History of Leprosy in Sri Lanka: Saga of three millennia

By Ifham Nizam

Nearly 1500 new patients with leprosy are diagnosed each year. Almost 50 percent of them are residents of four districts, Colombo, Kalutara, Gampaha and Batticaloa. Some areas in the northern, Uva and Central provinces have very few cases and may be considered areas that have “eliminated” leprosy in the true sense, says a senior medical officer.

Dr. Indira Kahawita, Consultant Dermatologist, Anti Leprosy Campaign, Sri Lanka, told The Island that 10 percent of the patients are children below 14 years of age.

“This is an indication of ongoing transmission within the country. About seven percent of the patients have permanent nerve damage at the time of diagnosis. This means there is a delay in diagnosis,” Dr. Kahawita stressed.

Excerpts of the interview with Dr. Kahawita:

* Does leprosy have a long history in Sri Lanka?

Yes, the history of leprosy is as long as the history of the country itself. There is evidence from the ancient medical books, as well as from the chronicles on history. But one need to remember that the disease wasn’t called leprosy then.

In some of my descriptions I have used the terms leper and asylum. These words are used only in the historical context. In the modern world these words are considered discriminatory and are not used.

* Then how is it possible to come to conclusions?

Firstly, some ancient books on medicine, written in the Anuradhapura era, describe symptoms and signs of skin diseases, similar to leprosy. The most notable among them are; Sarartha Sangrahaya” by the Surgeon King Buddhadasa in the 5th century, “Yogarnavaya”, written by Bhikku Buddhaputhra in the 12th century, and “Bhesajja Manjusawa”, written by “Paspiruvan mula/head of five piriven” Bhikku in the 13th century. All these books describe several presentations of “kushtha” that are identical to leprosy. The same is true for the well known Ayurvedic books, “Charaka Sanhithawa” and “Susrutha Sanhithawa”.

After going through these texts very carefully, one can deduct that the word “kushtha” was an all-encompassing term similar to the word ‘rash’ in today’s context, and that leprosy was definitely one of them. Both the Sushrutha and Charaka Sanhitha give almost identical descriptions of “kushtha poorwa roopa”or symptoms of “kushtha”. The absence of sensation, absence of sweating, paraesthesia, goose bumps, unusual pain in the wound (neuropathic pain), ulcers that occur easily and last longer and numbness of organs have been described as symptoms of “kushtha”. Several types of “kushtha” described in the books written in Sri Lanka are identical to the individual features of leprosy.

Secondly, the “Mahawansa” narrates how king Buddhadasa cured a leper of his deranged mental condition when he used abusive language at the king in the marketplace. The statue “Kushtaraja Gala” in Weligama, is now established as an Avalokitheswara bodhisatva. Bodhisatva worship was used for relief from illness and it is believed that lepers of the South worshipped this statue seeking relief.

* What about the legend of the “lion” and Suppa Devi and the

beginning of the Sinhala race?

If one were to think of a medically plausible explanation for the lion, the most suitable would be a well-built young man with lepromatous leprosy who had who had fled to the jungles due to his disease. In fact, the changes in the face in lepromatous leprosy are termed “leonine facies” – face of a lion.

If this is the case, the fact that their offspring were later received at the Royal Court confirms that discrimination against those affected was minimal at that time.

* Was leprosy a dreaded disease in the ancient past?

It is difficult to say that persons affected were not discriminated at all. But the story of Sinhabahu and the fact that the leper who abused king Buddhadasa was able to do so in the market place suggest that those affected were allowed to live freely within the society. The Thripitaka contains the “Suppabuddha Kutti suttha” narrating the story of a person affected who sat in the audience with the others to listen to the preachings of the Buddha who gained enlightenment as the Buddha preached aiming him specifically. Even the bioarcheological work in the Indus valley have shown evidence that there was an empathetic attitude towards those affected.

* What was the status of leprosy in the colonial period?

Even though there are no written records from the Portuguese period, many documents from the Dutch period give details about the status of leprosy. The disease was prevalent in the areas under the Dutch rule and the rulers had started to segregate those affected in order to prevent further transmission. Initially, they were banished to Tutucorin, in India. Later the Dutch East India company allocated funds to build the leper asylum in Hendala. Leprosy was a major health problem in the Dutch era and the officials had been prompt in tackling the situation.

The highlights of the British period are the lepers ordinance no 4 of 1901, the building of the leprosy hospital in Manthivu, off Batticaloa, and the introduction of the early treatments for leprosy. The Lepers Ordinance imposes compulsory segregation of those confirmed to have leprosy. Since all those diagnosed could not be housed within the leprosy hospitals, home quarantine was also practiced.

* What is the status of leprosy hospitals now?

The hospital at Hendala houses patients who were admitted several decades ago. They are there as they have lost family ties due to long separation. In its prime the hospital had boasted of around 700 patients, the best possible medical care and nursing support of religious sisters from many sects. The eminent doctors had done immense service to leprosy care in the country and some have even been honoured by the British empire.

The hospital at Manthivu was opened in 1921 due to the logistic difficulties in transporting patients from the East to Handala. It was decided to close the hospital and transfer 38 patients to Hendala due to safety concerns during the civil unrest in 1996. Two patients who had refused to be moved still remain there.

A leprosy colony, meant for able bodied patients to undergo inpatient care while being economically independent, functioned at Uragasmanhandiya, in the Galle district, for a short period, from 1952 to 1963.

* Why were patients segregated?

There was no effective treatment at that time. In fact, in the Dutch period, it wasn’t even known that leprosy was caused by a bacterium. But it was accepted that spread of the disease could be contained by removing those affected from the community. Initially, segregation was voluntary but after 1901 all patients diagnosed were under segregation, irrespective of their status.

* Does it mean that there was no treatment whatsoever during those days?

The initial treatment options were oils extracted from certain plants as external applications. During the late 19th century, two oils; gurjun oil extracted from the plant Dipterocarpus turbinatus and chaulmoogra oil extracted from the plant Hydnocarpus wightianus were used as massage oils.Chaulmoogra oil became the mainstay of therapy in the 1920s, when better techniques of preparation made it possible for the oil to be used as an oral drug and an injection. But the injections were painful and the response to treatment was around 50%.

With the introduction of a group of drugs called sulphones in the 1930s the treatment took a new turn. By the 1950s dapsone, a better and newer sulphone, was used as monotherapy (single drug therapy) for long periods. Since the organism has the tendency to alter itself to escape the effects of one antibiotic resistance to dapsone was soon identified.

* When was effective treatment for leprosy available in Sri Lanka?

In 1982 the World Health Organization (WHO) introduced a combination of antibiotics called the Multi Drug Therapy (MDT). Sri Lanka started using the MDT island-wide in 1983 and approximately 100 000 patients have been treated with MDT over the past 40 years. There are two types of treatment, paucibacillary (PB) given for six months for those with less severe disease and multibacillary (MB) given for 12 months for those with the more extensive form of the disease. The treatment is provided free of charge by the WHO and is available at government hospitals island-wide. The treatment can be used safely even in pregnant and lactating mothers and children.

*There were popular awareness programmes in the past. Were they effective?

The most effective awareness programme was conducted in the late 1980s with messages about the signs and symptoms of leprosy and that leprosy is curable over all available media. The two teledramas, “Ella langa walawwa” and “Ira Paya” were very effective in taking the message about leprosy to the masses. With improved awareness, the number of patients identified almost trebled in 1990. Many patients presented for treatment by themselves. Since 2000, approximately 1500 to 2000 new patients have been diagnosed each year. There was a drop in the detection of new cases after the COVID-19 pandemic, the Anti-Leprosy Campaign has started a social marketing programme over mainstream and social media called “LIFE Sri Lanka” in 2022.

* Has Sri Lanka eliminated leprosy?

When the WHO introduced the goal of “Eliminating leprosy as a public health problem” in the 1990s the parameter used was “less than one patient with leprosy per 10,000 population”. This highly technical point was not understood even by some healthcare workers. So, the message that was accepted by the public was that “Sri Lanka has eliminated leprosy, or leprosy is no longer present in Sri Lanka”. This misconception may have led to the missing of the diagnosis in many patients. If we look at the statistics for leprosy in Sri Lanka for the past 60 years, we can see that the numbers detected in the country have been within the WHO’s parameters even in the 1960s.

* What is the status of leprosy in Sri Lanka now?

Approximately 1500 new patients with leprosy are diagnosed each year. Almost 50% of them are residents of four districts, Colombo, Kalutara, Gampaha and Batticaloa. Some areas in the northern, Uva and Central provinces have very few cases and may be considered areas that have “eliminated” leprosy in the true sense

10% of the patients are children below 14 years of age. This is an indication of ongoing transmission within the country. About 7% of the patients have permanent nerve damage at the time of diagnosis. This means there is a delay in diagnosis.

*What measures have the authorities taken to control leprosy in Sri Lanka?

The Anti Leprosy Campaign (ALC), the organization in charge of leprosy control, is using a multi-pronged approach to improve awareness about leprosy, both among healthcare workers and the public. The ALC has mapped the country into risk areas according to the WHO’s most recent recommendations and is now in the process of using GIS technology to identify areas with high disease burden and to target those areas for awareness and case detection.

Our aim is to use strategies specifically suited for each area of the country so that all possible cases are diagnosed and started on treatment early. Since treatment of cases and minimizing the reservoir of infection is the only effective method of disease control for leprosy, we are hopeful that the improved strategies will take the country towards zero leprosy or true elimination of the disease.