Professor Cairns Smith (third from
left in the back row) with the
members of the ILEP Technical
Commission
Photo © ILEP (*See end for all names)



Professor Cairns Smith took up a position as Emeritus Professor of Public Health at the University of Aberdeen on 1st July 2011, retiring from his post as lead of the Section of Population Health at the end of this June. Passionate about promoting excellence in public health policy and practice, Professor Smith shares here some of his extensive experience, knowledge and thoughts on leprosy and its global control, over which he has long been playing a significant role. 

What lead to your interest in medicine? What or who were your early influences? Did you have a mentor?

I guess I always wanted to be a missionary doctor and avidly read books such as the Jungle Doctor series when I was a boy.

When did your involvement with leprosy begin? How did this evolve?

As a medical student I got to meet famous names who came as guest lecturers such as Denis Burkitt (of Burkitt’s lymphoma). I was inspired by one visiting lecturer, Edward Short, who worked in a leprosy centre in Andhra Pradesh, India. I was interested in leprosy surgery and after graduating I sat the surgical exams in the UK, got some surgical experience before going off to a post in a leprosy centre in India.  At that time the centre had 28,000 out-patients with leprosy and a treatment compliance of around 15%. I became more interested in leprosy control, early case detection, and prevention of disability than in surgery. I did an MD thesis in 1986 on why the main outcome of leprosy programmes should be absence of Grade Two Disability – interesting that it is now the target for the global programme. I re-trained in public health, did a PhD in epidemiology before going to South East Asia as The Leprosy Mission Director for the region at a time when multi-drug therapy coverage was beginning to increase.   

In your opinion what is the most challenging fact about the disease of leprosy and what are the most challenging aspects of coping with leprosy?

How leprosy is transmitted, and why some people develop disease, while others do not is a key challenge – if we knew more we might be able to prevent disease. The challenging aspects are preventing disability in people with nerve function impairment, and changing community attitudes to those who are affected. 

Can you comment on the current distribution and incidence of leprosy around the world, including countries that have reached a threshold beyond which they are currently finding it hard to reduce numbers of new cases of leprosy?

The challenge is how to sustain leprosy services when the numbers reduce – if we fail to sustain early detection the numbers of undetected patients will increase in the community and diagnosis will be delayed with increased disability. 

What person affected by leprosy has had the profoundest impact on you?

Probably the African pastor affected by leprosy who served me communion ten or fifteen years ago – it was a moving experience.

What are the connections between global anti-leprosy policy and national policies to tackle this disease? How important is it for policy-makers to recognise and take these into account, especially in today’s increasingly globalised world?

The connections are very good between the WHO Global Leprosy Programme and the global policy with the national programme managers. The involvement of national programme managers in the formulation of the global policy has made it more acceptable at national level. The work of WHO through regional meetings, with ILEP Members and with national programme managers supporting each other has helped the national implementation of the global policy into national guidelines.

You have been a member of WHO’s Technical Advisory Group on Leprosy since 1999 and chaired it for many years. Does any piece of advice or finding of WHO’s Technical Advisory Group on Leprosy stand out from the others in your view?

The Technical Advisory Group has been there as an important point of reference for the global programme – its independence from WHO has been important to provide objective advice. The challenge to assess the possibility of eradicating leprosy and identify the research needs to develop the tools for eradication was an important discussion.

Moving on to medical advice and guidance provided to ILEP through its medical body the ILEP Technical Commission of which you were previously Chair 1996-2000, and are again up until October 2011, what do you consider have been the key successes and achievements of the ITC during the mandate of its current members? 

The important part has been working with ILEP Members to define the Members’ needs and then working to address the priorities of Members. In the past the production of Technical Bulletins and Learning Guides was very important. The reviews of evidence are important in ensuring that evidence is translated into policy and practice. In recent years the close working with WHO has been very important in providing consistent technical advice to both ILEP Members and to national programmes.  

In your opinion what do we most need to now discover about leprosy? Why is research so vital?

The current process to develop of a research strategy for leprosy shows that there is no one single priority, but a range of priorities covering the spectrum from prevention of leprosy through to reduction in stigma. This requires a range of skills and multidisciplinary methods.

How real a threat is the emergence of drug-resistant strains of mycobacterium leprae do you think to reversing achievements made in leprosy control?

The emergence of drug resistant strains is real, but very rare. The surveillance system being established is critical to continue to monitor the situation; we cannot close our eyes to it. We need to have this early warning system in place to give us time to respond should the situation change.

Are you optimistic about an effective vaccine for leprosy being found? At an ILEP Meeting last October you wondered whether the new TB vaccines currently being tested could also be effective against leprosy; have any approaches been made to the researchers leading this to enquire as to whether they might also investigate its effectiveness against leprosy?  

There are two issues – having an effective vaccine and then deciding how it can be used. The development work by the Infectious Disease Research Institute in Seattle has been important in establishing links with the tuberculosis development initiative. An editorial was written on the issue of the effectiveness of new TB vaccines against leprosy which has produced a positive response from the TB people so hopefully this will lead to recognition of the importance of new vaccines protecting against both leprosy and tuberculosis.

You have been pro-active in drawing together research proposals for ILEP. Could you elaborate further on this indicating perhaps including why at this particular juncture in time and the reason for the research topics that have been included?  

The strategy to control leprosy has not basically changed since the 1950s, the change from dapsone mono-therapy to multi-drug therapy did not fundamentally change the approach – it was still based on case detection and chemotherapy. The successful elimination programme has reduced the prevalence of patients registered for treatment and the treatment workload, but it also has had the effect of seeing a reduction in leprosy research. There is a need to improve the way we tackle the continuing transmission of leprosy, the issue of disability and complications of leprosy, and therefore leprosy needs a serious research and development approach.  We need to develop better tools to prevent and treat people with leprosy; we need to actively address the issues of disability and discrimination. We must not become complacent that what we are doing is good enough; we need to be committed to continuous improvement. The research and development agenda now driving Neglected Tropical Diseases is an example to leprosy and we have a lot to learn and a lot to share working with other diseases of poverty which affect around a billion people.  

In your editorial choice to the December 2010 issue of Leprosy Review you wrote “Radical re-thinking is necessary if we want to sustain early case detection, treatment, prevention of disability, and reduction in the consequences of leprosy including stigma”. Please can you elaborate on this and share your own ideal re-think?

That issue of Leprosy Review included some very important contributions. Our thinking and our traditional approaches to leprosy can be rather isolating and restricting. The idea of sustaining leprosy programmes by more of the same, working harder, with more resources, will not work. Dr York Lunau stated that sustainability needs change and innovations that are transferable to other Neglected Tropical Diseases. Siân Arulanantham made the linkage between leprosy and the Millennium Development Goals (MDGs) stressing the importance of poverty reduction, education, children, women and partnership working.      

How can activities related to leprosy work be better integrated into development activities as a whole?

The MDGs is one way – presenting leprosy in the wider context. It can be challenging as leprosy is a relatively small problem compared to other issues, but in keeping it separate we deny people affected with leprosy the benefits of wider development.

You played a key role in steering discussions that lead to endorsement of the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy 2011-2015 – how far do you think its goal target will be met?

The purpose of setting this new target was to help change the direction of the programme. The target changes the focus to early case detection as the way to reduce transmission and to prevent disability. Many countries will be able to achieve the target while others will find it more challenging. The Leprosy Expert Committee Report will set a longer term goal for the leprosy programme to sustain the momentum towards reducing leprosy and the burden of leprosy through early detection. Of course the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy 2011-2015 includes lots of other developments; particularly exploring the use of chemoprophylaxis, the greater contribution of people affected by leprosy, and addresses the human rights questions.    

What are your thoughts on the direction and aims of the next ILEP Technical Commission? 

The direction will be determined by the Members through a forum in 2012. However, I think there are three key points – training, research, and developing links to Neglected Tropical Diseases. I think we need to revisit the question of training – the training needs have changed, who needs to be trained, what they need to be trained to do, and what resources are needed to support this? The ongoing training needs exercise will be important in informing this process. The research agenda is crucial for leprosy – to develop and test innovations. It will keep the pressure on wanting to improve all aspects of our work. And finally we need to work closer with other Neglected Tropical Diseases, exchange ideas and expertise, and look for synergy at all levels.    

What do you consider your most significant contribution to anti-leprosy work during your career?

I think that is probably for others to comment – I have certainly learned and continue to learn a great deal from leprosy, from people affected by leprosy, and from the people who work in this field.

Can you share some of your semi-retirement plans with us?

I retire from my post as lead of the Section of Population Health at Aberdeen University and from NHS work in Health Protection at the end of June this year.  From the 1st July I will take up a position as Emeritus Professor of Public Health at the University of Aberdeen. I will continue to supervise five PhD students, three Masters students, and to work with a number of projects in international health including leprosy and I plan to continue involvement with The Leprosy Mission, ILEP and WHO in various capacities. Christine and I plan to travel a bit – we have four children and two granddaughters scattered across Asia and Europe. We are moving to live in a more rural part of Scotland and I hope to do some more fishing, hill walking and maybe some golf. 

 

*In the photo:
Back row from left to right: Dr Etienne Declercq, Mr Douglas Soutar, Professor Cairns Smith, Dr Hugh Cross, Dr Myo Thet Htoon, Dr Roch Christian Johnson
Front row from left to right: Dr Wim van Brakel, Professor Diana Lockwood, Dr Sunil Deepak, Dr Paul Saunderson

Categories: News and Notes