Success and Challenges for the WSO - Words from Michael Brainin, WSO President

02 Nov 2020 Words from the President

At our strategy meeting in the first year of my tenure as president in May 2019 in Milan we confirmed our mission and vision which had been laid down at our first meeting four years previously under the presidency of Stephen Davis. The vision was ‘a life free from stroke’ and our mission: ‘to reduce the burden of stroke’.

The reality still shows harsh numbers: by 2050 we can expect about 200 million stroke survivors and 106 million people with dementia and each year thereafter over 30 million new strokes, 12 million deaths from stroke and almost 5 million deaths from dementia (1).

Is our vision wrong? Is it too utopian? Wishful thinking? Wishful thinking, yes, but wrong, no.

We have no way of measuring our global input to change, but we do have means to look at the effects of single measures such as the World Stroke Day. Our slogan ‘One in four’ ‘Don’t be the one’ has attracted a large audience. In 2019, 125 registered events were taking place around the world and we registered 2 million mentions on Twitter (2). This shows that we have progressed and that, as a result, stroke awareness has been increasing. This year we have added to the campaign: “Join the Movement” and “1 in 4 adults will have a stroke but being active can help decrease your risk” and this is likely to draw even more attention.

Awareness being the first step to prevention shows that there can be effective prevention.

We have endorsed the Stroke Riskometer App and the project Cut Stroke in Half (3,4). This project is now gaining momentum. On World Stroke Day this year, the Cut Stroke in Half project was launched in Brazil. Training programs for the work force of community health workers are being implemented also by partner organisations by which they are trained to cope with the modification of behavioural risk factors in their communities. Using the Heart’s Program, a compilation of training protocols edited by the WHO and endorsed by many organisations including ours, successful best practices have been made in stroke prevention campaigns in India and neighboring countries. There is good evidence that elevated blood pressure can be reduced on a population level by community health workers. The use of the polypill for primary prevention has been recommended by us and an updated review has shown the polypill to be optimally suitable for primary prevention in many populations. Last year, a multicompartmental pill for antihypertensive treatment has been put on the WHO list of essential medicines. With the full development of this strategy we have reasonable expectations that eventually every other stroke can be prevented.

While such efforts are notable, we cannot change the spread of this fatal disease by our own efforts alone. We need the support from SSOs from all over the world and team up with alliances from related organisations, such as the World Heart Federation, the Circulatory Health Alliance, The American, European, Asian, Chinese, and Iberoamerican Stroke Organisations and also now with the newly founded African Stroke Organisation.

In acute stroke we have progressed by promoting care facilities and implementing our stroke road-map and guidelines. Last year we have also succeeded in adding Alteplase onto the list of essential medicines of the WHO. Moreover, last year we helped to monitor progress of acute stroke care settings with the WSO Angel Awards movement. Since then, dozens of stroke care hospitals have received this award, several have even reached platinum status. Many lectures, workshops, congress sessions and webinars have been held to improve stroke care. They are too numerous to be listed here. WSO sponsored travel grants and fellowships to young stroke physicians supplement these efforts. We recently decided to reduce the interval of our world congresses from biannual towards annual. This documents our efforts to reach out towards and involve the global stroke community even it is now limited to virtual events.

These encouraging efforts have been clouded by the rage of the COVID-19 pandemic.

We have learned to accept that that there is a Covid-19 world with a new set of rules that have been forced on our communities and health care systems. As a consequence, we have lost momentum. Many acute stroke patients have hesitated to seek hospital care once they notice stroke symptoms. Thus, they lose the opportunity of undergoing rapid diagnosis, timely intervention, and effective secondary prevention and rehabilitation. From very early on in the Covid-19 pandemic, during the first wave in late March and early April, we have received reports from stroke centers, regions and whole countries, that stroke admissions to hospitals have decreased. A survey conducted by Marc Fisher and colleagues showed that the decline of admissions was between 20% and 80%. Other reports confirmed these findings (5-7). In response to the delay or loss of patients reaching the acute settings we enforced the ‘Don’t Stay at Home’ campaign hoping to reach many others and convincing them to seek hospital care also during the ongoing pandemic.

In spite of some progress, we have lost momentum in our fight against stroke and the pace of change towards effectively preventing and treating stroke on a global level has slowed down considerably. Economical threats to many families, the stress to health care systems and the insufficiency of general health care in many regions in the world endanger the progress we have made. We have to adapt to the new ‘normality’ with the ongoing raging of the pandemic.

How can we pick up our activities and become effective again? I think the most important issue is to realize that effective stroke prevention also means effective protection from severe COVID-19 illness. If we reduce the number of strokes and of stroke-prone individuals among our populations, then we also reduce the risk for these people to suffer severe symptoms once they contract a COVID-19 infection. This is the reason that Richard Horton in his Lancet editorial named the pandemic a syndemic (8) because its deadly consequences are mostly seen among people with risk factors, many of which are bundles of risks for stroke as well.

Picking up pace again means joining forces with vascular prevention programs that also reduce the risk of contracting severe COVID-19 infections.

Brainin M, Feigin VL, Norrving B, Martins SCO, Hankey GJ, Hachisnki V, the World Stroke Organisation of Directors. Global prevention of stroke and dementia: the WSO Declaration. Lancet Neurology 2020; 19:487-8).
WSO Annual Report 2019, www.world-stroke.org.
Brainin M, Feigin V, Martins S, et al. Cut Stroke in Half: Polypill for primary prevention of stroke. Int J Stroke 2018; 13: 633-647;
Brainin M, Feigin V, Bath P, et al. Multi-level community interventions for primary stroke prevention: A conceptual approach by the World Stroke Organisation. Int J Stroke 2019; 14: 818-825).
Liu L, Wang D, Brainin M, et al. Approaches to global stroke care during the COVID-19 pandemic. Stroke Vasc Neurol 2020; 5: 107-109
Markus HS, Brainin M. COVID-19 and stroke- A global World Stroke Organisation perspective. Int J Stroke 2020; 15:361-364
Zhao J, Wang Y, Fisher M, et al. Slower recovery of outpatient clinics than inpatient services for stroke and other neurological diseases after COVID-19 Pandemic. CNS Neurosci Ther 2020; Oct 15. Doi:10.1111/cns.13459 Epub ahead of print. PMID:33058536
Horton R: Offline: Covid-19 is not a pandemic. Lancet 2020; 396: 874

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