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AMBASSADOR'S JOURNAL
From the Mediterranean to the Himalayas
WHO Goodwill Ambassador Yohei Sasakawa visited two very different nations recently: Malta, where leprosy is considered to have been eradicated, and Nepal, one of the world's six major leprosy-endemic countries.

MALTA
At the end of March, I had the opportunity to visit Malta, an island republic of some 400,000 people located south of Sicily, more or less in the middle of the Mediterranean Sea. As multidrug therapy (MDT) becomes the standard approach to treating leprosy throughout the world, Malta has succeeded in eradicating the disease through what might be called Malta-style MDT. I was very interested to learn more about this and find out where Malta stands today vis--vis leprosy.
 One of the earliest recorded cases of leprosy on Malta dates back to 1629, but the disease is thought to have existed much earlier. At one point, more than 200 patients were listed, which by today's WHO elimination yardstick of less than one case per 10,000 people would indicate a very high prevalence rate given the population at the time. In 1918, there were 4.72 patients per 10,000, or 4.7 times today's elimination standard.
 Malta was part of the British Empire for many years, and in common with other British colonies, it was thought necessary to isolate and confine those with leprosy. Accordingly, a leprosarium was constructed near the site of the “poor house” on Malta island, based on an 1893 ordinance, and a second leprosarium was built on the island of Gozo in the 1930s.
 In 1953, however, the segregation policy was abolished, reflecting both the progress made since the 1940s in the development of drugs for treating leprosy and changing attitudes worldwide.
Thereafter, people with leprosy were mainly treated as outpatients, and both leprosaria were closed in the 1970s. The former poor house is now a nursing home for the aged, but nothing remains of the leprosarium.
 In 1957, a few years after the switch to outpatient treatment of leprosy patients, there were 152 patients in a population of 314,369 - still a considerable number. At the time, the only treatment available was dapsone, which had to be administered over a long period; however, because of emerging resistance to dapsone, the search continued for a new form of chemotherapy.
 In 1972, Malta initiated a leprosy eradication program. Led by the Ministry of Health, it was supported by the Order of Malta, the German Leprosy Relief Association, and the Research Center Borstel of Germany, which came up with an MDT called Isoprodian-RMP combining rifampicin, isoniazid, prothionamid and dapsone.
 Over time, 261 patients were treated with the new therapy, for a period of six months to a maximum of seven years, depending on their symptoms, and all of them were cured. A followup survey continued for 27 years until December 1999. Today, about 100 people who once had leprosy are still alive, with the last known case of the disease diagnosed six years ago. Leprosy on Malta is considered eradicated.
 I was told that in 1974, when St. Bartholomew Hospital (as the leprosarium on Malta island was later renamed) and Sacred Heart Hospital (the facility on Gozo) were both closed, 22 individuals who had no homes to return to were transferred to the site of a former army barracks on Malta called Tal-Farha Estate. There, they were provided with accommodation and land for cultivation, and given pensions and access to medical treatment.
But when I sought out the location, the only traces to be seen were the words Tal-Farha written on the bottom of a stone wall.
 Malta has done away with leprosy. I applaud this success, but we must never forget the history of human suffering that preceded its elimination.
 
 
 
 
(Top) Malta's old quarantine station, or lazaretto, where new arrivals, including those with leprosy, were detained; Tal-Farha Estate: these walls are all that remain.
 
 
NEPAL
In April, I finally realized a long-held wish to visit Nepal. This is one of the six major countries where the leprosy prevalence rate is rather high, and with this trip I have now been to all six in my capacity as WHO ambassador.
 Nepal has a population of some 24.8 million. According to health ministry figures as of mid March 2004, the leprosy prevalence rate was 2.4 people per 10,000, down from 3.4 per 10,000 as of February 2003. Given that the prevalence rate was 70 per 10,000 about 15 years ago, Nepal is making steady progress toward elimination. However, although 31 out the country's 75 districts have now achieved the elimination target, in the mountainous west and in the southeastern Terai (lowlands) bordering on India, there are places where the prevalence rate exceeds five per 10,000, so still more effort is needed if the elimination target is to be reached by the end of 2005.
 During my visit, I met with then-Prime Minister Surya Bahadur Thapa and Health Minister Bhekh Bahadur Thapa in the capital, Kathmandu. I requested that the government make all efforts for leprosy elimination from an awareness as well as a medical standpoint. They replied that the government had made elimination a high priority both on the policy side and in practice, and were working toward elimination by the end of 2005.
 
 
In Nepal, leprosy education is now part of the school curriculum.
 
 The prime minister said leprosy education was now part of the school curriculum and that the government was determined to spread information about the disease throughout the country by making greater use of the media. For my part, I said that in order to turn leprosy elimination into a major social movement, it was necessary to involve a broad spectrum of NGOs, as well as forge even closer ties with NGOs that specialize in leprosy, and both the prime minister and health minister agreed with me about this.
 
 
 
Overview of Khokana settlement, home to some 200 recovered individuals and their families.
 
 
 
Outside the Khokana settlement leprosarium
 
 
 I also had discussions with Health Secretary Lock Man Singh Karki, Director General Dr. B.D. Chataut, and Public Health and Policy Advisor to the Health Ministry Dr. Rita Thapa. They gave me their commitment that they were working toward the elimination target by involving government, NGOs and the private sector in activities at every level, training human resources, and fostering a social movement all over the country from village to national level.
 Dr. Bimala Ojha, director of the Leprosy Control Division, said that Information, Education and Communication (IEC) programs were being strongly pushed, and that leprosy featured in elementary school textbooks.
 Given the key role played by NGOs in the drive to eliminate leprosy, I visited the Social Welfare Council, the government agency that coordinates the work of NGOs, and asked that it spread my three messages that “leprosy is curable, treatment is free, and social discrimination has no place” among all NGOs operating in Nepal.
 Because this was a short visit, and because of antigovernment demonstrations organized by Maoist rebels, I wasn't able to travel widely and see what was happening in the field.
However, I was able to visit a couple of leprosy-related facilities in the outskirts of Kathmandu. One was the Anandaban Hospital, operated by The Leprosy Mission International (TLMI), and the other was the Khokana settlement, a residential and rehabilitation complex handed over to the Nepal Leprosy Relief Association (NELRA) by the government.
Both are closely associated with my late father, Ryoichi Sasakawa. He visited the region in 1979 when he was head of The Nippon Foundation and held the hand of an elderly woman lying on her sickbed to pray for her recovery.
 Furthermore, he donated training centers to both the Anandaban Hospital and what is now the government Leprosy Control Department at Teku in Kathmandu. I was delighted to visit these facilities and see they are well maintained and being used for their original purpose.
 Khokana settlement is located in the village of Khokana along the Bagmati River about 40minutes by car from Kathmandu. On the premises are a clinic, the original leprosarium, new nursing homes, and a job training center. I had the chance to visit with the 200 or so recovered individuals and their families and saw people being taught how to make furniture at the training center.
 
 
 
Meeting with a patient from neighboring Bihar, India
 
 
 I also paid a short visit to one of two hostels on the outskirts of Kathmandu operated by NELRA for children of rural families affected by leprosy, which enable them to commute to schools in Kathmandu.
 Anandaban Hospital, which was established by TLMI in 1957, is Nepal's biggest leprosy hospital, and the main hospital of the Central Development Region. It has a total of 121 staff (of whom 115 are Nepalese), and 115 beds. The hospital undertakes a variety of activities, including early detection and treatment, prevention of disability and reconstructive surgery, rehabilitation and elimination campaigns. Dr. Yo Yuasa, executive and medical director of Sasakawa Memorial Health Foundation, served as medical superintendent at the hospital in the 1970s when he worked for TLMI.
 I visited both inpatients and outpatients, including those with complications and those undergoing rehabilitation. I also saw the laboratory where research is being conducted on a leprosy vaccine. The wards were clean and well-run, and the patients seemed to be in good spirits.
 I was interested to learn that some of the patients were from Bihar State in India. Leprosyaffected people living in the border regions of both countries pass back and forth across the frontier, making it difficult to keep track of them and provide treatment. I proposed that the relevant parties of both countries have a meeting on this issue at the earliest possible date.
 It was very important for me to see for myself the commitment of senior Nepalese political leaders to achieving the goal of elimination.
According to the health officials concerned, the infrastructure to achieve leprosy elimination in Nepal is in place. I was also impressed that education about leprosy begins at elementary school level.*
 However, on the human resources front, numbers are lacking, and a lot of training will be needed for the infrastructure to be properly utilized. Another problem is that because of social disturbances, leprosy elimination campaigns are restricted to 25 of the country's 75 districts.
 Still another concern is that cooperation between government departments and NGOs, which have traditionally been at the heart of social activities in Nepal, including leprosy elimination, could be better.
 At any rate, I look forward to paying another visit to Nepal, when hopefully time and circumstances will permit me to travel the country and see the situation in the field at first hand.
 

LEPROSY LEXICON
●MDT
Multidrug therapy (MDT) is the standard treatment for leprosy.
A combination of two to three drugs - dapsone, rifampicin, and clofazimine - MDT kills the bacillus that causes leprosy and interrupts transmission of the disease. Treatment takes six to 12 months and there is virtually no recurrence.
 
Reference
* The following is summarized from a Nepalese school book:“Leprosy is caused by a bacterium.
It is not hereditary, punishment for sin or the result of a curse.
Early diagnosis and multidrug therapy cures leprosy without any disabilities or deformities.
People who are receiving regular treatment or have completed treatment do not transmit the disease and can lead a normal life. People with leprosy should not be discriminated against; they should be loved.”
 
 

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