MS: A Perspective on the African American Experience

Mary D. Hughes, MDMedical Director, Neuroscience Associates

University Medical Group Greenville Hospital System

Why have this teleconference?

Access to health care differs

• Women’s Health– Less likely to receive care– More likely to receive it late

• Immunization rates– Pneumonia vaccine rates 26 versus

50%– Flu vaccine rates 47 versus 66%

Difference in Type of Health care Accessed

• Increased reliance on alternative medications and home remedies

• Increased usage of health professionals such as chiropractors rather than physicians

Diseases that we know are different

• Diabetes

• Hypertension

• Heart disease

• Stroke

• Osteoporosis

Mistrust of the Health care system

Tuskegee Syphilis Experiment

“The United States government did something that was wrong-deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens…. Clearly racist.”

President Clinton’s apology

May 1997

Disparities in the Experience of Health Care

• Patient–physician communication

• Cultural competence in health care services

• Quality of clinical care

• Access to care

Demographic features of MS

• Gender– Female predominance 4:1 in Relapsing Remitting– 1:1 in Primary progressive

• Age– Onset 15-50 90% , average 30

• Race– Caucasian predominant (>90%)

• Frequency – Varies dependent on geographic location

Environmentalfactors

Abnormal immunologic response

Genetic predisposition

Infectious agent

MS

Potential Triggers for Multiple Sclerosis

So what do we know about MS across different Ethnic

backgrounds?

Epidemiology of multiple sclerosis in US veterans:VII. Risk factors for MS

“….there were insufficient numbers of black women and women of other races to permit their study.”

Kurtzke, J.Neurology 1997

Epidemiology of multiple sclerosis in US veterans:VII. Risk factors for MS

“Among black male WWII subjects, MS risk was significantly higher among those with more education, higher socioeconomic status, and higher service test score…”

Kurtzke, J.Neurology 1997

Experience in FDA trials for medications for MS

Of the 939 Patients who participated in a Phase III study for Betaseron® in secondary progressive MS patients there were:

62 African American

15 Hispanic

MS in Africa?

Multiple Sclerosis: epidemic in Kenya

Adams, AMEast African Medical Journal

1989

Review of 66 patients

Demyelinating disorder of the central nervous system occurring in black South Africans

“To date there are only 12 reported black patients from South Africa and Zimbabwe with possible MS.”

G Modi, et al.

J Neurol Neurosurg Psychiatry 2001

MS: Does ethnicity matter?

Evidence Trial

Race AA CA

Number of patients 36 616

Baseline lesions 2.3 2.6

Mean attack Rate in prior 2 years

2.4 2.6

Relapse free 48 weeks 47% 57%

Mean Relapses .73 .57

Cree et al. Annals of Neurology 2003

Evidence Trial

Race AA CA

Number of patients 36 616

Baseline lesions 2.3 2.6

Mean attack Rate in prior 2 years

2.4 2.6

Relapse free 48 weeks 47% 57%

Mean Relapses .73 .57

Cree et al. Annals of Neurology 2003

Evidence Trial

Race AA CA

Number of patients 36 616

Baseline lesions 2.3 2.6

Mean attack Rate in prior 2 years

2.4 2.6

Relapse free 48 weeks 47% 57%

Mean Relapses .73 .57

Cree et al. Annals of Neurology 2003

Common symptoms of MS

• Blurred or double vision

• Loss of vision in one eye

• Slurred or slowed speech

• Easy fatigability• Problems with

thinking

• Poor balance• Numbness or pins

and needles• Poor bladder or

bowel control• Difficulty with

walking

• Tremor

Optic Neuritis in African Americans

“The AA study patients with a single episode of demyelinating optic neuritis had visual acuities more severely affected at onset and after 1 year of follow-up compared with the white study patients and with patients in the ONTT.”

Phillip, PArchives of Neurology, 1998

Optic Neuritis in African Americans

“In the AA patients, MS occurred more frequently in a ‘neuromyelitis optica’ form.”

Phillip, PArchives of Neurology, 1998

Is it in the Genes?

Mapping Of Genes

Am. J. Hum. Genet. 74:979–1000, 2004

Proportion of European Ancestry is ~ 20% for African Americans and ~60% for Hispanic American Populations

My Inspiration