Leprosy Mailing List – August 3, 2014
Ref.: (LML) Is there no place for Deformity or Disability in POID?
From: Jerry Joshua, Karnataka, India
Dear Editor LML,
I would like this letter circulated among your readers for discussion, if you think it is worthwhile.
Regards,
Jerry Joshua
Is there no place for Deformity or Disability in POID?
When the original concept of Prevention of Deformity (POD) in leprosy was raised, it focussed more on prevention of deformities in the anaesthetic limbs and damage to the eyes in leprosy. Early diagnosis was just one of the components. Later it grew to include prevention of loss of sensation itself with early treatment using MDT and early interventions by steroids and nerve decompressions. Then we had newer concepts like impairment and disability introduced and it became POID (Prevention of impairment and disability). All the while, prevention of worsening of disability or deformity had a large place to play in POID. Podiatry in its true sense struggled to find its way into the programme, because of the principle of ‘keep it simple’. Because of this lack of understanding of the complexities of disintegration of anaesthetic feet, many feet are still disintegrating with everyone thinking that soaking and scraping and oiling (reduced to ‘SSO’) was the panacea for all evils to the anaesthetic foot.
We all agree there are different levels at which deformity and disability can be prevented. Namely:
- Early diagnosis and treatment of the disease with MDT,
- early recognition and adequate treatment of nerve function impairment and
- prevention and treatment of secondary impairments due to nerve function loss.
Early detection and treatment with MDT, though significantly finding a place in the national programme was in the realm of ‘epidemiology’, ‘control programme’ etc.
With the advent of integrating the vertical programmes into the general health care system and stopping active case detection, ‘early diagnosis’ was almost discarded and has been trying to find a place as a concept in the mind of officialdom.
‘Early diagnosis’ is extremely important and has been trying various routes to stay above the horizon. Repeated references to ‘contact tracing’, ‘sample surveys’, etc and the need to bring down the proportion of ‘grade 2’ deformities and disabilities in check have kept ‘early diagnosis’ in the minds of people working in the field of leprosy.
People already affected by leprosy and who have been diagnosed with leprosy of course have other concerns, and among them the need to limit their deformity and disability. Many of them have nerve damage already with grade 1 and grade 2 disability. We continue to educate them on soaking, scraping and oiling and to a lesser extent on the need for less stresses and strains on the insensitive parts. Photographs of programmes dealing with ‘POID’ have people sitting with their feet and hands soaking in water.
Meanwhile, ‘early diagnosis’ trying to find a forum, was given one in ‘POID’. This was necessary and very important and has to be stressed in the now ‘integrated’ programmes as early diagnosis is probably the single most important factor in limiting disability. But with ‘early diagnosis’ coming into the picture and taking over all discussions in POID, the concepts of ‘limitation of existing disability’, ‘management and limitation of existing disability’ and ‘prevention of secondary impairment’ is steadily being pushed out of attention. People already having primary impairment are not in focus except for ‘SSO’ camps. Discussions on these aspects are not given importance, and no one gives them a second thought, perceiving that this is a narrow area, of interest to a select few or not significant enough to address for ‘impact’. The ‘impact’ being measured in terms of the number of people benefitted and not in terms of damage to the individual.
Insensate limbs and deformed limbs continue to disintegrate, have ulcers and have recurrent ulcers and slide down a ‘slippery slope’ because of a lack of understanding of the mechanisms of disintegration and people walk their way to amputations while everyone continues to focus on ‘early diagnosis’.
This may sound like a lament for attention and it probably is. But I would like to put forward the suggestion that this ‘secondary impairment’ is what ‘affects’ people already ‘affected’ by leprosy. This should be given a forum of its own. It should not be sent to seek another forum, now that ‘early diagnosis’ has moved from ‘epidemiology’ and ‘leprosy control’ into ‘POID’ and usurped its place.
I think that when we talk of Prevention of Impairment and Disability, prevention of secondary impairment should be given its significant place, for the sake of those who have already suffered nerve damage. ‘Early diagnosis’ should be discussed with ‘leprosy control’, ‘epidemiology’ and ‘programme management’.
Jerry Joshua
The Leprosy Mission Trust India
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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