Review of Current Workforce for Rheumatology in the Countries of the Americas 2012–2015

Abstract

Background: With the increases in and aging of the populations of the
Americas, monitoring the number of rheumatologists is critical to address
and focus on areas of greatest need.
Objectives: The aimof this study was to gather data on the rheumatology
workforce from 21 national societies in the Pan American League of Associations
for Rheumatology (PANLAR).
Methods: In September and October 2012 and again in October and
November 2015, the heads of the 21 rheumatology national societies were
contacted in the 2012 survey; all national societies responded except Cuba.
In the 2015 survey, all responded except Nicaragua, for which information
was provided by national society presidents in adjacent countries.
Results: The data from 21 societies contained in PANLAR consist of
10,166 adult and 678 pediatric rheumatologists serving 961million people.
The number of rheumatologists per 100,000 population varies greatly from
3.9 per 100,000 people (Uruguay) to 0.11 per 100,000 people (Nicaragua).
The number of training programs also varies widely, with some countries
having no indigenous programs. The distribution of rheumatologists is
mainly in the large cities, particularly in the smaller countries. Pediatric
rheumatologists have dramatically increased in number in 2012, but 96%
reside in 6 countries. This remains an underserved area in most countries.
Conclusions: The rheumatology workforce in the Americas has improved
between 2012 and 2015, especially in the number of pediatric rheumatologists.
However, numerically and in the perception of the 21 member
societies of PANLAR, the number is still inadequate to meet the increasing
demands for rheumatologic care, especially in the care of children with
rheumatic disease and in rural areas.
Key Words: health services, Latin America, pediatric rheumatologists,
trainees, workforce

Full text

Review of Current Workforce for Rheumatology in the
Countries of the Americas 2012–2015
John D. Reveille, MD, Roberto Muñoz, MD, Enrique Soriano, MD, Miguel Albanese, MD, Graciela Espada, MD,
Carlos Jose Lozada, MD, Ruben Antonio Montúfar, MD, Fernando Neubarth, MD, Gloria M. Vasquez, MD,
Michel Zummer, MD, Rosa Sheen, Carlo V. Caballero-Uribe, MD, and Carlos Pineda, MD
Background: With the increases in and aging of the populations of the
Americas, monitoring the number of rheumatologists is critical to address
and focus on areas of greatest need.
Objectives: The aim of this study was to gather data on the rheumatology
workforce from 21 national societies inthe Pan American League of Asso-
ciations for Rheumatology (PANLAR).
Methods: In September and October 2012 and again in October and
November 2015, the heads of the 21 rheumatology national societies were
contacted in the 2012 survey; all national societies responded except Cuba.
In the 2015 survey, all responded except Nicaragua, for which information
was provided by national society presidents in adjacent countries.
Results: The data from 21 societies contained in PANLAR consist of
10,166 adult and 678 pediatric rheumatologists serving 961 million people.
The number of rheumatologists per 100,000 populationvaries greatly from
3.9 per 100,000 people (Uruguay) to 0.11 per 100,000 people (Nicaragua).
The number of training programs also varies widely, with some countries
having no indigenous programs. The distribution of rheumatologists is
mainly in the large cities, particularly in the smaller countries. Pediatric
rheumatologists have dramatically increased in number in 2012, but 96%
reside in 6 countries. This remains an underserved area in most countries.
Conclusions: The rheumatology workforce in the Americas has im-
proved between 2012 and 2015, especially in the number of pediatric rheu-
matologists. However, numerically and in the perception of the 21 member
societiesof PANLAR, the number is still inadequate to meet the increasing
demands for rheumatologic care, especially in the care of children with
rheumatic disease and in rural areas.
Key Words: health services, Latin America, pediatric rheumatologists,
trainees, workforce
(J Clin Rheumatol 2016;22: 405–410)
In the 2010 World Health Organization Global Burden of Dis-
ease study, rheumatic and musculoskeletal diseases (RMDs)
were reported to be the second leading cause of disability world-
wide, as measured by years lived with disability. Estimates sug-
gest that almost 2 billion people are affected worldwide.
1
Recent
estimates of the prevalence of RMDs in the Americas have shown
that many RMDs are more common than previously suggested.
1–14
With the striking worldwide population increases, the aging of
the population, and increased prevalence of obesity, osteoarthritis,
low-back pain (LBP), and so on,
15
theneedforarheumatologic
care has never been larger.The current burden of RMDs far exceeds
service capacity in most countries.
16
This has led to projections
showing that the demand for rheumatologists is expected to fur-
ther exceed supply in the coming decades.
17
The Pan American League of Associations for Rheuma-
tology (PANLAR) is an umbrella organization of rheumatology
national societies in the Americas, encompassing 21 countries;
of those, 19 nations are located in Latin America and the Carib-
bean region.
18
PANLAR was founded on Wednesday May 31,
1944, in order to stimulate and promote awareness and develop-
ment of knowledge and means to prevent, treat, rehabilitate, and
relieve diseases of rheumatic origin and to stimulate the continu-
ing development of rheumatology (Fig.).
The purposes of this study are 4-fold: (1) to gather data on the
rheumatology workforce from the national societies in PANLAR
in order to better assess areas of greatest need for adult rheumato-
logic care in the Americas, (2) to establish the areas of greatest
need for pediatric rheumatology care, (3) to examine trends in
the growth of the rheumatology manpower force in the Americas
between 2012 and 2015, and (4) to determine the source of rheu-
matology trainees. Another purpose is to assess the challenges of
delivering rheumatologic care in the Americas as identified by the
presidents or representatives of the respective national societies.
MATERIALS AND METHODS
In September and October 2012 and again in October and
November 2015, the heads of the 21 national societies were
contacted by e-mail and asked to respond to a cross-sectional type
survey written in Spanish, English, and Portuguese. The question-
naires were structured by means of an interactive exchange of
ideas during meetings and followed by electronic communication
to define the most important and relevant issues implicated in
rheumatology manpower force in the Americas. Specific ques-
tions included the number of adult and pediatric rheumatologists;
the number of rheumatology training programs, both adult and pe-
diatric; and the number of rheumatology trainees. The heads of the
national societies were also asked to comment on the greatest
challenges confronting the delivery of rheumatology care in their
country. The proportion of pediatric fellows was not collected for
2012, and the 2015 survey did not take into account the gender
distribution. In the 2012 survey, all national societies responded
except Cuba. In the 2015 survey, all responded except Nicaragua,
for which information was provided by national society presidents
in neighboring countries. For the pediatric rheumatology trainee
and program numbers, corrections to those given by the society
presidents were made from 3 surveys conducted by Dr Graciela
Espada, member of the PANLAR Board of Directors representing
the PANLAR Pediatric Rheumatology effort, over this period.
RESULTS
The Workforce Overall
The population of the countries of the 21 PANLAR member
societies increased by 4.8 % between 2012 and 2015, from
917 million to 961 million. The highest rates of increase were in
From the Division of Rheumatology, The University of Texas Health Science
Center at Houston, Houston, TX.
J.D.R. and C.P. contributed equally to this article.
The authors declare no conflict of interest.
Correspondence: John D. Reveille, MD, Division of Rheumatology, The
University of Texas Health Science Center at Houston, 6431 Fannin, MSB
5.270, Houston, TX 77030. E‐mail: john.d.reveille @uth.tmc .edu.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-1608
DOI: 10.1097/RHU.0000000000000465
ORIGINAL ARTICLE
JCR: Journal of Clinical Rheumatology •Volume 22, Number 8, December 2016 www.jclinrheum.com 405
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Ecuador (9.4%) and Nicaragua (8.3%). Two countries, Bolivia and
the Dominican Republic, decreased slightly in population (minus
2.8% and 1.0%, respectively). (www.prb.org/Publications/Datasheets/
2012/world-population-data-sheet.aspx, https://en.wikipedia.org/
wiki/List_of_Latin_American_countries_by_population).
In 2012, there were 9887 rheumatologists servicing the 21
member countries of PANLAR (excluding Cuba). The number of
rheumatologists varied widely, from a high of 5602 in the United
States in 2012 and a low of 4 in Nicaragua in that year (Table 1).
By 2015, the number of rheumatologists had increased to 10,844,
with the United States still having the largest number (5716) and
Nicaragua the fewest (7).
The distribution of rheumatologists (both adult and pediatric)
per 100,000 population improved between 2012 and 2015, with a high
of 3.3 per 100,000 in Uruguay and 0.08 per 100,000 in Nicaragua
in 2012 to 4 per 100,000 and 0.11 per 100,000 in Nicaragua in
2015. The distribution of rheumatologists is mainly in the large
cities, particularly in the smaller countries (data not shown).
Gender distribution was available only for 2012. Overall, the
proportions of men and women were approximately equal, with
the highest proportions of women in Argentina (59%), Brazil
(53%), Uruguay (74%), and Venezuela (54%).
No data were available from other American countries without
rheumatology societies (Belize, Guyana, French Guyana, Suriname,
Haiti, Jamaica, and some Caribbean islands).
Distribution of Pediatric Rheumatologists in the
Americas 2012–2015
The number of pediatric rheumatologists grew dramatically
from 458 in 2012 to 638 (39%) in 2015 (including 9 in Cuba),
where 5 nations: Costa Rica, El Salvador, Honduras, Peru, and
FIGURE. The national societies comprising PANLAR.
Reveille et al JCR: Journal of Clinical Rheumatology •Volume 22, Number 8, December 2016
406 www.jclinrheum.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Venezuela still lacked pediatric rheumatologists. This substantial
increase in pediatric rheumatologist workforce was particularly
seen in Argentina, Brazil, Chile, and the United States. However,
the distribution remained markedly skewed, with 96% residing
in only 6 countries (United States, Canada, Mexico, Brazil,
Argentina, and Chile) (Table 2).
Distribution of Training Programs in the
Americas 2015
The number of training programs varied widely, with some
countries (Costa Rica, El Salvador, Honduras) having no indige-
nous programs. The number of adult rheumatology training pro-
grams in the Americas increased slightly from 250 in 2012 to
258 in 2015. If it is assumed the number of programs in Cuba re-
mained constant over this interval, this would constitute a 2.3% in-
crease. These increases were most striking in the United States,
which added 4 programs. On the other hand, in El Salvador and
Venezuela, the number of programs actually decreased (Table 3).
The number of pediatric rheumatology programs increased
also, rising from 55 in 2012 to 57 in 2015. These increases were
most striking in the United States, which gained 6 programs. Some
countries lost pediatric rheumatology programs (Bolivia, Chile).
Distribution of Rheumatology Trainees in the
Americas 2015
The number of rheumatology trainees rose dramatically in
the Americas between 2012 (n = 820) and 2015 (n = 1088). The
TABLE 1. Summary of the Rheumatology Workforce in the Americas 2012–2015
a,b
Country
2012 Population 2015 Population
No. of
Rheumatologists
No. of
Rheumatologists No. per 100,000 No. per 100,000
(Million) (Million) 2012 2015 2012 2015
Argentina 40.8 43.1 563 780 1.38 1.81
Bolivia 10.8 10.5 30 39 0.28 0.37
Brazil 194.3 205 1585 1770 0.82 0.86
Canada 34.9 35.8 388 525 1.11 1.47
Chile 17.4 18 155 153 0.89 0.85
Colombia 47.4 48.2 148 165 0.31 0.34
Costa Rica 4.5 4.8
c
21 28 0.47 0.58
Cuba 11.2 11.3 NA 164 NA 1.45
Dominican Republic 10.1 10.0 20 25 0.20 0.25
El Salvador 6.3 6.5 16 18 0.25 0.28
Ecuador 14.9 16.3 53 80 0.36 0.49
Guatemala 15 16.2 32 35 0.21 0.22
Honduras 8.4 9 13 15 0.15 0.17
Mexico 116 121 609 755 0.53 0.62
Nicaragua 6 6.5 5 7 0.08 0.11
Panama 3.6 3.8 16 17 0.44 0.45
Paraguay 6.7 7.0 17 24 0.25 0.34
Peru 30.1 31.2 172 229 0.57 0.73
United States 314 322 5602 5716 1.78 1.78
Uruguay 3.3 3.3
c
108 133 3.27 4.03
Venezuela 30 30.6 159 166 0.53 0.54
Total 917 961 9887 10,844 1.09 1.12
a
Population for 2012 from www.prb.org/Publications/Datasheets/2012/world-population-data-sheet.aspx
b
Population from 2015 from https://en.wikipedia.org/wiki/List_of_Latin_American_countries_by_population
c
Data from June 30, 2014, not available for 2015.
TABLE 2. Distribution of Pediatric Rheumatologists in the
Americas 2012–2015
Country 2012 2015 Percent Change (%)
Argentina 38 46 +21
Bolivia 1 1 0
Brazil 42 100 +138
Canada 35 35 0
Chile 9 11 +22
Colombia 12 14 +17
Costa Rica 0 0 0
Cuba NA 9 NA
Dominican Republic 2 2 0
El Salvador 0 0 0
Ecuador 1 2 +100
Guatemala 2 2 0
Honduras 0 0 0
Mexico 41 45 +10
Nicaragua 1 1 0
Panama 2 2 0
Paraguay 3 2 −67
Peru 0 0 0
United States 264 364 +38
Uruguay 3 2 −67
Venezuela 2 0 −200
Total 458 638 +39
JCR: Journal of Clinical Rheumatology •Volume 22, Number 8, December 2016 Rheumatology Workforce in the Americas 2012–2015
© 2016 Wolters Kluwer Health, Inc. All rights reserved. www.jclinrheum.com 407
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

proportion of pediatric fellows was not available for 2012, and
the 2015 survey did not take into account the gender distribu-
tion. Of note, 92% of the 119 pediatric rheumatology fellows
came from 4 countries (Brazil, Canada, Mexico, and the United
States) (Table 4).
Concerns About the Practice of Rheumatology
From National Society Presidents
The leading concern of the society presidents was manpower
(11 countries), particularly in rural parts of the countries and with
pediatric rheumatologists. Lack of governmental support for rheu-
matologic care, especially access to biologics, for supporting
training programs, and for research (7 countries) was also an im-
portant concern. Other issues included the lack of epidemiologic
data on the disease burden and about education of primary care
practitioners to promote knowledge of rheumatic disease and
allow earlier referral of patients, lack of training opportunities
for fellows/residents, and, in the larger countries, governmental
legislation complicating the delivery of care.
DISCUSSION
The data from 21 societies contained in PANLAR consist of
9887 adult and 457 pediatric rheumatologists serving 906 million
people. The number of rheumatologists per 100,000 population
in 2015 varied greatly from 4.0 per 100,000 people (Uruguay)
to 0.08 per 100,000 people (Nicaragua). The number of training
programsalso varies widely, with some countries having no indig-
enous programs. The distribution of rheumatologists is mainly in
the large cities, particularly in the smaller countries. Despitea dra-
matic increase in the number of pediatric rheumatologists in the
last years, pediatric rheumatology remains an underserved area
TABLE 3. Distribution of Training Programs in the Americas 2015
Country
No. of Adult
Rheumatology Training
Programs 2012
No. of Adult
Rheumatology Training
Programs 2015
No. of Pediatric
Rheumatology Training
Programs 2012
No. of Pediatric
Rheumatology Training
Programs 2015
Argentina 25 25 4 4
Bolivia 0 1 1 0
Brazil 49 49 7 7
Canada 15 15 3 3
Chile 15 15 2 1
Colombia 5 5 2 2
Costa Rica 1 1 0 0
Cuba NA 4 NA 1
Dominican Republic 1 2 0 0
El Salvador 2 0 0 0
Ecuador 0 0 0 0
Guatemala 2 2 0 0
Honduras 0 0 0 0
Mexico 15 15 3 3
Nicaragua 0 0 0 0
Panama 1 1 0 0
Paraguay 1 2 0 0
Peru 5 6 0 0
United States 108 112 30 36
Uruguay 1 1 2 NA
Venezuela 5 3 1 NA
Total 250 258 55 57
TABLE 4. Distribution of Rheumatology Trainees in the
Americas 2015
Country
Tota l N o . o f
Rheumatology
Trainees 2012
Tota l N o . o f
Rheumatology
Trainees 2015
No. of Pediatric
Rheumatology
Trainees 2015
Argentina 40 110 4
Bolivia 0 3 0
Brazil 135 122 14
Canada 62 78 14
Chile 16 16 1
Colombia 18 22 3
Costa Rica 10 6 0
Cuba NA 45 2
Dominican
Republic
013 0
El Salvador 2 0 0
Ecuador 0 0 0
Guatemala 6 6 0
Honduras 4 0 0
Mexico 76 71 11
Nicaragua 0 0 0
Panama 1 1 0
Paraguay NA 6 0
Peru 5 57 0
United States 416 497 70
Uruguay 10 17 0
Venezuela 18 18 0
Total 820 1088 119
Reveille et al JCR: Journal of Clinical Rheumatology •Volume 22, Number 8, December 2016
408 www.jclinrheum.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

in most countries. One potential disclaimer in this survey is recall
bias on the part of the society president or representative providing
us this information. In some societies, manpower statistics are
kept in regularly updated databases, and as such, the information
from that society may be counted as reliable. However, for other
societies, especially large ones, where such databases are not kept
or where rheumatologists who were not members of the National
Society were counted in one and not the second survey (and vice
versa), this may be a concern.
Health systems in America’s developed countries are gradu-
ally responding to the rising burden and the complex needs of peo-
ple with RMDs through the implementation of multidisciplinary,
patient-centered models of care and centers of excellence.
19
Not-
withstanding, these are far from universal in the developed world
and of rare occurrence in developing countries. While the number
of rheumatologists in developed countries far exceeds that in de-
veloping countries, there remain national and regional shortfalls
in the provision of rheumatologists and the many other allied
health professionals to the provision of best care for RMDs.
18
Analysis of the distribution of rheumatologists across the
Americas using the 2015 PANLAR survey database was limited,
as most of the societies did not provide these data. However, in in-
dicating the challenges facing their societies, many society presidents
indicated concerns that their workforce was distributed mainly in
large cities, leaving metropolitan and rural areas underserved.
Many areas of the Americas are devoid of specialists in rheu-
matology. General practitioners, family doctors, or specialists in
other disciplines who do not have the training or experience in
the care of these conditions manage patients with RMDs; thus,
the appropriateness of patient management is uncertain. Increas-
ing the numberof specialists in rheumatology across the Americas
will, however, be a costly challenge, especially given the shortage
of physicians and other health professionals. Ensuring specialists
offer equitable access within countries is also a challenge as most
congregate in urban areas.
20,21
The history of the World Health
Organization–International League of Associations for Rheuma-
tology COPCORD (Community-Oriented Program for Control of
Rheumatic Disease) for developing countries, although hampered
by lack of funding and manpower, has given an estimate of the
challenges facing this workforce
4–9,12,13,22
(Table 5). Low-back
pain, osteoarthritis, osteoporosis, and rheumatoid arthritis (RA)
have been the priority. The projected prevalence rates of chronic
LBPinupto19.4%,
11
RA in up to 1.5%,
8
axial spondyloarthritis
(AxSpA) in up to 1.4%,
10
and chronic inflammatory back pain in
up to 6.0%
11
require adequate control. After 5 to 15 years, the
consequences of RA and AxSpA are disability, reduced produc-
tivity, loss of career and income, lowered quality of life, and early
mortality notwithstanding existing therapy. The application of the
biologic DMARDs in these diseases in the third world for reasons
of treatment costs from $15,000 to $25,000 per patient per year is
not feasible for all patients. The majority of the third-world popu-
lation has an income of less than US $1.00 per day to less than US
$2000.00 per capita. Thus, the need for careful and early diagno-
sis, staging, and identification of patients at greatest need for these
treatments has never been higher. The question is whether we will
have the manpower and financial resources to meet this challenge.
CONCLUSIONS
The data from 21 societies contained in PANLAR consist of
10,166 adult and 678 pediatric rheumatologists serving 961 million
people. The number of rheumatologists per 100,000 population
varies greatly from 4.0 per 100,000 people (Uruguay) to 0.11
per 100,000 people (Nicaragua). The number of training pro-
grams also varies widely, with some countries having no indige-
nous programs. The distribution of rheumatologists is mainly in
the large cities, particularly in the smaller countries. Pediatric
rheumatologists have dramatically increased in number in 2012,
but 96% reside in 6 countries. This remains an underserved area
in most countries.
ACKNOWLEDGMENT
The authors thank the presidents of the 21 national societies
of PANLAR for their patience and cooperation in providing the
data for this article.
TABLE 5. Frequencies of Rheumatic and Other Musculoskeletal Disease by COPCORD and Related Surveys
Country Year
Sample
Size
Musculoskeletal
Pain , %
Chronic
LBP, % IBP, % RA, % Osteoarthritis, % AS, % Gout, % SLE, %
Brazil
5
2004 3038 30.9 NA NA 0.46 4.1 NA NA NA
Cuba
6
2005 3155 43.9 11.3 NA 1.2 20.4 0.1 0.4 0.06
Peru
7
2007 1968 46.5 7.1 NA 0.5 14.4 0.4 NA 0.05
United States
23
2008 Variable
a
NA 14 NA 0.6 4.9 0.52 0.9–3.1 0.05–0.1
b
/0.4
c
Mexico
8
2011 19,213 25.3 8.0 NA 1.5 10.2 0.15 0.35 0.06
Guatemala
9
2012 8000 11.9 0.5 NA 0.7 2.8 0.01 0.01 0.06
United States
d,10,11
2012/2013 5103 NA 19.4 6.0 NA NA 1.4
e
/0.6
f
NA NA
Venezuela
12
2015 3973 22.4 2.8 0.2 0.4 15 0.1 0.3
g
0.07
Ecuador
13
2016 4877 32.5 9.3 1.6 0.8 7.4
h
0.08 0.4 0.06
a
Data combined from previously published studies.
b
Whites.
c
Blacks.
d
National Health and Nutrition Examination Survey 2009–2010.
e
AxSpA.
f
AS).
g
Including all crystal arthropathies.
h
Knee only.
AS indicates ankylosing spondylitis; SLE, systemic lupus erythematosus.
JCR: Journal of Clinical Rheumatology •Volume 22, Number 8, December 2016 Rheumatology Workforce in the Americas 2012–2015
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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