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Brazzil - Health - September 2004
 

Leprosy Still a Plague in Brazil

Brazil is second, after India, for the total number of cases of
leprosy in the world. In 2003, there were nearly 50,000 new cases
of leprosy detected in the country. Several million Brazilians
live in favelas today. The situation in the favelas, with people living
in cramped quarters, are ideal for the transmission of the disease.

Cassandra White


Brazzil

Picture "Leprosy? That comes from dogs, right?" ("Lepra? Vem do cachorro, né?")1 "Doesn't that cause your limbs to fall off (cair em pedaços)?"

One of the first things I learned as I conducted anthropological research on cultural aspects of leprosy in Rio de Janeiro is that few people in the general public in Brazil knew much about this disease or how it is transmitted.

Why would it be important to know more? This disease couldn't be a problem in the modern world, could it? Unfortunately, the incidence of leprosy is still very high in a number of countries worldwide, and Brazil is second, after India, for the total number of cases of the disease.

In 2003, there were nearly 50,000 new cases of leprosy detected in Brazil.

Leprosy is caused by the bacillus Mycobacterium leprae and is closely related to the tuberculosis bacillus. Like TB, it is transmitted through breathing—through droplets emitted by a person with an active case of the disease.

Unlike TB, however, it is not highly contagious. Most people (90-95%) have a genetic immunity to leprosy, and leprosy experts generally say that prolonged and intimate contact with a contagious individual is required for a susceptible person to acquire the disease.

Leprosy is also known as Hansen's Disease (and is commonly referred to as hanseníase in medical and media reference to the disease in Brazil), after Gerhard Armauer Hansen, the Norwegian scientist who first observed the bacillus under a microscope in 1873 and identified it as the cause of leprosy.

Leprosy does not cause limbs to fall off or flesh to rot. The bacillus does damage the peripheral nerves, causing insensitivity or lack of feeling. Nerve damage is the major cause of disability associated with leprosy.

The painlessness that results from nerve damage allows affected individuals to ignore cuts, burns, and other injuries sustained during everyday activities. These injuries may thus become infected or even gangrenous, and amputation is required in some cases.

A patient in early stages of the disease often has very minor symptoms, such as a whitish or depigmented spot that is numb. If leprosy is detected and treated during its early stages, patients are unlikely to develop any physical disabilities or deformities.2

A multidrug therapy treatment program, which cures the disease and renders patients noncontagious, is available free of charge in Brazil at public health posts and hospitals. Why then, is leprosy still such a public health problem in Brazil?

Indians Didn't Know Leprosy

The answer to this question is complex. One might first ask why leprosy was ever a problem in Brazil. The disease did not exist in the Americas prior to colonization by Europeans.

Leprosy was present in Portugal and in other nations that sent ships to Brazil (Holland and France, for example); some of the healthcare workers with whom I worked in Brazil told me that one of Pedro Cabral's (Cabral was a Portuguese explorer whose ship was the first from Europe to land on Brazilian soil) men was infected with the disease.

The Portuguese imported nearly 4 million enslaved Africans to Brazil, many of them from areas where leprosy was endemic, and the conditions of slavery (close quarters and harsh working conditions, for example) may have contributed to the perpetuation of the disease.

The abolition of slavery in 1888 was followed by the development of large shantytown, or favela, communities in Brazilian cities, as freed slaves could not generally afford to buy their own homes or own their own land.

Several million Brazilians live in favelas today. The living conditions in the favelas, in which large families usually share a relatively small space, are ideal for the transmission of leprosy.

Brazilian history is also characterized by the frequent movement and migration of peoples in search of jobs and better economic conditions, and internal migration is often a boon to the spread of disease.

The continued existence of leprosy in Brazil today can be linked to the current socioeconomic situation. Leprosy is not a tropical disease; in the past, leprosy was endemic in many parts of the Northern Hemisphere.

It was eradicated from Europe, North America, and Japan as living conditions improved for the general populace and as potable water, sanitation, and adequate nutrition became accessible to people in all social classes.

A recent article on Brazzil's website3 included the statistic that 90 million people in Brazil, nearly half the country's population, do not have proper sewage collection and treatment; another 15 million are without garbage pickup services.

These factors serve to lower overall immunity in people susceptible to leprosy and thus may increase the chances for people to acquire the disease.

Although a drastic improvement in living conditions for the majority of Brazilians would almost certainly result in the elimination of leprosy from Brazil, it is currently more practical to seek other solutions to this problem.

Early detection of the disease is the most important factor in halting its spread and preventing disability. Many physicians in Brazil do not recognize leprosy in its early stages.

Misdiagnosis Is Common

In interviews I conducted with 43 people affected by leprosy in Rio de Janeiro, 41% had received a misdiagnosis of their condition. Healthcare workers who are not trained in leprosy diagnosis mistook skin patches and nerve problems for various ailments, including diabetes, vitiligo, allergies, skin funguses, arthritis, and syphilis. Some patients were given treatment for other conditions and spent years trying to get a correct diagnosis.

In a nation where there are so many new cases of leprosy every year, there is no logical reason why all healthcare professionals do not receive mandatory training in leprosy diagnosis, which is relatively simple.

For example, Boy and Girl Scouts in several endemic countries have been trained as volunteers in leprosy screening efforts. A person with a depigmented spot on the skin should be asked to close their eyes while another person lightly taps the spot with the tip of a pen and asks if he or she can feel anything.

If the person has no feeling in the spot, he or she should be directed to a treatment center for leprosy to confirm the diagnosis.

Media campaigns in Brazil in recent years have attempted to raise awareness of leprosy and its symptoms among the general public in Brazil. MORHAN (the Movement for the Reintegration of people affected by Hansen's Disease), a non-governmental organization with offices in nearly every state of Brazil, organizes educational campaigns in schools and in the media designed to reduce stigma and to increase the potential for patients to diagnosis themselves and seek the appropriate treatment at a health post.

MORHAN maintains a telephone line (Telehansen) to which people from all over Brazil can call with questions they have about leprosy. MORHAN has recruited celebrity volunteers, such as actress Solange Couto and singer Ney Matogrosso, and has worked with novela (Brazilian fixed duration soap opera) writer Glória Perez to incorporate the topic of leprosy into an episode of The Clone, a hugely popular novela which aired in 2001-2002.

Treatment for leprosy is in the process of being decentralized in Brazil, which means that, ideally, people affected by leprosy will be able to receive treatment at any public health post in Brazil.

This will increase access to treatment for those who live further away from centers that exclusively treat leprosy; there are potential drawbacks to this approach, since patients with complications associated with nerve damage require specialized care to prevent severe disability, but decentralization has the potential to reach more affected individuals throughout the country.

Leprosy remains a major public health problem in Brazil, though its presence is often overshadowed by the presence of other serious infectious diseases that receive more media attention, such as HIV and TB.

However, leprosy complicates the lives of tens of thousands of Brazilians every year. Several thousand patients are rendered temporarily or permanently disabled each year, forcing them to rely on government pensions, or in the case of some of the undocumented domestic workers I interviewed who had leprosy, on the kindness of charitable groups, friends, and family members.

Leprosy elimination is not an easy task in Brazil, but it is possible. Elimination will require a sustained focus on the part of the Brazilian populace and the international community.

1. The belief that leprosy (lepra) comes from dogs is a common folk belief in Brazil. It may derive from the fact that lepra is also a word for dog mange. This is one of many reasons, including the stigma associated with the term lepra, that the term was outlawed in Brazil in 1995 in favor of hanseníase (Hansen's Disease).

2. This figure is based on the World Health Organization's document, Global Leprosy Situation 2004. Online: http://www.who.int/lep/stat2002/global02.htm (individual country statistics in spread sheet document, "Details by Country").

3. http://brazzil.com/mag/content/view/139/2, "In Brazil 90 Million Have No Sewage Collection," Agência Brasil; accessed September 10, 2004.


For further information on Hansen's Disease/leprosy, consult:

MORHAN's website (in Portuguese): http://www.morhan.org.br/

Brazilian medical research institution, Fundação Oswaldo Cruz (site in Portuguese): http://www.fiocruz.br/ccs/glossario/hanseniase4.htm

World Health Organization: http://www.who.int/lep/


Cassandra White - http://monarch.gsu.edu/people/cwhite.htm - has a Ph.D. in Anthropology from Tulane University. She is a Visiting Lecturer in the Department of Anthropology and Geography at Georgia State University in Atlanta, GA. She is currently writing a book about her research, conducted in 1998-1999 on a grant from the Fulbright Organization, on leprosy in Rio de Janeiro. She can be reached at cwhite@gsu.edu.




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