While in South Africa I also visited Robben Island, used to isolate persons with leprosy from 1846 to 1931, and more recently famous as the place where Nelson Mandela served 18 years of a 27-year prison sentence. IDEA and ILA's Global Project on the History of Leprosy had organized a workshop on stigma, identity and human rights in association with the Robben Island Museum. The program included a moving ceremony at the so-called “Leper Graveyard” on the island to remember those buried there.
　When the Robben Island leprosy asylum was closed down in 1931, patients were transferred to other leprosy sanatoria on the mainland. One of these was Westfort, near the capital, Pretoria, which I had visited a few days earlier.
　Westfort Leper Institution opened in 1898 and was one of only two multiracial leprosaria in South Africa. From 1948, under South Africa's apartheid system, patients who were already isolated from society by their disease were subject to further segregation within the hospital on the basis on their race ― giving a special character to the leprosy experience in South Africa.
　When it opened, Westfort housed 1,450 patients. But for much of the 20th century it was home to an average 200 to 300 patients. It was run like a small town, and had a post office, clinic, churches, pharmacy and shop. However, two guards were posted at the entrance, and visits from family members were restricted to once every two weeks, with patients forced to sit behind a glass screen in a prison-like atmosphere when they received visitors.
　Hospitalization for leprosy treatment was compulsory in South Africa until 1977, after which specialized institutions for leprosy began to shut down. Westfort, the last of these, closed in 1997.
　After visiting Westfort, I called on Johann, 55, a recovered person who lives with his wife, daughter and two granddaughters in the suburbs of Johannesburg. Before being diagnosed with leprosy and sent to Westfort, he was a steel worker. Unfortunately, his MDT treatment was interrupted, as a result of which he suffers disability in his right eye and leg. Without regular work, he receives a disability allowance from the South African government. Although he has the support of his wife and family, he has no contact with the neighbors, and when he goes to hospital once a month for a checkup, he is seen separately from other patients. I was troubled to hear Johann say he feels he has no place in society, and sometimes thinks he was better off in Westfort. But his comments renewed my determination to root out discrimination.

　

　

From South Africa I proceeded to Madagascar, where I attended a World Leprosy Day event organized by the Ministry of Health and sponsored by the Association Francaise Raoul Follereau (AFRF). I also met with the prime minister and health minister and visited a number of health facilities.

　

　

　

　Lying off the southeast coast of Africa, Madagascar is the world's fourth largest island, with a population of some 17 million. Seeing it from the air, one can appreciate the physical challenges the terrain presents in the way of reaching remote rural populations. Added to this, heavy rains can cut off communities during the cyclone season. Nonetheless, the WHO, government, NGOs and all concerned are making real efforts to combat the disease. As a measure of progress, when I visited Madagascar in September 2003, the prevalence rate stood at 4 per 10,000. Now it is down to 2.93.
　As I learned in Johannesburg, the main challenges facing Madagascar include improving the quality of patient diagnosis by peripheral health workers, improving patient follow-up to make sure that only genuine leprosy patients are on the register, and social mobilization.
　Promoting awareness of leprosy is an important part of the strategy, so I was happy to participate in the World Leprosy Day event held in Tulear, a city of 50,00-60,000 in the southwest of the country, where the PR stands at around 4/10,000. Held in a carnival-like atmosphere, the day-long event included music, dance, puppetry and film and was a good platform from which to deliver important messages about the disease.
　Both the prime minister and the health minister took part in the ceremony, and their commitment will certainly be necessary to keep elimination moving in the right direction. I told the people of Madagascar they had my full support, and I would come back and celebrate with them when the country achieved the target.
　After Tulear, I visited three towns on the southeast coast of the island, Mananjary, Manakara and Farafangana, all with high prevalence rates, where I met with health workers and visited local hospitals and health facilities.
　Basic health centers are at the frontline of the health care system, and each caters for an average 5,000-6,000 people. All told, there are around 2,500 such centers in the country, and the people who work there play a vital role educating about the disease and spotting new cases. But they are not just dealing with leprosy but all health issues, so their job is extremely demanding.
　I found that not every health center keeps complete records of patients or MDT. In particular, in some places, MDT isn't getting from the regional hospital to the basic health center, while in others there is a surplus of MDT. Getting this right is essential to the elimination strategy.
　Wherever I go, I like to talk with patients, and was able to do so at several locations, including Tulear regional hospital, the Marovhay leprosy and TB center, and St. Vincent Hospital in Farafangana.
　Speaking with some of them, I was struck by their solemn expressions. Even though they have been assured that leprosy is curable, they appeared to be suffering the effects of social discrimination.
　Madagascar is clearly walking the final mile toward elimination. But the work to eliminate deep-rooted stigma and discrimination is perhaps only just beginning. The three messages I tell to people around the world are all-important, and the third message, that social discrimination has no place, must not be forgotten once elimination is achieved. Driving that message home might be more difficult than treating the disease itself.