INTRODUCTION:
“Leprosy work is not merely medical relief; it is transforming frustration of life into joy of dedication, personal ambition into selfless service...” – Mahatma Gandhi Leprosy is one of the major public health problems in some developing countries and also well known for the strong stigma associated with it. Leprosy Stigma is a kind of social stigma, a strong feeling that a leprosy patient is shameful and is not accepted normally in the mainstream of the society. It is also called leprosy related stigma, ‘leprostigma’ and ‘stigma of leprosy’. It is a chronic infectious disease caused by “Mycobacterium Leprae”. It mainly affects the peripheral nerves and the skin. Person suffering from lepromatous leprosy harbors very large number of leprosy bacilli in the body. In them, leprosy is generalized disease affecting several systems and many organs, especially the skin, subcutaneous nerve trunks; the mucosa of the upper respiratory tract, eyes, liver, testes, muscles and bones. The incubation period of leprosy is not known with certainty. WHO estimates that between 2 and 3 million individuals are disabled due to leprosy. Early detection of leprosy patients and their treatment with WHO recommended Multi Drug Therapy (MDT) are key elements of the present strategy to halt transmission of the disease and to bring about cure with disabilities. During the past 15 years over 11 million leprosy patients have been cured with MDT. The best way to prevent the spread of leprosy and eliminate it is to treat all patients with MDT. WHO report says that leprosy has been eliminated as a public health problem from 107 countries.2

PREVALENCE:
Though leprosy remains a public health problem in 10 countries, the greater part of the global burden is now focused on the top 6 endemic countries, namely: India, Brazil, Madagascar, Mozambique, Nepal and Tanzania. The total number of cases registered in these six countries combined represents 83% of the global prevalence and the prevalence rate is 3.4 per 10 000. India alone represents around 64% of prevalence and 76% of new cases world-wide. At the state level in India, there are eleven endemic states (having a prevalence of more than 10 000 and also a prevalence rate higher than 2 per 10000), which together represent more than 90% of the disease burden in India. These states are: Andhra Pradesh, Bihar, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal.3

WHO Leprosy Elimination Project: Status Report 2003

Top endemic countries at the start of 2003
Region Registered cases at end of 2002 (rate per 10,000) Cases detected during 2002 (rate per 100,000)
India 344,377(3.3) 473,658(46.0)
Brazil 71 139 (4.1) 38 365 (22.3)
Madagascar 6 602 (4.0) 5 482 (33.4)
Mozambique 7 136 (3.6) 5 830 (29.1)
Nepal 7 291 (3.0) 13 830 (56.5)
Tanzania 7 063 (2.1) 6 497 (19.0)
Total 443 608 (3.4) 543 662 (41.9)

HISTORICAL BACKGROUND: Leprosy is one of the oldest diseases of mankind which most probably originated in India. The law of Manu, stated in the Vedas written as early as 1400 BC in India, included instructions for the prevention of leprosy. Leprosy was referred to as “Kustha” in Ancient India. The first authentic description of leprosy and its treatment with Chaulmoogra Oil is given in “Sushruta Samhita”. According to Vagbahata (600AD), The name “Kustha” was derived from “kushnati” which means “ Eating away” in Sanskrit. The history of leprosy stigma is also as old as the history of leprosy. In Western Europe it reached at its peak in the Middle Ages since the church considered leprosy as “Unclean” and many “Lazar house” were built. Patients had carried bells to signal their presence. Since leprosy was found infectious, another kind of cause worsened leprosy stigma. In Japan, forced segregation strengthened leprosy sigma. Leprosy stigma has been universal, and has been present in all parts of the world where leprosy was present.2

FACTORS CONTRIBUTING TO LEPROSY STIGMA:
• General public's misconceptions: The general public has misconceptions about leprosy, particularly regarding the degree of its contagiousness.
• Doctors: Doctors and nurses who are ignorant of leprosy may worsen leprosy stigma.
• Leprosaria: The presence of lazar hospitals, leprosaria, colonies is the reflection of leprosy stigma. Some of the leprosaria and colonies are situated in remote lands.
• The press: In the past, there was a history of the press which worsened leprosy stigma.4

ISSUES FACED BY PEOPLE AFFECTED BY LEPROSY:
The fear of leprosy leads to the stigma and discrimination. Leprosy doesn’t just affect people’s health. Apart from medical issues people with leprosy and their relatives also face exclusion from their community and loss of access to their means of employment and government facilities including education and healthcare.
Stigma & Discrimination: Stigma is a negative opinion or judgment held against a person or group of people who are ‘different’ from the norm. According to the definition of Goffman (1963), “Stigmatization is a process that results in the reduction of life chances and hence in restriction for opportunities for an individual’s social participation in the community.”1 When stigma is acted upon these groups is considered as an act of discrimination, which can be categorized as given below:

 Social Discrimination: In India a strong stigma is attached to leprosy and people affected by leprosy are often discriminated against. Leprosy is seen as a curse or a justified punishment for those who have committed sins and is misperceived as highly infectious and transmitted through touch or ‘contamination’ of common goods like water or food. People affected by leprosy are prevented from accessing community resources (e.g. water) or marrying “normal” individuals and are excluded from festivals, religious areas, employment, and education and health care facilities. Fear of stigma and discrimination prevents people with leprosy seeking medical help and if they do seek help they can face discrimination from health workers themselves. Relatives of people affected by leprosy also face stigma and exclusion therefore, a person with leprosy may be rejected by their family and spouse and lose their home and social and support networks. As a result of stigma and discrimination people affected by leprosy often experience a loss of self esteem and dignity and feel fear, shame, hopelessness and guilt. Leprosy often affects the poorest and most marginalized communities who have a history of powerlessness, discrimination and lack of access to their rights and therefore have limited capacity to defend their rights and combat stigma.

 Legal Discrimination: At least 17 national and 40 state laws contain discriminatory provisions against people affected by leprosy including prohibiting people affected by leprosy from contesting elections, obtaining a driving license and travelling in trains. The law also allows leprosy as grounds for divorce meaning a person affected by leprosy can lose their home, belongings and access to their children. Many legislators, legal bodies and members of the Government are not aware of the existence of discriminatory legislation or its devastating impact on people affected by leprosy therefore action has not been taken to end these practices.

 Religious Discrimination: Christian, Islamic, Hindu, Buddhist and other religious texts negatively portray leprosy as divine punishment for the sinful and immoral behaviour of the person with leprosy. Negative images of leprosy in religious texts are used to legitimize stigma and discrimination against people affected by leprosy in modern society.5

CONCLUSION: Leprosy has been eliminated as a public health problem in most countries of the world according to the WHO, but the social stigma to the disease is still very high. Leprosy stigma is a global phenomenon, occurring in both endemic and non-endemic countries. The consequences of stigma affects effectiveness of leprosy control activities as well as the many aspects of the lives of people affected by leprosy including mobility, interpersonal relationships, marriage, employment, leisure activities, and attendance at social and religious functions. One of the most important reasons is a lack of a dedicated national-level programme and funding for prevention and management of leprosy. The fight against stigma associated with leprosy needs to be taken up by the whole society. If the misconceptions about leprosy are not changed, it will be difficult to eliminate leprosy as a public health problem.

REFERENCES:

1. Goffman E. Stigma: Notes on the management of spoiled identity. 1963, Simon and Schuster Inc., New York, NY, USA, pp 1-173.
2. Yawalkar S. J. –Leprosy, 2002, Novartis Foundation for Sustainable Development, Basel, Switzerland.
3. WHO Leprosy Elimination Project: Status Report 2003
4. http;//en.wikipedia.org/wiki/leprosy stigma
5. http;//www.tlmindia.org