Arthritis in Uganda

Arthritis is the name for a group of joint disorders. the name comes from the Greek arthro-, joint and -itis, inflammation. Arthritis is characterized by joint swellings. Wikipedia says the are over 100 different kinds of arthritis. The most common form of arthritis is osteoarthritis which is a degenerative joint disease which is usually the result of trauma to a joint, infection of a joint, or wear and tear. Generally arthritis is one of these diseases:

Osteoarthritis: Is normally the result of trauma and is common in old age.
Rheumatoid arthritis: Is a long-lasting autoimmune disorder that primarily affects joints.
Gout and pseudo-gout: Gout is recurrent attacks of inflammatory arthritis, pain comes on in less than twelve hours; the joint at the base of the big toe is affected in about half of cases. Pseudo-gout is the accumulation of crystals of calcium pyrophosphate dihydrate in the connective tissues of the joint.
Septic arthritis: Is cause by an infection in the joint.
Ankylosing spondylitis: Is a chronic inflammatory autoimmune disease that mainly affects joints in the spine.
Juvenile idiopathic arthritis: Is the most common form of arthritis in children and adolescents. Idiopathic refers to a condition with no defined cause, and arthritis is the inflammation of the synovium, the covering of a joint.
Still's disease: A rare system inflammatory disease.

Assessing the prevalence of arthritis in Uganda is difficult. There is very little data. This 1970 paper Rheumatoid arthritis in Ugandan Africans opens stating:

Until recently rheumatoid arthritis has been considered to be rare in the tropics. Gelfand (1957), in his extensive review of disease in Africans, stated that he had rarely seen a true case in a native of Central Africa. Goodall (1956) described two atypical cases amongst ninety patients with polyarthritis in Malawi. Since then eight cases have been reported from Kenya (Harries, 1962; Hall, 1966), three from Liberia (Hijmans, Valkenburg, Muller, and Gratama, 1964), 39 from Uganda (Kanyerezi, 1969), and 71 from Western Nigeria (Greenwood, 1969). Lawrence, Bremner, Ball, and Burch (1966) conducted a survey of rheumatoid arthritis in Jamaica (a sub-tropical zone) and concluded that the disease 'occurs at least as frequently as in a Caucasian population in the United Kingdom'. 

The paper concludes with the following statement:

It is apparent that rheumatoid arthritis is commoner in Ugandan Africans than was previously recognized. It may be that Western Nigeria and Buganda are different from the rest of Africa in having a higher incidence of the disease though Dr. Ojiambo in Nairobi states that more cases have been seen there than have been reported in the literature (personal communication).

The paper ends lamenting the lack of good studies and requesting more studies.

Arthritis, Wikipedia says, is the fastest growing disease in Africa and it has been largely ignored. The 2015 paper Prevalence of Arthritis in Africa: A Systematic Review and Meta-Analysis  assessed the prevalence of arthritis across Africa. The results were as follows:

• Rheumatoid arthritis: 0.1% in Algeria (urban setting); 0.6% in Democratic Republic of Congo (urban setting); 2.5% and 0.07% in urban and rural settings in South Africa respectively; 0.3% in Egypt (rural setting), 0.4% in Lesotho (rural setting)
• Osteoarthritis: 55.1% in South Africa (urban setting); ranged from 29.5 to 82.7% in South Africans aged 65 years and older

• Knee osteoarthritis has the highest prevalence from all types sites of osteoarthritis, with 33.1% in rural South Africa

• Ankylosing spondylitis: 0.1% in South Africa (rural setting)
• Psoriatic arthritis: An arthritic condition that comes as a result of the skin condition psoriasis, 4.4% in South Africa (urban setting)
• Gout: 0.7% in South Africa (urban setting)
• Juvenile idiopathic arthritis: 0.3% in Egypt (urban setting)

The 2003 World Health Organization paper Burden of major musculoskeletal conditions states:

Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged >60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020.

The hands of Rose....a beautiful lady around 50 years old who has a quickly progressing, degenerative form of arthritis....she has gone from fully active, to nearly bed ridden in 3 years.

Arthritis is a disease that does not seem to be considered very important in Uganda. From the discussion above, it would seem that it is possible that there are high numbers of people with arthritis. This information is largely unknown. This 2010 article, Arthritis- Uganda has one specialist, makes interesting reading. This doctor is suggesting that for a population of 33.99 million around 300,000 or  0.9% (9 people in every thousand) of the population suffer from arthritis:

UGANDA has only one specialist for rheumatic arthritis infections, Dr. Mark Kaddumukasa, 35. He also teaches and trains at Makerere University Faculty of Medicine.
"We have only one clinic at Mulago. Due to the limited space that is also shared by the other departments, the clinic opens only on Fridays," he says.
Kaddumukasa has been in charge of the clinic since 2006. "Due to the increasing number of arthritis patients, the Uganda Rheumatic Arthritis Association was started to create awareness about the disease," he says.
The association also disseminates information and research about the disease as well as other related infections.
Mulago together with Makerere University have embarked on training postgraduate students in basic knowledge on rheumatology so that they can support the clinic.
What is rheumatic arthritis? It is a unique illness that presents with fever and pain in the muscles and joints, usually resulting in disfiguring or deformities of the limbs.
Kaddumukasa says when it is severe, rheumatic arthritis can deform every joint in the body, muscles, skin and other organs like the heart, liver and kidney.
Kaddumukasa says out of Uganda's population of about 30 million, 300,000 are affected by the disease. He says the condition affects women more than men and normally begins at about 13 years, although it can also affect children.
Kaddumukasa says the disease is hard to diagnose. "It is often confused with sickle cell, especially when it starts during childhood," he explains.
Causes: Rheumatology is caused by diseases which lead to arthritis. Infections include rheumatoid arthritis, osteoarthritis, osteoporosis, HIV, gout and systemic lupus.
He says most of them are immunological diseases which come about when the body fails to recognise itself, leading to the swelling of the joints.
Treatment: Kaddumukasa says there is no cure, but the disease is managed by pain killers and medication to prevent inflammation and strengthen the joints to prevent damage of the bones and cartilage.
"This is important because the longer the disease exists, the greater the joints become damaged," he says.
Patiants are given painkillers and steroids, although these are not enough to manage the disease. Worse still, the drugs are not available at many district hospitals.
"The Government should subsidise the drugs and train more specialists. The cheapest drug costs sh400,000 for a month's dose," Kaddumukasa says.
He says patients are also engaged to participate in physical exercises and sports to reduce pain, and relax the muscles and joints.
Heat or a warm bath can also offer short-term, temporary relief of pain.
"Soak a piece of cloth in warm water and wrap it around the effected joints to relieve pain and stiffness. Do not exceed 20 minutes," he explains.
If not treated, the disease can result in deformed joints or a disfigured body.

What is the experience of arthritis like for the patient? This article from 2014, Patients speak out on what it means to live with arthritis, describes the experience of several patients with arthritis:

“Of all the orthopaedic patients we receive here, 60 to 80 per cent usually have arthritis, a condition which causes pain and inflammation of the body joints,” says Dr Michael Mukasa, an orthopaedic surgeon at Comprehensive Rehabilitation Services in Uganda (CoRSU). The disease mostly affects the hip bone, knee joints, shoulders, spine and other jointed parts of the body. Dr Mukasa says although this disorder affects many people, public knowledge is still low, with many still associating it with witchcraft.
Atai’s story: Maria Aguti Atai, 59 an anaesthetist at CoRSU has lived with arthritis for the last 26 years. “It started in 1988 when I developed a painful left knee. Since I worked in a theatre at Nsambya hospital, I was close to doctors so I told them but they laughed,” Atai recalls.
The next day, the pain had shifted to her right knee. This time, the pain lasted for one week.
Doctors who she worked closely with recommended that she takes anti-inflammatory drugs. This reduced the pain and one month later, she decided to go for another test after doctors suspected a case of arthritis. “I went for a medical test used for diagnosis of rheumatoid arthritis as the pain had spread to all joints. I tested positive for auto immune arthritis,” she says.
Auto immune arthritis is usually associated with genetics. The doctor told me there is no cure, but all I had to do was try to reduce pain by taking anti-inflammatory drugs. Five years after the test, I used to suffer great pain, even while I was on medication,” says Atai.
Treatment: Atai recalls a time in April 2013, when she had to raise Shs16m for her young sister who also suffered from the same condition. Her sister had severe hip arthritis, and the only solution to relieve her pain was through a hip replacement surgery.
Through this surgery, the affected joint is removed and replaced with an artificial one. It took Atai and her family six months to raise the money for the surgery. Three months after the surgery, her sister got healed.
“The pain is no more. She has resumed normal life, and she can ride a bicycle,” says Atai. But even though Atai lives with the disability of arthritis, she prefers to look at the positive side of life. “I have learnt to live with it positively because it seems to be a family problem, yet there is no cure for it. What I do now is to keep myself active so that the disability does not get worse,” she explains.
Regular exercise: Christine Tumusiime, a physiotherapist and head of allied health services at CoRSU says, “Regular exercise is important for an arthritis patient because it helps reduce the chance of joint deformity and keeps the muscles functioning.” Atai uses hand braces, which are assistive devices that help keep her fingers in position at night, and she gets massage for her feet every evening, to keep blood in proper circulation and maintain joint flexibility.
She says she can do almost everything for herself without any assistance, and attributes this to the supportive staff that she works with. She, however, finds difficulty in squatting and kneeling, because this involves bending some of her joints. When this happens, she uses painkillers.
Atai also says she always feels cold, and thinks cold weather stimulates arthritis. But Dr Mukasa says there is no connection between arthritis and cold weather.
Nine-year-old Davis: Another patient, nine-year-old Davis Ainebyoona has lived with arthritis for three years now. His mother, Beneth Turyahebwa, a resident of Isingiro District says her son was normal for the first three years after birth, before he started feeling pain in his right leg.
“Whenever he came back from school, he complained of pain in the shorter leg, especially in the knee and hip joints and could not move the leg. It became stiff,” says Turyahebwa.
She took her son to Mbarara University Hospital, but after two years of severe pain, she was referred to Mulago. However, she could not afford the Shs500,000 that was needed to undertake an X-ray. “We then learnt of CoRSU, where they offered free treatment services for children so we came here in August and my child was operated on August 18,” Turyahebwa says.
Dr Paul Muwa, an orthopaedic surgeon at the hospital explains how the surgery was carried out. “The head of his right femur had been destroyed and this caused the shortening of the leg. I had to remove the head of the femur to reduce the pain and make the joint flexible. Thereafter, we shall make him a compensation shoe to help him walk normally again.”
Causes: Although the exact cause for arthritis is not known, it has been associated with genetic factors. Another possible cause of arthritis, according to Dr Mukasa is trauma, especially through accidents.
Types of arthritis: There are two major types of arthritis, rheumatoid and osteoarthritis. There are however, other types of arthritis depending on the cause, such as septic (infection) and systematic arthritis, which is caused by illnesses such as malaria and HIV.
Arthritis due to age (wear and tear of joints) as a result of drugs and trauma, and gout arthritis caused by crystals that collect in the joints, especially excess carbohydrates and proteins. Rheumatoid arthritis occurs when the body’s immune system does not function properly. In such a situation, the joints feel stiff and achy. “This type of arthritis is more severe than the osteoarthritis, as it occurs when there is a fault in a person’s immune system that makes the body attack its own tissues,” says Dr Mukasa.
The fault is usually genetically inherited from a family member.
Rheumatoid arthritis usually affects older men than women. Osteoarthritis on the other hand, is a degenerative joint disease, where the cartilage gradually wears away. As more damage occurs, the more cartilage is worn away.
This type of arthritis mostly affects the hands, spine, knees and hips. According to Dr Mukasa, this type of arthritis mostly affects people in their 50s, but can also develop at any age as a result of injury or any joint related condition.
The major difference between these two types of arthritis is that osteoarthritis usually affects a few joints, while rheumatoid arthritis affects all joints in the body.
During the surgical process, the surgeon inserts a narrow tube, consisting of a fibre-optic video camera through a small cut, the size of a pin-hole,” explains Dr Mukasa. The process is also used in draining pus and blood from joints, especially in cases where the person has tuberculosis of the joints.
According to Dr Mukasa, if arthritis is not treated, the person gets stiffness in the joints, sleep discomfort due to excessive pain, difficulty in walking and sometimes the limbs become non-functional. In severe cases, total disability in joints may happen.
Prevention and treatment: Proper diet that is rich in calcium and vitamin D, low salt, sugar and fat combined with proper and regular exercise is crucial to maintain healthy muscles and keep joints strong. “Avoid forceful stretching of the joints because ligament structures around the joints can tear, which may later cause pain in the joints,” says Dr Mukasa notes.
Regular health visits for bone density tests, may save an arthritis patient the costs involved in treating the condition when it is in advanced stages.

In summary, it is estimated that rheumatoid arthritis affects more than 300,000 people in Uganda. It is estimated that osteoarthritis affects more than 50% of the people in Uganda. Research into arthritis is sparse and urgently required in Uganda because it is estimated that osteoarthritis will become the fourth leading cause of disability worldwide. Osteoarthritis is predominantly a disease of old age, affecting more than 82% of those over 65. Almost twice as many women are affected than men. Both the elderly and women are vulnerable and more likely to live in poverty. Combine with this the stigma and prejudice and the effects of arthritis should not be underestimated.

For more information on arthritis see the South African Rheumatism Arthritis Association (SARAA) website or The Arthritis Foundation of South Africa website.