Epidemiology of Arthritis in India – A Personal Perspective

Arvind Chopra MD, DNB, FRCP (London), Master American College of Rheumatology
Director and Chief Rheumatologist, Centre for Rheumatic Diseases, Pune

What made you interested in epidemiological research?

During the days of my post-graduate medicine training (1980-90), I used to feel disappointed whenever I heard somebody declaring nonchalantly ‘There is no data (on this subject) from India’ and continued with ‘Data from the West’. Billions of people and millions of patients and yet we don’t have Indian data. There was a general diktat that epidemiology belonged to the Preventive and Social Medicine departments and clinicians don’t make good epidemiologists.
I was fortunate to have met some outstanding rheumatologists and epidemiologists earlier on in my rheumatology career who were the founders and leaders of an endearing WHO ILAR COPCORD (community-oriented program for control of rheumatic disorders) launched in the 1980s to measure the burden of musculoskeletal pain and arthritis and disability. I grabbed the offer to begin COPCORD in India which I did so in a village named Bhigwan near Pune in 1996. The Bhigwan model of epidemiology and community service gathered a lot of attention and recognition and was replicated several times in India and all over the World. The COPCORD Bhigwan is now in its 28th operational year. Besides collecting data, it offers free of cost rheumatology services. It also became a part of the rheumatology training fellowship run at our center.

Please share your experiences of conceptualizing, formulating, and executing epidemiological research on arthritis in India.

Epidemiology per se is an overlooked discipline in India and not to forget that rheumatology also is neglected in several ways. One epidemiological survey cannot represent India. Conceptualizing and planning COPCORD surveys was challenging but a delightful exercise. Getting rheumatologists to volunteer for these surveys took some time (and persuasion) but finally, there were at least seventeen rheumatologists and many younger fellows and trainees who joined this initiative. Some surveys were also carried out under the auspices of the Ministry of Health-ICMR. We have data on prevalence, incidence, and risk factors. COPCORD data has been the basis of several health education initiatives.
Over the years, we have now acquired sufficient population data on several aspects of arthritis through COPCORD surveys. In 2008, it was declared an ideal model for developing countries by the global Bone and Joint Decade Program 2000-2010. The WHO ILAR COPCORD program can be accessed on the internet (www.copcord.org).

Your opinion on how epigenetic mechanisms in the immunopathogenesis of AIRDs in Indian circumstances are impacted by environmental factors, especially infections. 

The effects of community-based infections, Chikungunya virus (CHIKV)and recently COVID-19 infections, on rheumatological disorders are quite intriguing. There are ongoing outbreaks of CHIKV arthritis in various parts of the country. We still do not have a grip on post-CHIKV arthritis. The impact of the COVID-19 pandemic on rheumatological diseases is yet to be fully understood. We are continuously learning the impact of epigenetic mechanisms on etiopathogenetic mechanisms in rheumatic disorders. The gene-environment interactions are a subject of ongoing research. We now know from a decade of genome research (G-WAS) about several precise risks in the causation and progression of disease, and even therapeutic response in common disorders but the overall contribution remains much less than what is desired. Several answers lie in defining the RNA-mediated epigenetic post-translational mechanisms mostly mediated by methylation or acetylation. The role of microRNAs is increasingly recognized in autoimmune rheumatic disorders and osteoporosis. Several epigenetic therapeutic targets are being researched. In the Bhigwan COPCORD studies, we identified different sets of HLA DR B1* susceptibility alleles for rheumatoid arthritis, however, we have not looked at epigenetic research in our population surveys.

Primary care rheumatology services are non-existent in India, resulting in delayed diagnosis and unsatisfactory care delivery to a sizable proportion of arthritis patients. What can be done to decrease this deficiency in our healthcare system?

I look at the bigger picture. We don’t have primary care cardiologists or any of the several specialties that provide pivotal community health care. It is unlikely that rheumatologists will make an exception. We do need rheumatologists to step out in the smaller towns and cities and even bigger taluka places. Community rheumatology has a distinct set of clinical problems and challenges. COPCORD population surveys all over the country have shown that ill-defined and poorly diagnosed musculoskeletal pains (non-traumatic) degenerative arthritis and spine disorders, and not inflammatory arthritis, are the predominant community burden. We need rheumatologists oriented toward these community needs. In the health care system, all health personnel involved in primary care must be adequately trained to recognize rheumatology disorders early enough for proper referral and management. Similarly, we need to educate the community as well.

Your recommendations for rheumatologists and rheumatology fellows who wish to conduct epidemiological studies in India.

I believe that clinicians can be good epidemiologists and epidemiology experience helps clinical practice also. Epidemiology is much simpler than breaking the genetic code and personally more rewarding. To begin, set up a simple research question, identify the denominator (the community), plan well with a doable protocol, follow timelines, pursue deliverables (that you seek), and gather data efficiently. Once you learn what is meaningful, make sure you present it to a wider audience and publish it too.
Good luck- you will need it.