Infectious apathy

THE NUMBER of contagious leprosy cases in the State is reportedly on the rise. According to figures given by the Directorate of Health Services, 2,364 cases were reported between April 2002 and February 2003. Of these, 1,022 were contagious.

These account for 43.23 per cent of the total number of cases. For the year 2001-2002, of the 2,420 reported cases, 986 were contagious -- that is, 40.74 per cent. In 1997-98, this figure was only 26.45 per cent -- that is, only 1,243 cases of the 4,699 cases reported were contagious. The national average remains at 35 per cent.

While the total number of leprosy cases has reduced by half over a period of six years, the same cannot be said of contagious cases. However, the State Leprosy Officer, Dr. M. Thampi, said it was difficult to scientifically conclude that contagious or Multibacillary leprosy cases were on the rise, for the diagnosis of leprosy was based on clinical signs and symptoms detected by health workers.

More than a century after the Norwegian physician, Dr. Gerhard Armauer Hansen, discovered leprosy in 1873, it continues to evade complete eradication.

The World Health Assembly in 1991 was prompted to call for the "elimination of leprosy as a public health problem by the year 2000", defining elimination as attaining a level of prevalence below one case per 10,000.

While the defined elimination level was attained at the global level at the end of the year 2000, India, together with Brazil, Madagascar, Mozambique, Myanmar and Nepal, represent 90 per cent of the global leprosy burden. The number of registered cases in India comes to 62 per cent of the global burden. The WHO says it is clear that some countries will not reach the elimination target at the national level by the end of the year 2005.

The Government of India had begun the National Leprosy Control Programme (NLCP) in 1955. The NLEP was first implemented in the State in Alappuzha district in 1987 and subsequently introduced in the other districts in a phased manner. The first phase of the programme ended on September 30, 2000. The second phase started on October 1, 2000 and is scheduled to end on March 31, next year. The prevalence rate of one in 10,000 has already been achieved by the State in March 2000. So, the Centre instructed that the State too take up the campaign. But after March 2004, no financial help from the Centre will be forthcoming. Therefore, the Government intends to integrate the highly specialised vertical staff into the general health services.

With this aim in mind, the 500-odd vertical staff were sent for a health inspector course by the Government in 2002. But sources say, no further steps have been taken in this direction. This has affected the leprosy eradication campaign as well.

The Health Secretary, K. Ramamoorthy, said though the vertical staff wanted to be integrated, the general health workers were resisting every effort in this direction.

He said the meetings convened to facilitate a smooth integration process were not being attended by them.

Sources also claim that the second stage of the campaign is hardly operational in some districts of the State.

The State president of the Kerala Leprosy Eradication Staff Association, K. Bhuvanendran Chettiar, raised the issue of the role of Block Primary Health Centres, Community Health Centres and District Leprosy Units after the integration is over and done with. "If quality eradication work has to go on, these have to be retained, at least for some time."

But the core issue remains something else.

The Government is convinced that the campaign has succeeded in bringing down the prevalence rates (PR) to levels that do not require concentrated efforts anymore.

But its claim is questionable. Sources say a sample survey and assistance unit, which monitors the work done, assesses and evaluates it, has not been set up in the State ever -- not even at the height of the campaign in the 1980s and 90s.

They also allege that the campaign is in full force in Thiruvananthapuram, Ernakulam and Alappuzha.

But the same cannot be said of the other districts. For instance, in Wayanad, of the five posts of Leprosy Inspectors (LIs), only one is occupied. In Kasaragod, only 5 of 40 posts are occupied. In stark contrast, in Thiruvananthapuram, of the 75 posts, 75 are filled.

This, they say, is a pointer to the fact that where the staff deployed is more, the detection rates are higher. Where their number is low, detection levels too remain low. For instance, in Wayanad, 3 of the 3 cases detected in January 2003 are of contagious leprosy. The number is 14 and 16 in Thiruvananthapuram and Ernakulam, respectively.

This is substantiated by figures from the CAG's audit review for the year 2000-2001.

The report says all hidden cases can be detected only when the same population is covered repeatedly. And with the available manpower, this was not possible.

The Government claimed that the vacancies were not filled up because the programme was proposed to be integrated with the general health services. The review, however, held that "the reply was not tenable as the vacancies had remained in existence since 1991 and the programme of integration had not been carried out till March 2001."

The report says the annual reports on the coverage of population were highly inflated and the prevalence rate, calculated on the basis of case detection and population coverage, was incorrect. The method for calculating PR, the review says, was also defective. The PR rate was to be worked out based on the incidence of disease per population of 10,000 with reference to population actually covered and new cases detected in a year. But PR was actually calculated by the department by adopting the incidence as at the close of the year (number of new cases detected minus the number of cases in which treatment was completed), for the whole population of the districts and projecting the incidence to a population of 10,000 population resulting in unrealistic projection of PR. In Kottayam, the range of PR as per the department was 0.40 to 2.59 but as per the audit, it came to 10.90 to 57.78 between 1996-97 and 2000-01.

In the light of these facts, the Government's claim that elimination levels have been achieved in the State rings hollow. The drive necessary for covering the entire population of the state in a foolproof manner is imperative to make the campaign a true success story.