Wall Street Journal - August 20, 2001
Miriam Jordan, Staff Reporter of The Wall Street Journal

SOBRAL, BRAZIL -- Folk healer Maria Julia Costa da Silva prays to alleviate back pain, heartache and other ailments troubling her neighbors in an impoverished quarter of this northeastern town. Local lore holds that folk healers can be as effective as modern medicine. But recently, Mrs. Costa, 54, has been telling some of the visitors to her mud hut, "I can pray for you. But I can't solve your problem on my own."

Her advice is a critical element in Sobral's attack on a fearsome, centuries-old disease: leprosy. Local health officials recently trained Mrs. Costa to recognize the telltale discolored, numb patches on the skin that mark the disease's onset. Now she refers patients with the symptoms to the nearby public health clinic.

Brazil, Latin America's biggest country, is winning the battle against AIDS, but it is still struggling to wipe out leprosy. Like AIDS, leprosy is a communicable disease that elicits powerful feelings of dread and stigmatizes sufferers. Yet unlike AIDS, it is simple and inexpensive to treat, and, in cases where it is arrested early, recovery is usually complete.

It costs $3 to treat a mild case of leprosy, with two antibiotics taken over the course of about six months, and about $20 to cure a more severe case, with three antibiotics taken over the course of about a year.

Still, leprosy continues to afflict thousands of Brazilians, in the working-class suburbs of Rio de Janeiro in the south, in the Amazon jungle in the north, and here on the parched plains of Ceara state. Last year, 41,000 new cases of leprosy were reported in Brazil, compared with fewer than 20,000 new cases of AIDS. Only India has more leprosy cases.

Sobral health official Maria de Jesus examines numb patches on the legs of a clinic patient, Eliete Maciel.

"Brazil's AIDS program is a model of prevention and treatment," says Maria Neira, chief of communicable diseases for the World Health Organization, in Geneva. "The fact that it's No. 2 in leprosy world-wide sends a very negative signal. It's shocking."

To break leprosy's stigma, many people refer to it as Hansen's disease, after the Norwegian doctor Gerard Hansen who discovered the bacterium that causes it.

The disease is slow to spread, usually only after years of close contact. Left untreated, it attacks tissue and damages nerves, leaving skin scarred, muscles atrophied and limbs deformed.

Leprosy patients, who may suffer with peg legs and clawed hands, have historically been treated as outcasts. They cease to be contagious with the first dose of medication, but their scars and disfigurement are a lasting legacy.

A decade ago, the WHO resolved to eliminate leprosy world-wide by 2000, which means reducing the prevalence to one case for every 10,000 inhabitants. After Brazil and 11 other countries failed to meet the target, the goal was extended to 2005. The WHO provides the medicines to treat leprosy at no charge.

Indeed, the obstacle to elimination isn't money, says Jose Serra, Brazil's health minister, who is expected to be a candidate in next year's presidential vote. "The problem with leprosy is first, finding the victims and second, getting them to keep taking the drugs."

Mr. Serra has been a visible champion of Brazil's acclaimed AIDS program. Last year alone, the country's Health Ministry sponsored three major AIDS ad campaigns. But Brazil hasn't had a national leprosy campaign since 1987. "Nobody scores political points with leprosy," says Artur Custodia, chief of Morhan, a leading leprosy advocacy group. "It's the disease of the downtrodden."

Mr. Serra's policy has been to concentrate federal resources in municipalities such as Sobral where leprosy is endemic. The efforts of professionals on the ground make the difference, he says. "There is no question of favoring AIDS for political reasons," Mr. Serra says, while acknowledging that Brazil's middle class "has rallied around AIDS."

Officials at the Health Ministry's leprosy unit point to a sharp drop in the disease's prevalence, to four cases per 10,000 people in 2000, compared with 18.5 per 10,000 people in 1990. The disease has been eradicated in two states and is likely to be eliminated in three others this year. Still, thousands of cases of leprosy remain unreported and undetected in Brazil, Mr. Custodia, the activist, says.

Some activists are trying to raise awareness. Francisco Rodrigues de Oliveira, whose hands were left disfigured by leprosy, is suing the Ceara state government after a civil servant refused to fingerprint him for a new identity card. A Ceara town has elected a former leprosy patient to its city council.

In Sobral, home to 160,000, officials are working to quash prejudice and encourage treatment. Leprosy prevalence is high: nine cases for every 10,000 inhabitants. In Mrs. Costa's district, the rate is about 16 cases per 10,000.

Advanced leprosy can cause scarring.

Advanced leprosy can cause scarring.Marlene Bezerra, a mild-mannered nurse, used to work alone tending to the city's leprosy sufferers at a downtown public clinic. Hardly able to keep up with demand, she had a strong sense that many more victims were "in hiding." Many patients would travel hours by mule or foot to reach the clinic but couldn't manage the monthly visits to get a fresh supply of pills.

So in 1998, Sobral began dispensing treatment at 26 neighborhood medical clinics. The city's health secretariat, in partnership with Morhan, the advocacy group, sponsored educational campaigns on the radio and in schools.

Last year, health workers fanned out across Sobral signing up folk healers, including Mrs. Costa. She received a stack of green cards with "Hansen's disease" stamped on it. "When I think one of my visitors has the disease, I tell them to show the green card at the clinic," she says.

Sobral's awareness program so far has yielded a sharp increase in the number of reported cases, to 149 in 2000, compared with 14 in 1994. But as a result of treatment, the prevalence rate is falling, to 8.8 cases per 10,000 people last year compared with 12.6 per 10,000 in 1998.

The response from folk healers prompted officials to approach brothels. "You can be our partners," Maria de Jesus, a city health official, tells a gathering of prostitutes. "You have a full view of every part of your client's body."

"Tell them softly, affectionately," advises Ms. Jesus. "Say: 'These spots worry me. Can you feel the hot or cold sensation on them? No? Then maybe you should visit your community health center.' "

A radio commercial about leprosy prompted Eliete Maciel, a 32-year-old mother of five, to seek help for twitching sensations "like ants biting me" in her feet and "dormant" spots on her leg. Now, she says, "Hansen's disease is nothing but a minor inconvenience for me."

Write to Miriam Jordan at miriam.jordan@wsj.com1

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