Indian Rheumatology Association (IRA)

The Indian Rheumatology Association (IRA) is the professional organization of rheumatologists and other health professionals in India.The specialty of Rheumatology deals with arthritis, autoimmune diseases, musculoskeletal pain disorders and osteoporosis. Rheumatologists are physicians who are experienced in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. The other health professionals who manage these diseases include internists, orthopedic surgeons, immunologists, pediatricians, and physiatrist. Allied health professionals like physiotherapist, physical and occupational therapists, rheumatology nurse etc provide ancillary support in care of patients with rheumatic diseases

IRA strives to propagate and consolidate Rheumatology endeavours in India. Towards this end the IRA publishes a quarterly journal, Indian journal of Rhuematology (IJR) and the Manual of Rheumatology, a concise text on Rheumatology authored by Indian experts.

The IRA contributes to Continuing Medical Education by way of regular scientific workshops, conferences, symposia and special interest groups.

The premier meeting organized by the IRA every year is IRACON (Annual Conference of Indian Rheumatology Association) which brings together rheumatologists,internists, orthopedic surgeons, clinical immunologists, physiatrists, physical and occupational therapists, pediatricians and researchers from allied disciplines on a common platform so as to provide the best forum in the region for deliberations on all aspects of musculoskeletal diseases.

IRA spearheads the fight against arthritis in India. IRAs mission and goals focus on providing state of the art care to Indian patients with arthritis and other musculoskeletal diseases through continuing professional development of members, increasing the awareness and understanding about rheumatic diseases, patient advocacy and empowerment, and fostering research in the field of rheumatic diseases.

IRA is affiliated to APLAR (Asia Pacific League of Associations for Rheumatology) and through it to ILAR (International League of Associations for Rheumatology). The members, thus, have a global outreach.

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An Overview of Rheumatology in India
Compiled by Dr. VR Joshi

The early days

Rheumatology in India has evolved greatly since its inception in 1959, when (Late) Dr. MM Desai established the first rheumatology clinic at T. N. Medical College and B. Y. L. Nair Hospital, Mumbai. Four years later, in 1963, SEAPAL (South East Asia Pacific League, now APLAR) was formed with India as one of the founding members. In parallel, the Indian Rheumatism (now Rheumatology) Association (IRA) was formed, with the head office at Mumbai (shifted to New Delhi in 2004). The next milestones came in 1968 when the first SEAPAL conference was organized in Mumbai by Dr. MM Desai and in 1971 when the first National Conference of IRA was held in Mumbai under the chairmanship of Dr. MM Desai. Dr. CV Vanjani was the organizing secretary.

Consolidation

By the end of 1980s, rheumatology was firmly established. During this period, academically active rheumatology centers were established and private clinics were set up.

Following academic centers were established in the 1970s (the list may not be complete):

• 1971 – PGI Chandigarh, by (Late) Dr. SD Deodhar
• 1972 – Madras Medical College and Hospital, Chennai, by Dr. AN Chandrasekaran
• 1973 – AIIMS, New Delhi, by Dr. AN Malaviya
• 1978 – Seth G. S. Medical College, and KEM Hospital Mumbai, by (Late) Dr. GH Tilve
• Other centers, established during the period were
  • MRS Medical College and Hospital, Kolkata, by (late) Dr. Manjushree Mitra
  • Lady Hardinge Women’s Medical College and Hospital, New Delhi, by (Late) Dr. S Sachdev
  • Army Hospital and RR Center, New Delhi, by (Late) Brig. ND Menon
  • Irwin hospital (now Lok Nayak Jai Prakash Narain – LNJPN hospital), New Delhi, by (Late) Dr. Hari Vaishnav
  • Following the death of Dr. MM Desai in 1979, Dr. VR Joshi assumed charge of the unit at Nair Hospital

These centers provided training and promoted research. Most of today’s senior rheumatologists of India are the from these centers. Importantly, unlike their mentors, they became full-time rheumatologists and established training centers. The process continues.

Private clinics

In the 1980s, private clinics were started by Dr. KM Mahendranath (1984, Bangalore), Dr. PK Pispati (Mumbai), Dr. SN Amin (1988, Mumbai), and Dr. SJ Gupta (1986, New Delhi) (The list may not be complete).

Growth and spectrum of IRA activities

Since the 1980s, rheumatology has grown from strength to strength. In this journey, IRA has played an important role of stimulating, fostering, and sustaining growth. Rheumatology is now recognized as an essential subspecialty of Internal Medicine. Nearly all major public and private hospitals provide rheumatology services.

Here is the bird’s eye view of the spectrum of IRA activities.

Members, Chapters, Foundations, Societies, and Registries

• There has been a steady increase in IRA membership, presently standing at 1197 Life Members and 99 Associate Members. Members receive the Indian Journal of Rheumatology (the official Journal of IRA) at no additional cost. Dr. Carol Black and Dr. Ravinder Maini were awarded the Honorary IRA membership in 2000 and 2002, respectively. In 2000, Dr. Gumdal Narsimulu brought out the first edition of the members’ handbook. It is updated periodically.

• In 2005, Rheumatology Foundation was established by Dr. Siddharth Das at Lucknow. Subsequently Dr. Shrikant Wagh from Pune established Know Your Arthritis (KYA) Foundation in 2011. Presently, there are 12 IRA chapters. Their activities include holding workshops, seminars, mini conferences, and diagnostic camps. The Delhi chapter has recently been renamed “the Delhi Rheumatology Association.”

• Sjogren’s Society of India was formed in 2006 by Ms. Kirtida Oza and Ms. Purvi Desai at Ahmednagar.

• In 2016, Society for Osteoarthrits (SOAR) was formed by Dr. Siddharth K Das at Lucknow.

  Pediatric Rheumatology

  For many years, pediatric patients were managed by adult rheumatologists. In 2001, Dr. Sujata Sawhney established the first Department of Paediatric Rheumatology at Sir Ganga Ram Hospital, New Delhi. Other hospitals have followed the suit. The Rheumatology Chapter of Indian Academy of Paediatrics was formed in 2001. It functions as an independent body. In 2014, DM in Paediatric Rheumatology was started at PGI Chandigarh by Dr. Surjit Singh. Presently, it is the only center offering DM in Pediatrics.

Annual Conferences

Annual conferences are the showcase of IRA. In the early years, the annual conferences were often held along with annual conferences of either Association of Physicians of India or Association of Physical Medicine and Rehabilitation. This was mainly due to logistic and participation issues. However, the arrangement did not help the growth of rheumatology. Therefore, since 1985, IRA has been organizing conferences independently. The first conference was held at New Delhi; Dr. GG Mansharamani was the organizing secretary. The quality and contents of the conferences are of high standards. The participation of international faculty provides young rheumatologists an opportunity to interact with them and explore the possibilities of (specialized) training.

Training

Until 1989, no formal degree or diploma course was available.

In 1989, DM in clinical immunology was instituted at SGPGIMS, Lucknow, by Dr. SS Agarwal. It included training in rheumatology. Subsequently, in 1991, DM Rheumatology was started at Madras Medical College and Hospital by Dr. AN Chandrasekaran. Presently, DM Rheumatology can be pursued at KGMC (Lucknow), IPGME & R (Kolkata), Nizam’s Institute of Medical Sciences (Hyderabad), Christian Medical College & Hospital (Vellore), PGI (Chandigarh), and JIPMER (Puducherry). AIIMS (Delhi) is also likely to introduce a DM in Rheumatology. The Government of India has recently changed the nomenclature of DM Rheumatology to DM Rheumatology and Immunology.

DNB Rheumatology

In 2005, Nizam’s Institute of Medical Sciences, Hyderabad, was the first institute to introduce DNB in Rheumatology, but it discontinued the course after the starting of DM Rheumatology. Similar has been the case with Christian Medical College, Vellore. Indian Spinal Injuries Centre, New Delhi, has discontinued DNB Rheumatology program. Presently, DNB Rheumatology is offered for in-service candidates by the Army Hospital Research and Referral Center (New Delhi). The other DNB centers are PD Hinduja Hospital, Mumbai; Krishna Institute of Medical Sciences, Hyderabad; Intraprastha Hospital, Apollo, Delhi; and Medantha Medicity, Haryana.

PhD in Rheumatology

This was instituted at Madras Medical College, Chennai, under Dr. AN Chandrasekaran. Thus far, six students have successfully completed PhD.

Fellowship in Rheumatology

This is available at CMC, Vellore; PD Hinduja Hospital, Mumbai; Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi; ChanRe Rheumatology and Immunology Center & Research, Bengaluru; LokManya Tilak Municipal General hospital and Medical College, Mumbai; and Smt. NHL Municipal Medical College and hospital, Centre for Rheumatic Diseases, Ahmedabad.

In 2005, Indo–UK fellowship was established by Indian rheumatologists settled in the United Kingdom to provide an opportunity to Indian trainees to gain additional training and experience. Thus far, 12 students have received the fellowship. APLAR offers a 3-month training fellowship for training in the APLAR region. There is an IRA-ACR exchange initiative of one month fellowship. There are support groups – Ahmedabad-based Antardhwani (ankylosing spondylitis); Lupus support group, Kolkata; and at Pune under Dr. Chopra.

The first CME program was initiated in 1992–1993 by Dr. VR Joshi in collaboration with Pfizer India. Around 3–4 CMEs were held every year in cities across India. Mumbai, Delhi, Chennai, Kolkata, and Lucknow with established rheumatology centers were excluded. While the company provided logistical support, it had no say in the content or selection of faculty. The program is no longer active. Presently, CMEs are supported by IRA. These are held at teaching institutions. There are 3-4 CMEs per year.

Special Interest Groups

Establishment of disease-specific special interest groups (SIGs) is a relatively recent development. The groups along with their leaders are listed below:

• Vasculitis – Dr. Ramnath Misra
• Myositis – Dr. Liza Rajshekhar
• Fibromyalgia – Dr. BG Dharmanand
• Paediatric Rheumatology – Dr. Sujata Sawhney
• Sjogren’s Syndrome – Dr. Sapan Pandya
• Multi-institutional SLE network – Dr. Amita Aggarwal

Workshops

Workshops on diagnostic modalities (immunology, radiology, musculoskeletal ultrasound, CT scan, MRI, and PET scan), research methodology, statistics, and medical communication are conducted at the annual IRA conference and independently by the chapters.

Publications

IRA members have edited/published text books, manuals, and monograms. These are:

• 1994 – Practical Rheumatology. Dr. GN Menon, Dr. Caroline Smith, Dr. URK Rao, eds.
• 1999 – First edition of Manual of Rheumatology, Dr. PK Pispati, Chief Ed. (5th edition is under preparation.)
• 2001 – Connective Tissue Disorders, Dr. SK Mukherjee, ed.
• 2003 – Text Book of Immunology, Dr. Sengupta, Dr. SK Mukherjee, eds.
• 2001 – Rheumatoid Arthritis, Dr. Siddharth Das, ed.
• 2010 – Rheumatology Principles and Practice, Dr. Ashit Single, (Late) Dr. SD Deodhar, eds.
• 2012 – Rheumatoid Arthritis, Dr. SK Mukherjee, Dr. Alakendu Ghosh, eds.
• 2015 – API monogram on Vasculitis, Dr. G Narsimulu, ed.
• 2015 – Text book of Systemic Vasculitis, Dr. Aman Sharma, ed.
• 2017 – Paediatric Rheumatology Clinical View Point, Dr. Sujata Sawhney, Dr. Amita Aggarwal, eds.

(The list may be incomplete)

IRA Bulletin and Journal of Rheumatology
IRA Bulletins

• 1978–1980 – Quarterly rheumatology bulletin. Dr. CV Vanjani, Dr. Krishna Das, eds.
• 1985–1989 – Bulletin Indian Rheumatology Association. Dr. SD Deodhar, ed.
• 2010–2011 – IRA News and Views Ed*.
• Since 2013, a monthly (now quarterly) Rheumatology e-bulletin has been published. Dr. Banwari Sharma was the first editor of this bulletin. From July 2017, the bulletin was be published every quarter with Dr. Sapan Pandya as the editor. In 2020, Dr Vineeta Shobha took over as editor and is now published at https://www.indianrheumatology.org/ira-e-newsletter

Journal

• In 1994, a long-overdue step was taken. The Journal of Indian Rheumatism was started under the editorship of Dr. AN Chandrasekaran. In 2006, it was renamed Indian Journal of Rheumatology. The journal is published every quarter. From humble beginnings, the journal now has a wide readership and attracts contributions from foreign nationals.
• In 2013, an open journal, Internet Journal of Rheumatology and Clinical Immunology was started by Dr. S Chandrashekara.
• Dr. AN Malaviya manages a Yahoo group. It has been operative for many years now. It provides information from international journals that are not easily accessible to most rheumatologists and trainees.

Audio Visual Films and Compendium

Following audiovisual films and compendiums have been produced:

• 1990 – An Audiovisual Film on Rheumatic Diseases, by Dr. VR Joshi (supported by Cipla)
• 1996 – An Audiovisual film on “Rheumatic Disorders, The Diseases & Their Management,” by Dr. VR Joshi (supported by Pfizer)
• 2000 – Rheumatology Compendium, first edition, Dr. VR Joshi, chief editor (supported by Pfizer)
• 2006 – Rheumatology Compendium, second edition, chief editor, Dr. VR Joshi, chief editor (supported by Pfizer)

Rheumatology Quiz

• The first IRA – Dr. SD Deodhar Postgraduate Rheumatology Quiz was organized by Gp. Capt. S Shankar in 2010. Preliminary rounds were held in 4 zones, and 35 colleges participated. The final round was held at IRACON 2010. It is now a regular feature at the annual conference. More than 300 medical institutions participated in 2016.
• Rheuma Quiz for fellows of rheumatology in India was developed by Gp. Capt. S Shankar in 2013.
• For the first time, an International Quiz organized by Gp. Capt. S Shankar was held during 2015 APLAR at Chennai.

Undergraduate Teaching

Recognizing that there is almost no exposure to rheumatology during undergraduate training, IRA has formed a subcommittee to incorporate rheumatology teaching at the undergraduate level.

• Patient Education

  IRA and its members are conscious of the importance of patient and public education. Although individual rheumatologists do engage in patient education, this area needs to be strengthened. A few examples of initiatives are as follows: A patient education booklet in English was published in 1999 by Dr. KM Mahendranath. The information booklet on Aches and Pains of ILAR was translated into Kannada by Dr. KM Mahendranath, and later into Tamil by Dr. AN Chandrasekaran, who in addition has prepared other educational materials in Tamil. The APLAR booklet was also translated in Marathi. Dr. S Wagh from Pune has published educational booklets on arthritis (Sandhivat), drugs and diet, and exercise and yoga. He has started a free information website under KYA banner. (This information may be incomplete.)

• Research

  The bulk of past and current research has been clinical. Laboratory-based studies were, until recently, confined to a few institutions such as AIIMS, Delhi; SGPGIMS, Lucknow; and Madras Medical College, Chennai. Currently, more centers are engaged in such research, making significant contributions. There is a growing number of publications in peer-reviewed international journals. Many fellows now regularly present posters and oral presentations at International Rheumatology Conferences. Epidemiological studies on prevalence of RA and SLE in adult population were conducted by Dr. AN Malaviya in 1983 and 1993, respectively. COPCORD studies were started by Dr. A Chopra in 1996. So far, 14 COPCORD studies have been conducted.

  • As an incentive to boost research aptitude and interest, IRA Boots best paper award was instituted to be bestowed at the annual conference. Dr. Rosalind Siqueira was its first recipient in 1979. The award has been replaced by IRA best paper award. Initially, there was one best paper award. This later, evolved into two best paper awards, one for a clinical paper and a one for a basic sciences paper.
  • Today, five young investigator’s awards are given during the annual conference, one each for the following categories: of: clinical paper, basic science paper, clinical poster, basic science poster, and overseas original work by Indians.

Orations and Awards

Owing to the efforts of Dr. PK Pispati, IRA-Boot’s oration (also called IRA Boots-Knoll oration) was instituted in 1983 to be delivered at the annual conference. Dr. NK Mehra was the first recipient of the award in 1983. The oration was discontinued in 2003 and replaced by IRACON – IRA-Aventis oration during 2003 and 2004. Presently, the oration is known as IRA oration. Other orations are Zydus and Kolkon orations, and these were instituted in 2001 and 2002, respectively. The orations are delivered during the annual conference. The first recipients of the two awards were Dr. P Bambery and Dr. URK Rao, respectively.

Dr. MN Passey award was instituted in 2004. It is awarded during the annual conference to a senior member of IRA for his/her contribution to Indian rheumatology. (Late) Dr. S Sachdev and Dr. KM Mahendranath were first recipients of the award.

In 1992, Dr. AN Chandrasekaran received Dr. BC Roy National Award for the development of the specialty of rheumatology.

Guidelines, Scores

Following guidelines and scores have been developed:

• 2000 – Validated Indian HAQ by Dr. Arvind Chopra
• 2001 – “Guidelines for the Treatment of Rheumatoid Arthritis in India” under the chairmanship of Dr. VR Joshi
• 2002 – “Guidelines on the Management of Systemic Lupus Erythematosus” under the chairmanship of Dr. Ashok Kumar
• 2002 – Validated Indian version of HAQ, by Dr. Ashok Kumar
• 2006 – TB prophylaxis during anti-TNF treatment, IRB guidelines for tuberculosis prophylaxis during antitumor necrosis factor
  • treatment by Dr. Rohini Handa and others
• 2008 – Indian Rheumatology Association consensus statement on the management of adults with rheumatoid arthritis under the chairmanship of Dr. Ramnath Misra
• 2010 – The Indian Takayasu Arteritis Activity Score (ITAS) by Dr. Ramnath Misra and Prof. Paul Becon
• 2010 – Indian Rheumatology Association consensus statement on the diagnosis and treatment of axial spondyloarthropathies by Dr. AN Malaviya
• 2011 – Osteoporosis Position Statement of the Experts Group Meeting. Osteoporosis Society and AIIMS by Dr. AB Dey and Dr. Rohini Handa.

International Participation and Recognition

• 1968 – The first SEAPAL conference was organized by Dr. MM Desai at Mumbai
• 1969 – Dr. MM Desai was made Hon. Member of Czechoslovakia Rheumatology Society
• Dr. MM Desai (1972–1976), Dr. PK Pispati (2002–2004), and Dr. Rohini Handa (2010–2012) have been past presidents of SEAPAL/APLAR.
• Dr. CV Vanjani (1972–1976) and Dr. Rohini Handa (2006–2008) have been past Secretary Generals of SEAPAL and APLAR, respectively.
• 1984 – Dr. VR Joshi and Dr. AN Malaviya participated in SEAPAL interlaboratory standardization of tests for RFs and participated in the workshop during Bangkok conference
• 1988 – Dr. VR Joshi and Dr. AN Malaviya participated in SEAPAL interlaboratory standardization program of SEAPAL of tests for ANA and attended the workshop at the SEAPAL conference
• 1988 and 1994 – East West International Conferences in Rheumatology were held at Chennai, under the chairmanship of Dr. AN Chandrasekaran.
• COPCORD – Dr. Arvind Chopra conducted COPCORD studies in 1996, 2004, and 2006 and supervised COPCORD surveys in India. More than 1 lakh Indian population has been surveyed.
• 2001–2010 – Bone and Joint Decade; Dr. Arvind Chopra was the founder secretary-coordinator and is presently its chairman.
• 2006 – Dr. KM Mahendranath was the only Indian to be awarded Fellowship of British Society of Rheumatology
• 2006 – Dr. AN Malaviya was recognized as Master ACR (American College of Rheumatology) and Master APLAR in 2016.
• 2008 – Pune BJD world congress was organized by Dr. Arvind Chopra.
• 2012 – Dr. Rohini Handa was Chair of International League of Associations for Rheumatology (ILAR)
• Dr. PK Pispati was conferred Master APLAR and International Fellow Member of APLAR.
• Dr. Debashish Danda is presently the Chief Editor of International Journal of Rheumatology, the official Journal of APLAR. Under his editorship, the impact factor of the journal has gone up significantly. He is the present APLAR treasurer.
• 2015 – A highly successful second APLAR conference was organized by Dr. V Krishnamurthy at Chennai.
• 2017 – Dr. PK Pispati is the first editor voice of APLAR e-bulletin.

Diagnostic Camps

These are regularly conducted by members in individual capacity.

IRA constitution

• The original constitution of IRA was written at IRA inception.
• Major constitutional amendments were made at IRACON, Lucknow, in 1999.
• The present constitution was updated and registered at Delhi in 2004.

Going Beyond India

Dr. Pispati was instrumental in encouraging rheumatology in the neighboring countries by conducting the first CMEs in Bangladesh, Sri Lanka, Pakistan, Myanmar, Muscat, and Dubai.

Conclusion

Rheumatology in India has come a long way, and its sphere of activity continues to widen. With increased availability of specialty training in India, top students have started opting for the specialty. However, there are areas such as patient education and participation; outreach to poor and remotely placed patients; simple, feasible, and practical diagnostic and therapeutic guidelines; a stronger, vibrant research base force; and better undergraduate and postgraduate training in rheumatology that need more involvement.

Current address of IRA head office

Indian Rheumatology Association, D-110, Defence Colony, New Delhi 110024.

Footnote
This effort is the beginning of what should be an ongoing process of updating IRA information; it is our history. The information is by no means complete. It is based on the information provided by members supplemented by accessing or deriving information from other sources. There could be some errors. I request the members to bring them to the notice of the IRA office for corrections. The major responsibility of regularly updating will be of IRA and annual conference secretaries. In this overview, it was not possible to include detailed information on individual centers. It is incumbent upon the centers to publish and maintain their websites separately.

Acknowledgments

It is not possible to name all those who have provided the information included in this review. However, without their inputs, this task would not have been possible. My sincere thanks to all of them, especially to Dr. Amita Aggarwal for taking the lead.

Last but not the least, I must put on record my thanks to Ms. Madhuri, my secretary, for smilingly putting up with my demands and the repeated additions and corrections of the manuscript.