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Stroke rates are rising in Nigeria, projections suggest an epidemic in years to come – Ovbiagele

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From leading the highest number of stroke research studies in sub-Saharan Africa among vulnerable and underserved populations in the region to being the first individual of African ancestry to receive distinct international role and awards, BRUCE OVBIAGELE, a Professor of Neurology and Associate Dean at the University of California, San Francisco speaks with Associate Editor, KEMI AJUMOBI on stroke, his findings and what Nigerians need to know and do. Excerpts.

Bio

Bruce Ovbiagele is Professor of Neurology and Associate Dean at the University of California, San Francisco as well as the Physician-in-Chief at the San Francisco Veterans Affairs Health Care System. Prior to these roles, he served for six years as Professor of Neurology and Head of the Department of Neurology at the Medical University of South Carolina, the first Black Head of an academic neurology department in the country. He holds Adjunct Professorships at Favaloro University, Buenos Aires, Argentina; Capital Medical University Beijing, China; Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; and the University of Ibadan, Nigeria.

Professor Ovbiagele has expertise in leading scientific programmes, to address disparities in stroke outcomes in under-resourced communities, and his work is chronicled in more than 600 peer-reviewed articles, with over 130,000 citations. Of note, he has led the highest number of stroke research studies in sub-Saharan Africa, involving over 10, 000 individuals, with findings that have greatly advanced our knowledge of stroke mechanisms and management among vulnerable and underserved populations in the region. These studies have characterised unique aspects of stroke among Africans and tested the efficacy of clinical task shifting, polypill drug formulations, and technology solutions to improve stroke outcomes. Results from his research studies have positively influenced stroke science, practice, and policy in Africa. His research work has been recognised with the highest scientific awards from the American Academy of Neurology, American Stroke Association, and American Heart Association. For all these preeminent awards, he was the first individual of African ancestry to receive them.

He was the founding Editor-in-Chief of the World Federation of Neurology open-access journal (2014-2019) and is currently the Editor-in-Chief of the Journal of the American Heart Association.

Ovbiagele earned his medical degree from the University of Lagos, Master of Science in Clinical Research from the University of California, Los Angeles; Master of Advanced Studies in Healthcare Organisations from the University of California, San Diego, Master of Business Administration from the University of Massachusetts, Amherst, Master of Legal Studies from Washington University, Saint Louis; as well as Executive Certificates in Public Leadership and Nonprofit Leadership from Harvard University, and Global Leadership from Yale University.

What motivated you to pursue a career in neurology, and how did your Nigerian background influence your journey?

I‘ve always been intrigued by the brain and how it works. Growing up in Nigeria, I was privy to situations of stigmatisation towards people with mental health and neurological disabilities. I observed first hand as a citizen and later as a medical student at the University of Lagos, how individuals with medical conditions like stroke, epilepsy, Parkinson’s disease, and schizophrenia were treated by their families and society. Making things worse, there were few therapeutic options for these patients in our healthcare systems, and that was even when they got access to such facilities. Back then, I often thought about what it would take to better understand and address the plight of people with or at risk for neuropsychiatric challenges. I was greatly inspired by the example of Professor Thomas Lambo who was the first Western-trained psychiatrist in Africa. He conducted important research work into the nature of mental illness in Nigeria and established the first psychiatry hospital in the country. He made a tremendous difference. His achievements and contributions ultimately led him to become the Deputy Director General of the World Health Organisation.

I am eternally grateful to my dear country of origin for the rich educational and experiential exposure I received (Corona School Ikoyi, Igbobi College, Kings College, University of Lagos, Military Hospital Ikoyi, State house Dodan Barracks). My father (Bruce Ovbiagele Snr) worked in broadcasting and advertising, my mother (Helen Ovbiagele) is a novelist and worked as Woman editor for the Vanguard for several years, and my immediate younger brother (Desmond Ovbiagele) is a banker turned filmmaker. While I pursued a medical and scientific career, this pedigree steeped in verbal communication, writing, and creativity has helped me (and continues to help me) to effectively convey, persuade, and innovate in my biomedical research pursuits.

From your perspective, what are some of the key similarities and differences in the practice of neurology between Nigeria and the USA?

At first glance, there are hardly any similarities, primarily because substantial advantage the USA has in terms of resources. The USA has a higher number of neurologists to the size of the population; more diagnostic, therapeutic, and rehabilitative options, more community amenities, more research opportunities, and more continuing medical education resources than Nigeria. However, these resources are not evenly distributed, and the United States does not have a national healthcare system. As such, there are major racial and regional disparities in neurological care within the United States that negatively impact brain health outcomes and foster some similarities to what happens in Nigeria.

How do you combine being an Associate Dean at the University of California, San Francisco as well as the Physician-in-Chief at the San Francisco Veterans Affairs Health Care System?

At the San Francisco Veterans Affairs Health Care System, the Associate Dean role oversees all aspects and levels of medical research and education, while the Physician-in-Chief role oversees all aspects of clinical care delivery and health outcomes. Both roles are strongly correlated because the San Francisco Veterans Affairs Health Care System is an academic health system delivering care to almost a hundred thousand military veterans in Northern California while training medical students, medical registrars, dental students, dental registrars, pharmacy students, pharmacy registrars, physical/occupational/speech therapy students, optometry students, and nursing students and nurse practitioners. All told each year we have about 1800 trainees rotating through the San Francisco Veterans Affairs Health Care System. The organisation is also the leading research Veterans Affairs Health Care System in the USA with approximately $100 million in direct research expenditures each year.

Tell us about being the first Black head of an academic neurology department in the country.

Yes in 2012 I was privileged and humbled to become the first Black Head of a nationally accredited academic neurology department in the USA. I was in that position for six years before coming into my current role. It was a tremendous honour to lead the neurology department at the Medical University of South Carolina, which is the pre-eminent academic healthcare system in the state of South Carolina. While I certainly did not seek the position to become a “first”, after being in it for a little while, I realized the responsibility, I had to perform well and inspire more Black people to go into the field of neurology and lead within it. In 2011, Dr. Marian Wright Alderman said, “You can’t be what you can’t see”. Even though Black or African Americans account for 14% of the USA population, they represent just 2.5% of the nation’s neurologists and bear a disproportionate amount of the nation’s burden of neurological disease. As such, I was and continue to be involved in developing and leading national programs to bolster the numbers of individuals who are underrepresented in the field of neurology, and in particular academic neurology.

People are working remotely using robots to help remove brain blood clots in stroke patients

Read also: 90% of strokes attributed to high blood pressure, says Pate

Share your expertise and discoveries with us in leading scientific programmes, to address disparities in stroke outcomes in under-resourced communities

Most of the work in this regard has so far been focused on the United States, Nigeria, and Ghana. In the United States, we 1) led the Stroke PROTECT programme, which was a clinical pathway-based initiative to improve sub-optimal post-discharge utilisation of proven secondary prevention measures, after stroke hospitalisation. We showed that the PROTECT programme helped to maintain high utilisation of eight medication classes and lifestyle modification approaches after stroke, and that compared with conventional care, PROTECT was associated with a significant reduction in the occurrence of new strokes, 2) we led a pivotal study to determine the national impact of changing the clinical definition of transient ischemic attack also known as “mini-stroke”, 3) we identified the tripling of stroke prevalence among women aged 35 to 54 between 1988-2004 and found this coincided with rises in obesity prevalence among US women at midlife. This called public attention to the need for more vigorous lifestyle modification efforts, and as of 2020, a follow-up analysis showed that the surge had abated. 4) we led several pivotal analyses examining the optimal blood pressure therapeutic targets after stroke, 5) we showed that women hospitalised for acute stroke in the US were less likely than men to receive crucial evidence-based therapies, 6) we showed that Blacks in the US are less likely to receive a blood clot retrieval procedure after an acute ischemic stroke and are 60 percent more likely to experience a recurrent stroke within 2 years than their White counterparts, 7) we showed that Blacks in South Carolina aged < 65 years have experienced a rise not a decrease in stroke hospitalisations (unlike Whites and Blacks ≥ 65 years), and that Blacks in SC overall are at higher risk for dementia than whites within 5 years of ischemic stroke, 8) Leading a clinical trial testing the efficacy of a blue-toothed enabled medication tray monitoring to improve blood pressure control after stroke, 9) I led the first ever policy paper looking at stroke projections in the country entitled “Forecasting the Future of Stroke in the United States”.

In Africa, 1) we conducted the largest epidemiological investigation of stroke in sub-Saharan Africa (4000 cases and 4000 controls), which characterised key and unique characteristics associated with stroke, 2) conducted the first implementation stroke trial in sub-Saharan Africa, which suggested that text-messaging and a modest financial incentive may enhance post-stroke outcomes, 3) co-led the first genome-wide association analyses of stroke among indigenous Africans which suggested emerging roles of key proteins in the cause of stroke in indigenous Africans, 4) led a clinical trial of a nurse-guided smart-phone app intervention which showed efficacy for controlling blood pressure after stroke in Ghana and is being tested now for scaling up, 5) conducted an early phase study testing safety and prelim efficacy of a polypill formulation to reduce recurrent stroke risk in Ghana, 6) led a 760 subject case control study which helped characterise the presence and progression of heart disease and stroke risk HIV patients in Ghana, 7) co-developing a scalable mobile health-based stroke information and surveillance system.

You have led the highest number of stroke research studies in sub-Saharan Africa. How were you able to achieve this?

Through fruitful collaborations with wonderful colleagues all around the world.

Having tested the efficacy of clinical task shifting, polypill drug formulations, and technology solutions to improve stroke outcomes in Africans, what has the result been so far?
Our results so far show that these strategies have tremendous promise to prevent stroke, but we are now conducting large-scale definitive trials that include cost-effectiveness evaluations, which will be important for policymakers to be aware of once, the definitive efficacy results are all available.

How have the research studies positively influenced stroke science, practice, and policy in Africa?

Yes, a Stroke prevention and control bill was passed in the Oyo State House of Assembly in 2018, which incorporated the results of our SIREN study. Also, several of our other study results have made their way into national and international practice guidelines and policy statements.

From the American Academy of Neurology, American Stroke Association, and American Heart Association, you have received preeminent awards, and you were the first individual of African ancestry to receive them. How does this make you feel?

I feel extremely humbled. None of these recognitions reflect my individual effort. All credit to God for these blessings and I am grateful for the collegiality and support of various sponsors, mentors, mentees, and collaborators.

From starting your academic career in 2002, you did not see or have role models with a similar racial or cultural background, how are you, in your own way ensuring that the cycle of lack of mentors in science doesn’t continue?

I am trying my best to set a good example through my work and actions. Developing and implanting programmes in the United States and Africa to grow the pipeline of individuals who come from groups underrepresented in medicine and science. So far, these programmes have mentored or supported over 150 individuals, many of whom are now independently conducting outstanding research work and gaining international recognition.

What is it about stroke that everyone needs to know?

The best stroke is the stroke you never had. 80% of strokes are preventable through medication and lifestyle practices. Most strokes especially in Africa are due to 11 modifiable factors, the most important of which is hypertension. It is important to know what your risk of stroke is and manage it accordingly in consultation with your physician. Know your numbers so to speak (what are your blood pressure numbers? What are your cholesterol numbers?) It is important to know the warning signs of a stroke because it is possible that if you get to a capable hospital on time, you could limit the damage from the stroke or even reverse its effects. We say “time is brain” because with every minute after a stroke occurs, brain cells are dying and so the sooner access to appropriate medical care is secured the better in terms of salvaging brain cells at risk of dying. A common acronym to be aware of whether you might be having a stroke is “BE FAST” (balance, eyes, face, arm, speech, time). If you experience or notice a loved one (or anybody else) suddenly experience a BE FAST symptom, get them to the hospital immediately.
· B = Balance – Is the person suddenly having trouble with balance or coordination?
· E = Eyes – Is the person experiencing sudden blurred or double vision or a sudden loss of vision in one or both eyes without pain?
· F = Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person’s smile uneven?
· A = Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
· S = Speech Difficulty – Is speech slurred?
· T = Time– Stroke is an emergency. Every minute counts. Get to the hospital.

Read also: Nursing exodus threatens healthcare in key ‘Japa’ destinations

What is your heart cry for Nigeria’s healthcare delivery system? What do you have to say to the Nigerian government?

Stroke rates are rising in Nigeria and projections suggest there will be an epidemic in years to come. The clock is ticking. Of particular concern, beyond the personal and familial toll, is that strokes in Nigeria are increasingly affecting people in young adulthood to the middle aged thereby exacting societal economic costs in terms of lost productivity. Would humbly suggest that the Federal Government consider passing Federal legislation to prevent and control the substantially rising burden of stroke in Nigeria based on accruing scientific evidence obtained locally and published internationally. The Oyo State Stroke Prevention and Control Bill could be a possible template to adopt and adapt. Create an infrastructure for addressing stroke. Support public health messaging to alert people to risk factors and warning signs of stroke. Invest money in research to further understand the nature of stroke in Nigeria and develop interventions to address it.

What are some key challenges you have experienced as a neurologist and how have you overcome them?

There are always doubters, naysayers, and obstructionists, but thankfully I address them, through faith in God.

Are there any specific advancements or breakthroughs in neurology that you find particularly exciting or promising for the future?

Using novel multimodal imaging, clot-busting drugs, and cutting-edge catheter techniques, we are now able to dissolve or pull the dangerous blood clots that cause strokes directly out from a patient’s brain thereby restoring much-needed blood flow back to the brain. These techniques have also helped to expand the very narrow time window to treat stroke. Increasing research is being focused on developing neuroprotective therapies that can be applied early and keep brain cells alive shortly after a stroke. Artificial intelligence promises to ramp up the applicability of these therapeutic options and create new ones. People are working remotely using robots to help remove brain blood clots in stroke patients who are encountered in regions that might not have the experts available to do this in person. However, as noted, the best stroke is the one you never had. While developing superb stroke treatments is welcome and wonderful, the adage “prevention is better than cure” still holds true. Even with modern day techniques, only one in ten stroke patients returns 100 percent back to normal. Always know your numbers and have them under control.

How do you see the intersection of culture, race, and neurology impacting patient care, and what steps can be taken to address potential disparities or biases?

People of African ancestry experience the highest burden of stroke worldwide. This includes all the developed nations. At this point, there is no evidence that this is genetic. It seems more linked to the psychosocial stressors that people of African ancestry experience more than other groups around the world. Much more research is needed but, in the interim, addressing the social determinants of health in these cultures and regions and developing more people of African ancestry to ably care for their communities is crucial.

Facts about Nigeria on Stroke

We found that in our SIREN study in Nigeria, eleven factors predict the risk of stroke. Four are medical conditions and seven are lifestyle factors. Hypertension is the most powerful predictor of stroke. The medical conditions include hypertension, diabetes, high cholesterol, and heart disease. The lifestyle practices include regular meat consumption, low green leafy vegetable consumption, adding salt to meals at the dining table, elevated waist-hip ratio (i.e. fat around the waist), psychosocial stress, physical inactivity, and active cigarette smoking.

What is your view on brain drain in Nigeria?

The Federal Government needs to stem the medical and scientific brain drain of our best and brightest, through the initiation and maintenance of ongoing public-private partnerships to support (via financial and logistical means) research and training opportunities for aspiring local clinicians and academicians interested in enhancing neurological care and outcomes. These local partnerships could be with industry (pharmaceutical, biotech, and device companies), philanthropic foundations, professional societies, and non-governmental organizations. The government should also seek to develop and nurture relationships with international partners to provide additional funding streams, exchange information, foster network collaborations, and create consortia. The international partnerships could be high-income country governments, high-income country academic institutions, global non-governmental organisations, and world professional associations.

Concluding words

I am honoured to be a fellow of the highest scientific and medical organisations in Nigeria and Africa and hope to continue to work within these fora to strongly advance equitable brain health for all Nigerians and Africans.