An encounter at Nagashima Aisei-en Sanatorium
in his youth when he was aspiring to become a doctor
When did you become involved with leprosy?
I was born in 1926, and am now 89 years old. I studied at Jiyu Gakuen in Hibarigaoka as a child and therefore I knew that there was a leprosarium (Tama Zensho-en) nearby in Kiyose.
I later contracted tuberculosis and spent many years receiving treatment at Haruna Inn, a small sanatorium in Gunma Prefecture in the northwestern Kanto region. I was there when World War II ended. Through my experience at the sanatorium, I came to realize that the doctors were not treating patients in the most favorable way. One of the main problems in the medical profession is that doctors and nurses are too healthy and tend not to be sensitive to their patients' feelings (laugh). That's why I wanted to be a doctor who feels empathy for tuberculosis patients.
Furthermore, the meals at the sanatorium were another problem. We were fed a poor diet, for example, only one egg a week. But I heard rumors that the treatment at the national leprosarium was much better. After I was discharged from Haruna Inn sanatorium, I visited Aisei-en Sanatorium in Okayama Prefecture (western Japan) with a friend. It was right after the war so hardly anyone visited AIsei-en, We received a warm welcome, and Mr. Kensuke Mitsuda, then director of Aisei-en, showed us around.
At the time, leprosy was still very much a feared disease, wasn't it?
I did not even know then that Hansen's disease was considered a “dreaded disease.” Nobody talked about it and although I gained some knowledge by reading the novels of Hojo Tamio (a leprosy affected writer), I had no feeling of fear upon meeting a patient for the first time, and I feel the same even to this day.
When I visited Aisei-en, I met Mr. Shigeo Suzuki. He was called "Mr. Tanaka” (*) at the time and his position was representative of the resident patients. We continued to correspond with each other and I visited him often. Mr. Suzuki was diagnosed with leprosy when he was a third-year student at the Tokyo University of Commerce (current Hitotsubashi University) and had been a resident of Aisei-en for many years. After being discharged, he was rehabilitated and became very much involved in nationwide leprosy advocacy activities. He ran for mayoral election of Karakuwa (current Kesennuma city), Miyagi Prefecture in northwestern Japan. My father (Dr. Hachiro Yuasa, former President of Doshisha University and International Christian University) went to support him in the election campaign. Unfortunately, Mr. Suzuki lost the election by a small margin.
One day, in 1957, I received a letter from Mr. Suzuki asking me to teach English to the high school students at Aisei- en (Nirada Class of Oku High School). He was very concerned that with their current English skills, they would never be able to pass the university entrance examination. In those days, Aisei-en was the only leprosarium that had an attached high school.
I had a health problem then and I had even given up hope of becoming a doctor. I was studying psychology at the International Christian University. Furthermore, when I received Mr. Suzuki's letter, it was already decided that I would go to the United States the following year for my PhD studies.
So I agreed to help for a short period and taught English to about thirty students attending night school. Five out of them successfully passed the university entrance examination. One entered the Medical School of the University of Osaka and later became a doctor specializing in leprosy. It was a rewarding experience.
Note: (*) Residents of leprosaria in Japan were encouraged to use “resident names” to avoid cruel prejudice and to protect their families. The majority of patients no longer used their real names, but instead lived under fictitious names.
Were these experiences the motivation to devote your life to leprosy?
When I was at Aisei-en, the Tofu Association asked me on very short notice if I would help at the International Leprosy Congress to be held by the International Leprosy Association in Japan, as they needed someone who could speak English. I agreed and helped with the conference preparations. When the conference started, I was asked to serve as intermediary between the International Leprosy Association and the Preparatory Committee in Japan.
As soon as the conference ended, Dr. Kikuo Hamano, President of the Tofu Association (Japanese Leprosy Foundation) ordered me to write up the minutes of the conference proceedings. He was a very competent man who decided everything himself (laugh), But the delegates had already left Japan, so I had to quickly write to the participants in South Africa and Brazil to collect data from them. Things were not as easy as they are today. For example, publishing an English book in Japan was quite a struggle. I would go to the printing factory every day and check the proofs, sitting next to the printers. It took one whole year to complete an impressive 536-page record of the proceedings.
It was through these experiences that my interest in leprosy deepened. Both the president and the executive director of the International Leprosy Association asked me if I would become involved in leprosy work and I was determined to do just that.
I first spent four months in India to get hands-on field experience in leprosy and then pursued medical studies at the University of Edinburgh in Scotland to become a doctor. During my few months in India, I witnessed the misery of people with physical disabilities due to leprosy. My wish was to become a reconstructive surgeon no matter what it took so that I would be able to cure these people. I knew that if only they were cured of their deformities, they would not suffer as much discrimination and they could be rehabilitated and fully participate in society.
To Sasakawa Health Memorial Foundation after hopes
and despair experienced during my days in Nepal
Your first post after becoming a doctor was Nepal, wasn't it?
What was the reason for your decision?
I wanted to work in India but since there were already enough doctors there I thought I would go to Africa. While I was an intern at a hospital in England, I worked in as many different departments as possible because if I were to work in the jungles of Africa, I would need to be able to handle internal medicine, surgery, pediatrics, gynecology, in fact, everything.
With my mind made up and ready to go to Africa, I consulted Dr. Stanley Browne (later Advisor to the Leprosy Mission and Honorary Vice President of the International Leprosy Association) who told me that the International Leprosy Mission needed a doctor to work in Nepal. So in 1972, I went to Kathmandu as a member of their international staff.
For one year before going to Kathmandu, I studied leprosy medical care working at the British Empire Leprosy Relief Association hospital in Hong Kong. It was a wonderful hospital. What I also learned then was that with well-trained staff and money, so much could be done for leprosy patients.
What was the hospital in Nepal like?
It was a leprosy hospital with 110 beds, in Anandaban on the outskirts of Kathmandu. The then director of Anandaban Hospital was an outrageous British Christian missionary who was only concerned about his own missionary work and did almost nothing in the way of leprosy work.
After three years, I became the Director of Anandaban Hospital. In this new position, I wanted to carry out a thorough reform of the hospital.
But no matter how much we wanted to improve the hospital, we just did not have enough money.
At that time, dapsone was used throughout the world to treat leprosy. It was used first in the United States in 1941and its efficacy was so highly recognized that it was even called “The Miracle of Carville.” Dapsone was even cheaper than aspirin. Yet there was not even enough money to buy dapsone at our hospital. We asked the secretariat of the Leprosy Mission for help, but no solution was to be found.
It was just at that time that the Sasakawa Memorial Health Foundation was established (1974). Its founders were people whom I had known for a long time such as Dr, Shigeaki Hinohara, Dr. Morizo Ishidate, Dr. Kenzo Kiikuni, and the executive director was Mr. Suminori Tsuruzaki who was a friend from the days of Aisei-en. I sought advice from Mr. Tsuruzaki on how we could have dapsone provided for the patients at Anandaban Hospital.
Mr. Tsuruzaki immediately made arrangements to provide us with sugar-coated dapsone.
But after a while, the patients started to say that they only wanted the sugar-coated tablets because they are sweet and easy to take (laugh).
You joined the Sasakawa Memorial Health Foundation as medical director
Dr. Yuasa examining the feet of a patient (1996 Bihar, India)
At that time, it was a general practice at the Leprosy Mission to serve at your first assigned post for life.
I too had the intention of staying in Nepal my whole life. I had a responsibility to fulfill which would not allow me to leave so easily. However, at the same time, I was also frustrated because the Leprosy Mission was very reluctant to accept my proposals.
What made me decide to return to Japan to join the Sasakawa Memorial Health Foundation were the words of Dr. Stanley Browne who said that I would be able to do more work on a global level from Tokyo.
The Sasakawa Memorial Health Foundation was founded by the generous financial contribution of Mr. Ryoichi Sasakawa who was determined to “attack leprosy” as the next disease after the eradication of smallpox. I had heard many rumors about the late Mr. Sasakawa, but once I met him I immediately knew that he was a man of strong conviction. He was a man who motivated us to work “to accomplish our goal.”
The 2000 Asian Leprosy Congress, Agra, India (Dr. Yuasa, second from right; Mr. Yohei Sasakawa, third from right)
The discovery of multidrug therapy (MDT)
and establishing the elimination goal
What were your activities at the Sasakawa Memorial Health Foundation?
International Workshop on the Chemical Treatment of Leprosy (1977, Manila. Dr. Yuasa standing on the right)
Awarded the Damian Dutton Award for his contribution to leprosy (Mrs. Yuasa, far left)
At a leprosy colony in Benguela, Angola
Chatting with Dr. S.K. Noordeen, WHO Director, Action Programme for Elimination of Leprosy
Dapsone could suppress mycobacterium leprae but could not kill it. Drug resistant bacteria had built up to dapsone and its efficacy was being lost. Consequently, there was a sense of crisis that if left unattended, it would be detrimental to the world leprosy program. Workshops were held to discuss a possible solution in Bangkok and Manila, where chemotherapists and officials in charge of leprosy program got together. Simultaneously, we established a study group for multidrug therapy (MDT) in Thailand, the Philippines and South Korea.
The major characteristic of the work of the Sasakawa Memorial Health Foundation is that its activities were all geared to “strengthen leprosy programs of every state government.” The goal and work of our foundation received high recognition internationally.
Yet, at that time the only goal was to stop the emergence of drug-resistant bacteria and nobody thought that leprosy could be cured with MDT. However, when MDT was actually used, it was found that it could not only stop the emergence of drug-resistant bacteria, but it could also completely kill the bacteria. In other words, there was heightened expectation that leprosy could be cured using this regimen. That's when I became active in the movement to spread MDT throughout the world.
MDT was put on the table for recommendation at the 1981 WHO Experts Meeting and it was publicly recognized as the standard regimen for leprosy the following year.
Thanks to MDT, the number of leprosy cases dramatically declined
throughout the world.
The peak number of registered leprosy patients during 1970s and 1980s was a little less than 6 million, but the total number of patients was assumed to be between 10 to 12 million patients. But as you are all aware, with the introduction of MDT today, the number has gone down to 200,000.
Ninety percent of the funding for the leprosy activities of WHO has been provided by The Nippon Foundation under two generations of its chairmen, Ryoichi Sasakawa and Yohei Sasakawa. I do not think we would have achieved such results without their support.
In the beginning, it was very difficult to have MDT accepted as people were very skeptical about MDT, which was such a novel regimen. So I traveled around the world to the endemic countries, taking the three drugs used in MDT, rifampicin, clofazimine, and dapsone, to promote the use of MDT.
Also from 1983, we started an experimental project in the Philippines with WHO funding to use of MDT not only at existing leprosy offices, but also in pilot research conducted by the general public health staff. This proved to be successful in spreading the implementation of MDT throughout the country and further in the prevalent countries of the world.
It goes without saying that the important thing to note about MDT is that, on the one hand, it cures patients, but more than that, leprosy becomes no longer infectious within one week. It is therefore of utmost importance that as many patients as possible be given MDT as soon as possible in order to stop the source of infection. I think I can very well say that it was my lifework to propagate the implementation of MDT throughout the world.
Dr. Yuasa, you were the one who suggested setting an elimination goal,
This was an idea that came out of a serious discussion with Dr. Jong–wook Lee, then WHO West Pacific Regional Office director (later WHO Director-General). We spent many hours thinking of how we could convince health ministers and leprosy officers to tackle leprosy as a public health issue and thereby be able to disseminate MDT to the very last patient needing medical treatment.
I happened to come across a brochure that an officer in charge of chemotherapy at Carville (Louisiana, USA) had brought with hiｍ. The line “tuberculosis will be eliminated in the western part of the United States by 2010” caught my eye. This was what moved us.
“This is it! Let's convince each country with a clear goal of reducing the number of patients to less than one patient per 10,000 population.”
Dr. Lee was scolded by WHO headquarters for not having consulted with them (laugh), but eventually in 1991, WHO came up with a clear definition of “elimination” which was defined as less than one patient per 10,000 population by the year 2000.
You were appointed President of the International Leprosy Association
The International Journal of Leprosy (left)) and the second series of [ILA Forum] (right) published by Dr. Yuasa
At the time, the main activities of the International Leprosy Association were to publish the International Journal of Leprosy four times a year and to organize international congresses on leprosy once every five years. Furthermore, the position of the president was more an honorary position, having to give a speech upon induction to office and another one in five years on leaving the office. But I wanted to be a working president if I were to take up the position. I served two terms, a total of nine years during which time I initiated many new activities.
One of them was the publication of the journal ILA Forum. The International Journal of Leprosy of ILA was purely a scientific journal with only scientific papers, but the ILA Forum is a publication composed of articles from the members on the topic of how effective leprosy control should be. I also started regional congresses to discuss region-specific problems in Asia, Africa and the Americas because until then people of these regions couldn't become members of ILA because of the membership fee of $100.
We also started the “Global History Project” to create a database of the history of leprosy from material all over the world and documents from leprosaria. This project has played an important role in preserving the history and records of leprosy.
What I wanted to achieve was to make the International Leprosy Association into a functioning pro-active organization by thoroughly discussing its role. It had always been just an organization for the presentation of research results by its members at conferences. But I felt that it must change. I was met with much objection from the members, but on the other hand, I think I did contribute tremendously to leprosy control.
How are we to confront leprosy,
today and tomorrow?
Is there a possibility of chemoprophylaxis for prevention of leprosy?
There is a possibility if only mycobacterium leprae could be artificially cultivated. BCG (vaccine for tuberculosis) is said to be effective to a certain degree, but it isn't a prophylactic agent for the prevention of leprosy. Even it were possible scientifically, it would be difficult to procure funding considering the cost-effectiveness and acceptability of such prophylaxis now that leprosy cases have been reduced to less than one per 10,000 population, and therefore, it would be of no use for the rest of the 99% of the population.
The problem with leprosy is that it can affect the nerves of the body, leaving patients with deformity if treatment is delayed. I therefore believe that what is needed, even right now, is a preventive vaccine to stop mycobacterium leprae from reaching the nerves. If the nerves are not damaged, leaving only patches on the skin, this can be easily concealed thorough plastic surgery.
What do you think is important in the way we confront leprosy now and
into the future?
(left to right: daughter Yoko, Dr. Yuasa. Mrs. Yuasa)
Publication of Collection of speeches and Writings of Dr. Yo Yuasa (Published by the Sasakawa Memorial Health Foundation)
I think that in another forty to fifty years, leprosy will disappear from the face of the earth. In fact, mycobacterium leprae has become much less harmful to human beings. It will most probably become no different from one of the many bacteria that reside in the human body.
For mycobacterium leprae to survive, it cannot continue to abuse a host like the human body, which lives close to 100 years. Therefore, I think mycobacterium leprae will live together in symbiosis with human being. This is how nature works.
But it will take some time for this to happen. What is important and indispensible now is to continue with early detection and early treatment of leprosy patients as a public health matter like any other disease. It then becomes important for doctors who are in contact with patients daily, or furthermore, for health nurses to be able to find more patients who are affected and to possess deeper knowledge of leprosy.
A “world without leprosy” means a “world without leprosy-related medical and social problems.” There is still so much work to be done to create such a world. I would also like the world to know that in the long history of humankind we have committed a grave mistake in discriminating against and isolating people affected by leprosy. It becomes all the more important now to narrate the history and preserve the records of leprosy for future generations so that the mistake will never be repeated.
I have been told that a book will be published in English compiling all your
speeches and writings.
Yes, it is a selection of my speeches at international congresses and articles that I wrote while serving at the Sasakawa Memorial Health Foundation, which was compiled by Mrs. Kazuko Yamaguchi. It is the culmination of my long years of thinking about leprosy and my activities. My writings and my speeches are mainly addressed to experts and people involved in leprosy activities, but given my unaffected personality, I think the book can easily be read and understood by anyone.
Interview and editing：Kaho Oota / Photo by：Kaoru Kishimoto