One of the basic postulates of the MDT elimination program has been that by reaching low levels of prevalence, the transmission of the disease will automatically plug into the natural low endemicity dynamics, rendering further surveillance somewhat redundant. Such an assumption should now be revised of view of the persistence of relatively high detection rates. Incidentally, reports on the trends of leprosy in those areas where it has been on the way of disappearing for a long period of time are particularly valuable to test the validity of this postulate.
Secondly, priorities. There are so many health issues requiring attention and competing for resources that it would be naive to expect political commitment being maintained at the present level while leprosy would have vanished as a public health problem. There are such things as challenge fatigue.
Many issues will still be facing the disease once elimination as a public health problem has been achieved. One should therefore strive to keep leprosy on the agenda, even if, as one participant put it, no longer with capital letters. Just as high priority does not mean exclusivity, reduced priority should not be taken as absence of priority.
Among the issues for the future, the most important is no doubt the disablement leprosy causes among a large proportion of the affected persons. Leprosy is said to be one of the four main causes of disability in the Third World. Statistics presented at the Congress were eloquent in this respect. It has even been proposed that early detection be defined as "detecting a case of leprosy before disability sets in".
As the number of patients detected lowers, the proportion of disabled among them could increase. There is a danger that stigmatization and exclusion would again set in, as is already suspected in some countries. Good programs for the prevention and management of disabilities should help in convincing governments and funding agencies that leprosy still constitutes a problem deserving careful attention.
Finally, leprosy activities in the years to come will likely have to be carried out in a context of accelerating reforms of the health sector, including increasing privatization of services.
In low endemic situations, vertical programs are no longer effective or justified. There will be a need to dismantle vertical leprosy programs and shift to a policy of suspicion at the periphery, and referral to specialized levels for diagnosis and the management of complications. Detection and referral will have to be integrated into general health services, which supposes training and the capacitating of health workers. Private practitioners, and especially dermatologists, as well as the traditional sector whenever appropriate, should also be involved in referring suspect cases. Public awareness of the disease should be promoted.
