Is Multiple Sclerosis Underserved?

As we enter a new year still grappling with a global pandemic, we can reflect on the many lessons we have learned about the strengths and weaknesses of our health care system. The COVID-19 pandemic has especially put a spotlight on the impact social determinants of health have on disease outcomes. We have seen marginalized communities disproportionately affected by access to care, implicit bias, and decreased enrollment in clinical trials brought to the forefront of the charge to improve equality in care. Although it is disheartening that these inequities continue to exist, the situation lends itself to a unique opportunity for change. This issue of Practical Neurology seeks to shed light on the disparities in care and differences in outcomes for several underserved populations within the MS community. The goal of shining light on these areas is to increase understanding and hopefully lead to better outcomes.

Although we have an increasing number of high-efficacy disease-modifying therapies, our treatment plans still lack specific biomarkers to help us truly tailor therapy to individual patients. The quest Toward Personalized Care for Multiple Sclerosis is addressed by Dr. Thomas P. Leist who delves into the current and emergent biomarkers and how they can aid in both improving patient outcomes and understanding the underlying biology of differing phenotypes in the diverse population of everyone who is living with MS.

Next, Dr. Annette F. Okai discusses the dire need for more Inclusive Research for Multiple Sclerosis, briefly highlighting the often poor outcomes seen in Black and Hispanic/Latinx people and how the paucity of data focused on these groups and poor enrollment in clinical trials leads to difficulty generalizing data and discerning the roles of biology vs social determinants of health. She also discusses both individual and institutional barriers to trial enrollment and potential solutions.

Multiple Sclerosis in the Black Population in the United States has come to the forefront in recent years. Despite data suggesting increased incidence of disease and potentially increased risk of MS, particularly in Black women, there is still scant research to help understand these outcomes. Drs. Petra Brayo and Dorlan Kimbrough share available data around diagnosis, disease characteristics, and treatment goals.

Similarly, research on Multiple Sclerosis in the Hispanic/Latinx Population reveals poor outcomes despite a lower incidence of disease. Drs. Mirla Avila and Smathorn Thakolwiboon provide a broad overview of MS in Latin America and how characteristics, including genetic profile, compare with the Hispanic/Latinx community in the US.

Men With Multiple Sclerosis are often overlooked and underserved as a result of much lower incidence and prevalence, but may have worse outcomes. Drs. Neha V. Safi and Stephen Krieger delve into these issues including disease course, MRI characteristics, and family planning. They also address specific symptomatic management including sexual dysfunction.

As treatments improve and our patients live more productive lives, we see Multiple Sclerosis in People Over Age 55 more often. Much of our research, however, only included people age 55 or less, leaving us with a poor understanding of the utility, efficacy, and risk-benefit ratios of therapies in the setting of immunosenescence. Drs. Abedallah A. K. Balusha and Sarah A. Morrow thoroughly address these points in addition to discussing cognitive function—a concern for all MS patients, but especially those in later stages of life.

Some of the poor outcomes in underserved populations can, in part, be attributed to Comorbidity Disparities in Multiple Sclerosis. Drs. Kathryn C. Fitzgerald, Daniela Pimentel Maldonado, and Ellen M. Mowry provide a comprehensive overview of these conditions, from metabolic and cardiovascular diseases to anxiety and depression.

It has truly been my pleasure and honor to be Guest Editor of this issue. Increasing diversity of participants in clinical research, from racial and ethnic identities to sex, age, and health status is key to achieving the goal of offering truly individualized care. Although I recognize that all these problems cannot be solved in one setting, better understanding can certainly open the conversation for creating solutions to improve the lives of all people living with multiple sclerosis.