COPCORD — An Unrecognized Fountainhead of Community Rheumatology in Developing Countries

Nobody has paid more heed to the woe of aches and pains in the community than the WHO-ILAR COPCORD (Community Oriented Program for Control of Rheumatic Diseases)1. With wings spread over the Asia-Pacific region, South America, and more recently Africa, COPCORD is a unique fountainhead of community data on rheumatic musculoskeletal (MSK) disorders and pain2. A Web search3,4 for COPCORD on related sites proved futile or revealed an outdated, meager description. COPCORD has yet to be explored for its global merit and use. Although active for over 2 decades, COPCORD remains largely unrecognized by the rheumatology community. In COPCORD, the focus is on disease burden and information deficit, especially in the rural communities of developing countries. A baseline systematic population survey (Stage I) is followed by identification of risk factors and community health education (Stage II) and preventive and control measures (Stage III). Prevalence data from several COPCORD studies, especially from the Asia-Pacific region, have been published and compared5,6. But not all studies have conformed to the basic COPCORD design. Logistics, ignorance, and unexpected hurdles (political upheaval in a few cases) have sometimes compelled the investigators to digress5,7. Different personnel have collected data, and some surveys took a long time to complete. The operative words in COPCORD are “community” and “control.” Control is a difficult proposition. To begin with, we ought to measure the disease burden. The COPCORD Bhigwan (India) rural survey6,8 demonstrated that among all the ailments recorded in Stage I, phase 1, rheumatic MSK disorders were the commonest in 18.2% of adults (95% confidence intervals, CI, 17.1, 19.2). The majority had soft tissue pain and rheumatism (Figure 1). In nearly one-third of survey cases (Figure 1), the ailment could be best grouped as “symptom-related” disorders for want of a better classification entity. Knee (13.2 %), lumbar (11.4%), and shoulder (7.4%) pains were common, and similar trends have emerged from other Asia-Pacific COPCORD5,8. The strikingly low prevalence of inflammatory rheumatic disorders compared to the dominance of soft tissue pain and rheumatism and degenerative disorders in COPCORD communities needs to be realized by the rheumatologist. Unfortunately, even the recently launched Bone and Joint Decade9 has failed to recognize this truth. It is against this background that the COPCORD study by Zeng and colleagues in this issue of The Journal should be viewed10. In their article about 2 universally acclaimed community ailments — knee pain and lumbar pain — the authors speculate on the role of geographical, environmental, and dietary influences in their etiology. They draw attention to the weaknesses of the current diagnosis/classification system in rheumatology, with special reference to the epidemiology of osteoarthritis (OA)11, and reaffirm that soft tissue pain and rheumatism is the major community rheumatic MSK problem. Of the COPCORD Shantou study population, 7.9% and 11.5% were found to suffer from knee pain and lumbar pain, respectively, substantially lower than that reported from population studies in North China12. Only 2040 subjects, predominantly government employees, were surveyed and presumably the majority enjoyed sedentary jobs. The investigators, several of whom had participated in the earlier studies13, concluded that the prevalence of knee pain and lumbar pain appear to lessen with reducing latitude10. There are several slips between the cup and the lip. A major confounding factor seems to be the variation in the technique of recording rheumatic MSK pain in these Chinese studies. Doctors recorded pain in the North China studies, which were not strictly designed along COPCORD lines. The entire modus operandi of determining, recording, and reporting rheumatic MSK pain in the epidemiological