3–15 Jan, 2000: A Report By
Dr Arvind Chopra, MD, Rheumatologist, Pune, India

Introduction
The launch of the WHO BJD 2000–2010 is a culmination of the efforts put in by numerous experts and visionaries to curb the growing menace of the rheumatic–and–musculoskeletal diseases (RMSD). These disorders, inclusive of the traumatic etiology, predominantly contribute to the morbidity across the globe, in terms of impaired quality of life (QOL). After having effectively launched several programs to control numerous communicable infectious diseases with a fair measure of success, over the decades, the WHO has now begun to increasingly focus on the non–communicable diseases. Among the latter, the cardiovascular disorders and cancers have preoccupied the health planners for reasons obviously connected to human longevity. But having realized that reduction in mortality must be matched with improved QOL, the WHO has now launched one its most ambitious programs, the WHO–BJD 2000–2010.

Initiated by the medical faculty of the Swedish University at Lund, the inaugural consensus meeting was held in April 1998 to set up an international steering group. Further, a proposal for a global collaboration by the latter was accepted by the WHO. Secretary General Kofi Annan, on behalf of the United Nations, has officially welcomed the WHO–BJD initiative, and has appealed to the World community in stating: ‘There are effective ways to prevent or treat these disabling conditions. But we must act on them (RMSD) now’.

The BJD is actually an umbrella organization of over 750 patient and professional organizations in the world concerned with bone and joint disorders. It is endorsed by the International League of Associations for Rheumatology (ILAR) and its components in Asia Pacific (APLAR), and the rest of the world. Numerous national organizations, including the Indian Orthopedic Association and the Indian Rheumatism Associations, have been listed among the organizations supporting the BJD movement. Over 17 governments have endorsed the WHO–BJD project.

The Government of India has yet to offer its official support.
The WHO proceeded to organize a scientific expert group meeting in Geneva, Switzerland, in January 2000 for the official launch of the BJD. To begin with, this meeting focused on five major disorders among the many that constitute RMSD. These were rheumatoid arthritis (RA), osteoarthritis (OA), osteoporosis, spinal disorders and severe limb trauma.

Background information and inaugural address
Arthritis accounts for over 50 per cent of all chronic conditions in persons aged 60 years and above. In over 25 per cent of the latter community, Osteoarthritis of the knees and spine, causes dominant pain and disability. Back pain, one of the commonest causes for seeking medical consultation, is the second leading cause of sick leave from work. About 10 to 20 per cent of the population visits the doctor for all kinds of soft tissue rheumatism and trauma related MSD, and the latter are often related to occupational overuse and/or misuse. {mospagebreak} Dr Jie Chen, Director, Non–Communicable Diseases Division, WHO, in her inaugural speech stated that currently there are about 12 million cases of rheumatoid heart disease (RHD) reported annually from all over the world. It must be added that RHD is caused by rheumatic fever arthritis, which if diagnosed early and treated appropriately is curable. Rheumatic fever arthritis, a post–bacterial disorder, is a preventable and a major scourge of the young population in developing countries.

It is anticipated that based on current trends, road traffic accidents (RTA), already in epidemic proportions, would compete with cardiac and vascular disorders and cancers to be among the leading causes of human mortality and morbidity by 2020. Almost, 7,00,000 people are killed globally by RTA, which are estimated to be the tenth leading cause of death (World Health Report, 1999). About 25 per cent of the health expenditure in developing countries is expected to be spent on trauma related care by the year 2010. Fragility fractures, due to osteoporosis, have doubled in the last decade, and it is estimated that over 40 per cent of all women over the age of 50 years (as women are more likely to suffer from osteoporosis after menopause) will suffer from an osteoporotic fracture. Prof Lars Lidgren, Chairman, BJD International Steering Committee, in his inaugural address stated that the number of hip fractures will further rise from 1.7 million in 1990 to 6.3 million by 2050 unless aggressive preventive programs are started.

In the inaugural address to the meet, Dr Gro Harlem Brundtland, Director General, WHO, stated that “The increased life expectancy recorded in recent decades, together with changes in lifestyle and diet, have led to a rise in non–communicable diseases (NCD), also in the developing countries. NCD now cause nearly 40 per cent of all deaths in the developing countries, where they affect younger people than in industrialized countries”. The latter underscores the significance of the NCD, including the WHO–BJD, all over the world.

Scientific Meeting
Over 70 expert participants belonging to different fields (Rheumatology, Orthopedics, Epidemiology, Social Sciences, Statistics, e–Conomics, Health Planning etc), from all over the world were invited. Prof Anthony Woolf, a rheumatologist from UK, was elected chairman of the meeting.

Prof Shanmugasundram, (Chennai, orthopedic surgeon), Dr Arvind Chopra (Pune, rheumatologist), Dr A Mittal (Delhi, endocrinologist), and Prof D Mohan (Delhi Trauma Expert), were invited from India. The participants were divided into five working groups, one each for RA, OA, trauma, osteoporosis and spinal disorders.
The two–day program consisted of key lectures and workshop–brain storming sessions to:

1. Review the existing epidemiological data on RMSD.
2. Achieve a consensus on disease definitions, staging and natural history.
3. Identify health and socioeconomic indicators of RMSD.
4. Identify gaps in the knowledge and understanding of RMSD.
5. Raise awareness of the BJD.

The currently available validated instruments to measure health status, disease outcome and overall QOL were discussed in detail for future adoption to measure the burden of disease, with particular reference to socio–economics. The disability–adjusted life year methodology (DALY), based on health and socio–economic indicators, was presented by WHO experts with a view to measure the RMSD burden quantitatively in a standardized manner from all countries irrespective of their development status. Similarly, DALY could be calculated for all diseases, and then be used to allot health expenditure priorities.

The WHO also presented the new classification nomenclature of diseases, their functioning and disability. The well known WHO model paradigm of impairment–disability–handicap to describe disease consequences will be replaced by the ‘Impairment–activity–participation’ model for better humane connotations and acceptance.

The conclusions of the five working groups, one for each of the major RMSD disorders described above, were presented, discussed and a consensus of the participants obtained. Differences in opinions were recorded. A research agenda was conceptualized. Items to be contained in the future strategy of BJD were discussed with a view to fill the ‘Gaps’ identified during this meeting through organized global effort, devise appropriate interventions for reduction in the RMSD burden and provide better health care and health. The WHO will publish the proceedings of the scientific meeting through a WHO Technical Report.


The Indian Participation and Data
The epidemiological data on RMSD generated by the WHO COPCORD (community–oriented program for control of rheumatic disease) project in village Bhigwan, Dist. Pune, India, was accepted and listed in the BJD global data inventory. The Bhigwan COPCORD, the first of its kind in India, and seventh in the world, was launched in 1996, under the auspices of the WHO–ILAR–APLAR COPCORD by Dr Arvind Chopra, a consulting rheumatologist in Pune, India. The Bhigwan COPCORD 1996–2004 is the first ongoing prospective study of its kind in the world, and has provided prevalence and incidence figures of various types of RMSD from a 7,000 rural population
It was recognized during the WHO meeting under reference that the Bhigwan COPCORD had amply shown:

1. About 13–14 per cent of the population reported RMSD symptoms and required medical care.
2. Besides the five major RMSD entities under focus, soft tissue rheumatism problems (STR) are dominantly reported by almost 55 per cent of the RMSD rural patients, a fact that was endorsed by the participants for evaluation and inclusion in the BJD agenda. STR problems, dominantly reported by working female class, were largely due to occupational overuse, also called repetitive stress syndrome in this village. Psycho functional factors, especially anxiety, can also lead to a form of STR, often called fibromyalgia but the latter though found in the village population was much less. Overall, STR problems are preventable and amenable to treatment largely by appropriate health education.
3. Almost 10 per cent of the RMSD patients had inflammatory arthritis, and that the prevalence of RA was almost 0.5–0.6 per cent in the Bhigwan population; the highest ever reported from a rural study of this kind.
4. Almost 5.5–0.6 per cent of the village population suffer from osteoarthritis.
5. Further, the COPCORD Bhigwan model for the study of the epidemiology of RA in a prospective manner, presented buy Dr Chopra initially to the working group on RA and later to the participants of the meeting, was adopted by the WHO BJD, in the place of the proposed model, for future application.

The Bhigwan COPCORD is also carrying out immunogenetic studies of rural patients and communities in collaboration with Prof Alan Silman and colleagues at the University of Manchester, UK. The Bhigwan COPCORD will also identify risk factors in causation of MSD, and design and valuate control strategies. Dr N Khaltaev, Co–ordinator, Non–Communicable Diseases, WHO, and Secretary to the WHO–BJD meeting, had earlier visited village Bhigwan to evaluate the COPCORD project, and further endorsed a WHO sponsorship to publish and distribute basic health education material in the village.

Prof Sunderam presented his statistics on spinal disorders based on hospital experience in Chennai, with special reference to spinal injuries and tuberculosis. He further described the problems of collecting hard core epidemiological data on spinal disorders in the Indian scenario. Dr Mittal expressed his concern on the lack of data on osteoporosis in developing countries, and further stated though the lack of technology did not allow precise diagnosis, the disease was rampant and often in association with Vitamin D deficiency. The latter was accepted by the participants.

Prof D Mohan, an engineer from IIT, New Delhi, and in charge of a WHO collaborating center on transportation injuries and prevention, cited his socio–economic–cultural data from village surveys carried out in North India, and further highlighted the etiology and prevention of thumb trauma. Besides RTA, he also emphasized the need to curb agricultural–related trauma in the developing countries.

At present, India does not have a national program of any kind concerning RMSD/rheumatic diseases.
The WHO–BJD Future Strategy
The key goal is summed up in its slogan “Keep people moving”. Based on the proceedings and conclusions of the recently conducted scientific expert group meeting in Geneva, and available world statistics, the WHO BJD hopes to accomplish the following goals in the current decade:

1. Raise awareness of the growing burden of MSD on society: This will be done through translation of the epidemiological global burden of RMSD into financial costs. This will be further communicated to the national decision makers in different countries, who will then devise methods and means to reduce the RMSD burden to society by shifting indirect to direct health care costs.
2. Promote the prevention of RMSD and empower patients through education campaigns:
   The BJD national action networks (NAN), in close liaison with the national government health authorities and agencies, and the International WHO–BJD Steering Group, will design public awareness and education campaigns. Patients must be empowered to participate in their own health care.
3. Advanced research in the prevention, diagnosis and treatment of RMSD, including rheumatic disorders:
   It is expected to triple the existing research funding during the decade.
4. Improve diagnosis and treatment of RMSD.
   The specific goal would be to influence the medical schools and colleges to impart a better and practical training program, of at least six months, to undergraduates. The diagnostic and treatment skills of the GP need to be improved. Similar proposals will be made for other medical groups engaged in the care of RMSD.
   Finally, it is hoped that at the end of the current decade there will be 25 per cent reduction in an expected increase in joint destruction by arthritis, osteoporotic fractures, severely injured people, and indirect health cost for spinal disorders.

To begin with, the WHO BJD Steering Group expects at least 100 countries to be actively participating in achieving some of the above mentioned objectives of the BJD decade by 2002.

The BJD National Action Network (NAN) For India
In close liaison with the International Steering Committee, a NAN committee for India has been proposed and accepted. The committee will consist of:
Prof T K Shanmugasunderam (chairman), Prof D Mohan (coordinator),
Dr Arvind Chopra (secretary), Dr A Mittal, Dr S Goyal.
The committee will initiate a dialogue with Government health authorities and other concerned national associations and agencies to promote the activities of the WHO–BJD in India. It will co–opt experts from related medical disciplines from different parts of India. The initial attempt will be to create a national data base on some of the RMSD, and encourage data collection through well organized epidemiologically driven multicentric studies. In all earnest and at the earliest, the Indian NAN committee will try to obtain an official endorsement of the WHO BJD project by the Government of India.