Leprosy control, public health paradigms and stigma

AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 9 © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia as ‘incurable’, ‘outcast’ or ‘unclean’ are pejoratively labelled as ‘lepers’ of their era. As at the end of 2009, 244,796 new cases of leprosy were detected globally, compared with 5.5 million cases in 1990, when multi-drug therapy was introduced. Of all newly detected cases, 14,320 had developed severe (grade 2) disability at diagnosis, with rates varying from 0.04/100,000 population in the Western Pacific Region to 0.41/100,000 population in the African and South-East Asia Regions. A chronic infection of the skin and peripheral nerves caused by the Mycobacterium leprae bacterium, leprosy is rare in Australia, with the majority of cases occurring among migrants to Australia from leprosy-endemic countries and occasional locally acquired cases within Indigenous communities. Between 1991 and 2008, annual leprosy notifications in Australia varied between 20 and 3. In 2008, three of the 11 notifications were identified as Indigenous (Figure 1). Leprosy control remains strongly influenced by evolutions in medicine and social structures, which are incorporated public health’s prevailing dominant paradigms and action frameworks. This article reviews approaches and legacies of seven public health eras in leprosy control, especially in relation to leprosyrelated stigma. 1. Health Protection: The dominant paradigm of the Health Protection era – from antiquity until 1830s – was disease prevention through enforced regulation of human behaviour. Such regulation was mediated via legislation, cultural practices and religious doctrines. In India, the Laws of Manu (1500 BC) mention various skin diseases translated as leprosy. The Laws prohibited contact with those affected by leprosy and punished those who married into their families. India’s Sushruta Samhita (600 BC) recommended treating leprosy with oil derived from the chaulmoogra tree; this ineffective prescription remained a mainstay of treatment until the introduction of sulfones. According to Mosaic Law, consequent upon transgression, illness was punishment for sin and the particular set of syndromes 6. Campbell J. Invisible invaders: smallpox and other diseases in Aboriginal Australia 1780-1880. Melbourne: Melbourne University Press 2002. 7. Tuberculosis Act 1948. Commonwealth of Australia. 8. Taffe S. Health, the law and racism: the campaign to amend the discriminatory clauses in the Tuberculosis Act. Labour History. 1999;76(May 1999):41-58. 9. Thomas DP. The upsurge of interest in Indigenous health in the 1950s and 1960s. Med J Aust. 2004 May 17;180(10):521-3. 10 Moodie PM. Aboriginal Health. Canberra: Australian National University Press 1973. 11. National Health and Medical Research Council. Tuberculosis in Australia and New Zealand into the 1990s. Canberra: National Health and Medical Research Council; 1990. 12. Simpson G, Knight T. Tuberculosis in Far North Queensland, Australia. Int J Tuberc Lung Dis. 1999 Dec;3(12):1096-100. 13. Simpson G, Clark P, Knight T. Changing patterns of tuberculosis in Far North Queensland. Med J Aust. 2006 Mar 6;184(5):252. 14. Australian Bureau of Statistics. Population Characteristics, Aboriginal and Torres Strait Islander Australians, 2006, Cat. no. 4713.0 Canberra: ABS 2006. 15. Krause V, Zweck N. Tuberculosis in the Northern Territory: highlights from 2000. Northern Territory Disease Control Bulletin. 2002 September 2002;9(3):9-14. 16. Krause V. Tuberculosis (TB). In: Couzos S, Murray R, eds. Aboriginal primary health care: an evidence-based approach. 3rd ed. South Melbourne: Oxford University Press 2008:674-707. 17. O’Connor B, Fritsche L, Christensen A, McAnulty J. Tuberculosis in NSW, 2003-2007. NSW Public Health Bulletin. 2009;20(3-4):59-68. 18. Lim E, Tisch C, Williman J, Hefferman H. Tuberculosis in New Zealand. Annual Report 2008: Institute of Environmental Science and Research Limited; 2009. 19. CDC. Reported Tuberculosis in the United States, 2008. Atlanta, GA: Department of Health and Human Services, CDC; 2009. 20. Public Health Agency of Canada. Tuberculosis in Canada 2008 Pre-release. Ottawa: Minister of Public Works and Government Services Canada; 2009. 21. Oxfam Australia, National Aboriginal Community Controlled Health Organisation. Close the gap: solutions to the Indigenous health crisis facing Australia (A Policy Briefing Paper from the National Aboriginal Community Controlled Health Organisation and Oxfam Australia). Fitzroy, Vic 2007. 22. Australian Bureau of Statistics. The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, 2008 (ABS cat. no. 4704.0). Canberra: ABS; 2008.