Indonesia has work to do in order to further reduce its leprosy burden.
Clint Eastwood doesn't normally feature in PowerPoint presentations on leprosy, but the director of Indonesia's department of transmissible disease control used the actor's photograph recently to draw attention to the "The Good, the Bad, and the Ugly" in Indonesia's fight against the disease.
Indonesia, a sprawling archipelago of 23 4 million people, is the fourth largest country in the world in terms of population, and its people are scattered over some 12 ,000 of the country's more than 17,000 islands. These facts alone indicate the logistical challenges involved in delivering health services to every citizen, and efforts to control leprosy are no exception.
The good news is that Indonesia eliminated leprosy as a public health problem at the national level in 2000, reducing the prevalence of the disease to less than one case per 10,000 people nine years after the World Health Assembly set the target in 1991. But the bad news, said Dr. Iwan M. Muljono, is that the proportion of child cases among new cases stands at 9.6%, that of grade 2 disability at 11 .4%, while 82.2% of new cases are multibacilliary (MB).
What makes the situation ugly, he went on, is that the situation has remained static over the past decade, with little change in either the prevalence rate or the new case detection rate. Similarly, there has been no reduction in the ratios of child cases and grade 2 disability cases, while the proportion of MB cases has increased.
After India and Brazil, Indonesia reports the largest number of cases of leprosy annually. In 2008, it detected 17,243 new cases. Of its 33 provinces, 4 had over 1,000 cases each.
Of these, East Java has the highest incidence of the disease, reporting 5,083 new cases last year. In particular, the burden is heaviest in 15 districts/municipalities on the northern coast and on Madura Island. Between 1994 and 2008, a cumulative total of 78,396 people have been cured of leprosy in East Java, of whom 7,641 suffer from permanent disability.
According to the East Java health authorities, the problems the province faces include lowlevel commitment of policy makers ("leprosy is not interesting for them"), a lack of IEC activities and materials in high-prevalence areas, low involvement of public hospitals in treating leprosy and insufficient community empowerment related to social problems.
"Indonesia faces a number of challenges over leprosy," says Dr. Christina Widaningrum of the health ministry's Directorate General Disease Control and Environmental Health. "Perhaps the biggest is to develop community awareness, so that people come forward and seek treatment."