Challenges of Rheumatology practice in the Himalayan area

Paramjeet Singh MD
Associate Professor, Department of Internal Medicine and In-charge Rheumatology Clinic, Dr. Sushila Tiwari Government Hospital & associated Government Medical College, Haldwani, Nainital, Uttarakhand.

What is the epidemiology of Rheumatological diseases in the Himalayan areas?

There are no formal studies on the prevalence of rheumatic diseases in hilly areas of Uttarakhand. Our hospital-based data shows Osteoarthritis of the knees to be the most prevalent condition. It may partly be because in hilly villages it’s a common practice that people carry fodder for their cattle from the forest on narrow hilly footways and overall, the use of steps is much more as compared to those living in non-hilly areas. A small hospital-based study (unpublished data) of 156 patients found lower BMI and early age of presentation compared to subjects residing in non-hilly areas.  The prevalence of common inflammatory rheumatic conditions seems to be similar to the other parts of the country.

How adequate is access to healthcare facilities?

The health care facilities and healthcare providers are concentrated in the cities situated at the foothills and in the plains. Due to a lack of basic infrastructure in remote hilly areas, health care providers are sparsely available. Motorable roads are not available in all the villages which add to the pain faced by patients with musculoskeletal conditions. As far as the rheumatic drugs are concerned conventional DMARDs are available in the cities but the use of biologics is restricted because of non-availability and financial constraints. At times, ascertaining the diagnosis may be difficult due to a lack of proper diagnostic facilities.

Any challenging situation you recall?

I remember that during a free health camp in a remote hilly area, a female patient was carriedon a ‘chaarpai’ (cot) by the villagers through difficult hilly footways for several kilometers as she was unable to move and there was lack of motorable road to the village. That young patient with rheumatoid arthritis had active disease with swollen knees. The knees were aspirated and injected and she was given other medications with advice on regular follow-up. It was heartening to find her doing well on subsequent visits.

What are some of the practical learnings?

Intense cold in winter poses a difficult situation for patients who have Raynaud’s phenomenon. Patients of scleroderma thus usually have a painful time. Families relocating and settling in plain areas in the foothills on the health grounds have been observed. We prefer to schedule pre-winter visits for such cases.

The roads may get blocked during the rainy season by landslides and in winter due to snowfall in high-altitude areas. Often patients are lost to follow-up and resort to the locally available powdered cocktail medications (likely to contain corticosteroids and NSAIDs) to get symptomatic relief. Patients with aches and pains may have to book a taxi to visit the tertiary care center which adds to their financial burden. We often have to write prescriptions for a longer duration.

We organize regular health camps in remote areas and conduct refresher courses for the health care providers posted in those areas. We wish to strengthen rheumatology telemedicine services and improve laboratory and medicine services

(Note: The author was a recipient of the prestigious IRA Kolkon Oration 2021 for community services. The views expressed by the author are based on his observations and experience.)