History and Geography

The history of leprosy has been dominated by three questions or problems. One question concerns stig-matization. Most ancient societies identified some individuals as "lepers," and the leper was stigmatized, although surely lepers as a group included many suffering from something besides Hansen's disease. Stigmatization of the leper has persisted into the late twentieth century despite advances and refinements in the medical diagnosis and treatment of leprosy. The second problem focuses on medical evidence for leprosy's changing incidence and prevalence over time, particularly in western European history during the period between 500 and 1500 of the present era. Finally, the world distribution of leprosy and failures to impede its spread have emerged as a historical problem of the past 250 years.

In the Old Testament Book of Leviticus, the disease zara'ath or tsara'ath was identified by priests and its victims were cast "outside the camp" as unclean and uncleansable. They were viewed as both chosen and rejected by God and, consequently, not exiled altogether from the community, as were criminals, but rather made to live apart as if the living dead. Thus, central problems posed by the disease zara'ath involved, on the one hand, the spiritual identity of diseased individuals who, although probably morally "tainted," were not, apparently, personally responsible for their disease; and on the other hand, the delegation of the process of making the diagnosis to religious, not medical, authorities.

Because the opprobrium attached to leprosy was handled dramatically by writers of the Biblical Old Testament and because this Judaeo-Christian tradition was of central importance to western European history for the next 2,000 years, stigmatization of the leper was derived from religious, medical, and social responses to individuals carrying the diagnosis. Thus, during the High Middle Ages (A.D. 1100-1300), lepers were identified by priests or other spiritual authorities, and then separated from the general community, often ritualistically. Considered "dead to society," last rites and services might be said in the leper's presence, sometimes as the victim stood symbolically in a grave. Thereafter the person's access to his or her city or village was severely limited. Italian cities, for example, posted guards at the city gates to identify lepers and deny them entrance except under carefully controlled circumstances. Leprosaria, or isolation hospitals to house lepers, were constructed at church or communal expense, although medical services to these facilities were limited. Where public services were less well organized, lepers had to depend upon begging or alms.

Laws in western Europe illustrated the exagger ated fear of contagion lepers generated. Lepers had to be identifiable at a distance, leading to the creation of legendary symbols of the leper: a yellow cross sewn to their cape or vestment; a clapper or bell to warn those who might pass by too closely; a long pole in order to point to items they wished to purchase, or to retrieve an alms cup placed closer to a road than lepers were allowed to go.

The stigmatization of lepers, however, was not limited to Western tradition, and in most societies of the past those labeled as lepers were denied legal rights in addition to being socially ostracized. In traditions of both East Asia and the Indian subcontinent, marriage to a leper or the offspring of a leper was prohibited, and, as in Western tradition, the disease was often attributed to moral causes (sin) as well as to contagion. Interesting in this regard is the iconographie representation of the leper in Tibetan art, a man covered with vesicles and ulcers, which parallels Western depictions of Job as a man covered by sores in punishment by God for his sins. The stereotype of the leper as filthy, rotten, nauseating, and repulsive is so strong that most "hansenolo-gists" today advocate rejection of the name "leprosy" in favor of Hansen's disease. The only exception to this pattern of stigmatization seems to be in Islamic society, where the leper is neither exiled nor considered perverse, promiscuous, or otherwise morally repulsive (Dois 1983).

In contrast to ancient Chinese texts of approximately the same period, in which leprosy destroying the center of the face is well described, the clinical evidence for leprosy in the ancient Mediterranean is meager. Nowhere in the Biblical tradition is there more than a general description of the disease that created such a severe response. Hippocratic texts provide no evidence that true leprosy existed in ancient Greece, but the Hippocratic, Greek word lepra, probably describing psoriasis, gave origin to the disease's name. Thus a coherent and powerful tradition in the West stigmatizing the leper was begun in what appears to have been the absence of any organized and reasonably accurate medical description of how these sufferers could be identified. Indeed, the earliest clinical description of leprosy in the West appears neither in the Hippocratic corpus (written in Greek between 400 and 100 B.C.) nor in the 20 surviving volumes of the works of the great second-century Greek physician, Galen, but rather in the writings of the tenth-century Persian physician Avi-cenna, and it is his Canon of Medicine that provides the description upon which medieval European physicians relied.

The decline of leprosy in Europe coincided with increasing medical sophistication in diagnosing what we might recognize as leprosy. This decline may be due in part to an increase in another mycobacterial disease such as tuberculosis; to improvements in living standards; to high catastrophic mortality from plague and other epidemics, effectively reducing the number of lepers in the general population; or to the simple fact that medical authorities began to share the burden of diagnosis with religious and communal leaders. Surely other skin infections and afflictions that might earlier have been taken for leprosy were better recognized in the late Middle Ages. Nonetheless true leprosy certainly existed in Europe, as the exhumations of medieval skeletal materials from northern Europe have well illustrated (M0ller-Christensen 1961; Andersen 1969; Steinbock 1976).

Knowledge of leprosy in modern medical terms evolved during the nineteenth century, coincident with development of the germ theory of disease. During this period, the precise description of the clinical characteristics of lepromatous leprosy by Danish physician Daniel C. Danielssen in the 1840s; the discovery of the microorganism by Hansen in 1873; and widespread attention to the contemporary geographic distribution of leprosy in European colonial territories served to identify the disease as a contagious tropical infection. As such it was believed to be eradi-cable by Western medical efforts in public health intervention. Methods of quarantine and isolation were enthusiastically employed, despite skepticism about these methods in general public health control.

In the same year that Hansen found the causal organism of leprosy, a devoted Catholic priest, Father Damien de Veuster, drew worldwide attention in an attempt to humanize the treatment of leprosy by going to live among lepers in Hawaii. But he may have underscored fear of the contagion of leprosy because he eventually contracted the disease. Thus in modern times, increasing medical knowledge of the incidence and prevalence of M. leprae may have served to increase alarm and fear as leprosy was "discovered" to be the resilient global problem it remains to this day.

Ann G. Carmichael

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