Multiple sclerosis (MS) awareness has increased in India, especially in the past decade. Growing awareness of the disease among medical specialists and the public and the availability of MRI in many cities in India are partly responsible. However, income inequity and the need for out-of-pocket spending create special challenges for MS care within the region. In low-income settings, some of these limitations may be partially mitigated through subsidized inpatient and outpatient care, prescription of generic and biosimilar alternatives of MS disease-modifying therapies, and remote monitoring of patients with stability. Improving the knowledge gap among medical professionals and generating country- specific guidelines are equally important. This paper will highlight some successful measures, using the example of the Mangalore Demyelinating Disease Registry.

Lekha Pandit, MD, DM, PhD

Multiple sclerosis (MS) has been recognized in India since the early 1950s, as evidenced by early publications by Indian physicians who had trained in the United Kingdom and the United States.

 In the 1990s, the rising prevalence of disease was documented through a detectable increase in hospital admissions over time.

 A decade later, in Mangalore, an industrial port city in South West India, a population-based prevalence study was conducted between 2011 and 2013.

 Age-standardized prevalence of MS relative to the world population was 7.8 per 100,000 people. This is likely a highly conservative estimate, and in our populous nation of approximately 1.4 billion, there is the possibility of approximately 110,000 people with MS. These figures align with the estimated prevalence of 106,600 people (83,800-130,300) reported by the Global Burden of Disease studies in India (2009-2019).

 Earlier literature suggested that optic nerve and spinal cord involvement was significant among admitted people with MS. However, after the availability of aquaporin-4 (AQP4) antibody IgG testing, it became clear that this involvement was more likely to signify neuromyelitis optica spectrum disorders rather than MS.

 Overall, the clinical presentation of MS in India is similar to that seen in the West.

There are approximately 2500 neurologists in India (approximately 1 neurologist per 1 million people).

 Most practice in large metropolitan cities, whereas most Indians live in rural and semirural regions, making access to quality neurological care extremely challenging. Subspecialty training is in its infancy, and there are few qualified neuroimmunologists in the country. The diagnosis of demyelinating disorders is often made in a general neurology practice. Availability of MRI scanners has improved but is limited to teaching and corporate hospitals. Special tests such as cerebrospinal fluid (CSF) oligoclonal band testing and fixed cell-based assays for myelin oligodendrocyte glycoprotein (MOG) IgG and AQP4-IgG testing are available through commercial laboratories that have collection sites in different parts of India as well as a few laboratories attached to academic centers. The costs and availability vary between cities and hospital settings.

Disease-modifying therapies (DMTs) are available and include interferon beta, glatiramer acetate, dimethyl fumarate (Tecfidera; Biogen), teriflunomide (Aubagio), fingolimod (Gilenya), natalizumab (Tysabri; Biogen), and ocrelizumab (Ocrevus; Roche), which are mostly imported. More than 70% of patients in low/middle-income countries cannot access these due to the high costs.

 In India, less than 40% of the population has insurance coverage and most treatments are out-of-pocket expenditures.

 Most insurance providers also do not cover MS treatments. The few that do require a coverage period of 5 years before they will pay for the treatments.

Currently, Indian companies manufacture generics for fingolimod, dimethyl fumarate, and teriflunomide, which are cheaper than the original formulations.

There are several manufacturers of the rituximab biosimilar, which has been used in MS therapy.

 In 2023, the World Health Organization approved the inclusion of 3 DMTs—rituximab, cladribine, and glatiramer acetate—on the Essential Medicines List, but this has not yet been implemented in India.

Diagnostic delays and lack of affordable care make it impossible for the majority of Indian people with MS to initiate and sustain treatment. In addition, there are recurring costs for hospitalizations, MRI scans, follow-up visits, and disability-related services that take a toll on low- and middle-income families.

The Mangalore Demyelinating Disease Registry (MANDDIR): Addressing the Challenges of MS Care in South West India

MANDDIR began in 2011 as a hospital-based registry at K S Hegde Medical Academy, a teaching hospital at a private university in the coastal city of Mangalore in India. I started and continue to manage the registry with help from a rotating pool of junior neurologists, trainees, and a dedicated nurse coordinator. The neurophysiology technicians (n = 3) and physiotherapists (n = 2) who work on MANDDIR are permanent hospital employees and integral to the smooth functioning of our registry. Our multispecialty, 1000-bed hospital has a single MRI scanner (1.5T) run by general radiologists and technicians. A dedicated demyelination protocol to acquire patient images was developed by the MANDDIR team in conjunction with the radiologists. The scanner works 24 hours a day and 7 days a week, and the time to obtain an appointment is less than 24 hours. All images are stored on a cloud-based system and are available immediately.

In the initial years, MANDDIR included patients identified by our population-based survey (2011- 2013).

 Over the ensuing years (2011 to present), the registry has expanded to include patients within a radius of 500 km

 from Mangalore. Patients from other regions often enroll after being referred by their treating doctors or patient support groups or after an online search for an MS specialist. Currently, our registry has approximately 1550 patients, including 750 people with MS. A majority have low (annual family income < $6000) or middle income (annual family income ≥ $6000 -$35,000).

Patient-Friendly Initiatives for Outpatient and Inpatient Care

Our teaching hospital is based in rural Mangalore and offers subsidies for investigations and admission unlike the private or corporate hospitals in the area. In consultation with the hospital administrators, several patient-friendly initiatives were put in place to further reduce the cost of inpatient care and testing, including MRIs (

In our registry-affiliated research center, we have a small diagnostic wing where our research staff perform CSF oligoclonal band testing and live cell-based assays for MOG-IgG and AQP4-IgG testing. We were able to upgrade our electrophysiology laboratory with the purchase of a visual evoked potential machine and an optical coherence tomography unit. Charges are nominal for the reports generated from these units.

Through philanthropic donations, we developed an independent neurorehabilitation center affiliated with our registry. Our therapists have developed novel ways to engage patients and their primary caregivers during rehabilitation sessions. These include but are not limited to making video clips of their exercise program on smartphones and periodically supervising the same through WhatsApp video calls after the patients are discharged from the hospital. Because our center is based in a multispecialty hospital, the services of other departments such as psychiatry, psychology, and urology are also used for treatment of MS-related comorbidities.

Our negotiations with pharmaceutical companies allow us to purchase drugs at a discounted price (Table). It is also possible to stock generic versions of DMTs, which are significantly cheaper than the original formulations, in our pharmacy. In addition, immunosuppressants such as generic azathioprine (AZA) and mycophenolate mofetil (MMF) were made available to us at subsidized prices, including, recently, the biosimilar of rituximab. Treatment costs are reduced to less than one-third of nonsubsidized therapies (Table). We deliver drugs via courier at no cost to patients who cannot visit our center. They pay our hospital for the medications online through phone-based money transfer apps or by direct bank transfer.

All registry patients are encouraged to call our personnel on a dedicated phone line. Personnel calls are also able to receive patient reports via WhatsApp. Patients are encouraged to send prescriptions from local physician visits, soft copies of old MRI scans, and prior admission records attached to WhatsApp or email messages before their scheduled visit. Our information technology department has developed a simple, user-friendly app for MANDDIR that helps our coordinator track patients due for routine tests. Nearly 1100 patients in our registry are on regular follow-up either in person or via telephone, including 560 people with MS. Nearly 55% of patients on follow-up are adherent with medications. Among those who discontinued treatment, financial constraints, perceived lack of response, and a preference for alternative medicines were cited as reasons.

With informed consent from patients and permission from our institutional ethics committee, we have published about our experiences. Our epidemiological survey in urban Mangalore determined the prevalence of MS in South West India.

 Findings from genetic susceptibility studies showed close similarity with Western populations.

 Findings from our environmental association studies suggested that urban living, higher education, and family income were associated with MS.16 Infection with 

correlated negatively in patients compared with matched controls and suggested a protective role.

Based on MANDDIR experiences, treatment algorithms have been presented at national and regional meetings and published (

DMT choice was primarily driven by financial status. Those who had milder disease opted for generic oral medications. Rituximab was reserved for more aggressive disease. Though original formulations such as dimethyl fumarate, natalizumab, and ocrelizumab are marketed in India, none of our patients could afford these DMTs. We have highlighted the need to incorporate off-label therapies in the MS management algorithm.

 These included the effective use of MMF and AZA early in the disease course

 and relaxing the interval of rituximab infusions.

Our experience in the management of our registry was tested during the COVID-19 pandemic.

 More than 600 patients remained in telephone contact during this time, and we were able to monitor treatment adherence, deliver medications via courier, and provide advice regarding vaccine safety and necessary preventive measures. A majority of our patients opted to take the mRNA vaccine and continued MS therapies (including off-label medications) successfully, and we had no COVID-19–related deaths.

Against this backdrop, the publicity generated by MANDDIR and the support of a neurologist with interest in autoimmune disorders made it possible to lobby the Indian Academy of Neurology to start a subsection for autoimmune disorders. Annual meetings are conducted under its auspices and are attended by a national audience of neurologists and allied specialists. Currently, we run a recognized fellowship course in clinical neuroimmunology and conduct yearly workshops for trainees and new graduates. Efforts are ongoing to establish a national database of MS and related disorders.

Despite many challenges, MANDDIR developed into a sustainable model of care for people with MS through a collaborative effort with several stakeholders, including administrators, pharmaceutical companies, and philanthropists. Off-label therapies and subsidized care are at the core of our management strategy. MANDDIR is, above all, a patient-centric, physician-driven effort by a small team, and I strongly believe that our model is replicable in other low-income settings.

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Multiple Sclerosis Care in a Low/Middle-Income Setting in South West India

Multiple sclerosis (MS) is a chronic, inflammatory, and neurodegenerative condition characterized by the immune system's attack on the myelin sheath, leading to neurological dysfunction. While the prevalence of MS in Africa remains lower than in other regions, it has been rising steadily in recent years, with unique challenges hindering its effective management. These challenges include limited health care resources, inadequate diagnostic tools, financial constraints on accessing disease-modifying therapies, and a lack of trained health care professionals (HCPs). Cultural stigma surrounding MS further complicates patient care and treatment adherence. However, ongoing efforts by patient organizations, international collaborations, and local HCPs are focused on raising awareness, enhancing diagnosis and treatment access, and training HCPs. Future directions include integrating MS into national health policies, expanding education and research initiatives, and improving patient support networks. These efforts are vital in addressing the growing burden of MS in Africa and ensuring equitable access to care.

Nicholas Aderinto, MD

Multiple sclerosis (MS) is characterized by the immune system's attack on the myelin sheath, leading to inflammation and neuronal damage.

 The global burden of MS is substantial. In 2019, there were 59,345 MS incident cases and 22,439 MS deaths worldwide.

 Despite the relatively low prevalence of MS in Africa compared with other regions, in recent years there has been an increase in reported cases.

 According to the global burden of disease study, in sub-Saharan Africa, the latest estimate of MS cases is approximately 49,000, with approximately 2800 new cases yearly.

The rising number of cases highlights a critical need for effective diagnostic and therapeutic strategies tailored to sub-Saharan Africa.

 However, managing MS in this region presents distinctive challenges, including limited health care resources, inadequate infrastructure, and insufficient disease awareness among health care providers (HCPs) and the general population.

 This editorial explores current practices in MS management across sub-Saharan Africa and highlights the significant challenges that HCPs and patients face.

Despite the challenges encountered by individuals with MS in Africa, ongoing initiatives are aimed at improving the management of the disease. The unique socioeconomic, cultural, and health care systems of various African nations complicate the effective management of MS, leading to disparities in diagnosis, treatment access, and patient support. However, efforts are underway to address these issues and enhance care for those living with MS. Recent studies have focused on providing more accurate estimates of MS prevalence across the continent.

 Accurate epidemiological data is crucial for understanding the scope of MS in Africa, which has historically been underresearched compared with other regions. A 2018 study indicated that the prevalence of MS in South Africa (5-30 cases per 100,000 people) is significantly higher than previously estimated, reflecting both a true increase in cases and improved diagnostic capabilities within the health care system.

 This finding not only highlights the growing recognition of MS as a pressing public health issue in the region but also shows a commitment to advancing MS research. Additionally, these studies have prompted initiatives to train HCPs to recognize and more effectively manage MS.

Current efforts to enhance MS care in Africa emphasize the critical importance of awareness, education, and access to treatment. These elements are vital for addressing the gaps in knowledge and resources that affect the quality of care for individuals with MS. Patient organizations are at the forefront of such advocacy and outreach, offering support, education, and resources to individuals with MS and their families. Multiple Sclerosis South Africa stands out as a leading patient organization in the region, hosting annual MS Awareness Week events, organizing support groups, and advocating for government support.

In addition, organizations such as the Multiple Sclerosis International Federation (MSIF) spearhead collaborative research initiatives. One notable project, the Atlas of MS, compiles global data on MS prevalence and health care resources. As of 2023, the atlas has provided critical insights that have influenced national health policies across various countries, further emphasizing the importance of data-driven approaches in improving MS care.

 Moreover, the data derived from the atlas have been vital in advocating for increased funding and resources dedicated to MS research and care. Armed with data, patient organizations and advocates communicate the pressing needs of individuals living with MS, thereby gaining governmental and institutional support.

While ongoing efforts are being made to improve MS care in Africa, significant disparities in access to diagnostic tools and trained HCPs persist across the continent. This variation leads to considerable inequalities in the care available to patients. Africa remains predominantly rural, with countries such as Niger, Burundi, Rwanda, and Malawi having only 1 in 5 inhabitants living in urban areas.

 Despite the appeal of its megacities, Nigeria hosts the continent's largest rural population, totaling approximately 95 million people, closely followed by Ethiopia with about 85 million. In these rural regions, health care infrastructure is often severely underdeveloped, leading to limited access to diagnostic services and patients frequently experiencing significant delays in receiving accurate diagnoses.

 Studies have demonstrated that MS patients often endure symptoms for years before receiving appropriate medical care.

 A retrospective study conducted in Egypt revealed that approximately 49.3% of MS patients were initially misdiagnosed.

The shortage of trained neurologists further exacerbates these challenges. Africa has an alarming ratio of approximately 0.03 neurologists per 100,000 people, contrasting with Europe's 8.45 neurologists per 100,000.

 Moreover, the uneven distribution of health care resources further complicates matters: Most of the neurologists practice in urban areas, leaving rural areas without resources.

In addition to these diagnostic challenges, the treatment of MS in Africa comes with issues related to accessibility and affordability. The proposed 2024 revised diagnostic criteria for MS necessitate MRI findings as a key component for diagnosis.

 This shift raises important questions regarding the feasibility of implementing these criteria in resource-limited settings, particularly in many African countries where MRI availability is limited. In 2017, Africa had 0.7 MRI scanners per million people, the lowest density among 6 World Health Organization (WHO) regions.

 In several regions of Africa, access to MRI is constrained by factors such as the high cost of the equipment, the scarcity of MRI machines, and the limited number of trained radiologists capable of interpreting MRI results. These challenges are particularly pronounced in rural or underserved areas, where health care infrastructure does not support the widespread use of advanced diagnostic technologies like MRI. As a result, the proposed reliance on MRI in the diagnostic criteria could present significant barriers to accurate and timely MS diagnosis in these regions.

Disease-modifying therapies (DMTs) are essential for managing the progression of MS; however, access to these vital medications remains limited across the continent. A survey conducted by the MSIF revealed that countries like Sudan and Syria lack any approved originator DMTs.

 Among the countries surveyed, interferons were identified as the most widely available low-efficacy DMTs; 3 countries reported having no high-efficacy DMTs approved. Follow-on DMTs were available in only 50% of the countries surveyed, indicating a significant gap in treatment options. Patients are often compelled to rely on generic versions of these medications, which vary in quality and availability. The inconsistency in the supply of generics poses a considerable risk, as fluctuations in medication quality directly affect treatment efficacy and safety.

 Moreover, the high cost of branded and generic DMTs often results in nonadherence, as many patients are forced to forgo necessary treatments due to financial constraints. The annual total costs per patient with MS range from approximately USD $463 to USD $58,616, a significant burden beyond most African patients’ reach, where the combined GDP is roughly USD $3.1 trillion.

 Additionally, cultural stigma and misinformation regarding MS can further complicate care. Many individuals view MS as a form of mental illness and hold misconceptions about its causes and management.

 This stigma deters patients from seeking necessary medical attention and adhering to treatment regimens, ultimately leading to poorer health outcomes.

Integrating MS into national health policies is essential to enhance disease management across Africa. This approach would address the unique challenges people with MS face, align with broader public health goals aimed at improving health care systems and outcomes, and ensure that MS is recognized as a significant public health issue. Given the growing prevalence of MS in Africa, which has been highlighted by recent studies indicating that African countries have higher prevalence rates than previously estimated, this integration would be especially timely. A national health policy framework that includes MS could facilitate better resource allocation for diagnostic tools, treatment options, and HCP training. Countries that have integrated MS into their health policies, such as the United Kingdom's National Health Service, have reported improved patient access to care.

 It would be beneficial for African nations to adopt a similar structured approach to funding health care services to enable improvements in patient care.

Furthermore, implementation of cost-reduction strategies are needed, including government subsidies, generic medication production, and partnerships with international organizations to provide funding or medication donations. Regional collaborations could enable pooled procurement strategies to negotiate lower prices for essential MS medications. Establishing and expanding access to nonpharmacological treatments is also needed. Rehabilitation services, including physical and occupational therapy, should be integrated into public health systems through targeted training programs for HCPs, the establishment of dedicated neurorehabilitation centers, and using telemedicine to extend services to underserved areas. Culturally adapted mental health services should also be developed to address the psychological burden of MS, with a focus on counseling, support groups, and training primary workers to deliver basic mental health care.

With the rising prevalence of MS in the region, it is crucial to equip HCPs with the necessary knowledge and skills to manage the disease effectively. Current training programs often lack a specific focus on MS; consequently, many HCPs are unfamiliar with its symptoms, progression, and treatment options. Specialized training programs focusing on MS should be developed and implemented in medical schools and continuing education initiatives in Africa. Incorporating MS into neurology residency curricula can ensure that future neurologists are well-versed in the latest diagnostic criteria and treatment protocols. Online training modules could provide more accessible resources for HCPs in remote or underserved areas, allowing them to enhance their understanding of MS without requiring extensive travel.

Collaborations with international organizations, such as the MSIF, could play a pivotal role in expanding educational opportunities and facilitate knowledge exchange, offering local HCPs access to global best practices and cutting-edge research. Expanding education and training programs will lead to better diagnostic accuracy, more timely interventions, and improved overall management of MS, which would facilitate early detection and prompt initiation of treatment, both of which are vital for slowing disease progression and enhancing patient quality of life.

Establishing more networks for patients and caregivers is essential to deliver holistic support to individuals in Africa who live with MS, as collaboration facilitates access to critical information, resources, and emotional support, all vital for enhancing patients’ quality of life.

 Support groups, patient advocacy organizations, and community outreach programs empower individuals with MS and their families by creating supportive environments

 and studies have shown that community support enhances treatment adherence and well-being.

 These initiatives can also serve as platforms to raise awareness and educate the public about MS, combating stigma and misinformation. Through these efforts, support networks would be pivotal in improving individual and communal outcomes in managing MS.

Encouraging research focusing on the unique challenges and solutions relevant to the African context is paramount for advancing MS management. There is a significant gap in epidemiological data, treatment outcomes, and disease progression studies specific to African populations. Collaborative research efforts involving local universities, health care institutions, and international organizations can help fill this void. Establishing research networks dedicated to MS can promote data sharing and encourage large-scale studies that reflect the diverse experiences of individuals with MS across the continent. In addition, funding initiatives that support local researchers can stimulate innovative approaches to addressing the specific needs of African patients. Enhancing research capacity in low-resource settings benefits local populations and contributes to the global understanding of MS.

Significant challenges and promising initiatives characterize the management of MS in Africa. As the prevalence of MS continues to rise across the continent, there is a pressing need to adopt approaches that prioritize awareness, education, and equitable access to treatment. Current efforts by patient organizations, HCPs, and international collaborations are essential to foster a supportive environment for individuals living with MS, both in Africa and around the world.

 The author declares that he has no competing interests, financial or otherwise.

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Current Practices, Challenges, and Future Directions in Multiple Sclerosis Management in Sub-Saharan Africa 

Rural regions face significant health care disparities, including decreased access to insurance, increased access barriers to specialty care, worse medical outcomes, and increased mortality rates. People with multiple sclerosis (MS) residing in rural regions in the United States, as well as globally, face similar barriers to accessing MS care and experience poorer disease outcomes. Barriers to health care access include cultural and financial constraints, scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet service. The Appalachian region, which contains a high degree of rurality, experiences increased disparities compared with the rest of the nation and can be used to highlight the unique challenges rural populations face. Appalachian residents can identify as private, and mistrust is a major factor in providing health care. Increasing the quantity and retention of Appalachian providers is essential to building trust. Still, it has proved difficult due to issues with compensation, taxes, malpractice fees, adverse actions against physicians, and high turnover rates. Telehealth interventions such as Project ECHO (Extension for Community Healthcare Outcomes) have improved rural outcomes in multiple diseases, including MS, but limited technology and technological literacy in rural areas impede the implementation of these interventions. Given the increasing rural population and ongoing disparities these communities face, there is a need to develop targeted interventions to improve access and outcomes in rural populations.

Kaitlyn Palmer, MD

Jill Cochran, PhD, APRN

Marisa McGinley, DO

According to the 2020 US Census, the rural population increased from 19.3% in 2010 to 20.0% in 2020.

 Rural regions are associated with increased barriers to health care,

 The Appalachian region, which contains a high proportion of rural areas, can be used to highlight these challenges, as health disparities are often worse in both rural and urban parts of this region.

 People with multiple sclerosis (MS) residing in rural areas face similar challenges in accessing care

 although this is not as well studied. Given the significant disparities these communities face, there is a need to develop targeted interventions to improve access and outcomes in rural populations.

HEALTH CARE DISPARITIES IN RURAL REGIONS 

 varies, the definition used by the 2020 Census states that rural populations are those outside of urban areas, which are defined as a densely settled core of census blocks with a minimum population of 5000 or a minimum housing unit threshold of 2000 units.

 Over the past decade, diversity has increased in rural areas, but 76% of this population still identifies as non-Hispanic White.

 Rural residents are also more likely to lack health insurance,

 have a lower income, and face housing and food insecurity.

 However, these gaps have narrowed in recent years.

Significant differences in health care access exist between rural and urban areas. A retrospective study analyzing 474,674 patients from a large midwestern academic health center from June 2018 to March 2019 determined that patients in rural clinics had lower health care utilization, including primary care and specialty care visits, and overall worse health status than patients in urban clinics.

 A 2023 study using census block groups to evaluate access to intensive care unit beds within a 60-minute drive time across the US found that rural areas had a higher percentage of no or below-average access than urban block groups.

 Multiple barriers to access issues have been identified, including cultural and financial constraints, scarcity of services, a lack of trained physicians, insufficient public transport, and poor availability of broadband internet services.

Lack of access is likely related to the elevated morbidity and mortality seen in rural areas. Prior studies showed that rural patients with acute myocardial ischemia were less likely to undergo cardiac catheterization,

 and patients with acute ischemic stroke were less likely to be seen by a neurologist and receive thrombolysis or thrombectomy.

 A study evaluating mortality in rural compared with urban areas found that mortality rates are higher in rural areas for conditions including cerebrovascular disease, heart disease, and diabetes.

 From 1999 to 2017, the rural-urban age-adjusted mortality rate ratio for cerebrovascular disease remained stable at 1.13 in 1999 and 1.09 in 2017. However, the ratios for heart disease increased from 1.06 to 1.21 and from 1.09 to 1.30 for diabetes.

 The lack of improvement in rural-urban morbidity and mortality over the past 2 decades emphasizes the ongoing disparities faced by rural populations despite attempted interventions.

The Appalachian region includes 420 counties in 13 states, including all of West Virginia. The region roughly follows the Appalachian mountain range and covers 205,000 square miles, stretching from Mississippi to New York.

 Despite demographic and socioeconomic status similar to that of rural areas across the US, rural Appalachia continues to have even worse access to care and health outcomes; this region can be used to further highlight disparities faced by rural areas nationwide and explore unique patient perspectives.

 Appalachia experiences worse mortality from many conditions (eg, heart disease, cancer, chronic obstructive pulmonary disease, injury, stroke, and diabetes), a higher number of physically and mentally unhealthy days, increased prevalence of diabetes and obesity, increased suicide rate, and increased poisoning mortality rate compared with the US as a whole.

 These outcomes are even worse in rural compared with metro Appalachian regions.

Health care in rural areas such as Appalachia is defined by multifaceted perspectives that affect access and outcomes. Appalachian residents can define themselves as private, self-reliant, and resistant to charity.

 Trust and mistrust are major factors in a patient’s health care in rural areas,

 and Appalachian residents are less satisfied with convenience, information, quality, and courtesy of health care provided.

 Lack of access is also a possible etiology behind poorer health outcomes. Compared with the US as a whole, the Appalachian region has 12% fewer primary care physicians, 35% fewer mental health providers, 28% fewer specialists, and 26% fewer dentists, and these percentages are all worse in rural compared with metro Appalachian regions.

 Regarding neurologic care, a recent 2022 study found that Appalachian counties have between 25% and 35% less access to neurologic care within 60 miles compared with their non-Appalachian counterparts; this difference persisted even when stratified by urban and rural status.

Increasing the quantity and retention of providers in Appalachia has proven difficult. In West Virginia, the number of specialty physicians per 100,000 is 24% lower than the national average,

 and health care providers have named West Virginia the third-worst state in which physicians can practice.

 Causative factors are related to compensation, taxes, malpractice fees, adverse actions against physicians, and high turnover rates. Workforce shortages and lack of necessary diagnostic equipment add to the state’s characteristics.

Finally, rural providers have reported discrimination within these communities.

 Providers can be drawn to rural communities in part due to the closeness of the people in the area, but providers in minority groups have reported micro-aggressions, insults, harassment, and exclusion in their community, office, and the wider medical community.

 When providers are unable to establish positive relationships or find acceptance in their community, this can lead to relocation resulting in failed retention.

 Recruiting and retaining health care providers is imperative to improve access and build patient trust.

Although there is an abundance of literature describing rural health care disparities, few data are evaluating the unique challenges people with MS face in rural areas. Like other rural medical populations in the US, they may have difficulty accessing medical care. A 2007 observational study of 14,723 people with MS from the Veterans Affairs Multiple Sclerosis National Data Repository showed that veterans residing in rural areas and places farther from a medical center were less likely to have a specialty care visit.

 A study of 1518 people with MS residing in all 50 states found that those in rural areas reported greater difficulty in accessing MS-related and mental health care. Rural residents also reported more barriers, such as a lack of nearby or convenient facilities, money, or health insurance coverage, as well as an increased level of impairment compared with people with MS in urban areas.

 Most recently, a study computed geospatial access to a neurologist within 60 miles using 2022 Centers for Medicare & Medicaid Services Care Compare physician data for all US census tracts. Of 70,858 census tracts, 388 had no access to a neurologist within 60 miles, and rural regions had an 80% lower spatial access to a neurologist than urban areas.

 Access to an MS specialty center was even more limited, with 25% (17,837) of census tracts in the US not having access within 60 miles, and rural regions with 37% lower odds of having an MS center within 60 miles compared with urban areas. In addition, rural areas with higher percentages of Hispanic and Black individuals had lower access than rural communities with higher percentages of White individuals. These findings highlight the significant access needs in rural communities and the potential disparities of other important at-risk populations.

Given the lack of access to neurologists and MS specialists, it is not surprising that other studies have shown people with MS in rural areas were significantly more likely to receive their MS care at a family or general practice and reported less satisfaction with the quality of care received.

 They have also been shown to have restricted access to services separate from their MS-specific care. A study analyzing nursing home residents from June 1998 to December 2000 found that those who had previously lived in rural areas averaged significantly fewer minutes of physical, occupational, and psychological therapy and were less likely to have seen a licensed mental health specialist,

 suggesting there are undisclosed factors related to obtaining all facets of health care.

In addition to poor access to care, people with MS living in rural areas have been shown to have worse health outcomes. A study of 1518 people with MS living in all 50 states found that those in rural areas reported lower physical health- related quality of life,

 received less of the recommended combined medication and psychotherapy treatment for depression, and perceived their care was of lower quality.

 In another study, rural veterans with MS were less likely to attend specialty visits; however, veterans attending specialty visits were more likely to have an active prescription for a disease-modifying therapy (DMT).

Volume 27, Issue Theme

Multiple Sclerosis Care in a Low/Middle-Income Setting in South West India

Current Practices, Challenges, and Future Directions in Multiple Sclerosis Management in Sub-Saharan Africa

Unique Health Care Delivery Considerations in Rural America

Multiple Sclerosis Care in Latin America

LETTER FROM THE GUEST EDITOR - Volume 27, Issue Theme - December 2024