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Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1136 (Published 07 February 2014) Cite this as: BMJ 2014;348:g1136
  1. Diana N J Lockwood, professor of tropical medicine1,
  2. Vanaja Shetty, senior researcher2,
  3. Gerson Oliveira Penna, medical and senior researcher3
  1. 1London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
  2. 2Foundation for Medical Research, Mumbai, India
  3. 3Tropical Medicine Centre, University of Brasilia, Brazil
  1. Correspondence to: D Lockwood Diana.Lockwood{at}lshtm.ac.uk

Diana Lockwood and colleagues reflect on the global leprosy elimination programme and challenge the wisdom of WHO’s elimination strategies

Elimination of a disease sounds attractive, but as the recent re-emergence of polio has shown, it is difficult to accomplish. As part of its roadmap for reducing the burden of neglected tropical diseases, the World Health Organization has identified five diseases for elimination by 2015 and a further eight by 2020.1 Although setting these ambitious targets has the potential to focus money and resources, unless the targets are realistic they can have unforeseen consequences. We use the experience of the 1991 campaign to eliminate leprosy to show how targets can end up causing harm to patients.

Box 1: Neglected tropical diseases identified by WHO for elimination1

By 2015

  • Rabies in Latin America

  • Chagas disease transmission through blood

  • Human African trypanosomiasis in selected countries

  • Onchocerciasis in Latin America

  • Schistosomiasis in Eastern Mediterranean region, Caribbean, Indonesia, and Mekong river

By 2020

  • Rabies in South East Asia and Western pacific

  • Blinding trachoma

  • Leprosy

  • Chagas in most Latin American countries

  • Human African trypanosomiasis

  • Visceral leishmaniasis in Indian subcontinent

  • Lymphatic filariasis

  • Endemic treponematoses (yaws)

Why choose leprosy?

Leprosy is a stigmatising and potentially disabling disease. Despite the introduction of an a global treatment programme in the 1980s around 230 000 cases are diagnosed annually, mainly in India and Brazil but also in 41 other countries.2 Leprosy is caused by Mycobacterium leprae and is spread through droplets.3 However, the disease can be treated with a six or 12 month course of multidrug therapy (rifampicin, dapsone, and clofazimine), which has a cure rate of 98%.4 The condition can be diagnosed clinically by recognising a range of characteristic skin lesions and palpating thickened peripheral nerves (box 2). Diagnosis can be confirmed through detection of acid fast bacilli in slit skin smears or through granulomatous inflammation in skin and nerve biopsy samples.5 Up …

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