Dixon Yang, MD
No, ”glocal” isn’t a typo. In the 2021 William Feinberg Award Lecture given at the International Stroke Conference of the same year, Dr. Bruce Ovbiagele discussed inequities in stroke burden among Black individuals in the United States and sub-Saharan Africa, opening with the term “glocal.” A portmanteau of global and local, glocal is an encompassing term that refers to consideration of issues on both a global and local scale in a highly interconnected manner. Often used in political or business realms, Dr. Ovbiagele brought the term to the forefront in thinking about how to best address stroke disparities.
Locally in the United States, it is well known that Black individuals experience higher stroke incidence and mortality than other race and ethnic groups. While stroke mortality in the United States has been improving, including among Black individuals, the mortality inequities have not objectively diminished. Conversely, projections suggest a further widening of the Black-White stroke prevalence gap in the next decade despite better risk factor control. A more nuanced approach to assessing vascular risk factors (i.e., differential impact by race and ethnic group, or temporal factors like duration and fluctuations of risk factors) may be needed. Furthermore, psychosocial, socioeconomic, and neighborhood level factors are increasingly recognized as potential risk factors in stroke disparity. In addition to studying risk factors, Dr. Ovbiagele urged identification of strategies in reducing stroke disparities, discussing his own local randomized trial testing efficacy of Bluetooth-enabled pill trays with reminders and BP monitoring among stroke survivors, half of whom are Black individuals.
In sub-Saharan Africa, the stroke inequities for Black individuals are no better than in the United States, especially as the burden of disease in the developing world shifts from communicable to noncommunicable diseases. With fewer resources, stroke prevention has been the most favorable in terms of cost-to-benefit; however, there is an absence of location-specific practice guidelines. The SIREN (Stroke Investigative Research and Educational Network) study conducted in Nigeria and Ghana identified many of the same risk factors established in the United States for stroke, but interestingly found regional variances and a greater role for hypertension, diet, and psychosocial stress as stroke risk factors than high income nations. Further studies have been geared towards community-based interventions in management of vascular risk factors among stroke survivors.
Harmonizing local and global efforts, Dr. Ovbiagele discussed SIREN’s collaboration with the REGARDS (REasons for Geographic and Racial Differences in Stroke) study of the United States to compare differential effect of stroke risk factors by race and region. They noted higher rates of hypertension and diabetes among those of African ancestry when compared to European Americans. The difference may be driven by genetic, psychosocial, or inflammatory factors, which could represent future modifiable targets. Further observational cohort study that specifically includes participants of Indigenous Africans, Black individuals, and European Americans may better elucidate these potential targets. Additionally, Dr. Ovbiagele discussed efforts in developing stroke disparity researchers at home and abroad. At home, programs like TRANSCENDS and HEADS-UP promote development of underrepresented in medicine physician-scientists, who may be more likely to engage in stroke disparity research and mentor future physician-scientists from a diverse background. Abroad, he discussed efforts to build sustainable training programs for physician-scientists, including the NIH-funded TALENTS program, which will seek to partner U.S. institutions, African institutions, and the African Academy of Neurology in developing physician-scientist recruitment efforts, postdoctoral scholar programs, and formal coursework.
In summary, there is clearly an urgent need to better address stroke disparities, especially as the inequities are expected to worsen. As Dr. Ovbiagele highlighted, a glocal approach may open promising new avenues for collaborative and international data collection, creating scalable models of stroke care delivery models and developing sustainable physician-scientist training programs that address stroke inequities.