Addressing musculoskeletal health inequity in Africa

Authors


Following the recent World Health Organization (WHO) report (1), the issue of health inequity and health care disparities is gaining greater global recognition together with an increasing international will and commitment to address these inequalities. Nowhere are these inequalities starker than on the African continent, where the disparity between the developed and developing world is at its greatest. Currently, 21 out of the 30 poorest nations of the world, and 33 out of the 41 most heavily indebted nations worldwide, are in Africa (2). In addition, there are also huge health disparities within the countries of Africa.

Musculoskeletal health has been almost completely neglected for most of sub-Saharan Africa principally due to the fierce competition for scarce resources. As a result, rheumatology remains very much a Cinderella specialty in Africa. We consider this unfortunate, not only because there is a huge burden of musculoskeletal disease in Africa, but chiefly because we believe that this gap can be narrowed. The health care challenges faced by Africa are many and include political instabilities, wars, low income, and unemployment. These in turn contribute to poor nutrition, housing, sanitation, and education. Communicable diseases such as malaria, tuberculosis, and more recently human immunodeficiency virus (HIV) are endemic and put a huge strain on health resources in Africa. These matters are further compounded by the woefully inadequate availability of health care personnel. In the different regions of the world, the density of the health workforce per 1,000 population is 24.8 for the Americas, 18.9 for Europe, 5.8 for Western Pacific, 4.3 for South East Asia, 4.0 for Eastern Mediterranean, yet only 2.3 for Africa (3). The WHO has recommended that there should be at least one rheumatologist per 100,000 people. However, in sub-Saharan Africa (excluding South Africa) there are less than 20 rheumatologists serving ∼800 million people; that is one rheumatologist per 40 million people (2).

These various issues are hugely detrimental in tackling what we believe to be a significant burden of musculoskeletal disorders on the African continent. According to a report, musculoskeletal disorders contributed 3.4% and 1.7% of the total disease burden in the developed and developing world, respectively, with osteoarthritis (OA) being the single largest contributor (4). However, the burden on musculoskeletal disorders in terms of disability-adjusted life years (DALYs) on the developing world (21,076,000 DALYs) was estimated to be almost 2.5 times that of the developed world (8,723,000 DALYs). The lack of data from the developing world suggests that this figure may even be an underestimate (3, 4). Using the WHO/International League of Associations for Rheumatology Community Oriented Programme for Control of Rheumatic Diseases, a study from Egypt suggested that 16.2% of adults had musculoskeletal pain (3). There is also a remarkable range and variety of rheumatic disorders in Africa, which adds to the overall burden of disability, as well as mortality. Not only are there specific tropical arthropathies to contend with in Africa, but there are also varying and often atypical expressions of the more universal musculoskeletal diseases such as rheumatoid arthritis (RA). Additionally, there is evidence of an increasing prevalence of conditions such as RA, lupus, and gout in Africa (2), concomitant with evidence of an increasing severity of these conditions. For example, in West Africa where RA and lupus were previously considered uncommon and mild, there is evidence to indicate an increasing prevalence and severity of these diseases (5). Lupus is a case in point. It is well recognized that there is a higher risk of systemic lupus erythematosus in persons of African origin in North America (6). Recent reports suggest that the severity of lupus in Africa is now of a similar level, with associated morbidity and mortality (2, 5, 7). This raises the need for at least the same urgency as that required for tackling lupus and addressing health inequalities as among persons of African origin in North America (8).

A recent community-based study in West Africa highlights the high burden of disease from knee OA (9). A total of 1,044 adults over the age of 40 years were randomly selected and, using the American College of Rheumatology (ACR) clinical criteria for knee OA (10), a point prevalence of symptomatic knee OA of 19.6% was found. This finding suggests that 1 out of every 5 West African adults over the age of 40 years has symptomatic knee OA, with a female preponderance in a ratio of 1.2:1. Using the Lequesne Algofunctional Index categories of reported knee OA severity, the majority (98.5%) of people with knee OA were found to range from those with moderate disease to those with extremely severe disease, with the extremely severe category having the largest percentage (35.1%) of people. Similarly, there has been previous evidence indicating that soft tissue musculoskeletal disorders, such as rotator cuff lesions, are just as common in Africa as in the developed countries (4, 11).

Yet in the face of this significantly high burden of musculoskeletal disease in Africa, there are huge constraints preventing patients who are experiencing these conditions from receiving appropriate treatment. These many constraints include problems with human resources, finance, infrastructure, and education. One major challenge is the difficulty in obtaining accurate information about the burden of various rheumatic diseases in Africa. This difficulty reflects the more general constraints relating to availability of census statistics, as well as morbidity and mortality data. There are also a number of disease-specific limitations, including the uncertain sensitivity and specificity of current criteria for the diagnosis of rheumatic diseases. As a result, rheumatic diseases with mild or atypical presentations are often overlooked or even misdiagnosed. There is also an urgent need to translate and validate disease severity and functional questionnaires and assessments, as well as other quality of life measures, in order to better understand and eventually improve the impact of these conditions on disability, function, and quality of life.

Access to musculoskeletal health services in most parts of sub-Saharan Africa is woefully inadequate. A survey (conducted by one of the authors) among clinicians who were involved in musculoskeletal health in Africa and attending a conference on rheumatology in Africa (2) found that in sub-Saharan Africa (excluding South Africa) less than 10% of the population had access to joint replacement surgery. Access to disease-modifying drugs for RA was scarce with less than 1% of the population having access to biologic agents. Worse still, at least 30% of the population had no access to even the standard disease-modifying drugs. The length of time from the onset of symptoms to diagnosis for the majority of African patients with RA has been found to be well over 1 year (12). Unfortunately, by virtually all available indicators, access to musculoskeletal preventative care, medical care, and education in Africa is extremely poor.

In our view, however, the fact that the challenges in tackling musculoskeletal health in Africa are numerous and formidable does not mean that effective action cannot be taken. Strategies to reduce inequities in musculoskeletal health must be multidisciplinary and multilevel. Clearly, interventions are required at the societal and political levels. Nevertheless, other strategies can and should be adopted. These include conducting epidemiologic studies and health services research so as to continue to highlight and, more important, accurately measure musculoskeletal health disparities in Africa. The findings from such research can then inform the formulation of comprehensive health policies in Africa. Collaboration and partnership with health administrators and government agencies are required to promote musculoskeletal health awareness and education across African communities. There is a need to develop affordable health care delivery models to provide access to suitable musculoskeletal care for the population as a whole, and not just for the affluent few in sub-Saharan African countries. We believe that with the paucity of rheumatology specialists, community health workers need to be galvanized, educated, and equipped with multiple skills in order to identify patients with musculoskeletal disorders from underserved communities who need further investigations and more intensive disease management. Importantly, treatment strategies for musculoskeletal health in Africa must be context specific, recognizing the high prevalence rate of infection as a background. There is the daily challenge of treating rheumatic diseases with immunosuppressive and immunomodulatory drugs in an environment with a high background prevalence of infections such as tuberculosis, malaria, HIV, and other parasitic and viral infections, with increased resultant mortality (13, 14). The potential problem of using biologic agents in areas endemic for tuberculosis and HIV is one example of this (15, 16).

Perhaps the most powerful strategy of all is that of self-efficacy and education at all levels. Educating the public and empowering patients improves health across a number of rheumatic conditions. Health professional education is clearly important and doctors, nurses, and rehabilitation professionals need to be trained in the prevention, diagnosis, and management of musculoskeletal disorders. However, as well as professional education, there must be public health campaigns, multimedia information, and other educational programs to enable and empower Africans with musculoskeletal symptoms to seek both self-help and musculoskeletal care when appropriate.

We are firmly of the view that all is not lost. Methotrexate is relatively low-cost and could fairly easily be made available for patients with RA in Africa. Rituximab may be better suited as a biologic agent for the African context than the relatively more expensive anti–tumor necrosis factor drugs. However, there are also simple and low-cost effective interventions such as the benefit of aerobic and strengthening exercises for both RA and OA. Government health departments in all African countries should be encouraged to undertake the promotion of musculoskeletal health. This can be done within their existing resources provided they are made to understand the disability and even mortality associated with musculoskeletal conditions. The few rheumatologists in Africa can help with giving health talks so as to raise awareness of these conditions among the population. These rheumatologists can also support each other for their educational needs and in the training of other physicians and health professionals including community health workers, as well as develop treatment algorithms and management strategies based on low-cost interventions.

We also believe that rheumatologists in the industrialized countries can contribute effectively to helping reduce musculoskeletal health inequalities in Africa by embarking on short-term teaching missions to Africa. Such teaching missions can be directed at nonspecialist physicians in Africa and even other allied health professionals to enable them to identify and diagnose patients with rheumatic conditions as well as initiate at least basic-level management of these conditions. Travel scholarships for physicians in Africa for short-term courses and exposure to rheumatology in industrialized countries would also be beneficial in helping to increase the number of African physicians who specialize in rheumatology. The provision of rheumatology journals and books to African physicians at a discounted rate would help ensure access to continuing medical education relating to the rheumatic diseases. In time, distance learning via the Internet may prove invaluable.

Such a partnership between the industrialized countries and Africa would be of mutual benefit. Health care professionals in the industrialized countries would have an opportunity to learn about new models of providing care (e.g., through the use of nonphysicians and even nonphysician health care providers) (17). In addition, Africa provides a wonderful opportunity to learn about the complex interactions between the use of biologic agents and disease-modifying antirheumatic drugs and infections such as HIV and tuberculosis. Consequently, the benefit and learning will go both ways.

It is heartwarming that international initiatives such as the Bone and Joint Decade and international bodies such as the ACR are working in partnership to help meet these challenges and to reduce the musculoskeletal health inequalities and unmet needs in Africa. However, to be successful and sustainable, all of this work, including the international endeavors to validate and standardize outcome measures and quality of life instruments, must involve the people of Africa not only as active participants in their own care, but as stakeholders for the future of health on their continent.

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