A New Strategy for an Uncertain Futurehappen after 2005? Leprologists and people involved in disease control fear that once leprosy is declared “eliminated as a public health problem”, the future of anti-leprosy services and of leprosy workers and researchers will be at high risk. Elimination is not eradication, many warn, and it must be clear to everyone that leprosy will continue to exist even in areas where the “elimination goal” has officially been reached. The term elimination itself makes people think the problem is over, say critics of the WHO policy, which can have detrimental effects on the future commitment of governments to sustain control activities, making it at the same time difficult for leprosy NGOs and scientists to raise funds for field and lab work.
Others believe that the concept of elimination itself, and the choice of prevalence as an indicator to measure the progress of the WHO-orchestrated campaign, are scientifically devoid of significance—as is the 2005 deadline. “As a matter of fact, the wrong indicator has been selected to reflect the progress toward elimination of leprosy,” says Piet Feenstra at the Royal Tropical Institute of Amsterdam (Amsterdam, The Netherlands), remarking that new-case detection and the proportion of children among new cases would serve much better to monitor the real disease status.
Others believe that the concept of elimination itself, and the choice of prevalence as an indicator to measure the progress of the WHO-orchestrated campaign, are scientifically devoid of significance—as is the 2005 deadline. “As a matter of fact, the wrong indicator has been selected to reflect the progress toward elimination of leprosy,” says Piet Feenstra at the Royal Tropical Institute of Amsterdam (Amsterdam, The Netherlands), remarking that new-case detection and the proportion of children among new cases would serve much better to monitor the real disease status.
The “elimination” strategy must be swiftly converted to a “post-elimination” strategy.
The International Leprosy Association's Technical Forum has also noted that the expectation that reduction of prevalence to very low levels would lead to a reduction of the incidence within a few years was overoptimistic, as there was little evidence to support this hypothesis. Since patients are only registered while they are on medication, prevalence figures by WHO standards vary depending on how long treatment lasts. “The decrease of prevalence is attributable primarily to the cleaning of the registers (discharge of cured or defaulting patients), to shortening the duration of treatment and, in some countries, to improved diagnostic accuracy, and is not a consequence of reduction of the transmission of Mycobacterium leprae,” Feenstra says.
“I believe there is probably a lot more leprosy in the world than the World Health Organization currently accepts,” agrees Helen Donoghue, a leprosy researcher at the Windeyer Institute of Medical Sciences (London, United Kingdom). The political implications of the “elimination goal”, and the way it was enforced by WHO, have also been questioned. “Over the last years, the elimination target has more and more become a political target [rather] than an epidemiological or program quality target,” says Feenstra. “For many, the indicator—the prevalence of patients registered for treatment—has become the goal in itself, and the actual goal—reduction of the leprosy transmission and incidence—has practically got out of sight”. Furthermore, the fixing of numerical targets may put excessive pressure on national leprosy programme managers, discouraging them from actively working to detect new cases, which in turn could jeopardise the country's elimination status.