As the global population ages, Alzheimer's disease (AD) emerges as a chief concern for health systems and increasingly as a mirror reflecting the deep inequalities in access to medical advances across the world. The journey of Alzheimer's research, marked by decades of exciting scientific advances but disappointments in clinical trials, is now optimistically entering a new era of successful drug development¹. It has been over two decades since the first patient trial of Elan’s amyloid-targeting immunotherapies, the active anti-amyloid AN1792 vaccine, followed by the first passive amyloid antibody to reach late-stage Phase 3 clinical trials, Bapineuzumab. Those pioneering programs were ultimately unsuccessful, but much was learned from these and several subsequent anti-amyloid immunotherapy trials. More recently, the introduction of blood-based biomarkers is aiding in the accurate diagnosis of Alzheimer’s and in tracking treatment responses in clinical trials. Together, these advances have allowed the full approval of lecanemab, an amyloid-antibody treatment for the early symptomatic stages of Alzheimer’s disease, and others may soon follow.

However, these new treatments, primarily expensive monoclonal antibodies, are mainly studied and destined to be marketed for individuals in the predominantly white and wealthy western populations. The excitement surrounding these breakthroughs for this devastating disease brings with it an imperative question: What about the majority of Alzheimer's patients globally who belong to different ethnicities who live outside these geographies, particularly those in the LMICs?

The challenges we face in LMICs are multifaceted. The promising new therapies, predominantly tested primarily Caucasian populations in developed countries, might not address the genetic and environmental variations found across the diverse global populations most affected by Alzheimer’s. Furthermore, the high cost of these treatments, combined with the infrastructural demands for their development, distribution, and administration—such as local manufacturing facilities, specialized infusion centers, and sophisticated brain imaging—places these promising treatments beyond the reach of many who need them the most.

The reality is stark: over two-thirds of the global dementia population lives in LMICs, a proportion expected to rise to 68% by 2050. This demographic trend underscores the pressing need to ensure that clinical trials and subsequent treatments are inclusive of the populations most at risk. Current research and treatment approaches must expand their focus to encompass these underrepresented groups, as highlighted by the National Institute on Aging² which has emphasized the significant racial disparities in Alzheimer’s disease diagnosis and treatment efficacy.

As we consider the future of dementia care in LMICs, particularly in Africa, it is crucial to integrate the specific needs and circumstances of these populations into the global research and development agenda. Reflecting on the output of World Alzheimer’s Day³ ,  we must consider new strategies to ensure that the advancements in Alzheimer’s treatments benefit all of humanity, not just the privileged few. This includes advocating for more inclusive clinical trials that reflect the diverse global population affected by this disease. Events like the upcoming Nature Conferences on ‘The Future of Dementia in Africa: Advancing Global Partnerships in September 2024 (Nature Conferences) are critical in shedding light on the unique challenges faced by African nations in managing AD.

Encouragingly, the development of oral medications for Alzheimer’s offers a potential solution that could overcome many of the logistical barriers associated with parenteral treatments. Oral drugs, as currently pursued by companies like Alzheon, are in their late-stage trials, as seen on their News Page⁴ ,  and represent an easier and potentially more equitable method of administration that could be beneficial in regions lacking in healthcare infrastructure.

Also, in a recent feature by the Journal of Prevention of Alzheimer's Disease⁵ , a new direction in prevention emphasizes the need for “multimodal precision prevention.” The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability  (FINGER)⁶  has pioneered this study, demonstrating the potential of multi-domain interventions in reducing the risk of cognitive decline among older adults at risk. This approach recognizes that effective prevention strategies must not only be tailored to individual genetic, biological, and environmental factors but also consider socio-economic contexts, particularly in LMICs. By integrating these diverse data, researchers hope to design interventions that are both more effective and equitable, addressing the unique challenges these populations face.

The journey towards equitable healthcare is long and fraught with challenges. Similarly, the journey to develop effective treatments for AD, as detailed by Scientific American⁷ ,  has spanned many decades of basic science and clinical research, filled with both progress and setbacks. As we continue to make progress in understanding the basic pathophysiology of AD and identify potential targets for drug treatment, this journey must not only continue but also expand its vision to include those who are often overlooked in clinical trials and health policy planning.

In this transformative era, Bio Usawa is committed to being at the forefront of this evolution, advocating for more inclusive clinical trials that reflect the diversity of the global population affected by AD. Our mission at Bio Usawa is to make healthcare accessible by developing effective and affordable medical treatments for individuals in LMICs and to address these disparities. Our approach includes collaborating with international partners to conduct trials in diverse populations and investing in local healthcare infrastructures to facilitate access to advanced treatments. By focusing on these areas, we aim not only to bridge the gap between cutting-edge medical innovations and local access but also to ensure that these advancements are equitably shared with the populations that need them the most.

The fight against Alzheimer’s disease is not just a medical challenge; it is a moral imperative to ensure that no individual, regardless of their economic or geographic circumstance, is left behind. Only with the concerted global efforts of all stakeholders and an overarching commitment to equity will we finally turn the tide against this disease and offer hope to millions of people around the world.

References:

1.     Bairu M, Weiner M. Global Clinical Trials for Alzheimer’s Disease: Design, Implementation, and Standardization. Edition Academic Press; 2024.

2.     National Institute on Aging. Data Shows Racial Disparities in Alzheimer’s Disease Diagnosis Between Black and White Research Study Participants. December 16, 2021. Accessed June 11, 2024. https://www.nia.nih.gov/news/data-shows-racial-disparities-alzheimers-disease-diagnosis-between-black-and-white-research

3.     Bairu M. On World Alzheimer’s Day, Emerging Nations Need New Commitments to Research. LinkedIn. September 22, 2015. Accessed June 11, 2024. https://www.linkedin.com/pulse/world-alzheimers-day-emerging-nations-need-new-menghis-bairu-md/

4.     Alzheon Inc. News Page. Accessed June 11, 2024. https://alzheon.com/alzheon-news/

5.     Barbera M, Perera D, Matton A, et al. Multimodal Precision Prevention – A New Direction in Alzheimer’s Disease. Journal of Prevention of Alzheimer's Disease. 2023;4(10):718-728.

6.     Rosenberg A, Ngandu T, Rusanen M, et al. Multidomain Lifestyle Intervention Benefits a Large Elderly Population at Risk for Cognitive Decline and Dementia Regardless of Baseline Characteristics: The FINGER Trial. Alzheimer’s and Dementia. 2018;14:263-270.

7.     Andreou A, Nigam M. Opinion: The Unequal Burden of Early Dementia on Black Americans and How We can Change It. Scientific American. May 3, 2024. Accessed June 11, 2024. https://www.scientificamerican.com/article/the-unequal-burden-of-early-dementia-on-black-americans-and-how-we-can/