SEQUINS Hall of Fame: George Howard, DrPH, on Understanding Geographic and Racial Stroke Disparities

The Society for Equity in Neuroscience (SEQUINS) will recognize several leaders in neurologic research and care during its upcoming annual conference (May 14^th) through the organization’s Hall of Fame initiative, honoring individuals whose work has helped advance equity and improve health outcomes across neuroscience. Among this year’s honorees is George Howard, DrPH, Professor Emeritus of Biostatistics at the University of Alabama at Birmingham.

Howard spent more than 20 years on faculty at UAB, where he helped shape the understanding of racial and geographic disparities in stroke and cerebrovascular disease. He is perhaps best known for leading the landmark REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, a large-scale NIH-funded cohort study that enrolled more than 30,000 participants and has produced hundreds of peer-reviewed publications examining stroke risk, mortality, and public health inequities across the United States. His broader research portfolio has also included work on stroke prevention, cardiovascular epidemiology, and major trials such as CREST-2.

In a recent Q&A with NeurologyLive^®, Howard reflected on the significance of being recognized as a SEQUINS Hall of Famer, the mentors who shaped his career in stroke epidemiology, and the major lessons learned from decades of disparities research. He also discussed why future progress may depend less on focusing solely on stroke outcomes and more on addressing the upstream factors driving disparities in hypertension, diabetes, and overall vascular risk.

NeurologyLive: What does it mean to you to be recognized as a SEQUINS Hall of Famer?

George Howard, DrPH: Of course I am honored, but what it really does is offer me the opportunity to reflect on the wonderful people who mentored me, and who I have had the great pleasure to work with over 40-plus years. Health disparities research is such a “team sport,” and I have been lucky to work with smart and very fun people over so many years.

What led you to focus on stroke disparities and population health research?

I have had several mentors, but my “medical mentor” was James Toole, MD, a neurologist at Bowman Gray School of Medicine, now Wake Forest University School of Medicine. Jim had a strong interest in the stroke belt and greatly supported my early work in that area. Once working in the area, the expansion to racial disparities followed naturally.

Your work has highlighted geographic and racial disparities in stroke. What findings have been most impactful for the field?

Most likely the sort-of-simple work on the sources of the disparities. Both racial and geographic disparities were initially documented on mortality data. There are two ways there can be high mortality, either through a high incidence or a high case-fatality.

This is a critically important distinction because if incidence is driving the disparity, then interventions need to be community-based, meaning removing the disparity in the development of the disease. Alternatively, if case-fatality is driving the difference, then interventions need to be more hospital- and medical care-based. So this information is critical to targeting interventions to reduce the disparity.

For racial disparities, really Black-White disparities, the driving force is nearly completely incidence, and so we need to focus on what can be done to reduce the burden of the development of stroke in the Black population. Alternatively, the stroke belt appears to be driven about equally by incidence and case-fatality, suggesting that more of a mixed-model approach of community and hospital interventions is needed.

How have disparities in stroke outcomes changed over time, and where do gaps remain?

Certainly a good-news/bad-news question. The good news is that stroke incidence and mortality have fallen by over 75% since the 1960s for both the Black population and for residents of the stroke belt.

The bad news is that the relative burden of the disparity has been constant, or perhaps even increased, suggesting that we have failed miserably to meaningfully reduce the disproportionate allocation of the burden of stroke.

What strategies should health systems prioritize to meaningfully reduce disparities in stroke care?

The older I get, the more I realize that perhaps I have been asking the wrong question. Perhaps we should not be focused on stroke disparities, but rather disparities in stroke risk factors.

What is it that makes the Black population have such a remarkable prevalence of hypertension and diabetes? Why does the same difference in risk factor levels, such as blood pressure levels, have a larger association with stroke risk for the Black population relative to the White population?

We need to “go upstream” to fix the problem that is causing the problem.