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 but under recognized menace of the rheumatic-and- musculoskeletal
diseases (RMSD). These disorders, inclusive of the traumatic
aetiology, 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. Amongst the latter,
the cardio-vascular 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 of 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 BJD 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 that ‘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 rest of the World. Numerous national
organizations, including the Indian Orthopedic Association and
the Indian Rheumatism Association, have been listed amongst
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 Jan 2000 for the official launch
of the BJD. To begin with, this meeting focused on 5 major disorders
amongst the many that constitute RMSD. These were rheumatoid
arthritis (RA), osteoarthritis (OA), osteoporosis, spinal disorders
and severe limb trauma.
Background Information & Inaugural Addresses:
Arthritis accounts for over 50% of all chronic conditions in
persons aged 60 years and above. In over 25% of the latter community
OA of the knees and spine causes dominant pain and disability.
Back pain, one of the commonest causes of seeking medical consultation,
is the second leading cause of sick leave from work. 10-20 %
of population visit the doctor for all kinds of soft tissue
rheumatism and trauma related MSD, and the latter are often
related to occupational overuse &/or misuse.
Dr Jie Chen, Director, Non-Communicable Diseases Division, WHO,
in her inaugural speech stated that currently there are about
12 million cases of rheumatic heart disease (RHD) reported annually
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 young population in
the developing countries.
It is anticipated that based on current trends, road traffic
accidents (RTA), already in epidemic proportions, would compete
with cardiac & vascular disorders and cancers to be amongst
the 3 leading causes of human mortality and morbidity by 2020.Almost,
700,000 people are killed globally by RTA, which are estimated
to be the tenth leading cause of death (World Health Report,
1999). 25% of the health expenditure in the 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% 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
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 lead to a rise in non-communicable
diseases (NCD), also in the developing countries. NCD now cause
nearly 40% 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 WHO BJD, all over the World.
Meeting Program & Deliberations:
Over 70 expert participants, belonging to different fields (Rheumatology,
orthopedics, epidemiology, social sciences, statistics, economics,
health planning, etc), from all over the World were invited.
Prof Anthony Woolf, a rheumatologist from UK, was elected chairman
of the meeting.
The participants were divided into 5 working groups, one each
for RA, OA, trauma, osteoporosis and spinal disorders.
The 2 day program consisted of key lectures and workshop-brain
storming sessions to
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 other diseases, and then be used to allot
health expenditure priorities.
||review the existing epidemiological
data on RMSD
||achieve consensus on disease
definitions, staging and natural history
||identify health and socioeconomic
indicators of RMSD
|| identify gaps in the knowledge
and understanding of RMSD
||raise awareness of the BJD.
The WHO also presented the new classification nomenclature of
diseases, and 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 5 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 though 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 this scientific meeting
through a WHO Technical Report.
The Indian Participation
Prof Shanmugasundaram (Madras, Orthopedic Surgeon), Dr Arvind
Chopra (Pune, Rheumatologist), Dr A Mithal (Delhi, Endocrinologist)
and Prof D Mohan (Delhi, Trauma expert) participated from India.
The epidemiological data on RMSD generated by the WHO COPCORD
(community oriented program for control of rheumatic diseases)
project in village Bhigwan (Pune District), India, under Dr. Arvind
Chopra was accepted and listed in the BJD global data inventory.
It was recognised during the WHO meeting under reference that
the Bhigwan COPCORD had amply shown:-
Prof Shanmugasundaram, presented his statistics on spinal disorders
based on hospital experience in Madras, 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.
||besides the 5 major RMSD entities
under focus, soft tissue rheumatism problems(STR) are
dominantly reported by almost 55% of the RMSD rural patients,
a fact that was endorsed by the participants for evaluation
and inclusion in the BJD agenda
||Further, the COPCORD Bhigwan
model for the study of the epidemiology of RA in a prospective
manner, presented by Dr Chopra, was adopted by the WHO
BJD, in place of the proposed model, for future application.
Dr N Khaltaev, Co-ordinator, Non-Communicable Diseases,
WHO, and Secretary to the WHO-BJD meeting, who had earlier
visited village Bhigwan (Pune District) to evaluate the COPCORD project
endorsed a WHO sponsorship to publish and distribute basic
health education material in the village.
Dr Mithal 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 incharge
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 aetiology and prevention of limb trauma. Besides RTA, he
also emphasized the need to curb agriculture-related trauma
in the developing countries.
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
wide statistics, the WHO BJD hopes to accomplish the following
goals in the current decade :-
||raise awareness of the growing
burden of RMSD 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.
||promote prevention of RMSD
and empower patients through education campaigns:
The BJD national action networks (NAN), in close liaison
with the national Govt. 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.
||advance research in prevention, diagnosis
and treatment of RMSD, including rheumatic disorders:
It is expected to triple the existing research funding
during the decade
||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 6 months, to the undergraduates.
The diagnostic and treatment skills of the GP need to
be improved. Similar proposals will be made for other
medical groups engaged in care of RMSD.
Finally, it is hoped that at the end of the current decade there
will be 25% reduction in 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 TK Shanmugasundaram (Chairman),
Prof D Mohan (Co-ordinator), Dr Arvind Chopra (Secretary), Dr
A Mithal, Dr S Goyal to initiate dialogue with Government Health
authorities and other concerned national associations and agencies
to promote the activities of the WHO-BJD in India.