Editorial: Rheumatology education without borders—a global approach to basic instruction on the complex disease of SLE

Editorial on the Research Topic
Rheumatology education without borders—a global approach to basic instruction on the complex disease of SLE

In a 2007 editorial “Rheumatology without borders” (C-S Lau, PH Feng) the rheumatology community was challenged to expand the global reach of the specialty starting with education. This action was deemed both necessary and enriching, especially for developing nations. The concept of rheumatology development unconstrained by geography was the inspiration for this research topic focusing on the complex and heterogenous disease-systemic lupus erythematosus (SLE), a disease which is apt to be more frequent and severe in populations with limited access to essential resources, highlighting the critical need for equitable and sustainable healthcare solutions.

We were fortunate to find that the 5 articles within this research topic represent contributions from 4 continents—Africa, Asia, Oceania and the American subregion (Caribbean). Each article carries unique, contextualized perspectives with international relevance and enduring lessons of the global community.

Dey et al. in Ghana described the Rheumatology Initiative (tRi) which was established in 2012 to overcome challenges in improving patient care such has poverty, dearth of specialists and testing facilities, and lack of knowledge. The Rheumatology Initiative aims to improve the understanding, diagnosis, and management of rheumatic conditions through educational activities, research projects, and targeted interventions. Educational programs bring knowledge to the doorstep of the community by engaging schools, churches, and workplaces. Their strong advocacy has resulted in antirheumatic drugs being added to the list of essential drugs in Ghana. A toll-free telemedicine line “Rheumchat” was set up to screen individuals with symptoms of rheumatic disease. Funds raised by tRi have been used in the most impactful ways such as for training of rheumatology specialty nurses, the setting up of an infusion room at a teaching hospital and the provision of discounted medication.

Navarra from the Philippines highlighted the established programs to increase medical student exposure to rheumatology such as the Lupus Initiative of the American College of Rheumatology, while proposing additional strategies to strengthen lupus education in developing countries. One strategy outlined in her paper was to provide highly motivated medical students and internal medical residents with special interest in rheumatology with the opportunity to engage with centres of excellence or attend international meetings. Dr. Navarro also advocated for the establishment of dedicated lupus clinics and the formal training of lupus patients as instructors, otherwise called “patient partners.” The Applied Rheumatology Made Simple (ARMS) educational program improved the knowledge and clinical skills of Primary Care doctors, thus increasing their capacity for patient care and facilitation of a sound networking relationship with lupus specialists.

A prospective study (2013–2020) of a large multinational 13-country Asia Pacific patient population (the Asia Pacific Lupus Collaboration cohort) found that anti-malarial users had lower exposure to glucocorticoids and immunosuppressants and experienced fewer severe flares compared to non-users. However, antimalarial use was found to be suboptimal in clinical practice with some countries not meeting international treatment guidelines. In less affluent countries in Indonesia less than 50% of patients received antimalarials. These findings underscored the need to identify modifiable barriers to antimalarial use.

Lin et al. reviewed the issue of SLE disease activity assessment both in clinical practice and research. It was initially acknowledged that activity indices are important for routine treat -to -target medical interventions as well as for the formulation of appropriate clinical trial endpoints. Notwithstanding that fact, the complexity and heterogeneity of SLE makes development of reliable disease activity instruments difficult. Assessment for potentially reversible inflammatory disease manifestations is typically made in the absence of a single quantifying biomarker and requires clinical judgement for correct attribution, including exclusion of all plausible alternative disease states. The most widely used disease-activity measure is the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). One of its’ limitations for use in developing countries is the inclusion of serologic markers such as antidsDNA and complements which are often inaccessible in these settings. Lin et al. discussed emerging disease activity measures before concluding with a statement of the enduring importance of a comprehensive medical history and physical examination support by appropriate investigations.

Lawrence et al. and the Caribbean Association for Rheumatology (CAR) group reviewed SLE in the Caribbean and educational priorities for primary care physicians who are often at the helm of SLE case ascertainment and management. It began with answers to a simple yet insightful question-: “When educating general practitioners and internists, what topics in SLE education would have the greatest impact on improving clinical outcomes for Caribbean patients with SLE?”. There was consensus on 15 items including early recognition of the systemic, dermatologic and musculoskeletal manifestations of SLE and early screening for kidney involvement. For SLE management, the focus was on understanding the appropriate use of Hydroxychloroquine and corticosteroids, and education on contraception and pre-pregnancy planning. The future endeavor of the CAR group is to identify and educate primary care physicians eager to be rheumatology champions.

There are challenges to the growth of knowledge of SLE as most countries have compelling competing priorities, financially strained healthcare systems and workforce shortages. In this setting it is particularly important for journals to facilitate the exchange of information and ideas. This crucial role of medical journals, complemented by other strategies such as the formation of international partnerships and development of innovative educational initiatives will broaden the perspective of what is possible in addressing global inequities in SLE care.

Author contributions

CF: Conceptualization, Writing – original draft, Writing – review & editing. CL: Conceptualization, Writing – review & editing.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that no Generative AI was used in the creation of this manuscript.

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