Nazma is a 55-year-old housewife who began to feel “bone pain” all over her body, some years ago. “First, it was mild. But after a while, I felt it constantly”, she says. “I went to many doctors. We got a few normal X-rays, so they gave me painkillers. But I did not get better. One doctor even prescribed an antidepressant, thinking it was all in my head. After two or three years of this treatment, I consulted a doctor who said my bones were probably becoming weaker as my periods had stopped long ago. It was the first time I had heard such a thing. She suggested a scan to check my bone strength. The reports showed osteoporosis. The doctor said that alongside causing me pain, osteoporosis would also increase the chances of fractures.”
Ms. Nazma’s case is not an exception, unfortunately. Even today the unpleasant reality is that only a small percentage of people in India receive care for their osteoporosis - a condition characterised by weakening of bones.
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We have all seen people begin to stoop as they grow older. That is because of osteoporosis. The weakening of the bone not only causes long-term pain but also changes in posture and increases chances of fractures and nerve injury if the bone affected is the spine. All of these problems negatively impact the quality of life and increase disability and financial burden on the family, and yet osteoporosis is not receiving the attention it deserves in medical practice.
Though there are no large-scale studies on osteoporosis in India, projected data shows that at least 46 million women in India currently live with post-menopausal osteoporosis, which is only one type of osteoporosis. If you include women who had surgeries to remove their uterus, people who used steroid medication for a long time and, men who developed osteoporosis because of old age, the number may be over double. A 2019 study also revealed that India was the highest contributor to osteoporosis fracture-related deaths/disabilities worldwide.
“There are enormous gaps in knowledge about osteoporosis, even among doctors,” says Alfia Kaki, a doctor in Guwahati. “Nobody with long-term pain is going to make an appointment with an endocrinologist (which is where all the knowledge about bone conditions is concentrated, as of date). They will either come to a general practitioner or, if it worsens, to an orthopaedic. And in India, doctors in this capacity are ill-equipped to handle osteoporosis.”
Dr Alfia’s claim is supported by a study conducted among 222 medical practitioners at both graduate and postgraduate levels in south India to test their knowledge about osteoporosis. The study revealed that the mean score of doctors was 22.5% with every single doctor scoring less than 50%.
“Considering that Indian women have many micronutrient deficiencies and do not set aside time for exercise, there needs to be a high index of suspicion for osteoporosis in every patient,” says Manisha Deka, a consultant physician working in Central Railway Hospital, Guwahati. “Every other older female patient I see has osteoporosis. And because I understand how widely prevalent it is, I make it a point to look for it. Osteoporosis isn’t a secondary diagnosis a doctor can keep at the back of their mind. One must actively look for and rule it out in patients with vague bone pains.”
“Even in patients who have had fractures and have undergone surgery, it is not routine for doctors here to go back to see why the patient’s bone was fragile enough to break. That is truly unfortunate,” says Dr Alfia.
Also of interest is that most of the Indian population does not have access to DEXA or the bone mineral density scan - the gold standard test for osteoporosis. “When I wanted a DEXA for my mother, I called many hospitals and centres,” said Mohammad Aslam Ali. “Only two or three centres have the scan facility in Guwahati - all private. And Guwahati is a state capital. I can only imagine what it’s like in other areas”, he says. A study found that in India, there are only 0.26 DEXA machines per million of the population.
“There are enormous gaps in knowledge about osteoporosis, even among doctors.”Alfia Kaki, a doctor in Guwahati
“If you look at guidelines for treatment, they say, perform a DEXA for diagnosis and start medication. The guidelines also ask us to repeat the DEXA scan yearly to see if the treatment is working. This focus on a scan which is barely available to 10% of the population for diagnosis and treatment is unreasonable,” adds Dr Alfia. “There is a need for conversations in the medical circle about how to diagnose and effectively treat osteoporosis in resource-limited set-ups.”
“In resource-limited settings, I used the Singh index to diagnose osteoporosis”, says Suranjan Bhattacharjee, a retired professor of Physical Medicine and Rehabilitation who worked in a mission hospital in Bissamcuttack, Odisha, serving a poor locality. “The Singh index is a score that requires only an X-ray of the patient’s pelvis to diagnose osteoporosis. I didn’t have the facilities to check vitamin D levels in blood, so I also started them on calcium and vitamin D supplements without the blood tests,” he adds.
Dr. Suranjan’s experience suggests that, in the realm of osteoporosis care, India’s infrastructure limitations can be overcome by acquiring proper knowledge and engaging in meaningful discussions within our context.
This osteoporosis day’s (20th October) the theme was ‘Build better bones’. To do so, we must realise that our nation is grappling with this silent epidemic. Millions suffer in silence as their pain goes unnoticed and their quality of life is compromised. To bridge the osteoporosis care gap in India we must promote awareness and aim for early intervention. It’s time to empower healthcare providers everywhere with context-specific knowledge to diagnose, treat, and prevent this debilitating condition, ensuring a healthier and pain-free future for all.
