The Mystery of the Southeast Stroke Belt

Trecolia Bussey often slept with her hair wrapped tightly in a scarf to keep her hairdo intact. So when she woke up one morning with a bad headache in July 2002, she wasn't too worried. The former cosmetics director from Durham, N.C., still planned to sit in on a seminar that day at the conference she was attending in Dallas, Texas. But as she made her way through the convention center she began to feel dizzy and her speech started to slur. Four hours later, she was in Baylor Hospital's emergency room, unable to speak. She'd suffered a brainstem stroke. "It happened in the twinkling of an eye," recalls Bussey, now 53.

Though the stroke caught Bussey off guard, her case is far from rare. Some 750,000 Americans will suffer strokes in 2005; about 160,000 will be fatal, according to the National Stroke Association. A good portion of them will occur among African-Americans like Bussey, who live in a large swath of the southeast that stretches from the Carolinas west through Louisiana and Arkansas. The region is known as the "Stroke Belt" because its residents have a 50 percent higher risk for stroke than Americans living in other parts of the country. And race is an added risk: twice as many blacks suffer strokes as whites nationally, and blacks in the South are about 50 percent more likely to die from stroke than blacks elsewhere, according to the American Heart Association. 

In late October, the Stroke Belt Consortium, a national group of doctors, researchers, pharmaceutical representatives, politicians and public health officials held their 12th annual meeting in Orlando. Though they discussed several issues, the looming questions remained: why is the incidence of stroke so high in the Stroke Belt and how can the number be lowered?
The disparity in stroke risk among residents in the southeast was first noted more than 50 years ago. Over the years, it's been attributed to the prevalence of risk factors like hypertension (high blood pressure) and the popularity of high-fat diets and smoking in the region, but health experts have yet to confirm the precise reason. "This is a remarkable mystery," says Dr. George Howard, a biostatistician end epidemiologist at the University of Alabama at Birmingham.  "We should be really embarrassed that we don't know the answer."

Health officials are getting closer to finding it though. In 2002, the National Institute for Neurological Disorders and Stroke (a division of NIH) launched a $28 million study of the Stroke Belt, the first of its kind.  Howard is leading the effort to identify why the disparity exists, and why African-Americans are so disproportionately affected. Through a unique and thorough survey system that includes in-home screenings, Howard and his team should have data on 30,000 people—selected by race, gender, and region—by next fall.

Another area of concern is the disproportionately high rate of death by stroke in the region. As recently as 2001, a government study found the average number of deaths from stroke in that area was 26 percent higher than in the rest of the country. Some health experts atrribute the higher death rate in part to the fact that many Stroke Belt residents live in rural areas, so they don't have access to medical centers that specialize in stroke care. Those who live in isolated areas are also at higher risk of missing the traditional 3-hour window after a stroke hits for acute treatment to be effective. The prevalence of stroke in outlying coastal areas of the Carolinas and Georgia , for example,  is 1.2 times the rest of the belt—so high it has been dubbed the belt's "buckle."  Officials in central Alabama  have tried to address the problem in the past few years through a coordinated program with emergency medical technicians that routes patients using real-time computers to emergency rooms that have an open bed and a neurologist or neurosurgeon on staff—a sort of air traffic control for stroke. And in North Carolina, there is an effort to certify stroke centers in accordance with the national Joint Commission on Accreditation of Healthcare Organizations so that they meet the same high standards.

Medical professionals and health advocates are also expanding their efforts to lower the incidence of strokes in the region. Earlier this year, Howard found that residents of the Stroke Belt were no less likely to be aware that they had high blood pressure (the number one risk factor for stroke), than those living anywhere else in the country. But he did discover that African-Americans are 40 percent less likely nationwide to have their hypertension under control once they are diagnosed. That has led to new efforts to raise awareness in the area about the importance of reducing hypertension through medication and lifestyle changes like eating fewer fatty foods and finding ways to relieve stress.

Bussey says she realized that she had high blood pressure just weeks before she suffered her stroke, but initially dismissed her symptoms as nothing serious. That's changed. In September, Bussey, who still walks with a slowed gait, spoke to around 120 mostly middle-aged African-American members of her church at a half-day screening and stroke seminar about the importance of identifying potential warning signs of stroke. In conjunction with the University of North Carolina, and with funding from the Stroke Belt Consortium, she'd set up the seminar to get to people she doubted would find out about their risk for stroke any other way.

In fact, when doctors asked members of her audience if they knew the risk factors for stroke,  few raised their hands. (Nationally, about one in three Americans tend to know the symptoms, says the National Stroke Association). Many were at risk, but hadn't realized it. The nurse practitioner who'd helped set up the seminar found that 83 percent of those screened had hypertension and 65 percent were overweight. 

The National Stroke Association estimates that an astounding 80 percent of first and recurrent strokes can be prevented through risk factor control. But many people don't realize they are at risk, nor do they recognize the often subtle warning signs that precede the nation's third-deadliest condition. Warning signs of a stroke are hard to discern: often just a strong headache, grogginess, or extremity numbness. The victim might waste critical time waiting for those to go away.

Community outreach programs like the seminar Bussey helped organize are important, say health officials, because they put stroke education into a less clinical atmosphere. Bussey has since moved to Alabama, where she is working with the American Heart Association to set up similar efforts there.

Other initiatives are aimed at salons and barber shops, through which health officials can reach many people at once. Black women suffer twice as many strokes as white women, and salons—where stylists often take on the roles of confidant and therapist—have become a nexus for community outreach.  

Cleopatra's Hair Salon in Atlanta's South DeKalb Mall is one of 11 area salons promoting stroke education through an Emory University program. The salon tends to about 400 clients weekly, and manager Charm Vega and her stylists have dispensed stroke advice to many of them, from handing out statistical literature and emergency quick-reference cards to dissuading them from patronizing the convenient southern-fried food court around the corner.

Vega, who is black, has two grandparents who suffered strokes. Though she's only 32, she recently reduced her systolic blood pressure by 70 points. "I don't have a degree, but just talking about the risk factors [helps]," Vega says. "We're able to talk about things they might not talk to other people about."

Though widespread figures are difficult to attain, there's anecdotal evidence that such efforts are already having an effect. Bussey estimates that more than half of those who attended her church workshop made immediate appointments to see doctors. "You have two choices," says Bussey. "You can be defeated by the stroke, or you can defeat the stroke." For Bussey, the answer is obvious.

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