Leprosy: a problem solved by 2000?

It is now the year 2001, and in many endemic regions leprosy remains a public health problem by any definition. It is clear that defining leprosy purely by prevalence side-steps some of the real issues. There is still much to do to solve the problem of leprosy. Control programmes require better tests for early diagnosis if leprosy is to be reduced much further. Treatment of the infection and of reactions is still far from ideal, whilst an effective vaccine would be valuable in high-risk regions. Research into the true incidence in each endemic area is essential, and control programs of the future will need a more detailed understanding of the transmission of M. leprae to permit new logical interventions. Leprosy remains a devastating disease. Much of the damage that it inflicts is irreversible, and leads to disability and stigmatization. This is perhaps the greatest problem posed. It is easy to dwell on the successes of the elimination campaign, so diverting attention from those populations of 'cured' patients who still suffer from the consequences of infection. Leprosy should be regarded as a problem unsolved so long as patients continue to present with disabilities. WHO has carried out a highly successful campaign in reducing the prevalence of leprosy, and this needs to be acknowledged, but what is happening to the incidence in core endemic areas? Maintaining this success, however, may be an even greater struggle if funding is withdrawn and vertical programmes are absorbed into national health structures. We must take heed of the historian George Santayana, 'those who cannot remember the past are condemned to repeat it'. We should take the example of tuberculosis as a warning of the dangers of ignoring a disease before it has been fully controlled, and strive to continue the leprosy elimination programmes until there are no new cases presenting with disability. The World Health Organisation has shown that leprosy is an eminently treatable disease, and has prepared the ground. The leprosy elimination campaigns truly are 'at a height... ready to decline'. Can it be that this is the chance to take leprosy 'at the flood'? If so, perhaps an extension of the elimination programs beyond the year 2001 would indeed 'lead to fortune'.