Mamysoa realized she had a problem after she stepped too close to the fire. “I burned my foot quite badly, but it hardly hurt at all,” she recalled. The 20-year-old housekeeper recently became one of five new cases of leprosy that Abdoul Zamandrahengo detects every month from his tiny public clinic in Antalaha, a small town on Madagascar’s east coast.
Zamandrahengo’s clinic has become a centre for the treatment of leprosy in the region. “It’s my own fault,” he told IRIN. “When I came here, I was told there were no new cases. Then I trained environmental workers...to look for signs. These rangers go far into the forest and to the remote villages. They tell potential patients as far as 200km away to come to Antalaha and see me.”
Leprosy is often called the disease of the poor, as healthy, well-fed people are rarely affected. It is caused by the bacillus, Mycobacterium leprae, which are transmitted via droplets, from the nose and mouth.
According to the World Health Organization (WHO), the disease is not highly infectious but can be spread by living in close quarters with someone who has gone untreated. A weakened immune system caused by poor nutrition and health care can make someone who has been exposed more vulnerable. Without treatment, the disease can cause progressive and permanent damage to the skin, nerves, limbs and eyes.
A surge in new leprosy cases in this remote region of Madagascar could not have come at a worse time. Once a prosperous vanilla-exporting town, Antalaha has suffered the economic consequences of two years of political instability that began with the March 2009 coup in which Andry Rajoelina, with the support of the military, deposed President Marc Ravalomanana. Numerous foreign aid and trade benefits on which the country was heavily reliant, particularly for the funding of social sectors, have since been suspended.
“There is no security, so vanilla planters had their vanilla stolen from their fields. These thieves sold the beans for low prices,” said a mayor of one of the communes outside Antalaha who declined to be named. “On the other hand, the price of rice has been going up. One `kapok’ of rice now costs 2,000 ariary [US$1 for a small tin-full]. Poor people can’t afford this.”
While people are becoming poorer and more susceptible to illness, the public healthcare system is receiving less money from the government. According to the UN Children’s Fund (UNICEF), government spending for health dropped to $2 a person in 2010, compared to $5 in 2009 and $8 in 2008. Clinics in remote places like Antalaha are the most likely to suffer from shortages of drugs and medical supplies.
Six to 12 months of treatment with multidrug therapy - a combination of two antibiotics and an anti-inflammatory (medicines that WHO distributes for free) - stops the disease from spreading, but there are other obstacles to overcome.
The main one, according to medical workers, is that the Malagasy authorities declared that leprosy had been eliminated from the country in 2010, a decision that makes Zamandrahengo fume with frustration.
“This is the work of someone who is behind a desk. Everyone here in the field knows that there are new cases,” he told IRIN. “Instead of helping us, they say that I don’t know how to diagnose leprosy and that I hand out too much medicine.”
Diagnosing the illness can be tricky in a tropical climate that causes many dermatological problems. Another of Zamandrahengo’s patients, a 26-year-old farmer presented with a skin problem that initially looked more like a symptom of syphilis, said the doctor. “But he also had bumps around the earlobes and that is a typical sign of leprosy."
At a small dispensary outside town, another health worker who did not wish to be named displayed a school notebook in which he had also recorded leprosy cases. Last year, he referred five new patients to Zamandrahengo. This year, there are already nine. “Please don’t write that I said there are new cases here because officially, there aren’t any,” he said.
Official figures notwithstanding, WHO continues to send drugs to treat the disease to the provinces. “The problem is that they only send the exact amount of treatment for existing cases,” said Gregoire Detoeuf of the Foullereau Foundation, an NGO that works to help leprosy patients all over the country. “So often it takes time for treatment to reach the new patients.”
Although the treatment stops the disease from spreading, many leprosy patients need care for the rest of their lives. After losing feeling in affected limbs, people with leprosy often end up with severe wounds on their hands and feet. “A woman who is cooking will just pick up the pot from the fire and burn her hands without noticing,” Detoeuf said. “A man who is walking home can step on sticks and rocks and hurt his feet.”
Boiled cloth for a bandage
In addition to medicine to treat the disease, leprosy patients need bandages to dress their wounds. But these basic items are often lacking in health centres. “We went into the villages to show health workers how to dress wounds,” said Odile Valat, a French nurse who volunteers for three months a year in the region. “We told them to cut one piece of gauze into eight parts, but they didn’t even have one gauze. So then we started with boiling pieces of cloth.”
Traditionally, leprosy patients have been housed in special villages and taken care of by local NGOs. “People here know what leprosy is, and they used to ostracize the lepers,” said Valat. Now that there is treatment that also prevents patients from infecting others, this policy has changed and newer patients stay in their own villages and receive treatment at home.
This shift in approach has been accompanied by its own set of problems. While the patients in the two remaining leprosy villages in Antalaha enjoy free health care and schooling for their children and grandchildren - and earn a living by working in the village plant nurseries, all supported by local aid workers - the newer patients often struggle with the consequences of their disease without any assistance. Families may lack the means to support a non-productive member of the household and patients with families of their own, cannot support them.
One of Zamandrahengo's patients, an elderly man, can no longer work as a result of his leprosy. “He has 10 children and can’t afford school fees for them," said the doctor. "I try to get money from anybody who visits here to help him out. It’s hard work, to help all of these people.”