Status	Medical Missionary
Country	Australia

Interview by Dr Jeanette Hyland with Dr Michael Langford at Sale, Gippsland Victoria August 2005.

Brief Biography.

Dr Michael Langford is a specialist General Practitioner, who with his wife, also a Doctor, worked in Nepal with the United Mission to Nepal from 1985 to 1996. His recollections about leprosy in eastern Nepal during those years are from the perspective of a generalist working in a small (22 bed) and isolated rural hospital at Okhaldhunga. People with leprosy were cared for in the context of the general hospital. His account of visits to the British Nepal Medical Trust (BNMT) in Biratnagar and to the Duncan Hospital in Raxaul, north India are of particular interest. Dr Langford is now working at the Sale Hospital, in Victoria, Australia.

Transcription

In Sale, Victoria, 24 th August 2005, I am talking to Dr Michael Langford who has kindly agreed to tell me about his experience in Nepal with general health and leprosy. He worked in Nepal from 1984 to 1995 and has got some really good stories to tell.

Thanks Mic. for agreeing to talk to me. I’d like to ask you what the situation was in Okhaldhunga, how the people with leprosy were seen along with other people. And was it very common, did you see many people with leprosy in the general hospital?

We had about 75 people on our books when we arrived there. The people with lepromatous leprosy suffered much more from social isolation than those with tuberculoid leprosy who I don’t think people in the village knew what was going on. Certainly those with the obvious stigmata of leprosy would be divorced if they were women or struggling to maintain a social presence.

A few people spring to mind. One was our pastor, Hari Bhaktur who came from a Chhetri (Warrior caste, next highest caste to Brahmin) family who had been a Policeman and was very well educated. He had become a Christian while being treated for leprosy in India. Even though he was a Christian and suffered from leprosy he was still well accepted by the community and had quite a good standing there, really. He went to Jail during the time of the Revolution (1990) - was put in jail and was there with the various people who were supporting the revolution until the revolution was successful. During that time he gained more standing amongst the people who had become the leaders in the district.

So Hari Bhaktur is one person. He had very obvious stigmata. I remember him punching the air to make a point with his stumpy fingers while preaching. He had to wear very thick glasses because of corneal ulceration and very often had ulcers. Hari Bhuktur was on just DDS for years and then went onto the multi-drug therapy and eventually came off the books as an active sufferer.

Interestingly enough another pastor, at Twetar, about two days walk away from us, used to be quite critical of Hari Bhaktur because he though he should be cured of his illness. This church had developed because they had had some miraculous healings in answer to prayer. Someone had brought a Bible to the village and this was a very homegrown, non-missionary orientated church at the confluence of the Solu and Dudh Koshi Rivers. We had quite a lot to do with them over the years and Rishi Dan Rai used to be quite critical of Hari Bhaktur. Funnily enough he came to me one day and he had two numb patches on his back and he had contracted leprosy. He was quite shocked to think that he could develop leprosy. That led to a change in his thinking about Hari Bhaktur and Hari Bhaktur’s frailty.

The other person that comes to mind is a Gurung lady who came originally from Rumjatar (village with air strip - 4 hours walk west from Okhaldhunga). She was married to one of the very powerful Rumjatar politicians and Rumjatar was a politically powerful centre in the district. I think her husband might have been a member of parliament – anyway she developed leprosy – she had quite nasty leprometous leprosy and was thrown out of home. She really existed as a beggar amongst the Sherpas in upper Okhaldhunga, up high in the mountains. She largely lived by … I think the way she did it was to pick up apples that had fallen to the ground and carry them down and sell them to anyone stupid enough to buy them ‘ cause they were always the worst apples, but of course everybody was willing to buy them.

Fascinating. She … even though she was from a prominent family, she was not accepted in the family…?

No, and interestingly her son was put out with her too.

How old was he, in his teens?

Well he was when we knew her, but he would have been much smaller when she was put out, and I think that was because the husband was wanting to take another wife and didn’t want this wife to be encumbered with a son. She was always trying to … she reminds me of the importunate widow … she was always battering down the doors of the justice system to get justice for herself and her son. I think that eventually she got it recognised that the son should be part of the family inheritance.

Because even for herself, women didn’t have the right to inherit in those days, but her son surely did.

Yes …

So … you used to get new patients sometimes?

Yes, we’d probably get a new one every month or two months. We had a worker who was specifically assigned to leprosy and tuberculosis education, so if a new patient was diagnosed, usually clinically, but we’d also take the skin scrapings to see if there were positive for Mycobacterium because that used to determine the treatment. So the laboratory would get involved and then our educator would get involved. Usually we’d ask them to stay in hospital for a few days and just … they’d need encouragement about taking their medication … and then they’d go onto our books. Then if they didn’t turn up for the their medication – it used to be once a month – then we’d go and find them … one of the health workers would go and find them – that was the system.

And were you aware of any of these people having social isolation problems?

Only those that showed the real stigmata, the others seemed to just settle back in, so it wasn’t such a big deal. It was the people who had the loss of their fingers and the ridges of their noses who people could identify very easily as suffering from leprosy.

And foot ulcers?

Foot ulcers … foot ulcers were obviously a big problem, but I don’t think they were recognised in the villages as a big deal.

Right.

Obviously if they developed then it became a big deal … part of the education of course was to teach people to use the stones to hone away the thick skin …

Se we are talking about east Nepal and quite high up. But you spoke to me about Biretnagar the British Nepal Medical Trust …

We had quite strong contacts with BNMT. Most of our doctors would try and do leprosy training and that was usually done at Anandaban, so we had contacts there, but we also had contacts with BNMT because basically Biratnagar was directly south of us. I spent some time down there looking at their programme and basically talking about ours. There was an English bloke down there named Richard something who was a nice guy. He used to think that UMN was a bit ‘hair-shirtish’ about the way we went about things … but they provided us with drugs and support at times and he came up and visited and talked to our staff about leprosy. They had so many more numbers than us. Plus TB was big for us, we’d have about 140 new cases a year in Okhaldhunga; whereas, leprosy we might see five or six so TB was big for us and leprosy was small. Down on the Terrai (plains across the south of Nepal) I know that leprosy was big too.

And it was the same … there was another disease that had a similar pattern called K?? [sic] They saw a tremendous amount in the Terrai and we just saw occasionally. So we’d get excited about one case, and they’d see them all the time.

And you were telling me about the time you spent some time in Raxaul…

Yes, I went down to – I was actually trying to get some obstetrics experience with a visiting Australian obstetrician who went there for two weeks – it was the beginning of our second term, I think – I spent two weeks down there, and Raxaul was such a busy hospital, totally different ethos from Okhaldhunga and made me so glad to be at Okhaldhunga.

The day that particularly imprinted itself on my mind was – they had a charity day once every two weeks – called ‘Golden Hands Day’. As I remember it - it was sponsored by a Mr Golden who was a rich benefactor from the United States, but I’m not too sure on that. (Probably Dr Golden). But anyway ‘Golden Hands Day’ you would hear a crowd gathering at 4 o’clock in the morning and by the time the doors were opened at 7 o’clock there’d be 4 or 500 people and we had three doctors to see them and a pharmacy that had medication. So we’d see these people … we’d barely examine them really. We just had to give them … a minute or two minutes we had to give them a diagnosis and each – we had a choice of about 50 diagnoses - and each diagnosis had a number and we’d write the number on a piece of paper, give it to them and they’d take that to the pharmacy. That number correlated to the medication that they would then get. I’m sure the pharmacist was just as put upon as us so I’m sure he didn’t give them much education either … but I just remember seeing - in that morning seeing - four of five cases of leprosy that had previously been undiagnosed. For somebody who just saw it five of six times a year as a new case, it was devastating. Much as a lot of the work in north India was devastating because it was … TB, Tetanus, Japanese Encephalitis … they were all diseases that were being seen all the time, but there was no time for a preventive health component and health education … it was all just happening, and it was all about treatment. That is why I was glad to be working in the north, in a place where there was more time to give some thought about what was going on.

So did you see a change in the leprosy in the 10 or 11 years you were there, and how it was coped with? You mentioned the Multi-drug therapy coming in …

That made a huge difference to the way we saw it and I don’t know if it made such a big difference to how the community saw it. Apart from the people with obvious long-standing leprosy, I didn’t get the feeling that is was such a deal because it was so uncommon. It was always a shock for people to know that they had leprosy but once we could say, look we can treat this, it was a pleasant surprise for people to find that.

And it certainly made – well, the numbers on our books decreased obviously very quickly. When we first started, there were very strict rules about who could go onto Multi-drug therapy – I think the Clofazamine was quite expensive and we didn’t want failures - so we only had people who were quite accessible to us go onto multi-drug therapy. We didn’t want to have defaulters. That relaxed a bit as time went by and I think … my impression was that BNMT was much more relaxed about it than Leprosy Mission. I remember when Richard, this guy from BNMT, came and visited he was very surprised that we didn’t just blanket give it to everybody. That’s my memory of it and that relaxed my thinking about it.

It was beneficial to go there and see how they ran their programme…?

It is always good to see somebody dealing with lots of something ‘cause then it takes away the sense that you are, you know, treading on eggshells – that something is common - so for me that was good to see that.

We didn’t do any clever surgery or anything like that for leprosy …

Did you refer anybody to Anandaban or other places …?

I can’t remember doing that, no. I was certainly aware that it was being done, but I can’t remember anybody needing a tendon transfer or anything. Most of the severely affected people had been affected for many years. We never saw anybody develop severe lepromatous leprosy that we were unable to be involved with controlling.

That was another thing, of course, that was interesting we used to use … what was the name of the drug … that was banned in Australia ‘cause …

Oh yes, Thalidomide…

Yes, Thalidomide. We used Thalidomide for lepromatous reactions, and this was always a bit of a political hot potato. We stopped being able to get it after a while as I remember it because …

It has come back again I hope because it was so effective.

Yes, we used it and we stopped using it … it hadn’t come back by the time we left.

And the other thing; I remember when Rifampacin and Clofazamine first started to be used people were always complaining bitterly that their patches would go very dark – very dark red and that was always big deal because I suppose people would feel then they became more obvious – more noticeable – different so they took some convincing it’s worth it, because in the end would benefit …

Thank you – very much appreciated.

You’re welcome.

Interview ends.