SAN FRANCISCO — Many factors play into why some populations have a higher risk of having and dying from a stroke: genetics, blood pressure, cholesterol, diabetes, access to healthy food, lifestyles that do not allow for regular exercise. It’s where those factors meet — the intersection of genetics, geography, gender, race, ethnicity and quality of life — that Bruce Ovbiagele, MD, MSc, MAS, MBA, has dedicated his career to investigating.
Born and schooled in Nigeria, Ovbiagele is a vascular neurologist and chief of staff at the San Francisco VAMC whose research into stroke has shed light on what is a common cause of death around the world.
Ovbiagele originally chose to focus on stroke because it was one of the leading causes of death in Nigeria and one that disproportionately impacts vulnerable populations according to gender, race and geography. When he came to VA, he found that disparity applies to veterans, as well.
“Being in this country, I realized that veterans are a vulnerable population themselves, because of all the comorbidities,” Ovbiagele explained. “I realized that the burden of stroke is higher in veterans than the general population, and then in veterans there are differences in the burden of stroke according to race and ethnicity.”
That disparity has persisted despite the overall lowering of stroke incidents in recent decades.
“The incidence and mortality from stroke has dropped about 25% over the last two or three decades, due to better treatments for hypertension and diabetes and other things,” Ovbiagele explained. “But while it’s dropped for everybody, the gap between—let’s give one example, Blacks and whites—the gap in outcomes between them remains the same.”
And that’s a big gap. Black adults are 50% more likely to have a stroke than their white counterparts; Black men are 70% more likely to die, if they have a stroke; and Black women are twice as likely to die.
As he began his career researching stroke outcomes, Ovbiagele quickly realized that, because many of the new stroke treatments must be administered within the first few hours, they would only help a privileged group of patients. Even when a patient manages to be treated, for 9 out of 10 of them, the stroke leaves some lingering physical or neurological impact.
“I realized that my efforts should be on prevention, and particularly on prevention of stroke in communities of color.”
Much of Ovbiagele’s research has been done in Charleston, SC, one of the states in the “stroke belt,” which has the highest stroke burden in the country.
“I was amazed when I got there to practice and do research. I couldn’t believe the burden of stroke. People would have a stroke, have another one, have another one,” Ovbiagele declared. “And it’s not just racial. Obviously, there’s a regional difference, as well. Part of it is an access issue. … My interest became not just trying to understand the genetics of stroke, but also the social determinants. … [As they say] your ZIP code is more important than your genetic code.”
Ovbiagele’s research is particularly focused on how to take proven stroke prevention methods and apply them to populations that have the most challenges in adhering to treatment regimens.
It’s difficult to create an exercise regimen, if your work schedule doesn’t allow for it or if your neighborhood has no parks, he explained. And it can be daunting to eat four or five servings of fruits and vegetables a day, if your budget can’t accommodate it or if you live in a food desert.
“It’s so hard to translate the research into practice in the community,” Ovbiagele said. “And that’s what my research focuses on. … How can we better implement what we know works in a way that is translatable to that rural community? To that urban community? To areas of the country that are underserved?”
That means getting into the fine details of how patient health intersects with their day-to-day living. One way that Ovbiagele is hoping to do that is through a study on medication adherence in stroke victims in South Carolina.
“We’re giving each patient a Bluetooth-enabled blood pressure device and a Bluetooth-enabled pill tray. [Using the blood pressure monitor,] we can centrally tell what their blood pressure is in real time, day by day. [With the tray], we teach them to put their medications into the tray box. … And once they put it in, if they don’t take it [as scheduled,] it beeps for 30 minutes. And we’ll know when they take them.”
The end metric for determining efficacy will be blood pressure control after a year. However, the most valuable goal might be the conversations with the patient about why they missed their medications.
“The hypothesis is … we could use this in underserved areas to find out what’s going on,” Ovbiagele explained. “I have found, because of socioeconomic pressures and other things, [that] there’s a lot going on and the ability to adhere to treatment is a little more challenging.”
Even in the San Francisco area, which has a lower stroke burden than South Carolina, those disparities exist.
“We’re seeing the same differences in control of blood pressure in CBOCs in San Francisco and those that are more rural. Also, differences between Blacks and whites. Locally, I and my colleagues are trying to figure out ways to address that,” Ovbiagele said.
Asked whether he believes VA has the influence and power to overcome such widespread racial and geographic health barriers, he said, “I don’t know whether VA has the power, but I certainly think it should try.”