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SWASTH HIND
WISHES ITS READERS
A HAPPY NEW YEAR
In this issue
January 1983
Pausa-Magha
1
Social aspects of leprosy
Dr R. H. Thangaraj
and
Dr (Smi.) E. S. Thangaraj
4
Legal aspects of leprosy
Dr V. V. Dongre
7
Rehabilitation in leprosy
Dr J. M. Mehta
11
Childhood leprosy
Dr S. Theophilus
14
Importance of school
leprosy control
Dr R. Ganapati
Vol. XXVII No. 1
Saka 1904
Readers Write
I have conic across your publication Swasth Hind ..nd
found it very useful for research work as well as in keep
ing touch with developments in this field.
Ujjayant N. Chakravorty
Centr for Science and Environment
807 Vishal Bhawan
95 Nehru Place..
NEW DELHI-110019.
x
I am regularly reading your highly esteemed journal and
1 have been impressed with the papers published in the
journal.
Jyotsna Baruah
National Institute of Public Cooperation
and Child Development
Regional Field Unit
and
mass
surveys in
%
16
Training and development of manpower in leprosy
Dr Claire Veihit
18
Health education in leprosy control
Dr B. C. Ghosal
and
T. K. Parthnsarathy
22
Leprosy control ;
institutions
Dr S. P. Tare
24
Management of complications in leprosy
Dr G. Ramu
27
Socio psychotherapy : an adjunct in the treatment
of leprosy
Dr N. S. Chauhan
and
Dr Upinder Dhar
Journ.*.
31
National Medical Library
State Health Directorates arc requested to send reports of their
activities for publication.
32
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SOCIAL ASPECTS OF LEPROSY
Dr R. H. Thangaraj
and
Dr (Smt.) E. S. Thangaraj
The human problems of a person affected by leprosy will depend on
the direct and the indirect interaction with others in the society. His normal or
abnormal behaviour will be the result of biological, social and psychological forces.
Self-respect, recognition, ambition and future plans—all play a vital role in his
remaining as a member of the society.
pale patch is often the common early symptom
in leprosy. When a person sees this patch he is not
usually perturbed by it. But the moment the diag
nosis leprosy is told to him, it is no more just a patch.
But all the information he had learnt about leprosy,
and the leprosy patients he had seen flash through
his mind—that leprosy is a very infectious disease
which comes as a curse from God; it is chronic in
nature and it cannot be cured. He feels that one
day it will make him ugly, repulsive and that his fami
ly, friends and co-workers {the primary group) will
reject him. He will probably be confined to live in
a horrible place for the rest of his life. There he will
be physically and mentally crippled and die as an
outcast of society.
A
staying with the family. He foresees the possibility
of the whole family suffering from the consequences
of social stigma. His first reaction is to guard him
self from such a situation. So he does not want to
accept the diagnosis. He tries to flee from reality. He
tends to go from person to person (may be doctor,
void, traditional healer) hoping it could be something
other than leprosy.
Historical and religious beliefs about leprosy have
hardly changed and so he may develop a guilt com
plex that he is a sinner and he is cursed. Due to
this, he begins to hate himself, shuns society {the
secondary group). He may develop a negative atti
tude and become aggressive.
In fact, leprosy is not as contagious as people
think. Most patients do not spread the bacilli. Near
ly 98 per cent of the population have natural immu
nity and will not get leprosy. Leprosy is curable.
The reaction of the primary group will depend on
various factors as socio-economic status of his fami
ly, on his status whether he is the bread winner or
a dependent, whether the life of other family members
will be affected by his presence, and so on.
The affected person dreads that he might be aban
doned by his family;- at'the same time he is afraid ol
In the present day there is more emphasis on total
care of the patient.
The physical, social and
January 1983
1
Treated leprosy patients and their children are being trained in printing
psychological aspects must be fully understood by the
medical team. The role of the social scientist work
ing with the team will be of great importance.
Patients and employment
(i) It is difficult for the patients to get employed,
if identified.
Patients, family and community
(ii) It is difficult for them to retain the job.
The members of the medical team have to prepare
the patient to accept the diagnosis. The team must
exercise great care in revealing the diagnosis. They
must warn him about result of neglect; at the same
time they should not frighten him. It is important
to educate the patient, the family and the community
and see that the patient is not dislocated from the
family. Hospitalization, when necessary, must be for
a short time only.
(iii) In some cases there is disability and they are
unable to do certain types of work.
Medical world
Leprosy should not be considered as a special dis
ease. For instance people working in this field are
looked upon as persons doing great sacrifice. This
very attitude reflects the prejudice and stigma deep
rooted in the people in general. Accepting this dis
ease as one of major public health problems by all
those in the medical world is of prime importance.
2
(iv) Some types of work may cause damage to
limbs without sensation but they carry on their
work as there is no alternative, till there is
irreversible damage.
Patients and industrialist
Industrialists must have orientation about leprosy
and its problems. They must include leprosy as part
of the general health care programme for the emp
loyees. Early case detection and treatment will pre
vent disability and deformity in those affected and
protect co-workers from risk of probable infection.
Alternative job arrangements for the infected emp
loyees may be arranged whenever possible to prevent
damage from work hazardous to them.
Swasth Hind
There is high percentage of leprosy patients among
the migrant labour from endemic areas to cities. Most
of them end up in slums. Every community health
programme should include case detection and mana
gement of uncomplicated cases.
lifted to a better social level will no longer be a bur
den on the society but will be independent and hap
pily integrated into society.
Resettlement colonies
Extreme caution must be exercised to make leprosy
patients eligible for special privileges. By giving pri
vileges we create a situation where a person not really
disabled (c.g. having only few patches) when ostracis
ed by society will be tempted to choose to live on
these privileges. He will stop making any effort to
overcome obstacles, resign himself to fate and may
even resort to begging. It is very difficult to restore
him back, though not impossible. Badly crippled
patients will need support and this must be assessed
individually.
Every day there is increase in the number of self
settlement colonies. The patient tends to migrate for
many reasons:
(i) He attempts to flee from primary group and
mask identity.
(ii) He hopes to get job.
(iii) He wants to save his family from social ostra
cism.
(iv) Affected children abandoned by the parents in
order to protect other children end up in these
colonies.
(v) Women who do not have economic indepen
dence when rejected by their family may seek
refuge in such colonies.
Special privileges
Self reliance
Basically the patient does not need pity. He is not
just to be tolerated but he must feel wanted. He,
like anyone else, has skills, ambitions and above all
basic desire to live as a useful citizen with self-res
pect. We must be able to look at the leprosy patient
as a person and aim at a total care and restoration.
(vi) The patient wants to save other members from
being affected by leprosy.
(vii) Some families may migrate as a whole.
(viii) Some patients get married to other
and settle down in these colonies.
patients
The fact we ignore very often is that there arc many
healthy children in these colonies. Leprosy is not
hereditary. These children are brought up under very
poor socio-economic conditions and in an environ
ment unsuited for their normal physical and mental
growth. They are labelled as ‘Children from leprosy
colony’ forever. Such children face a number of
problems when they grow up:
(i) Difficulty in getting admission to schools, (ii)
Rejection by other students, (iii) Difficulty in procur
ing job due to the leprosy background, (iv) Inferio
rity complex, (v) Maladjustment, (vi) Fear of losing
job and friends once identity is disclosed and (vii)
Difficulty in getting married.
These children must be educated, given vocational
training and placed back in society. Left without
help there is every possibility of some of these child
ren becoming anti-social elements. The children
January 1983
Socio-economic and medical programme in resettle
ment colonies must run side by side. The role of
social scientists is very important. They have to
assess the needs, identify problems, overcome barriers
in communication and motivate the inmates. Once
motivated, theyxan turn out work to the best of their
abilities. Extreme care should be taken not to make
the group totally dependent on the working team.
Once the group becomes self-reliant the team can move
on to the next group needing help and continue to
give advice and guidance.
Any sick person needs support. The need is much
more for a victim of a crippling disease. Is the lep
rosy patient within the fold or outside, when we talk
about “Health for all by 2000 A.D”. When our
Government is aiming at this, are we giving the full
support to the leprosy patient we ought to?
>The health education of the community should not
stop at the stage of creation of awareness but should
continue till the expected behavioural changes are
achieved. This will fail if there is lack of community
participation.
3
eprosy is a disease which is shrouded in the midst
-/of ignorance and misconceptions and has perhaps
no rival in dislocating and dehabilitating a person
from his social, marital and economical spheres, ex
cept a mental disease.
I
LEGAL ASPECTS
OF
LEPROSY
When the question of control of leprosy is posed
to a lay person, the usual reply given is, “isolate the
leprosy patients and pass a legislation to that effect.”
It is time to oppose this line of thinking, in the light
of modern concepts of leprosy as a disease.
It is not a crime to contact leprosy.
There is legislation pertaining to the marital, school
ing, accommodation, transport and occupational as
pects of leprosy patients.
Indian Lepers’ Act of 1898
This Act provides for—
(1) The segregation of beggars with leprosy, and
Dr V. V. Dongre
Social reforms cannot be successful by
legislation alone. It is much more true
in a disease like leprosy having a medical
and social aspect. Leprosy is everyones’
concern. Therefore, active participation
of every segment of the society is neces
sary for the control and final eradication
of the disease.
(2) The control of leprosy patient, following certain
occupations or doing certain acts such as preparation
for sale or the sale of food, drink, drugs or clothing,
taking drinking water from or bathing and washing
clothes in the public wells and tanks, and the use of
public vehicles.
It is a permissive act which can be put into force
in whole or in part by notification by any State
Government. The special committee of the Govern
ment of India has expressed unanimously that it is not
desirable to maintain a special status for Leprosy
and it should be dealt with like any other public
health problem and the provisions made in the said
Act could no longer be considered valid in the light
of modern concepts of the disease. The existence of
such an act perpetuates and enhances the social
stigma. The Ministry of Law has opined that the
respective Stale Government may abolish this out
dated Act. Eighty per cent of the normal population
has natural resistance against the disease and only
20 per cent leprosy patients are open cases. There is
no conclusive evidence to prove that leprosy spreads
through food or water. At present this Act is clam
ped in Bombay, Amravati in Maharashtra State and
some parts of Andhra Pradesh. If the Act is annulled
it will make 500 beds available for voluntary leprosy
patients who need temporary hospitalization in
Bombay.
Marriage Acts
Hindu Marriage Act of 1956, Muslim Marriage
Act of 1939, and the Indian Christian Marriage Act of
1872 provide for divorce on the ground of leprosy.
4
Swasth Hind
Surprisingly, statistical data on the number of such
divorces in the Court of Law is not available as in
actual practice, the • leprosy affected spouse is just
abandoned. It should be noted that leprosy should
not be a ground for divorce, as
(i) All the types of leprosy are not infectious.
(ii) Leprosy is curable with modern drugs.
(iii) Leprosy is neither hereditary nor congenital.
There fore*, marriage acts should be amended suitably
without delay. A person suffering from a disease with
social stigma requires more compassion from the
spouse.
Children suffering from leprosy and
children of leprosy patients
A decade ago children with leprosy were not allowed
to attend schools. Children with “close” (non-infectious) type of leprosy are allowed to attend school
now-a-days as a result to the efforts of leprosy
workers. The same thing holds good for the children
afflicted with non-infectious tye of leprosy in the
Juvenile Remand Homes. But the problem of smears
—positive children (infectious) cannot be solved in a
satisfactory way. A handful of them are admitted in
the schools run by leprosy hospitals but they get
ostracized when they produce their School Leaving
Certificates before getting any employment. The
children of leprosy patients staying in a leprosy patients’
colony also get ostracized and do not get admission
in the schools if they give the true address of their
residence.
SHRI PARTHASARATHY RETIRES
Shri T. K. Parthasarathy relinqui
shed the charge as Editor,
Central
Health Education Bureau, at the time
of his retirement on 31 December, 1982,
after a meritorious service of a ^quarter
century almost right from the establish
ment of the Bureau. Shri Parthasarathy
has contributed a lot to strengthen the
Bureau and in .developing its multifari
ous activities.
It was during his period
that Swasth Hind has become what
it is today.
Shri Parthasarathy’s
interest in
media and communication research and
training has helped immensely in the
development of health communication as
a vital discipline in promoting public
health programmes through
health
education.
We hope that his continued associa
tion would be available to the journal and
the Bureau in its various functions.
Transport and leprosy patients
Indian Railways Act of 1890 prohibits all types of
leprosy patients from travelling b.y train along with
other passengers. However, this attitude has changed
considerably in the last decade and the leprosy patients
get concession for the purpose of journey to and from
leprosy hospitals for treatment.
Some State Road Corporations give similar conces
sion. However, the patients have to produce a certi
ficate that the disease is not easily recognizable. This is
an impediment to patients with deformities who are
actually non-infectious.
Motor Vehicle Act of 1939
Under this Act the leprosy patient is disqualified to
get licence to drive any vehicle. This needs rectifica
tion as all the leprosy patients do not have sensory loss
of the limbs.
January 1983
Life Insurance Rules
Premia rates are higher for leprosy .patients. This
should not be as leprosy per se does not shorten the
life of a patient.
Military Service Rules
It is not understood that why a smear negative
leprosy patient (close or non-infectious) is not readily
reinstated in his work as a civilian in an ammunition
or Ordnance Depot.
Leprosy patients as voters
Leprosy patients can exercise their franchise but it is
not understood why there should be a separate booth
for leprosy patients alone in their settlement. Not only
this but it is observed that the Election Officers on such
booths are also Leprosy Workers.
This procedure
enhances social stigma and should be abolished.
5
Rejection of the patient from a family, dislocation from the society due to dehabilitation
from the job, ultimately makes a leprosy patient a destitute. Mere law against begging
will not break this chain of events.
Education and motivation of the society only can
prevent dehabilitation of the would-be beggars.
Tenancy
Employment Rules
The Tenancy Acts do not favour leprosy patients for
accommodation. Complaints by the neighbours regar
ding the tenancy of leprosy patients are common in
cities.
There are no uniform employment rules for leprosy
patients employed in private and public sectors. The
Government Employee is better placed in this situa
tion than his counterpart in the private sector. The
smears negative (nori-infectious) patients are reinstated
in their jobs from the beginning. However, an open
case (infectious) has to struggle a great deal for the
job.
Alternate isolated job, employment to a family
member of such a case, extended sickness benefit,
provision for costly modern drugs could be some
satisfactory solutions.
Leprosy patients staying in villages at times suffer
from social boycott and the non-infectivity certificates of
patients sometimes are not respected by the village
leaders.
This attitude should be discouraged.
Prevention of Begging Act 1959
Beggars are arrested under this act and are referred
to certified institutions. If a beggar is found to have
leprosy he is sent to a leprosy hospital. He stays
there till he is cured, even though his term of deten
tion under the Act, expires earlier. The genesis of
leprosy beggars is due to the social stigma and ostra
cism. Rejection of the patient from a family, dis
location from the society, due to dehabilitation from
the job, ultimately makes a leprosy patient a destitute.
Merc Law against begging will not break this chain
of events. Motivation of the society only can prevent
dehabilitation of the would-be beggars.
Ignorance and apathy on the part of community is
seen in some of the procedures that are still prevailing
in some areas. Leprosy patients are cremated in
separate crematoria. This gives wrong idea to the
public mind regarding the infectivity of leprosy.
Leprosy beggars who are arrested under the Beg
gars’ Act arc carried in a separate vehicle meant for
“lepers”.
In some States, one per cent vacancies for the ortho
paedical ly handicapped in class 3 or 4 services are
reserved. However, leprosy patients with deformities
are not included in such list of handicapped persons,
which needs rectification. On occasions it is essential
to change the attitude of the co-workers and the em
ployers for the smooth reinstatement of the leprosy
patients in his original job which can be achieved by
effective health education. It is felt that those who
are away from their jobs for a long period, on account
of their infectivity, should be given special considera
tion and “Intensive Care Units'* should be established
for such patients to tackle their social, economical and
employment problems. This will ensure regularity of
•treatment and reduction in the drop-out rate from
treatment, thereby reducing quantum of infection and
break in the chain of transmission of the disease in
the community.
Leprosy patients are not easily entertained and ad
mitted in general hospitals.
Social reforms cannot be successful by legislation
alone. It is much more true in a disease like leprosy'
having a medical and social aspect. Leprosy is everyones’ concern. Therefore, active partipation of every
element of the society is necessary for the control and
final eradication of the disease.
Unwanted corners are given for Leprosy Treatment
Centres in the General Hospitals and Dispensaries.
Community leaders ask for shifting of leprosy hospi
tals or settlements of leprosy patients for the fear of
catching the disease.
In consonance with the recommendations of the ex
perts’ opinion on legislation, all derogatory provisions
in legislative Acts, adversely affecting the fundamental
rights of leprosy patients as citizens of India should
be forthwith repealed or annulled.
’
&
6
Swasth Hind
REHABILITATION IN LEPROSY
Dr J. M. Mhhta
eprosy from the medical and social stand points
This article restricts to socio-economic reha
bilitation but it must be remembered that
medical and physical rehabilitation by physio
therapy, reconstructive and plastic surgery,
protective footwear for plantar ulcers and other
such measures form a major aspect of any
rehabilitation programme.
Lis a highly misunderstood disease causing avoidable
human suffering and leading to the major problem of
rehabilitation. Proper medical treatment along with
the care of the hands, feet and eyes would result in
minimal deformity. But this is the ideal situation and
we have upon our hands thousands of deformed
leprosy patients who have been outcast from society
and for whom something has to be done urgently.
It is impossible to measure (he cost of suffering avoided
January 1983
7
Prevent dchabilitatiou
It is our initial duty to see that the leprosy patient
does not undergo a process of ‘dehabilitation’ which
can be prevented by early diagnosis and proper treat
ment. Notwithstanding this ideal situation the word
‘leprosy’ strikes terror not only in the mind of the
patient but also in the public, and this fear can be
treated only through aggresive health education.
The stigma brings about an unsympathetic public
and even official attitude. Though the present policy
of government is to assist the leprosy patient, this
does not work in practice due to lack of personnel
and lack of motivation on the part of the latter.
The National Leprosy Control Programme (NLCP)
of the Government of India did not consider rehabilita
tion as a part of the programme in the initial stages.
Now, after almost 25 years it has been realized that if
we are to control the disease, rehabilitation will have
to form an important aspect of the total strategy.
Correct understanding needed
To quote an example of the lack of understanding,
I would like to mention the case of one of our very
esteemed and highly educated patients who was re
commended for the National Award for the most
efficient physically handicapped employee. This wellrehabilitated patient who had in turn brought about
the rehabilitation of many other patients felt very
dejected when the National Award was not given to
him by excluding him from the category of the “orthopaedically handicapped”. It was the stigma that
came injiis way. Perseverance at last brought about
success and the said gentleman—a life that had bene
fited so many others—was given the award in 1979,
to the best of our knowledge the first of its kind in
the country, and, for the first time to an ex-leprosy
patient.
Medical certification
Another factor that interferes is the medical certi
fication of fitness in the case of lepromatous leprosy
patients. Such patients show the presence of lepra
bacilli in their skin smears for several years though
with adequate chemotherapy they become almost noninfectious within 9—12 months. But the government
directive is that he cannot be made fit till all his skin
smears are negative on repeated examination. As it
is impossible to achieve this, the man loses his job
adding to the problem further.
8
Administrators* lead: Thus a radical change is
needed immediately in our thinking and attitude and
especially for those who would become administrators
in government. Every administrator should know
about leprosy and should look at it in the correct pers
pective. Any amount of legislation is not going to
rectify the situation. But if public officers give a pro
per demonstration, by showing the correct way, it will
help greatly in changing the present public attitude to
leprosy. It must be remembered that we are dealing
.with a human problem and, therefore, though we may
not be absolutely scientific in our approach, compas
sion is of importance and would form a major factor
in the success of such welfare schemes. Otherwise,
most of the projects which look very good on the face
of it would remain merely as schemes on paper.
Integrated approach for rehabilitation
I feel that the integrated approach for bringing about
substantial rehabilitation and for breaking the stigma
should be implemented. In such a programme cured
leprosy patients with or without deformity should be
given vocational training, with the ultimate aim of
rehabilitation, along with the orthopaedically handi
capped, other handicapped persons like those with loss
of vision, and the socio-economically dis-advantaged
but able-bodied individuals in an integrated manner.
Such a programme is in its experimental stages in our
institution and we hope to produce some interesting
results in the next few years.
Self-employment and sheltered workshops : At
present it is well-nigh impossible to get leprosy patients
employed in open industry which means that after
their training they may have to be re-settled in self
employment or for certain cases in sheltered work
shops. Schemes of self-employment have indeed pro
ved successful but after a lot of spade work because at
every step the leprosy stigma interferes. Social wel
fare facilities like bank loans for the poor section of
society are denied to leprosy patients on the premise,
‘how will a leprosy patient earn in order to repay the
loan?’ This we have overcome and many patients have
received bank loans and have repaid them with a much
less defaulter rate than among non-leprosy cases.
Even then all these facilities are marginal and much
more requires to be done for the leprosy handicapped.
Cost benefit ratio' is favourable
I am confident that the cost-benefit ratio of rehabili
tation schemes is very favourable. The results of
available research studies do not appear to demons
trate any conflict between the humanitarian basis for
rehabilitation service provision, and the basic princi-
Swasth Hind
At present it is difficult io get the leprosy
patients employed in open industry, therefore.
self-employment is an important means of
rehabilitation.
pics of socio-economic planning. Disability will create
a cost to society regardless of whether or not rehabili
tation services exist. Nor can the cost-benefit model
indicate the value placed by disabled people on the
services they receive. In our planning we have only
been asking questions to di fie rent experts. Have we
cared to ask a leprosy patient what rehabilitation
means to him? Even the smallest service done to him
may have changed his entire life, and it must be
remembered that there is no scale by which human
values and happiness can be measured.
Rehabilitation in society
"'Inside the Society” and “Outside the Society”:
To begin with and as long as the stigma against leprosy
is strong the relevance of rehabilitation inside or out
side the society may not be taken as of great signi
January 1983
ficance. As long as the patient is socio-economical ly
well rehabilitated he gets assimilated into the com
munity—-and this is an encouraging feature. Full
integration “into the society” is an ideal situation.
striving for which, we should not lose our pragmatic
approach to the general question of leprosy rehabili
tation.
Four thousand years ago on a stone tablet is shown
a disabled Egyptian carrying out certain rituals in
which his family is helping him. No signs of social
stigma are apparent and the disabled man is allowed
to take part in all the religious rites in the temple
along with the other members of society. How and when
and at what period of time in the development and
evolution of the human race did stigma for the dis
abled come about?, consideration of the question
would be an interesting exercise for a social scientist.
o
(10) To break the stigma an integrated approach is
feasible and seems useful.
(11) In rehabilitation programmes one should not
forget the female leprosy patients who require
support as many of them after getting the
disease arc abandoned by their husbands and
are required to become self-reliant.
(12) Family planning should be vigorously pursued
so that the rehabilitated patient is not burde
ned by additional socio-economic problmes.
(13) Government departments and government offi
cials must give the lead in leprosy programmes
showing thereby conquest over stigma. This
can be achieved not only through scientific
understanding but in a great measure by the
application of compassion and dedication:
J
*
Leprosy patients should be given vocational training
such as carpentry with the ultimate aim of rehabilitation.
Points for education
At every stage the stigma comes in our way and in
conclusion the following points may be recapitulated:
(1) Leprosy is a mildly contagious disease.
(2) It is not hereditary.
(3) It is curable.
(4) Infectious cases become rapidly almost noninfectious when kept on adequate modem
chemotherapy.
(5; The degree of deformity is not a measure of
infectivity. As a matter of fact, many of the
highly deformed patients are of the non-lepromatous variety and completely non-infectious.
(6) Rehabilitation is possible through vocational
training centres.
(7) Self-employment is an important means of re
settlement.
(8) Sheltered workshops would be required for a
certain percentage of cases.
(9) Leprosy stigma is the one single interfering
factor in implementation of
rehabilitation
schemes.
10
(14) Compassion above all.
Will leprosy spread?
Lastly, arc there any chances that by taking the
above measures we would be increasing the spread of
leprosy? The answer to our above questions is an
emphatic ‘NO’. According to epidemiological studies
prevalence rate of one patient per thousand popula
tion constitutes a health hazard. In India the general
prevalence is five per thousand, and we are all ex
posed to a certain measure of danger which is not in
creased at all by the measures given above. As a
matter of fact, with the disease coming more into the
open and with greater stress being paid? to it and
with greater number of patients under-going treatment
the danger of spread should diminish.
There are several government schemes for the reha
bilitation of handicapped persons. There are also
directives that handicapped persons should be given
job preference and even legislation is mooted to re
serve a certain number of jobs for them. Leprosy is
supposed to come under the orthopaedically handi
capped group but this does not take place in practice.
Any amount of social welfare legislation will not solve
the proplcm. Therefore, the job selection and other
panels constituted by government should have on
them a leprosy worker interested in the welfare of
leprosv patients and having some experience of reha
bilitation work and above all he must not himself
suffer from the stigmatized attitude about the disease
which is universally prevalent.
A
Swasth Hind
CHILDHOOD LEPROSY
Dr S. Theophilus
The child is liable to be infected not only from a family member if there is
a case in the house, but also from his schoolmates. The infection the child gets
from the schoolmates surprises the family when a single child in a family is
infected and the parents and the relatives are completely free from the disease.
the beginning it might be prudent to mention
that the word “leprosy” is embarrassing to many
people and so we will henceforth refer to this as
“Hansen’s disease” and avoid the use of the word
“leprosy”, especially “leper”.
t
A
Leprosy, also called Hansen’s disease after the dis
covery of leprosy bacillus by Dr A. Hansen, in
children presents some characteristics which make it
different from the disease seen in grown-ups. By
children we shall consider the whole age group from
school-going age to around 15 years. During this time
the child has already been weaned from the mother
and started going through kindergarten to primary
and middle schools. The child is liable to be infected
not only from a family member if there is a case in
the house, but also from his schoolmates. The infec
tion the child gets from the schoolmales surprises the
family when a single child in a family being infected
when the parents and relatives arc completely free
from the disease. Sometimes this leads to despairing
cry of the parents “we don’t know how this child got
the disease. Nobody in our family has ever had this”.
The following points are important in case of child
hood leprosy—
1. It must be remembered that the child does not
remain as such for a long period and any use
ful treatment should be not only effective and
safe, but also of relatively short duration to
come within the childhood period.
2. A good portion of the child’s time should be
- occupied with education and recreation,
intellectual and physical activities. So any use
January 1983
ful therapy should guarantee freedom from
physical pain and muscle weakness which could
only be effected by long-term immuno-suppressive treatment.
3. The social and psychological aspects of the
child’s life, being of paramount importance,
should be specially taken care of by creating a
sense of security and if need be, by transferring
him to a more congenial social milieu.
The disease in its simplest form shows a vague patch
which is paler than the surrounding normal area.
Usually these patches are single or a few only. They
do not lead to any great discomfort and sometimes
fade away spontaneously or after regular treatment, in
a few years. However, if they are on exposed parts
of the body they may cause embarrassment to the
child because the child might be the target of derision
or aversion from other children.
There is, nowever, a more dangerous variety which
does not show itself so clearly by changes in the
skin colour but involves the more deeper lying nerves.
Initially, there might be slight weakness of the hand
or foot muscles which is not considered significant
enough to be shown to a doctor. The result is that
the disease progresses in the body and becomes evi
dent after some years in the form of paralysis of the
hand or foot, and often also in contracture of the
fingers and toes. Since sometimes these nerve dama
ges are multiple, they lead to serious limitations in
movement and work and also to unsightly and pro
minent deformities.
11
The most dangerous type, however, is where the
disease has spread into the deeper organs and shows
itself in widespread skin and nerve damage. Again
because these changes initially are mild and insigni
ficant treatment is not sought for by the sufferers till
many years later. Sometimes this could be as long as
10 or 15 years. By ihis time the infection has spread
widely throughout the body, needing sometimes almost
a lifelong treatment. These types of cases which arc
classified as ‘lepromatous type* of Hansen's disease
are a further danger to the society because they can
be highly infective and healthy persons who come in
intimate contact • might also acquire this disease.
A boy of eight years with single hypopigmented patch
children should be kept in such a state of health as to
be able to attend to their school activities as comple
tely as possible. This means that they not only have to
study but also to actively participate in games and
other physical activities. Most vital of all their capa
city to normally integrate socially should not be
Spread of infection throughout the body.
Only face is shown here with nodules on
the earlobes, cheeks, nose and chin.
It is, therefore, necessary that whenever a change
in '‘he skin colour or sensation is noticed, the child
should be examined by competent medical personnel
and treatment initiated at an early stage. Otherwise
what would be a few years of simple treatment will
have to be prolonged to many years with the need for
a more careful medical supervision and greater co
operation of the patient. Finally, some who are not
properly treated early enough may even need a life
long treatment.
One aspect has to be thought of very seriously with
regard to Hansen’s disease in children. The affected
12
Multiple deformities in hands and feet in a boy
of about 12 years. '
Swasth Hind
impaired. So, treatment has to be carefully but vigor
ously monitored so that the physical pain and dis
abilities arc minimized as much as possible. Added
to this, there should be an orientation and motivation
of the child. He should be able to realistically adjust
to the idea of having the disease which is interwoven
with prejudice and superstition. He should not be
allowed to get depressed to that extent that he be
comes estranged socially from the other children. This
will demand not only counselling of the child but also
of the parents and the group of people closely involved
with the child in his daily activities like the supervisors
and teachers. It is not a very great advantage to the
child to have expert medical attention which looks
after his physical problems, if his psychological and
social background is neglected to that extent that he
becomes maladjusted in the society. Obviously, there
fore, treatment should be integrated by the help of
a team which should consist of competent doctors,
psychiatrists and social workers who could channelize
and programme the total rehabilitation of the child.
This will need also the help of the parents and
teachers.
Treatment
So far as the treatment is concerned, the child
should preferably be started with multi-drug therapy.
Where it is thought that the commencement of the
disease is of recent origin it might be safer to avoid
Depsbnc because the greater possibility of resistance
to this drug today than it was some years ago. The
combination drugs should be Clofazamine
plus
Thiacctazone. together with, when necessary, the more
costly Rifampicin which should be judiciously and
carefully employed. Physiotherapy for stiffness and
deformities of the feet and hands should be started
early so that there will be no interference in the dayto-day activities of the child like walking and writing.
There should be a continuous and sustained treat
ment to keep the child free from pain, swellings and
stiffness of joints, which might interfere with his nor
mal active study and movements. A more vigorous
but at the same time regular supervision during treat
ment with drugs like corticosteroids, thalidomide and
analgesics is essential.
Finally emphasis must be given to the great need
and importance of the day-to-day social counselling
and periodically psychiatric reviewing of these cases.
This will help to keep them in a normal social
balance and prevent untoward after effects that lead
to their slowly evolving into anti-social elements or
worse still becoming social outcastes who find an
asylum only in the slums of big cities and take to
begging.
A
January 1983
SWASTH HIND
INFORMATION FOR CONTRIBUTORS
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try of Health and Family Welfare. Opinions express
ed by the contributors arc not necessarily those of the
Government of India.
Articles on every aspect of public health are invited.
They should be such as have not been published or
accepted for publication elsewhere.
The articles should be written in simple and non
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layman.
Articles should not exceed 2,000 words in length.
The name, designation and all relevant details about
the author should be clearly indicated in the begining of the article itself.
Manuscripts should be typed on one side of the
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Good illustrations enhance the value of the articles
and contributors are requested to submit photographs,
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Photograhps should be in black and white on glossy
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All photographs, charts, etc., should bear captions
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Lettering on charts, tables, etc., should be in black
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While sending photographs, drawings, etc., contri
butors should take care to see that they are not
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Each contributor whose article is published receives
one complimentary copy of the issue and 25 reprints
of his article.
13
IMPORTANCE OF SCHOOL AND
MASS SURVEYS IN LEPROSY CONTROL
Dr R. Ganapati
This article sums up the experience of the author about school surveys carried out
in the city of Bombay over a period of more than a decade. Figures collected over this
period under urban field conditions also indicate the importance to be given to the school
surveys in planning leprosy eradication programmes.
eprosy control programme in India is essentially
L
based on the principle of survey, education and
treatment (set). In the absence of the availability of
effective vaccine, and working under conditions where
isolation of all infectious patients is impossible, it is
but reasonable to lay great emphasis on surveys of
whole population in order to unearth early cases and
bring them under regular treatment with multiple
drugs which are advocated widely today in order
to reduce the quantum of infection. Surveys of whole
population undertaken with great case in villages by
trained para-medical workers are not always easy to
carry out in urban areas. In rural as well as urban
areas school survey has been thought of as an impor
tant method of case detection, as the coverage of
such captive population is much easier and inexpen
sive. Since the school-going population is relatively
more in urban areas and because of the fact a very
large number of school-going children can be sub
jected to screening in quick time, school surveys
specially in urban areas have come to occupy a very
high place of priority in leprosy control programme.
How are they important?
The high proportion of children in 6 to 14 year
age-group suffering from leprosy and attending leprosy
clinics in Bombay prompted massive school surveys
in the early part of the last decade. While surveys of
10 per cent of child population attending randomly
selected municipal schools revealed a general preva
14
lence rate of 3 per 1000, there existed pockets of endemicity of the order of 10.8 per 1000, in some schools
situated in the northern suburbs of the city. Even
private schools catering to the not-so-poor sections
of the community showed prevalence rates of over
6 per 1000, confirming the hyperendemicity of leprosy
in Bombay city, with no socioeconomic or age-group
immune from exposure.
Clinical observations on 1265 leprosy cases identi
fied in the course of the above surveys covering a total
population of nearly 1.8 lakh school children showed
that 24.7 per cent of the cases had either the potential
to develop into progressive forms of leprosy in view
of the multiplicity of patches or were already in an
advanced stage of the disease.
Poor substitutes to mass surveys
Analysis of 953 cases with single patches revealed
greater frequency of distribution (58.4 per cent) of
patches in parts of the body which are generally
covered. It is striking that 26.4 per cent.of the solitary
patches were found on the buttocks and thighs empha
sizing the need for thorough examination of these
parts during surveys. However, it must be stressed
that school surveys should not be looked upon as a
separate entity and it should be considered in the
larger context of total leprosy control programme
whose aim is to successfully break the chain of trans
mission of the disease in the community. The question,
therefore, arises as to how such a large number of
Swasth Hind
PREVALENCE RATES. 0F LEPROSY IN
in the identification of significant number of cases
in the community, cither in numbers or in proportion
of infectious eases. This observation implied that most
children detected to have leprosy in the school were
infected from sources outside their homes. So if our
objective is to unearth infectious patients in the whole
community and bring them under effective treatment,
school surveys are poor substitutes for mass surveys.
If the experience in Bombay is any indication, the
infectious patients are to be found in alarming num
bers in the slums and in 8 to 10 leprosy colonies
which are situated in and around the city and the
infectious sources which act as reservoirs are gene
rally the adults and not children. A look at the follow
ing diagram will indicate the relative pools of in
fection existing in various strata of the community in
Bombay with 8.3 million population, 50 per cent
of which lives under most insanitary conditions imagi
nable, namely slums, as opposed to situations where
leprosy patients group together in self settled colonies.
Community problem
1------- V---- ’
SCHOOLS
TENEMENTS COLONY
children gets infected and how to prevent this. It
is also important to see whether by examining the
household contacts of children detected through
school surveys, we can identify the infectious sources
in the community at large and thereby bring them
under treatment. In order to get an answer to these
problems, an epidemiological study was conducted in
a large isolated slum in Bombay with a certain num
ber of schools situated within the slum catering to
the education of the children of the slum. The results
of this Study showed that although school and family
contact examination was more economical as regards
time, money and personnel involved, it does not result
It is easy to imagine how leprosy spreads from
such reservoirs to infect the child population at large.
According to modern concepts of transmission of
leprosy, it is believed that the leprosy germs can
pollute the atmosphere in the same manner as those
causing tuberculosis. Prolonged intimate contact with
the persons suffering from the disease does not seem
necessary. Only susceptible subjects exposed to in
fection develop the disease.
Repeated screening of child population in leprosy
control programmes will be meaningless if reservoirs
of infection are not tackled with proper chemotherapy
with multiple drugs as now advocated by recognized
world authorities. There is no doubt that it is because
these sources are not properly managed, there is a
continued chain of transmission placing the school
children at large at high risk. It has to be concluded
that if school surveys have .to be meaningful, leprosy
should be thought of as a problem in the whole com
munity and not as one confined to schools alone. A
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Kotla Marg
New Delhi-110 002
January 1983
15
TRAINING AND DEVELOPMENT
OF MANPOWER IN LEPROSY
Dr Claire Vellut
patient with early signs of leprosy consults
usually either the medical officer of the Primary
Health Centre or a general practitioner. A few exam
ples, all seen by us personally, will show that the first
need in training is, in fact, in medical colleges.
A
The first need in thereontrol of leprosy is the
arrangement of adequate teaching in medical
colleges, schools of nursing,
centres
for
multipurpose
training
workers,
health guides, general physiothera
pists and laboratory technicians.
As long as this
is not done,
leprosy will continue to be
considered as a ‘special
disease’and the patients
will not get the benefits
°f proper diagnosis
and treatment.
— a boy in high school, with a patch on the
forearm is treated with ointment, ignoring the
thickening of the ulnar nerve, till he deve
lops a claw hand.
— a girl with a few patches on the skin, an ulcer
on the sole of the foot, is treated with tonics
and antibiotics.
— patients with severe erythema nodosum arc
treated in general medical wards and nursing
homes, without the diagnosis of erythema
nodosum leprosum being made.
— Facial palsy due to leprosy is treated as Bell’s
palsy and borderline leprosy is treated as
urticaria.
These examples will make us understand the prime
importance of adequate teaching in medical colleges,
schools of nursing, training centres for multipurpose
workers, health guides, general physiotherapists and
laboratory technicians. As long as this is not done,
leprosy will continue to be considered as a ‘special
disease' and the patients will not get the benefits of
proper diagnosis and treatment.
Moreover the new approach in therapy of leprosy
has to be made known not only in colleges but in all
professional medical and para-medical associations.
16
Swasth Hind
Being given the high number of leprosy patients in
India (about 40 lakhs) a special programme has been
drawn since 1955. The National Leprosy Control
Programme (nlcp) started in 1955 has been deve
loped progressively during the yea,rs> covering 324.00
million population and treating 21.50 lakh patients.
The nlcp has recently received a new priority as
leprosy control has been included in the Prime Minis
ter’s 20 points programme.
The objective of the nlcp is to detect and treat
all patients so that all arc cured without deformity
and the transmission of the disease is stopped.
About 25,000 medical and para-medical personnel
are working, under nlcp, in leprosy control units
and institutions all over the country. Their training
is to be planned and organized so that each type of
personnel is prepared to perform clearly definite acti
vities and functions. Many voluntary organizations
and international agencies are making an important
contribution in the field of training.
Medical. Officers
At any point of time, 1,500 doctors should be
working full time in leprosy. There is a great difficulty
in recruiting doctors in this field as many miss the
'professional interest of this challenging disease and
fear financial loss. A separate and specialized cadre for
medical officers in leprosy with sufficient promotional
incentives, has been proposed.
About 400 medical officers should be trained every
year.
This orientation course should last for six
weeks and should be given before their posting in
leprosy units. The contents has to include the develop
ment of leadership and communication skills as well
as the teaching of the clinical and therapeutical as
pects of the disease.
(2) education of the public and the patients and
encouraging community participation;
(3) distribution of drugs; and
(4) diagnosis of complications to be referred to
the medical officer in the unit.
1,700 have to be trained annually in the 42 existing
recognized centres. The duration of the (raining is six
months and includes field posting with trained staff.
Refresher courses have to be given to them regu
larly, specially at this juncture when therapy of
leprosy undergoes drastic changes.
The supervisory staff’s posts are to be filled by
promotion of the basic workers. They are to be given
a refreshers course of two to four months duration in
leprosy and supervisory techniques.
There should be one supervisor for every 5/7
workers. About 2,000 non-medical supervisors are in
service, but only 500 of them have been trained ade
quately. For the moment only four centres are re
cognized for training.
Health Educators, Physiotherapists, Laboratory
technicians are employed directly by nlcp.
These categories of personnel trained in general
centres arc not sufficient in’ number and arc not keen
to work in the field of leprosy. Hence, the creation of
specialized centres for the formation of “technicians”
employed only in leprosy institutions. There is one
centre for health educators, four for physiotherapist
technicians, four for laboratory technicians. The num
ber of these training centres is hopelessly inadequate
and more centres are to be opened.
Six centres have been recognized for giving this
training and 15 others have been proposed.
Para-medical field staff
The basic workers are called para-medical workers,
non-medical assistant leprosy technicians, leprosy ins
pectors etc. At present, there are 15,000 of them in
the country, about 5,000 are not trained. It is difficult
to understand how untrained staff can do justice to
their work, namely,
(1) detection of cases (clinical and bacteriological
examination);
January 1983
As bacteriological examinations of all cases is very
important, it is proposed to have a cadre of “field
laboratory assistants” to carry out routine skin
smears and certain basic clinical tests only.
A full army of medical and para-medical workers
can be mobilized, at high cost by the National Leprosy
Control Programme, but the battle will be lost if the
general medical and para-medical personnel do not
deal in a competent manner, with leprosy patients,
as with any other disease.
/\
17
HEALTH EDUCATION
IN LEPROSY CONTROL
Dr B. C. Ghosal
. and
T. K. Parthasarathy
The perceivable changes in the people’s belief and attitude towards the disease and the
patients, brought about by the modern scientific advancement, highlight the important role
health education will have to play in bringing about the eradication of the disease.
he mention of the word ‘leprosy’ brings to one’s
mind the picture of patients with deformities in
the hands and feet, begging at public places or seeking
alms at places of worship. There are patients with
depressed nose, blind eyes, nodules in the ear lobes,
etc. All these deformities are more due to neglect of this
disease for a long period and not the direct result of
the disease itself. If the cases had been detected in
the early stages and put on treatment and continued
as long as medically advised, the deformities would
not have set in. The delay in taking treatment is due
to many factors. People consider that leprosy, which
has been prevalent from time immemorial, is caused
by divine curse for the sins committed in the previous
birth and cannot be cured. This divine curse theory
results in the patients not taking treatment even though
drugs are available to cure the disease completely. It
is also believed that the disease is hereditary, and con
sequently families with leprosy patients suffer social
stigma. The disease is concealed to save the honour
of the family and this concealment leads to the ad
vance of disease with consequent deformities.
T
Though the discovery of leprosy bacillus as a cau
sative organism by the Norwegian Scientist, Dr G.H.A.
Hansen in 1893 had exploded the hereditary theory
and superstitious beliefs. False notions and wrong
beliefs still plague us even today. Mahatma Gandhi,
who had deep concern for leprosy patients, had said:
18
“Why should there be a stigma about leprosy any
more than about any other illness.”
Leprosy is not just a medical problem but a socio
economic one as well and had to be tackled on both
the fronts.
The perceivable changes in the people’s belief and
attitude towards the disease and the patients, brought
about by the modem scientific advancement, high
light the important role health education will have
to play in bringing about the eradication of the disease.
There are nearly 3.2 million leprosy cases in India.
Of these 15 to 20 per cent are of infectious type and
25 per cent with disability of varying degrees, It is
poignant to note that 25 per cent of the cases are
children. About 2.4 million cases have been detected
and 2.2 million have been put under treatment. It is
reported that in certain leprosy control unit areas
there has been reduction in the number of cases. This
is yet another pointer for intensifying the health edu
cation, which aims at bringing about changes in the
beliefs, attitudes and practices of the people through
a process of education. It should provide scientifically
correct information on leprosy, its causation, mode of
transmission, treatment and rehabilitation. This will
enable people to go in fbr medical check-up on the
appearance of signs and symptoms of the disease
such as discoloured patch in the skin with and without
loss of sensation.
Swasth Hind
Objectives of health education
1. Remove wrong notions about the disease and
the patients.
2. Motivate people to go for medical examination
on the appearance of signs and symptoms of
the disease.
3. To motivate patients to take regular and com
plete treatment.
4. To help in rehabilitation of the cured patients.
Plan of health education
Health education has to identify the problems of
different target groups and initiate a programme to
remove these.
Health education plan has to be geared to the
needs and aspirations of different identified target
groups. These are general public, patients, patients’
family and close friends; medical and para-medical
personnel, employers and employees.
Message content also will vary according to the
needs of different target groups.
A set of general information on leprosy can be used
with all target groups.
(1) Leprosy is like any other disease and caused
by an organism, known as lepra bacillus.
(2) Leprosy is not hereditary.
(3) Leprosy is preventable.
(4) Leprosy is curable.
(5) A depigmented patch on the skin with the
loss of sensation may be leprosy. The person
having such patch should go to the doctor for
check-up.
(6) There are very powerful drugs to cure leprosy.
(7) Not all cases of leprosy get deformities.
(8) Most of the patients begging are not infectious.
(9) Regular and complete treatment with adequate
drugs can cure the disease and prevent defor
mity.
(10)
All patches are not leprosy.
These messages should be put out in different
channels of mass communication media. Health edu
cation does not exclude any media of communication
January 1983
nor does it exclude any educational method. There
fore, the scope of health education is very wide as it
encompasses all situations and all sections of the
population although educational efforts should be
directed towards specific groups according to the
nature of the problem and the specific work to be done.
Mass media channels can be used to carry the
general messages identified for the education of the
community. The messages should be suitably modi
fied to suit the different media but the spirit behind
these messages should be respected. The mass media
can create a general awareness about the problem and
this sensitization should be properly cashed in by
organizing work groups—professionals, public spirited
persons, voluntary organizations, youth and women’s
organizations, etc.,—to take up specific work to carry
the messages further down.
Patient education
Patient education is best done by the treating doctor
and the para-medical and health personnel. All that
the patient needs is reassurance that he can be com
pletely cured and that, he should cooperate with the
medical team for regular and complete treatment. This
can be effectively done by organizing group meetings
of patients and discussing with them the why’s and
how’s of the procedures to be followed during the
total treatment period. The health team can be cata
lysts and the community should take up such pro
grammes. Teaching aids as flip charts, flash cards,
2x2 slides, film strips, picture books, etc., can be
very useful in group education. Some of these can be
made locally at low cost. The workers should also
be trained in the preparation and utilization of such
communication media.
MESSAGE FOR PATIENTS
General Message plus :
* Regular and adequate treatment can cure leprosy
and prevent deformity.
* Even deformity can be corrected by surgery.
* Patient can live with his family while
going treatment.
under
* Patient need not get admitted to hospital
routine treatment.
for
* Regular and adequate treatment not only cures
the patient but also helps in preventing disease
spreading to family members.
19
Family members
School system
The next in the order of priority is the family of
the patients including close friends. The family needs
to be convinced that leprosy is the least communicable
of all diseases; there is no need to segregate the pati
ent; the all family members should get themselves
examined at least once a year. The family should help
the patient to take his medicine regularly and in
adequate quantity and as long as the doctor has ad
vised him to do so.
■ Nearly 25 per cent of the leprosy cases being chil
dren. health education should place higher stress on
this group. The children should be brought for medi
cal examination so that those who arc found positive
may be put on treatment immediately. Dr S.G.
Browne. Director of the Leprosy Study Centre, Lon
don, in his introduction to the who booklet “Lepro
sy in Children” by Dr F.M. Noussitou says that a
thorough inspection of the skin is all important. Dr
Noussitou says that “coordinated health education
activities should be carried out by the public health
services in change of leprosy control activities, the
school health officers, and private social organizations
concerned with leprosy or with child health problems
in the community”.
MESSAGE FOR PATIENT’S FAMILY
General Message plus :
* Leprosy is the least communicable of all in
fectious diseases.
* There is no need of segregating the patient.
* Get all the family members
year.
examined once a
* Help the patient to take his medicine regularly,
in adequate dosage as per the advice of doctor.
Health workers
Health workers including para-medical
workers
should reassure the patients and the family about the
possibility of complete cure. There is no necessity
for any specialist’s help to diagnose leprosy. They
should keep themselves updated about latest infor
mation on leprosy.
MESSAGE FOR MEDICAL AND
PARA-MEDICAL WORKERS
General Message plus :
* Diagnosis and treatment of leprosy is like treat
ing any other disease.
MESSAGE FOR TEACHERS
General Message plus:
* There is no need for specialist’s help in diag
nosis and management of leprosy.
* Leprosy is the least communicable of all
infectious diseases.
* Assure and re-assure the patient in a human
way about the treatment and reduce his trauma.
* Most of the child patients can continue
to attend school.
* Encourage the patient's family members to get
examined at least once a year.
* Ensure that the child patients take regular
and adequate treatment.
* Keep him abreast of the latest scientific infor
mation on leprosy.
* Ha’p voluntary agencies and public men in
their assistance to leprosy work.
20
Dr Noussitou emphasises the need for regular sur
veys where the general prevalence rate of leprosy is 5
per thousand or more. According to some published
reports, among 50,697 school children, most of them
in 5-16 years age group, examined in greater Bombay,
51 cases of leprosy were detected giving a rate of
2.97 per 1000. Another 2912 children, aged 5-16 years.
in schools located in a hyperendemic locality. 33
leprosy cases were seen giving rate of 11.3 per 1000.
Such findings in large urban community underline the
importance of school surveys as a case detection
method........... , says Dr Noussitou. This highlights
the importance of working with school system—the
educational authorities, the school health services, tea
chers and parents—in health .education.
Teachers.
parent-teacher
Associations need to be given
orientations in leprosy so that they can offer their
cooperation to the leprosy control authorities. Book
lets, folders, identification cards, etc., will be useful.
Teaching aids such as 2x2 coloured slides, film strips
picture books can be used in this area of work.
* Get all the children in the school examin
ed at least once a year.
* Help spread correct information about
leprosy, among school children and
among people.
Swasth Hind
Employers
The employees and the employers are the next
important group to be reached. They are very impor
tant because the patient should be able to go back to
his job once he is completely cured. These groups
must be given correct information about the disease,
its causation, treatment and how a completely cured
patient can do normal work. Once declared negative,
the patient is no more a danger to others. The initial
investment in the employee is secured once lie is taken
back into service. Only in a very few cases change
of jobs will be necessary.
MESSAGE I OR EMPLOYERS
General Message phis:
*>Gct your employees medically checked
up.
* Send the leprosy patients for
treatment.
prompt
* Encourage patient (employee) to take re
gular and complete treatment.
All these activities have to be carried out invoking
the general public. Where public participation is en
sured, half the battle is won. People who can give
time for public service, retired people who would
like to serve public cause, can play a dynamic role in
health education. They can explain the general mes
sage al public»meetings, conferences, and also help
in case detection, case holding', rehabilitation and
treatment. They can ensure that the patients take
drugs regularly and go through the complete course.
The emphasis has to be laid on the prevention of
dchabilitation. All such public spirited men and
women should be supplied educational/publicity
materials and helped whenever they needed assistance
from programme experts. Voluntary organizations
such as the Hind Kusht Nivaran Sangh. Rotary, Lions,
etc., by their nature, are closer to the people. They
should be assisted in their programme activities.
MESSAGE FOR PUBLIC MEN/OP1N1ON
LEADERS/REL1G1OUS LEADERS
General Message plus:
* Take back into employment cured leprosy
patients. They do not spread the disease.
Spread correct knowledge about leprosy
among the people.
• Change jobs for cured leprosy
wherever necessary.
lake active part in the anti-leprosy pro
gramme.
patients
MESSAGE FOR EMPLOYEES
General Message plus:
* Be understanding to your colleagues who
might have suffered from leprosy.
* Help your community to detect cases and
ensure that the patients take regular treat
ment and in the rehabilitation of cured
patients. Set an example by participating
in (he National Leprosy Control Pro
gramme.
* AH leprosy cases are not infectious.
Training of workers
* Cured leprosy patients
disease.
do not spread
* Report to the medical authorities if any
of your colleagues show signs and symp
toms of leprosy.
* Do not despise a cured patient.
The factory administration can be supplied lite
rature on the subject. Newsletters regarding latest
information about the leprosy can be regularly mailed.
Bulletin Boards can be successfully employed in the
factories/working places for general information.
January 1983
Leprosy programme workers should be given sotjnd
training in health education and communication so
that they -can understand their role clearly and or
ganize suitable educational programmes. This will
help in case detection, case holding and prevention of
dchabilitation.
A concerted attack on the problem with sustained
educational programmes will go a long way to reach
the goal of eradication within the next two decades.
The programmes should be continued till the goal
is reached.
a
21
LEPROSY CONTROL
Contribution of
Voluntary
Institutions
Dr S. P. Tare
The voluntary institutions have a special role
to play in leprosy field where there is so much
to explore and great scope from innovation,
experimentation, initiative and sympathy.
Their contribution in the national leprosy
work has to be qualitative in a manner which
can be helpful for the Government to expand
its work on a national scale.
rganized leprosy
work in India was being done
by voluntary institutions for about a hundred years
before the government stepped in a real big way.
Some of the State Governments were running a few
leprosy clinics and managing a few leprosy colonies
in the thirties and forties of the present century, but
that was only a token work. Since 1954 the Govern
ment of India has accepted leprosy work as its res
ponsibility and has taken it up with the objective of
controlling it, leading to the final goal of eradicating
the disease. The voluntary leprosy institutions, who
were pioneers in this field are still working, have mul
tiplied to some extent and have expanded their work.
Their contribution in quantitative terms is smaller
when compared to the expansion of the Government
work, in the last 21 years, but that contribution, as is
accepted by all, is indeed valuable.
O
22
There will be no two views about the definite place
for voluntary activity in any field of work, be it
leprosy or social welfare or education. It is more so in
case of leprosy work because of some of the charac
teristics of the leprosy problem. But it must also be
admitted that all voluntary institutions together cannot
fully tackle the problem in their respective field of ac
tivity without government’s active participation on a
large scale. Hence, when it comes to wide coverage or
quantitative .expansion, it has to be left to the Gov
ernment. What we should expect from the Govern
ment is that it should cover all endemic areas by the
control work and make the drug available to all
patients through a very wide net-work of out-patient
departments. Evidence of control of leprosy has to
come from voluntary leprosy institutions which can
work intensively and effectively in a comparatively
smaller areas.
Voluntary leprosy institutions have the advantage of
a band of committed workers, a smaller and compact
area to cover, facilities of constant and closer super
visions and a flexibility in the approach where modi
fications or corrections can be quickly introduced.
Taking these characteristics into account, the volun
tary institutions can cooperate in the National Leprosy
Control Programme nlcp in four spheres: 1)
Demonstrative, 2) Exploratory, 3) Supplementary, and
4) Ameliorative.
Demonstrative work
Voluntary leprosy institutions can conduct model
leprosy centres of various types (set. Leprosy control
Units, Urban Leprosy Centres, Referral Hospitals,
etc.) where utility of such a centre can be established,
and necessary modifications to the plan and methodo
logy can be considered depending on changing cir
cumstances. All these centres in more numbers will
also be run by the Government and hence the centres
run by voluntary institutions will serve as demonstra
tive models for the Government workers and also to
try out or experiment with the changes necessary from
time to time.
In order to help the private leprosy institutions to
fulfil their role of doing demonstrative model work,
the Government should give following assistance:
1. To encourage voluntary institutions, to esta
blish any type of leprosy work if they have
necessary trained personnel. For this, the
Government should be prepared even to vacate
from an already covered area in favour of a
private institution.
Swasth Hind
2. To give freedom to these voluntary institutions
for making modifications in the methodology
of work provided they adhere to the objectives
as laid down in the Operational Guide.
Exploratory work
The second field of activity which should be left
largely to private leprosy institutions is exploratory
work. This includes taking up of pilot studies or pro
jects to find answers to various facets of leprosy pro
blem. Such studies are immensely essential for the
success of the leprosy control programme. For exam
ple, though our aim is to control leprosy, we have not
yet been able to demonstrate it in any area in the
country. There are some good institutions who have
given ample demonstration that the intensity and
complexity of the leprosy problem can be consider
ably reduced with control programme but there are
numerous factors which hamper and hinder control
of the disease. These and other epidemiological pro
blems need to be studied in field. Such studies are
urgently essential and voluntary institutions must de
vote themselves to this rather than duplicating the
government leprosy work.
Supplementary work
There are some fields of activity which can be
organized both by the Government and voluntary ins
titutions. but where the Government has some limi
tations in doing it effectively, these activities can be
entrusted to voluntary leprosy institutions, whereverthey exist, as supplementary work to the Govern
mental efforts.
1. Training centres’.
This is an activity whose
importance for success of the (nlcp) has unfortu
nately not been given due attention. In any training,
what is important to impart to the trainee is not mere
ly knowledge of the subject but also a sort of intellec
tual commitment to the subject. From this point of
view, the training imparted by a few private institu
tions in the country is definitely better and the Gov
ernment should encourage involvement of voluntary
institution in training of personnel.
(ii> Referral centres : With a wide network of
field leprosy centres manned mostly by paramedical
personnel and with increasing number of private prac
titioners taking up diagnosis and training in leprosy
there is greater need for centres where they can refer
difficult, complicated or cases not responding to treat
ment for advise and treatment. There are some well
developed private institutions with competent and
experienced medical staff which can be recognised as
referral centres. These centres, one in two or three
endemic districts, can be useful to leprosy techni
January 1983
cians of set centres, medical officers of leprosy con
trol units and private practitioners treating leprosy
patients.
(iii) Intensive health education work : Even
though health education is incorporated in the set
pattern of work since beginning, it has been observed
more in default all along these years. No aids of any
kind are available to most of the field workers. As
a result, health education which is so essential for
bringing out new cases and in holding cases for
treatment till their cure, has been and is being
totally neglected.
’ Voluntary leprosy institutions can be helpful in
getting their workers trained in health
education
techniques which is now a speciality, and they can
be entrusted with the responsibility of doing health
education work not merely in their own area of
work but also in the surrounding area or part of the
district which is covered by the Government.
(iv) Participation of Medical Practitioners and
other social bodies : It is accepted that active parti
cipation of all medical practitioners is absolutely
necessary for success of leprosy control and for re
moval of stigma about the disease from the society.
As long as the people feel that the attitude of the
doctors towards leprosy patients is not the same as
that towards the patients of tuberculosis or syphilis,
they (people) will not believe that the leprosy is like
any other disease. Those voluntary institutions who
have experienced medical men with ability to address
medical groups can take up this activity in their own
areas.
Ameliorative work
Leprosy is a medical problem but with very ser
ious social repercussions due to the chronic nature
of the disease and the cefituries old stigma prevalent
in all societies. The National Leprosy Control Pro
gramme has restricted itself primarily to the medical
side of it from strictly public health point of view.
It cannot, however, be denied that the patient has
not only the problem of having the disease but also
more serious problem of social boycott. The big
gest social problem, is that of rehabilitation of lep
rosy patients. The other allied problem is that of
beggar leprosy patients. There is also the problem of
married women patients who have been divorced or
disowned by the hunbands. We cannot completely
shut our eyes to the immense unjust suffering of
lakhs of leprosy patients, whether they are women,
cripples, beggars or other dehabilitated groups.
Voluntary leprosy institutions can and should look
after them.
A
23
This paper considers the management of immunological complications {reactions). Reactions
are episodic, inflammatory, excerhat ions of skin and mucous membrane lesions, occurrence of
fresh lesions and aggravation of pre-existing lesions in nerves andfor other sites. These epi
sodes are encountered in tuberculoid, borderline and lepromatGus leprosy.
Management of Complications in Leprosy
Dr G. Ramu
are manifestations which do not
form part of leprosy but interrupt the chronic
course of the disease resulting in increased morbidity
and sometimes mortality.
C
omplications
Complications can be divided into two important
groups:
1. Immunological complications or reactions.
2. Complications arising out of nerve damage.
Lepra Reaction
This paper considers the management of immu
nological complications (reactions) are considered.
Reactions are episodic, inflammatory, exccrbations of
skin and mucous membrane lesions, occurrence of
fresh lesions and aggravation of pre-existing lesions in
nerves and or other sites. These episodes are encoun
tered in tuberculoid, borderline and lepromatous le
prosy. Essentially reactions are due to a sudden alter
ation in the existing relationship between M. leprae
and the human host i.e., immunological response.
Tuberculoid Reaction
Borderline reaction
Acute, sometimes
insidious.
Less intense than Lepra
Reaction. Rarely
severe.
Onset
Acute
Insidious
Constitutional
symptoms
Fever, malaise, prostration, headache,
nausea, body aches, muscle & joint pains
Absent
Skin lesions:
Exudative exacerbation of nodules, plaques Pre existing plaques
and infiltration, (eel) erythema nodosum swollen, enlarged, and
Leprosum, scn or pemphigoid, pustula erythematous, tender,
Oedema in and around
ting and/or ulcerating lesions.
lesions. Rarely ulcera
tion of lesions.
Polymorphic lesions
erythematous, violaceous
circinate. Concentric, geo
graphic or psoriasiform,
oedema in lesions, ulcera
tion of lesions. Rarely
ENT. and pust ulation.
Extra cutaneons manifestation.
Neuritis, lymph adenopath. Iridocyclitis, Neuritis of cutaneous
orchitis, hepatosplcnomegaly,
arthritis and regional nerve trunk.
Rarely
nephristis oedema limbs, tendency to Nerve Abscess.
regional lymphadeno
recurrence.
pathy.
Neuritis, arthritis
Lymphadenopathy,
Oedema, Rarely systemic
involvement.
Prognosis:
Increased morbidity and mortality. Para Paralysis of muscle
lytic and non paralytic deformities (from groups supplied by
contractures resulting from deep seated peripheral nerve trunk
inflammatory reaction in the hands & involved.
feet and art hr hies of MP, pip).
Rarely
nephropathy from amyloidosis.
Tendency to assume ‘L*
forms. Multiple para
lytic deformities, if
change from bl or bb
to BT.
Cause
Due to combination of antigen/antibody Exquisite lymphocyte
and complement (immune - complex) response
locally or due to precipitation of circu
lating immune complex.
Combination of immune
complex and lymphocyte
response in varying
proportion.
24
Swasth Hind
Certain factors have been recognized to provoke
reaction namely injudicious antileprosy therapy and
some commonly used drugs such as (1) potassium
iodide, sulphanamides, hetrazan, etc., (2) physical,
physiological or psychological stress; (3) concurrent
infection, e.g., malaria, filaria, streptococcal and viral
infections, e.g., sore throat, chickenpox; (4) t.a.b.
vaccination and tuberculin testing; (5) excess of hot
food (spiced) and alcohol. At the very beginning of
treatment the provocative factors may be eliminated
by taking appropriate measures.
Treatment of mild reaction
In patients with mild reaction, i.e., a few enl or
excerbation of lesions (eel) with temperature below
100°F the treatment is with simple analgesic drug,
e.g., aspirin 300 mg twice or thrice a day.
Treatment of moderate reaction
In patients with a rise of temperature between 100102°F, enl and eel involving both extremeties and
or face and trunk give analgesics (aspirin) for painful
a rlh iritis, neuritis, etc. Chloroquine sulphate 150 mg
of the base or chloroquine phosphate 250 mg of the
base three times a day till fever subsides and later
twice a day for two weeks. If no response is obtained
within a week give potassium antimony tartarate
(PAT) 0:02 gm for three injections and later 0.04 gm
on alternate days for three more injections i.v. If
PAT is not available sodium antimony gluconate
(sag) two cc is given intramuscularly or i.v.
Treatment of acute severe reaction
In very severe reactions with temperature rising
above 102°F and enl or eel with pustuation, care
ful nursing and re-assurance are necessary. Use tranquilisers (diazepam) and aspirin and sag or pat
i.v. on alternate days for six to ten injections.
In
very severe reactions not responding to antimony or
in patients with severe anaemia and kidney involve
ment where antimony should not be given, give cor
ticosteroids Prednisolone (Deltacrotril) 20 to 40 mg
once a day. Reduce the dose gradually every six
days. A corresponding dose of Bctamethosonc or
Dexamethsone may be given.
anti-inflammatory properties. The steroids can be
taken off after four to six weeks in a gradual fashion.
In some casesit may take eight weeks to withdraw
steroids. The dose of clofazimine is reduced to 100
nig when reaction is controlled, i.e., in six to eight
weeks. A maintenance dose of clofazimine 100 mgm
daily for six months to one year is found to be neces
sary.
Side effects of clofazimine
In the anti-inflammatory doses used, besides red
and black pigmentation, and ichthyosis gastro-intes
tinal disturbances manifesting as griping pain or buring in the epigastrium, vomiting and/or diarrhoea
may be encountered. Rarely symptoms may simu
late acute abdomen.
The drug should be withdrawn at the first symptom
of abdominal pain and inh 300 mgm given to mobi
lize clofazimine from the intestinal wall. The drug
can be restarted after a week in a smaller dose—100
mgm daily. The symptoms are particularly severe in
female patients in whom a smaller dose is indicated.
Thalidomide'. Another very useful drug in steroid
dependant recurrent lepra reactions in male patients
is thalidomide. It is given in doses of 100 mgm thrice
daily till the reaction is controlled. Two to four
weeks later, 100 mgm daily (1 tablet) is given. A
maintenance therapy of 50 mg of thalidomide may
be required for well over a year or till the patient
becomes negative since after stopping thalidomide a
rebound phenomenon is frequently seen. Thalidomide
is known to inhibit the formation of antibodies and
does not have any action on lymphycyte response pf
t or bt reactions.
A combination of clofazimine and thalidomide
in a dose of 100 mgm of each drug three times a day
controls reactions in a very short lime enabling with
drawal of steroids in a week, thalidomide can be
withdrawn in the fourth week, clofazimine has to be
continued for six to eight months in a dose of 100
mgm daily.
Treatment of certain manifestations
Treatment of recurrent lepra reaction or chronic lepra
reaction
Acute Iritis:—One per cent atropine drops or atropine
ointment daily is essential. Steroid ointment or drops
can be usefully added. If eye ball tension is high
Diamox 1 tablet a day is given.
In such cases and in cases who cannot be weaned
off cortisteroids and who are in a state of smoulder
ing reaction, clofazimine is given along with steroids
in a dose of 100 mg three times a day because of its
Acute painful neuritis:—Give rest to the part with the
nerve in the relaxed position. Alleviate pain by anal
gesics and tranquilisers. If a single nerve is involved
give a perineural infiltration of novocain J ml. duva-
January 1983
25
dilan (a vasodilator) two ml Prednisolone 12.5 mg.
and Hyalasc 1200 units. This injection can be repeat
ed after two days. Prednisolone (Deltacortril) by mouth
is indicated in multiple nerve involvement. In the
acutely painful neuritis encountered in tuberculoid or
borderline cases use non-steroid anti-inflammatory
drugs, e,g.t capsules of Indomethacin or tablets of oxy
phenbutazone or brufen twice a day. whatever may
be the type of painful neuritis, clofazimine appears to
be' useful if given, in adequate doses e.g., 300 mg daily
for a week.
Reaction hand:—In chronic reactions, deep seated
inflammations of the dorsum of the hand results in a
painful swollen hand. If not splinted properly, on
subsidence it results in fibrosis causing non-paralytic
deformity. Therefore, during the painful stage keep
the hand elevated and in a functional position by
using a proper splint. When the acute phase passes
off, local corticosteroid injections with hyalase are of
help in mobilizing the skin from the adhesions. Phy
siotherapy is essential in such cases after the acute
phase has subsided.
Renal involvement:—When there is macroscopic or
microscopic haematuria with albumin and casts in the
urine, avoid antimony and give steroids. Fluid in
take is guided by urine output withdrawn.
Arthritis and periosteitis.—In some cases in the be
ginning arthritis may be associated with inflammatory
skin lesions. In others arthritis of multiple joints
sometimes with effusion occurs in painful episodic
attacks. This may involve the m.p. and i.p. joints
resembling rheumatoid arthritis. Intravenous or in
tramuscular s.a.g., two ml daily or alternate days is
very beneficial. Application of icthyol glycerine to
the joints gives comfort. Thalidomide given alone
does not give relief in this complication. A combina
tion of thalidomide and clofazimine is rapid in action.
Orchitis-. Painful orchitis should be treated with sys
temic steroids and with local application of
ten percent icthyol glycerine. Recurrent orchitis
results in destruction of the testes and in gynaecomastia.
Supre-renal involvement:
Superarenal involvement
may suddenly supervene over a reactional episode,
'particularly when the patient has been on long con
tinued steroids. This is manifested by a sudden sub
normal temperature, fall in blood pressure, hypogly
caemia and increased serum potassium levels. Ade
quate quantities (five per cent of total body weight)
of glucose and saline with 100 mg of hydrocortisone
succinate intravenously may be followed by 1 m
injection of hydrocotisone 25 mgm every eight hours.
Following recovery, oral cortico-steroid therapy and
gradual withdrawal under thalidomide or clofazimine
cover is indicated.
In the treatment of reactions in tuberculoid and
borderline leprosy where acute painful neurities is a
prominent symptom corticosteroids must be given in
adequate doses to avoid paralysis. In tuberculoid
and Borderline reaction including those of reversal
reaction without neuritis sag (sodium antimony glu
conate) 2 ml on alternate days gives dramatic results.
Continuation of anti-leprosy therapy
Unlike in the past anti-leprosy therapy with dapsone
is maintained in most cases. However, in cases who
are gravely ill or in cases with severe anaemia it may
be necessary to suspend antileprosy treatment with
dapsone for a short period.
A
CHANCHAL SINGH MEMORIAL PRIZE—1983
The Tuberculosis Association of India will award in 1983 a cash prize
of Rs. 1000 to a tuberculosis worker, preferably below 45 years of age, for
an original article not exceeding 30 double spaced foolscap typed pages
(approximately 6000 words), excluding charts and diagrams, on a subject
relating to Tuberculosis in which he or she is specializing or has worked and
adjudged best by a Special Committee of this Association. The article sent
in for this competition should be original and it should be certified that it
has not been published elsewhere.
Article or paper already published will not be considered for this award.
26
Those interested may send their article to the Secretary-General,
Tuberculosis Association of India, 3 Red Cross Road, New Delhi-110001, to
reach him on or before 30 July, 1983.
Swasth .Hind
SOCIO PSYCHOTHERAPY
an adjunct in the treatment of leprosy
Dr N. S. Chauhan and Dr Upinder Dhar
Medical treatment alone is not sufficient for the chronic disease like leprosy, but
the introduction of socio-psychotherapeutic programme is a must. This is one of
the most important tools that can help us in alleviating the persistent tensions of our
patients. Those tensions■> which remain in them although in the absence of proper
stimuli} can well be reduced by this procedure.
eprosy is a chromic infectious disease, affecting
the peripheral nervous system, skin, mucosa of
upper respiratory tract, reticuloendothelial system,
eyes, bones and testes. It is caused by mycobacterium
leprae, first discovered by Gerhard Armauer Hansen
(1841-1921) a Norwegian Physician in the year 1873.
L
The disease is characterized by a long incubation
period, of about 2 to 5 years, and a chronic course
with the development of lesions in the skin and peri
pheral nerves. It appears particularly in areas where
human contact is close and continuous in unhygienic
conditions.
There'are two types of the disease, the lepromatous
and the tuberculoid, with every variety of intermediate
development. Lepromatous leprosy developes in pati
ents with little resistance to the organisms, which are
able to multiply and disseminate freely in the tissues.
But, the tuberculoid type of the disease occurs in
patients with profound tissue reaction to the infection.
Incidence of non-lepromatous cases is between 70 to
75 per cent among all the cases of leprosy.
Cardinal signs of leprosy are: (1) Loss of sensation
(tactile, thermal or pain) in skin lesions, and (2) the
thickening of nerves.
In advanced cases of leprosy, it is not difficult to
arrive at diagnosis, but diagnosis is indeed difficult
in early cases where clinical manifestations are not
definite or evident.
Absence of itching is characteristic of leprosy, un
less it is superimposed by such infections as scabies,
ringworm, etc.
January 1983
The ■ certain diagnosis of leprosy depends on the
demonstration of mycobacterium leprae in the lesions.
The most satisfactory drug is dapsone (diaminodi
phenyl sulphone or d.d.s,). d.d.s. is given first in
very small doses which is gradually increased over a
period of months to a full dosage which continues for
a very long period.
Leprosy is neglected, frequently overlooked, com
monly misdiagnosed, often inadequately treated and
is generally a much feared and dreaded disease. It
is one of the most feared of all diseases, feared even
by those who have not met anyone actually suffering
from it. Hence, the psychological handling of a case
of leprosy is of great importance especially when the
case is seen in an area in which it is rare.
The chief factor that influences the prognosis in
leprosy is the type of the disease. In the non-lepro
matous types, the prognosis on the whole is good; in
the lepromatous type it is usually grave. However
there are some other factors, a consideration of which
helps in making a prognosis. These are (i) the result
of the lepromin test, (ii) the race of the patient, (iii)
the age and sex of patient, (iv) the physical fitness and
nutritional state of the patient.
It has been seen that the disease progresses more
rapidly, producing crippling deformities and blindness
in certain races than in others. In India, prognosis
is more favourable in Indians than in Anglo-Indians
and Europeans. Prognosis is also not very good in
people of the Mongolian race.
\
27
Sufferers of leprosy, in whom the development of
the disease has been arrested by the use of sulphones,
elect to remain in seclusion when eligible to return to
the general community.
Early detection
Rehabilitation, in the conventional sense, should
ideally be not necessary, if every person suffering
from leprosy is detected early and treated adequately.
Thus, if society does not discriminate against the
leprosy
patient,
the patient will never be
in need of rehabilitation. He will not become psy
chologically disrupted or isolated, since the environ
ment will not necessarily induce such an attitude;
and he will not be socially dislocated, because he will
continue to be accepted as member of the family, the
community and the village.
However, where this ideal of early diagnosis and
adequate treatment is not yet attained, the con
cept of rehabilitation must be introduced from the
onset of treatment and every-thing should be done to
instil the principle of prevention—not only the preven
tion of deformity but also the prevention of frustrat
ed mental attitude.
The process of de-stigmatization of the disease
should have priority in all parts of the world where
it is necessary to combat it. So long as there is stig
ma, personal demoralization and social degradation,
it will be impossible to expect co-operation from the
patients.
One of the fundamental components of the stigma
in Western countries is intimately related to the term
‘Lepra’ and no educational efforts may ever succeed
in the presence of this ‘tragic name’.
‘Hanseniasis’ is a new name suggested for the dis
ease by certain societies because the label ‘leprosy’
is considered to be repulsive. Dr Rotberg, of the
Division of Hansenology and Public Health dermato
logy in Sao Paulo, Brazil, has proposed that the term
‘leprosy’ be forgotten and that in recognition of the
great merits of Gerhard Armauer Hansen, who des
cribed mycobacterium leprae, the disease be called
hanseniosis or Hansen’s disease.t As per his saying,
the words ‘Leprosy’ and ‘Leper’ have gained an un
pleasant reputation and when mentioned, evoke fear
and abhorrence. He believes that the name Hanse
niosis would be psychologically more acceptable to
paients afflicted with leprosy (Hanseniasis, Abstracts
and News, 3 (1), 1972).
Leprosy is not a congenital disease. According to
the age at detection, leprosy is more common in child
ren and the young than adults. Tn children, the pre
28
valence is almost equal in males and females. But
with decreasing incidence of the disease, age group
in certain countries has shifted to higher age groups,
e.g., in Japan and Norway. Lepromatous leprosy
starts a little later in age than non-lepromatous type.
According to Cochrane, all depends on the oppor
tunities of contact. Under similar circumstances,
adults are as likely to become infected as children
and females as likely as males.
Leprosy has a very wide distribution. It is preva
lent in parts of the middle East, Asia, Africa, Central
and South America and occurs in North Australia,
some of the Pacific Islands and Southern Europe
and the Mediterranean littoral.
In 1965, the leprosy cases in world were 10.8 mil
lion. It was regarded that in India there were 2.5
million cases but according to 1971 census, the esti
mate is 3.2 million.
Jalma Institute for leprosy at Agra, was established
by the Japanese Leprosy Mission for Asia in the year
1963.
On 1 April, 1976, the Centre was officially
attached to the Indian Council of Medical Research,
which was given the responsibility of administration,
medical care and research.
The Institute offers treatment and service facilities
to a very large number of leprosy patients in the nor
thern region. All medicines are provided free of cost.
The major departments of the Centre are: out-patients
department, in-patients department, reconstructive sur
gery theatre, pathological laboratory, X-ray depart
ment, and physiotherapy department.
In addition to all this, research activities, tod, are
carried out in the Institute. New drugs expected to
have action on leprosy are first tried on experimental
animals to assess their effectiveness. Leprosy germs
can be grown to a limited extent in the foot-pad of
mice. A large mouse colony with over 2,500 mice
is being maintained by the Institute. Various bioche
mical studies are undertaken on the blood and other
body fluids in the leprosy patients of different types
with an aim of understanding the physiopathology of
the disease.
Proposed methods* of assessment and
treatment for psychopathology
There is an important and most needed department
missing in the Institute. This department is that of
the phychotherapy, which should fee introduced for
the well-being and preservation of mental health of
the leprosy patients.
When the patient realizes that he is feeing discri
minated against—he fosters the stereotypes of preju
dice by accepting the social roles and inferior status:
Swasth Hind
in essence, he introjects and identities the values put
forward by the society. His self-concept gets de-valued and deteriorated. Prejudice and discrimination are
based on learning. They are maintained because they
arc reinforced.
Psychological assessment has traditionally focussed
on the individual while sociological assessment has
focussed on the individual's life situation in a com
munity or in a social environment. And in psycho
social assessment these two orientations are combin
ed to provide a realistic picture of the individual in
interaction with his environment.
Since a wide range of factors may play significant
roles in causing and sustaining the maladaptive beha
viour, assessment typically involves the co-ordinated
use of medical, psycho-social and socio-cultural assess
ment procedures.
The clinical assessment data can commonly be
used to:
(1) Detect pathological trends before a disorder
becomes acute or to anticipate possible prob
lems and help the person prevent them.
(2) Plan an appropriate treatment programme and
make necessary modifications as therapy pro
gresses.
(3) Evaluate given treatment procedures and out
comes.
(4) Identify the nature and severity of the indivi
dual’s or group’s maladaptive behaviour.
(5) Provide a basis for discussing the problem with
the individual, his family or the group.
In many instances, clinical assessment data can also
be used to increase self-understanding—for instance,
helping the individual understand his motives, atti
tudes, feelings and maladaptive coping patterns. Psy
chological tests should also be launched for the ass
essment of intelligence as well as the personality struc
ture of leprosy patients.
Socio-psychotherapy
Next comes the therapeutic part,
take up the two aspects:
where we can
(i) Psychotherapy
(ii) Sociotherapy
Both individual and group psychotherapy can be
of great use. It should be directed at helping the
patients discriminate between real and imagined dan
gers, learn more effective methods of coping, and
modify conditions in their life situations that arc serv
January 1983
ing to maintain the maladaptive behaviour. A patient
is to be trained to tolerate the life stresses.
Individual psychotherapy
Taking cue from Wolpe’s systematic desensitization,
behaviour that is being negatively reinforced—rein
forced by the successful avoidance of a painful situa
tion—is harder to deal with. Since the individual be
comes anxious and withdraws at the first sign of
painful situation, he never gets a chance to find out
whether the aversive consequences he fears are still
in operation. His avoidance is anxiety reducing and
hence is itself reinforced.
After assessing the details, time should be spent in
constructing a hierarchy of the individual's anxieties.
This anxiety hierarchy should be a list of related sti
muli ranked in the descending order, according to the
amount of anxiety they evoke in the patient.
While the patient or client will be relaxing comple
tely in a comfortable chair with his eyes closed, the
therapist would describe the series of scenes to him,
directing him to imagine himself experiencing each
situation. The first scene presented should be a neu
tral one. If the patient remains calm and relaxed
the lowest scene on the hierarchy should be present
ed; then the therapist would more progressively step
up the hierarchy until the patient or client indicates
that he is experiencing anxiety and the scene will be
terminated. Treatment should be continued until the
patient is able to remain in a relaxed state while
vividly imagining the scenes that formerly evoked the
greatest anxiety.
The care is to be taken that the hierarchy should
not be misleading or irrelevant. It should be made
only after going through the personality structure and
life situation of the patient, thoroughly. Further, the
client should be asked to explore himself in reality to
situations to which he has just been desensitized in
imagination. This appears to accelerate the dcsensitization process and may be the best method for indi
viduals who do not respond to imagined anxiety-elicit
ing situations in the same way they do to real life
situations.
Assertive training, too, can be of great help to us
in our psychotherapeutic programme. Assertive train
ing has been used as a method of desensitization as
well as a means of developing more effective coping
techniques. It appears particularly useful in helping
individuals who have difficulties in interpersonal situa
tions because of conditioned anxiety responses that
prevent them from ‘speaking up’ for what they consider
to be appropriate and right. Such inhibition leads them
to continual inner turmoil.
29
Social workers should be appointed for edu
cating the public and removing all baseless
beliefs about leprosy. People should express
sympathy towards the patients instead of
abuse and hatred;
The expression of assertive behaviour first by role
playing in the therapy setting and then by practice in
life situations—is to be guided by the therapist. Atten
tion be focussed on developing more effective interper
sonal skills.
Taking an idea from Rogerian client centred therapy
—the primary objective is to resolve the incongruance,
to help the client become able and willing to be balanc
ed. A Psychological climate should be established in
which the patient or client may feel unconditionally
accepted, understood and valued as a person. It will
free him to explore his real feelings and thoughts and
to accept them as part of himself. As his self-concept
becomes more congruant with his experiencing, he will
become more self-accepting, more open to experience
and a better integrated person. Therapist should reflect
and clarify the patients’ feelings and attitudes in such
a way as to promote positive action on the part of the
patient. Emphasis should be laid on the present and
useful existence of the patient.
Group therapy
Group therapy can be carried out by delivering some
formal lectures to the groups of the patients. In these
lectures they should be made aware of the disease they
are suffering from, as well as, the role they have to
play in the society. From making them aware, I mean
to acquaint them with full relevant details of the dis
ease. Encouraging and informative films should be
shown to them.
Sociotherapy
In the case of sociotherapy, we have to focus on the
modification of circumstances hi the individuals’ life
situation that tend to perpetuate his psychopathology.
Often there are pathogenic family interactions that keep
the patient in a continually ‘sick situation’.
The foremost need is to improve faulty communica
tion, interactions and relationships among family mem
bers and fostering of a family system that better meets
the need of family members. This purpose can be ful
filled through family therapy. Therapy for the family
group overlaps with the marital therapy, hence killing
two birds with one stone.
Social workers should be appointed for educating
the public and removing all baseless beliefs about the
30
disease. People should express sympathy towards the
patients instead of abuse and hatred.
Both psychotherapy and sociotherapy are concerned
with the alleviation of culture-induced stresses that
foster the production of psychopathology in the pati
ents of leprosy. People should be made aware of the
fact that a treated patient is non-infectious. It is true
that the only reservoir of infection is a case of leprosy
but the condition of openness is at a particular stage
medical treatment leaves the case closed—that is, it is
made non-infectious. Whenever medical experts pro
claim that a case is cured—it means he has become
non-infectious. He should be accepted by the society
as a member of the society. He should not be discri
minated from the cured cases of other infectious dis
eases. He should be given a proper' place in his fami
ly as well as in the society.
Society should provide means of livelihood to him.
For .communicating this message to the members of
society, we can utilize the mass media, education and
other social institutions to change established attitudes
and to foster the view that leprosy is a disease caused
by a bacterium, not by his sins in the previous birth.
The patients need sympathy not hatred. Society should
learn to eliminate and hate the disease not the patient.
Thus by adopting this therapeutic programme, of
these two aspects, as an adjunct to the treatment of
leprosy—patients can be expected to return to their
families, communities and society, without any harm
to their mental make up. They should not be admitt
ed for longer lapses of time in the hospital—as their
longer stay may degrade their position in the society.
They should be allowed to be with their family memb
ers as soon as they are non-infectious.
Last of all, we would like to comment that only
medical treatment is not sufficient for the chronic dis
ease like leprosy, but the introduction of socio-psychotherapeutic programme is a must. The later is one of
the most important tools that can help us in alleviate
ing the persistent tensions of our patients. Those ten
sions, which remain in them although in the absence
of proper stimuli, can well be reduced by the hinted
procedures.
bibliography
Cochrane, R. G. and Davey, T. F. (1964). Leprosy in Theory.
and Practice. Second Edition.
Coleman, J. C. (1976) Abnormal Psychology and Modem Life
Fifth Edition.
Hanseniasis, Abstracts and News, 3 (1). 1972.
Scott. S. R. B. Price’s Textbook of the Practice of Medicine.
Tenth Edition. (1966) Oxford University Press;
Svvastli Hind
NATIONAL MEDICAL LIBRARY
SELECTED BIBLIOGRAPHY ON LEPROSY—H
Compiled by M. K. Bhatt
We publish below the second part of the selected Bibliography on Leprosy compiled by the National Medical
Leprosy (DGHS) as part of its activities aimed at providing Documentation Services to the health science
community in the country. It covers selected contributions on leprosy in India published during 1980-1982.
Entries follow a classified arrangiment using main subject headings and sub-headings.
Metabolism
Prevention, & Control
Nilkanta Rao, MS et al.—
Kumar, B. et al.—
Chaudhary DS.—
Problem of leprosy in Karnataka.
In vivo and invitro drug metabolism
Greater Calcutta Leprosy Treatment
Lepr. India, 1980 Apr;
in patients with leprosy.
and Health Education Scheme (GRE52(2) : 236—44.
Lepr. India 1982 Jan:
CALTES).
Prasad, S.—
54(1) : 75—81.
Lepr. India 1981 Apr;
A survey of leprosy deformities in a
53(2) : 292—302.
Sharma, SC et al.—
closed community.
Chaudhary
DS.—
Drug metabolism in leprosy;
Lepr. India 1981 Oct;
Summary report of Jhargram Leprosy
Indian J. Med Res 1980 Mar;
53(4)
:
626
—
33.
project.
71 : 456—9.
Lepr. India 1981 Apr;
Rao, PSS el al.—
Microbiology
53(2) : 303—6.
A study of leprosy among urban and
Kaur, S et al.—
rural school children of Andhra Pra Gershon, W et al.—
Choice of sites for slit skin smears.
desh.
Programme of Health education among
Lepr, Rev. 1981 Mar;
Lepr. India 1982 Jan;
school teachers : A study conducted
52(1) • 27—33.
54(1) : 100—9.
at GREMALTES (Greater Madras Lep
Saha, K. et al.—
rosy Treatment and Health Education
Decreased cellular and humoral anti- Revankar. CR et al.—
Scheme).
infective factors, in the breast secre Leprosy surveys in urban slums—possi
Depr. India 1981 Oct;
tion? of lactating mothers with lepbilities for epidemiological investiga
53(4) : 641—55.
romatous leprosy.
tions.
Guillemot, L et al.—
Lepr. Rev. 1982 Mar;
Lepr. Rev. 1982, Jun;
Integration of leprosy and tuberculosis
53(1) : 35—44.
53(2) : 99—104.
control—a field experiment
Sarkar, JK et at.—
Vijayshankar, P.—
Lepr. India 1980 Oct.;
New types of Propionibacterium from
Leprosy in urban setting;
52(4) : 491—500.
lepromatous nodules and deep layers
Lepr. India, 1982 Jan;
, of normal skin.
Matthews,
CME et al.—
54(1): 155—61.
Indian J Med. Res. 1980 Mar :
Health education and leprosy.
71 : 354—8.
Lepr. Rev. 1980 Jun;
Pathology
51(2) : 167—71.
Guha, PK & Ghosh, M.—
Occurrence
Progressive lepra reaction : A case re National Leprosy Control Programme.—
Bhavsar, BS & Mehta, NR.—
port.
An assessment of school survey as a
Annual Report of the Union Ministry
Lepr. India, 1982 Jan;
method of detection of leprosy cases.
of Health & Family Welfare 1981—
54(1) : 149—51.
Lepr. India 1981;
8g
53(4) : 620—5.
pages 13—16.
Kaur, S. et al.—
New Delhi, 1982.
Chaudhary, RC.—
Pathologic changes in striated muscles
A clinico-social study of leprosy cases
News and notes (on leprosy) India.—
in leprosy.
in a rural population of Rajasthan.
Int. J. Lepr. 1981 Mar;
Lepr. India 1981 Ian;
Lepr. India. 1981 Apr;
49(1) : 99—104.
53(1) : 52—6.
53(2) : 259—65.
Sehgupta. U,—
Kumar, B et al.—
Christian, M.—
Towards a vaccine against leprosy.
Ciinico-pathological study of testicular
Lepr. India 1981 Jan;
Epidemiological situation of leprosy in
involvement
in
leprosy.
India.
53(1) : 88—95.
Lepr.
India
1982
Jan:
Lepr- Rev, 1981 Dec;
54(1)
:
48
—
55.
World Health Organization.—
Suppl. I;
A guide to leprosy control.
52; 35—42.
Mehta, L et al.—
Geneva, WHO, 1980;
Evolution of nasal mucosal lesions in
Ganapati, R. et al.—
97 P.
leprosy
(histological
study);
Prevalence of leprosy among in-patients
Lepr.
India
1981
Jan;
in general hospitals—a survey in
Psychology
53(1): 11—6.
Bombay.
Behre.
PB
—
Lepr. Rev. 1980 Dec;
Psychological reactions to leprosy.
Sakuntala, R et al.—
51(4) : 325—8.
Lepr. India 1981 Apr;
Histological profile in apparently nor
Guha, PK et al.—
53(2) : 266—72.
mal
skin
of
leprosy
patients.
Age of onset of leprosy.
Lepr. India 1982 Jan;
Lepr. India 1981 Ian;
Rehabilitation
54(1) : 40—7;
53(1) : 83—7.
Hasan, S.—
Marshall, J T et al.—
Pharmacodynamics
The aims and methods of physiothe
Prevalence of leprosy among slum Ghosh, S.—
rapy in field conditions in the National
dwellers.
Drug resistance in leprosy.
Leprosy Control Programme.
Lepr. India 1981 Jan;
Indian J. Dermatol. 1980 July.
Lepr. India 1981 Oct;
53(1) : 70—82.
25(3) : 1—4.
53(4) : 608—19.
January 1983
31
impact on priorities in leprosy control.
Kulkarni. VN & Mehta, JM.—
Lepr. India 1981 Jan*
Lepr. India 1980 Jan;
Observations on peg-prosthesis in lep
53(1) : 1—5.
52(1) : 104—13.
rosy.
Srinivasan,
H.
—
Lepr. India 1982 Jan;
Kotteeswaran, G et al.—
Leprosy patient and rehabilitation.
54(1): 110—6.
Skin adnexa in leprosy and their role
Karnataka Med. J. 1981 Apr.-Jun;
in the dissemination of M. Leprae.
Kumar, JMR et al.—
46, Special issue, 149—53.
I epr. India 1980 Oct;
Domiciliary rehabilitation : A 5 year
Surgery
52(4): 475—81.
x follow-up study on self employment of
disabled leprosy patients.
Palande, DK.—
Mycobacterium Leprae
Lepr. Rev. 1982 Jun;
Preventive nerve surgery in leprosy.
Balakrishnan. S et al.—
53(2) : 133—9.
Lepr. India 1980 Apr.
Effect of Desoxy Fructo Serotonin
52(2) : 276—98.
Mehta, JM.—
(DFS) on the multiplication of M. Lep
rae in mouse foot-pad.
Medical certification of leprosy patients
Therapy
Lepr. India 1982 Jan;
and reservation in service for the phy Gershon, W et al.—
54(1) : 56—8.
sically handicapped including persons
The need for a full-fledged social wel
with leprosy.
fare department in every leprosy pro Chatterjee, BR.—
Int. J. Lepr. 1980 Sept;
ject.
Attempt to induce immune-tolerance
48(3) : 332—3.
Lepr. India 1980 Jul;
to M. Leprae in mice,
Mehta, JM.—
52(3) : 440—2.
Lepr. India 1981 Jan;
Note on medical certification in respect
53(1); 34—7.
of leprosy patients vis-a-vis reservation Mathai, R.—
Risk
of
treating
leprosy
in
a
general
Ganguly. NK et al.—
in service for the physically handicapp
hospital:
BCG induced immunity to mycobac
ed including those due to leprosy.
Int.
J.
Lepr.
1980
Sept;
terium leprae in mice.
Lepr. India 1981 Jan;
48(3)
:
298
—
302.
Lepr. India 1981 Jan;
53(1) ; 96—8.
53(1) : 57—62.
Transmission
Samy, CA.—
Industrial rehabilitation for leprosy Davey, TF.—
MB: Photocopies of the references inclu
patients merits and limitations (edito
ded in this Bibliography can be
New dimensions in our understanding
rial).
of the transmission of leprosy and their
ordered from the NML.
BOOKS
Contemporary patterns of breast-feeding. Report
of the WHO Collaborative Study on Breast
feeding, Geneva, World Health Organization, 1981.
ISBN 92 4 156067 3. 211 pages. Price: Sw. fr. 24.-.
In recent years the importance of breast-feeding as
a basis for healthy child development has become in
creasingly recognized. Evidence has accumulated on
the unique nutritional and immunological properties of
Dr Candau is dead
Dr M. G. Candau, who. served as the second
Director-General of the World Health Organiza
tion (WHO) from 1953 to 1973, passed away in
Geneva on 24 January, 1983.
Dr Candau joined the staff of the World
Health Organization at Geneva in 1950 as Di
rector of the Division of Organization of Health
Services. Within a yearb he was appointed Assis
tant Director-General in charge of Advisory Ser
vices.
In 1952, he moved to Washington as
Assistant Director of the Pan American Sanitary
Bureau, which is also the Regional Office of
the World Health Organization for the American.
While occupying that position, he was elected
by the World Health Assembly to become the
second Director-General of the World Health
Organization, to succeed Dr Brock Chisholm of
Canada.
3a
breast-milk, as well as on the effects of breast-feeding
on reproductive function and mother/child bonding,
and concern has been expressed about the possible ad
verse consequences of a decline in breast-feeding (and
a simultaneous increase in the use of breast-milk sub
stitutes) on the wellbeing of children, particularly in
developing countries.
While efforts are being made to correct this situation
(a particularly important effort in this regard has been
the adoption of the International Code of Marketing
of Breast-milk Substitutes by the Thirty-fourth World
Health Assembly), it has become clear that the success
of national and international programmes to promote
better feeding of infants and young children, especially
by breast-feeding, depends on adequate information on
contemporary patterns of infant feeding among diffe
rent socioeconomic and cultural groups. It was with
this intention that the WHO Collaborative Study on
Breast-feeding was launched.
First phase
This book is a report on the first phase of the study,
which was conducted in nine countries of Africa, Latin
America, South-East Asia, Europe and the Pacific and
involved some 23,000 mothers and children. The aims
of this phase were to describe:
—
patterns of breast-feeding among specific social
groups in selected areas of the world.
—
relationships between patterns of breast-feeding,
supplementary feeding, and various maternal,
family, and socioeconomic characteristics:
Swasth'Hind
—
—
the relationship between breast-feeding and re
production, including the return of menstrua
tion;
Authors of the month
Dr R. H. Thangaraj
the views of mothers on breast-feeding and its
duration, their reasons for not breast-feeding or
discontinuing breast-feeding, and their knowledge
of commercial and other baby foods;
&
Dr (Smt) E. S. Thangaraj
The Leprosy Mission
4th Floor, Sheetla House
73-74 Nehru Place
NEW DELHI-110019.
— ways in which health services were organized
with reference to maternal and infant care and
infant feeding, as well as the nature and extent
of legislation as it might affect ma'.ernity leave
and breast-feeding: and
Dr V. V. Dongre
Hony. Secretary
Hind Kusht Nivaran Sangh
(Maharashtra Branch)
C/o H. T. T. College
Adarsh Nagar. Worli,
BOMBAY-400025.
— the ways and extent to which industrially pro
cessed infant foods were marketed in the areas
studied.
Dr J. M. Mehta
Hony. President
Poona Distt. Leprosy Committee
PUNE
The results indicate that, although there are consider
able variations between countries with respect to the
prevalence and duration of breast-feeding, some dis
tinct patterns can be identified: urban middle-and upper
income groups are less likely to breast-feed than ur
ban lower-income groups and, when they do, they
do so for shorter periods of time; similarly, urban
poor groups are less 1 kely to breast-feed than rural
traditional groups and again, when they do, they do
so for shorter periods of time. The age and parity
of mothers do not appear to influence breast-feeding
behaviour; educational background and health care
practices, on the other hand, appear to be associated
with the decision to breast-feed or not to do so. At
the time of the survey advertising and distribution of
breast-milk substitutes was widespread in some of the
countries studied and large proportions of mothers
in all the socioeconomic groups knew brand products
by name. The results of this study are already serv
ing as a basis for planning national and regional ac
tion programmes in the nine countries studied and else
where.
Dr S. Theophilus
54-A, Srinagar Colony
KUMBAKONAM
(Tamil Nadu).
Dr R. Ganapati
Director
Bombay Leprosy Project
6$27, Amar Bhavan,
Sion (East)
BOMBAY-400022.
Dr Claire Vellut
Consultant
Damien Foundation
Hemerijckx Govt. Leprosy Centre
POLAMBAKKAM
(Tamil Nadu).
Dr B. C. Ghosal
Director
and
Shri T. K. Parthasarathy
Editor
Central Health Education Bureau,
Kot la Road,
NEW DELHI-110002.
Dr S. P. Tare
Asstt. Director
Gandhi Memorial Leprosy Foundation
P.O. Hindi Nagar,
WARDHA (Maharashtra).
After an introduction and description of the study
design and the characteristics of the communities that
participated, the findings are reported under the fol
lowing headings: the prevalence and duration of
breast-feeding; breast-feeding and reproduction; birth
weight, weight gain in infancy, and mortality among
previous children; the introduction of supplementary
food: and the marketing and distribution of breast
milk substitutes. A summary of findings is given at
the end of each chapter. The final chapter, which
contains the conclusions, also includes comments on
possible action that can be taken to improve breast
feeding. The questionnaires and data collection guid
es used in the study are reproduced in annexes.
Dr G. Ramu
Deputy Director
Central Jalma Institute for Leprosy
Taj Ganj
AGRA-282001.
Dr N. S. Chauhan
Professor of Psychology
Meerut University
MEERUT
and
Dr Upinder Dhar
M-36, Greater Kailash-I
NEW DELHI-110048.
ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU, KOTLA MARG, NEW DELHI-110 002 f.nd
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Index for
Volume XXVH
SI.
No.
1. January
Month
Pages
....
1—32
....
2. February
3. March.......................................
33—60
1
> 61—96
J
97—124
4. April.......................................
5. May........................................
6. June .....
.
153—180
7. July.......................................
....
.
181—208
9. September ....
.
209-236
10. October
....
.
237—260
11. November
....
.
261- 288
12. December
....
.
289—312
8. August
January to December
1983
125—152
SWASTH HIND
INDEX
VOLUME xxvn
January to December 1983
The following is the index for all reading material published in Swasth Hind during 1983.
This is the title index. (The authors’ names are given in italics).
A
Page
Action leads to adoption
—a case study
A dramatic success for radio
All India Institute of Hygiene and Public
Health. Calcutta —Five decades of Pro
gress
......
— Dr A.K. Chakraborly
A malnourished village child
—Sint. K.R. Rama Rao
— Dr (Smt.) Leela Phadnis
A roof over every head ....
— M.K. Mukharji
A health card for every child .
—Dr A. Abubecker
54
59
108
-qj
Brain injury—an avoidable tragedy
— Dr A.K. Banerji
-
6?
163
274
308
C
Childhood leprosy
—Dr S. Theophilus
Care of the aged
—Dr B.C. Ghosal
Communications : a potent force for change
—Salim Loire
Communications for development at the vil
lage
11
37
...
117
123
D
Development and environment
—S.B. Chavan
Diarrhoeal diseases and their control
Diarrhoea : knowledge can save lives
— Denise Ayres
Diet and your heart........................................
Diet, platelets and migraine
—Staniforth Webb
Development of health delivery system
at PHC level—a workshop .
Drug addiction—a social evil .
— Mohammad Najmi
Drug dependence .....
—Awni Arif
Drug abuse increasing in many societies .
Deteriorating global environment
—Dr Arthur Westing
139
147
171
209
212
214
246
E
B
Blindness prevention and control
—The scene today
....
—Prof. Madan Mohan
Behaviour modification
—laboratory experiments to treatment of
mental sickness
•
>
.
—Dr K.G. Agarwal
—Upinder Dhar
Blindness in children—Vitamin A deficiency
Page
Energy requirements and recommended
allowances . .
....
—B.S. Narasinga Rao
Expanded programme on immunization
—Dr R.N. Basu
50
101
F
Family Welfare—an essential input for
development
.....
— B. Shankaranand
Food poisoning
.....
—Dr L.N. Mohapatra
Feeding & toilet training of children
’ —Dr Arun K. Gupta
—Asha Khosa
237
279
281
G
Goitre can be prevented ....
—DrP.C. Sen
Golden Jubilee Celebrations
Genital herpes infection ....
104
113
173
H
45
48
135
Health education in leprosy control .
—Dr B.C. Ghosal
—T.K. Parthasarathy
Health for all by 2000 AD: malaria control
—Dr S.R. Dwivedi
18
63
Page
Page
Health for all: the count down has begun .
97
Health problems in elderly females .
—Dr (Snit.) Daksha D. Pandit
106
.
Health in 1982-83—year of achievements .
—Dr S.S. Sidhu
181
Hospitals and Society and their expectations
—Dr T.R. Sachdeva
—Dr (Smt.) Tripta Bhasiii
225
Health education: Cornerstone of Primary
health care .
.
.
.
.
.
Housing and environmental planning
.
—S. V. Joshi
Health and family welfare
.
.
.
—a collective responsibility towards people
Health education—new tasks,
proaches .
.
.
.
—Prof. Kenneth Standard
—Annette Kaplun
new ap
.
.
Health education through socially useful
productive work........................................
—G. Guru Gouri R. Ghosh
228
248
266
275
Mental health as part of primary health care
—R. Srinivasa Murthy
153
Man and biorhythms
•
—Fedor I. Komarov
167
.
•
•
Medical services in rural community through
mobile clinics
.....
—Suresh Chandra
—J.S. Mathur
—R.R. Gupta
Maternal and child health care
174
’.
187
Measures to control environmental noise
pollution
.....
—K.R. Swadeshi
255
Malnutrition—an invisible enemy
.
261
Monitoring of school health service pro
gramme
.......................................
—Smt. C.K. Mann
304
•
.
N
295
I
New look for health :
Statement on national health policy
86
Nutrition and the elderly
.
—Capt. Jayanta Dutta
—Surg. Lt. Cdr. MukeshPaul
.
.
137 >
.
Importance of school and mass surveys in
leprosy control
....
— Dr R. Gandpali
14
Nutrition and cataract .
—Dr K. Se'etharam
.
144 *
Is stress beneficial for life ?
— P. Bhattacharyya .
.
.
.
.
162
Newer infection in STD ....
172
Insomnia and biological rhythms
.
.
169
National awards 1981 and 1982 for nursing
personnel.................................................
234
Integrated effort in malaria control
— Nedd Willard
.
252
New approaches in leprosy control •
.
258
Integrated child development services
.
272
Nutrition and welfare of the family .
—B. V.S. Thimmayamma
•
269
Impact—India launched
.
399
Influence of physical defects on academic
performance and intelligence.
.
.
— Vijay Suple
311
Ninth Joint conference of councils of health
& family welfare—Important recommen
dations
.................................................
284
National Medical Library
...
31
Need for sex education ....
—Dr V.N. Rao
—R. Parthasarathy
Nutrition extension through primary school
—V. Ramadasmurihy
—Dr M. Mohan Ram
302
.
.
L
Legal aspects of leprosy ....
—Dr V.V. Dongre
Leprosy control: contribution of voluntary
institutions
—Dr S.P. Tare
Leprosy eradication : recording, reporting and
assessment ......
—Dr C.S. Gangadhar Sharma
Loss of nutrients in home preparation of
foods..............................................
.
Lack of sleep may lead to fibrositis
.
.
M
Management of complications in leprosy .
—Dr G. Ranni
Malnutrition among children
.
.
4
77
306
O
141
Open heart surgery in infancy and early
childhood .
.
.
.
.
— Dr M.R. Girinath
P
Primary health care role of communicable
diseases control
....
— Dr I.D. Bajaj
Population problem— a planners view
— S.B. Chavan
.
257
61
73
Page
Priorities in communications research in
Asia...........................................................
Protective properties of mothers milk
— Sint. K. Saroja
Prayer hastens recovery .
120
.
129
.
.161
.
•
222
Planning health for all by 2000 AD .
— DrN.K. Sinha
.
241
Promoting mental health in classroom
—Role of teacher
— Dr Prem Lata Chawla
.
297
Physical fitness— what it means
— Dr S.K. Manchanda
Population award—and honour to dedicated
workers and parents ....
—Sint. Indira Gandhi
298
Preparing for school
307
.
.
.
.-
R
Rehabilitation in leprosy .
—Dr J.M. Mehta
.
7
Role of medical sociologist in health care .
— Ktnn. R.K. Manelkar
166
Rural health services
....
|
188
Social aspects of leprosy ....
-?-Dr R.H. Thangaraj
— Dr (Sint.) E.S. Thangaraj
1
Sociol psychotherapy : an adjunct in the
treatment of leprosy ....
—Dr N.S. Chanhan
— Dr Upinder Dhar
Sanitation pays
.....
—Jitendra Tuli
Safe drinking water for villages
—a national perspective
27
.
33
.
190
Training of para-medical personnel in con
trol of blindness—scope and possibilities
—Prof. Madan Mohan
199
.
Towards population control in India
—J.S. Baijal
Traditional medicine in an Indian city
—A. Ramesh
—B. Hyma
.
Traditional birth attendants winning accep
tance .................................................. ..........
—Peter Ozorio
Thirtysixth World Health Assembly
.
Two Hundred & Thirty million women in
developing world suffer from nutritional
anaemia
......
—Peter Ozorio
215
220
230
264
W
World Assembly on Ageing
...
World Communications Year 1983: deve
lopment of communications infrastructure
Women opt for laparoscopic way of birth
control
.
.
.
.
.
—G. Venkataraman
Water supply and sanitation programme in
India.
......
— V. Venugopalan
World Health Day—7 April 1983
.
.
56
116
176
194
236
Y
Yoga for keeping fit in the old age .
— O.P. Tiwai’i
41
SPECIAL NUMBERS
84
Strategy for health and nutrition education
— Dr Suvira
125
•Strategies for research in mental health
.
156
Schistosomiasis—an environmental disease
256
.School health programme considerations
for a national policy
....
—J.S. Manjul
289
•School health scheme for urban areas
— Dr B. Loomba
Strong and beautiful—a story
.
Tobacco smoking and our health
— Dr D.B. Bisht
74
•
.
Page
January
Leprosy-H
March-April
World Health Day
(Theme : Health for All By the
Year 2000: the count-down has begun)
May
Woild Communications Year—1983
June
Rood and nutrition
July
Mental Health
August
Health Progress in India
.
312
Novembei
.
back
inside
cover of
December
Children's Day
Theme : Hungry’ Child— a Challenge
to world’s conscience
December
School Health
OTHER ISSUES
T
Training and development of manpower in
leprosy
— Dr Claire Vollut
16
September
Accent on, Drug, Dependence
October
Accent on environment
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