Time to focus on endemic districts, or risk losing gains that have been made.
India declared the elimination of leprosy as a public health problem by the end of 2005, indicating that prevalence of leprosy had been reduced to a national average of less than one case per 10,000 people. This meant that there were still over 100,000 cases in the country, the largest number for any country in the world.
More importantly, these cases were distributed very unevenly among the states and districts. Some areas were left with quite a high number of cases and about one third of the country's 630 districts still had prevalence levels above the elimination cut-off point of one case per 10,000 population.
Currently the leprosy situation is causing considerable concern, to the extent that the Indian Parliament is looking into the issue and has asked for a national sample survey to be undertaken to understand better the problems being faced. The survey is already under way and the results are expected during the latter half of the year. It is possible that the survey will bring out the very difficult situation being faced in certain parts of the country.
The general perception among those interested in the problem of leprosy is that there has been a perceptible decrease in political commitment as well as in the priority given to leprosy at different levels. Leadership at the state and district levels has weakened considerably and in some places it is totally absent. One misses the exemplary vigor and commitment that were very visible and characteristic of the National Leprosy Program of the 1990s and early years of the 2000s.
It is likely that at the decision-making level leprosy is no more considered important as the leprosy prevalence rate has come down to less than one case in 10,000 population, even though this is only a national average. Even worse, at some levels there is a misconception that leprosy is currently only a question of rehabilitating those who have been cured and is no more a medical problem. This can be seen by the fact that many states and a large number of districts have no full-time personnel to provide adequate leadership.
|Elimination status: states and districts|
The currently available information indicates that leprosy continues to cling to certain parts of the country, and to certain population groups, as a result of inadequate attention received and the absence of intensified activities. This is particularly true in areas where there are significant numbers of marginalized populations, particularly tribal populations
In view of the above, there is a great need to strengthen and invigorate the program to ensure adequate case finding and treatment, failing which there is every chance that the disease problem will increase. This calls for a national dialogue involving all interested parties, so that it becomes possible to have personnel responsible for leprosy at the state level in all states and full-time personnel responsible for leprosy in all districts facing challenges - with the latter provided with sufficient resources, both financial and manpower, in a flexible manner.
"More of the same" or "one size fits all" approaches are not likely to work. It will be necessary to identify problem areas and communities, analyze the specific challenges that they face and implement locally specific solutions.
The elimination of leprosy from every part of India is an eminently doable job. If anti-leprosy activities are further intensified, new case detection can come down further before it reaches a plateau of 10,000 cases a year, which is equal to a detection rate of less than one case per 100,000. The possibility of such a steep reduction has already been clearly evidenced in countries as varied as China, Vietnam, Thailand and Uganda.
But we need to mobilize all the necessary ingredients, including political commitment. If timely action is not taken now, we may have to face difficult problems in the future. Hence we must act to ensure that the gains made so far are not compromised and a leprosy-free India becomes a reality sooner rather than later.
Dr. S. K. Noordeen is chair of the Technical Resource Group of the National Leprosy Eradication Program of the Ministry of Health & Family Welfare, India.