MEDICAL GAZETTE
THE INDIAN
438
[Sep*., 1944
Public Health Section LEPROSY CONTROL WITH PARTICULAR REFERENCE TO THE MADRAS PRESIDENCY
By R. G. COCHRANE,
m.d.
(Glas.),
d.t.m.&h. (Eng.)
m.r.c.p.
(Lond.),
Chief Medical Officer, Lady Willingdon Leprosy Sanatorium; Physician-in-charge, Leprosy Department, General Hospital, Madras
Introduction '
There
time
when tuberculosis was and the unfortunate victim was ashamed of his affliction. Consumption somehow cast a stigma upon its victim. The social background was little understood and the public thought that people suffering from consumption were somehow blameworthy '
regarded
was a
as a
disgrace
(Clarke, 1933).
An article on the control of leprosy could not better than with the above quotation. Syphilis, tuberculosis and leprosy are the three diseases which for many decades have been under a social stigma, and of these diseases leprosy least deserves the opprobrium which has been showered upon it. Therefore, before considering the question of the prevention of leprosy, it would not be out of place to make a plea that medical men in their speaking and thinking should adopt the recommendation of the leprosy conference held at Manila in 1931 ' and drop the word leper' from their vocabuthis I stress lary. particularly for it is not the patients against whom we are fighting but the disease. Leprosy, as far as public health is concerned, is primarily a medical and preventive problem and secondarily a social one. There is the social aspect of the leprosy just as there is the social aspect of infantile paralysis, rheumatoid arthritis, or any disease or condition which produces deformity or disfigurement, but there is no reason why a word should be used which carries with it the taint of disgrace. A is now seen in tubervery different outlook ' has largely word the and consumptive' culosis, disappeared from medical literature. In general, a patient is described as suffering from a certain disease, and a noun is not used descriptive of the patient, and therefore there is no funda' ' mental reason why the noun leper should not also be relegated to the past. The work of the past eight years has seen the completion of the preliminary steps in the organization of the campaign against leprosy in the Madras Presidency, and it is now possible to consider a more comprehensive policy which aims at setting up a system of control within the next two decades. Once leprosy .is brought under an efficient system of preventionfTihen it will only be a matter of time before tn4_msease is eliminated. Since any system established will be applicable with local modifications to commence
_
all areas, it is thought that a sketch of the suggested future developments of the leprosy campaign in Madras might make a useful contribution to leprosy control in general, and it is with this end in view that this article is
published.
It is of interest to note that the routine treatment of leprosy is now accepted by the authorities as a proper function of the general medical service of the Presidency, and that it is now agreed that if a patient has leprosy, he has as much right to receive treatment at a general hospital as has a person suffering from tuberculosis, cancer or syphilis. Therefore, at all Government and Mission hospitals and at Local Fund dispensaries, treatment for leprosy should be available. If the number of cases warrants it, a special clinic should be organized, but all clinics which are primarily for the routine treatment of the disease, should be, and in Madras generally speaking are, under the control of the District Medical Officer (Civil Surgeon). A further advance in the preliminary organization of the leprosy campaign was made when an order from the Surgeon-General's department was issued making it incumbent upon all district hospitals to admit patients suffering from leprosy who require immediate medical or surgical treatment, either for diseases other than leprosy or for acute complications due to leprosy. It is advised that these patients should be admitted into the septic or infectious diseases wards if infective or septic, and into the ordinary wards if not infective. Another milestone towards the establishment of an adequate anti-leprosy campaign was passed when a special leprosy department was organized in the General Hospital, Madras. Similar departments are under organization in the other teaching hospitals of the Presidency. Special leprosy investigation units have been developed in the Presidency, which cover urban, rural and child leprosy, and research work is being continuously undertaken at the Lady Willingdon Leprosy Sanatorium in co-operation with the King Institute, Guindy, and the pathological department of the Medical College, Madras. Post-graduate courses of 14 days' duration are organized, but the experience of the past six years indicates that this is too short a
period.
It is
our firm belief that leprosy can be controlled, but adequate finance and a properly equipped and sufficient medical personnel must be available. This fundamental point will be repeatedly emphasized, since half-hearted measures are of little value in dealing with the leprosy problem. In the past, the building of a few institutions, with emphasis on the philanthropic and social side of leprosy, and the establishment of out-patient centres were
LEPROSY CONTROL
Sept., 1944]
considered sufficient. An age-long problem such as
leprosy
the attention of the best qualified in the profession, and an expenditure of money which will reach many lacs. All this means that in future leprosy workers must be paid salaries comparable to other research workers, and doctors of similar grade of training and experience. It has been realized for some time and was strongly emphasized in ' The report on leprosy and its control' (Central Advisory Board of Health, 1942) that leprosy cannot be controlled by treatment. Therefore, treatment will play only a limited part in the campaign, and thus it will be understood that a leprosy policy based mainly on the establishment of out-patient centres can never be successful. It should be stated, lest the position be misunderstood, that treatment is of value for three reasons :? (?) In certain types, especially the early lepromatous variety, it is believed that not only is treatment beneficial, but all the evidence at present available indicates that the earlier and the more intensive the treatment the greater is the chance of recovery. (?) By making treatment available, patients are more ready to submit to the necessary preventive measures. (c) Many cases can only be kept under observation by regularly attending a treatment centre.
demands^
The
anti-leprosy
scheme
With these
introductory remarks we are now m a position to discuss the measures which should be adopted in any comprehensive antileprosy scheme ; these will be briefly considered under the following heads :? (1) Institutions. (2) Teaching. (3) Survey. (4) Rural leprosy. (5) Urban leprosy. (6) General hospitals and out-patient clinics. (7) Children's sanatoria. (8) Deformed and derelict
(9) (10) (11) (12)
cases.
Beggar problem. Research. Propaganda.
Place
of
voluntary organizations
in the anti-
leprosy campaign. (13) Legal measures. (14) Conclusion.
Institutions The question of the
place
of institutions in
the anti-leprosy campaign is discussed first, because without adequate institutional accommodation a complete anti-leprosy system is impossible to organize. The approach to this aspect of prophylaxis may be best illustrated by particular reference to the Madras Presidency, remembering that while principles re-
main, it is details ^he principles into on
different
factors.
which modify the putting of action. These details depend environmental, social and other
:
COCHRANE
As far
439 be
ascertained at present, endemic disease in the districts of the Presidency: Chingleput, North and South Arcot, Trichinopoly, Vizagapatam, East and West Godavari, Salem and Malabar. It is our firm belief that the aim should be to establish a leprosy institution for the treatment and segregation of open cases in all districts where leprosy is found to be a serious disease. While it may be impossible to cope with all cases which present themselves for treatment, it is undoubtedly preferable to isolate as many infective cases of leprosy as possible in institutions, for this is the most effective form of isolation. Further, as far as possible, admission to institutions should be confined to cases in the following categories :? 1. Early lepromatous cases (infective) who are liable to pass on to the more advanced stage unless given institutional treatment. 2. Infective cases whether early or late in whose
leprosy is following
3.
as
an
can
important
house there are young children liable to be infected. Acute conditions needing hospitalization might be admitted temporarily when there is a bed available, or if the patient is unable to go to a
general hospital.
4.
All active closed.
cases
among children whether open or
At present there are institutions in Chingleput, South Arcot, Vizagapatam, East and West Godavari, and Malabar. Therefore, with the
consent of the managing body of the existing institutions, which is generally the Mission to Lepers, steps should be taken to enlarge, and where necessary modernize, the institutions in the above districts, and new institutions should be considered for North Arcot, Trichinopoly and Salem districts. While it is accepted that institutions alone will not solve the problem, yet without institutions the leprosy campaign in a district is liable to be ill-balanced. Therefore,
institutions should be available for isolation of those cases which voluntarily present themselves for segregation. District survey officers should keep in close touch with these institutions so that they may be familiar with the practical methods of leprosy, diagnosis and treatment. Plans for these institutions, and new institutions .for North Arcot, Salem and Trichinopoly should be devised, so that they will each accommodate 300 to 400 patients and have the necessary medical and nursing facilities. At least two doctors would be required, and a reasonably wellequipped hospital should be part of these institutions. Occupational therapy such as weaving, carpentry, etc., should be available, with an adequate amount of land for agricultural purposes. Where there is an institution already in the district, it should, if possible, be brought up to the necessary standard of efficiency rather than an entirely new institution established. In addition, the Lady Willingdon Leprosy Sanatorium should be so developed that it could adequately fulfil its function of being the centre of the provincial leprosy campaign and the pre-
mier institution in the
Presidency. Details of
440
THE INDIAN MEDICAL GAZETTE
these developments need not be specified, but should include better facilities for post-graduate work and hostel accommodation for post-graduate students. No scheme of leprosy control is likely to succeed unless one of the institutions in the province is developed to such an extent that all aspects of research, treatment and training can be adequately covered and coordinated in it.
Teaching The place of teaching in the leprosy campaign is discussed now, because the greatest barrier to progress is the lack of realization among the medical profession that leprosy is first a medical problem and secondarily a social one. Until leprosy is given its right place in the thinking of all medical men, especially of administrative public health officers, little headway will be made. There is a considerable fear that in plans for post-war reconstruction, leprosy control will be given cursory attention, for often those who plan for medical developments, relief and research are not themselves familiar with modern thought on leprosy, and their thinking is to a great extent influenced by their contemplation of leprosy as a beggar problem and a social problem. The teaching of the subject of leprosy, therefore, should be -placed on an adequate footing. It can be stated that, except perhaps in the Madras medical colleges, nowhere is the importance of leprosy stressed. The teaching is usually a part of dermatology, and is left to a person who may be enthusiastic, but who neither from experience nor qualification is able to give that prestige to a subject which would ensure the interest and attention of the students. While a beginning has been made in Madras, it is impossible to do justice to the teaching of leprosy in the three medical colleges if one person is responsible for the organization of the whole work. Therefore, every medical college in areas where leprosy is an important endemic disease should have a separate leprosy department in the charge of a physician who has higher medical qualifications. The department should work in close association with that of dermatology, but leprosy should not be considered merely as part of dermatology, for then it would be given scant attention. Where leprosy is not an important disease in a province, then leprosy can be considered along with dermatology, but the lecturer should himself have taken an advanced course in training. The prevailing opinion that a fortnight's course in leprosy qualifies a person to become a leprosy expert should not be encouraged. A disease which has baffled mankind for centuries cannot be mastered in 14 days ! Post-graduate teaching in leprosy should cover the following courses :?(1) Elementary, (2) Advanced, (3) Refresher, (4) Specialist. (1) Elementary courses.?These need not be for more than 14 days' duration and all practitionerVshould be encouraged to take at least this course. (2) Advanced courses.?These should be open to all who have taken the elementary course and wish to
[Sept.,
1944
fuller acquaintance with the subject, and should month's duration. All persons in charge of out-patient leprosy work should be encouraged to take this course as a very minimum. (3) Refresher courses.?These should be for senior medical officers, health officers and school of medical officers and of 10 days' duration. The object of such an abridged course is not to train specialists, but to give district medical officers and those in administrative position up-to-date information so that they may be able to take a greater interest in the treatment and prevention of leprosy. Too often a leprosy clinic is established and a junior doctor is placed in charge, and the medical head of the district is unable to encourage or help because he knows very little about the subject. If such refresher courses as indicated were available, the doctor in charge of routine treatment of leprosy would receive encouragement and help, and leprosy treatment would become an integral part of the outpatient department of a district hospital, and not relegated to a shed in the back of the compound and given the minimum and scantiest attention. Health officers should be encouraged to take this course, so that the3r too may be in a better position to co-operate in any leprosy campaign. (4) Specialist courses.?These should be for those who intend to specialize in leprosy and should be of 6 months' duration_ covering all aspects of the problem including the practical working and management of an institution. Such a comprehensive course should be taken by those who are in charge of leprosy institutions, survey units, teaching departments and any special investigation units. Only thus will men of adequate calibre be attracted.
have be
a
of a
Survey Muir
(1931)
many years ago stressed the necessity for survey units and developed the idea of propaganda, treatment survey parties. Since then widespread sample surveys have been conducted. In this connection the excellent work of Santra should be mentioned. While in the development of an anti-leprosy campaign survey is essential, the days for sample surveys, as far as the Madras Presidency is concerned, have passed. It is felt that no survey should be undertaken unless it has one of three objects in view : (1) as a basis for the organization of a preventive unit ; (2) in order to ascertain whether leprosy is a serious disease in a given area ; (3) to ascertain whether leprosy is diminishing or not in an area as a result of preventive measures. Type 1 (Lowe et al., 1941) survey should be undertaken as a preliminary survey in fulfilment of the first two objects. Where a complete epidemiological survey or a follow-up survey is contemplated at least a type 2 survey should be undertaken, but preferably type 3. The following points should be stressed ,in~the preliminary survey : (1) gross incidence; (2) child incidence; (3) child rate; (4) (vide infra). It is believed open case rate that a comparison of these figures will give a very fair idea as to whether leprosy is a serious endemic disease or not. In addition, careful attention should be paid to the percentage of cases in the various age groups, as we believe that an increase in the percentage of cases arising in the. higher age group (15 to 34, 34 and above) indicates a satisfactory state and a tendency for the epidemic of leprosy to come under control. As stated elsewhere, it is our
LEPROSY CONTROL
Sept., 1944]
belief that the epidemic of leprosy cannot be maintained in the absence of child infection
(Cochrane, 1943).
In building survey units should consist (1) A doctor, methods.
up
an
would of the
several The staff minimum :?
anti-leprosy system, be
necessary.
following
as a
adequately trained in modern leprosy
(2) A clerk. (3) A lady worker, preferably an elderly lady, or if possible and suitable the wife of one of the members of the unit. (Santra who has had a great deal of experience in survey lays much stress on the necessity for a woman worker.) (4) A peon.
The doctor in
should have the
charge
of
necessary
the
survey party to under-
apparatus
take smear examinations and when necessary examine suspicious open cases, taking all slides back to headquarters, carefully numbering them for examination. One or more survey units should be organized in each district where leprosy is prevalent. Survey parties should not be sent out in a haphazard fashion, but only on reasonable evidence that leprosy may be a prevalent disease in a given area. All survey findings should be scrutinized by a specially trained officer, preferably the director of the leprosy campaign, who would decide whether active measures need be taken in a given district. Rural
leprosy
It is our firm conviction that leprosy can only be dealt with in rural districts by the establishment of rural units ; these would correspond to the regional leprosaria which were established so successfully in the Philippine Islands. ' It is no use adopting an attitude, as is sometimes done, that isolation in India is impracticable and therefore other methods must be used. There is no other method which will replace isolation. What has to be done is to evolve methods of isolation which are suitable to Indian conditions With this statement in the Report of Leprosy and its Control in India we entirely agree, ft can further be pointed out that isolation has hitherto been considered impracticable because, when authorities look at the problem in the mass, the size of it overwhelms them, and there is a general feeling of despair. If, however, it is realized that even in a highly endemic Presidency such as Madras, there are only certain areas where the disease is of such prevalence that active measures need be taken, and even in these areas there are only certain groups of villages where a segregation unit need be organized, then the question of isolation becomes a more reasonable proposition. As a result of the work of survey units, villages will be gradually discovered where measures need to be taken and an effective preventive scheme will slowly be evolved. Several methods of rural isolation have been suggested, but all such methods should have the aim of discovering the minimum amount of segregation necessary to control the disease. Ninety per cent of
:
COCHRANE
441
persons in many rural areas are agriculturists who spend the greater part of the day in the fields, and so it may be that if measures are enforced to provide for night segregation, and thus keep infective cases away from their children at night, this one measure alone might reduce the chances of infection sufficiently for it to be increasingly difficult for the disease to spread. It might be helpful to describe briefly the rural leprosy prevention unit, organized in the Chingleput district, 23 miles south of Chingle-
put. The staff consists of (1)
(3) nursing orderly, (4)
doctor, (2) compounder, gardener. Each member of
the staff has a house at the centre and in addition there are the following buildings : (1) treatment clinic, (2) guest house, (3) laboratory, (4) store-room, and water tower which supplies the laboratory with running water.
On the other side of the road 6 cottages are built for night segregation of infective cases and in this area there is a well for the patients' use. Patients are given a i measure of rice a day and are required to come to the huts after their evening meal. It is granted that it may be unsatisfactory for patients to take their evening meal with the family and only later come for segregation, but after the war, if considered necessary, arrangements will be made for cooking or for the supplying of cooked food. If leprosy can be controlled by this amount of segregation, then the method has the merit of simplicity, for total segregation would necessarily involve compensation of the person segregated if he were the wage earner of the family.
Experimental rural units should be established, and as the most practical and efficacious method of rural segregation is discovered, these units could be gradually extended until the need of all rural areas where leprosy is a serious endemic disease has been met. Urban
leprosy
Urban leprosy is a more difficult problem than rural leprosy because of the difficulty of enforcing segregation. There are only two possible methods of urban segregation : (a) home isolation and (b) institutional isolation. If every open case would adopt the following precautions then much would be achieved in the control of the disease :? (a) Sleep in a separate room, taking care to sleep apart from children.
(b) Bedding, eating and cooking utensils to be kept apart. (c) Personal clothing, bed clothes, towels, etc., to be soaked in antiseptic solution before washing, or preferably washed apart from the family clothes. (d) The patient to have his own chair or mat, and not come in close contact with children.
While it is recognized that such precautions to be remay be difficult to maintain, yet it.is membered that leprosy is not solely a disease of the poor, and, therefore, if practitioners were properly instructed and health authorities sufficiently zealous, it should be possible by such means in more well-to-do areas,"to accomplish a great deal towards the control of leprosy in urban districts. It cannot be too strongly stressed that just as in rural leprosy, so in urban leprosy, the disease cannot be controlled except
THE INDIAN MEDICAL GAZETTE
442
by segregation. Because home segregation is impossible, except for those with sufficient means, the only alternative is institutional con-
trol of all infective cases who will not or cannot isolate themselves in their own homes. Therefore, in every town where leprosy is a serious endemic disease, the municipalities, aided by Government, should actively consider the question of building a leprosy institution to care for infective cases. There is no other way in which this problem can be solved, and the sooner this is realized, the quicker will money be forthcoming for such work, and the nearer the day when leprosy will be controlled. It should be said, however, that before any institution is organized a systematic investigation into leprosy in the urban area in question should be undertaken. Leprosy is not found uniformly throughout a town, but there are certain areas where there are higher incidences than others, and a survey unit should be established whose object would be to discover where the greatest concentration of cases is to be found. This means both extensive and intensive survey. Once the need for an institution is demonstrated, then the headquarters of the urban campaign should be at the institution established for the town, and the doctor in charge of the urban investigation should be actively associated with the institution, for it is a bad principle to dissociate field and survey officers completely from institutional experience and practice. General
hospitals
and
out-patient
clinics
It has already been stressed that a person with leprosy has as much a right to receive treatment at a general hospital as a person with tuberculosis, syphilis or cancer. If the policy is accepted that all cases of leprosy suffering from acute medical or surgical conditions either due to leprosy, or to some other concomitant disease, can be admitted into a general hospital, then it would be considerably easier to develop rural centres, for if a patient in a centre needed active medical or surgical care the headquarters' hospital in the district could deal with such a situation, and it would not be necessary to overcrowd an existing leprosy institution. Similarly, while out-patient work must be part of all leprosy institutions, the fact remains that treatment should be available at all hospitals and dispensaries in a district, for again, while specialization is necessary, the ordinary general practitioner, whether in a hospital or in private work, ought to be prepared effectively to deal with cases which present themselves for treatment.
Children's sanatoria No anti-leprosy project is likely to succeed unless the question of child leprosy isvactively considered. It has been emphasized that leprosy is largely a children's disease and, therefore,
[Sept., 1944
child investigation is of the utmost importance. As far as is known, the Silver Jubilee Clinic for the study of child leprosy is the only institution of its kind, and it is realized that to develop such an institution the situation must be unique, as it is in Saidapet (near Madras). It would only be profitable to consider such an institution if the number of child cases in a given area is sufficiently large, and follow-up work and repeated observation of cases is possible. Nevertheless the fact remains that the child with infective leprosy cannot be isolated under home conditions, and, therefore, the whole question of children's sanatoria for such cases must be carefully considered. These sanatoria should either be attached to existing institutions, or be specially developed?e.g. The Ettapur Children's Leprosy Sanatorium, Salem District. Whether these are separate or attached to existing institutions, they should, for all practical purposes, be separate units, with their own plans for occupational therapy, planned school curriculum, etc. The observation of child contacts of open cases is particularly important. This would normally be done in all rural units. The doctor in charge would see that all contacts, particularly children, are examined either through periodic survey or by making special arrangements. It appears that the chief type of cases in children which need to be kept under observation is ' simple macular' leprosy and the vague
hypopigmented (incipient lesion) macule
which has the appearance and distribution of lepromatous leprosy but is negative to bacteriological examination. Owing to the objection raised to the term incipient it might be better to style these lesions prelepromatous. Prelepromatous macules, we are of opinion, occasionadults but such lesions are more correctly ally occur in ' designated suspicious' for no definite diagnosis can be made without cardinal signs. We have seen at least one adult with such vague lesions develop into lepromatous
leprosy.
It is our opinion that most neural cases remain neural and seldom develop leproma, and that leproma arises either from the simple macule or from these so-called prelepromatous macules. We have not seen leproma ever commence as leproma. The views Dharmendra and Sen (1943) have expressed in a recent article have been ours for a long time, except that we believe that if the previous history of the cases which, he claims, start as leproma could be ascertained then it would be discovered that lepromatous leprosy is ' preceded by the prelepromatous maculeThese are points important in the control of leprosy, because it is the lack of knowledge or inability to recognize these lesions that results in these potentially lepromatous cases developing unknown to those responsible for leprosy control, and thus becoming potent sources of infection. Patients with the yet unplaced ' intermediate lesions' should generally be isolated as they are
usually positive.
Any follow-up system should bear in mind the need to keep track of discharged cases. This should ordinarily be done through the district health officer and local sanitary inspector, who should be given a list of all cases discharged from institutions.
Sept., 1944]
LEPROSY CONTROL: COCHRANE
Deformed and derelict cases This aspect of the leprosy problem falls under two heads :? (a) Those who have become derelict through failure in treatment. (b) The persons who beg because their deformities are a possible source of income. It is recognized that even with modern methods of treatment, 60 to 85 per cent of all persons who suffer from lepromatous leprosy do not recover sufficiently for them to return to work, and the great majority of these remain infective. It may be said with regard to advanced cases that the medical profession has little appreciation of the difficulty of caring for these, particularly the advanced lepromatous patients who may be blind, badly ulcerated and crippled. These cases not only present a very difficult problem in nursing, but they usually remain infective all their days. The still commonly accepted opinion that the average life of a lepromatous case is 10 years needs to be revised. In fact it is our belief that lepromatous leprosy does not unduly shorten life, and the expectation of life is frequently almost as high as that for the country in general. If this then be the case, the time has come to consider the question of infirmaries for such cases. All institutions for the isolation of leprosy should include in their plan an infirmary section. The nursing and care of the advanced case is a constant tax on the staff of the institution. These infirmaries should be separate from the main institution, but should be an integral part of it, and special arrangements made to facilitate the nursing of such cases ; a suitable staff ^nd equipment should be provided for the care of the bed-ridden. In such infirmaries, proper bathing, cooking and toilet facilities should be available. Apart from the humanitarian side of the work, there is a great deal of investigation yet to be done in advanced leprosy. The arrangements for caring for the deformed and advanced case lag far behind the need, and no modern state should tolerate the position now seen in this country.
The
Beggar problem beggar with leprosy should
not be specifor discriminate treatment. This situation can only be met by approaching the problem of mendicancy as a whole. This is largely an urban problem which has never been taken up in a comprehensive manner. As far as possible, beggars should not be treated as criminals. Where there is evidence that an individual or individuals are making their livelihood out of this unfortunate class of person, then they should be severely punished. Arrangements should be made for the care and permanent housing of all persons whose economic condition is such that they cannot maintain themselves without resource to begging. ?Such institutions should be staffed and managed
ally selected
443
a philanthropic organization which is experienced in this work. If facilities for the voluntary care of such persons are available, then all those who refuse to isolate themselves in such homes, or escape, should then be treated as trespassers against the law and be incarcerated in a prison. In these beggar homes, facilities should be given for the separation of infective cases of leprosy, but no person with leprosy who is non-infectious need be specially separated from the general class of beggars. With regard to the person with deformity, whether he is in an establishment for beggars or in the infirmary of a leprosy sanatorium, the question of occupational therapy should be actively considered, and where persons are ablebodied and unable to be reabsorbed into society after discharge, it might be well to consider, in the tuberculosis authorities, co-operation with ' the question of after-care' colonies.
by
Research
Leprosy research to date has been confined chiefly to. the School of Tropical Medicine, Calcutta, where the leprosy department has led the way in leprosy research in India and the world. As far as possible, leprosy research is carried out in Madras, but the research programme is handicapped by lack of sufficient staff and has to be pursued in conjunction with the management and direction of the several units involved in the gradual building up of a leprosy campaign. Many of the researches are undertaken in co-operation with the King Institute, Guindy, and the pathological department of the Government General Hospital, Madras. No leprosy campaign is likely to succeed unless research units with their own personnel are established, and these should work in co-operation with the proposed All-India Institute for Leprosy Research, with the leprosy departments of the teaching hospitals, the King Institute, Guindy, the Silver Jubilee Children's Clinic, Saidapet, and the Lady Willingdon Leprosy Sanatorium. Thus co-ordinated, research on a more comprehensive scale could be undertaken. Propaganda A great deal has been said about propaganda in leprosy. This actually is one of the hardest tasks, for it is very difficult in all propaganda not to give the impression that treatment is the essential measure. Propaganda material must be very carefully sifted and selected so that all publications have the same objects which are (1) to overcome the fear, of leprosy ; (2) to emphasize, as in tuberculosis, cancer, etc., that early diagnosis is essential ; (3) to impress on the public that all leprosy is not serious; (4) to emphasize that there are three main types of leprosy from the propaganda point of view : (a) infective, (b) mutilating, (c) mild innocuous and generally abortive ; (5).to stress the importance of preventing children from coming into contact with leprosy.
THE INDIAN MEDICAL GAZETTE
444 The
should then be taught that there is to prevent leprosy and that is to insist that any case which is open or infective should not be permitted to come into close contact with children. It should be remembered that the educated public, not forgetting the medical profession, should be the first to receive attention. Sets of lantern slides, provided they are not based on before and after treatment photographs, are very useful, and a new setting for the leprosy film more in keeping with modern ideas might be considered by the Central Government.
only
public
one way
Place of voluntary organizations in the anti-
leprosy campaign While the control and eradication of leprosy is an inescapable duty of the Government, and nothing should be contemplated which does not emphasize this fundamental principle, the help of voluntary organizations, especially in connection with caring for the advanced and crippled cases, should not be forgotten. In this connection the pioneer work of. the Mission to Lepers should be borne in mind, and wherever possible, and if mutually agreeable, their cooperation should be actively sought. As an initial step it is probably true to say that, in the first instance, in the organizing of the campaign, a medical mission's active support and help is most valuable, but unless the leprosy campaign is developed on the principle that the whole must ultimately be directed by an adequately trained and remunerated officer in Government employment, continuity is likely to be lacking, and the campaign may fail owing to insufficient official interest and support. By official interest is meant every state medical organization including the medical and health services, and the official teaching units in the province. Thus and thus only will leprosy come within the purview- of all senior administrative officers. Then civil surgeons, professors of the medical colleges and central and local health officers will all combine in a united and comprehensive leprosy control system.
Legal measures past two decades,
there has been to the matter of compulsion in the developing of antileprosy measures. In this connection, two fundamental principles should be borne in mind. First, any measures of compulsion which encourages concealment of the disease defeats its
During
a
the
great deal of controversy with regard
purpose. Therefore, any widespread ^compulsory measures, unrelated either to available accommodation or to areas of high incidence of leprosy, will never succeed and cannot therefore be considered. However, some steps must be taken to compel the open case to isolate himself if he refuses to do so when proyisipn for such isolation is available. With this_end in view, the Madras Public Health Act with regard to leprosy is under modification. Leprosy in own
[Sept.,
1944
the present Act is a notifiable disease aild any one who moves in the public or exposes himself in the street can be warned by a health officer, and if he continues to mix with healthy members he can be forced into isolation. In addition, various restrictions can be imposed .with regard to cases of leprosy travelling in conveyances or indulging in trades. No distinction, however, is made between open and closed leprosy. It has, therefore, been proposed that the Act be amended as far as leprosy is concerned to read :? ' A local authority may, and if so required by the Government shall, make such arrangements in its local areas as may be directed by the Government for? (?) the free diagnosis and treatment of
persons suffering, or suspected to suffer, from leprosy. (?) the prevention of infection from leprosy '. Certain occupations are prohibited to persons suffering from leprosy. In addition to the above general measures, if found necessary, provision' ' is made for declaring any area a Special Area ' or a In the former inSegregation Area stance, regulations would be laid down prohibiting open cases from travelling in public conveyance, or in other ways coming into close contact with the public ; in the latter instance, where there are facilities for segregation, such as at a leprosy rural prevention unit, persons who persistently refuse to segregate themselves and thereby are likely to jeopardize the whole scheme would be forced to isolate themselves in the segregation unit. While uncontrolled compulsory measures are bound to fail, it may be found practicable to. enforce compulsory measures in local areas where there is an adequate segregation scheme. Ultimately the person who persistently refuses to come under isolation in an area where leprosy is an important endemic disease must be dealt with by methods of compulsion. This does no harm provided that (a) there are facilities for segregation and that the segregation area is near to his village, and (6) and compulsory measures are used only in cases of emergency and not applied generally. Voluntary segregation should be the main method, but where this fails it is legitimate to apply compulsion. It is hoped that as soon as the amended Act is on the Statute Book, four villages in that area which the present rural centre serves will be declared Segregation Areas within the meaning of the Act, and this will then give an opportunity of demonstrating whether a limited amount of compulsion will achieve its object. Once a method of prevention is discovered which can be applied to a rural area, this method can gradually be extended to other rural areas where it has been shown that leprosy is a serious endemic disease. The merit of the amended Act lies' in the. fact that prohibitive measures are only enforced where these are considered practical, and that
CURRENT TOPICS
Sept., 1944]
coercive measures are put into force except the recommendation of the director of health who would ordinarily seek the advice of an expert on the subject." In this connection it might be mentioned that a general rule prohibiting railway travel is not advised because this only penalizes the badly deformed and often less infective cases, whereas the better-to-do, less obvious, but often more infective case is allowed to travel without let or hindrance. The axiom that preventive measures must keep pace with facilities for segregating cases cannot be too strongly reiterated ; otherwise widespread compulsory regulations without the means to enforce them will prove irksome and will hinder rather than help the development of an anti-leprosy c.ampaign. no
oil
445
lead the way to the conquest of a disease which, if not of great economic importance, yet results in more misery to the lives and souls of men than almost any other disease known to mankind. REFERENCES Central Advisory Board Govt, of of Health, India (1942).
Clarke, W. (1933) Cochrane, R. G. (1943). ..
Dharmendra N. (1943).
and
Sen,
Lowe, J., Dharmendra, and Santra, I. (1941).
Conclusion It will be realized that in the development of such a campaign as indicated the right type of personnel is the first prerequisite. No leprosy campaign, which will of necessity take many years to organize, can be successfully pursued unless it is under the direction of an officer who will be able to control the whole development from its inception to its final completion. Therefore, provincial authorities who contemplate an adequate system of control should be prepared to appoint a medical man, young but of sufficient training, educational calibre and prestige, who will command the respect of the whole profession. This officer should have the qualifications and standing of a senior administrative health officer, and be remunerated accordingly. The first essential then is to recruit and train sueli an officer and place him in charge as director of the leprosy campaign. This officer should, if possible, be attached to, or be able to work in, an institution, and would also be responsible for the organization of the teaching of leprosy in the medical colleges. It is not feasible to detail the other staff necessary, such as district officers, officers in charge of survey units, etc.; these needs would arise as the campaign developed. If officers of the right type were trained to develop the campaign, and encouragement were given to medical men to take up leprosy work, it would not be. long before an efficient leprosy cadre would be recruited to carry on the campaign. Once it is realized that leprosy is "worthy, of the attention of the best trained men, and these men are adequately remunerated, the prevailing belief that leprosy is not of sufficient interest to warrant the time of a highly qualified doctor will be dispelled. It is hoped that this contribution will assist all authorities considering schemes for post-war reconstruction, and that leprosy in the years to come will receive increasing attention, so that a problem which has baffled mankind for centuries will be tackled with determination, and the work attract the best minds of the profession. Thus, and thus only, will the prevailing apathy be dispelled, and this land
Muir. E. (1931)
..
Leprosy and Its in India, 1941. Manager, Govt, of India Press, New Delhi. Amer. J. Syph., 17, 1. Epidemiology,Pathology and Diagnosis of Child Leprosy. Supdt., Govt. Press, Madras. Leprosy in India, 15, 105. Report
on
Control
Report
of Leprosy Survey
Sub-Committee the of Indian Research Fund Association. Secretary, Indian Research Fund Association, New Delhi. Leprosy in India, 3, 50.
The Report of the International Congress of Leprosy (Cairo, 1938) defines the following terms:? (1) The gross incidence of leprosy is the number of cases of leprosy per thousand of the total population.
rate is the number of child cases per hundred cases of leprosy. (3) The open case rate is the number of open cases per hundred cases of leprosy.
(2) The child
S
THE INDIAN
438
[Sep*., 1944
Public Health Section LEPROSY CONTROL WITH PARTICULAR REFERENCE TO THE MADRAS PRESIDENCY
By R. G. COCHRANE,
m.d.
(Glas.),
d.t.m.&h. (Eng.)
m.r.c.p.
(Lond.),
Chief Medical Officer, Lady Willingdon Leprosy Sanatorium; Physician-in-charge, Leprosy Department, General Hospital, Madras
Introduction '
There
time
when tuberculosis was and the unfortunate victim was ashamed of his affliction. Consumption somehow cast a stigma upon its victim. The social background was little understood and the public thought that people suffering from consumption were somehow blameworthy '
regarded
was a
as a
disgrace
(Clarke, 1933).
An article on the control of leprosy could not better than with the above quotation. Syphilis, tuberculosis and leprosy are the three diseases which for many decades have been under a social stigma, and of these diseases leprosy least deserves the opprobrium which has been showered upon it. Therefore, before considering the question of the prevention of leprosy, it would not be out of place to make a plea that medical men in their speaking and thinking should adopt the recommendation of the leprosy conference held at Manila in 1931 ' and drop the word leper' from their vocabuthis I stress lary. particularly for it is not the patients against whom we are fighting but the disease. Leprosy, as far as public health is concerned, is primarily a medical and preventive problem and secondarily a social one. There is the social aspect of the leprosy just as there is the social aspect of infantile paralysis, rheumatoid arthritis, or any disease or condition which produces deformity or disfigurement, but there is no reason why a word should be used which carries with it the taint of disgrace. A is now seen in tubervery different outlook ' has largely word the and consumptive' culosis, disappeared from medical literature. In general, a patient is described as suffering from a certain disease, and a noun is not used descriptive of the patient, and therefore there is no funda' ' mental reason why the noun leper should not also be relegated to the past. The work of the past eight years has seen the completion of the preliminary steps in the organization of the campaign against leprosy in the Madras Presidency, and it is now possible to consider a more comprehensive policy which aims at setting up a system of control within the next two decades. Once leprosy .is brought under an efficient system of preventionfTihen it will only be a matter of time before tn4_msease is eliminated. Since any system established will be applicable with local modifications to commence
_
all areas, it is thought that a sketch of the suggested future developments of the leprosy campaign in Madras might make a useful contribution to leprosy control in general, and it is with this end in view that this article is
published.
It is of interest to note that the routine treatment of leprosy is now accepted by the authorities as a proper function of the general medical service of the Presidency, and that it is now agreed that if a patient has leprosy, he has as much right to receive treatment at a general hospital as has a person suffering from tuberculosis, cancer or syphilis. Therefore, at all Government and Mission hospitals and at Local Fund dispensaries, treatment for leprosy should be available. If the number of cases warrants it, a special clinic should be organized, but all clinics which are primarily for the routine treatment of the disease, should be, and in Madras generally speaking are, under the control of the District Medical Officer (Civil Surgeon). A further advance in the preliminary organization of the leprosy campaign was made when an order from the Surgeon-General's department was issued making it incumbent upon all district hospitals to admit patients suffering from leprosy who require immediate medical or surgical treatment, either for diseases other than leprosy or for acute complications due to leprosy. It is advised that these patients should be admitted into the septic or infectious diseases wards if infective or septic, and into the ordinary wards if not infective. Another milestone towards the establishment of an adequate anti-leprosy campaign was passed when a special leprosy department was organized in the General Hospital, Madras. Similar departments are under organization in the other teaching hospitals of the Presidency. Special leprosy investigation units have been developed in the Presidency, which cover urban, rural and child leprosy, and research work is being continuously undertaken at the Lady Willingdon Leprosy Sanatorium in co-operation with the King Institute, Guindy, and the pathological department of the Medical College, Madras. Post-graduate courses of 14 days' duration are organized, but the experience of the past six years indicates that this is too short a
period.
It is
our firm belief that leprosy can be controlled, but adequate finance and a properly equipped and sufficient medical personnel must be available. This fundamental point will be repeatedly emphasized, since half-hearted measures are of little value in dealing with the leprosy problem. In the past, the building of a few institutions, with emphasis on the philanthropic and social side of leprosy, and the establishment of out-patient centres were
LEPROSY CONTROL
Sept., 1944]
considered sufficient. An age-long problem such as
leprosy
the attention of the best qualified in the profession, and an expenditure of money which will reach many lacs. All this means that in future leprosy workers must be paid salaries comparable to other research workers, and doctors of similar grade of training and experience. It has been realized for some time and was strongly emphasized in ' The report on leprosy and its control' (Central Advisory Board of Health, 1942) that leprosy cannot be controlled by treatment. Therefore, treatment will play only a limited part in the campaign, and thus it will be understood that a leprosy policy based mainly on the establishment of out-patient centres can never be successful. It should be stated, lest the position be misunderstood, that treatment is of value for three reasons :? (?) In certain types, especially the early lepromatous variety, it is believed that not only is treatment beneficial, but all the evidence at present available indicates that the earlier and the more intensive the treatment the greater is the chance of recovery. (?) By making treatment available, patients are more ready to submit to the necessary preventive measures. (c) Many cases can only be kept under observation by regularly attending a treatment centre.
demands^
The
anti-leprosy
scheme
With these
introductory remarks we are now m a position to discuss the measures which should be adopted in any comprehensive antileprosy scheme ; these will be briefly considered under the following heads :? (1) Institutions. (2) Teaching. (3) Survey. (4) Rural leprosy. (5) Urban leprosy. (6) General hospitals and out-patient clinics. (7) Children's sanatoria. (8) Deformed and derelict
(9) (10) (11) (12)
cases.
Beggar problem. Research. Propaganda.
Place
of
voluntary organizations
in the anti-
leprosy campaign. (13) Legal measures. (14) Conclusion.
Institutions The question of the
place
of institutions in
the anti-leprosy campaign is discussed first, because without adequate institutional accommodation a complete anti-leprosy system is impossible to organize. The approach to this aspect of prophylaxis may be best illustrated by particular reference to the Madras Presidency, remembering that while principles re-
main, it is details ^he principles into on
different
factors.
which modify the putting of action. These details depend environmental, social and other
:
COCHRANE
As far
439 be
ascertained at present, endemic disease in the districts of the Presidency: Chingleput, North and South Arcot, Trichinopoly, Vizagapatam, East and West Godavari, Salem and Malabar. It is our firm belief that the aim should be to establish a leprosy institution for the treatment and segregation of open cases in all districts where leprosy is found to be a serious disease. While it may be impossible to cope with all cases which present themselves for treatment, it is undoubtedly preferable to isolate as many infective cases of leprosy as possible in institutions, for this is the most effective form of isolation. Further, as far as possible, admission to institutions should be confined to cases in the following categories :? 1. Early lepromatous cases (infective) who are liable to pass on to the more advanced stage unless given institutional treatment. 2. Infective cases whether early or late in whose
leprosy is following
3.
as
an
can
important
house there are young children liable to be infected. Acute conditions needing hospitalization might be admitted temporarily when there is a bed available, or if the patient is unable to go to a
general hospital.
4.
All active closed.
cases
among children whether open or
At present there are institutions in Chingleput, South Arcot, Vizagapatam, East and West Godavari, and Malabar. Therefore, with the
consent of the managing body of the existing institutions, which is generally the Mission to Lepers, steps should be taken to enlarge, and where necessary modernize, the institutions in the above districts, and new institutions should be considered for North Arcot, Trichinopoly and Salem districts. While it is accepted that institutions alone will not solve the problem, yet without institutions the leprosy campaign in a district is liable to be ill-balanced. Therefore,
institutions should be available for isolation of those cases which voluntarily present themselves for segregation. District survey officers should keep in close touch with these institutions so that they may be familiar with the practical methods of leprosy, diagnosis and treatment. Plans for these institutions, and new institutions .for North Arcot, Salem and Trichinopoly should be devised, so that they will each accommodate 300 to 400 patients and have the necessary medical and nursing facilities. At least two doctors would be required, and a reasonably wellequipped hospital should be part of these institutions. Occupational therapy such as weaving, carpentry, etc., should be available, with an adequate amount of land for agricultural purposes. Where there is an institution already in the district, it should, if possible, be brought up to the necessary standard of efficiency rather than an entirely new institution established. In addition, the Lady Willingdon Leprosy Sanatorium should be so developed that it could adequately fulfil its function of being the centre of the provincial leprosy campaign and the pre-
mier institution in the
Presidency. Details of
440
THE INDIAN MEDICAL GAZETTE
these developments need not be specified, but should include better facilities for post-graduate work and hostel accommodation for post-graduate students. No scheme of leprosy control is likely to succeed unless one of the institutions in the province is developed to such an extent that all aspects of research, treatment and training can be adequately covered and coordinated in it.
Teaching The place of teaching in the leprosy campaign is discussed now, because the greatest barrier to progress is the lack of realization among the medical profession that leprosy is first a medical problem and secondarily a social one. Until leprosy is given its right place in the thinking of all medical men, especially of administrative public health officers, little headway will be made. There is a considerable fear that in plans for post-war reconstruction, leprosy control will be given cursory attention, for often those who plan for medical developments, relief and research are not themselves familiar with modern thought on leprosy, and their thinking is to a great extent influenced by their contemplation of leprosy as a beggar problem and a social problem. The teaching of the subject of leprosy, therefore, should be -placed on an adequate footing. It can be stated that, except perhaps in the Madras medical colleges, nowhere is the importance of leprosy stressed. The teaching is usually a part of dermatology, and is left to a person who may be enthusiastic, but who neither from experience nor qualification is able to give that prestige to a subject which would ensure the interest and attention of the students. While a beginning has been made in Madras, it is impossible to do justice to the teaching of leprosy in the three medical colleges if one person is responsible for the organization of the whole work. Therefore, every medical college in areas where leprosy is an important endemic disease should have a separate leprosy department in the charge of a physician who has higher medical qualifications. The department should work in close association with that of dermatology, but leprosy should not be considered merely as part of dermatology, for then it would be given scant attention. Where leprosy is not an important disease in a province, then leprosy can be considered along with dermatology, but the lecturer should himself have taken an advanced course in training. The prevailing opinion that a fortnight's course in leprosy qualifies a person to become a leprosy expert should not be encouraged. A disease which has baffled mankind for centuries cannot be mastered in 14 days ! Post-graduate teaching in leprosy should cover the following courses :?(1) Elementary, (2) Advanced, (3) Refresher, (4) Specialist. (1) Elementary courses.?These need not be for more than 14 days' duration and all practitionerVshould be encouraged to take at least this course. (2) Advanced courses.?These should be open to all who have taken the elementary course and wish to
[Sept.,
1944
fuller acquaintance with the subject, and should month's duration. All persons in charge of out-patient leprosy work should be encouraged to take this course as a very minimum. (3) Refresher courses.?These should be for senior medical officers, health officers and school of medical officers and of 10 days' duration. The object of such an abridged course is not to train specialists, but to give district medical officers and those in administrative position up-to-date information so that they may be able to take a greater interest in the treatment and prevention of leprosy. Too often a leprosy clinic is established and a junior doctor is placed in charge, and the medical head of the district is unable to encourage or help because he knows very little about the subject. If such refresher courses as indicated were available, the doctor in charge of routine treatment of leprosy would receive encouragement and help, and leprosy treatment would become an integral part of the outpatient department of a district hospital, and not relegated to a shed in the back of the compound and given the minimum and scantiest attention. Health officers should be encouraged to take this course, so that the3r too may be in a better position to co-operate in any leprosy campaign. (4) Specialist courses.?These should be for those who intend to specialize in leprosy and should be of 6 months' duration_ covering all aspects of the problem including the practical working and management of an institution. Such a comprehensive course should be taken by those who are in charge of leprosy institutions, survey units, teaching departments and any special investigation units. Only thus will men of adequate calibre be attracted.
have be
a
of a
Survey Muir
(1931)
many years ago stressed the necessity for survey units and developed the idea of propaganda, treatment survey parties. Since then widespread sample surveys have been conducted. In this connection the excellent work of Santra should be mentioned. While in the development of an anti-leprosy campaign survey is essential, the days for sample surveys, as far as the Madras Presidency is concerned, have passed. It is felt that no survey should be undertaken unless it has one of three objects in view : (1) as a basis for the organization of a preventive unit ; (2) in order to ascertain whether leprosy is a serious disease in a given area ; (3) to ascertain whether leprosy is diminishing or not in an area as a result of preventive measures. Type 1 (Lowe et al., 1941) survey should be undertaken as a preliminary survey in fulfilment of the first two objects. Where a complete epidemiological survey or a follow-up survey is contemplated at least a type 2 survey should be undertaken, but preferably type 3. The following points should be stressed ,in~the preliminary survey : (1) gross incidence; (2) child incidence; (3) child rate; (4) (vide infra). It is believed open case rate that a comparison of these figures will give a very fair idea as to whether leprosy is a serious endemic disease or not. In addition, careful attention should be paid to the percentage of cases in the various age groups, as we believe that an increase in the percentage of cases arising in the. higher age group (15 to 34, 34 and above) indicates a satisfactory state and a tendency for the epidemic of leprosy to come under control. As stated elsewhere, it is our
LEPROSY CONTROL
Sept., 1944]
belief that the epidemic of leprosy cannot be maintained in the absence of child infection
(Cochrane, 1943).
In building survey units should consist (1) A doctor, methods.
up
an
would of the
several The staff minimum :?
anti-leprosy system, be
necessary.
following
as a
adequately trained in modern leprosy
(2) A clerk. (3) A lady worker, preferably an elderly lady, or if possible and suitable the wife of one of the members of the unit. (Santra who has had a great deal of experience in survey lays much stress on the necessity for a woman worker.) (4) A peon.
The doctor in
should have the
charge
of
necessary
the
survey party to under-
apparatus
take smear examinations and when necessary examine suspicious open cases, taking all slides back to headquarters, carefully numbering them for examination. One or more survey units should be organized in each district where leprosy is prevalent. Survey parties should not be sent out in a haphazard fashion, but only on reasonable evidence that leprosy may be a prevalent disease in a given area. All survey findings should be scrutinized by a specially trained officer, preferably the director of the leprosy campaign, who would decide whether active measures need be taken in a given district. Rural
leprosy
It is our firm conviction that leprosy can only be dealt with in rural districts by the establishment of rural units ; these would correspond to the regional leprosaria which were established so successfully in the Philippine Islands. ' It is no use adopting an attitude, as is sometimes done, that isolation in India is impracticable and therefore other methods must be used. There is no other method which will replace isolation. What has to be done is to evolve methods of isolation which are suitable to Indian conditions With this statement in the Report of Leprosy and its Control in India we entirely agree, ft can further be pointed out that isolation has hitherto been considered impracticable because, when authorities look at the problem in the mass, the size of it overwhelms them, and there is a general feeling of despair. If, however, it is realized that even in a highly endemic Presidency such as Madras, there are only certain areas where the disease is of such prevalence that active measures need be taken, and even in these areas there are only certain groups of villages where a segregation unit need be organized, then the question of isolation becomes a more reasonable proposition. As a result of the work of survey units, villages will be gradually discovered where measures need to be taken and an effective preventive scheme will slowly be evolved. Several methods of rural isolation have been suggested, but all such methods should have the aim of discovering the minimum amount of segregation necessary to control the disease. Ninety per cent of
:
COCHRANE
441
persons in many rural areas are agriculturists who spend the greater part of the day in the fields, and so it may be that if measures are enforced to provide for night segregation, and thus keep infective cases away from their children at night, this one measure alone might reduce the chances of infection sufficiently for it to be increasingly difficult for the disease to spread. It might be helpful to describe briefly the rural leprosy prevention unit, organized in the Chingleput district, 23 miles south of Chingle-
put. The staff consists of (1)
(3) nursing orderly, (4)
doctor, (2) compounder, gardener. Each member of
the staff has a house at the centre and in addition there are the following buildings : (1) treatment clinic, (2) guest house, (3) laboratory, (4) store-room, and water tower which supplies the laboratory with running water.
On the other side of the road 6 cottages are built for night segregation of infective cases and in this area there is a well for the patients' use. Patients are given a i measure of rice a day and are required to come to the huts after their evening meal. It is granted that it may be unsatisfactory for patients to take their evening meal with the family and only later come for segregation, but after the war, if considered necessary, arrangements will be made for cooking or for the supplying of cooked food. If leprosy can be controlled by this amount of segregation, then the method has the merit of simplicity, for total segregation would necessarily involve compensation of the person segregated if he were the wage earner of the family.
Experimental rural units should be established, and as the most practical and efficacious method of rural segregation is discovered, these units could be gradually extended until the need of all rural areas where leprosy is a serious endemic disease has been met. Urban
leprosy
Urban leprosy is a more difficult problem than rural leprosy because of the difficulty of enforcing segregation. There are only two possible methods of urban segregation : (a) home isolation and (b) institutional isolation. If every open case would adopt the following precautions then much would be achieved in the control of the disease :? (a) Sleep in a separate room, taking care to sleep apart from children.
(b) Bedding, eating and cooking utensils to be kept apart. (c) Personal clothing, bed clothes, towels, etc., to be soaked in antiseptic solution before washing, or preferably washed apart from the family clothes. (d) The patient to have his own chair or mat, and not come in close contact with children.
While it is recognized that such precautions to be remay be difficult to maintain, yet it.is membered that leprosy is not solely a disease of the poor, and, therefore, if practitioners were properly instructed and health authorities sufficiently zealous, it should be possible by such means in more well-to-do areas,"to accomplish a great deal towards the control of leprosy in urban districts. It cannot be too strongly stressed that just as in rural leprosy, so in urban leprosy, the disease cannot be controlled except
THE INDIAN MEDICAL GAZETTE
442
by segregation. Because home segregation is impossible, except for those with sufficient means, the only alternative is institutional con-
trol of all infective cases who will not or cannot isolate themselves in their own homes. Therefore, in every town where leprosy is a serious endemic disease, the municipalities, aided by Government, should actively consider the question of building a leprosy institution to care for infective cases. There is no other way in which this problem can be solved, and the sooner this is realized, the quicker will money be forthcoming for such work, and the nearer the day when leprosy will be controlled. It should be said, however, that before any institution is organized a systematic investigation into leprosy in the urban area in question should be undertaken. Leprosy is not found uniformly throughout a town, but there are certain areas where there are higher incidences than others, and a survey unit should be established whose object would be to discover where the greatest concentration of cases is to be found. This means both extensive and intensive survey. Once the need for an institution is demonstrated, then the headquarters of the urban campaign should be at the institution established for the town, and the doctor in charge of the urban investigation should be actively associated with the institution, for it is a bad principle to dissociate field and survey officers completely from institutional experience and practice. General
hospitals
and
out-patient
clinics
It has already been stressed that a person with leprosy has as much a right to receive treatment at a general hospital as a person with tuberculosis, syphilis or cancer. If the policy is accepted that all cases of leprosy suffering from acute medical or surgical conditions either due to leprosy, or to some other concomitant disease, can be admitted into a general hospital, then it would be considerably easier to develop rural centres, for if a patient in a centre needed active medical or surgical care the headquarters' hospital in the district could deal with such a situation, and it would not be necessary to overcrowd an existing leprosy institution. Similarly, while out-patient work must be part of all leprosy institutions, the fact remains that treatment should be available at all hospitals and dispensaries in a district, for again, while specialization is necessary, the ordinary general practitioner, whether in a hospital or in private work, ought to be prepared effectively to deal with cases which present themselves for treatment.
Children's sanatoria No anti-leprosy project is likely to succeed unless the question of child leprosy isvactively considered. It has been emphasized that leprosy is largely a children's disease and, therefore,
[Sept., 1944
child investigation is of the utmost importance. As far as is known, the Silver Jubilee Clinic for the study of child leprosy is the only institution of its kind, and it is realized that to develop such an institution the situation must be unique, as it is in Saidapet (near Madras). It would only be profitable to consider such an institution if the number of child cases in a given area is sufficiently large, and follow-up work and repeated observation of cases is possible. Nevertheless the fact remains that the child with infective leprosy cannot be isolated under home conditions, and, therefore, the whole question of children's sanatoria for such cases must be carefully considered. These sanatoria should either be attached to existing institutions, or be specially developed?e.g. The Ettapur Children's Leprosy Sanatorium, Salem District. Whether these are separate or attached to existing institutions, they should, for all practical purposes, be separate units, with their own plans for occupational therapy, planned school curriculum, etc. The observation of child contacts of open cases is particularly important. This would normally be done in all rural units. The doctor in charge would see that all contacts, particularly children, are examined either through periodic survey or by making special arrangements. It appears that the chief type of cases in children which need to be kept under observation is ' simple macular' leprosy and the vague
hypopigmented (incipient lesion) macule
which has the appearance and distribution of lepromatous leprosy but is negative to bacteriological examination. Owing to the objection raised to the term incipient it might be better to style these lesions prelepromatous. Prelepromatous macules, we are of opinion, occasionadults but such lesions are more correctly ally occur in ' designated suspicious' for no definite diagnosis can be made without cardinal signs. We have seen at least one adult with such vague lesions develop into lepromatous
leprosy.
It is our opinion that most neural cases remain neural and seldom develop leproma, and that leproma arises either from the simple macule or from these so-called prelepromatous macules. We have not seen leproma ever commence as leproma. The views Dharmendra and Sen (1943) have expressed in a recent article have been ours for a long time, except that we believe that if the previous history of the cases which, he claims, start as leproma could be ascertained then it would be discovered that lepromatous leprosy is ' preceded by the prelepromatous maculeThese are points important in the control of leprosy, because it is the lack of knowledge or inability to recognize these lesions that results in these potentially lepromatous cases developing unknown to those responsible for leprosy control, and thus becoming potent sources of infection. Patients with the yet unplaced ' intermediate lesions' should generally be isolated as they are
usually positive.
Any follow-up system should bear in mind the need to keep track of discharged cases. This should ordinarily be done through the district health officer and local sanitary inspector, who should be given a list of all cases discharged from institutions.
Sept., 1944]
LEPROSY CONTROL: COCHRANE
Deformed and derelict cases This aspect of the leprosy problem falls under two heads :? (a) Those who have become derelict through failure in treatment. (b) The persons who beg because their deformities are a possible source of income. It is recognized that even with modern methods of treatment, 60 to 85 per cent of all persons who suffer from lepromatous leprosy do not recover sufficiently for them to return to work, and the great majority of these remain infective. It may be said with regard to advanced cases that the medical profession has little appreciation of the difficulty of caring for these, particularly the advanced lepromatous patients who may be blind, badly ulcerated and crippled. These cases not only present a very difficult problem in nursing, but they usually remain infective all their days. The still commonly accepted opinion that the average life of a lepromatous case is 10 years needs to be revised. In fact it is our belief that lepromatous leprosy does not unduly shorten life, and the expectation of life is frequently almost as high as that for the country in general. If this then be the case, the time has come to consider the question of infirmaries for such cases. All institutions for the isolation of leprosy should include in their plan an infirmary section. The nursing and care of the advanced case is a constant tax on the staff of the institution. These infirmaries should be separate from the main institution, but should be an integral part of it, and special arrangements made to facilitate the nursing of such cases ; a suitable staff ^nd equipment should be provided for the care of the bed-ridden. In such infirmaries, proper bathing, cooking and toilet facilities should be available. Apart from the humanitarian side of the work, there is a great deal of investigation yet to be done in advanced leprosy. The arrangements for caring for the deformed and advanced case lag far behind the need, and no modern state should tolerate the position now seen in this country.
The
Beggar problem beggar with leprosy should
not be specifor discriminate treatment. This situation can only be met by approaching the problem of mendicancy as a whole. This is largely an urban problem which has never been taken up in a comprehensive manner. As far as possible, beggars should not be treated as criminals. Where there is evidence that an individual or individuals are making their livelihood out of this unfortunate class of person, then they should be severely punished. Arrangements should be made for the care and permanent housing of all persons whose economic condition is such that they cannot maintain themselves without resource to begging. ?Such institutions should be staffed and managed
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a philanthropic organization which is experienced in this work. If facilities for the voluntary care of such persons are available, then all those who refuse to isolate themselves in such homes, or escape, should then be treated as trespassers against the law and be incarcerated in a prison. In these beggar homes, facilities should be given for the separation of infective cases of leprosy, but no person with leprosy who is non-infectious need be specially separated from the general class of beggars. With regard to the person with deformity, whether he is in an establishment for beggars or in the infirmary of a leprosy sanatorium, the question of occupational therapy should be actively considered, and where persons are ablebodied and unable to be reabsorbed into society after discharge, it might be well to consider, in the tuberculosis authorities, co-operation with ' the question of after-care' colonies.
by
Research
Leprosy research to date has been confined chiefly to. the School of Tropical Medicine, Calcutta, where the leprosy department has led the way in leprosy research in India and the world. As far as possible, leprosy research is carried out in Madras, but the research programme is handicapped by lack of sufficient staff and has to be pursued in conjunction with the management and direction of the several units involved in the gradual building up of a leprosy campaign. Many of the researches are undertaken in co-operation with the King Institute, Guindy, and the pathological department of the Government General Hospital, Madras. No leprosy campaign is likely to succeed unless research units with their own personnel are established, and these should work in co-operation with the proposed All-India Institute for Leprosy Research, with the leprosy departments of the teaching hospitals, the King Institute, Guindy, the Silver Jubilee Children's Clinic, Saidapet, and the Lady Willingdon Leprosy Sanatorium. Thus co-ordinated, research on a more comprehensive scale could be undertaken. Propaganda A great deal has been said about propaganda in leprosy. This actually is one of the hardest tasks, for it is very difficult in all propaganda not to give the impression that treatment is the essential measure. Propaganda material must be very carefully sifted and selected so that all publications have the same objects which are (1) to overcome the fear, of leprosy ; (2) to emphasize, as in tuberculosis, cancer, etc., that early diagnosis is essential ; (3) to impress on the public that all leprosy is not serious; (4) to emphasize that there are three main types of leprosy from the propaganda point of view : (a) infective, (b) mutilating, (c) mild innocuous and generally abortive ; (5).to stress the importance of preventing children from coming into contact with leprosy.
THE INDIAN MEDICAL GAZETTE
444 The
should then be taught that there is to prevent leprosy and that is to insist that any case which is open or infective should not be permitted to come into close contact with children. It should be remembered that the educated public, not forgetting the medical profession, should be the first to receive attention. Sets of lantern slides, provided they are not based on before and after treatment photographs, are very useful, and a new setting for the leprosy film more in keeping with modern ideas might be considered by the Central Government.
only
public
one way
Place of voluntary organizations in the anti-
leprosy campaign While the control and eradication of leprosy is an inescapable duty of the Government, and nothing should be contemplated which does not emphasize this fundamental principle, the help of voluntary organizations, especially in connection with caring for the advanced and crippled cases, should not be forgotten. In this connection the pioneer work of. the Mission to Lepers should be borne in mind, and wherever possible, and if mutually agreeable, their cooperation should be actively sought. As an initial step it is probably true to say that, in the first instance, in the organizing of the campaign, a medical mission's active support and help is most valuable, but unless the leprosy campaign is developed on the principle that the whole must ultimately be directed by an adequately trained and remunerated officer in Government employment, continuity is likely to be lacking, and the campaign may fail owing to insufficient official interest and support. By official interest is meant every state medical organization including the medical and health services, and the official teaching units in the province. Thus and thus only will leprosy come within the purview- of all senior administrative officers. Then civil surgeons, professors of the medical colleges and central and local health officers will all combine in a united and comprehensive leprosy control system.
Legal measures past two decades,
there has been to the matter of compulsion in the developing of antileprosy measures. In this connection, two fundamental principles should be borne in mind. First, any measures of compulsion which encourages concealment of the disease defeats its
During
a
the
great deal of controversy with regard
purpose. Therefore, any widespread ^compulsory measures, unrelated either to available accommodation or to areas of high incidence of leprosy, will never succeed and cannot therefore be considered. However, some steps must be taken to compel the open case to isolate himself if he refuses to do so when proyisipn for such isolation is available. With this_end in view, the Madras Public Health Act with regard to leprosy is under modification. Leprosy in own
[Sept.,
1944
the present Act is a notifiable disease aild any one who moves in the public or exposes himself in the street can be warned by a health officer, and if he continues to mix with healthy members he can be forced into isolation. In addition, various restrictions can be imposed .with regard to cases of leprosy travelling in conveyances or indulging in trades. No distinction, however, is made between open and closed leprosy. It has, therefore, been proposed that the Act be amended as far as leprosy is concerned to read :? ' A local authority may, and if so required by the Government shall, make such arrangements in its local areas as may be directed by the Government for? (?) the free diagnosis and treatment of
persons suffering, or suspected to suffer, from leprosy. (?) the prevention of infection from leprosy '. Certain occupations are prohibited to persons suffering from leprosy. In addition to the above general measures, if found necessary, provision' ' is made for declaring any area a Special Area ' or a In the former inSegregation Area stance, regulations would be laid down prohibiting open cases from travelling in public conveyance, or in other ways coming into close contact with the public ; in the latter instance, where there are facilities for segregation, such as at a leprosy rural prevention unit, persons who persistently refuse to segregate themselves and thereby are likely to jeopardize the whole scheme would be forced to isolate themselves in the segregation unit. While uncontrolled compulsory measures are bound to fail, it may be found practicable to. enforce compulsory measures in local areas where there is an adequate segregation scheme. Ultimately the person who persistently refuses to come under isolation in an area where leprosy is an important endemic disease must be dealt with by methods of compulsion. This does no harm provided that (a) there are facilities for segregation and that the segregation area is near to his village, and (6) and compulsory measures are used only in cases of emergency and not applied generally. Voluntary segregation should be the main method, but where this fails it is legitimate to apply compulsion. It is hoped that as soon as the amended Act is on the Statute Book, four villages in that area which the present rural centre serves will be declared Segregation Areas within the meaning of the Act, and this will then give an opportunity of demonstrating whether a limited amount of compulsion will achieve its object. Once a method of prevention is discovered which can be applied to a rural area, this method can gradually be extended to other rural areas where it has been shown that leprosy is a serious endemic disease. The merit of the amended Act lies' in the. fact that prohibitive measures are only enforced where these are considered practical, and that
CURRENT TOPICS
Sept., 1944]
coercive measures are put into force except the recommendation of the director of health who would ordinarily seek the advice of an expert on the subject." In this connection it might be mentioned that a general rule prohibiting railway travel is not advised because this only penalizes the badly deformed and often less infective cases, whereas the better-to-do, less obvious, but often more infective case is allowed to travel without let or hindrance. The axiom that preventive measures must keep pace with facilities for segregating cases cannot be too strongly reiterated ; otherwise widespread compulsory regulations without the means to enforce them will prove irksome and will hinder rather than help the development of an anti-leprosy c.ampaign. no
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lead the way to the conquest of a disease which, if not of great economic importance, yet results in more misery to the lives and souls of men than almost any other disease known to mankind. REFERENCES Central Advisory Board Govt, of of Health, India (1942).
Clarke, W. (1933) Cochrane, R. G. (1943). ..
Dharmendra N. (1943).
and
Sen,
Lowe, J., Dharmendra, and Santra, I. (1941).
Conclusion It will be realized that in the development of such a campaign as indicated the right type of personnel is the first prerequisite. No leprosy campaign, which will of necessity take many years to organize, can be successfully pursued unless it is under the direction of an officer who will be able to control the whole development from its inception to its final completion. Therefore, provincial authorities who contemplate an adequate system of control should be prepared to appoint a medical man, young but of sufficient training, educational calibre and prestige, who will command the respect of the whole profession. This officer should have the qualifications and standing of a senior administrative health officer, and be remunerated accordingly. The first essential then is to recruit and train sueli an officer and place him in charge as director of the leprosy campaign. This officer should, if possible, be attached to, or be able to work in, an institution, and would also be responsible for the organization of the teaching of leprosy in the medical colleges. It is not feasible to detail the other staff necessary, such as district officers, officers in charge of survey units, etc.; these needs would arise as the campaign developed. If officers of the right type were trained to develop the campaign, and encouragement were given to medical men to take up leprosy work, it would not be. long before an efficient leprosy cadre would be recruited to carry on the campaign. Once it is realized that leprosy is "worthy, of the attention of the best trained men, and these men are adequately remunerated, the prevailing belief that leprosy is not of sufficient interest to warrant the time of a highly qualified doctor will be dispelled. It is hoped that this contribution will assist all authorities considering schemes for post-war reconstruction, and that leprosy in the years to come will receive increasing attention, so that a problem which has baffled mankind for centuries will be tackled with determination, and the work attract the best minds of the profession. Thus, and thus only, will the prevailing apathy be dispelled, and this land
Muir. E. (1931)
..
Leprosy and Its in India, 1941. Manager, Govt, of India Press, New Delhi. Amer. J. Syph., 17, 1. Epidemiology,Pathology and Diagnosis of Child Leprosy. Supdt., Govt. Press, Madras. Leprosy in India, 15, 105. Report
on
Control
Report
of Leprosy Survey
Sub-Committee the of Indian Research Fund Association. Secretary, Indian Research Fund Association, New Delhi. Leprosy in India, 3, 50.
The Report of the International Congress of Leprosy (Cairo, 1938) defines the following terms:? (1) The gross incidence of leprosy is the number of cases of leprosy per thousand of the total population.
rate is the number of child cases per hundred cases of leprosy. (3) The open case rate is the number of open cases per hundred cases of leprosy.
(2) The child
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