Hansen's Disease: The Shared Paradigm

Hansen's Disease: The Shared Paradigm by M J de Mallac. The Book Guild Ltd, £12.95, pp 116. ISBN 1 85776 597 4. Rating: ★

The word leprosy evokes a range of responses. To the patient it means devastation and fear of being outcast; to an immunologist it is a complex tissue-damaging immune response; to a surgeon it may be the problems of protecting a neuropathic foot. It is these differing perspectives that de Mallac sets out to explore through a series of Socratic dialogues. In true French fashion he starts out with a statement of his philosophical position, rejecting Cartesian thinking and focusing on developing the notion of a shared paradigm and conceptual framework that he argues is needed for effective action against leprosy.

De Mallac progresses from a historical to a social analysis of leprosy. He looks at how hereditary and sanitary aetiologies were seriously considered in the 19th century while fish eating was briefly popular as a cause in the early 20th century. He has interesting observations on how society kept itself unpolluted by excluding leprosy patients, and how the mythologies of leprosy increase the marginalisation of patients by giving them a distorted image of disease.

De Mallac is rightly critical of the World Health Organization leprosy elimination campaign, which set the target of eliminating leprosy as a public health problem by 2000 (elimination was defined as reducing prevalence to less than 1 case per 10 000 population). This was to be achieved by rigorous application of multidrug therapy, and de Mallac points out that multidrug therapy alone is unlikely to interrupt transmission. This is because Mycobacterium leprae can survive in the environment for months and the disease has a long incubation time. The WHO target was also based on the premise that when prevalence reached 1 case per 10 000 population the disease would die out naturally, but there is no evidence to support this.

This is a difficult book to read. It is written in an excessively philosophical style, but without using data to develop arguments. Many will share de Mallac's deeply felt need for an approach to leprosy that encompasses the immunological, therapeutic, self-awareness, and psychological needs of leprosy patients, but this book is unlikely to convince sceptical readers of the importance of his arguments.