi Nakajima Eliminating leprosy - a winnable war 4 S.K. Noordeen Facts about leprosy 6 John Bland History of a disease 8 Michel F. Lee hat The legacy of leprosy research 11 Barry R. Bloom Voluntary action and the continuing task in leprosy Paul Sommerfeld Success story in Thailand Charoon Pirayavaraporn Leprosy in Yemen Yasin AI-Qubati Control efforts in India N.S. Dharamshaktu A future without leprosy Artur Custodio M. de Souza Overcoming the stigma Le Kinh Due Guinea-worm eradication programme Coalition against guinea-worm Donald R. Hopkins & Trenton K. Ruebush Mission almost accomplished Gautam Biswas & K.K. Datta Technology aids eradication 14 17 18 20 21 22 24 25 26 campaign 28 Guinea-worm disease 29 Jean-Philippe Chippaux World Health • 49th Year, No.3 May-June 1996 IX ISSN 0043-8502 Correspondence should be addressed to the Editor, World Health Magazine, Wand Health Organization, CH-1211 Geneva 27, Switzerland, or directly to authors, whose addresses ore given at the end of each article. For subscriptions see order form on page 31. HEALTH World Health is the official illustrated magazine of the Wand Health Organization. It appears six times o year in English, French and Spanish, and four times o year in Arabic and Farsi. The Arabic edition is available hom WHO's Regional Office for the Eastern Mediterranean, P.O. Box 1517, Alexandria 21511 , Egypt. The Farsi edition is obtainable hom the Public Health Committee, Iron Un~ersity Press, 85 Pork Avenue, Teheran 1587S-47 48, Islamic Republic of Iron. Front cover: W HO/ Association fram;:aise Raoul Follereau page 17 ©Wand Health Organization 1996 All righ~ reserved. Articles and photographs that ore not subiect to separate copyright may be reproduced for non-commercial purposes, provided that WHO's copyright is duly acknowledged. Signed articles do not necessarily reflect WHO's views. The designations employed and the presentotion of material published in World Health do not imply the expression of any opinion who~oever on the port of the Organization concerning the l119ol stotus of any country, territory, city or area or of its authorities, or concerning the delimitation of i~ hontiers or boundaries. World Health • 49th Yeor, No.3, Moy-June 1996 3 Editorial leprosy and guinea·worm disease Dr Hiroshi Naka;ima, Director-General of W HO. l eprosy is no longer the disease of lost hopes for the patient, the family and the community. The disease is curable today, thanks to the effective treatment of patients with multidrug therapy (MDT) which WHO has recommended since 1981. The fact that it has been possible to cure more than 8 million patients with MDT in the last 10 years, and to save over a million people from lifelong disablement, speaks for itself. The cost-effectiveness of this therapy has encouraged the interna- tional community, including the least developed countries, to seize the opportunity to conquer leprosy, in many cases with remarkable success. WHO has played an important role in developing and promoting MDT, and once again has demonstrated that the key to success in public health lies in making effective and robust tech- nologies accessible to the communi- ties in need. In 1991, the World Health Assembly adopted a resolution to aim for the worldwide elimination of leprosy as a public health problem by the year 2000. Elimination was defined as the attainment of a level of pre valance below one case per 10 000 population . This was an important landmark in the global fight against leprosy. While remarkable progress has been made towards the elimination goal set by WHO, with a reduction of more than 80% in the global disease burden over the last ten years , much remains to be done. This is true particularly in areas where leprosy has entrenched itself because of poverty, geographic inaccessibility and poor health infrastructure. The World Health Organization is doing its utmost to reach underserved populations and make freedom from leprosy a reality everywhere. The concerted efforts made by Member States and many government and nongovernmental organizations, both national and international, need to be strengthened further and the momentum towards elimination needs to be accelerated. With only four years to go before the target date , there is no room for compla- cency. Guinea-worm disease (dracuncu- liasis) is another public health prob- lem which is linked to poverty and lack of information , as it is caused by drinking contaminated water. Yet it can be overcome easily and effec- tively. Controlling the disease does not require costly and sophisticated technology. It calls for political determination and for the local com- munities concerned to understand what is at stake and what must be done. The proof of this lies in the 97% reduction in cases achieved since 1986, when the World Health Assembly decided that an all-out effort should be made to eradicate dracunculiasis. The number of affected villages has been reduced from an estimated 23 000 to fewer than 8000 and, in 1995, most endemic villages recorded one to four cases only. The task now is to fully contain every remaining case and interrupt transmission as quickly as possible. To eliminate leprosy as a public health problem and to eradicate guinea-worm disease- here are two great opportunities we cannot afford to miss. • Hiroshi Nokoiimo, M.D., Ph.D. 4 World Health • 49th Year, No.3, May-June 1996 Eliminating leprosy - a winnable war S.K. Noordeen Leprosy is dreaded because it is communicable and produces lifelong crippling deformities. In many societies it exposes the sufferers to intense social stigma and discrimination. It has been shrouded in myths and mysteries for centuries and seen as an affliction unlike any other. l eprosy had no cure until 1950 when dapsone came into use. Although the drug acted very slowly, it was at first effective, but after many years it was found that patients failed to respond because the leprosy germs developed resistance to it. Therefore even the small gains made in the initial years proved not to be durable. Fortunately, new and more potent drugs became available and the answer to drug resistance was found to be the treatment of patients with a combination of drugs. This led to the WHO recommenda- tions on standard treatment of lep- rosy through multidrug therapy (MDT) in 1981. MDT involves the use of three drugs against the more serious form of the disease, and two drugs against the less serious form. Over the years,WHO-recommended MDT has proved to be highly effec- tive and acceptable to patients. This treatment has brought new life to a very large number of patients and, Leprosy victims often suffer intense social discrimination. together with improvements in early diagnosis, has prevented them from becoming crippled. In addition, the success of MDT has greatly encour- aged and motivated health workers who in the past have had to endure a great deal of frustration in dealing with the disease. For the first time, it became possible to envisage putting an end to leprosy. In 1991 , the Member States of WHO adopted a resolution at the World Health Assembly which set the goal of eliminating leprosy as a public health problem by the year 2000, defining elimination as attain- ing a level of prevalence below one case per 10 000 population. In doing so, the Member States and other participating agencies set for them- selves a goal which could not have been remotely imagined even ten years earlier. The progress made over the last 10-15 years, and even more so since 1991, has more than justified WHO's optimism about reaching the leprosy elimination goal. The results so far speak for themselves. Today, practi- cally every registered leprosy patient in the world has access to treatment and is able to receive MDT drugs free of cost. Over the last ten years, nearly 8 million patients in the world have been cured, and the global disease burden has been reduced by over 80%. More than a million indi- viduals have been saved from being crippled. All of this has become possible largely through the key role that WHO has played in developing and promoting MDT, and in mobiliz- ing partners and resources to ensure that MDT is available to all patients in need. In addition, the drive to- wards elimination has resulted in countries setting targets and making time-bound action plans to reach their goal. In this connection, it is important to recognize the highly significant role played by interna- tional nongovernmental organiza- World Health • 49th Year, No.3, May-June 1996 5 Health workers go from house to house looking for early signs of leprosy. Registering leprosy patients is an important step towards universal access to treatment. tions in supporting leprosy work in a large number of endemic countries. Challenges ahead The progress made so far is impres- sive. However, although the disease burden has been massively reduced, the remaining 20% of the problem represents a major challenge. It involves finding and treating patients in underserved communities in difficult conditions, such as geo- graphic inaccessibility, poor health infrastructure, or civil strife. The WHO Action Programme for the Elimination of Leprosy (LEP) is striving to reach these underserved populations through special mecha- nisms. These call for considerable innovation and the simplification of technical requirements, including the involvement of relatively unskilled village volunteers. In many areas where leprosy programmes are reasonably well organized, a proportion of patients fail to come forward for treatment or to complete the course of drugs for various reasons, including the poor quality of health services available and the patients' fear of social stigma. In such areas, a limited campaign approach to reinforce existing activities is considered useful, and LEP is currently support- ing a number of such "campaigns" aimed at finding hitherto undetected cases and bringing them under treat- ment. Here again, a number of innov- ative approaches are being tried. Leprosy, if it is not treated in time , produces deformities which are the reason for the age-old dread of the disease. There are between one and two million people in the world who have leprosy-related physical disabilities , largely as a result of late detection and late treatment. Even though they may be cured of the disease and no longer risk transmit- ting it to others , the residual disabili- ties they have are a lifelong burden for them. The best way to tackle this problem is through community- based rehabilitation, which tries to ensure that patients receive simple, cost-effective support in coping with the difficulties caused by disability. Ideally, it should take maximum advantage of the already existing coping mechanisms within the fam- ily and the community. Certainly the most important and most cost-effec- tive approach to overcoming the overall problem of disability in leprosy is to prevent it from occur- ring in the first place, through early detection and prompt treatment of patients. LEP therefore recommends that disability prevention and man- agement should form an integral part of MDT programmes and that, once patients are cured of the disease, any residual deformities should be han- dled through community-based rehabilitation activities. It is beyond dispute that today it is possible to conquer leprosy. We have the means and the will to reach our goal. The task ahead calls for concerted and intense efforts on the part of all concerned- the leprosy- afflicted communities, the govern- ments concerned, and the supporting agencies. WHO has been able to put together a treatment technology that works and is able to support the national programmes in applying it. The pace of progress in the different leprosy-endemic countries may vary, but the direction is clear and so is the determination. Victory against lep- rosy, which is a disease of poverty, will be a symbol of humanity's power to overcome poverty itself, and will mark a confident step for- ward towards the overall goal of Health for All. • Dr S.K. Noordeen is Director of the Action Programme for the Elimination of Leprosy, World Health Organization, I 2 I I Geneva 27, Switzerland. In january, he received India 's prestigious International Gandhi Award for 1996 for his seNices to leprosy control. 6 World Health • 49th Year, No. 3, May-June 1996 Facts about leprosy John Bland three. Called multi-drug therapy (MDT), this is the weapon that now seems certain to stop the disease in its tracks . • MDT has proved remarkably effective, reasonably cheap and highly acceptable to all patients. The treatment lasts 6 months for paucibacillary cases and 24 months for multibacillary cases. At the end of those periods, the cure is complete . • Provided all the countries where leprosy is endemic maintain their case-finding and MDT treatment Sensitization of the population to early signs of leprosy in Cambodia. activities, and provided donors worldwide keep up and even increase the flow of resources -with only four yea<S to go, the and eyes. But the visible symp- world is well on the way to toms may not show themselves attaining the World Health for 10, 15 or even 20 years. financial and human -to maintain the momentum, leprosy can be eliminated as a public health Organization's declared goal of problem by the year 2000. eliminating leprosy as a public health • By that time, paucibacillary cases problem by the year 2000. Provided (having few bacteria in their • What does this mean? WHO there is continued commitment from bodies) may have less than one considers leprosy is no longer a involved governments, international million bacteria; multibacillary public health problem when the bodies and nongovernmental organi- cases may have up to 7000 mil- number of cases in a given coun- zations, the goal can be reached. This lion bacilli in just one gram of try falls below one per 10 000 is where we stand with this age-old skin tissue. population. Globally, there has disease at present. already been an astonishing • At the start of this century, lep- decrease in the estimated number • A wasting and debilitating dis- rosy was universally regarded as of cases in the world, from 5 .4 ease, leprosy has been dreaded incurable. The first breakthrough million in 1991 to about 1.3 through the centuries . In past came in the 1940s with the devel- million in early 1996. ages, sufferers were forced to live opment of the drug dapsone. This in isolation and were shunned by cured the disease, but only if the • A total of 60 countries are techni- their own community. But today patient regularly took the proper cally endemic for leprosy today. we know that leprosy is hard to dose over many years. Moreover Only 16 of these are rated as "the "catch"; physical contact with a M. leprae started to develop most endemic countries," and patient has to be frequent and resistance to dapsone, and it they account for 90% of all cases. long-term for the disease to be seemed as if the world's only They are: Bangladesh, Brazil, transmitted to someone else. We known safe anti-leprosy drug was Cambodia, Ethiopia, Guinea, also know that leprosy is curable . about to become useless. India, Indonesia, Madagascar, Mozambique, Myanmar, Nepal , • Leprosy is caused by a bacillus, • In 1981 a WHO Study Group Nigeria, Philippines, Sudan , Mycobacterium leprae, which was able to recommend treatment United Republic of Tanzania, and reproduces very slowly and with a "cocktail" of three drugs - Zaire . mainly affects the skin, nerves dapsone, rifampicin and clofaz- and mucous membranes. If un- imine- which effectively pre- • By the end of 1995, nearly 8 treated, there can be progressive vented the bacillus from million patients had been cured and permanent damage to limbs becoming resistant to any of the with MDT, which had also pre- World Health • 49th Year, No.3, May-June 1996 A child taking multidrug therapy in Manaus, in the Amazonas area of Brazil. vented the development of physi- • WHO, through its Action cal disabilities in perhaps as many Programme for the Elimination of as 2 million individuals . The Leprosy, oversees the quest for global coverage of MDT cur- resources, monitors and evaluates rently stands at 88%. the activities in each endemic country, and generally coordi- • A person may be completely nates the progress towards elimi- cured but, if there has been severe nation worldwide.lt also damage to the limbs, that damage promotes the building up of cannot always be put right. So national capabilities to carry out there will be a long-term need for leprosy elimination programmes rehabilitation and treatment for and encourages research for still people disabled by the disease. more effective drugs as compo- In many parts of the world, they nent parts of MDT. may also have a struggle to rein- tegrate themselves into their • WHO also works in close collab- communities. Ancient fears of oration with the member associa- leprosy die hard . tions of the International Federation of Anti-Leprosy • In July 1994, an International Associations (ILEP) - and other Conference on the Elimination of NGOs which are making impor- Leprosy was convened in Hanoi , tant contributions to work in the VietNam, where governments , field among leprosy patients- international agencies and con- and with such agencies as the cerned NGOs reaffirmed their Nippon Foundation and the commitment to this goal . This World Bank. reaffirmation was enshrined in the Hanoi Declaration , which • Through the support of the recommended, among other Nippon Foundation of Japan, things, putting into effect a WHO supplies the drugs needed Global Plan of Action for the for MDT in blister packs in order closing years of the century. to treat about 800 000 patients per year in some 25 countries. • The Global Plan of Action drawn up by WHO and its collaborators • Can we look forward to total in the leprosy field envisages the eradication of leprosy? Provided identification and cure of about 3 countries don't relax their guard million cases by the year 2000. and provided health personnel everywhere remain alert for the 7 occurrence of any new case that might arise, there is every reason to suppose that- some time in the early decades of the 21st century -leprosy will go the way of smallpox and will disappear entirely from our planet. • Mr john Bland is currently working as a communications expert with the WHO Action Programme for the Elimination of Leprosy, World Health Organization, I 2 I I Geneva 27, Switzerland. The leprosy burden in 1996 • 1.26 million estimated cases • 60 endemic countries • 926 000 new patients registered for treatment • about half a million new cases detected per year • 1 to 2 million individuals disabled because of leprosy • current estimated prevalence rate 1 .7 cases per 1 0 000 population Progress with MDT • 8 million patients cured • 840 000 patients currently on MDT If health personnel remain alert to cases of leprosy, the active disease will soon disappear 8 History of a disease Michel F. Lechat l eprosy has always been seen as a part of humanity's burden of misery. It has dogged our foot- steps from century to century. Only today can we put an end to that long and wearisome story. The means and the will exist to do it , and the will was expressed in a resolution adopted unanimously by the World Health Assembly in 1991 . Just what does that story consist of? Apart from the reality of the disease itself and those whom it afflicts , there are many myths of sin and expiation associated with it. Is leprosy the disease men- tioned so often in the Bible , where it is associated with ideas of impurity? This has been much discussed , but inconclusively. The disease is described in Indian and Chinese medical treatises dating from about the fifth century BC. It existed in Egypt in the second century BC, as an examination ofthe mummies proves. It seems to have been intro- duced into Italy when the legions of the Roman general Pompey returned from fighting in Egypt in the first century BC, then spread throughout Europe during the Middle Ages and reached its peak at the time of the Crusades. King Baudouin of Jerusalem fell victim to it. Indeed its victims were so numerous that it was presumed to be highly contagious, and the only defence seemed to be confining sufferers to lazarets or leprosaria. In France alone there were nearly 2000 hospices of this kind. This "setting people apart from life" was accompanied by funeral rites. Isolation followed meticulous guidelines that determined, for in- stance, on which side of a narrow Human beings and leprosy have a uniquely shared history. Unlike most communicable diseases, leprosy appears to be transmitted only by humans, and the bacillus has virtually no other host. G. Armauer Hansen, the Norwegian physician who, in 1 873, discovered Mycobacterium leprae, the bacillus of leprosy. road the sufferer must walk depend- ing on the wind direction, the wear- ing of special clothing, the use of separate holy water fonts in church, husband-wife relations, and inheri- tance laws. These various regula- tions, however, seem to reflect psychological mechanisms which World Health • 49th Year, No. 3, Moy-June 1996 were not recognized as such but which govern exclusions of all kinds, the disease only serving as a pretext. Whether such measures had a real preventive effect is doubtful, but leprosy began to decline in Europe around the 15th century AD, except in a few endemic areas in the Mediterranean basin and in Norway. It is clear that leprosy was trans- mitted to the inhabitants of the Americas by the European conquis- tadors , and the slave trade served to reinforce the disease in the New World. The focus observed in Louisiana, in the United States, resulted from the immigration of French-speaking colonists expelled from Nova Scotia, Canada, in 1755. Person-to-person Pompey's legions, the con- quest of Gaul, the Crusades, the discovery of the Americas , the slave trade, immigration from Canada- whatever the route, leprosy was transmitted by person-to-person contact over the centuries. But not always gradually; occasionally there have been sudden local outbreaks among populations which had never before been exposed to it. This was the case in certain Pacific islands , particularly Nauru, where early this century one-third of the population was infected within several years of the arrival there of a woman with the disease. Legend has it that many centuries ago a king of Burma who contracted leprosy was advised by the gods to eat the fruit of a forest tree called Kalaw, and he was cured. Oil of chaulmoogra, extracted from that World Health • 49th Year, No.3, May-June 1996 9 I With the discovery of the bacillus, leprosy entered the realm of scientific scrutiny. The presence of bacilli in skin snips reveals new cases of leprosy. Insert: Mycobacterium leprae in a hair follicle. fruit, has been used ever since, but without any real success. In the 1850s, the French scientist Louis Pasteur ushered in the bacteri- ological era by discovering the germs responsible for some infectious diseases. At that time, leprosy was still strongly endemic in Norway, affecting 2% of the rural population in the south. It was there, in Bergen in 1873, that the physician Armauer Hansen discovered the bacillus Mycobacterium leprae under the skin of his patients. Leprosy had at last entered the realm of scientific scrutiny. For want of anything better, since leprosy was now recognized as a communicable disease, communities went on isolating patients, or re- turned to the practice, and continued to treat them with oil of chaul- moogra. It was a dark chapter in the history of leprosy. Isolation may have been stripped of its traditional lugubrious trappings but these were replaced by coldly rational rigour. It was the period of Molokai island in Hawaii, where the Belgian mission- ary Father Darnien ran a leper colony, and of many other institu- tions, which often had many of the characteristics of a prison. M. leprae, also called Hansen's bacillus, was the first bacillus to be recognized as responsible for a disease in man, but to cultivate it in the laboratory or in animals proved to be impossible. Had we had a laboratory model, a bacillus culture or an experimental animal, it might have been possible from the start of this century to try out drugs known to be active against Mycobacterium tuberculosis, a microorganism closely related to the leprosy bacil- lus. For lack of knowledge- and this clearly shows the importance of supporting fundamental research- it was not until 1941 that an American doctor, Paget, took the audacious step of giving some of his patients a sulfone drug discovered some decades earlier. Mass campaigns In the 15 years that followed, mil- lions of patients around the world were treated with these sulfone products- dapsone or its derivatives. Most were treated as outpatients because, a few years earlier in Cebu in the Philippines, the epidemiolo- gists Doull and Guinto had demon- strated that the tuberculoid form of leprosy -today called paucibacillary leprosy and the most common form in many countries -was not signifi- cantly contagious. Now the saga of the mass campaigns against leprosy began, with dapsone being adminis- tered at the roadside, under trees, in temple squares or in garages, and being transported by bicycle or canoe, on mule-back or on foot. Then, however, leprosy gradually reasserted its resilience. The treat- ment was very long, sometimes lasting for a lifetime. Patients grew weary and relapses appeared more and more frequently. In 1960, Shepard succeeded in inoculating leprosy in the footpads of mice. This soon made it possible to demonstrate the appearance of mutant forms of M. leprae that were resistant to dapsone. On the other hand, the mouse model also made it possible to test the efficacy of other drugs which proved much more effective against 10 the bacillus , in particular clofazimine and rifampicin , which could effect a cure in a matter of months. New possibilities now opened up, beyond all previous expectations. In fact, human beings and leprosy have a uniquely shared history. Unlike most communicable diseases , leprosy appears to be transmitted only by humans , and the bacillus has virtually no other host. This mutual allegiance has at last allowed us to envisage the early treatment of pa- tients and hence the interruption of transmission . In 1981 , a WHO Study Group defined the appropriate therapeutic regimens on the basis of rigorous clinical trials. This paved the way for the World Health Assembly Resolution of 1991, which set the goal of eliminating leprosy as a public health problem. • Professor M. F. Lechat is Professor Emeritus of the Catholic University of Louvain, Belgium, and Professor Emeritus of the International Leprosy Association {/LA). His address is I 09 rue des Trois Tilleuls, I 170 Brussels, Belgium. World Health • 49th Year, No.3, Moy-June 1996 Taking multidrug therapy under surveillance in Thailand Superstition and preiudice S.D. Gokhale While MDT can eliminate Mycobacterium leprae from the body of the patient, it cannot overcome the loss of sensation or correct the deformities or disfigurement caused by late detection and delayed treatment. Medically, leprosy is in most respects like any other disease; what makes it different is the irreparable loss of sensation or facial disfigurement it may cause. Th is marks out the patient as a special individual and can be a cause of stigma -the social reiection of what is not considered as normal or what is not in tune with the accepted pattern of society. There is an abysmal lack of accurate in formation about disability, its causes and consequences, and about what we can do to counter it. There is also a mountain of misinformation, preiudice, superstition and fear. This is a maior factor in the family's inadequate reaction to the problem when it arises; it is a fundamental reason for the community's ostracizing indivi duals and families that are affected with disabil ity due to leprosy. Misinformation on these matters exists in all echelons of government, from the village chiefs to the ministers. Sufferers from leprosy have four maior needs: to be cured of the disease, to prevent further impairment, to recover their physical abilities and appearance, and to recover their social status. Prevention of further impairment should be given priority, along with planning for commun ity-based rehabilitation . In fact, leprosy is a far more serious problem than the mere number of cases implies, since disfigurement from the disease leads to serious psychological , economic and socia l difficulties for the patients, particularly in the many societies where social stigma is still highly prevalent. The two goals of rehabilitation must therefore be as follows: firstly, to provide all leprosy patients wi th services aimed at preventing or reducing disability and maximizing ability, and secondly, to provide society w ith the means of regaining the disabled person's economic contribution while reducing the cost of institutional care, sickness benefits , disability pensions and other such expenses. Dr S.D. Gokhale is the Chairman of the International Leprosy Union and former Chairman of the Gandhi Memorial Leprosy Foundation. His address is Bharat Scout Grounds Building, 1779·1784 Sadashiv Peth, Pune-4 I I 030, India. World Heolth • 49th Year, No.3, May-June 1996 11 The legacy-of .leprosy research Barry R. Bloom Thanks to the low body temperature of the armadillo, a large number of Mycobacterium leprae can be grown in this animal and thus provide material for researchers all over the world. From ancient times and in virtu-ally every culture, leprosy has evoked particular images of horror and fascination. For no other illness have people been buried alive, burnt at the stake, or given last rites for the dead before being expelled from walled cities with a bell and candle . As Dr S.K. Noordeen, Director of WHO's Action Programme for the Elimination of Leprosy, has written, "For ages leprosy remained a disease without hope" . The challenge implicit in establishing the research programme on leprosy at WHO in 1974 was to determine whether not only the physical manifestations but also the ancient stigmatization of this disease could be vanquished by the applica- tion of modern scientific approaches. Leprosy is caused by a bacterium, Mycobacterium leprae, a distant relative of the bacillus that causes tuberculosis. In fact it was the first bacterium identified as the cause of a human disease , and was discovered by a Norwegian physician , G. Armauer Hansen, in 1873. Although it was the first microbial pathogen identified, M. leprae remains one of very few which cannot be grown and studied in the test tube. This explains why research was less developed for this disease than perhaps for any other infectious disease. The discov- ery that M. leprae could grow in the footpads of mice , which have a low temperature , was a major scientific breakthrough. This provided an animal model to study and revealeg why leprosy involves primarily the skin, which has a lower temperature than the rest of tlie body. While small numbers of bacilli could be obtained from the mice for study, WHO's decision to recommend multidrug therapy took great courage and a deep understanding of scientific principles. Today, a disease that was thought to be without hope is being targeted for elimination as a public health problem. there were not nearly enough organ- isms for testing drugs and developing vaccines . A second breakthrough occurred in 1971, when it was dis- covered that M. leprae could grow to very high numbers in the nine- banded armadillo, which has a low body temperature. Because of its armour-plated skin, the armadillo has not developed a powerful immune system and hence allows the growth of the human leprosy bacillus. The possibility thus existed of obtaining many organisms for study, but few scientists were interested in this difficult and slow disease, and there was no leadership. Laboratory without walls In 1972, WHO held a meeting in New Delhi to explore the possibility for research on leprosy. From that meeting came two WHO reports which suggested experiments that could provide insight into leprosy 12 World Health • 49th Year, No. 3, Moy-June 1996 A patient suffering from nerve damage in his hands caused by leprosy is wailing for reconstructive surgery. The first case of drug resistance had been reported in 1964 from Malaysia, and by 1982 rates of dap- sone resistance had risen to between 10 and 100 per 1000 treated individ- uals. Dapsone monotherapy was losing its usefulness, and leprosy workers were losing their enthusiasm for its use. After a year-long study, a WHO Study Group on Chemo- therapy of Leprosy for Control Programmes made a dramatic policy statement- to recommend the simul- taneous use of three drugs, which has now become known as multidrug therapy (MDT). Their logic was sound . The probability of a bac- terium developing a mutation that spontaneously renders it resistant to any single drug is about one in a million (10-6), and if an individual has a million or more bacilli, they are likely to harbour a drug-resistant mutant. Lepromatous leprosy pa- tients often have 1012 (a million million) bacilli, which means they could have a million organisms resistant to any single drug. But the probability of an organism being spontaneously resistant to three effective drugs would be 10 18 (a and permit a rational approach to new drugs and vaccines. A hundred years after Hansen 's discovery of the leprosy bacillus , the Norwegian government gave funds to WHO to lead an effort to answer some of the scientific questions raised at that meeting. Thus were born the Immunology of Leprosy (IMMLEP) and Chemotherapy of Leprosy (THELEP) committees. With the gift of three years' worth of armadillo-derived leprosy bacilli to study, the committees began to recruit the best scientists available with special expertise in this field. This network of scientists became a "laboratory without walls". There were two strategies: one was to make a vaccine to prevent leprosy; the other to discover and test new antileprosy therapies. For the vaccine effort, the most modem scientific approaches from molecular biology to immunology were under- taken, and a vast amount of knowl- edge was gained about the leprosy bacillus, about human immune responses , about tissue damage. Yet we still do not have a vaccine against leprosy. The THELEP committee on the development of new drugs made its first priority to examine the current state of treatment, which was lifelong dapsone therapy. There was concern that dapsone resistance was increas- ing. The principal new scientific tool for detecting drug-resistant leprosy bacilli was not high technology, but the simple laboratory mouse; drug- resistant bacilli could be identified by their ability to grow in animals treated with individual drugs. Early diagnosis makes if possible to kill the leprosy bacilli before they have caused irreversible damage. World Health • 49th Year, No. 3, May-June 1996 millionth of a millionth of one in a million), and thus highly unlikely. Courageous decision Thus with therapy using three drugs, mutant organisms resistant to any one drug will be killed by the others, and the likelihood of resistance to all three would be infinitesimal. But there were no human data on MDT, only laboratory findings in mice that several drugs besides dapsone were effective in inhibiting growth of M. leprae. Based on the knowledge that rifampicin , clofazimine and dapsone were effective in animal models, WHO recommended that these three drugs be used to treat 13 patients with leprosy in programmes A health worker is trained to recognize the leprosy bacillus under his microscope. around the world. The Study Group 's decision was courageous , and was promptly criticized because it was not based on field data. But time has proved it to be right. THELEP set up two large-scale field trials of MDT in south India with 2224 multibacillary leprosy patients , and the treatment was found to be safe and the relapse rate less than 1%. Since then MDT has proved its effectiveness , and almost 90% of today 's leprosy patients are receiving MDT. The greatest legacy of the WHO leprosy programme has been the reduction of the number of registered cases from 5 .4 million people in 1985 to 926 000 in 1996. There are others. A combination of three drugs was thought to be too expensive and too complex to be practical for peo- ple in developing countries , but MDT has shown that to be wrong. The fact that WHO could form a network of scientists to work to- gether in the battle against leprosy has inspired other initiatives such as the Special Programme for Research and Training in Tropical Diseases (TDR) and the Global Programme for Vaccines (GPV). There remains a continuing need for research, for early diagnosis of disease, for deter- mining when all the bacilli are killed , and for solving problems in the field. Knowledge gained from research on a leprosy vaccine is already being applied to developing a better vac- cine against tuberculosis. The WHO decision to recom- mend MDT took great courage, but also a deep understanding of scien- tific principles and a recognition of the value of scientific research in disease prevention and treatment. Today, a disease that was thought to be without hope is being targeted for elimination as a public health prob- lem. For the scientists and field workers who have collaborated with WHO on leprosy over the years, the ultimate legacy will be the eventual eradication of leprosy, like smallpox , from the face of the earth . • Dr Barry Bloom is Professor of Microbiology and Immunology at the Albert Einstein College of Medicine, 1300 Morris Pork Avenue, Bronx, New York 10461, USA, and former Chairman of the Scientific and Technical Advisory Committee to the UNDP /World Bonk/WHO Special Programme for Research and Training in Tropical Diseases. 14 World Health • 49th Year, No.3, May-June 1996 Voluntary action and the continuing task in leprosy Paul Sommerfeld Even when patients no longer suffer from active leprosy, they remain affected both physically and socially. The story ofMokseda (see box) demonstrates the tragedy of leprosy. It is a disabling disease with- all too often- a long-term social impact on the life of the indi- viduals affected and on the lives of their family and community. Mokseda is a woman who has been successfully treated for leprosy and no longer suffers from the active disease. But she remains affected both physically and socially. The 20 voluntary organizations that come together in ILEP, the International Federation of Anti- Leprosy Associations, try to respond to the total impact of leprosy on the lives of the people it affects and of those who are close to them. Well into the next century there will still be new patients to treat, old patients with disability to support, and a search for the tools that might one day permit complete eradication of this disease. They share with WHO and gov- ernments a determination that the first priority is to give everybody with the active disease the most effective available drugs. Thus 20 years ago, ILEP member associations were active in pioneering the use of multidrug therapy (MDT); and in 1990 they pledged themselves to a target of MDT for All by the Year 2000. This is similar in purpose to the target adopted in 1991 by the World Health Assembly of ending leprosy as a public health problem, and keeps it clear that what is being achieved is control of leprosy, not yet its eradication . About one-third of all the people in the world being treated for leprosy are receiving their care from projects supported by members of ILEP- an exceptional achievement for volun- tary associations . Last December the ILEP Medical Commission was able to say that, from the data so far World Health • 49th Year, No.3, May-June 1996 available, ILEP Members have- except in a small number of areas- achieved their interim target of getting MDT to all the patients in the projects they were already support- ing. It still remains for them to work with governments and other agencies to get MDT to the last 20% of known patients worldwide. They also still have to reach the estimated half a million or more people who have the disease but have not yet been de- tected by health services. A trickster ILEP associations are very conscious that leprosy is a trickster. It is a slow-growing bacterium, which means a person commonly has the disease for a long time before clinical symptoms appear. So although over the last few years it has been a mas- sive achievement to bring down drastically the number of people who have the disease, it remains to be seen if that success translates into a similar drop in the number of cases , currently about 600 000, detected each year. We are doing very well at treating and clearing the backlog of cases; but have we significantly reduced transmission of the bac- terium to new people? It is also evident that new cases will still be appearing even after achievement of the WHO target of not more than one case of leprosy per 10 000 population. There will be a need in many places for leprosy backup teams, and for training to assist the general health services to diagnose and treat what may still be a problem of 200 000 to 300 000 cases a year worldwide after the year 2000. In September this year the ILEP Medical Commission is arranging a workshop of specialists to formulate advice on sustaining leprosy services after the number of cases has been brought down. The next great priority is to re- member the many people like Mokseda who, even after treatment with MDT, are left disabled or at risk of developing disabilities due to the nerve damage caused by the disease. Leprosy affects certain nerves , caus- ing Joss of feeling. Not sensing the warning signals of pain, the patient allows small cuts, bums and sores to develop into chronic ulcers that lead eventually to deformities . That process is not inexorable. Patients can be taught to overcome the loss of sensation and take appropriate care: to wear sandals or shoes that protect their feet, and to notice and respond to the early signs of damage. Programmes need to build disability prevention into their leprosy control activities: training staff in how to help patients learn to care for them- selves, advising on or providing footwear, and monitoring changes in each patient's ability to feel. ILEP associations see an immediate need to help programmes to build into their work simple but effective pro- cedures for the prevention of disabil- ities . New advice has been prepared and ILEP-supported projects are being encouraged to follow it. Mokseda IS A young leprosy patient in Mozambique holding the pack of pills that will save him from disability. Even with improved preventive activity, members are also aware that there is a generation of several mil- lion people, already damaged , who will live the rest of their lives with disability caused by leprosy. Once feeling has been lost, small wounds cause damage that can get worse as time goes on. Thus even after being "cured" there are many people af- fected by leprosy who will continue to need specialized medical and social services for support in self- care procedures, for reconstructive surgery, and for provision of special footwear or artificial limbs. Mokseda lives in Bangladesh and contracted leprosy several years ago. Her husband left her for fear of the disease, and she had to labour even harder in the fields to make a living. Then she was successfully treated with multidrug therapy. Life began to get better and her daughter was accepted into the local school. But the disease left her with loss of feeling in her feet. N ow, the pressures of field work have caused ulcers. So other people think she still has leprosy and shun her. Thus she has long since been "cured " but is still affected by the pain of social ostracism and remains in danger of serious disability. Crippling damage to her feet would severely limit her ability to provide for herself and her children. COIIIIIJuled by Or. li. Croft, Leprosy Mission, Thokurgoon, Bangladesh 16 d . nose on . f ding helps to rog d treat the rseos Systemotrc case- rn irreversible damage. Social integration Then there are the social difficulties. Individuals like Mokseda need more than physical care; they also need assistance to achieve reintegration into society. That means both ac- tions aimed at the community in general and actions for the individ- ual. Public health education can put across the message that leprosy is an "ordinary" disease like any other, not a curse from God or punishment for sins. It is an illness that is curable. That message is important both to encour- age people to come forward when they have the disease and to ensure that families and communities ac- cept and support individuals who have or have had leprosy. Besides emotional support, real economic assistance can also be crucial: a small sum of money to travel back to their own community, or a loan to start a little business can make all the difference. This total vision of the person affected by leprosy - from diagnosis to social reintegration - underpins the contribution of voluntary associ- ations to anti-leprosy work. Collecting funds from the general public in their own countries and using them to support all kinds of anti-leprosy work throughout the world, ILEP members distribute around US$ 70 million every year to hundreds of field projects and over 50 research projects. Research is necessary to find tools for improved treatment (six months or two years is an awfully long time to be taking capsules daily) and for prevention of disability, for prevention of the disease, and -let us hope- one day for its eradication. World Health • 49th Year, No.3, May-June 1996 To ensure that all the voluntary funds for this wide range of activi- ties are used effectively and without unnecessary duplication of effort, ILEP provides an interesting exam- ple of coordination among non- governmental organizations. For each project and most countries, one member association is appointed to act as ILEP Coordinator. That coordinator is then the one point of contact between the project and all ILEP members, simplifying life for both the project and the donor asso- ciations. Through an information service , members know in detail which projects each member is funding, and through standardized reporting systems a range of patient data is available for each project. This structure has served volun- tary donor agencies in the field of leprosy well since the late 1960s. Now, as ILEP celebrates its thirtieth anniversary, it is giving increased emphasis to disability prevention and to the social aspects of anti- leprosy work. Voluntary associa- tions are very conscious that, while the introduction of MDT has made possible a massive achievement in recent years , the story of leprosy is not yet finished. Well into the next century there will still be new pa- tients to treat, old patients with disability to support, and a search for the tools that might one day permit complete eradication of this disease. • Mr Paul Sommerfeld is General Secretory of the International Federation of Anti-Leprosy Federations (I LEP), 2 34 Blythe Rood, London W 14 OHJ, England. World Health • 49th Year, No.3, May-June 1996 17 Success story in Thailand Charoon Pirayavaraporn Thailand's success in eliminating leprosy as a public health problem underlines the value of a sustained international relationship in its long history of leprosy control. l eprosy control in Thailand can be dated back to the year 1908, when King Chulalongkorn granted a large piece of land in Chiang Mai upon which the first leprosarium for patients was built. As in many other countries, the isolation of leprosy patients in Thailand lasted from 1908 to 1951. Isolation was costly and the treat- ment and care of patients difficult, but the patronage of His Majesty the King and the Chakri Dynasty light- ened the burden. Before long there were two leprosaria and 13 colonies covering almost every region of Thailand . From about 1950 , the drug dap- sone was used and improved so that it could be administered orally instead of by injection. In 1953, with WHO support, UNICEF and the Ministry of Public Health con- ducted a national randomized survey to estimate the number of leprosy sufferers in Thailand. It found there were about 140 000, while the esti- mated prevalence was some 50 cases per 10 000 population. Almost 60% of the patients lived in the north- eastern region. Again with initial financial support from the King , the Leprosy Division developed two-year train- ing courses and set up teams of leprosy staff to carry out the Specialized Control Programme. By 1970, the programme had expanded to reach 40 provinces in which the prevalence of leprosy constituted a Examinations are carried out at the zona/leprosy centre. public health problem. Up to 1970, a total of 111 722 leprosy cases had been detected and treated and 33 653 patients had been successfully treated and discharged. Under the country's Third Health Development Plan (1972-1976) , the emphasis was placed on a compre- hensive health plan, and the national leprosy control strategy was devel- oped and integrated into local public health services. Quality control and efficient programme management were ensured by supervision from a series of Zonal Leprosy Centres. From 1982, community participation was promoted and accelerated, the ultimate goal being health for all by the year 2000. Leprosy training workshops promoted the dissemina- tion of related information and techniques of self-care to peripheral health staff, primary health care workers and the affected communi- ties. In 1984, multidrug therapy (MDT) was introduced to medical staff at all provincial and district levels. It greatly improved the efficiency of the control programme, increasing the confidence of health staff and the compliance of patients. By 1989, through vigorous efforts of training and supervision , all leprosy patients were covered by MDT. At present there are only 3015 regis- tered cases; about 1300 new cases are detected each year, and the national prevalence rate of cases is 0.51 per 10 000 population. Thailand has thus been converted from one of the endemic countries in 1953 to one of the foremost coun- tries in eliminating the leprosy problem. This success can be attributed to continuous efforts , close cooperation and assistance from WHO and various nongovernmental organiza- tions, particularly the Rajpracha- Samasai Foundation, the Sasakawa Memorial Health Foundation, the German Leprosy Relief Association and the Netherlands Leprosy Relief Association. It is an achievement which clearly shows the importance of good international relationships for disease control. This is true not only for Thailand but for leprosy- endemic countries everywhere. • Dr Charoon Pirayavaraporn is Director, Leprosy Division, Department of Communicable Disease Control, Ministry of Public Health, Thailand, Moo 4, Tiwanond Road, Nonthaburi I I 000, Thailand. 18 leprosy in Yemen Yasin AI·Qubati The inhabitants of those areas be- came accustomed to seeing these leprosy patients as strangers wander- ing in the deserts or mountains. The cruel legend arose that, in order to be cured from the disease, these unfor- tunate castaways would kill human beings, eat their brains and drink their blood. In some areas of Yemen there is a belief that, if the leprosy l eprosy -in Arabic Gutham-dateS. back some 1350 years in the history of Yemen. In ancient times the Abbassid Wali (Ruler of Yemen), M. Z. Abou-Al-Madan, collected huge quantities of wood to burn all the leprosy patients to be found in the country's capital , Sana'a, as a way of solving this problem. Fortunately, however, he died before he was able to commit this crime. More positively, "Kaidoon festi- val"- a national leprosy day - is traditionally celebrated on the last Friday of Rajab month. This festival was started in 1230 AD by Saeed Bin Isa Al-Amoodi in a village called Kaidoon in Hadramout. It is widely believed that on this day leprosy will not be transmitted and therefore healthy people mingle with leprosy patients. " patients walk in the rain, the rain water will become contaminated and will eventually infect people who eat the plants irrigated by this water. In the 19th and early 20th cen- turies, if leprosy sufferers were found among the crews of trading ships, the captains used to throw them into the sea or send them by boat to be put ashore in the coastal regions of Al- Mahara or Hadramout, or at Zafar. All these wrong-headed beliefs have tended to influence not only individuals but even the decision- makers of the government. As a result the leprosy problem in Yemen is considered more as a social than as a public health problem. Ideas of guilt In many societies, leprosy is associ- ated with ideas of guilt, rejection and isolation which were influenced mainly by social beliefs and religious misconceptions. Most Muslims The Skin and Venereal Diseases Hospital at the City of Light, Taiz, Yemen. World Health • 49th Year, No.3, May-June 1996 would remember a saying of the Prophet Mohammad, that they should "escape from a leper as you escape from a lion" . Only a few of them would recall that the Prophet ate with a leprosy patient, that Ayeshah , the wife of the Prophet, encouraged people to accept leprosy sufferers and that it was said she had a person with leprosy working in her house as a servant and sharing all their utensils. Yahia Ali-Nasser, a 20-year-old male patient at the City of Light , Taiz, remembers his isolated life in his village . He says: "When I started to have patches on my body and developed deformities of both hands, I was forbidden to join in meals with my family. I was put in a separate room without proper food or a proper place to sleep. I was not allowed in the mosque or in the souk (market) ." Victims of leprosy are obliged to get divorced , and they are isolated from their families as well as being ostracized from society. Their property is usually taken by other members of the family. In fact, from the moment that leprosy is diag- nosed they are considered socially dead. I remember, in 1986, during one of my field visits to Hajj a gover- norate , I met an old man living all alone in a cave outside the village on the charity of some village people. In front of his cave he could see the huge apartment buildings that his own children had constructed . It was very hard to persuade him to shake hands with me; for many a long year he had never met a healthy person. In AI-Mahara governorate, near the border with Oman, I found a whole family living in one small room of their neighbour's home. They had deserted their own big house for the simple reason that a leprosy patient had died in that World Health • 49th Year, No. 3, May-June 1996 Paying homage during the Kaidoon Festival, which is Nat~onal Leprosy Day in Yemen. house. And I recall once happening to see the identity card of a patient, in which against the column "profes- sion" was written "leper" . Before 1964, leprosy patients were subjected to obligatory isola- tion in unsanitary houses. These houses were built by the King in the north, by the English colonial admin- istrators, or by the Sultans in the south of the country. The City of Light hospital , not far from the centre ofTaiz city, was built in 1964 and the area became a refuge for outcasts. Houses grew up around the hospital and a leprosarium was erected nearby. Between 1964 and 1973 , Taiz and Mukalla were the only places in the country known to be giving medical care by dapsone monotherapy to leprosy patients. Revitalized able advice and to direct financial aid from WHO. In 1989, an agreement was signed between the Ministry of Public Health and the German Leprosy Relief Association . This paved the way to the foundation of the National Leprosy Control Programme (NLCP) in Yemen. Today the NLCP work is being carried out in two different areas: running the Skin and Venereal Diseases Hospital at the City of Light in Taiz (which is also the headquar- ters of the NLCP) , and field activities covering 80% of the country. 19 In 1990 intensive health educa- tion programmes were started in an attempt to overcome the long- entrenched stigma of leprosy, making full use of the mass media. Slowly, attitudes are changing. Mr Ahmed Al-Kafri- a former leprosy patient living in the City of Light- says: "Ten years ago there was no one to visit me. I was totally isolated. But, now, Al-Hamdullah! (Thank God!) I can visit my relatives in my village . My house is filled with visitors and sometimes I even find it difficult to play host to all of them." We can constantly hear similar stories in the City of Light. Al-Hamdullah! The grateful smile on the face of leprosy patients and the gleam of hope in their eyes serve to encourage the NLCP of Yemen- in spite of political instability, inflation, geo- graphical constraints such as the difficult terrain , poor health care infrastructure and inadequate com- munications system- to press on towards the goal of elimination; it's not very far away! • Dr Yasin Af.Qubati is Director of the National Leprosy Control Programme, P.O. Box 55722, Taiz, Yemen. The leprosy work was carried out by the Missionaries of Charity from 1973 in Taiz, Hodeidah and Al- Sukhnah. In 1982, during a WHO conference at Mogadishu, Somalia, I invited Dr S.K. Noordeen of WHO, Geneva, to visit Yemen . After his visit the leprosy control activities, which had fallen into stagnation , were revitalized thanks to his valu- The Kaidoon Festival in Hadramout is the day when healthy people mingle with leprosy patients. 20 World Heolth • 49th Yeor, No.3, Moy-June 1996 Control efforts in India N.S. Dharamshaktu As the country with the largest number of leprosy cases in the world, India is making good progress towards elimination thanks to the concerted and coordinated efforts of the government, NGOs and international agencies. Programme, when there were thought to be about 1.4 million cases of leprosy. Control was based on dapsone monotherapy which had to be taken by patients for anything from three years to a lifetime, depending on the type of disease. While the pro- gramme remained only input- oriented for a long time, in 197 6-77 targets were allotted to the States and Union Territories for case-detection, treatment and discharge so as to make the programme performance- Taking multidrug therapy under control ensures the regularity of the treatment. he ancient Hindu literature of Sushrita Samhita, written around 600 BC, gives a fairly good description of leprosy, its spread and treatment. Voluntary organizations working in India have a long history of involvement in leprosy relief work, starting with leprosy asylums established in the early 19th Century in Calcutta and Varanasi. The Mission to Lepers started at Chama in 1875 , and the Indian Council of the British Empire Leprosy Relief Association was established in 1925. The first at- tempt to control leprosy throughout India started in 1955 with the launch of the National Leprosy Control oriented. After Independence in 1947, a large number of NGOs doing leprosy work came into being , and by 1987 they numbered about 285, covering almost 30% of the recorded patients in the country. Recognizing the contribution and potential of these organizations, the Government of India evolved a system for sup- porting them in important priority activities. Regular interaction has also been organized, so that they can share their experiences. A working group appointed by the government in 1980 laid down the revised strategy, aiming at lep- rosy eradication through reducing the pool of infection in the population, curbing the sources of infection and breaking the chain of disease trans- mission . Considering the magnitude of the problem (estimated in 1981 as 4 million cases of leprosy in India out of a total of 12 million cases in the world), and in view of effective treatment available in the form of multidrug therapy (MDT), the pro- gramme was revitalized and redesig- nated as the National Leprosy Eradication Programme (NLEP) in 1983. The objective was to elimi- nate leprosy by the year 2000 , thereby reducing the case-load to less than 1 per 10 000 population. Under the strategy adopted, district MDT societies were formed and funds were released to them to ensure that the drugs reach the patients in a phased manner. Eventually these societies expanded to cover all201 endemic districts with prevalence of more than five per 1000 population , while the remaining districts were covered by mobile leprosy treatment units with the help of general health care staff. By 1995 all districts of the country had been brought into the MDT scheme. MDT for all With the launch in 1993 of the World Bank-assisted Programme for Elimination of Leprosy, the NLEP received a further boost by being enabled to provide full MDT cover- age in all hitherto uncovered en- demic and non-endemic districts. The government declared that from the start of 1996 no leprosy patient should be on monotherapy, since MDT would be available to patients in every part of the country. The programme is also receiving regular technical support from WHO, and leprosy work has been further sup- ported by many international volun- tary agencies and bilateral aid World Health • 49th Yeor, No.3, May-June 1996 Even when patients are cured of the disease, the physical damage left by leprosy necessitates further treatment for many years . agencies . Since 1983 , the NLEP has been reviewed by State Programme Officers 11 times at national level , and five independent evaluations have also been carried out. Many aspects of the programme are regu- larly reviewed at national , state and peripheral levels. Thanks to the concerted and coordinated efforts of the govern- ment and all other agencies up to March 1995, the total patient load has been reduced to 740 000, and a total of 5.8 million cases have been A future without leprosy Arlur CustOdio M. de Souza Early treatment with MDT is an absolute must if leprosy is to be eliminated. But this requires early diagnosis, which in its turn requires early recognition. People in leprosy-endemic areas should be able to recognize the signs of the disease in order to seek treatment at a health unit equipped to provide adequate services of diagnosis and treatment. In Rio de Janeiro, the Brazilian Institute for Innovations in Social Health and the Movement for the Reintegration of Hansen's Diseased Persons (MORHAN) have jointly started a Project for Early Recogn ition of Leprosy IREPRE- HAN) which, in 1996, will receive some support from the Netherlands Leprosy Relief Association (NSL) . REPREHAN is devoted to enabling people living in situations of social and economic deprivation to recognize the discharged after completion of MDT. The programme will need to be reviewed thoroughly at more fre- quent intervals as we approach the year 2000 to ensure that timely remedial action is taken . Dealing with remaining patients and problem cases living in difficult areas will call for unremitting efforts, with the involvement of general health care staff and strong public support. If such activities are undertaken promptly, there is every possibility of achieving the goal of eliminating signs of leprosy and to be aware of what they themselves can do to control the dis- ease. Thi s sort of soc ial mobi lization is an essential step to building a society wi thout leprosy, with less prejudice and with a better quality of life for people who have had the disease. Vo lunteers and others are working within their own social sectors in order to increase awareness. The ability of the mass media to reach each individual is wel l recognized. In addition , such means as plays, puppet shows, posters , televi- sion ta lks, sports events, T-shirts, buttons and stickers are all being used to disseminate infor- mation about the disease and to encourage a new perspective on it through- out Brazil. A future without lep- rosy is only a short step away. It depends not only on health workers but on patients, managers , so- Health education and active case-finding in a school in Manaus, Brazil. 21 Special shoes are used to avoid complications due to the loss of sensitivity in the Feet caused by leprosy. leprosy by the year 2000. The gov- ernment's announcement that it will start five pilot projects of commu- nity-based rehabilitation on a regular basis will provide a further boost to much-needed rehabilitation services for former leprosy patients now cured but left with disabilities. • Dr N.S. Dharamshaktu is Assistant Director General for Leprosy in India's Directorate General of Health Services, Room 754-A, Nirman Bhavan, New Delhi- I I 00 I I, India . cial workers and the public at large to bring about this new perspective and en- su re that the social exclusion which lep- rosy has entailed for so long becomes a thing of the past. • Dr Artur Custodio M. De Souza is a member of the National Council of Health, Brazilian Ministry of Health. He is both Coordinator of MORHAN, Rio de janeiro, and Coordinator of the Proiect for Early Recognition of Leprosy (REPREHAN) of the Brazilian Institute for Innovations in Social Health . 22 World Health • 49th Year, No.3, May-June 1996 Overcoming the stigma Le Kinh Due I n 1960, a protest was sent to the Ministry of Health asking for the immediate transfer of a leprosy treatment centre- the Qua Cam Leprosarium. It had been built during the French colonial period on the top of a hill , around which lay four villages engaged in agriculture and gardening. The protest expressed the view that, since the leprosy patients were on an upper level , leprosy bacilli and infective materials such as pus and other secretions would be carried along with the flow of rainwater to the lower fields and villages , and would constitute a permanent source of leprosy contamination for the "nor- mal" population. It was a knotty problem. A team of leprosy workers was sent to the spot to conduct a concrete investiga- tion. A systematic mass survey was done in all the four villages , resulting in the discovery of four cases among a population of 8000 people. This prevalence of five cases per 10 000 was not higher than that of other areas where no leprosarium was present. This proved that the existing leprosar- ium did not constitute a danger for the surrounding population, but the fear of leprosy remained un- changed , and there were no relations between the patients and the "normal" people. The people of Viet Nom prefer poetry to prose, so health messages written entirely in verse have been used to explain the true nature of leprosy and thus to overcome long-entrenched preiudices against sufferers from the disease. leprosy workers was sent to make a new mass survey of the same four villages. This time not a single new case was found . A new announce- ment was made: "Almost 50 years after the building of the leprosarium in 1913 , the prevalence of leprosy found in 1960 in the four villages was no higher than that of other areas of the country. And now, ten years later, not one new case has appeared! So there can be no grounds for say- ing that the leprosarium is a source of leprosy infection threatening the Ten years later, in 1971, a new team of A leprosy patient exercises his hands deformed by leprosy. population of our villages" . Since then , normal relations have little by little been established between the patients and the people of the vil- lages. VietNam is a poor country of 74 million inhabitants, heavily devas- tated by a long war. The average prevalence of leprosy was never very high ; but the stigma and prejudice against leprosy proved relatively serious in many areas , and consti- tuted an important constraint to leprosy elimination and eradication. Stigma sets up a vicious circle in that it leads to segregation, which intensi- fies fear, which leads those infected to hide it for as long as possible , which leads to further infection and deformities, thus strengthening the stigma. This to a large extent ex- plains how the disease was able to remain endemic in the country. A "social" disease Stigma appears as one of the most important factors in the vicious circle of leprosy persistence and spread among the community. Therefore, the crucial point of VietNam's leprosy eradica- tion programme is to carry out continuously and unremittingly a long-term pro- . gramme of health education on leprosy, with the aim of wip- ing out the exist- ing stigma World Health • 49th Year, No.3, May-June 1996 among various categories of popula- tion , with special attention to general health staff, political and govern- ment authorities, teachers , leaders of popular organizations, leprosy patients themselves and their fami- lies . One advantage we enjoy in VietNam is the full support of the government in the campaign against leprosy, which is not simply consid- ered to be a communicable disease, as is the case in many other coun- tries, but is viewed as a "social" disease, implying that collaborative "social" and well-coordinated action of the entire society is required for its successful elimination. Poetry and health education Vietnamese people prefer poetry to prose, partly because it is easier to memorize. Taking advantage of this traditional way of learning, we have produced educational materials that are written in verse. Simple poems explain the possible signs of leprosy, the treatment and prevention of deformities, the characteristics of the disease, the options available to patients, and appropriate humanitar- ian and scientific attitudes. School- children in particular can read them aloud at home , and all the members of the family can eventually know them by heart. Since wiping out the existing widespread stigma is not an easy task , and since leprosy elimination must be conceived as a long-term endeavour calling for the contribu- tion of several generations, we have, since the 1980s, made the subject of leprosy part of the curriculum of primary and secondary schools in many provinces . Thanks to this education policy, the younger gener- ations will grow up with a reliable and scientific understanding of what leprosy is. There will no longer be any room in their minds for prejudice against those who have the disease. Thus, in the long run , the stigma will disappear. This strategic and practical sys- tem of health education has been carried out not only by specialized information services , making use of the mass media and all other means available, but also by all strata of the general population, including teach- ers and schoolchildren. As a result, awareness of leprosy within the community, and subsequently the detection of patients and their com- pliance with treatment and rehabilita- tion, have all proved in general satisfactory. Many patients were, in fact, detected by teachers or their pupils among members of their own family or in the neighbourhood. 23 So after more than 30 years of leprosy control activities, the epi- demiological status of this disease in VietNam has been much improved. The proportion of patients under 15 years of age among newly detected cases, particularly in the Mekong delta area, has decreased from 9% in 1960 to 2.9% in 1994. The preva- lence has dropped to an average of 1.4 per 10 000 population. Prelimi- nary evaluation shows that we have reached the goal of leprosy elimina- tion put forward by WHO in more than 230 of the total 527 districts. To put it another way, some 72% of the entire population of VietNam are now living in areas where leprosy has been eliminated as a public health problem, that is , with a preva- lence of less than one case per 10 000 inhabitants. • Professor Le Kinh Due is Head of the Chair of Dermatology, Hanoi Medical College, and Director of the Vietnamese Leprosy Control Programme. His address is Vien Do Lieu, B. V. Bach Moi, Hanoi, Viet Nom. One of the most important targets of the leprosy campaign is to eliminate the stigma attached to leprosy among ordinary people. Schoolchildren are ideal transmitters of health messages that change attitudes. 24 World Health • 49th Yeor, No.3, Moy- June 1996 Guinea·worm eradication programme Guinea-worm disease has been the target of a global campaign that was initiated in 1980, in conjunction with the start of the International Drinking Water Supply and Sanitation Decade (1981-1990). The eradication of this debilitating and crippling disease is a common goal for WHO and UNICEF. The World Summit for Children set the aim of eradicating dracunculiasis by the year 2000, and a World Health Assembly resolution in 1991 ex- pressed commitment to this goal , "this being technically feasible given appropriate political, social and economic support." In February 1996, WHO was able to report that eradication had been 97% completed, and ~hat the global number of cases had fallen from an estimated 3 .5 million in 1986 to about 130 000 by the end of 1995; the number of endemic vil- lages had been reduced from over 23 000 at the end of 1992 to fewer than 8000 at the end of 1995. By that time, many of these villages were experiencing just a handful of cases each- indeed the average number of cases per village was only 16. Essentially, half of the dracunculia- sis remaining was to be found in one country. The basic strategy adopted for eradication was: • identification of all infected villages; • establishment of community- based surveillance systems , under which the community registered and reported all cases on a monthly basis; • health education to intensify social mobilization, as well as the distribution of filter materials; • targeting of appropriate water supply systems; • intensified case-containment measures to ensure that all new cases could be quickly detected and contained; • improved monitoring and map- ping of the situation through the use of Geographical Information Systems (GIS); • interagency collaboration at all levels for the exchange of infor- mation , operational research and technical assistance; • certification of eradication by the International Commission for the Certification of Dracunculiasis Eradication (ICCDE). Moreover, with French government cooperation, WHO published a brochure entitled "Dracunculiasis" which has been widely distributed, and also co-produced with ORSTOM (the French institute of scientific research for cooperative develop- ment) and the National School of Medicine and Pharmacy of Mali, a film entitled "Yoro, the empty gra- nary" which has received prestigious awards. What makes dracunculiasis susceptible to being eradicated is that only humans and the intermediate hosts , tiny crustacea called cyclops, act as disease vectors. Providing safe drinking-water suffices to prevent the parasite- larvae of the nematode worm Dracunculus medinensis- from passing from the cyclops into a human host, and thus interrupts the cycle of transmission. A typical integrated scheme for guinea- worm control involves health work- ers , teachers, hydraulic engineers, politicians, local leaders and the threatened community itself. The invaluable support offered by the international donor community has helped to make the total eradication of this disease possible. For the affected communities , eradication is providing an added bonus: improving the quality of drinking-water directly safeguards them from a large number of poten- tial waterborne infections. More- over, a community which has seen for itself how diseases can be pre- vented is a community alert, in- formed and ready to make further efforts for its own welfare. In fact , we have here a shining example of disease control being successfully integrated into national health pro- grammes, thus ensuring its sustain- ability. • Filtering water to remove cyclops in case they contain the larvae of the guinea-warm. World Health • 49th Year, No.3, May-June 1996 25 .Coalition against guinea· worm Donald R. Hopkins & Trenton K. Ruebush The global campaign to eradicate dracunculiasis began in 1980, when scientists from the Centers for Disease Control and Prevention (CDC) in the United States began persuading supporters of the International Drinking Water Supply and Sanitation Decade (1981-1990) to target dracunculiasis for eradica- tion. Providing safe drinking-water was already a principal goal of the Decade when its Steering Committee adopted dracunculiasis eradication as a sub-goal in April1981. CDC began providing consultants to countries, helped to organize the first international conference on dracunculiasis in Washington, DC, in 1982, prepared surveillance sum- maries for WHO's Weekly epidemio- logical record, developed an exhibit, and worked in other ways to secure passage of the first resolution on dracunculiasis by the 1986 World Health Assembly. WHO appointed CDC as a Collaborating Centre for Research, Training and Control of Dracunculiasis in 1984. The Carter Center 's Global2000 Program in Atlanta, Georgia, joined the battle in November 1986, when former US President Jimmy Carter and Pakistan's leader, General Mohammad Zia ul-Haq, agreed to cooperate in eradicating dracunculia- sis from Pakistan. Under this and other agreements with Ghana (1987), Nigeria (1988), Uganda (1991), Mali (1993), Niger (1993) and Sudan (1995), Global 2000 assigned an adviser to work in the ministry of health with each country 's national Guinea-Worm Eradication Pro- gramme, providing modest funding, logistic support and technical assis- tance. The national case searches in Pakistan (1987), Nigeria (1988) and Ghana (1989) were the first such searches for dracunculiasis outside of India, and for the first time docu- mented the extent of dracunculiasis in parts of Africa. Pakistan also pioneered the "case containment" strategy. Mr and Mrs Carter took up the cause of guinea-worm eradication enthusiastically. Since attending the African Regional Conference on Dracunculiasis in Ghana in 1988, they have travelled to Africa annu- ally for the campaign, visiting most endemic countries as well as the Organization of African Unity and WHO's Regional Office for Mrica. Global 2000 arranged an interna- tional donors' conference (with UNDP and UNICEF) in Lagos, Nigeria, in 1989, which attracted US$ 10 million in support. Mr Carter later led efforts to secure major donations from the United Arab Emirates, Saudi Arabia, USAID, Japan International Co- operation Agency, a consortium of Japanese businessmen (Keidanran) and others. Filter material was obtained from DuPont Corporation and Precision Fabrics Group, and temephos from American Cyanamid, while logistic support poured in from other sources. Mr Carter also recruited former Malian head of state General Amadou Toumani Toure to the cause while visiting Mali in 1992, and brokered a four-month "Guinea- Worm Cease-Fire" to halt Sudan's civil war in 1995. Global 2000 and CDC have worked closely together since 1986, sharing personnel, producing a newsletter (Guinea Worm Wrap-Up) and other technical documents, mak- ing an award-winning movie (with UNICEF and UNDP) and advising workers in endemic countries. In these and other ways, the two organi- zations have spearheaded the diverse coalition which is helping countries to eradicate dracunculiasis. • Dr Donald R. Hopkins works with the Global 2000 Program of the Carter Center, I Copenhi/1, Atlanta, Georgia 30307, USA, and Dr Trenton K. Ruebush II is Director of the WHO Collaborating Centre for Research, Training and Control of Dracunculiasis, Division of Parasitic Diseases {F-22), Centers for Disease Control, 4770 Buford Highway, N. E., Atlanta, GA 3034 I, USA General Amadou Toumani Toure of Mali and former US President)immy Carter at the celebration of Guinea-Worm Day on 4 December 1995, when a reduction of 97% of cases throughout the world since 1986 was announced. 26 World Health • 49th Year, No.3, May-June 1996 Mission almost accomplished Gautam Biswas & K.K. Datta Drinking water from step wells can cause guinea-worm disease. Guinea-worm disease (dracuncu-liasis), locally known in India as Naru, Nevra or Bala, has occurred for centuries in the water- scarce regions of the states of Andhra Pradesh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra, Rajasthan and Tamil Nadu. The disease mainly affected the rural population, but in particular those who did not have easy access to safe drinking-water. Besides the agony it caused to suffer- ers, it resulted in the further impover- ishment of individuals who belonged to the poorer population groups. A prolonged period of incapacitation- that might range from four to six weeks - resulted from the emergence of the female worm measuring 60-100 em in length. This often caused ulcers which were highly likely to become infected because of poor hygiene. India's Ministry of Health and Family Welfare launched the National Guinea Worm Eradication Programme in 1983-84, with the National Institute of Communicable Diseases as the agency responsible for planning, coordination, monitor- ing, evaluation, training and opera- tiona] research. In order to make the programme cost-effective, it was put into effect through the existing pri- mary health care network of the affected states, which were charged with carrying out the following strategies. • Guinea-worm disease surveil- lance through active case search operations with regular surveil- lance for the early detection of cases. This involved health officials, government and non- governmental agencies , and individuals such as schoolteach- ers, village development workers, opinion leaders and local volun- teers. To strengthen disease surveillance and case contain- ment, 12 Guinea-Worm Epidemiological Surveillance Teams were deployed with the financial assistance of WHO in the most highly endemic districts. • Appropriate management of the identified guinea-worm cases to provide relief and prevent further transmission. • Provision and maintenance of safe drinking-water through installation of hand pumps, tube In December 1995, an independent international evaluation of India's National Guinea Worm Eradication Programme concluded that transmission of this disease had probably been completely interrupted, and that no further case was likely to occur in the future. wells and piped water supplies, as well as the conversion of step- wells into draw wells. The Rajiv Gandhi National Drinking Water Mission and the State Public Health Engineering Departments, with assistance from UNICEF, gave high priority to the affected villages for water supplies and the upgrading of unsafe sources. • Vector control measures through treatment of the unsafe drinking- water sources with the chemical temephos eight times a year and distribution of fine-mesh nylon strainers to the community in the affected villages . • Community involvement and participation through regular health education using all avail- able mass media. Interpersonal communication and local folk media, which have wide commu- nity acceptance, were also used and proved to be extremely useful in areas with low rates of literacy. • Training for the primary health care workers to ensure that they carried out the programme effec- tively. • Regular monitoring and evalua- tion of the programme through weekly and monthly special World Health • 49th Year, No.3, Moy-June 1996 reports , task force groups and independent evaluations . The efficiency of programme activi- ties was maintained at a satisfac- tory level through continued operational research activities. Cash incentives At the beginning of the Programme, guinea-worm disease was endemic in 12 840 villages in 89 districts , with around 40 000 cases and 13 million people at risk of catching it. In 1995, only 60 cases were recorded in the country, from 24 villages in three desert districts of Rajasthan. This represents a reduction of over 99% in guinea-worm cases since 1984. As the incidence of the disease came down to very low levels, the surveil- lance activities were further strength- ened so that every individual case could be detected and properly con- tained. To lend further encourage- ment , a cash incentive of between 500 and 1000 rupees is offered to the first informer of any new case, and special searches are being under- taken in vulnerable areas. During December 1995, an inde- pendent international evaluation of the Programme was carried out which acclaimed India's achieve- ment. It noted that this country has probably been able to interrupt guinea-worm disease transmission completely and that no further case is likely to occur in the future. Since then, no case has been recorded. However, highly active surveillance for this pernicious disease continues, and the most recent house-to-house search took place in April this year. • Dr Gaulam Biswas is Deputy Director and Head, Division of Helminthology, National lnslilule of Communicable Diseases, 22 Sham Nath Marg, Delhi- 110 054, India, and Dr K. K. Datta is Director of the Nationallnslilule of Communicable Diseases, 22 Sham Nath Marg, Delhi - 110 054, India . A health worker demonstrates the presence of cyclops in step-well wafer. Using a hand pump protects people from guinea-worm disease. How can we be sure of eradication? In 1995, WHO's Director-General established the International Commission for the Certification of Dracunculiasis Eradication (ICCDEl, which first formally met at WHO headquarters in Geneva in March 1996. It is composed of 12 independent public health experts from all of WHO's six regions . Altogether 32 countries w ill require special attention during the final countdown to success and the process of certifying that guinea-worm disease no longer exists. Under the overall supervision of the ICCDE, international certification teams will visit all these countries . They will meticulously examine water sources in all localities w here recent cases of the disease have been reported, and will take samples of the tiny crustacea called cyclops which act as host to the larvae of the nematode worm Dracunculus medinensis . Cyclops will st ill be present in many wells and streams, but they should no longer be infested with the larvae. The teams will carefully review data indicating the absence of the disease, and will also consider whether there is any risk of imported cases from neighbouring countries. Only when all the criteria have been met wi ll they be able to report that the vicious cycle of transmission from human to human through drinking contaminated water has finally been interrupted. Countries or groups of countries where the disease existed during the 1980s will be declared free of the disease only after three consecutive years have elapsed w ithout any cases being found by the intensive survei llance system. The process of cert ification is expected to be completed three years after the last case of the disease has been reported from any part of the world. Only then will it be safe to declare that the forces of international public health have succeeded in putting an end to an ugly and debilitating scourge, and that dracuncul iasis has followed smallpox into oblivion. • 27 28 World Health • 49th Yeor, No.3, Moy-June 1996 Technology aids eradication • campa1gn The very latest technology is being deployed in the bid to eradicate guinea-worm disease, also known as dracunculiasis. Computer-aided database manage- ment and mapping technologies have been applied in recent years to iden- tify the precise areas of the globe where transmission of the disease still continues, and to pinpoint the location of each endemic village. This has then made it possible to improve the capabilities of health administrators to monitor the eradi- cation of guinea worm. "Before" and "after" maps for the West African state of Burkina Faso, for instance, use red dots to represent villages still affected in 1994 and empty circles to show those which were affected in 1990. This gives an exact picture of the significant decrease in the num- ber of endemic villages between 1990 and 1994. The same techniques have been used to map the locations of all vil- lages in which guinea-worm disease is endemic throughout the 17 African In 1993, WHO and UNICEF formed a joint programme on map- ping and Geographic Information Systems (GIS) for the Dracunculiasis Eradication Programme. Given the name DEPGIS, it was established within WHO's Division of Control of Tropical Diseases. The combination of WHO/UNICEF collaboration, broader applications of the technol- ogy, and increasing demand from countries has led to a steady evolu- tion of the capacities and objectives of the programme. Today, it is tech- nically feasible to map not only the villages affected by guinea-worm disease but virtually every village and hamlet in Africa, with precise information on their status with regard to selected diseases. In each of the 17 endemic coun- tries, a GIS focal point and a team of GIS users have been trained; these users are from the ministries respon- sible for water, health and planning, but also include technical experts from WHO/UNICEF and certain nongovernmental organizations. The programme has worked closely with the WHO/UNICEF Interagency Technical Teams for West and East Africa, who provide technical assis- tance to countries in putting into effect integrated community-based surveillance systems and in planning operational outreach strategies. Within two years of the start of the operation, a data bank had been created containing public health information on more than 78 000 villages in 20 African countries. While the programme continues to support the countries suffering from guinea worm, it will now also aim to expand its data management and mapping activities for disease sur- veillance to all countries in Africa south of the Sahara and to any other country which requests services . In fact, the WHO/UNICEF Joint Programme on Data Management and Mapping now provides a broad range of services and products re- lated to the production and use of maps to support public health plan- 0 Villages which had cases in 1990 and are naw free from guinea-worm disease. ning. These services and products are offered either directly or indi- rectly, under a subcontracting arrangement, through the programme team based within WHO's Division of Control of Tropical Diseases in Geneva. This team serves as a technical link between clients and service providers. • countries con- cerned. The resulting map, showing a wide band across the continent from Senegal and Mauritania in the west to Kenya and Ethiopia in the east, high- lights regions where prevalence of the disease is highest, and therefore reveals at a glance where resources to combat it are most urgently required. The high precision of computerized maps gives a clear image of the significant decrease of guinea- worm d isease in most affected countries. World Health • 49th Year, No.3, Moy-June 1996 29 Guinea·worm disease Jean-Philippe Chippaux Discovering how dracunculiasis is transmiffed made it at last possible to envisage total eradication of the disease. Today, the endemic countries have evaluated its importance, counted the number of cases, and put in place the means of control and surveillance. Although not a fatal disease except in rare cases of infec-tious complications, dracuncu- liasis is a serious problem because of its prevalence in affected communi- Ci 11'11!- ... These 17 th century engravings s extracted the worm ties, its long duration and the disabil- ity that it causes . The adult worm can attain a length of one metre, so its spectacular appearance and the annual recurrence of epidemics leave an indelible impression. Known since ancient times, it has received many names: dragon worm, Pharoah worm, Medina worm, Avicenna worm and more recently guinea worm. Linnaeus described the adult worm in 1758 and Fedchenko the parasitic cycle in 1871. The evidence in antiquity The Ebers papyrus dating from 1550 BC described both the disease and the treatment that is still used today. The discovery of a calcified male Dracunculus worm in the abdominal cavity of an adolescent mummy confirms the presence of the infec- tion in Egypt at the start of the first millennium BC. The Egyptian myth of the Serpent of Isis has been interpreted as relat- ing to dracunculiasis. Jealous of the knowledge and power of Ra, Isis creates a serpent from a mixture of saliva and earth. The reptile strikes the Sun God on the heel and pro- vokes inflammation, pain and fever, endangering the god's life. Ra has to reveal his real name to Isis, thus conferring on her his knowledge and power, before she will agree to heal him. Although the reference in the Ebers papyrus proves that the disease was present in Egypt and even affected those close to the Pharoah, it is doubtful whether it was endemic, since the ancient writers did not consider it to be so. These were 30 How the guinea worm is extracted today. more probably imported cases ob- served in travellers, traders , soldiers or slaves corning or returning to Egypt. Before the 15th century BC, Egypt received slaves and warriors from Yam, believed to be present-day Sudan, so the disease may have come from there or from even further afield. The Pharoah worm is next men- tioned in the earliest Assyrian med- ical treatises , which date from the 7th century BC. Without clearly stating its parasitic etiology, one treatise describes the infection as occurring in the lower limbs, usually the foot, but also in the joints. It surfaces from deep within the flesh as a vesi- cle containing a clear liquid , and should be punctured. Various parts of the Bible seem to refer to dracunculiasis occurring among the children of Israel. The fiery serpents which decimated the Hebrews during the Exodus from Egypt, sent by Jehovah to punish them for their complaints, are thought by some commentators to refer to a guinea-worm epidemic. Others doubt this, since the disease is not fatal, and since biblical refer- ences to burning serpents have more commonly been associated with scorpions or adders. The Middle Ages: recognized as a parasite In the Middle Ages, the disease was described by Arab and Persian writers , who were probably the only people directly in contact with it. Rhazes , a Persian doctor of the 9th and lOth centuries, identified a worm as the cause . Avicenna, on the other hand, although he seems to have had considerable first-hand experience of the disease, refused to accept the zoological explanation , and preferred to consider it as an ulcerated nerve. His precise descrip- tion of the disease, its treatment and evolution, and the complications if the worm breaks during extraction, was written in the 11th century, and makes it clear that the disease was common in the Persia of those days . He also described its geographical distribution, reaching from south of Bokhara, where he lived , to as far as Egypt "and other countries" . He particularly mentioned Medina, hence its name, the Medina worm. World Health • 49th Year, No.3, Moy-June 1996 Speculation about the etiology was to continue until the 19th century. Modern times: discovery of the transmission and treatment The slave trade brought guinea- worm back into the picture from the 17th century onwards. There were many clinical accounts of the disease among slaves during transport or after their arrival in the New World. There can be no doubt that guinea- worm was endemic in West Africa in the 16th century and perhaps even earlier. Did it originate in sub- Saharan Africa, as Adamson sup- posed in 1988, or was it imported as a result of Arab conquests in the 11th century? The slaves who came from the Gulf of Guinea often suffered from it, and we can identify certain partic- ularly endemic areas of Ghana, Gambia and Benin. On the other hand , those from Cote d'Ivoire seemed to be less infected and those from Angola show no signs of it. Dracunculiasis never became en- trenched in the New World, even if a World Health • 49th Year, No.3, Moy-June 1996 31 dracunculiasis has already vanished from Central Asia and is on the point of being eradicated from 16 coun- tries of Africa and two countries of Asia. • Or )ean-Philippe Chippaux is a Research Officer with ORSTOM, the French institute of scientific research for cooperative develop- ment, and Director of the Centre de Recherche sur les M<!mingites etles Schistosomoses {CERMES), B P 108 87, Niamey, Niger. Photo Credits Front cover: WHO/ Associoijon fran~oise Raoul Follereou Page 3: WHO/ H. Anenden Page 4: WHO/ Associoijon fran~oise Raoul Follereou Page 5: H. Joeggi ©; WHO/J. Mohr Poge 6: WHO/ Noijonolleprosy Control Programme, Cambodia Page 7: WHO/ Insmuto de Dermotologio tropical e A villager looking at a glass tube of well-water containing living cyclops. Venereologio "Alfredo de Motto", Monous, Brazil; WHO/J. Mohr few rare foci persisted for a few years in Curas;ao and in areas of Bahia (Brazil), Suriname and Guyana. Just how it entered the human body was not known, and this gave rise to much controversy. Most commentators believed it penetrated the skin; others blamed contaminated water and a few, in the 16th century, believed in contamination via the digestive tract. This last theory was proved to be correct by Fedchenko in 1871. Tomorrow - eradication Discovering the mode of transmis- sion marked a decisive step forward , because it made it possible to envis- age the total eradication of the dis- ease. From the start of this century, health education about boiling and filtration of drinking-water was In the next issue WHO is launching a Global School Health Initiative to help all schools become "health promoting schoo ls". The july- August issue of World Health wi ll report on the development of th is init iative and provi de examples of schools throughout the wor ld that are stri vi ng to become "health-promoting schools". • widely diffused in the regions where guinea worm was endemic . At the same time, malaria control indirectly resulted in the elimination of guinea worm from the Islamic Republic of Iran; treating the wells with DDT had the effect of destroying the cyclops responsible for transmitting the larvae. At the start of the eradication campaign, it was clear that system- atic disease control offered the only hope of success. In the space of a few years, the endemic countries have assessed the importance of the disease, counted the number of cases , defined the needs , planned their eradication pro-grammes and put in place the means of control and sur- veillance. Those responsible for national programmes have kept the public informed and brought the political leaders - often at the highest level- into the struggle. Today, Page 8: Page 9: Page 10: Page 11 : Page 12: Page 13: Page 14: Page 15: Page 16: Pagel?: Pogel8&19: Page 20: Page 21: Page 22: Page 23: Page 24: Page 25: Page 26 & 27: Page 28: Page 29: Page 30: Page 31 : Bock cover: WHO WHO/ Associoijon fron~oise Raoul Follereou; WHO WHO/ leprosy Division of Thailand WHO/ Albert Einstein College of Medicine's Graphic Arts Center, New York WHO/Schieffelin leprosy Research and Training Centre, Tamil Nodu, Indio; WHO/ Noijonolleprosy Control Programme, Cambodia H. Joeggi © The leprosy Mission lnternoijonolj lens Ideas © WHO/ Associozione itoliono Amici di Raoul Follereou WHO/ A. Kochar WHO/ leprosy Division ofThoilond WHO/ Noijonolleprosy Control Programme, Yemen H. Joeggi © H. Joeggi ©; WHO/Insijtuto de Dermotologio tropical e Venereologio "Alfredo de Motto", Mono us, Brazil WHO/ leprosy Division of Thailand l. Maurice © WHO The Corter Center/B. Fitz-Patrick © WHO/ G. Biswos Mop by WHO 17th century engravings from Verschius "Vena Medinensis", by courtesy of the Choir of History of Medicine, Paris Faculty of Medicine, Rene Descartes University WHO/ P. Ronque WHO WHO/ P. Ronque Did you enjoy this issue? Why not toke out o ·subscription to World Heolth and enjoy reading about the world's major health issues six times a year. 1996 subscription prices are listed below. WHO also offers its popular 'Health Horizons" subscription, a combined subscription lot a reduced rate I to World Heofth and the quarterly World Heolth Forum. Order form Card number------------- 0 World Health 11996 subscription! at Sw. fr. 30.-/US$ 25.00 Expil)' date ____ Date of order------ 0 Health Horizons 11996 subscription! 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