Mario H. Cardiel

Ruben Burgos Vargas

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EDITORIAL
Rheumatoid arthritis in Latin America. Important challenges
to be solved
Ruben Burgos Vargas1 & Mario H. Cardiel2
Received: 26 July 2015 /Accepted: 2 August 2015 /Published online: 9 August 2015
# The Author(s) 2015. This article is published with open access at Springerlink.com
Since the introduction of biologic agents for the treatment of
patients with rheumatoid arthritis (RA), there have been enor-
mous advances in clinical and therapeutic aspects of the dis-
ease. Likewise, there is now much more information on the
role of genetics and environmental factors in the pathogenesis
of the disease. Throughout the years, the main therapeutic
target is the control of disease activity as soon as possible to
prevent structural damage and functional consequences.
RA is a diagnosis that is not easily recognized at early
phases. Lay people associate rheumatic diseases with old
age, minor physical trauma, weather, dietetic conditions, or
emotional issues. It is not a surprise that many patients seek
medical care at late stages, when irreversible damage has al-
ready occurred.
Sustained remission or low-disease activity levels with-
out joint space loss and erosions have become the main
objective of current therapies. Health-related quality of life
(HRQoL) improves and long-term socioeconomic conse-
quences decreases.
Primary care physicians are usually the first medical con-
tact. These clinicians should have special tools for early
diagnosis, proper referral, and initial treatment in all patients
with a clinical suspicion of RA. This is not the case in many
countries where rheumatology training in undergraduate pro-
grams is not fully implemented.
Rheumatology societies in Latin America should have a
more active participation in medical education in under-
graduate programs including practical activities. This will
be probably an important investment to diminish the burden of
illness that RA causes to the society [1].
Another challenge that many countries face is having an
insufficient number of rheumatologists. As expected, rheuma-
tologists usually have busy clinical activities. The time devot-
ed to individual care is not enough to establish an adequate
relationship, consultations are not usually as frequent as they
should be, medical resources are not always what medical
guidelines suggest, and patients tend to receive a subopti-
mal medical care. This should motivate rheumatology or-
ganizations to identify intelligent and practical alternatives
to improve medical care despite a shortage of rheumatol-
ogists. Education, innovation, and coordination seem to be
the key activities to be done.
Once a clinical diagnosis has been made, clinicians should
be aware that low educational level in RA patients in Latin
America has been associated with higher disease activity,
more radiologic progression, and poor clinical outcomes. This
is probably related to late diagnosis and some practical and
therapeutic variables [2]. All patients and particularly those
with a low educational level require special health education
programs.
Patient education in rheumatoid arthritis is an urgent need
to discuss what is expected of medical and nonmedical treat-
ments and the importance of patient and family participation
and improve patient-doctor communication skills.
Adherence to medical treatment in chronic diseases re-
mains a very important problem in the world. It is recognized
that poor adherence is associated with worse clinical and ra-
diological outcomes [3].
Costs of medication impose an important economic burden
to patients and their families [4]. Comorbidity in rheumatoid
* Mario H. Cardiel
mhcardiel@hotmail.com
1 Department of Rheumatology, Hospital General de México,
Faculty of Medicine, Universidad Nacional Autónoma de México,
México City, Mexico
2 Centro de Investigación Clínica de Morelia, Virrey de Mendoza
1998. 522. Col. Félix Ireta, Morelia, Mich, Mexico 58070
Clin Rheumatol (2015) 34 (Suppl 1):S1–S3
DOI 10.1007/s10067-015-3048-1
arthritis increases complexity to medical care. In many cases,
rheumatologists are the team coordinators and should be pre-
pared to offer proper management. There is a need to imple-
ment therapeutic strategies that include a more comprehensive
medical care.
It is now 20 years since the first report on the efficacy of a
monoclonal antibody—infliximab—to tumor necrosis factor
alpha (TNF-α) in patients with RA [5]. Compared to placebo,
the effect of the TNF-α blocker was impressive and authors
concluded that such Bresults provide the first good evidence
that specific cytokine blockade can be effective in human
inflammatory disease and define a new direction for the treat-
ment of rheumatoid arthritis.^
That new direction has benefited thousands of patients all
over the world through the implementation of programs for
early recognition of the disease, redefinition of classification
criteria, improved designs of protocols for the study of the
efficacy and safety of biologics and DMARDs, continuous
increase in the number of agents—many directed to new tar-
gets, the instauration of biologic registries, and post-marketing
surveillance.
It is clear that the implementation and maintenance of such
programs require a considerable budget to cover the cost of
the infrastructure needed to accomplish their goals and the
cost of biologics itself. While most European countries relay
in the percentage of their gross domestic product (GDP) de-
voted to health care to comply with those programs, in other
parts of the world, including Latin America, the cost is
partially covered by a variety of entities, including patients’
and households’ own pocket money. Similar or even worst
situations occur in Africa and Asia resulting in a tremen-
dous gap between developed and underdeveloped countries
regarding the identification of RA and its current treatment.
In this sense, the implementation of programs for early
detection and treatment of RA might be less successful
than in developed countries.
Health care in Latin America is typically fragmentary [6].
In some countries, the state provides health care for the whole
population while in others, individuals pay for their medical
expenses. Reimbursement is very limited and is only available
in some countries. Access programs are available in some
countries where the government usually provides the drug.
In this sense, it is not convenient to make any generalization
of the characteristics of health care in Latin America. Barriers
to implement early recognition of RA and treat them early on
the course of the disease related to the healthcare system in
Latin America include several aspects.
The nation’s GDP budget for health care had a sustainable
increase in several Latin American nations. The mean per-
centage of Argentina, Brazil, Chile, Colombia, Mexico,
and Venezuela increased from 7.9 % in 2009 to an esti-
mated 8.1 % in 2017 [7]. The way each country handles
their annual budget is unknown. In general, most of the
budget goes to pediatric diseases, chronic degenerative
conditions, and metabolic diseases reducing the individual
life expectancy.
The situation here is that the percentage of such budget
devoted to rheumatic diseases is probably very small and in-
sufficient to run any health program at the national level. As a
group, rheumatic diseases are not considered of clinical, so-
cioeconomic, and cost relevance for the state. It is therefore
neither as a group nor individually deserve the attention of
health authorities whom apparently consider that rheumatic
diseases are not a health problem.
The role of the state—represented by healthcare system—
in implementing early arthritis clinics is limited. The cost of
such a program includes some infrastructure, human re-
sources, and effective treatment. The prevalence of RA in
Latin America ranges between 0.4 and 1.6 % [8–10].
At least in the Mexican population, there are variations in
the prevalence of RA related to geographic regions that might
be explained by the low educational and socioeconomic level
represented by people who only speak a native language.
In contrast to what health authorities consider, epidemio-
logical data supports the idea that RA is not a rare disease and
that late diagnosis is associated to bad prognosis.
It is possible that at the institutional level, the facilities to
carry on an additional clinic, specifically an early arthritis
clinic and human resources, would be impossible. Most
clinics, physicians, and nurses are overwhelmed by daily
consultations. Despite the fact that needs would depend on
the success of the program, some challenging situations
must be solved.
The infrastructure requires the space needed to take
care of patients with early disease. Space limitations may
account for inadequate care and communication between
the patient and the physician. There should be access to
laboratory examinations, imaging studies, infusion rooms,
and refrigeration systems.
Human resources include physicians—from general prac-
titioners to rheumatologists, nurses, joint counters, and some
administrative people. They should be paid for their services
and should be continuously trained.
The design of protocols according to the procedures to be
performed should be clear and well justified.
Similarly, the clinic should have the capacity to provide the
patient with the medication he needs. Despite its popularity,
recommendations for treating patients with RA according to
international standards, including the American College
of Rheumatology/European League Against Rheumatism
recommendations [11] and the Treat to Target initiative
[12], its implementation in clinical practice might be difficult
in the presence of some of the barriersmentioned before. Early
recognition and proper assessment of the clinical status of
the patient does not mean that medications would be
available for everyone.
S2 Clin Rheumatol (2015) 34 (Suppl 1):S1–S3
In summary, recognition and therapeutic advances in RA
have evolved very rapidly in the last 20 years. Unfortunately,
alongside with these advances, a gap between fragmented and
socialized healthcare services is becoming wide. And that
seems to be the case for some Latin American countries.
We have identified the most important challenges that pa-
tients, doctors, and medical systems face to improve the med-
ical care of one of the most important rheumatic diseases. RA
will remain a health problem despite medical advances if we
do not effectively act on these challenges to modify the out-
come in most RA patients in Latin America.
Open Access This article is distributed under the terms of the Creative
Commons Attr ibution 4.0 International License (http: / /
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a link
to the Creative Commons license, and indicate if changes were made.
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Rheumatoid arthritis in Latin America. Important challenges to be solved

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Rheumatoid arthritis in Latin America. Important challenges to be solved

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