This Podcast Will Kill You - Ep 2 Skin in the Game, Horse in the Race

Episode Date: November 7, 2017

This week we tackle leprosy. That biblical (or is it?) infection that, believe it or not, is still with us today. Leprosy has an ancient history that exemplifies some of the worst of human behavior, and its present day status may surprise you. See omnystudio.com/listener for privacy information.

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Hi there. We're the errands. And this is, this podcast will kill you. Welcome to episode two. This week we'll be talking all about leprosy, starting with biology, the history, and finally, the current state of affairs. Jumping right in with us. Before we start things off, it's quarantini time, it's quarantini time. Yeah, you heard her.

It's quarantini time. It is. And in case you don't remember what a quarantini is, it is our signature cocktail for each episode. And this week, we're calling it the harmodillo. Why are we calling it the harmodillo? Well, it turns out that armadillos are the only known carrier of the bacteria that causes lepros besides humans. Oh, I get it. So like, harm.

A joke is never funnier when fully explained. That's so true. So if you'd like to drink along at home, you can make your own harmodillo by mixing one and a half ounces of your favorite tequila, one and a half ounces of passion fruit juice, and a half an ounce of quontro, and serve it in a glass rimmed with a little salt and tahine or lehi-moie powder, if you have either of those. We want to start off each episode by defining some of the words that we'll be using, which may be new to you or not, but just in case we're going to give you some brief definitions.

So keep these in mind as you're listening. For this week, let's talk about incidents. What is the incidents, Aaron? Incidence is the number of new cases during a certain time period. So it's the rate of new infections. Okay. Now, what about prevalence? Prevalence is the proportion of cases in the population at a given time.

Okay. How about the incubation period? Incubation period is the time from when you are infected to when symptoms first appear. Gotcha. Okay. Let's see. What else? Genome.

The genome of an individual or an organ. organism is the entirety of the genetic material that makes up that organism. So for most organisms, that's all of your DNA, which is made up of nucleotides. What about gene? A gene is a sequence of nucleotides in your DNA that actually codes for a protein. Okay. And what about allel? An allele is a variant form of a given gene. Okay. I think that's all we need to do for today. I think so. I think we got it, at least so far. Cool. So, Erin, can you start us off with some firsthand accounts of what it is like to live with leprosy? I would love to. So I found a couple of firsthand accounts from a place that we'll be talking a lot about later in the episode, Kalaupapa, which is a leper colony on the island of Molokai in Hawaii.

So this is from a Hawaiian female around the 1970s, late 1970s. This is a direct quote from her. I remained in Calopapa for 30 years. I was finally paroled in 1966. My mother was still alive, so I wrote to her and told her I was finally cured. I could come home. After a long while, her letter came. She said, don't come home. You stay at Calopapa. I wrote her back and said I wanted to just visit to see the place where I was born. Again, she wrote back. This time she said, no, you stay there. You see, my mother had many friends, and I think she felt shame before them. I was disfigured, even though I was cured. So she told me, her daughter, don't come home. She said, you stay right where you are, stay there, and leave your bones at Kalalpapa. This place is finally my real home. They take good care of me here.

That's so sad. One of the reasons that we are talking about leprosite, today besides the fact that it's just an interesting infectious disease that's been around a long time is the fact that it is associated with so very much stigma. So even though it's a disease that today is technically curable, it is still very much relevant today just because of how much we have learned from how people were treated when they had this disease. So the next quote that I have comes from someone who probably became the islands Molokai's most famous resident, Father Damien. And so Father Damien was sent to Molokai to act as a spiritual advisor for the people there and ended up making a huge impact, which you'll hear more about later.

But when he first arrived, he was horrified by the conditions. This is what he wrote to his brother. It was a common sight to see people going around with fearful ulcers, which for the want of a few rags or a piece of lint and a little salve were left exposed to dirt, flies, and vermin. Not only were their sores neglected, but anyone getting a fever, diarrhea, or any of the other numerous ailments that lepers are so often heir to, was carried off for want of simple medicine. Okay, so that set the stage, I think, for this week's topic.

Yeah, definitely. I think so. Before we go into the history of leprosy, let's kind of get into the bones of what it actually is, what this disease is, is it virus, is it bacteria? What is it? Right. Let's talk about it. So we'll talk about the biology of leprosy. Leprosy, which is now in the U.S. also called Hansen's disease, because leprosy was associated with such stigma for so long. In the United States, it is now referred to as Hansen's disease, but worldwide it is still known and referred to by the WHO, for example, mostly as leprosy. So throughout the episode, I'll mostly be referring to it as leprosy.

Leprosy is caused by a bacterium named mycobacterium lepray, which is not too distantly related to the bacterium that also causes tuberculosis. But this is a particularly interesting bacteria for a number of reasons. One is that it's super, super slow growing. So what that means is, for example, E. coli, which is sort of the common laboratory bacteria, divides or reproduces every about 15 to 20 minutes. So if you leave it overnight on a plate, the next day you come back and there's just millions of E. coli bacteria on there. Micobacterium lepray on the other hand reproduces about once every 13 days. So for a bacterium, that's incredibly slow. That's crazy slow. I know. Yeah. It's, I read that and I was actually a little bit shocked. 13 days. 13 days is what

it takes just to reproduce from one cell into two cells, just to divide one time. Wow. Yeah, it's super slow. Another thing that's interesting about it is that its genome, or its genetic material, is super reduced. So compared to most other bacteria, it has a really, really small genome. And what that means is it has actually lost a lot of functional genes. What does that mean in practice? Like, what are the functional genes that it has lost? Well, I don't know the exact functional genes that it's lost because I didn't look that up. But I'll tell you that what it means is that this bacteria is what we call an obligate intracellular pathogen. So it doesn't live, for example, on the surface of things. It has to actually infect another cell in order to complete its life cycle, much like a

virus has to do. So it's obligated to live inside a cell. Exactly. Yeah. And so that's very different than most other bacteria, because most bacteria sort of live, they often can live in the environment because they're able to just reproduce all on their own. Leprosy is actually transmitted, funnily enough, by respiratory droplets. Yeah, I guess I don't know why that's funnily enough, but I guess I would assume that you would have to have skin-to-skin contact because it tends to manifest in your skin. But actually, it is so similarly related to tuberculosis,

which is also transmitted in what we call respiratory droplets. That is water droplets that are expelled when you cough or sneeze or breathe. So you really do need prolonged close contact with a person who is infected in order to become infected yourself. And also an immune system that can't quite kick it. Exactly. Right. Another thing about it is that the incubation period of this disease can range from one to 20 years. And on average, it's about five years. So that means that you could be exposed, become infected, and not show symptoms for one to 20 years. Yep.

Whoa. So then how would you ever know where you picked up the infection? Exactly. It's really difficult. And so we'll talk a lot about this when we get to the section on talking about the state of leprosy in the world today. But that's one of the things that makes diagnosis really, really difficult is that this incubation period is just so long that it's really hard to detect.

It also has made it so that it's really, really difficult to culture. It's impossible to culture this. bacteria in the way that we normally culture other bacteria, which is on a plate or in a little jar full of liquid that we call media. So this bacteria can only be cultured in living cells. So armadillos actually serve as the model organism to study lepros. Why armadillos? Well, the leprosy bacteria survives best at low temperatures. So most other animals have a much higher body temperature, for example, than humans do. But armadillos happen to have quite a low body temperature, so they serve as a perfect little host for leprosy. And additionally, in humans,

we tend to get infected in our extremities where our body temperature tends to be lower. So hands, feet, ball sacks, etc. What else about this bacteria do you want to know? Let's talk about, I want to know about disease progression. Right. Let's talk about the clinical presentation. I was about to just do that, even. There are three main forms of leprosy that are suspected to be sort of mediated by differences in individual immune response rather than differences in strain of the bacterium.

So the first is what's called a tuberculoid form. This is the least severe form of the three types. this is when the bacterium infects peripheral nerves. And what happens is it causes a loss of sensation and can also cause a swelling of the nerves. Peripheral nerves meaning fingers or toes or nose? Yes. At what point is it peripheral? Oh, that's a good question, but I don't know the answer to.

Okay. Yeah. Well, I mean, peripheral isn't not part of your central nervous system. So it doesn't attack your brain stem or spinal cord in general. Gotcha. So extremities. Yeah. It attacks the nerves.

of your extremities and it can cause loss of sensation, which can be dangerous because if you can't feel things, then you might injure yourself or be prone to another infection that you don't feel the pain of. Which is how a lot of cases become apparent in the first place, is that all of a sudden you have a, you burned yourself, but you didn't feel it. That's actually how Father Damien first found out. Sorry if I'm preempting your, your section a little bit, but the second form is called the lapromatis. I think that's how you pronounce it, form. This is has generalized involvement of the skin, including the eyes, the nose, the testes, it can even infect your bone.

And this is the form that causes those nodular, what's called granulomatous, which just means sort of these lesions that often are sort of blistery that can be full of actual active bacteria as well as immune cells. So that's the most severe form of leprosy. And the third form is called borderline, which is sort of in between tuberculoid and lepromatous form. And so can a case of leprosy go from tuberculoid to lepromatous? I don't know. I don't think so, but I don't know. Does it? Do you know? I thought I wrote it down somewhere.

Most of what I have seen talks about differences in individual immune response leading to presentation as one of the three forms. individuals whose clinical course vacillates between the two polar types are also viewed as intermediate. So it is possible to go between the two. But then it's kind of called an intermediate form. Oh, it's interesting. Yeah. So it's like the degree of reaction, of immune system reaction is what determines. Yeah.

So it's not a difference in bacterial strain or anything like that. It's a difference in your individual immune response that determines which form you end up presenting with. Another thing that's really interesting is that it's estimated that around 95% of the human population is essentially immune to leprosy. Unfortunately, I couldn't find the exact source of this number, but it's all over CDC and a bunch of other websites. And the reason is that most of the population's immune response is sufficient to sort of squash the infection to the point where you never end up being symptomatic. So, yeah. I wonder if we're part of the five or 95. I'm very, very curious to know about that.

There's a lot of genes, a lot of alleles that are known to be associated with immunity in one way or another, but there is not a single allele or a single gene that confers complete immunity. And so does that, do we know if that 95% number has anything to do with the risk of exposure, or is it just, you know, like if you are not living in a place where leprosy is common, are you part of the 95% regardless of your immune system status? It's a good question that I don't entirely know the answer to based on the literature that I've looked at. What it seems to me is that, for example, in the last episode we talked a lot about infectivity.

Leprosy has a very, very low infectivity. So if, for example, you took a random sample of 100 people and inoculated them with the mycobacterium bacterium, only about five of them would actually become infected. Okay. Okay. It's just very low infectivity. And I think that's all I have, actually, on the biology. It evolved millions of years ago, along with humans. It's a really interesting little bacterium.

So I want to talk a bit about the history of leprosy, both in evolutionary history and then also prehistory through the Middle Ages, the darkest, Dark ages all the way through present day. Awesome. Leprosy probably arose in people around 10,000 years ago. Wow. Or so is what it's estimated to be. Those are the first records of it?

No, the first skeletal records come from around 500 AD actually. Okay. But it's just looking at its evolutionary history in its genome and like the traces in its genome. It suggests that it's around 10,000 years ago. saw estimates of up to two million years ago, like with the evolution of humans even. I mean, mychobacterium has had long ties with humans. So whether it was mycobacterium lepray or a different, like the,

similar, right, the origin of the ancestor. Right. Of mycobacterium lepray. But either way, so it could have spread into humans in a variety of ways. One theory suggests it came from mice originally. Another suggests that it came from using. the hides of water buffalo. Like wearing them like clothing kind of?

Yeah. Just wearing them water buffalo, get you all kinds of sick. I didn't read further into that. But I did find that to be a little interesting tip bit. But what we do know is that the bacterium likely originated somewhere in India or East Asia. Okay. So as I mentioned, the first skeletal evidence comes from mummies in Egypt around 500,

but it was likely present throughout Egypt, throughout China, throughout India, and East Asia 4,000 years ago was like rampant in those areas, which is really interesting. And that's, that usually comes from information in texts and like old medical diaries and such. You may have heard of leprosy from its many mentions in the Bible or maybe watching Ben Hur. But you know, I've never actually, I've never seen. My mom forced me to watch it. Is it good? Should I watch it?

I don't remember because I just remember hating the experience. Yeah. The movie could have been fine. If you're forced to watch a movie, then you're probably going to hate it. Right. Especially if it's like four hours long and it's, yeah. Oh, good God. It was like, oh, it's Easter.

Time to watch Ben Hur. Oh, is it an Easter movie? I think so. I know nothing. I don't know. I didn't bother to look up anymore. But honestly, what I do remember from Ben Hur watching it was the scene where there are two leper women.

And that's the part that you remember. That's the part I remember. Budding disease ecologist. I mean, always. I was like, ooh, what do they have? Leprosy? How do I diagnose this? But what you may not know is that the leprosy of the Old Testament is almost certainly not actual leprosy.

The disease that we call leprosy today caused by mycobacterium lepray. So I always assumed growing up in a Catholic household that Lazarus died of leprosy. the one that was raised from the dead, right? Like, he must have, his name was Lazarus, so he died of leprosy, and leprosy was named after Lazarus. I think that's what I thought. It's an alliteration causation. Right, exactly. Sure.

So, but that's probably not true? No, not true. All right. Not true. Well then. And the reason that it wasn't leprosy in the Bible is because at the time that the Old Testament was being translated into Greek in the third. Third century BC.

Leprosy hadn't even reached Europe yet. Interesting. So by the time that the word leper and leprosy was used in the Old Testament, it wasn't actually about leprosy, but more likely it was used for any sort of skin conditions such as psoriasis or syphilis, advanced syphilis. Interesting. Or fungal infections. But leprosy itself as a bacterium did exist at the time of...

It did. Dear Jesus. Right? Dear Jesus. Perfect. Yes. Cool. The word leprosy, though, comes from, I love etymology. So I just have to throw this in here. Do it. I love it. I want to learn things. It comes from the Greek word lepra, which means, quote, a disease that makes the skin scaly. Wow. That's such a long definition for one little word. One word. Yeah. Which is probably why it was used later on for the disease leprosy because it still is a skin condition. blah, blah, blah. I want to talk a little about the treatment of leprosy victims from the time of the earliest

writings, which were in like the first century or before that, to about 50 years ago. Yeah. I'll take you through leprosy victim experiences all over the world and ending in Hawaii. Great. What comes to mind, Aaron, when you hear the word leper? I think of someone who is sort of shunned. I think of sort of grotesque skin conditions. I think of, honestly, it just makes me feel sad when I hear that word.

Someone who's an outcast. Yeah, an outcast. You're afraid of them. It's almost that word, I feel like, is almost synonymous at this point with the idea of an outcast. Yeah, it absolutely is. And that's part of the history of the treatment of victims of leprosy. Yeah. I mean, maybe you or I or you, dear listener, have used the word leper.

before to refer to the feeling of feeling shunned or of being rejected or whatever it is. And these associations exist because of how victims of leprosy have been treated throughout history and into present day. In fact, many health organizations such as the CDC no longer use the word leper or as Aaron mentioned leprosy anymore. And leper is actually not used at all. Right. And so when we do, so throughout the episode, I may use the word leper.

Aaron may use the word leper. And we're not doing it to call someone a leper. It usually is putting it in its historical context or we're reading from a quote. I'll use the term leper colony as synonymous with some of the other terms where victims of leprosy were quarantined. Exactly. Right. Yeah. This is sort of a disclaimer that we recognize that that word is extremely.

stigmatized and it's not commonly used today. So when we're using it in this episode, it is based in its historical context. Although specific practices differed region by region, the common thread and how victims of leprosy were treated was rejection and stigma. Yeah, it's horrible. Yeah. In some places, victims were made to wear cloaks and bells or clappers so that whenever they went through a village, their presence had to be announced. That's awful. Humans, we're terrible to each other. Yeah, we're terrible. Goodness.

That's, like, lucky. If you had to wear a cloak and have a bell, you were well off. You were one of the lucky ones. Oh, yeah. If you were a little bit less lucky. Oh, dear. You were made to, for instance, stand in a freshly dug grave, while a priest stood over you, threw dirt on you, and then said, you are dead to the world.

All your earthly possessions are taken away. Your marriage is dissolved and your kids are going to be orphans if you and your partner were both afflicted. Can you describe my face right now for listeners? It's horrified. Yeah. Her eyebrows are like asses. That is, wow. So they were essentially declared dead in the eyes of God and men.

Exactly. Yeah, exactly. Then that person who was made a stand in the grave was forcefully sent to a leprosaria, Lazar house, or leper colony. Those are the kind of interchangeable terms for an area in which it was secluded and you were sent up. Sidebar, a Lazar house. And this explains why I assume that Lazarus had leprosy.

I mean, I don't know about the etymology of Lazar. I'm going to go ahead and just claim it. You got it. Lazarus had leprosy. He's the one and only person in the Bible that really did actually have leprosy. That would be funny. Wouldn't it? I'd feel really proud of my like six year old intuition. So you think, okay, that sounds pretty bad. Yeah. I wouldn't want that. Nope. I definitely wouldn't. Do you know that that's not the worst off that someone was? Don't tell me. I don't know if I want to know this. Yeah, you do. You're going to know it anyway. Okay. Tell me. If you were really unlucky,

you were forced to undergo, quote, assisted suicide by burning or drowning. Are you serious? So they burned alive. Alive and drowned people who had leprosy. Right. Victims of a disease that we now know, obviously they didn't know then, but is so curable, it wasn't curable then. The other thing, though, is that back then it wasn't even, people weren't. certain that it was contagious, that it was contagious in origin that it was, yeah, so there

was a lot of discussion as to the cause, whether it was immorality. So, oh, you were drinking too late or sleeping around. Yeah, whatever it was. You need to be killed. Wow, geez. There's no excuse for it. I mean, you try, no, there's just, uh-uh. And in other cases, it was thought to be familial. And if your parents had it, so people who were victims of leprosy were not allowed to have kids often. Oh, so were they sort of forcefully sterilized or just prevented from having children or something? Exactly. Wow. It's not like anyone does that today. Just kidding. We absolutely do all the time. And there were other regions that did think, yes, this is contagious. And they still. But even still, despite the fact that it is a,

infectious disease, the forceful quarantines were probably did not prevent any future cases because of the extremely low infectivity. Extremely low infectivity and extremely long incubation period where, you know, it's, it, it just doesn't really make sense for a disease like this to quarantine people the way that they did. But it just was so incredibly stigmatized and people were, was there another word for stigmatized? Osterized? Ostracized.

One thing to note is that for thousands of years of leprosies existence, diagnosis was done by priests or other religious authorities. Well, that's fun. And not with a lab or microscope. Well, I mean, for thousands of years, we haven't had microscopes for thousands of years. No, no, no. Of course not. In their defense.

But this did mean that many leprosy victims probably didn't. have leprosy. Oh, because priests were just like, yep, I see that. That looks like it to me. That's a weird skin condition. You've got a bump there. You're definitely, I'm burning you alive. Yep. That's what they just did. That's exactly, exactly how it went. Wow. Direct quotes. Direct quote. We were there. Leprosy probably reached peak global prevalence in the late, late, dark ages, early middle ages. Can you remind me when that was? 500 to 500 AD. Oh, okay. That's a long time ago. It's a long time ago. Yeah. And after that time, leprosy began to decline rapidly. Hmm. And many leprosaria or Lazarus were abandoned. Interestingly, this decline in leprosy

happened around the same time that tuberculosis started to become super widespread. Interesting. And so tuberculosis and leprosy are closely related. Right. So this suggests that tuberculosis out-competed leprosy. Right, because so, I mean, you only have so much sort of surface area or cells in your body. So if you have two really closely related bacteria, they might be competing for space in your body. And so what you're saying is that tuberculosis might be a better competitor than the leprosy, mycobacterium lepray. Precisely.

Wow, that is so interesting. Isn't that interesting? Yeah. Basically humans traded one evil for another. They really did. And, you know, we'll have a whole episode to talk about tuberculosis. So don't worry. Don't worry.

Don't research it. Yeah. Well, I mean, research it if you want to. You could send us stuff you want us to talk about. All right. Leprosy declined. But did it disappear? No way.

No way. Did the horrible ways that victims were treated come to an end? Hell no. As humans grew more compassionate and understanding? If only. Right? That was so good. Earlier in the episode, you heard, first,

some firsthand accounts of what life was like in Kalopapa, the leper colony on the Hawaiian island of Molokai. In 1865, the Hawaiian king, Latkameha, signed into law, quote, an act to prevent the spread of leprosy, which basically made it a criminal act to have leprosy. Oh, my God. Humans. This act remained in effect for guess how long? Oh, way too long.

More than 100 years. That means 1960s. 1969 is when it was finally repealed. I'm sorry, but how many of you listening were alive then? I wasn't, but my parents were alive? Like, I know a lot of humans that were alive at the time that they were still forcibly putting leprosy victims into a colony on the island of Molokai. Are you kidding me?

Under this act, that's exactly what happened. If you were found to have leprosy, your will was executed, your marriage was dissolved, and you were forcibly removed from your home and sent to Molokai. This is exactly what you were saying with the putting someone in a grave and declaring them dead. Or in the 60s. In the 60s. So this would happen. Also, I'd like to point out that Hawaii was incorporated as a state in the 1950s.

Right. And that means that this was also happening in the United States of America. Oh, and it had, I mean, Hawaii had been under American U.S. influence for probably since the 1860s. Right. Because this, the whole act was done under the influence of the United States. Of the United States. Yeah. Yeah.

Because they were worried about whatever trade and like, oh, we can't dirty the hands of Americans who are coming to visit. Under this act, if you were found to have leprosy, you were exiled. And the place you were exiled to Molokai. You could say, oh, exiled to a beautiful Hawaiian island. That sounds like paradise. What's so bad about that? Well, how about the fact that you are stripped of your rights, any material goods, and forbidden from ever seeing your family again? Oh, my God. And then that's just leaving whatever island you were on and going to Molokai. Yeah. Once you were on the island, food and shelter was in no way guaranteed. Nope. And forget about

any medical treatment because it's not going to happen. No, no, they weren't bringing people to a, like a great hospital to give them treatment. They were just sending them away to die. There weren't structures. No. They thought, oh, you know what? We don't want to, Hawaii, you can just grow your own food. It doesn't matter if your fingers don't work anymore. If you can't walk, well, and what's interesting is that, I mean, that area of the island was very productive in sort of the, like for 900 years, people that native Hawaiians were living there in sort of a traditional Hawaiian system, but because they decided to take that over and turn it into a colony for leprosy victims, those structures that were in place were destroyed. So no, like there wasn't a way to just

sort of live happily on this part of the island. It wasn't. It was horrible conditions. If you were unlucky enough to be a female victim of leprosy sent to Molokai, you were probably taken as a sex slave by another sufferer. Wow. Yep. And if you were, If you were a child, you were taken as just a slave period. Wow. It was horrible. Just keeps getting better. I swear there's going to be an uplifting point at the end of this episode.

Just bear with us. Just hang in there, guys. During the first five years, it's not going to happen now, though. No, not yet. Because I'm going to hit you with some bad stats. During the first five years of exile in Molokai, mortality rate for the victims who are sent there, 46%. Oh my God. Which is around 150 to 200 people out of the 3 to 400 cent to Molokai in the first five years.

Oh, my God. Leprosy is not a fatal disease. No. You do not need to die of leprosy. Before there was treatment for it, you still, it was not, leprosy itself was not going to kill you. Right. It was the lack of adequate medical attention to other ailments that would get you. Because like we mentioned before, what happens is that this bacterium attacks parts of your

body and then makes it so that you're very susceptible to other infections. So if you can keep yourself clean and if you have access to even the most basic medical care, you don't need to die from leprosy even if it's not ever cured. And so these people who are exiled did not need to die. Right. And the other thing is that, so you've been there. I have. And so I want you to give a little description about what it would have been like to be dropped off by boat, which is how a lot of these exiles were dropped off. Yeah. So I had the opportunity to go. And so I had the opportunity to there a few years ago and we were taken to the point, this sort of rocky outcropping. So I'm going to back up a minute actually. Kalalpapa is this peninsula on Molokai that is surrounded by

the tallest sea cliffs. So it's isolated from the rest of the island of Molokai by these giant sea cliffs. And this peninsula extends out into the middle of the Pacific Ocean, right? and it is extremely rocky coastline. So we went to the edge and the waters there are so rough that often the boats that were dropping people off couldn't get anywhere near the shore to actually let people. Or didn't want to. Or didn't want to. There were no docks or anything like that. So they would dump people off the side of the boat.

And then they had to swim through extremely treacherous water to try and climb up a rocky face to actually make it to the colony itself. If they could even make it, I mean, if you are a victim of leprosy, you don't have nerve function at some of your extremities, which are the ones that you would use the most in swimming. And so drownings happened all of the time. People trying to escape to go back to Hawaii would drown, not make it. And even if you were a very young, healthy person, like I wouldn't have been able to swim that. To swim from a boat to the shore, I don't even think that I could have made it. So if you are a person who's ill, it's, it's incredibly amazingly horrific that they, that they sent people there in the first place and then that they did it in this way. When we stood at the edge of

this peninsula, there's a lighthouse there. And the wind itself was so incredibly strong and powerful that you couldn't talk to the person standing next to you because it was just so loud from the wind. And that's sort of just what it's like there all the time. So I can't even imagine what it must have been like besides absolutely horrific. Horrible. Yeah. It sounds from all accounts terrifying. Yeah. The population at Calapapa peaked at 1,174 in 1890. Wow. Yeah. And even though it no longer functions as a leprosy colony, former residents are still living there. And the area is now a national historical park. It is. Yeah.

Perhaps the most famous resident of the colony at Molokai is Father Damien, who was a Belgian Roman Catholic priest. So he was there from the time 18702 to 1889. Okay. He was one of the first people to treat leprosy victims with dignity and compassion on the island. He was sent to Molokai to save souls and all that. Convert people to Catholicism. And unlike any previous doctor or priest, he embraced the residence. He opened his doors to them.

He embraced them. He actually touched them. Yeah, like not just mentally and spiritually, but physically because these people were so ostracized that many of them, like they, people wouldn't touch them. And so that's hugely influential. He humanized leprosy, which had never been done before. Yeah. He grew crops for them. He built houses because he was able-bodied.

He really did a lot of good. Yeah. And his positive impact on the colony brought him recognition while he was alive. But when he revealed that after 11 years of living amongst these victims of leprosy, that he had actually contracted the disease, then he became an international sensation, the martyr of Molokai. The martyr of Molokai. It's got to be a white guy.

Let's just throw that one out there. Father Damien died in 1889, 17 years. after landing at Molokai. And it has been said about the hymn that his death did more good for the residents of Molokai than his life because it brought in tons of money. Wow. A lot of recognition. People started visiting from all over Robert Louis Stevenson, Jack London, Shirley Temple,

John Wayne. Wait, Shirley Temple? Yeah. She lasted an afternoon, I think. That's so random. Yeah. Eventually, he was canonized and is now Blessed Damien. Hashtag blessed.

Hashtag blessed. Even though the causative agent of leprosy was described in 1873, it took another 70 years for someone to come up with any successful treatment. Partially, because as Aaron mentioned, it is so hard to culture and studying the lab. Yeah. Once these drugs were introduced to Molokai, the effects were felt immediately. The disease progression for many stopped entirely. A lot of the sores went away, and people felt a lot better. Right. Now that there was a cure, though, the government tried to kick all the residents out of Calapapa so that they could take advantage of this beautiful, fertile land. Right. Like, oh, we want that land back now. Thanks. Bye. Exactly. Exactly. But the residents fought and fought and were eventually allowed to remain in the place that they had called home for decades. Now that an effective treatment for leprosy was on the scene, it should no longer be a public health problem, right?

Yeah, right. If only. Well, let's find out. Let's talk about it. What's the state of leprosy today? So this is where we finally get to some kind of good news. Yay. So leprosy has not been eradicated,

which means it still does exist in the world, but there has been some pretty incredible strides made towards seriously decreasing the burden of leprosy in the world. So I'm just, we'll throw some numbers out and then we'll talk about sort of what they mean. Does that sound good? I love it. So the World Health Organization has a global leprosy strategy that has three main targets. The first is to completely eliminate what they call disabilities associated with leprosy in children.

So no more children having disabilities associated with leprosy. That's one of their goals. Like a great goal. A great goal. The second goal. is to decrease the disease or excuse me to decrease the disabilities associated with leprosy in adults to less than one per million people okay so less than can we talk about what that sentence means disabilities associated with adults well disabilities associated with leprosy in adults

oh okay so in children they want to eliminate it completely and in adults they want to decrease it so that it's less than one in every one million people that has that Why is it saying disabilities associated with leprosy and not just leprosy? Well, I think that they want to eliminate leprosy entirely, but this is their strategic plan that they want to accomplish by 2020. So the World Health Organization tends to set a variety of different goals. And to me, what this seems like is a more achievable goal. Like a five-year plan, a 10-year plan, a millennial plan. So this is their 2020 plan.

And the third, which I think is one of the most important. and I'm shocked that they're still working on this, is that they want to make sure that there are zero countries in the world with legislation that allows for discrimination on the basis of leprosy. Oh, Japan only recently in the 2000s still had a law on the books. Yeah, and I mean, clearly there are other countries that still do as well. And so one of their goals is to make that go away, essentially, so that people with leprosy can no longer legally be,

discriminated against. Can we just do a quick sidebar and talk about the recent bit of news? Yeah. Betty Price. Betty Price is a Georgia state representative who recently inquired about the legality of separating, segregating, quarantining, quarantining, HIV patients so that they would not infect others. Like, seriously humanity? 2017, thanks. Have we learned nothing from how many mistakes we have made in the past? Are you kidding me? No, we haven't learned anything.

Clearly. It's so disgusting. Betty Price, shame on you. You're a bad person. Bad. And I don't like you. She said, I don't want to say the quarantine word, but I guess I just said it. Ew.

My nostrils are flaring. Your nostrils are flaring. I'm trying to curse. You have your extremely angry face on. Like, ugh. Let's get back to leprosy because it's a happier outlook there. It's a happier outlook, but just so you know, this is still going on. Right.

This is still something that is extremely relevant, depressingly enough. Getting back to leprosy, the worldwide prevalence, that is the people who are known to be infected and are currently receiving treatment for leprosy in the world was 174,680 people. as of 2015. And do you think that that is an underestimate? Well, every year there are new cases diagnosed. So certainly that's not everyone who's currently infected. It is possible that it's an under diagnosis because there is still a stigma associated with maybe you might think you have something like leprosy, but you don't want to go to the doctor to get treated because you might be stigmatized in your society because of it. It's also because the, like we talked about, the

incubation period for this disease is so long, there are going to be. be new cases that crop up every year, even though we've been treating for a number of years now. The new incidence of disease in 2015 was 210,758 new cases. So that's how many new cases were identified in 2015. Okay. So just, just as a reminder, yes, there were 174-ish,000 cases total in 2015. Right. That were receiving. treatment already. And then in 2016, no, in 2015, there were an additional 210,000 cases identified. And so in total, 370,000 cases total. Gotcha. Okay. And the World Health Organization, in association with another organization that I forget the name of, who friended the money for it,

offers free multi-drug therapy to every single person infected with leprosy. So every person, person who has this disease has the opportunity for completely free treatment as long as they have access to it, which is still a problem in a lot of areas. Where are the areas? Right. The area with the most number of cases every year by far is India. For example, in 2015, out of those 210,000 new cases, 127,000 of them were in India alone. Wow. That's 60% of the burden of leprosy is faced by India alone. So it is a very big problem there.

There are around 16 countries that still have leprosy transmission sort of on an annual basis, but only three countries that have more than 10,000 cases or that had more than 10,000 cases in 2015. And India by far, I mean, had over 10 times as many as. Brazil and Indonesia, which were the next two countries that were the most burdened by leprosy. One of the things that may contribute to the high burden of disease in India, besides the fact that it's a really massively huge population, is the fact that it was a few years later than other countries

that they started implementing multi-drug therapy. There was also something I read about how during British colonialism of India, there were several laws enacted to try to limit the spread of leprosy, except that wasn't really their intention. It wasn't to actually solve a public health problem. It was more like, let's get these unsightly people out of the way. That's such a common theme in dealing with leprosy historically. Yes.

So to sort of put an even happier spin on this, while 210,000 new cases might sound like quite a lot, and it is quite a lot, no mistaking it, that number has dropped drastically in the last 10 to 15 years. For example, in 2002, there was over 700,000 people known to be infected already receiving treatment and an additional 500,000 people that were infected or diagnosed in 2002. That's crazy. And it's crazy that we don't hear about this. Exactly.

And part of the reason, I'm sure, is that it's not that big of a problem in the United States. This tends to be a problem in the poorest regions of poor countries. and so it's very easy for the Western world to ignore it. We, we, like, the Western world doesn't have an incentive. Right. We have no skin in the game. Can we say that for leprosy? Skin in the game?

Yeah, that's, it's a thing you say about, like, football. Oh, I say horse in the race. Oh, because you're from Kentucky. Skin in the game, like football? Yeah, like, like, or isn't that, I feel like that's a phrase. Can someone correct us on that? Oh, are we keeping this in? Yeah, yeah, for sure.

100%. Great. It's horse in this race. Horse in the race, skin in the game. The U.S. doesn't have a lot of it. However... Dog and the sled team. Okay, that's cute.

However, in 2015, there were 178 new cases of leprosy reported in guess where? The United States. Oh my God, I'm getting looping. I know. We're almost at the end. 178 new cases. Okay, so were these people infected in the United States?

They were. Of those 178 new cases, 72% of them were reported by Arkansas, California, Florida, Hawaii, New York, and Texas. So with the exception of, let's say, Florida and Hawaii and New York, those are all areas where Armadillos live. Florida as well. Oh, in Florida, too. Yeah, it's a state speed bump. Oh, are you serious? Yeah.

I never knew. Florida. Got them Florida associations. Yep. So it is possible that some of these cases were contracted abroad or were from immigrants that emigrated to the United States. But what you're telling me... There is absolutely transmission that happens because of Armadillos. What else?

You're telling me that people are getting lepros from Armadillos. That is possible. How is that happening? Well, like we said before, armadillos are a known reservoir host. Right, right, right. But what are people doing to actually get infected? One case that I heard, which I probably should have fact-checked even more, is that a bunch of kids were playing soccer with an armadillo.

Like the soccer ball, the armadillo was their soccer ball. Okay, they deserve it. So part of the problem with both detection and treatment of something like leprosy is that the treatment itself is very long and arduous. So it's generally treated by what's called multi-drug therapy, which means exactly what it sounds like. You have to take multiple different antibiotic drugs, and you have to take them for a year to two years.

A year to two years. I can't even take a multivitamin every day. Oh, God, me neither. Right. So it's a really long course of treatment. And if you think about, especially because this tends to be a disease that infects and affects people in the poorest areas, it's exceptionally difficult to make sure that people are staying on a treatment regimen and not relapsing back into disease even though they've been on treatment in the past. Right. And I can imagine it would be hard to go to a medical center every month or however frequently you need to go. Yeah.

Refill your prescription or whatever it is. So even though these drugs are being provided, two countries and two governments and two individuals by the World Health Organization, it is not a perfect system. It's still difficult to treat the disease. All in all, the World Health Organization has done a really great job at trying to combat leprosy. They're not all the way there, but they're really putting a lot of effort in and you've got to give them props, you know? The reduction in cases is really impressive. Right. Yeah. I mean, hundreds of thousands of Fewer cases. Every, yeah.

Since 2002, the drop has been over 500,000 cases in just 10 years. Well, listeners, there you have it. That's leprosy. That's leprosy. An old, old, old disease that not very biblical, turns out. Turns out, except for dear old Lazarus. Still extraordinarily relevant. Absolutely.

And on its way out. Hopefully. Hopefully on its way out. Yeah. That's hopefully the good news that we can look forward. too. If you want to read more, we have a number of books and citations that we will post on our website and we'll give you a brief rundown right now. Yeah. I got most of my information on the history of leprosy from a few books. One is called The Colony by John Taman. The other is called A Disease

Apart, Leprosy in the Modern World by Tony Gould. And there's an interesting fiction book that we haven't read, but we want to. It got great reviews. We just haven't had time yet. called Molokai, and also from Plagues and Peoples by Arlo Carlin. And most of the statistics on the status of leprosy today come from the Centers for Disease Control and the World Health Organization, who publishes every year what they call a weekly epidemiological report. They also, if you're interested, have the global leprosy strategy document so you can see exactly what they're doing to try and combat leprosy. If you're interested in more of the genetics of immunity to leprosy, which is a really interesting field of research.

Honestly, there's a bunch of papers out there. My favorite one that I read was called On the Age of Leprosy. It was in the journal Plus neglected tropical diseases published in 2014. Thank you guys so much for listening. Don't forget to rate, review, and subscribe. That's how other people will be able to find our podcast. So please, please, please do that for us. You can find us on Facebook at This Podcast We'll Kill You.

Instagram at This Podcast Will Kill You. And Twitter at T-P-W-K-Y, our acronym. And you can always download this podcast from anywhere that you get your podcasts. That's where we're at. And tune in next episode when we talk about smallpox. Wash your hands. Yeah, filthy animals. Running my small business was like playing basketball five-on-one, and I was the one.

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