Axial Spondyloarthritis in India: A Tip of the Iceberg

Ved Chaturvedi MBBS, MD, DM
Professor, Department of Clinical Immunology & Rheumatology,
Gangaram Institute for Postgraduate Medical Education & Research (GRIPMER),
New Delhi

Axial Spondyloarthritis (axSpA) is a chronic inflammatory condition affecting the spine, and it poses a significant challenge in India, particularly given the country’s distinction as having the world’s largest young population. This article explores the problem of missed diagnoses, challenges arising from resource constraints, beliefs, and awareness issues, as well as logistical challenges in addressing axSpA in India.

Missed Diagnoses in India

AxSpA often goes undiagnosed or misdiagnosed in India, resulting in delayed or inadequate treatment for affected individuals. One of the primary reasons for this is the lack of awareness among healthcare professionals about the condition. Many patients suffering from axSpA experience symptoms such as chronic back pain, stiffness, and fatigue, which are often attributed to other musculoskeletal issues, leading to delayed or missed diagnoses. Furthermore, there is a general lack of emphasis on early screening and diagnostic techniques, contributing to the underreporting of axSpA cases in India. The absence of routine screenings and the failure to consider axSpA in the differential diagnosis for chronic back pain hinder the timely identification of this condition.
Recently a lot of work has been done on female spondyloarthritis. Now we have learned that the diagnosis of female SPA is more difficult due to a lack of objective signs like bilateral Sacroiliitis on imaging. The only way to increase the sensitivity toward the diagnosis of axSpA is by teaching inflammatory back pain at the undergraduate level as most undergraduate medical students only know prolapsed intervertebral disc and lumber strain as a cause of backache.

Challenges Related to Resource Constraints

Resource constraints, both in terms of healthcare infrastructure and financial limitations, pose significant challenges in the effective management of axSpA in India. The country’s healthcare system, despite its improvements in recent years, faces limitations in terms of accessibility, especially in rural areas. The limited availability of specialized healthcare professionals, diagnostic tools, and treatment options exacerbates the difficulty in addressing axSpA comprehensively.
Financial constraints also play a role, as many individuals in India may not have the means to undergo comprehensive diagnostic tests or afford long-term treatment plans. The high cost of certain medications, especially biologics, which are often effective in managing axSpA, poses a barrier to access for a significant portion of the population.

Challenges Related to Beliefs or Lack of Awareness

A prevailing challenge in addressing axSpA in India is the lack of awareness and misconceptions surrounding rheumatic diseases. Cultural beliefs and traditional perceptions of health may contribute to delayed medical consultations or reluctance to seek specialized care for chronic conditions like axSpA.
Educational initiatives aimed at both the public and healthcare professionals can help dispel myths and increase awareness about axSpA. There is a need for targeted awareness campaigns, not only focusing on the symptoms and consequences of the condition but also addressing the importance of early detection and management.

Logistical and other Challenges

Logistics, including long distances to healthcare facilities, transportation issues, and overcrowded clinics, contribute to the delayed diagnosis and treatment of axSpA. The sheer size and diversity of India’s population present challenges in implementing standardized screening programs and disseminating information effectively. Moreover, the stigma associated with chronic illnesses may deter individuals from seeking medical attention promptly. Addressing these logistical challenges requires a multi-faceted approach, involving improvements in healthcare infrastructure, community outreach programs, and the integration of technology for remote consultations and follow-ups.


Axial Spondyloarthritis in India is indeed a tip of the iceberg, with numerous challenges contributing to the underdiagnosis and inadequate management of this condition. To address this issue comprehensively, a concerted effort is required from healthcare professionals, policymakers, and the community at large. Increased awareness, improved access to healthcare resources, and the implementation of targeted strategies are essential to unveil the full extent of axSpA in India and ensure timely and effective management for those affected. A referral of inflammatory backache to a rheumatologist would resolve many issues associated with Spondyloarthritis, also insurance companies should bear the cost of biologics.

Suggested Readings:

  1. Malaviya A, Kumar A. Axial spondyloarthritis in India. In: Inman R, Sieper J,editors. Oxford Textbook of Axial Spondyloarthritis.Oxford Textbooks in Rheumatology. Oxford:Oxford Academic.2016;285-96.
  2. Malaviya A. Spondyloarthritis in India. Indian J Rheumatol.2020;15:S2-5.