2015 ACR/ARHP Annual Meeting: Global Challenges in Rheumatic Disease Care

Challenges for rheumatology patients in sub-Saharan Africa and other developing countries include a lack of resources and access to drugs and hospitals.
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SAN FRANCISCO—To convey the plight of rheumatology patients in sub-Saharan Africa, Girish Mody, MD, head of rheumatology at the University of KwaZulu-Natal in South Africa and past president of the African League of Associations for Rheumatology, recounted a story during the 2015 ACR/ARHP Annual Meeting from the World Health Organization about a diabetes patient.

The woman paid out of pocket for her doctor visit and her medications. Taxi fares to get to the doctor ate into her thin income, and because she didn’t get paid for the time she had to skip work to see the doctor, every visit meant lost wages. And, sadly, she was one of the lucky ones: At least she had a job, and at least she had a doctor.

The problems apply to rheumatology patients in many African nations as well, Dr. Mody said.

“Developing countries, especially sub-Saharan Africa, have other challenges, like social, education, cultural, political, financial,” he said. “There are also issues about resources and access to drugs and hospitals.”

Studies on the prevalence of rheumatic disease in Africa are scarce—just 27 were found in a meta-analysis from 1975 to 2014—but they show a much higher prevalence of osteoarthritis than rheumatoid arthritis.¹

In sub-Saharan Africa, communicable diseases might overshadow musculoskeletal diseases, but musculoskeletal diseases still account for 12% of years lived with disability, he said.

Access to Care

And access to rheumatologists, and physicians in general, is very limited: The doctor–nurse–population ratio is just 1.1 to 1,000, compared with 7.4 in the Americas and 9.6 in Europe.

Providing assistance to countries to address specific needs can make big differences, he said. In Nigeria, for example, there was just one rheumatologist 10 years ago, even though, with 173 million people, it’s the most populous country on the continent; now, there are 28 people at some stage of rheumatology training.

In sub-Saharan Africa, communicable diseases might overshadow musculoskeletal diseases, but musculoskeletal diseases still account for 12% of years lived with disability.

Musculoskeletal diseases are also a major burden in the region represented by the Asia Pacific League of Associations for Rheumatology, said Lyn March, MD, professor of rheumatology and musculoskeletal epidemiology at the University of Sydney. The association covers Asia, Oceania and Australia. Low back pain and neck pain ranked as top causes of disability-adjusted life-years in that region in the 2013 Global Burden of Diseases Study, a collaboration across 188 countries.²

Chronic Pain

Dr. March drew particular attention to management of chronic pain as a growing challenge for rheumatologists. An older, but telling, study from 2001 found that 17% of men and 20% of women said they’d been living with pain on most days over the previous six months.³

“Clearly, the management of musculoskeletal pain is going to be something that we all have to address as a key urgency as our population ages,” she said.

She urged continued research into the prevalence of musculoskeletal disease burden and pain, but said collaboration is needed to make sure the data collected can be compared to data collected elsewhere.

“Without data, we don’t have disease,” she said. “We need the data collected in a standardized way.”

In Europe, 22% of the population either is currently experiencing, or has previously experienced, long-term muscle, bone and joint problems, such as rheumatism and arthritis, said Gerd Burmester, MD, president of the European League Against Rheumatism. And one in three people experience musculoskeletal pain that restricts activities of daily living, he said.⁴

Yet there is just one rheumatologist per 100,000 people in Europe, he said. And rheumatic disease will only become more common, he said.

“The burden will increase—changes in lifestyles may be responsible,” and of course, there’s the aging of the population with its accumulation of co-morbidities, Dr. Burmester said. “Physical fitness is decreasing. Obesity is increasing. Alcohol consumption is still excessive in many countries. Smoking is still a problem.” And “in many countries, the lack of rheumatologists is a severe problem.”

John Reveille, MD—immediate past president of the Pan-American League of Associations for Rheumatology—said a lack of good epidemiologic data is a problem in the Americas. Although data exist in the U.S., that is not the case throughout Latin America and South America.

Surveys conducted in 2012 and 2015 found that PANLAR members feel that a lack of governmental support for rheumatologic care and research is a top challenge, Dr. Reveille said. The biggest issue, though, members reported, is a lack of manpower, particularly in rural parts of countries and in pediatric rheumatology.

“The distribution of rheumatologists is mainly in the larger cities, and this is a big, big problem in the smaller countries, where access to care in rural populations [is continuing to worsen].”

Thomas R. Collins is a medical writer based in Florida.

References

1. Usenbo A, Kramer V, Young T, et al. Prevalence of arthritis in Africa: A systematic review and meta-analysis. PLoS One. 2015 Aug 4;10(8):e0133858.
2. Blyth FM, March LM, Brnabic AJ, et al. Chronic pain in Australia: A prevalence study. Pain. 2001 Jan;89(2-3):127–134.
3. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Aug 22;386(9995):743–800.
4. European Commission. Health in the European Union: Special Eurobarometer 272e. September 2007.