The New Nation - Internet Edition

Leprosy : Remarkable success story of Bangladesh

Sardar Arif Uddin

Today is world Leprosy day (January 27, 2008). Since more then 50 years, on the forth Sunday of January every year, thousands of people across the globe has to remember those who suffer the horrendous effects of Leprosy. The Leprosy is a chronic infectious disease is known to occur at all ages ranging from early infancy to very old age. But the youngest age reported for occurrence of Leprosy in three weeks. On the other hand, in most parts in the world males are affected more frequently then females often in the ratio of 2:1. The exact mechanisms of transmission of leprosy in not known. At least until recently, the most widely held a belief was that the disease was transmitted by contact between cases of leprosy and healthy persons. More recently the possibility of transmission by the respiratory route is gaining ground. There are also other possibilities such as transmission through insects that cannot be completely ruled out. Leprosy is a diseases caused by the Mycobacterium leprae bacteria (some one called Hansen's disease) that attacks nerves to the hands, feet and face making them numb and without feeling. This issues that have to be address not only as medical phenomena rather it is also a social diseases due to those infected are less likely to go for help. Leprosy patient always face the social rejection even the people affected by leprosy are disowned by family and friends also.

The first known written mention of Leprosy is dated 600 BC and it was recognized in the ancient civilization of China, Egypt and India. In 1873 Norwegian scientist named G.A.Hansen first discovered that leprosy is caused by a bacillus, mycobacterium leprae (this is why it is sometimes called-Hansen's disease). The Leprosy Mission started work in 1874 but since that time leprosy was not curable. In 1940s scientist discovered the drug dapsone was effective against the leprosy bacterium-a 'cure' was at last being talked about but still it wasn't completely effective. The world had to wait until in 1982 when 'multi-drug therapy' (MDT) was developed by combining dapsone with two other antibiotics (Rifampicin and Clofazimine). The modern miracle of medicine proved to be the cure so desperately and today we can put a smile on people's faces and joy in their hearts by providing this cure! Although the effective medicine to cure the leprosy has already developed but there is still no vaccine available to prevent people catching it in the first place We have to further investment to research again and again up to discover the preventive vaccine of leprosy. In one side, modern medical science gave us the miracle medicine against leprosy in curative perspective but other side due to social injustice and lack of social ignorance, cured leprosy patients still faces to social isolation, negligence and discrimination by the social ideology, employment opportunity and so on.

The top 10 countries in new cases detection in 2005 are India, Brazil, Indonesia, DR Congo, Bangladesh, Nepal, Mozambique, Nigeria, Ethiopia and Tanzania. Together they constitute about 96% of the 2005 global new leprosy case detection. The South East Region (SER) contributed to about 69% of the 2005 global new cased detection. Basically all countries of the South East Asia Region were known to be endemic for Leprosy. The number of registered leprosy cases is falling 5.37 million in 1985, 3.1 million in 1992 and approximately 1.8 million in 2000. By 1999, 80% of all leprosy cases were occurring in 6 countries (India, Brazil, Bangladesh, Indonesia, Burma and Nigeria). At the beginning of 2006 about 219,826 cases were under MDT globally and the prevalence rate was about 0.2 per 10,000 populations. According to official reports from 109 countries and territories, the global registered prevalence of Leprosy at the beginning of 2007 stood at 224,717 cases while the number of new cases detected during 2006 was 259,017. The number of new cases detected globally has fallen by more then 40,019 cases (13.4% decreased) during 2006 compared with 2005. During the past five years, the global number of new cased detected has continued to decrease dramatically, at an average rate of nearly 20% per year.

In 1981 World Health Organization (WHO) study group recommended multi-drug therapy (MDT) that effectively kills the pathogen and cures the leprosy patient. Again in 1991 World Health Assembly passed a resolution to eliminate leprosy as a public health problem and eliminate the problem is defined as a prevalence rate of less than one case per 10,000 populations (>1 /10,000 populations) by the year 2000. Since 1995 World Health Organization (WHO) has been providing free MDT of all patients in the world, initially through the drug fund provided by the Nippon Foundation and since 2000 through the MDT donation provided by Novartis and the Novartis Foundation for Sustainable Development. Novartis has pledged free supply of MDT till 2010. The continuous effort and monitoring by WHO and widespread use of MDT has reduced the leprosy disease of burden dramatically but in 9 countries in Africa, Asia and Latin America leprosy is still considered a public health problem. These countries account for about 75% of the global leprosy disease of burden. According to the latest available information (2007), intensive efforts are still needed to reach the leprosy elimination target in five countries specially, Brazil, India, Madagascar, Mozambique and Nepal.

On the other hand, Leprosy has been a major health problem in Bangladesh for a long time. It was considered a high endemic country and was listed among ten countries with high caseload one. Bangladesh Government followed the WHO resolution (calling for elimination of leprosy by the year of 2000) and making substantial allocations to the national leprosy elimination program under the forth population health project (1991-98) and continuing it in the HPSP since July 1998. The National Leprosy program was first launched in 1965 with the introduction of Dapsone through Government and NGO hospitals.

Since 1996, 625 MDT units were established in the country. In 1993 Bangladesh was estimated to have a leprosy prevalence rate of 13 per 10,000 populations, i.e. 136,000 cased that made Bangladesh the country with the third highest leprosy caseload in the world. The estimated number of leprosy cases was revised to 80,000 in 1996 and by the end of 1997; the estimated prevalence of leprosy was 3.5 per 10,000 populations with a registered prevalence of 1.17 per 10,000 populations. Since 1994 all registered cased are provided with MDT.

Thus the MDT coverage of registered cases is 100 percent in Bangladesh. In that case, Bangladesh has made considerable progress in achieving the global elimination of leprosy at national level. The WHO goal of elimination of leprosy as a public health problem by the year 2000 is defined as to achieve leprosy prevalence (registered) to less then 1/10,000 populations. Bangladesh achieved elimination of leprosy at national level at the end of 1998 with prevalence of 0.86/10,000 populations before two years ahead of target date. The present leprosy work is going on for sub-national elimination by the year 2010

But still now Bangladesh has some challenges to go up from Leprosy elimination to eradiation stage. We have to address the Leprosy (as well as all the disease) as an integrated approach covering the medical and social dimensions.

The dominant discourse habituated to observe the health issues under the 'Medicalization Model' and using the 'Treatment observation Lens' only rather then in holistic perspective covering the social determinants factors of health. Health is not only the issue of medical; it's also an issue of social injustice. Only medical part /treatment part of any disease should be treated by medical professional but the other broad area of health as well as disease definitely should address by the social lens where, poverty, social and economic injustice, human rights etc issues are include. And non-medical professionals (Public Health Anthropologist, Health Economist, Health Journalist etc) can contribute more if the total health strategy and policy developed by medical and social perspective.

In the case of leprosy, it is transmitted by air through droplets from the nose and mouth during close and frequent contacts with untreated cases. Basically poverty and leprosy go hand in hand. Generally those who catch this disease have low immune systems due to the extremely poor environment in where they live.

In that sense, according to data, African region are more affected by Leprosy. So undoubtedly we can say there is co-relation between Leprosy and poverty to some extent. Regarding Millennium Development Goal (MDG) goal No 06- "Combat HIV/AIDS, Malaria Tuberculosis and Other Diseases", has no specific target to eradicate the leprosy (due to dramatically reduced the leprosy globally) but under the 'other diseases' word of goal-06 still now have to emphasis to address the issue. Although Bangladesh has better condition regarding Leprosy but extreme reluctant may occur again leprosy. We have to continue at least mass campaign in community for early detection.

Medicine at our doorsteps: Eshopgol

Jamayet Ali

Eshopgol is an important ingredient in preparing medicine in Aurvedic and Unani system. It is commonly known as Bhusi, available in the market both in towns and rural Bangladesh. There are no well-defined or commonly accepted standards of quality in vogue and each manufacture prepares his own grades by mixing varying proportions of husk obtained from different millings. The quality of husk is determined by its size, colour, presence of red scrapings of the upper layer of the kernel, husk powder and dust. Husk of large size, white in colour and free from red scrapings, is the best.

Botanical name of Eshopgol is Plantago ovata. It is indigenous to the Mediterian region and west Asia, extending up to Sind in West Pakistan. It has gradually been introduced into India. Attempts have been made to cultivate it in USA. Eshopgol is a hardy and can be grown on a variety of soil, but it does well on rich, well-drained losamy soil. The seed mucilage is used in cosmetics and as a basic stabiliser in ice-cream industry. It is also useful for sizing purposes and for the preparation of chocolates. Made into a paste, the husk forms an excellent thickener either alone or in mixture with wheat starch paste. A 19fdkjhksj useful as a substitute for agar-agar can be obtained by treating the husk with hot caustic soda solution and subsequent neutralisation.

Medicinal Properties: The seeds are sweet, acrid, mucilaginous, astringent to the bowels, tonic; useful in "kapha", biliousness, dysentery and leprosy; cause flatulence (Ayurveda). The seeds are cooling, demulcent; useful in inflammatory and bilious derangements of the digestive organs; applied as poultice to rheumatic and gouty swellings; good in dysentery and irritation of the intestinal tract; decoction useful in cough and chronic diarrhoea (Yunani).

Demulcent, and mildly astringent. The seeds have been found serviceable in febrile, catarrhal, and renal affections, but their chief use is in diarrhoea and dysentery. Moistened with water, they form a good emollient poultice. The seeds yield to water a good deal of mucilage, and form a cooling demulcent drink which is prescribed in cases where emollients are required. A slight degree of astringency and some tonic property may be imparted to the seeds by application of a moderate degree of heat, and it is said that this remedy cures the chronic diarrhoea of European and native children on the failure of other medicines.

The crushed seeds made into a poultice with vinegar and oil are applied to rheumatic and gouty swellings. With the mucilage a cooling lotion for the head is made. Two or three drachms moistened with hot water and mixed with sugar are given in dysentery and irritation of the intestinal canal to produce an easy stool. The decoction is prescribed in cough. The roasted seeds have been an astringent effect, and are useful in irritation of the bowels in children and in dysentery. Eshopgol seeds have demulcent and diuretic properties and are generally used in inflammatory conditions of the mucous membrane of gastro-intestinal and genitor-urinary tracts. They are generally given in the water of tender coconuts. The seeds were given in the form of an infusion in cases of specific urethritis and found to relieve considerably the burning and irritation accompanying the disease (Koman) The seeds of P. ovata are very beneficial in chronic dysenteries of amoebic and bacillary origin and chronic diarrhoea due to irritative conditions of the gastro-intestinal tract. A glucoside named aucubin has been found in the seeds, but it is physiologically inactive. The tannins which are present in appreciable quantities have little action on the entamoeba or bacteria. The action of the drug would therefore appear to be purely mechanical, being due to the large amount of mucilage which is contained in the superficial layers of the seeds. This mucilage is shown not to be acted on by the digestive enzymes, and therefore passes though the small intestine unchanged. It lines the mucous membrane of this part of the gut and its demulcent properties give it a protective and sedative action. In the large gut the intestinal bacteria have been shown to have little or no action on the mucilage. Practically the whole of it is passed out unchanged during the 12 to 24 hours following its administration. During its passage through the gut it coats the inflamed and ulcerated mucosa and protects it from being irritated by the fluids and gases, the products of gastro-intestinal and bacterial digestion. This enables the lesions to heal quickly. The toxins present in the gut are further absorbed by the gel and their absorption into the system is prevented. The seeds are taken in large quantities and as they swell up in contact with water they increase the bulk ofthe intestinal contents and in this way relieve chronic constipation by mechanically stimulating the intestinal peristalsis. The mucilage of P. ovata seeds acts in very much the same way as liquid paraffm. It is very much cheaper and is further free from the injurious effects produced by the habitual use of the latter drug, e.g., malignant diseases of the colon, eczema ani, paraffin pains, etc., (R.N. Chopra; Ind. Med. Gazette, August 1930, Indian Medicinal Plants, K.R. Kirtikar & B.D. Basu, 240,241)

Medicinal values: Eshopgol or "spogel" seeds are not mentioned by Sanskrit writers on medicine and were apparently unknown to them. They are however, very frequently referred to by Arabian and Persian writers, who appear to have long held the medicine in high esteem. The Persian physician Alherbi mentions them in the tenth century, a little later Avicenna refers to the drug and nearly all subsequent writers on Muhammadan medicine ascribe valuable properties to Eshopgol.

Fluckiger and Hanbury state that its valuable qualities were first brought to the notice of European science in 1719 by Luick, and towards the end of the century, Fleming, Ainslie, and Roxburgh have all something to say in its favour. Ainslie writes, "These seeds are of a very cooling nature and form a rich mucilage with boiling water, which is much used by native practitioners and indeed of late years by the European medical officers of India, in cases of catarrah, gonorrhoea and nephritic affections."

Fleming makes a similar statements regarding the utilisation of the drug in Bengal, "in all diseases in which acrimony is to be obviated or palliated." Later the valuable demulcent properties which they possess in cases of dysentery and certain forma of diarrhoea, were forcibly brought to notice by twining (Diseases of Bengal, 1,212) and in 1868 the seeds were admitted as officinal to the Indian Pharmacopaeia.

Some authors recommend that the seeds should be administered dry in doses of two and half drachms. Others prefer its exhibition as a mucilaginous decoction, four drachms being boiled in two pints of till the quantity is reduced to a pint and the whole given, in divided does, in the course of a day.

The latter course appears to be best adapted for cases of dysentery, while the former is most efficacious iiJ. diarrhoea, especially the chronic diarrhoea of children and "hill" diarrhoea. A slight degree of astringency may, it is said, be imparted to the seeds by slightly heating them. By natives they are considered cooling and demulcent, and are chiefly employed in diarrhoea, dysentery, other inflammatory and functional derangements of the digestive organs and fever.

The crushed seeds made into a poultice are applied to rheumatic and gouty swellings. A cooling lotion for the head is prepared from mucilage and a decoction is prescribed in cases of cough and colds. There is little doubt that mucilaginous decoction is a valuable adjunct to other curative agents in the treatment of dysentery and diarrhoea, important point in its favour being that it has no unpleasant taste and may be prescribed, while any other drug is being at the same time administered.

Eshopgol has attracted little attention in European medicine outside our subcontinent, though it is probably worthy of a fair trial in cases of ordinary and summer diarrhoea. Mr. Cristy recommends the seeds as a valuable remedy in fowl diarrhoea. The dried seeds and husk are used as a emollient, demulcent and laxative, and in the treatment of chronic coustipation, a moebic and bacillary dysentery and diarrhoea due to irritative conditions of gastro intestinal tract. Eshopgol preparations are given after colostomy to assist the production of smooth solid faecal mass. In indigenous medicine the seeds are considered cooling and diuretic as well, and recommended in febrile conditions and the affections of kidneys, bladder and urethra. A decoction of seeds is prescribed in cough and cold, and the crushed seeds made into a poultice are applied to rheumatic and glandular swellings (IP., 35354: Chopra, 1958,380,382)

Alcoholic extracts of the seeds exhibit cholinergic properties. They lower the blood pressure in anaesthetized cats and dogs, inhibit the isolated and perfused hearts of rabbits and frogs and stimulate the movements of intestines of rabbits, rats and guinea-pigs. The activity of the extract on smooth muscle is inhibited by atropine (Khorana etal. Indian J. Pharm. 1958, 20,3)

Special opinions: "A very valuable remedy in the treatment of chronic dysentery. I have used it largely with good results and can bear personal testimony of its efficacy. I use it in spoonful doses of the whole seed, steeped for 15 or 20 minutes in water, the resulting mucilaginous mass being swallowed. Many of the swollen seeds pass out whole with the motions, and I believe their actions to be mechanical as well as astringent to the intestinal ulcers.

I have used it largely for dysentery and chronic diarrhoea in both European and natives and consider it a very valuable medicine" (Surgeon C.H. Foubert, DaIjiling)."Useful in gonorrhoea, as well as in diarrhoea and dysentery" (Assistant Surgeon T.N. Ghose, Meerat). "The mucilage is very useful in cases of heat and scalding during micturition taken in the form of sherbet with sugar candy." (Asstt. Surgeon S.C. Bhattachargi (Dictionary Of The Economic Products Of India)

Poor management agravates HIV crisis

Syful Islam

Despite is having huge funds from different global initiatives the government of Bangladesh response to the management of AIDS patients is very poor, experts have opined.

"The lone government response to the AIDS patients is primary treatment at the Infection Disease Hospital where the patients are being locked in a ward like pet animals in the cage," said Dr Zahed Masud of AITAM Welfare Organisation.

According to Dr. Masud private clinics forcibly release the patients if they were tested infected with HIV/AIDS while the government institutions never admit them for treatment.

The government response is very poor except misusing the foreign funds through distributing the money among the non-compliant organisation through 'bidding' like tender for other government projects, he said.

AITAM Welfare Organisation, the lone non-government agency, is providing treatment to the AIDS patients. It has so far provided treatment to 215 AIDS patients at an affordable cost.

Dr. Yasmin Jahan, a consultant of the National AIDS/STD Programme (NASP) said IDH is the only government facility to provide treatment to the HIV/AIDS affected people. But the facility is far less in volume and quality in comparison to the infection rate.

She said the government has to establish management facility for the AIDS cases, which is absent till now.

According to her, some non-government organisations like Mukto Akash and Ashar Alo is trying to provide treatment facilities to the HIV/AIDS patients. Some physicians, one in Chittagong and another in Sylhet are providing treatment to the AIDS patients from their own initiative.

Dr. Yasmin said the government has secured some US$40 million from the sixth round of the Global Fund to deal with the problems of youths. From the fund the government will arrange treatment for HIV/AIDS patients free of cost.

Citing another critical point of HIV/AIDS patients' management she said, safe blood transmission facility is not available everywhere in Bangladesh. HIV/AIDs is spreading through blood transmission also here as facilities of checking all five disease is not available. The government is working to establish 100 Safe Blood Transfusion Centre at Upazilla Health Complexes level.

Dr. Yasmin, however, said the 8th Round Sero-surveillance Report on HIV/AIDS, which will be available on March, will help identify the exact scenario of Bangladesh's position on this deadliest disease. The injecting drug users are spreading the disease at an alarming rate, she added.

On stigma, she said HIV/AIDS patients here face disgrace and apathy from family members, the society and even from the doctors. All the physicians do not have enough knowledge of the disease so they often, willingly or unwillingly, stigmatise the patients.

No research or survey on HIV/AIDS stigma has been carried out in Bangladesh, Yasmin added.

Former Health Adviser Maj Gen (Dr) ASM Matiur Rahman (Rtd.) on his speech on Worlds AIDS day urged all concern for undoing the stigma and discrimination to the HIV/AIDS patients by changing their mindset, which's potentially inhuman in outlook and dealing.

He, however, said Bangladesh has a narrow window of opportunity to act decisively to prevent the spread of HIV among the vulnerable groups.

In 2007 a total of 333 persons were identified as HIV infected and 125 AIDS cases were recorded of which 14 patients died.