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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 14  |  Issue : 2  |  Page : 91-93

Access to rheumatology care: How near how far


Department of General Medicine, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication8-Jul-2019

Correspondence Address:
Dr. Annil Mahajan
Department of General Medicine, Government Medical College, Jammu, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_76_19

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How to cite this article:
Mahajan A, Tandon VR. Access to rheumatology care: How near how far. Indian J Rheumatol 2019;14:91-3

How to cite this URL:
Mahajan A, Tandon VR. Access to rheumatology care: How near how far. Indian J Rheumatol [serial online] 2019 [cited 2019 Sep 17];14:91-3. Available from: http://www.indianjrheumatol.com/text.asp?2019/14/2/91/261657



Rheumatological disorders (RDs) are major cause of morbidity and mortality in India putting huge financial burden on the family, society, and nation as a whole. There is a huge volume of rheumatological diseases both in rural and urban population of India[1] and across all ages and genders, but still the access to rheumatology care is not adequate and is far away from the reach of majority of the affected population.

With increase in life expectancy in developing countries such as India, the advancing age is likely to face the challenge of increasing demand of rheumatology care.

Rheumatology is still an emerging specialty in India and is facing a challenge of providing specialized care to huge burden of population presenting with RD. As per the data of the Medical Council of India (MCI), the course of DM Rheumatology or Clinical Immunology is offered only by a few institutes of the country such as AIIMS, New Delhi; SGPGIMS, Lucknow; Madras Medical College, Chennai; NIMS, Hyderabad; KGMU, Lucknow; IPGMER, Kolkata; PGIMER, Chandigarh; CMC, Vellore; JIPMER, Pondicherry; and few others. Thus, with the present intake capacity of candidates into various medical institutions, the number of rheumatologists being produced shall be far less in comparison to the increasing demand of adequate rheumatological care.

Hence, there is a need to train more personnel in the subject in India. Start of short teaching courses of 6 months–1 year or fellowship program, including rheumatology in undergraduate and postgraduate teaching program, and vertical and horizontal integration of rheumatology-related important topics in new proposed AETCOM model of curriculum of MCI, is the need of the hour.

More trained doctors and their frequent interaction for updating in the field of rheumatology regarding the prevalence of various rheumatic disorders in India, their clinical presentation, and treatment shall definitely help us to reduce the agony of these patients.

Further, providing rheumatological care in India has many fold challenges such as need to manage patients in a cost-constrained setting as various investigations for diagnosis and follow-up are very specialized and costly and even most of the teaching institutes are not able to provide all these investigations, and thus, patients have to depend on the private setups.

In urban areas, patients to some extent may be able to get various tests from private laboratories but think of rural population. Neither these tests are available in field hospital nor there is good access to private laboratories. Besides, poverty does not allow them to go for frequent tests. Thus, doctors have to treat most of the patients depending on their clinical presentation only. Lack of trained doctors, lack of education regarding ordering of relevant tests, lack of their interpretation coupled with poverty, illiteracy, and callous attitude of patients regarding their diseases pose a great challenge in rheumatology care, especially in rural India.

Further, the treatment being lifelong in most of the RDs brings huge financial burden on the affected population.[2] The most unfortunate part is that the most of the drugs required in treating majority of disorders are not available in most of the government hospitals. Policies of health-care providers is not sufficing and there is a lack of uniform government funding. Priority to optimize cost of medicines such as biologic therapy, disease-modifying agents and adding them into National Essential Drug List and bringing them under price control policy of the country is the need of the hour.

Availability of these drugs in government hospitals, cheap drugs, encouraging medical insurance for coverage of cost of various tests and drugs, and education of patients regarding regular and prolonged use of drugs should definitely help us to control rheumatic disorders.

Lack of education and understanding regarding the real cause of RD amounts to high rate of patients resorting to complementary and alternative medicines in India, compute and complicate the scenario in providing care to the patients.[3]

Furthermore, the high prevalence of infectious diseases such as tuberculosis continues to be a major contributor to mortality in patients with rheumatic disorders. Several other tropical diseases have relevance and impact on various rheumatological disorders including chikungunya,  Brucellosis More Details, leptospirosis, dengue, and melioidosis.[2],[3] Thus, along with care and treatment of RD, education regarding prophylactic vaccination and screening for infectious diseases has to be imparted to the treating doctors and patients.

The epidemiology of rheumatic diseases in India has been studied under the Community-Oriented Program for the Control of Rheumatic Diseases initiative.[4] Osteoarthritis (OA) knee, fibromyalgia, backache are predominant health problems of both urban and rural areas. Female preponderance was observed in all rheumatological diseases in both the urban and rural areas.[1] Similarly, musculoskeletal symptom pain is a predominant health problem of both rural and urban areas. Knee and back were highly prevalent pain sites in both rural and urban areas.[5]

In one of our own studies, we have suggested that the prevalence of RD is substantially higher among Indian women above 40 years demanding the attention of health-care providers. Among the total population evaluated, 37.69% of women presented with RD and 37.06% of women among the menopausal women had RD with the most common being low backache (LBA) (16.92%), followed by OA (12.30%), fibromyalgia (3.84%), and rheumatoid arthritis (2.30%). The most common site involved was knee (9.23%), followed by lumbar spine (8.46%), hip (3.07%), and other sites (16.92%) such as neck, upper back, hand joints, shoulder, and thighs.[6]

Similarly, in our previous study, rheumatic complaints are one of the most common afflictions in all the populations studied and are one of the leading causes of disability. LBA was the most frequently encountered rheumatic ailment.[7]

However, still, there is a lack of National Data Portal of RD in the country and nonavailability of National Standard Diagnostic and Treatment Guidelines or recommendations making it difficult to provide uniform and high standards of medical practice to the patients.[8] Often, we have to depend on International Treatment Guidelines which may not always be totally relevant with Indian population perspective.

Thus, awareness and education regarding the prevalence of frequent RD in our setup and an attempt to formulate and follow their treatment guidelines shall help us to suffice need of the patients suffering from RD.

Most number of publications on rheumatic diseases from India are on rheumatoid arthritis, lupus, and osteoporosis.[4] The Indian Rheumatology Association (IRA) is the national organization of rheumatologists. The flagship publication of the IRA, the Indian Journal of Rheumatology, is indexed in Scopus and Embase and PubMed Central and now has provided a platform for sharing original research and experiences of rheumatologist of our country. It is the responsibility of all those working in this field to contribute high-quality research in our own journal and make its impact factor more. This shall help us to know the type and kind of rheumatic disorders existing frequently in our country and their management and follow-up and also uncommon and rare presentation of few rheumatic disorders so that we can prepare ourself for the primary care to common rheumatic disorders.

It is very important that doctors in field and even in urban areas need to update knowledge of various aspects of basic and applied medical sciences relevant to common rheumatic disorders. We need to upgrade their skills and competence in diagnosis, knowledge in interpretation of investigations, and treatment of patients with common rheumatic disorders. Further, there is a need to create awareness of the value of supportive and complementary therapies such as physiotherapy, occupational therapy, assessment, timely referral to the concerned specialist, and regular follow-up. Basic training and continued education of practitioners in the field of rheumatology is thus need of hour.[9]

Finally, public awareness by adequate use of print and electronic media, delivery of public awareness lectures, continued medical education (CME), conferences in the field of rheumatology, and carrier up gradation of doctors in the field of rheumatology is need of the hour.

Curriculum reforms for early clinical exposure and acquaintance of medical students to the volume and presentation of different RDs in India, besides increasing DM/DNB seats in rheumatology. Promotion of fellowship programs among the qualified doctors, availability of cheaper and judicious use of various investigations and drugs, education of patients and their attendant, and administrative and political support for the establishment of rheumatology centers in hospitals in urban and rural areas are great challenges in the management of patients of rheumatic disorders.

Commitment and will at all levels shall certainly help in capacity building and improve quality of life in patients of rheumatic disorders with decrease in morbidity and mortality.

All these issues look resolved and rheumatology care looks very near but this is only in few tertiary centers in India but the fact is that rheumatology care is still very far to majority of patients, especially in the rural India.



 
  References Top

1.
Kumar P, Alok R, Das SK, Srivastava R, Agarwal GG. Distribution of rheumatological diseases in rural and urban areas: An adapted COPCORD stage I phase III survey of Lucknow district in North India. Int J Rheum Dis 2018;21:1894-9.  Back to cited text no. 1
    
2.
Misra DP, Sharma A, Agarwal V. Rheumatology science and practice in India. Rheumatol Int 2018;38:1587-600.  Back to cited text no. 2
    
3.
Handa R. Rheumatology in India – Quo vadis? Nat Rev Rheumatol 2015;11:183-8.  Back to cited text no. 3
    
4.
Misra DP, Agarwal V, Negi VS. Rheumatology in India: A bird's eye view on organization, epidemiology, training programs and publications. J Korean Med Sci 2016;31:1013-9.  Back to cited text no. 4
    
5.
Alok R, Srivastava R, Kumar P, Das SK, Agarwal GG, Dhaon P. Prevalence of rheumatic musculoskeletal symptoms in rural and urban areas: A cross-sectional study in Northern India. Int J Rheum Dis 2017;20:1638-47.  Back to cited text no. 5
    
6.
Kudial S, Tandon VR, Mahajan A. Rheumatological disorder (RD) in Indian women above 40 years of age: A cross-sectional WHO-ILAR-COPCORD-based survey. J Midlife Health 2015;6:76-80.  Back to cited text no. 6
    
7.
Prevalence of major rheumatic disorders in Jammu. JK Sci 2003;5:63-6.  Back to cited text no. 7
    
8.
Misra DP, Sharma A, Agarwal V. Guidelines for management of rheumatic diseases in developing countries from basics to real-world situation: Relevance, need, and processes for development. Rheumatol Int 2018;38:549-56.  Back to cited text no. 8
    
9.
Tandon VR, Mahajan A. Prescription mistakes in rheumatology practice. JK Sci 2010;12:50.  Back to cited text no. 9
    




 

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