Can Leprosy Be Cured?

By Magnus Vollset, PhD (University of Bergen, Norway) and Michael Sappol, PhD (Stockholm, Sweden)

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Can leprosy be cured? Should the practice of isolating and confining people afflicted with the disease come to an end? This silent motion picture from the early 1930s helps make the case that it should.

Leprosy in India [Lepra in India in the original German] is a hard film to watch. In the course of its 12 minutes, it puts before the camera patients who suffer from a variety of symptoms, ranging from mild discoloration of the skin to terrible facial and bodily disfigurement, and loss of fingers and toes. Leprosy is a devastating illness, with a long history. In the early decades of the 20th century, doctors were starting to understand it as a bacterial disease, but there was still no very effective treatment (today it is usually called “Hansen’s Disease” and can be cured with antibiotics). People who were afflicted were designated as “lepers” and stigmatized. In some places they were reduced to the most degraded conditions of beggary and homelessness. In other places they were segregated, remanded to “leper colonies” where they would live out their lives isolated from the general population.

Leprosy in India is also a document of medical attention and treatment (and even a bit of hope), in the setting of British colonial India. Some of the treatment is rough—patients are displayed with varying degrees of callousness—but they do receive care. We may be shocked to see the patients exhibited so starkly. That wouldn’t fly nowadays, but back then there were no standards of informed consent. The patients were positioned before the camera and they complied. Viewers will be uncomfortable with that, and should be. Some of us will not want to watch, will feel that we don’t have the right to watch. But if everyone averts their gaze, or worse if we are not permitted to see, then the people who suffered so grievously are erased from history, theirs and ours. Because Leprosy in India is most of all a document of the human condition, and human suffering, which is a shared history: We are, at some time in life, every one of us prey to pain and disability and, potentially, disfigurement and isolation.

Leprosy in India has two parts. Part one, a film clinic, shows a grand rounds of patients at the School of Tropical Medicine and Albert Victoria Hospital in Calcutta (now Kolkata), matched to intertitles that label the patient’s condition. Part two shows the layout of the hospital and the therapies it has to offer, including (at the very end of the film) a bit of physical fitness exercise.

The print that resides in the collection of the National Library of Medicine is a bit of a mystery: no other copies are known to exist; we don’t know of any documents that relate to its production or screening history. It was probably made in 1931, just after the scheme for classifying cases was decided upon at an extended international meeting in Manila. Its creator is probably Bernhard Nocht (1857–1945), director of the Hochschule für Tropenmedizin (Institute for Tropical Diseases) in Hamburg, Germany. Nocht had been the president at the second meeting of the League of Nations Leprosy Commission in Bangkok in December 1930, and after attending the meeting in Manila he was sent to Calcutta on a fact-finding mission.

Leprosy in India would have been screened at medical schools, especially schools of tropical medicine, and meetings and congresses convened by medical associations, governmental health authorities, and medical missionary organizations. A silent film, it undoubtedly would have been accompanied by voice-over commentary from a speaker. (A 1938 article reports that “Dr. Muir showed a cinematograph illustrating the activities of a leper settlement” at an “ordinary meeting” of the Royal Society of Tropical Medicine and Hygiene in London.) ^[1] Although the details of the making of the film, and the intentions of the filmmaker, are unknown, it was probably designed to demonstrate the “Manila-classification”. That new classification system distinguished cases by type and severity of clinical signs: The letters A or B were used to signify whether the disease affected the nerves or the skin, and the numbers 1 to 3 stated how far the disease had progressed.

The Cure

Classification was a big issue. The question of how to classify leprosy cases was interlinked with claims that a cure had finally been found: Chaulmoogra oil produced from the tree Hydnocarpus wightiana. As shown at the end of the film, the medication was prepared from the seeds of a chaulmoogra tree that grew in the hospital garden. The treatment regime consisted of a series of injections once or twice per week, and rubbing the oil into the skin.

Chaulmoogra was not new. The herbal medicine had been used as a lotion to treat leprosy for more than half a millennium in China and India, and was introduced to Western medicine in the 1850s. After being chemically analyzed around the turn of the 20th century—and fueled by reports of successful trials—the use of chaulmoogra-based derivatives proliferated around the world. In the interwar period, chaulmoogra’s main champion was the Scottish doctor (and former missionary) Ernest Muir (1880–1974), who took part in making Leprosy in India. In addition to being the director at the School of Tropical Medicine in Calcutta, he was one of the leaders of the British Empire Leprosy Relief Organization (BELRA), which collaborated with leprosy institutions all over the English-speaking world. Their close ally, the Mission to Lepers, introduced the slogan “Faith, Oil and Work.”

Not everyone agreed that leprosy could be cured. According to Étienne Burnet, secretary of the League of Nations Leprosy Commission, “The technical reviews give no idea of the spirit with which the question is being discussed by enthusiasts and sceptics alike. Some go so far as to say that all this excitement about cure is mere humbug, while others declare that to be lukewarm about treatment is as great a crime as to refuse quinine to a malaria patient or arsenobenzol to a person suffering from syphilis.” (Burnet 1930:39)

Deciding whether chaulmoogra could cure leprosy was easier said than done. First, exactly what was meant by the term “chaulmoogra” differed from place to place. For some chaulmoogra meant crushed seeds from the Hydnocarpus family, for others it was the fruit, or distilled oils mixed with chemical compounds, particularly salts and disinfectants. Second, how the treatment should be applied also differed. Should it be rubbed on the skin, taken orally, or through injections under the skin or directly into the veins? At what doses, and for how long? Third, there were no global standards for classifying cases. When proponents of chaulmoogra produced statistics showing up to 60 percent cure rates, opponents argued that those listed as “cured” had never had the disease in the first place, or that the disease inevitably would reappear.

According to Burnet, the lack of conclusive evidence of the efficacy of chaulmoogra was not due to bad faith, but due to the difficulty of organizing a large-scale trial in multiple locations. For everybody to agree on the outcomes, there had to be agreement on the premises. This is why the classification of cases became so important: “It is obvious that such uniformity would be most helpful in compiling statistics, and that statistics drawn up in a universal language are essential as an index of the results of treatment and the prophylactic campaign.” (LNHO-C.H.1042). The classification system shown in Leprosy in India was a tool for deciding whether or not a cure had been found. Was Muir right when he claimed that most cases of leprosy could be cured if only treatment started early enough?

The Politics

In the early 1930s, the dominant approach to leprosy prevention around the world was segregation. The recommendations from the Third International Leprosy Conference in Strasbourg in 1923 had insisted that those isolated should be treated humanely, but otherwise reaffirmed the policy advice first advocated by the Norwegian leprologist Gerhard Armauer Hansen at the First International Leprosy Conferences in Berlin (1897) and Bergen (1909): Leprosy was contagious, and the best way for society to defend itself was through isolating those affected.

According to the proponents of chaulmoogra, such as Muir, having a cure changed everything. First, segregation and leprosy laws should be abandoned. As long as the disease was seen as a crime and detection meant lifelong segregation, people would do their best to hide their disease for as long as possible. This increased the risk of contagion, and the risk of missing the window of opportunity for the chaulmoogra treatment to work. Second, the expensive isolationist institutions should be replaced by cheap outpatient clinics and treatment in the patient’s own home. (Unlike the rest of the world, there were by 1930 already more dispensaries than in-patient clinics in British India.) Third, it meant that treatments should be voluntary. Once former patients could return to their communities cured, they would spread the word and encourage others to seek help.

The medico-political program was also influenced by the situation in India. With more than 100,000 registered cases—Muir estimated that the actual numbers might be at least seven times higher—wholesale institutionalization was never an option. People suffering from leprosy were banned from certain trades and public spaces and transportation, but segregation was never pursued like it was in countries where the number of sufferers was deemed more manageable.

The vast majority of the leprosy institutions in India were established and financed by missionary organizations. However, the two institutions featured in Leprosy in India had a special place. The Albert Victoria Hospital (est. 1900) was one of a handful of institutions which relied solely on state funding. The School of Tropical Medicine (est. 1920) was where most of the leprosy workers in India (and also elsewhere) received their training.

The “Manila classification” showcased in the film did not last long as a global standard. Within months it was criticized for emphasizing effects rather than causes. The argument was that since leprosy was caused by the leprosy bacillus, any meaningful classification should be based on the workings of the bacillus. Still, it succeeded in putting classification at the top of the agenda. At the Fourth International Leprosy Conference, held in Cairo in 1938, classification was one of the main debates, with at least seven different alternatives on the table. The optimism concerning chaulmoogra would soon be eclipsed by the antibiotic sulfone-drug Promin, first tested in the U.S. and Vietnam during the Second World War. But that is another story.

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