Global Knowledge Gaps in Equitable Delivery of Chronic Edema Care: A Political Economy Case Study Analysis

Background: Most existing research in chronic edema (CO) care takes place in high-income countries and is both clinically and medically focused, although often accorded low prestige and status. A myriad of challenges define the problems and important gaps in understanding and translating what we know into sustainable practice. Less considered, however, are the consequences and socioeconomic significance of this "knowledge gap" in an increasingly globalized world. This article seeks to address this lacuna by suggesting a political economy approach across three different income settings, the United Kingdom (high), Kerala in India (middle), and Uganda (low), to learn from international practice and understand the contribution of local (community-specific) health traditions. Methods and Result: We used a comparative case study approach. In the three case studies we demonstrate how particular thinking, sets of power relationships, and resource distributions influence and structure the provision of CO management more generally. We demonstrate how these intertwined and often invisible processes reflect a market-led biomedical hierarchization that focuses on high-interventionist, high-cost approaches that are then imposed on lower income settings. At the same time, low-cost but evidence-based local knowledge innovation in wound and CO care from low- or middle-income countries is neither recognized nor valued. Conclusion: We conclude that unpacking these dynamics is a necessary route to providing a more equitable health delivery accessible for the many rather than the few.

EDITORIAL: MORBIDITY MANAGEMENT AND DISABILITY PREVENTION: AN AGENDA FOR DEVELOPING NATIONS INITIATED IN INDIA

Treatment of patients with lymphedema focuses on reducing limb volume with more recent recognition of the importance of quality-of-life issues. Perhaps due to the incidence of filariasis-related lymphedema compared to breast cancer-related lymphedema in the western world, the Institute of Applied Dermatology (IAD) in Kerala, India has developed a low-cost and culturally acceptable treatment with quality-of-life focus that works well in that area. Worldwide, there is also recognition of chronic edema as a potential co-morbidity and the recent advances in genetic analysis continue to shed light on lymphedema development that may be important in filariasis-related lymphedema. Although improvement in treatment outcomes by surgical means has been shown, there is often conventional treatment mixed in the therapy and no randomized controls of any therapy exist. In addition, these techniques require supermicrosurgical skill not available in many areas of the world. The WHO has documented the need in filariasis for both universal health care and innovative care for chronic conditions. The IAD has addressed these issues with its integrative model of treatment with patient quality-of-life at the forefront to incorporate traditional practice to involve the patient more fully in family and community support for an additional therapeutic tool.

Morbidity management and disability prevention: An agenda for developing nations initiated in India

Treatment of patients with lymphedema focuses on reducing limb volume with more recent recognition of the importance of qualityof- life issues. Perhaps due to the incidence of filariasis-related lymphedema compared to breast cancer-related lymphedema in the western world, the Institute of Applied Dermatology (IAD) in Kerala, India has developed a low-cost and culturally acceptable treatment with quality-of-life focus that works well in that area. Worldwide, there is also recognition of chronic edema as a potential co-morbidity and the recent advances in genetic analysis continue to shed light on lymphedema development that may be important in filariasisrelated lymphedema. Although improvement in treatment outcomes by surgical means has been shown, there is often conventional treatment mixed in the therapy and no randomized controls of any therapy exist. In addition, these techniques require supermicrosurgical skill not available in many areas of the world. The WHO has documented the need in filariasis for both universal health care and innovative care for chronic conditions. The IAD has addressed these issues with its integrative model of treatment with patient quality-of-life at the forefront to incorporate traditional practice to involve the patient more fully in family and community support for an additional therapeutic tool.

Future Research Priorities for Morbidity Control of Lymphedema

Background:

Innovation in the treatment of lower extremity lymphedema has received low priority from the governments and pharmaceutical industry. Advancing lymphedema is irreversible and initiates fibrosis in the dermis, reactive changes in the epidermis and subcutis. Most medical treatments offered for lymphedema are either too demanding with a less than satisfactory response or patients have low concordance due to complex schedules. A priority setting partnership (PSP) was established to decide on the future priorities in lymphedema research.

Methods:

A table of abstracts following a literature search was published in workshop website. Stake holders were requested to upload their priorities. Their questions were listed, randomized, and sent to lymphologists for ranking. High ranked ten research priorities, obtained through median score, were presented in final prioritization work shop attended by invited stake holders. A free medical camp was organized during workshop to understand patients’ priorities.

Results:

One hundred research priorities were selected from priorities uploaded to website. Ten priorities were short listed through a peer review process involving 12 lymphologists, for final discussion. They were related to simplification of integrative treatment for lymphedema, cellular changes in lymphedema and mechanisms of its reversal, eliminating bacterial entry lesions to reduce cellulitis episodes, exploring evidence for therapies in traditional medicine, improving patient concordance to compression therapy, epidemiology of lymphatic filariasis (LF), and economic benefit of integrative treatments of lymphedema.

Conclusion:

A robust research priority setting process, organized as described in James Lind Alliance guidebook, identified seven priority areas to achieve effective morbidity control of lymphedema including LF. All stake holders including Department of Health Research, Government of India, participated in the PSP.

Yoga protocol for treatment of breast cancer-related lymphedema

Introduction:

Vaqas and Ryan (2003) advocated yoga and breathing exercises for lymphedema. Narahari et al. (2007) developed an integrative medicine protocol for lower-limb lymphedema using yoga. Studies have hypothesized that yoga plays a similar role as that of central manual lymph drainage of Foldi's technique. This study explains how we have used yoga and breathing as a self-care intervention for breast cancer-related lymphedema (BCRL).

Methods:

The study outcome was to create a yoga protocol for BCRL. Selection of yoga was based on the actions of muscles on joints, anatomical areas associated with different groups of lymph nodes, stretching of skin, and method of breathing in each yoga. The protocol was piloted in eight BCRL patients, observed its difficulties by interacting with patients. A literature search was conducted in PubMed and Cochrane library to identify the yoga protocols for BCRL.

Results:

Twenty yoga and 5 breathing exercises were adopted. They have slow, methodical joint movements which helped patients to tolerate pain. Breathing was long and diaphragmatic. Flexion of joints was coordinated with exhalation and extension with inhalation. Alternate yoga was introduced to facilitate patients to perform complex movements. Yoga's joint movements, initial positions, and mode of breathing were compared to two other protocols. The volume reduced from 2.4 to 1.2 L in eight patients after continuous practice of yoga and compression at home for 3 months. There was improvement in the range of movement and intensity of pain.

Discussion:

Yoga exercises were selected on the basis of their role in chest expansion, maximizing range of movements: flexion of large muscles, maximum stretch of skin, and thus part-by-part lymph drainage from center and periphery. This protocol addressed functional, volume, and movement issues of BCRL and was found to be superior to other BCRL yoga protocols. However, this protocol needs to be tested in centers routinely managing BCRL.

Integrated management of filarial lymphedema for rural communities

The Global Alliance for the Elimination of Lymphatic Filariasis (GAELF) has recommended exploring local health traditions of skin care and a low cost treatment paradigm for rural communities has been proposed by Vaqas and Ryan. Our case study incorporates these promising treatments for use in treating filariasis in rural communities. Patients having lymphedema of one or both lower limbs (skin: normal, thickened or with trophic/warty changes) received treatment components from ayurveda, yoga and biomedicine simultaneously: including soap wash, phanta soaking, Indian manual lymph drainage (IMLD), pre- and post-IMLD yoga exercises, and compression using bandages for 194 days, along with diet restrictions and oral herbal medicines indicated for "elephantiasis" in Ayurveda. Entry points when infected were treated with biomedical drugs. The study was conducted in the reverse pharmacology design. 112 patients and 149 lower limbs completed 194 days of treatment during 2003-2006. Significant improvements were observed in the limb circumference measurements and the frequency of acute dermatolymphangioadenitis, use of preventive antibiotics, and reduction in the number of entry points were also improved. The objective to obtain significant benefit for a common problem using locally available, sustainable and affordable means has been achieved. It has not been our purpose to show that the regimen employed is better than another but the results do pose the question--"Are there components of Ayurvedic medicine that deserve further study?" It is important to understand that the regimen has been delivered mostly at home and that participants we have treated, representing a population suffering from a common problem, have not had access to effective conservative therapy that is culturally acceptable, safe, and efficacious.

Role of local NGOs as peer educators in slowing the slowing the spread of HIV in kasargod (1991-96)

The study reports the effective role of local NGOs in reaching traditional Indian community with information and education on HIV/AIDS. Target oriented IE programs with members of local NGOs as peer educators have resulted in significant slowing in the spread of HIV from the rate of 1.6% in 1992 to 0.4% in 1996.

Comparative efficacy of topical anthralin and intralesional triamcinolone in the treatment of alopecia areata

Efficacy of intralesional triamcinolone acetonide (10mg/ml) and topical anthralin 1.15% cream was compared in the treatment of alopecia areata. Study groups consisted of 37 patients for injection and 32 patients for cream. All of them belonged to Type I of Ikeda's classification. The study showed that triamcinolone induces more adequate response in terms of regrowth of hairs than anthralin. However, the relapse rate was higher with triamcinolone. No difference was noted in terms of complete regrowth of hairs on the lesional skin and side effects of drugs.