Lymphovenous Canada: The low-cost management of filarial lymphedema in rural Ind

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Lymphovenous Canada: The low-cost management of filarial lymphedema in

rural India using traditional medicine

 

 

 

Click here to go to an interview with Dr. Maclean on lymphatic

filariasis in Canada.

 

Sushrutha samhitha, Sutra sthana. Ch 4. Verse no 7 states, " If you

study only one science (Shastra) you will not understand that science

in its depth. Therefore a clinician should study all (related)

sciences to understand his own science "

..

 

[Picture of Dr.S.R. Narahari]

 

Dr. S.R. Narahari, Director, Institute of the Applied Dermatology

(IAD)in Kasaragod, India talks about the Shleepada-IAD-Ryan Regieme

his institute uses to treat filarial lymphedema

 

I am a dermatologist, trained in modern biomedicine, with a background

in agriculture from a rural town located in southern India.

 

When I first started clinical practice in 1990 patients would come to

me with chronic dermatological diseases - like intertrigo, lip and tip

varieties of Vitiligo, folliculitis etc. In follow-up visits for other

dermatological problems, I would notice that their original problem

was gone or reduced to patient's satisfaction. When I asked them what

happened to their earlier disease they used to say, " I went to so and

so, a traditional Indian medicine doctor and I didn't have a recurrence. "

 

Initially I never used to believe this. I thought the disease must be

in remission but when I followed these people for a long time I found

they never had the disease again.

 

So that gave me a curiosity and through these patients I contacted

those doctors and started interacting with them. We built a group made

up of doctors from different systems of medicine and then we founded

an NGO with the name of the Institute for Applied Dermatology. We

thought that by integrating modern biomedical methods of treatments

with traditional methods of treatment we would get the best of all

systems for the patients.

 

Kerala province in India lists more than 106 systems of medicine being

currently practiced in India. The " reverse pharmacology " approach to

developing integrated medicine holds the promise of bringing down the

cost of medicine, while recognizing the legacy of traditional wisdom

and India's rich biodiversity which could lead to beneficial drugs for

everyone.

 

" We applied modern medicine or allopathy outcome measurements to

traditional Indian " Ayurveda " and homeopathic medicines and used them

in along with western medicines/methods to treat patients. So patients

were happy and doctors were happy. "

 

We applied biomedical (modern medicine or allopathy as it is known in

India) outcome measurements to traditional Indian " Ayurveda " and

homeopathic medicines and used them in along with western

medicines/methods to treat patients. So patients were happy and

doctors were happy. The system we established on how to integrate

these different forms of medicines and deliver it through a low-cost

approach was presented at the World Ayurveda Congress in 2002. Experts

from 44 countries participated at that conference which took place in

Kochi, Kerala province.

 

Until that time our experiments did not deal with lymphedema because

we were focusing on eczema, Vitiligo, HIV/AIDS and a lot of other

diseases. Dr. Ryan, Emeritus Professor of Dermatology at Oxford

University, who is also involved in the Global Alliance for the

Elimination of Lymphatic Filariasis, was one of the delegates at that

conference and one of the speakers. He happened to listen to our

approach to the subject and he said, " Why don't you do experiments

with lymphedema? "

 

We started interacting with him and did our first experiment with

lymphatic filariasis (known in Ayurveda medicine as Shleepada) in

2002. When the results came out well, we presented our findings at the

International Society of Lymphology conference in Frieberg, Germany in

2003, now published, Role of Indian system of medicine in the

management of filarial lymphoedema, Lymphology 37 (suppl): 673-77,

2004. Lymphology experts there thought this was the right approach.

 

[Picture of a booklet from the proceedings of the National Seminar on

evidence-based and integrated medicine for lykmphatic filariasis,

other chronic dematosis and HIV/AIDS]

 

We estimate that our approach to treating lymphatic filariasis costs

just $581 Canadian dollars per patient or $500 American. (It was 28

Euros when we first presented this treatment at this conference,

however over the past three years we have improved it with more

medicines). This cost is in contrast to western approaches which would

have cost many times more. Most of these costs come from the use of

compression garments and fee to self help treatment training team at

the end of the treatment.

 

We are currently looking for funds where we can change the process of

getting compression garments to our patients and lower these costs.

There are plenty of weavers in rural areas in Kerala who need jobs.

Filariasis is common in these areas, and coincidently this is the same

place where rubber is grown. If we can find a machine that can squeeze

the rubber into very tiny, small strands, then the weavers can make a

low cost compression garment for our patients which would benefit

everyone economically.

 

" We estimate that our approach to treating lymphatic filariasis costs

just $581 Canadian dollars per patient or $500 American. "

 

Access to low cost antibiotics has not been a problem in the treatment

of Indians with lymphedema/lymphatic filariasis who develop an

infection. Historically, India's patent system has not covered drugs.

This has enabled India to manufacture generic drugs, including

antibiotics, at a low cost for many years. Even if it is covered under

WTO at a later date we can manage the infections in lymphatic

filariasis with those antibiotics that are not covered by TRIP(Note to

readers: as of January 1, India committed to awarding patents on drugs

in compliance with the World Trade Organizations' TRIP agreements).

 

The high costs of medical treatment, which puts it out of reach for

many low income rural Indians, is often attached to seeing

specialists, using high technology and receiving care in hospital

settings.

 

Our low-cost integrated approach uses culturally accepted practices

along with western approaches to medicine. We put the focus on getting

the patient and family members to carry out the treatments in the

community, under medical supervision. That's why we have incorporated

yoga into our treatment protocol along with skin care, diet, foot and

leg baths made out of herbs and massage, along with compression

bandaging. In our regieme, yoga therapy replaces physiotherapy and

compression bandages replace Venesection (rakthamokshana) of ayurveda.

 

The IAD's proposal to undertake evidence-based research using this

integrated protocol was submitted to the Centre for Advanced Research

in Clinical Pharmacology on Traditional Medicine at the Indian Council

for Medical Research (ICMR)and the Science and Technology Council of

Kerala province. Both approved our plan to use our protocol on 51

patients with lymphedema/lymphatic filariasis in one or both lower

limbs over a 1-½ year period. And the results were very good.

 

The IAD study was conducted as per the guidelines issued by ICMR, WHO,

Global programme for elimination of lymphatic filariasis (GPELF) and

the International Society of Lymphology Consensus Statement 2003.

 

" We have incorporated yoga into our treatment protocol along with skin

care, diet, foot and leg baths made out of herbs and massage, along

with compression bandaging. In our regieme, yoga therapy replaces

physiotherapy and compression bandages replace Venesection

(rakthamokshana) of ayurveda. "

 

The principal investigator of the filariasis study from IAD was

awarded the " BEES Bursary " by the British Epidemiological Society

prior to conducting the clinical study. Under this bursary he received

training from International Cochrane Skin Centre situated in

Nottingham, UK to conduct evidence based clinical studies. The IAD

study was performed as an International collaboration, guided by Prof.

Terence J Ryan, from the Department of Dermatology, Oxford UK. Prof

Ryan has stated that the study is unique and there are no other

similar examples anywhere in the world.

 

The study took place between October 2003 and 2005. A patient advocacy

group assisted with the study which met the requirements of the

Institute of Applied Dermatology's ethics committee.

 

In honour of Professor Ryan's encouragement and joint sponsorship of

this study, IAD named the protocol, " The Shleepada-IAD-Ryan Regieme " ,

which is a low-cost management for filariasis endemic to rural

communities.

 

[Left to right: Dr. Nandini, Prof. Ryan,Dr. Kokkal, Dr. Narahari, Sri

Minhaz Alam, IAS, Sri Abdul Rahiman listen when patients express their

ideas]

 

Patients were trained in the hospital for two weeks on how to

undertake these procedures which they then carried out for another six

month period following discharge. One month after the discharge from

the hospital they were called in for a review. In addition patients

were advised to take two oral medications of Ayurveda described for

lymphedema: Kanchanaraguggula and Mahamanjishtadi kwatha as

recommended by the Ayurvedic formulary of India.

 

While on these medications patients were required to observe certain

diet restrictions such as avoiding cold water and cool drinks, milk

and milk products, and to be strictly vegetarian in diet. Significant

differences among disease categories were found for end of calf bulk,

maximal bulk, maximum bulk on stand and volume.

 

We had patients who had micro surgery or debulking surgery and came to

us for this treatment. They were fine for a short period after the

surgery, but one to two years later they went back to their old

condition. After surgery, compression is needed. And surgery does

nothing to improve the skin.

 

Since the study took place, the Institute of Applied Dermatology has

treated 145 patients with this program. Results from the study will be

published in the Lymphology Journal.

 

The world needs to recognize the importance of reverse pharmacology

which acknowledges the importance of herbs and other medications which

have been used for hundreds and thousands of years safely. I urge

other countries to consider using this low cost treatment in the same

way we are using it in India.

 

Dr. Narahari received a president's award for the work of his

institute on this project at the September 2005 International Congress

of Lymphology in Brazil. For more information on the IAD's innovative

approach to treating lymphedema you can contact Dr. S. R. Narahari,

Institute of Applied Dermatology, Kasaragod, Kerala, India at:

srnarahari or visit the IAD web site at:

www.indiandermatology.org

 

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