Apple Podcasts 
Spotify July 27, 2026
Episode 465: On Being an MS Specialist In A Country That Believed MS Was Non-Existent with Dr. Avinash Chandra
Key Takeaways
- Dr. Avinash Chandra returned to Nepal after completing his fellowship in the U.S. and discovered that multiple sclerosis was widely considered virtually non-existent.
- Establishing MS care in Nepal required overcoming significant hurdles, including high out-of-pocket costs for MRIs and treatments in a country where the average family income is $500 to $600 a month.
- Dr. Chandra innovated local adaptations for diagnosing MS, such as using shortened, highly sensitive MRI sequences and optical coherence tomography (OCT) to lower diagnostic costs.
- Due to financial limitations, clinicians in Nepal often have to rely on older, more affordable immunomodulatory treatments rather than high-efficacy disease-modifying therapies.
- A recent study from Dr. Helen Tremlett's lab analyzed sex differences in healthcare usage and found that males with MS had consistently higher doctor visit rates up to a decade before the onset of symptoms.
- European guidelines and a 30-year review of autologous hematopoietic stem cell transplantation (aHSCT) demonstrate significant benefits for relapsing MS when used before irreversible damage occurs.
During his fellowship in the United States, Dr. Avinash Chandra trained to become an MS specialist at a world-class MS center. Then he returned home to Nepal and discovered that MS was largely considered non-existent. But Dr. Chandra knew it wasn't.
In this week's episode, Dr. Chandra discusses his experience creating a framework for MS care in Nepal that hadn't existed before. He also explains the necessary trade-offs in providing costly medical treatment in a country where the average family of four lives on an income of $500 a month.
It's been well-established that males living with MS tend to experience faster and more severe disease progression than females. We're sharing results of a study that shows clear differences in healthcare use by sex up to a decade before the onset of MS.
We'll tell you about a newly published review of 30 years of data measuring the efficacy of autologous hematopoietic stem cell transplantation (aHSCT).
And we're sharing the registration details for ECTRIMS Community Patient Day (it's a free live and online event you won't want to miss!)
We have a lot to talk about! Are you ready for RealTalk MS??!
This Week: MS care in a country that considered MS non-existent :22
A study analyzed sex differences in healthcare usage between males and females with MS up to a decade before the first MS symptom develops 1:45
30 years of accumulated data show significant benefits of autologous hematopoietic stem cell transplantation in treating relapsing forms of MS 6:17
It's time to support the National MS Society's $119.6 million active investment in MS research 9:32
Dr. Avniash Chandra discusses MS care in Nepal 12:43
Share this episode 35:40
Next week 36:01
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LINKS
If your podcast app doesn't allow you to click on these links, you'll find them in the show notes at www.RealTalkMS.com
STUDY: Sex Differences in Healthcare Use Before the First Multiple Sclerosis-Related Demyelinating Event
https://www.msard-journal.com/article/S2211-0348(26)00396-2/fulltext
PLAIN ENGLISH SUMMARY: Sex Differences in Healthcare Use Before the First Multiple Sclerosis-Related Demyelinating Event
https://tremlettsmsresearchexplained.wordpress.com/2026/07/22/sex-differences-in-healthcare-use-before-the-first-multiple-sclerosis-related-demyelinating-event-explained
LISTEN: Dr. Helen Tremlett Discusses the MS Prodrome
https://realtalkms.com/321
STUDY: Autologous Stem Cell Transplantation for Multiple Sclerosis
https://pubmed.ncbi.nlm.nih.gov/41482159
REGISTER: ECTRIMS Patient Community Day
https://ectrimspatientcommunity.eu
SUPPORT: National MS Society Research
https://nationalmssociety.org/research
JOIN: The RealTalk MS Facebook Group
https://facebook.com/groups/realtalkms
REVIEW: Give RealTalk MS a rating and review
http://www.realtalkms.com/review
Follow RealTalk MS on X, @RealTalkMS_jon, and subscribe to our newsletter at our website, RealTalkMS.com.
RealTalk MS Episode 465
Guest: Dr. Avinash Chandra
Frequently Asked Questions
What is the state of MS care in Nepal?
MS care in Nepal has historically been underdeveloped, with the condition long considered rare or non-existent. Specialists like Dr. Avinash Chandra have worked to build diagnostic and care frameworks from the ground up, educating doctors and co-founding the MS Society of Nepal.
How are MS diagnostics adapted in resource-limited countries like Nepal?
Physicians use local adaptations such as shortened, highly sensitive MRI sequences and optical coherence tomography (OCT) for eye evaluations to reduce the financial burden of diagnostic testing for patients.
What did the study on sex differences in healthcare use before MS find?
The study found that males who eventually developed MS had consistently higher rates of doctor visits—ranging from nervous system and mental health to respiratory and injury-related visits—up to a decade before their first MS symptom compared to males without MS.
What are the recommendations for autologous hematopoietic stem cell transplantation (aHSCT) in MS?
European guidelines recommend aHSCT as an escalation option for individuals under 45 with an EDSS score of 5.5 or lower who experience high clinical and MRI activity despite using high-efficacy DMTs.
WEBVTT
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It's July 28th, and we have a lot to talk about.
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I consider research to be the engine that drives the future.
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And when I think about how far we've come in just the past few years,
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I can't help but feel optimistic about the prognosis for someone living with MS today.
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But things could be very different. Imagine for a moment that whatever country
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you happen to be living in determined that MS didn't really exist there.
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That means there's no MS care, no MS society, no MS research.
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My guest this week is Dr. Avinash Chandra. During his fellowship at the University
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of Buffalo, Dr. Chandra trained at a world-class MS center to become an MS specialist.
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Then he returned home to Nepal and discovered that MS was considered non-existent.
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But Dr. Chandra knew it wasn't. So he began creating a framework for MS care
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that hadn't existed before.
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He went to medical schools to educate doctors. He co-founded the MS Society of Nepal.
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And if you look up what it means to be a difference maker, I think you're going
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to find Dr. Chandra featured prominently in that description.
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But before we get to my conversation with Dr. Avinash Chandra,
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there are a few other things that you should know about.
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Women make up about 70% of the MS population, but it's been well established
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that when men are diagnosed with MS, they tend to experience faster and more
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severe disease progression than women.
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Now, why this happens isn't clear. Experts believe that hormones,
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the immune system itself, along with lifestyle and environmental factors,
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all contribute to this difference in disease course.
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Research, most notably research from Dr. Helen Tremlett's lab at the University
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of British Columbia, shows that people with MS have a higher use of health care
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in the years before they experience their first MS symptom.
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This phase of nonspecific signs and symptoms before the onset of a disease is
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called the prodromal phase,
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and researchers are interested in understanding the MS prodrome because it may
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point to how MS actually begins.
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A new study from Dr. Tremlett's lab analyzed healthcare use in Ontario,
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Canada between 1991 and 2020.
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The researchers were able to identify 35,018 people with MS,
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and as you would expect, 69% of them were women.
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Each of these individuals was statistically matched with five people who didn't have MS.
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They were matched by sex, birth year, the area they lived in when they experienced
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their first MS symptom, and the length of time they lived in Ontario.
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So, the research team grouped these 35,018 people with MS by sex and compared
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how and how often they accessed healthcare
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compared with 136,007 people without MS.
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And the researchers discovered clear differences in healthcare use by sex up
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to a decade before the onset of MS.
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The research team discovered that compared to those people of the same sex without MS,
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beginning 10 years before MS onset, males had consistently higher rates of nervous
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system-related visits to the doctor than females.
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These rates peaked in the year before the onset of MS at 28.6 times higher for
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males and 13.6 times higher for females.
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Beginning four years before MS onset, males had consistently higher rates of
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mental health visits to the doctor than did females, peaking in the year before
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MS onset at three times higher for males
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and 2.1 times higher for females.
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Beginning three years before MS onset, males had higher rates of ill-defined
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signs or symptoms and injury-related visits to the doctor than did females.
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Males also had higher rates of respiratory-related, genital,
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and urinary-related visits than females beginning two years before MS onset.
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And in the year before MS onset, males had higher rates of healthcare usage
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for muscle and skeleton-related, digestive and infection-related visits to the
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doctor than did females.
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In all cases where sex differences were found, males who eventually developed
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MS had consistently higher doctor visit rates than females who eventually developed MS.
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It's one more piece of evidence that demonstrates men with MS have a more severe
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disease course that actually begins up to a decade before they develop the first typical MS symptom,
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which is also a significant clue that males and females living with MS have
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probably carried the disease for many years before they experience that first MS symptom.
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Now, if you'd like to review the details of this study, you'll find a link in today's show notes.
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And if you'd like to review my friend Sharon Roman's excellent plain English
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summary of this research, you'll also find that link in today's show notes.
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Finally, if you'd like to listen to Dr. Helen Tremlett explain her work exploring
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this prodromal phase of MS, you'll find that conversation in episode 321 of Real Talk MS.
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And you'll find that link in today's show notes as well.
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Today's high-efficacy disease-modifying therapies have been shown to do a great
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job at delaying progression and allowing people with relapsing-remitting MS
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to truly live their best lives.
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Unfortunately, not everyone with relapsing-remitting MS responds to these high-efficacy DMTs.
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So if you're someone living with a relapsing form of MS, what do you do when
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the high-efficacy disease-modifying therapies stop working for you?
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Well, in a 2025 consensus statement, the European Committee for Treatment and
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Research in MS and the European Society for Blood and Marrow Transplantation
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recommended autologous hematopoietic stem cell transplantation,
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or AHSCT,
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As an escalation option for highly active relapsing MS after the failure of
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at least one high-efficacy DMT and before irreversible damage. develops.
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A research team at the University of California, Irvine, reviewed more than
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30 years of data related to treating MS with autologous hematopoietic stem cell
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transplantation and discovered that AHSCT
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produced higher rates of what's referred to as no evidence of disease activity,
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which means no relapses and no new lesions.
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In fact, AHSCT produced lower annualized relapse rates and sustained functional
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gains compared with disease-modifying therapies in individuals.
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One of the studies reviewed was a randomized Phase III trial that enrolled 110
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participants with highly active relapsing-remitting MS.
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The study participants were evenly split into two groups.
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One group received AHSCT and the other group received disease-modifying therapy.
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The outcome of this clinical trial really speaks for itself.
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Disease progression occurred in 6% of the transplant recipients,
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compared with 67% of those on DMTs.
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And after 5 years, 85% of the transplant recipients remained relapse-free,
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compared with just 3% of those on DMTs.
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Transplant recipients also experienced improvement in their walking speed and
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arm function while accumulating fewer new lesions on MRI.
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While AHSCT is still considered experimental in the United States,
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European guidelines recommend AHSCT
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for people with MS who are under 45 years old with an expanded disability status
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scale or EDSS score of 5.5 or lower
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and high clinical and MRI activity despite using DMTs.
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Results from studies that focused on progressive MS have not been as positive,
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and there are multiple factors to consider in determining whether someone is
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a viable candidate for AHSCT.
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Meanwhile, if you'd like to review this analysis, you'll find that link in today's show notes.
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On this podcast, we often talk about the more than 20 different disease-modifying
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therapies that are available today.
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Well, research that's been funded by the National MS Society has contributed
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to the development of every one of those FDA-approved MS therapies.
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Today, more than half of the society-funded research projects are focused on
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stopping MS in its tracks.
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That means no new symptoms, no new damage, no more living with the uncertainty
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of what tomorrow might bring.
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There are more than 30 research projects being funded by the Society that are
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advancing biomarker research that could detect MS earlier, and early intervention
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directly translates to a better outcome for the patient.
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More than 50 society-funded research projects are working toward restoring myelin
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that's been damaged by MS, and that means regaining the function that MS has taken away.
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The pace of scientific discovery has never moved as fast as it's moving today,
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and with 80 years of progress and over a billion dollars of research investment
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behind us, we're at a pivotal moment.
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It's a moment for you to step up and support MS Research by supporting the National MS Society.
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Your donation will help power over $100 million in active research,
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accelerating the work that brings us closer to ending MS.
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We're in the final few days of the MS Society's research fundraising campaign.
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That means when you make your donation by July 31st, 100% of your gift will go to MS Research.
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Every donation in any amount counts. So if you're able, please visit nationalmssociety.org
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slash research and make a donation in whatever amount works for you.
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You'll find that link in today's show notes.
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While we're talking about research, I'll also mention that we're less than 90
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days away from the joint meeting of the European Committee for Treatment and Research in MS
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and the Americas Committee for Treatment and Research in MS,
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better known as the Joint ECTROMS and ACTROMS meeting.
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This is the largest MS research conference in the world, and it takes place
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October 21st, 22nd, and 23rd in Toronto, Canada.
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I want to remind you that on October 23rd from 3 to 6 p.m. Eastern Time,
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you can participate in the 2026 ECTROMS Patient Community Day.
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This is a live in-person and online event where you'll see some of the top MS
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experts in the world explaining the research that was presented at this joint
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ECTROMS-ACTROMS meeting in easy-to-understand language.
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You'll even be able to submit your own questions and have them answered by some
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of the best and brightest MS researchers in the world.
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I hope you'll take a moment to visit ectrumspatientcommunity.eu and register
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for what I know is going to be an amazing program.
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And you'll find that link in today's show notes.
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From discussing the very latest cutting-edge MS research and treatment,
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we're going to switch gears in a big way and talk with Dr. Avinash Chandra about
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his return to Nepal following the completion of his fellowship in the United States.
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Dr. Chandra returned to Nepal to discover that MS was considered virtually non-existent.
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So there was no MS care, no MS research, no MS society.
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And we'll learn firsthand what he decided to do about that.
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In a moment, we'll meet my guest, Dr. Avinash Chandra.
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What happens when you train at a world-class MS center in the U.S.,
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return home to practice, and discover the disease you specialize in is officially
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considered rare to non-existent in your country?
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My guest today is Dr. Avinash Chandra, a neuroimmunologist and the co-founder
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of the Multiple Sclerosis Society of Nepal, who's on a mission to build a diagnostic
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and care network from the ground up.
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Welcome to the podcast, Dr. Chandra. It's an honor to have you here.
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Thanks. Thanks so much, Jon. Thanks for having me. I'm really excited and delighted to be here.
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And talking to you, it feels like I'm back in the U.S. again when I was doing fellowship there.
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And it's been quite a long time. I'm back to Nepal and talking to you feels
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like I'm again in the U.S. So thanks. Thanks for having me.
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Well, as we're saying, you did your neuroimmunology and MS fellowship training
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in New York at Buffalo General Hospital, where you saw patients pretty much every day.
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As I just mentioned, when you returned to Nepal, the landscape was completely
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different, and MS was widely considered a rare or virtually nonexistent condition.
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What was that initial culture shock like for you as a clinician?
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And how did you begin to bridge that gap?
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Right, true. I mean, it's back 10 years, almost a decade back when I was in the U.S.
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Before that, even while in medical school, and to tell you the surprise that still in medical books,
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multiple sclerosis is written as not so common disease for Nepal and these kind
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of allied countries, like the countries which are near equator.
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So it's not so commonly found. It's still written in medical book.
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And back 10 years back, when we were studying in our medical school,
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it was just like that, that even we were taught that multiple sclerosis is more.
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For Western populations,
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the countries which are in the polar region.
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So that was pretty much taught and that was cemented in our mind.
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So when I was in, before going to U.S., I was in Singapore for a while.
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So in Singapore, also multiple sclerosis was not so much heard of.
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Not that it was very rare, but it was not very heard of.
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So when I went to U.S. and I saw the problem there, it was like there were lots
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of researches going on as it's going on right now.
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But back then there were lots of trials and lots of pathophysiology,
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to be understood for multiple sclerosis going on so,
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they were like oh we have vitamin d deficiency
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and we have this and this deficiency that's why we have more ms in in in this
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region and because you guys live near equator you get more sunlight you have
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more vitamin d you have less ms so that's what,
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was the scenario. But when I came back, when I started working.
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As a neurologist and especially an MS specialist, it was a completely different scenario.
00:16:56.260 --> 00:16:59.330
And then I wrote one paper.
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I did one research, a small research in hospital, and I tried to question,
00:17:06.150 --> 00:17:11.870
this dictum that are we really vitamin D deficient I mean if we are vitamin
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D deficient is that really
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the the the reason that we have MS because MS was not that
00:17:19.700 --> 00:17:25.350
less as it was expected so that was my surprise and just to tell you one scenario
00:17:25.350 --> 00:17:28.990
like I'm not just practicing multiple sclerosis in Nepal
00:17:29.290 --> 00:17:34.890
I have to practice the whole neurology because we are only 40-45 neurologists
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all over Nepal of 30 million people,
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So we do not have that liberty like my professors or my seniors,
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my mentors had in the U.S.
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That they would just practice multiple sclerosis.
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I'm not giving that liberty.
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I understand. Diagnosing MS in the West relies on the McDonald criteria,
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early MRI tracking, lumbar punctures.
00:18:02.320 --> 00:18:07.000
In Nepal, where health insurance coverage is minimal and the vast majority of
00:18:07.000 --> 00:18:12.660
health care costs are paid out of pocket, what does a diagnostic journey look like for a patient?
00:18:13.580 --> 00:18:20.870
Yes, that's true. I mean, all those guidelines that tell us how to diagnose
00:18:20.870 --> 00:18:23.050
or how to treat multiple sclerosis,
00:18:24.070 --> 00:18:28.630
cannot be implemented all 100% in Nepal.
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And that's what makes this disease as an expensive disease.
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So it's still regarded as the multiple sclerosis is regarded as a disease for
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the richer people because you have to get one MRI the MRI would cost almost like,
00:18:47.870 --> 00:18:52.390
let's say $150 and for a family,
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the whole the income for a month would be like under 50 to $200 $300 like for the average family.
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So it's not that easy to just get an MRI, which is one of the essential parts to see MS.
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And forget about the lumbar puncture or the other tests, because all of them
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add up the investigation prices.
00:19:24.300 --> 00:19:34.090
But given that, I mean, we still have the same diagnostic criteria and we still do multiple MRIs.
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We do lumbar punctures. We send oligoclonal bands and all those things that are required for MS.
00:19:41.310 --> 00:19:47.160
We do the OCTs for eyes to recognize MS.
00:19:47.530 --> 00:19:52.010
So we do all those kind of things. But yes, just like.
00:19:56.410 --> 00:20:04.590
When you have less abundance, you have less resources, you try to innovate more to make it adapted.
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Like the things that we have, we do not have that liberty to have all those tests at a time.
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So what we have, like I have innovated a few of the things that make us easier
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and cheaper for diagnosing MS.
00:20:23.140 --> 00:20:30.850
Like for MRI, we have shortened some sequences in the MRI, like the MRI that we should do.
00:20:31.160 --> 00:20:36.860
We do not do in the same way. We just pick up the highly sensitive sequences
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in MRI that would catch multiple sclerosis.
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So we just do that one and that brings down the cost to almost like 50% lesser than it should be.
00:20:50.090 --> 00:20:56.530
So we do like that. We like for oligoclonal bands and all those we try to prefer.
00:20:56.930 --> 00:21:04.590
I'm just giving you some examples like we try to prefer the OCT and the decoherence tomography for eyes.
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Rather than just relying on oligoclonal bands because for the lab part,
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we do not have everything available in Nepal. So we have to, again, outsource.
00:21:16.870 --> 00:21:24.330
So we have to send it to India and then get back the result from India and that
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cost the time and as well as the price.
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