REPORT ON A VISIT TO THE LEPER ISLAND OF CULION AND ON THE ANTI-LEPROSY WORK IN THE PHI- LIPPINE ISLANDS.

By Dr. E. MUIR. M.B., ch.ii., m.d., i'.r.c.S.,

Leprosy Research Worker, Calcutta School of Tropical Medicine.

This anti-leprosy work which has been carried out in the Philippine Islands during the last

19 years is valuable not only for what it has

done to stamp the disease out of these islands, but also for the stimulus which it has given to similar work in India and in other parts of

the world. It was, therefore, with keen ex-

pectation that I looked forward to my visit to the

leper island of Culion. 'The Americans, on their occupation of the

Philippine Islands, noticed the large numbers of

lepers frequenting public places and engaged in

occupations which rendered them a danger to

the general community, and it was determined in

1906 to remove this menace by the deportation of all bacteriologically positive lepers to Culion, an island some 200 miles to the S. W. of Manila.

This policy has been carried out for the last

19 years, and those engaged in anti-leprosy work in the Philippines are of the opinion that, while the ardent expectations of some of those who initiated the work have not been fulfilled in reducing leprosy to negligible proportions, the results have justified the steps taken in the very considerable reduction of its prevalance. As my experience in anti-leprosy work has

been almost entirely, confined to India, this

report will take the form of a comparison of con- ditions connected with leprosy in India with the corresponding conditions in the Philippines, as

far as I was able to become acquainted with

them during my very short visit. There are 11 million inhabitants of the Philip-

pine Islands, and it was estimated in 1906 that

there were some 10,000 lepers in the islands or,

roughly, 1 in every 1,000 was a leper. The Indian census of 1921 gives an estimate

of an average leper population of about 1 in

3,000, but those who have had the most oppor- tunity of judging are of the opinion that 1 in

600 or even 1 in 300 would be a more correct

figure. With a population about 30 times as great

and with a proportional endemicity perhaps 3 times as great, the problem in India is a very different one from that in the Philippines. Any attempt to follow the example of the smaller

country in carrying out general segregation would obviously be impossible, and it may, therefore, be useful to mention briefly what methods it is

proposed to adopt in India. We have no reason to believe that leprosy

is either rapidly increasing or diminishing in

India, and if" we assume what is probably the case, that it is at a standstill, it would mean that one leper in one generation infects, on an average, one healthy person in the next genera- tion, and thus a balance is kept up. I believe

that, if the programme that we propose is carried out efficiently, this balance will be upset and the disease will entirely disappear within a few generations. Two most potent factors which make for the

continuance of leprosy are the ignorance of medi- cal practitioners and still more of the general public of the early signs of the disease, and the general prejudice which there is against leprosy as compared with other more transmissible and more fatal diseases. Medical students are given' no practical training or clinical demonstrations which would enable them to make an early diag- nosis, and many doctors have such a horror of the disease that they would not willingly under- take its treatment. Although leprosy is a far less communicable disease than tuberculosis, the superstitious dread of the former is so great that those known lo be suffering from it are ostracised and, even before the disease has reached a stage

262 THE INDIAN MEDICAL GAZETTE. [Junk, 1925.

at which it is possible to find the bacilli on

bacteriological examination, they are removed from their employment and thus placed in the

very circumstances which are most favourable for the rapid increase of the disease. For we find in India that, in the great majority of cases, the disease may be diagnosed clinically from

signs of nerve origin at a stage when carefully made bacteriological examinations are negative, and the patient has, presumably, not yet become a possible source of danger. It is found, more- over, that the great majority of such early cases, when they are efficiently treated at out-patient clinics for a sufficient time, lose all active signs of the disease, and, provided they are able to

remain free from other diseases and otherwise

maintain a normal amount of general resistance, remain free from such signs for an indefinite

period. Though it would be unwise to speak of such patients as

"

cured," yet there is good reason to believe that the longer the time they remain sign-free, the less is the likelihood of recurrence.

It will thus be seen that, if a negative bacterio- logical result carried out by a medical man with sufficient experience relieves the early cases from the necessity of being isolated, and if the early signs of leprosy are widely known and recognised by medical men and by the public, and if doctors who are able to treat the disease efficiently are available for all, we should have the means of cutting off the transmission at its source, which is always the ideal method of dealing with a dis- ease.

We are, therefore, putting the chief emphasis in our campaign in India in this direction, and our programme may be classified under 6 heads:?

(1) The appointment in each of the 9 pro- vinces of an expert, who shall be a man of energy and personality, and who shall be responsible for the initiation and organisation of leprosy work in the province.

(2) The training of doctors and students by the experts.

(3) The establishment of out-patient skin clinics where suitable cases may be treated.

(4) The establishment of one or more leper colonies in each province.

(5) Propaganda work by preparation] and distribution of suitable literature, through the co- operation of the educational authorities and

teaching in schools, through various health autho- rities, and above all through the trained doctors, the out-patient clinics- and the leper colonies.

(6) Research work, which, though it is

placed last in the list, is to be considered the most important of all.

As regards treatment?leper patients may be divided into 4 groups:?

(1) Those who are bacteriologically negative and who can obtain expert medical assistance either from private practitioners or at out-patient clinics, within reach of their homes.

(2) Those who are bacteriologically positive,

but are able to isolate themselves in their homes and obtain local expert medical assistance.

(3) Those, bacteriologically positive or nega- tive, who cannot get efficient treatment locally and those, bacteriologically positive, who cannot effectively isolate themselves in their own homes.

(4) Those who are unable to support them- selves or whose relatives have refused to support them because of deformities, dread of the disease or other reasons.

Classes 1 and 2 should preferably be treated in out-patient clinics, and classes 3 and 4 in colonies or other segregation institutions.

Colonies will be situated within the province which they supply; each colony will be limited to 1,000 inmates and have a superintendent and n

well trained, high grade medical man with at

least 2 qualified medical assistants. Colonies will be on sites of at least 100 acres with good land for agriculture and the raising of cattle, etc., and a sufficient water supply. Inmates will be

encouraged to take part in agricultural, horticul- tural or industrial pursuits, and provision will be made for education and practical training. Abundant, suitable work and exercise will be

provided, and fresh vegetables and dairy pro- duce,?very necessary articles in the diet of those suffering from leprosy,?will be secured by the labours of the patients themselves.

Compulsion will not be used in sending patients to these institutions, except in the case of pauper lepers and of those who persist in endangering the public by carrying on certain trades; but, when necessary, compulsion will be used in carry- ing out discipline within the colonies and in the early removal of new-born and symptom-free children from bacteriologically positive parents.

Cases which are bacteriologically negative or nearly so, will, as far as possible, be separated from those with the grosser skin types of the disease.

Having thus outlined our proposed programme for India, which has only as yet begun to

materialise in some of the provinces, I shall place alongside of it the methods which are at present in use in the Philippines, along with other schemes which I have been informed are contemplated there, and compare, as far as I am able, the

differing conditions in the two countries. As far as I have been able to ascertain during

my brief visit, the following are the main differ- ences between the leprosy problem in the Philip- pines and that in India :?

1. The number of lepers to be dealt with both absolutely and relatively to the whole popu- lation.

2. The limitation of the disease in the Philip- pines almost entirely to poverty-stricken classes of the people and its comparative rarity among the socially higher classes; whereas in India all classes are affected, the very highest not being excluded.

3. The more rapid onset of the disease in the Philippines and the consequent impossibility of

June, 1925.] ANTI-LEPROSY WORK IN PHILIPPINE ISLANDS: MUIR. 263

diagnosing it by clinical signs before it is possible to make a positive bacteriological examination. I was told that this is the case by those in charge of the work in Culion Island. It would imply an almost entire absence of patients of class 1.

Now this last difference is one which I find

myself unable to accept without further investi- gation. It is true that such cases are not com-

monly seen in Culion; but, when I visited the

San Lazaro Hospital for lepers in Manila. I saw a possible explanation.

In this hospital there are more than 400 leper inmates, the great majority of whom have pre- sented themselves voluntarily for treatment on

the understanding that, if they become negative within a certain period, they will not be deported to Culion.

Now, according to the present law in the

Philippines, a leper is only a leper when-lepra bacilli can be found on bacteriological examina- tion. Cases of leprosy, which in India we should diagnose on clinical grounds because of anaes-

thesia, nerve-thickening and other signs of nerve involvement, are not recognised as cases of leprosy in Manila; they are not admitted to San Lazaro Hospital or other leper institutions or treated by Government doctors until they are found to be bacteriologically positive.

I was told by one of the doctors in charge at San Lazaro that there are large numbers of such clinically positive but bacteriologically negative cases in Manila, and that in cases admitted to

San Lazaro there was a history of clinical signs of the disease for an average period of about one year previous to their becoming bacteriologically positive. Now this would correspond more or less closely to what we have found in different

parts of India?in Calcutta, in the Deccan and in South India among various races and in differ- ent climates?wherever leprous patients have been attracted for treatment by efficiently run, volun- tary out-patient clinics.

Before we started a clinic in Calcutta we

had no idea that such cases existed in such

numbers; and I am inclined to think that there

might possibly be a similar finding in Manila and other places in the Philippines, if voluntary out- patient clinics were opened at various centres and run by first-rate doctors who had had extensive experience in the clinical diagnosis of leprosy from early clinical signs, as well as in the best methods of treatment. However, I think that no dogmatic statement should be made one way or the other before such an experiment has been made.

If such cases exist, it would only be natural that many of them should hide their malady out of fear of forcible detention, or should fail to

recognise the significance of early signs, especial- ly as they are not officially recognised in making the diagnosis.

It is obvious that the point is one that it is

important to clear up as such cases do not need

to be segregated and are by far the most amen- able to treatment; while by treating them the dis- ease may be cut off at its source.

I think that a step in the right direction has been taken by establishing institutions like San Lazaro which are not so far removed from the homes of the people, but our experience in India, so far as it goes, lays great stress on the import- ance of abundant vigorous exercise in the treat- ment of leprosy and of mental and physical occu- pation, and I am not sure to what extent this can be carried out in institutions which are

founded on the principle of the hospital ward, as at San L,azaro.

I believe that the principle of supplying exer- cise and occupation is being developed in connec- tion with the Culion Colony, where many of the lepers are living on small farms and are engaged in fishing, market-gardening and other active

employments. I am also glad to hear that there is a prospect of a road being opened up from the colony to another part of the island, which will further facilitate settlement on the land.

Another proposed development, which I con- sider of great importance, is the formation of

facilities for the early removal of the children from their leprous parents to Manila, as many such children have in the past fallen a prey to the disease through contact with their leper parents or other lepers. Our experience in India points to the great importance of such measures in preventing the disease, and of making arrange- ments for the proper care of such children from earliest infancy.

I was greatly impressed with the efficient way in which pathological research is being carried out by Dr. Wade and his staff. I am deeply indebted to him for all that he taught me in this direc-

tion, I feel strongly that anything which is done to help and develop the work that he is doing- will be of the greatest importance not only in the Philippines but wherever leprosy exists, and his work has its importance not only in connection with leprosy but in its bearing upon other dis- eases which are associated with leprosy.

It may not be out of place to mention here a scheme which Dr.. Wade is initiating, a proposal for the early circulation of papers written by those engaged in leprosy investigation, so that such workers throughout the world may be informed of each other's results without the delay of waiting for publication in medical journals. It is hoped that in this way much waste of time and money will be avoided by preventing the un- necessary reduplication of work. My visit has impressed upon me the import-

ance of such personal conferences of research workers and the great possibilities of their results. I hope, that it will be possible for us to welcome in Calcutta some of the workers from the Philip- pines. My thanks are due to Dr. Avellana, the head

of the Colony, and to Dr. Rodrigues, the chief physician; also to Dr. Perkins for all that he

264 THE INDIAN MEDICAL GAZETTE. [June, 1925.

showed me of the very important work that he is doing from the chemical side; also to the other members of the medical and pathological staff. Above all, I wish to thank General Wood,

Governor of the Philippine Islands, for his kind welcome and for all the facilities that he made for my visit to the Island of Culion.