Silver bullets, shotguns, and integrative community-based approach to lymphedema from lymphatic filariasis in India.

This letter is in response to the editorial “Silver Bullets and Shotguns” (1) and an article by Narahari et al “Integrated Management of Filarial Lymphedema for Rural Communities” (2) regarding use of multimodality treatment like ayurvedic massage, yoga, and bioengineering pressure therapy along with allopathic medicines and modalities. First of all, ayurvedic medicines, spas, and yoga are very expensive. They are no longer cheap modalities in India. All will agree that combined decongestive therapy (CDT or CPT) works in the management of lymphatic filariasis, which was presented by myself and Elizabeth Russell (American Physiotherapist) at the 2006 GEL Congress in Hinterzarten. The only problem with massage therapy is to maintain it in the optimal lymphedema control program. Patients need periodic intensive therapy, which is time consuming and expensive for patients in countries like India. That is why we recommend foot hygiene, elimination of foci of sepsis like carious teeth and fungal infections, and automassage (we teach the patients to do their massage themselves) at their convenience. If there are skin changes like nodules, ulcers, etc., we do surgical correction, which is rapid, less expensive, and produces longlasting results although pressure garments and foot hygiene are needed post-operatively. Where simple systems work better for the patients, why should we go to five to six modalities particularly when all of them are expensive, time-consuming, and not readily available, and, above all, not a cure for the disease? Just because a research group started a project necessitating patient participation for 194 days does not mean that this is practical in a country like India with very poor economical level in the community. Many patients and the health workers might feel that they are being offered a cure and in the end will be disappointed! We cannot afford either a silver bullet or shotgun at this stage since simple measures will help our patients. The readers of Lymphology must understand the reality in our country and not be led astray by this publication and its questionable statistics. The local public and patients are not accepting of the methods and protocols outlined by Narahari et al (2).