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BJD Launch

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 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 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 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.

Scientific 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
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 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.

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 & Data:

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:-
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.
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.

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.

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