Dermatologists Combat [Archives:1998/05/Health]

February 2 1998

Leprosy in Yemen
This article marks the occasion of International Leprosy Day,  January 25, 1998.
Introduction Leprosy, known in Arabic as ‘Gutham,’ dates back to the year AD 747 in the history of Yemen when its ruler, the Abbassid Wali, M. Z. Abou-Al-Madan, collected huge quantities of wood to burn the leprosy patients in Sanaa as a way of solving this problem.  However, he died before committing the crime. These well documented events in Yemeni history clearly demonstrate the social stigma attached to leprosy which continues to cause a lot of suffering. Victims of leprosy are ostracized. The moment that leprosy is diagnosed they are considered socially dead. The poor health infrastructure and inaccessibility of medical services are the main factors which delay diagnosis and treatment. Consequently, complications and deformities are common.
Establishment of National Leprosy Control Program in Yemen Before 1964, leprosy patients were subjected to obligatory isolation in unsanitary houses. Clinics in Aden, Sanaa, Taiz and Mukalla were the only places known for giving very basic medical care. It is documented by Fawdry in 1959 that leprosy patients were treated by Avlosulfon twice a week for two years under supervision.
The leprosy work was carried out by the Missionaries of Charity (Mother Teresa’s organization) from 1974 in Taiz, Hodeidah and Al-Sukhnah. In 1982, Dr. Yasin Al-Qubati, a dermatologist who was then Director of Republican General Hospital in Taiz, took over the duties part-time at the hospital at the City of Light in Taiz. Using the vehicles of the Republican Hospital, he made field visits assessing the leprosy situation in rural areas.  He attended the WHO meeting in Mogadishu, Somalia where he arranged a visit to Yemen by Dr.  S.K. Noordeen of WHO, Geneva and the late Dr. H. Bruce Ostler of Francis I. Proctor Foundation, San Francisco, USA. This culminated in support by the German Leprosy Relief Association (GLRA), Wurzburg, Germany.
From 1984 WHO leprosy control activities provided consultancy, supplies of equipment and drugs as well as fellowships for local and international training for leprosy staff. Finally in June 1989, an agreement between the Ministry of Public Health (MOPH) and the German Leprosy Relief Association (GLRA) was signed to strengthen the activities of the National Leprosy Control Program (NLCP).
In 1990, a pilot control program for national leprosy control was started in Dhamar, Taiz, Ibb and Hodeidah to serve the total population of 5,119,960. Following the principle of ‘Serving the poorest of the poor,’ the Missionaries of Charity left the service in the leprosy colonies in September 1991 and then the NLCP was taken over by the government.
At the beginning of 1992, the Yemen Leprosy Elimination Society (YELEP), a local non-government organization was established by Dr. Yasin Al-Qubati. YELEP provided buildings, equipment, vehicles, medical supplies and material as well as financial and social support for patients and their families.
In December 1993, an agreement was made between NLCP and Handicap International (HI), Belgium to set up an orthopedic workshop, to train the local personnel in shoe-making and to set up a health education program. The HI supported the NLCP from March 1994 up to July 1996, fulfilling all the objectives agreed upon by both parties.
From the early 1970s and to date the World Food Program (WFP) supported the leprosy patients and their families by supplying kitchen provisions.
Structure of NLCP The NLCP now covers 80% of the country and is supervised from the headquarters in Taiz. The control program comes under the jurisdiction of the MOPH and has 10 full-time Dermatologists (field supervisors) and 3 part-time Dermatologists working for the program. Apart from these physicians, there are also 8 medical assistants and 60 primary health care workers for leprosy control.  There are 64 leprosy clinics operating in 14 regions and 60 of these clinics are integrated into the primary health care program.
The Skin and Venereal Diseases Hospital located in the City of Light, Taiz is the only main referral hospital in the country for the treatment of leprosy and its complications.  It also has the main training institution for various categories of leprosy control workers.  It has 30 beds for in-patient care along with operation theater, physiotherapy unit, skin smear laboratory, pharmaceutical laboratory for making skin ointments, footwear workshop and out-patient department for general skin diseases.
Activities And Achievements of NLCP The case load of leprosy has declined from a peak of 2,379 registered for Multi Drug Therapy (MDT) in 1989 to 647 in 1997.  The bacteriologically positive patient (Multibacillary – MB) proportion among new cases in 1997 was 61%.  The registered prevalence has declined from 1.9 in 1989 to 0.37 per 10,000 population in 1997.
On the introduction of WHO’s Special Action Program for the Elimination of Leprosy (SAPEL) in April 1996 and Leprosy Elimination Campaign (LEC) in 1997, the NLCP activities were extended to remote areas of Al-Mahara, Hadhramaut, Shabwa and Hodeidah.
Year after year, the health education activities have been intensified to increase the passive case detection.  The international relationships of Dr. Yasin Al-Qubati have aided in producing posters to be used for health education. The first poster on leprosy was developed in 1988 with the financial support from Mr. J. Genoud of Lausanne, Switzerland.  The second and third posters were printed in 1992 with funds received from Saint Lazarus of Jerusalem, Canada through the efforts of Dr. Martin L. Robinson, University of Western Ontario, Canada and Dr. Don Zarfas, London Ontario, Canada.  Then the fourth and fifth posters were developed by the Department of Health Education, Ministry of Public Health, Sanaa, Yemen.  100,000 leaflets were printed and distributed in the mail box of the centers of the governorate for fund raising, especially during Ramadhan.
Since 1990, the mass media has been organizing special programs on leprosy and with funds received from GLRA, a mobile health education unit was formed. Health education messages were printed on the school timetable and students’_exercise books and were distributed.
In 1994, an orthopedic workshop was constructed and equipped with the necessary tools and raw materials received from GLRA, HI and YELEP. Late Dr. H. Bruce Ostler, Francis I. Proctor Foundation, San Francisco, USA; Dr. Stefan A. Rath, Neurologist, Augsburg, Germany; Dr. Christian Graviou, Orthopedic Surgeon, Order of Malta, France and Dr. J.A. Noirclerc, Traumatologist and Dr. Francois Javquine, Plastic Surgeon, Saint-Charles Clinic, Lyon, France, volunteered to conduct reconstructive surgeries for leprosy patients.
A rehabilitation program teaches sewing to the ex-leprosy patients.  They make and sell ready-made garments.  At the same time, a male rehabilitation program provides stone cutting, agriculture, cattle, rabbit and poultry farming. Since 1987, regular training courses have been conducted for medical personnel.  By the end of 1997, 882 medical personnel had been trained.  In the beginning, these training courses were conducted in coordination with 7 WHO consultants and 6 consultants from other organizations.  Since 1991, the Yemeni dermatologists have been conducting these courses themselves.
The NLCP medical officers are sponsored by WHO and GLRA for international training courses. The use of mass media, school health education and training of medical personnel, all led to early passive case detections, a  decrease in stigma and reintegration of leprosy patients into the community.
Plan of Integration of Leprosy with other Diseases The skin reflects most of the physiologic and pathologic changes occurring inside the body. It also reflects the psychologic and health status of a person.  Changes in the skin have a considerable influence on how people perceive themselves and interact with others.
In Yemen, hypo- or hyper pigmentation leads to stigmatization of the patients by the community especially for leprosy, vitiligo, onchocerciasis, psoriasis and other chronic skin conditions.  Scratching, too, is socially unacceptable. This stigma may prevent marriage and justifies the actions of Dermatologists. In spite of the increased activities of NLCP and the gradual decrease of leprosy case load, the stigma related to the disease still persists in the community.  To overcome this problem we have begun to integrate leprosy elimination activities with other skin problems.
Study on Onchocerciasis:  A histopathological study of the skin from onchocerciasis patients in Taiz, focused on before and after treatment with ivermectin, in collaboration with Prof. D. Richard Lenoble, a French Parasitologist and Dr. P. Gaxotte of Merck Sharp & Dohme, France.  This study is accompanied by a mass distribution of Ivermectin in the endemic areas. The results are under preparation for publication. Study on Ivermectin for Treating Scabies:  With the collaboration between NLCP and the Health Office of Taiz and Merck Sharp & Dohme Interpharma (MSD), France, a study on “Ivermectin for treating scabies”_was initiated.
Study on Intestinal Parasites in the Leprosy Community: A study of epidemiology of intestinal parasites in the City of Light village was possible following the gift of 200 Merthiolate Iode Formol (MIF) tubes from France to use for the collection of feces samples.
Leprosy – TB Combined Pilot Project Starting in 1996, the progressively expanding health services led the government and the international organizations to ask NLCP to extend the activity to TB control.  A combined Leprosy-TB pilot project has been developed with the funds received from GLRA.  10 TB clinics were opened in the City of Light, Dimnah, Rahida, Kabeita, Sharab Al-Salam, Sharab Al-Rona, Selwo, Haifan, Mawiah and Khazagah.  In 1997, 119 new cases were discovered.
Preparation of Dermatologists for Low Prevalence of Leprosy It is obvious from our statistics that leprosy will be eliminated as a public health problem in our country by the year 2000.  However, a few remaining cases may be present in rural areas.  With the low expectation of leprosy cases in dermatological practice, under-diagnosis will be a problem in the future.  Due to this fact, information on all health facilities in the country has been collected.  Starting in 1997, this data has been used for training the physicians and medical assistants in all the important health institutions of the country in the diagnosis and differential diagnosis of leprosy.
Conclusion Though the endemicity of leprosy in Yemen is very low, the stigma of leprosy, poor health care infrastructure and communication system, difficult terrain, inadequate resources and political instability are the continuing constraints.  With the support of MOPH, WHO, GLRA and YELEP, including the training of personnel, the wide distribution of MDT outlets covering most parts of the country and intensified health education activities, will certainly bring an end to the transmission of the disease as predicted by the year 2000. This article is under publication in the International Journal of Dermatology 1997, 36,000-000.
Dr. Abdulsamad Abdulaziz Dermatologist – cum – Field Supervisor, National Leprosy Control Program, Skin and Venereal Diseases Hospital