Walker, Stephen L

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Walker, SL (2008) Interviews with two key leaders in leprosy: Pro-fessor PL Joshi and Professor Maria Leide. Leprosy review, 79 (2).pp. 130-3. ISSN 0305-7518Downloaded from: http://researchonline.lshtm.ac.uk/7240/DOI:Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: Copyright the publishersInterviews with two key leaders in leprosy:Professor PL Joshi and Professor Maria LeideThe International Leprosy Congress (ILC) in Hyderabad (30th January to 4th February 2008)was an opportunity for the leprosy community to come together and share experiences, ideasand examples of best practice. The congress also provided an environment in whichpoliticians, policy makers, field workers, researchers and leprosy affected individuals couldinteract directly with one another.The Leprosy Review Editorial Board agreed at its meeting prior to the congress that theILC was an excellent opportunity to obtain the current views of the National ProgrammeManagers of India and Brazil, the two countries which contributed 71% of the new casesreported in 2006. The ILC was not just a convenient location, more importantly it was takingplace during a time of significant change: given the process of implementing the recentlyadopted Global Strategy for 2006–2010, India having achieved the World HealthOrganization (WHO) defined elimination target and continuing concerns in the leprosycommunity about integration.Dr. P. L. Joshi and Dr. Maria Leide W. de Oliveira were contacted prior to the congressand both kindly agreed to discuss issues concerning the leprosy programmes in theircountries. They were each interviewed using a set of questions compiled by members of theEditorial Board.Dr. Joshi was Professor of Community Medicine in Allahabad for 12 years. More recentlyhe has been Technical Director of the Indian National AIDS Control Organisation andalso for vector borne diseases. He had been National Leprosy Programme Manager at theIndian Ministry of Health for six months prior to the congress.Dr. Joshi highlighted the major challenges facing the Indian National Programme as thefull integration into mainstream society of leprosy-affected individuals, keeping leprosyissues high on the health agenda with continued commitment from political leaders and thefull integration of leprosy care into general health services. The point when all health workersrecognise that they are involved in the care of leprosy-affected persons is the goal. He feelsintegration of diagnosis and treatment is a better use of limited resources.The Indian programme has implemented its 5-year plan with the aim of further reducingthe burden of leprosy. The WHO ‘Global Strategy for further reducing the leprosy burdenand sustaining leprosy control activities (2006–2010): operational guidelines’ inform theprogramme and have been implemented successfully. It is hoped that the aim of reducingthe leprosy burden will be facilitated by decentralisation with independent monitoring of theprogramme at the state level.The programme aims at capacity building of health care staff in general and leprosyspecifically. There is a focus on prevention of disability and reconstructive surgery.The programme also aims to reduce stigma using information and education. Thepromotion of National Leprosy Day on 30th January will help to keep leprosy in the publicLepr Rev (2008) 79, 130–1330305-7518/08/064053+04 $1.00 q Lepra 130domain. It is also planned that activities involving leprosy-affected individuals will be heldthroughout the year.The importance of good data collection and monitoring is central to an effectiveprogramme and Dr. Joshi outlined the way this will be ensured in India. Monitoring reportsare sent by the states to the Ministry of Health in Delhi on a monthly basis and spot checks arecarried out. ILEP partners provide feedback and WHO coordinators also send reports to theMinistry of Health. There are also cohort analyses of paucibacillary and multibacillary caseswith respect to the successful completion of treatment.The prevention of disability is a key function of the leprosy programme and it is hopedthat this can be achieved using well-defined activities at the level of primary care such asdiagnosis and management. This includes improvement in the management of complicationsand there are clear guidelines for the referral of complicated cases.Individuals with disability will have access to reconstructive surgery which will beprovided in secondary care facilities where possible. Reconstructive surgical services areviewed as particularly important in the drive for full integration. The Indian programme isalso planning innovative financial incentives for people undergoing reconstructive surgeryand the government institutions providing such services. It is envisaged that both theindividuals and the institutions will be paid US$150 for each procedure carried out. Thisinitiative will be closely evaluated. Training in self-care for both leprosy-affected persons andvillage workers/volunteers is being implemented.A major concern of leprosy workers is that with declining numbers of patients and a movetowards full integration of health services, skills required to diagnose and care effectively forindividuals with leprosy will be lost. Dr. Joshi hopes that in time training in leprosy will beperformed at induction of all new staff and repeated on an annual basis. He believes that‘training is a continuous process’. Recognition of reactions and nerve damage is importantand should be a skill possessed by all health workers from the village level worker to thoseworking in health care centres.The quality of training is a concern and efforts are being made to improve this. He hopesthat task-orientated learning rather than didactic methods will become the norm. ILEPpartners are helping to monitor this.The ILC is fundamentally a research orientated conference and Dr. Joshi feels thatresearch priorities are broad but from a leprosy programme perspective operationalresearch is most important. Operational factors such as the quality of services, the skillsof health workers, the incidence of nerve damage and stigma reduction all need to bemonitored. It is especially important for health workers to be aware of the outcomes oftheir interventions.The role of dermatologists was the topic of a special issue of Leprosy Review inMarch 2007 and Dr. Joshi feels that their role in the Indian context is very important. Policyis being developed to better define their role because as new case rates fall (or greaterintegration is achieved) it is likely that an increasing proportion of individuals will bediagnosed by dermatologists. He hopes to develop a central registration system for casesdiagnosed by dermatologists.Dr. Joshi also views dermatologists as a valuable educational resource. Their skills arealso extremely valuable in reviewing the quality of programmes. He hopes to motivatedermatologists to be closely involved with the leprosy programme.Dr. Joshi welcomed the ILC as an excellent meeting which emphasised partnerships andalso allowed the sharing of information regarding programmatic systems.Interviews with two key leaders in leprosy 131Dr. Maria Leide was appointed manager of the National Leprosy Programme of Brazil inMay 2007. This is the third time she has led the Brazilian government’s leprosy campaign.She is Professor of Dermatology at the Universidade Federal do Rio de Janeiro. She has beeninterested in leprosy throughout her career, an interest which started as a medical studentwhen she was involved in a research project involving armadillos.Dr. Leide acknowledges that social factors, such as poverty, which are intimately relatedto leprosy are a challenge beyond the scope of the programme she leads. She also believesthat lack of knowledge about leprosy within local communities is a major problem.The Brazilian system of government of federal, state and municipal autonomy resultsin challenges which require the development of partnerships. She cites as an examplethat funds passed to states and municipalities for leprosy work can be redirected bythese agencies to other areas of need. This requires advocacy on behalf of the programmeand partnership between federal government and the states to ensure funds are used forleprosy work.The Brazilian strategies for reducing the burden of leprosy are very similar to thoseoutlined by Dr. Joshi. These include increased integration of services with a concomitantincrease in the number of health posts. Dr. Leide acknowledges the need to improve strategiesfor the prevention of disability and that the registration of cases needs improvement alongwith the monitoring of operational quality indicators such as the percentage of patients cured.The Brazilian National Programme has recognised that the percentage of patients withWHO Disability Grade 2 has remained constant at 6% of new cases for the last decade andhas proved very difficult to reduce. Twenty three per cent of new cases require some form ofcare to prevent or treat disability. A central aim of the Brazilian National Plan for 2008–2011is to reduce the total disability (both grades 1 and 2) by 30%. It is hoped this will beachievable with earlier diagnosis by improving coverage and local active case finding.An innovative partnership with the diabetes programme to provide foot care and footwearto both leprosy-affected people and individuals with diabetes is working well and a goodexample of integration where services requiring common skills can be shared and betterutilised.In Brazil the training of staff in diagnosis and treatment is performed by the states.The Ministry of Health in partnership with ILEP members is involved in disability training.The states sometimes request the National Programme to help with training.Dr. Leide is also initiating capacity-building workshops for managers in the mostendemic areas to give them the skills to be able to evaluate local programmes themselves.In association with the dermatological society of Brazil Dr. Leide has produced a leprosymodule for dermatologists to use as part of a Continuing Medical Education programme.The development of an electronic educational tool for leprosy and skin disease to increaseawareness of differential diagnoses may help to prevent misdiagnosis of conditions that arenot leprosy.Brazil has a high rate of leprosy in the under 15 age group and the programme is starting avalidation exercise of the diagnosis of leprosy in this group in hyperendemic areas.The research priorities outlined by Dr. Leide echoed those of her Indian counterpart inparticular operational research to ensure the effective delivery of quality services.The National Programme in Brazil has two workshops planned for the first half of 2008 todevelop affordable research initiatives at a local level.As a dermatologist herself it is understandable that Dr. Leide would welcome greaterinvolvement in leprosy issues from her dermatology colleagues but she recognises thatS. L. Walker132leprosy work is financially less rewarding than other areas of dermatological practice.Dermatologists undertake a large part of the diagnosis but few are involved in long termmanagement.She hopes that by encouraging informal links between state and municipal leprosyservices and regional dermatology societies that increased levels of participation bydermatologists will ensue.The most striking feature of the interviews with the National Leprosy ProgrammeManagers from India and Brazil is the similarity in the approach to dealing with the burden ofleprosy in their two countries. They both believe that political will is the overall driver ofchange in the improvement of services for those affected by leprosy. The two programmesare placing high priority on the maintenance and development of partnerships with othergovernment agencies and non-governmental organisations. The Global Strategy is beingimplemented and the development and monitoring of innovative projects to reduce levelsof disability are being fostered. Reassuringly they both recognise the need for continuedresearch to improve our understanding of leprosy and the best way to manage the disease andits sequelae.A recurrent theme throughout the ILC was the need to keep striving ‘towards a worldwithout leprosy’ and not to allow complacency to develop in the wake of successes that havebeen achieved. The leaders of the National Programmes in the two countries with the largestburden of leprosy are going to try to meet the challenges of the next 5 years with the aid of awide range of partners and by further integration of leprosy into general health services.They will act as advocates for their programmes and ensure that leprosy is kept on the healthagendas of their governments. This is the best way to ensure that the best possible servicesare available for leprosy-affected individuals.STEPHEN L.WALKERLondon School of Hygiene & Tropical Medicine,Keppel Street, London WC1E 7HT, UK(e-mail: drstevewalker@hotmail.com)Interviews with two key leaders in leprosy 133

Interviews with two key leaders in leprosy: Professor PL Joshi and Professor Maria Leide.

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Interviews with two key leaders in leprosy: Professor PL Joshi and Professor Maria Leide.

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