Reducing health disparities in asthma: how can progress be made

Abstract

Health disparities (recently defined as a health difference closely linked with social, economic, and/or environmental disadvantage) in asthma continue despite the presence of safe and effective treatment. For example, in the United States Black individuals have a hospitalization rate that is 6X higher than White individuals, and an asthma mortality rate nearly 3X higher. This article will discuss the current state of health disparities in asthma in the United States. Factors involved in the creation of these disparities (including unconscious bias and structural racism) will be examined. The types of asthma interventions (including case workers, technological advances, mobile asthma clinics, and environmental remediation) that have and have not been successful to decrease disparities will be reviewed. Finally, current resources and future actions are summarized in a table and in text, providing information which the allergist can use to make an impact on asthma health disparities in 2023.

Asthma is one of the most common chronic conditions in the United States. It is also a condition that highlights an unfortunate aspect of medical care in this country – that of health disparities and inequities. While progress has been made in decreasing overall asthma morbidity and mortality, disparities remain. In the following article, we will discuss the scope of asthma disparities in the United States, the factors involved in creating these disparities, interventions that have and have not proven useful in the goal of eliminating asthma disparities, and potential future interventions. We will do this around a case that highlights the challenges and potential of eliminating these disparities.

Case of T.D.

T.D. is an African American 11-year-old male who lives in the city with his mother, three of his four brothers and a cousin. T.D. has severe persistent asthma along with allergic rhinitis and eczema. He has had frequent urgent care visits and hospitalizations due to asthma and minimal clinical improvement on guideline-based asthma therapy. T.D.’s mother is not able to keep steady work due to her son’s health needs requiring her to take off from work often. His mother also has a diagnosis of anxiety and PTSD. She sees a therapist and takes medications. T.D.’s mother has limited social support from her extended family; her siblings and parents are also dealing with many difficulties of their own. There is a significant family history of loss and trauma. Several years ago T.D.’s younger brother died at 8 months from Sudden Infant Death syndrome. Another younger brother, who is now 9 years old, was born prematurely and has developmental delay. Just after T. D’s. recent hospitalization, two of his family members were murdered and one murder witnessed by his younger brother. T.D. has become extremely withdrawn. He has been diagnosed with conversion disorder (unusual reactions- non- epileptic reactions- black outs) to stressful situations. His mother’s partner has been a stable emotional and financial support for the family and lives with the family. However, he was recently arrested for unpaid parking violations and has been unable to be released due to the costs of bail. T.D.’s home was found to have mold inside and did not pass a “safe” environmental inspection by your hospital’s environmental health team. His mother was able to find a new rental home in her price range but it is in a dangerous neighborhood. T.D. tells you that he doesn’t like it because “we hear gunshots every night”. He is not allowed to go to the local park or spend much time outside due to safety concerns. T.D. has missed many days of school over the past year due to frequent asthma flare ups and has recently had to change schools when they moved. He used to be an “A” student and loved school but he is now behind his peers and is not enthusiastic about school anymore. T.D. and his family member have missed his asthma/allergy appointments. Transportation aid has been offered but his mother insists that she is able to drive them to the appointments. The mother/family was recently “hot-lined” to Children’s Services for medical neglect by their primary care clinic due to missing appointments. When you called T.D.’s mother she says that she can no longer trust you and your hospital. How do you best manage his asthma?

Definitions

Prior to proceeding, it is important to define what is being referred to when discussing health disparities. The term “health disparity” was coined around 1990, and broadly referred to worse health among socially disadvantaged people – perhaps especially those of underserved racial/ethnic groups and people who have been disadvantaged and experience oppression.(1) Recognizing the need for further clarity, the United States Department of Health and Human Services addressed these definitions in the ‘Health People’ initiative, with the most recent version being ‘Healthy People 2030’.(2) In this report, a health disparity is defined as:

“A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

As noted in their definition, health disparities can arise due to multiple attributes. In the following manuscript, we will focus on disparities that arise due to race and ethnicity. However, we clearly acknowledge that health disparities should be examined and eliminated when related to other factors as well and that intersectional identities and factors occur within individual patients which may compound experienced disparities.

The scope of the problem

Overall, asthma affects a significant proportion of the United States population. The 2020 National Health Interview Survey conducted by the CDC found that over 25 million individuals in the United States had current asthma, which equates to approximately 7.8% of the population.(3) This report found there was a disparity based on race and ethnicity. For example, among Black non-Hispanic individuals, the prevalence was 10.8% whereas among White non-Hispanic individuals, this number was only 7.6%. However, while the prevalence is somewhat higher among Black individuals, the observed asthma morbidity and mortality disparities for Black individuals are worse.

The ultimate failure of asthma care is a death caused by asthma. Among White non-Hispanic individuals, the CDC data from 2020 found that 10.8 per million died from asthma.(3) Among Black non-Hispanic individuals, this rate is nearly three times higher at 28.7 per million. Emergency department visits for a primary diagnosis of asthma show an even larger disparity. The 2019 data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) identified a rate of 43.2 per 10,000 for White individuals, yet this number was over four times higher at 164.8 per 10,000 for Black individuals.(4) Unfortunately, hospitalizations showed an even more extreme disparity, with Black individuals being hospitalized for asthma at a rate 6-times higher than for White individuals. Asthma disparities were observed in both the pediatric and adult cohorts. As shown in Figure 1, the slight increase in prevalence does not account for the significantly worse outcomes among Black individuals.

Figure 1:

Disparities seen in asthma prevalence,(3) mortality,(3) hospitalizations,(4) and ED visits.(4)

When examining ethnicity, Hispanic individuals also show significant disparities, albeit not as extreme as those between Black and White individuals separated by race. The NHAMCS survey found that emergency room visits for asthma were approximately twice as high among those of Hispanic ethnicity compared to those of non-Hispanic ethnicity (89.1 vs. 49.5 per 10,000).(4) While the mortality and hospitalization rates were similar for Hispanic and non-Hispanic individuals, there was tremendous variation within the Hispanic cohort, with those of Puerto Rican identity having some of the worst outcomes.

Factors involved in creating disparities

In 2003 the Institute of Medicine, now called the National Academy of Medicine (NAM) Committee on Understanding and Eliminating Racial and Ethnic Racism published a report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” which described the inequity in medical care experienced by Black, Hispanic, Indigenous, Native Hawaiians/Pacific Islanders, and some Asian populations and contributions to stark health disparities among these groups. The NAM report focused on the impact of racism, bias, and discrimination within health care on health disparities. The report was requested by Congress after an initial report was published under the leadership of the U.S. Health and Human Services director Margaret Heckler in 1985 describing higher health burdens and lower life expectancy for many racial and ethnic groups in comparison to people identifying as White(5, 6). The NAM report summarized that “Many sources – including health systems, healthcare providers, patients, and utilization managers – may contribute to racial and ethnic disparities in healthcare and; Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare”.

Interpersonal Racism and Bias

Interpersonal racism occurs between individuals and is described as intentional or unintentional discriminatory acts of omission or commission that are based on prejudice(7). Interpersonal racism is not uncommon in medicine and is well described within the literature. In contrast, implicit biases occur between a group or category attribute, such as being Black, and a negative evaluation, such as being violent, and typically occurs without conscious knowledge.(8) Implicit bias is seen among health care professionals at the same levels as the wider population, and evidence indicates these biases influence diagnosis and treatment decisions.(9) Interpersonal racism and implicit bias can both manifest as micro-aggressions, which are intentional or unintentional derogatory or prejudicial remarks that communicate some sort of bias toward members of marginalized groups. An example of how intentional and unintentional bias impacts care is reflected in studies that show that even when accounting for factors such as insurance coverage, Black and Hispanic patients are more likely to receive poor and/or incomplete care than those who identify as White(5).

Institutional and Structural Racism

The NAM report also summarized that “racial and ethnic disparities in healthcare occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life”(5). This summary point speaks to the much less addressed aspect of health disparities in recognizing the impact of institutional and structural racism on health outcomes for racialized groups. Structural racism “represents the totality of ways in which multiple systems and institutions interact to assert racist policies, practices, and beliefs about people in a racialized group” where institutional racism refers to racism that exists within institutions (e.g. medicine)(10, 11). In a more recent publication, the National Advisory Council on Minority Health and Health Disparities described that “one of the greatest barriers in achieving health equity has been that previous efforts have focused on the individual rather than on the systems (e.g., health care, social welfare, criminal justice, education, community) ……. so there is a need to emphasize systems change”(12).

T.D.’s case is not unusual. As shown in Figure 2, multiple factors related to structural racism contribute to the formation of asthma health disparities through persistent and pervasive ways. Contributions to health disparities relevant to severe persistent uncontrolled asthma in T.D. include the lack of opportunity for generational wealth within the Black population in the United States which continues to lead to a significant wealth gap, with resultant detriments in multiple facets affecting health.(13) A foundation of this wealth inequity was caused by the historical federal policy of housing discrimination called “Red-Lining” which has prevented wealth accumulation and led to neglected neighborhoods with lack of opportunity for home and property ownership for Black families, poor housing, disparity in safe green spaces(14), and subsequent areas with increased crime.

Figure 2:

Contributions to health disparities relevant to severe persistent uncontrolled asthma in T.D. include multiple overlapping and exacerbating factors resulting from interpersonal, institutional, and structural racism.

Similarly, schools in these communities most often inequitably funded in comparison to schools in more affluent areas and especially lack resources to adequately support students with increased medical or psychosocial needs. With such stark gaps in educational quality afforded to some students vs. others there is a direct link to increased crime in these communities and overall inequities within the criminal justice system leads to harsher and more frequent arrests and sentencing of Black, Hispanic and other non-White racial and ethnic groups(15). The compounding factors of these stressors on patients, families, and communities can also have “weathering” effects that may alter biological responses and increase risk of morbidities(16).

These intentionally neglected communities also lack access to quality primary care and especially have limited access to sub-specialty care like allergy/asthma/immunology care(17). Lack of access is due to structural barriers such as inadequate reimbursement from Medicaid programs which limit the number of asthma specialists able and willing to provide care to populations reliant on Medicaid insurance programs. This also leads to overall health care “deserts” within many communities of color especially when it comes to specialized care, requiring patients to often travel outside of their neighborhoods and communities to seek care. These types of barriers contribute to the finding that urban African American children with asthma have half the odds of having an asthma specialist in comparison to White children living in non-urban communities (18, 19). Finally, known bias within the healthcare system leads to culturally inconsiderate and inequitable care(20).

Interventions that have and have not helped decrease disparities

Despite the existence of two major asthma management guidelines: The Global Initiative for Asthma (GINA)(21) and The National Asthma Education and Prevention Program (NAEPP)(22) for over 30 years, asthma morbidity disparities remains high (see Figure 1).(23) New therapeutic advances, such as biologics offer the potential for even greater effectiveness in the treatment of severe asthma. However, concern has been raised of the lack of inclusion of Black and Hispanic participants in the clinical trials of effectiveness of these biologic agents.(24)

The disparities in asthma morbidity are not explained by a differential baseline efficacy across racial/ethnic groups of the asthma medication recommended in the two guidelines. With the increasing awareness of the role of social determinates of health in asthma disparities, the need for broader based interventions has become more obvious. The exemplar patient discussed earlier in this article brings this challenge into sharper focus.

Family/Patient

Even as interventions broaden in scope, increasing the family and patient’s ability to recognize asthma symptoms, appropriate use of medication, and the shared responsibility between parent and child for administering the medications are important steps in bringing asthma under control. What methods are effective to deliver this needed education in a challenging situation? Several interventions has been shown to be successful in disadvantaged populations. Trained community caseworks, drawn from the community, provided asthma education based on the Wee Wheezers curriculum during 6 home visits over the course of a year and resulted in improvement in asthma knowledge, symptoms, and MDI technique.(25) Other studies have expanded the asthma caseworker’s role to address the social determinants of health’s impact on the family. The National Cooperative Inner-City Asthma Study (NCICAS) demonstrated the effectiveness of a social worker trained in asthma education to help the family utilize the local safety net such as social services, food and/or rent assistance, access to medical clinics, etc., to meet some of the various challenges of their environment while at the same time increasing their asthma knowledge and skills.(26) Another variant of this model is the use of a clinic-based nurse case manager and community health worker who visited the home to both address asthma and the social determinants of health through use of the local safety net.(27) This comprehensive approach must extend beyond the patient to include the functioning of the caretaker as maternal depression and anxiety do influence health care usage and treatment adherence.(28, 29)

School

Another facet of tackling disparities is to expand our vison of how and where care can be delivered. The school setting has been found to be an alternate location for the delivery of asthma care and education. A variety of models of care have been shown to be effective in the school setting. Mobile asthma clinics staffed by knowledgeable clinicians providing care at the school have reduced asthma morbidity among both African American and Hispanic children.(30, 31) Other models have utilized a school nurse to provide asthma education\training and directly observed therapy for controller medication during school hours.(32–34) These programs have worked in conjunction with the patient’s primary care physician (PCP) to coordinate the asthma care. Involvement of the PCP has occurred through a variety of methods including telemedicine visits during school hours.(33)

Environment

Environmental factors such as allergens, molds, and indoor/outdoor pollution are important contributors to asthma morbidity. Decreasing exposure to harmful environmental elements can decrease the amount of asthma medications required to control asthma morbidly. The substandard housing present in neglected areas adds to the challenge of an environmental intervention.(35)

While some allergens such as dust mite are prevalent across the economic spectrum other allergens such as cockroach(36) or mouse(37) are more prominent among those living in poverty. Environmental interventions can be challenging. Interventions focused on a single allergen, such as an exterminator for cockroach(38), HEPA air filters (39), or dust mite-impermeable bed covers(40) have had little to no impact on asthma morbidity. However, an example of a comprehensive environmental intervention which successfully reduced dust mite and cockroach allergen exposure and subsequent asthma morbidity was the Inner-City Asthma Study (ICAS).(41) The intervention was tailored to each child’s allergen sensitization and environmental exposures including environmental allergens, mold, and environmental tobacco smoke (ETS). Over a 12-month period 5–7 home visits focused on environmental remediation with subsequent phone calls. The families were provided with high-efficiency particulate air (HEPA) vacuum cleaners, HEPA filters and mite-impermeable bed coverings, in addition to education on how to maintain a healthy home environment. The reduction of allergen levels in the homes was associated with a decrease in asthma symptom days and ED visits. Despite the intensity of the intervention, the intervention was found to be cost effective.(42)

Environmental interventions are generally focused on the patient’s home, especially the bedroom. Another important location for allergen exposure is the school. An intervention based in urban elementary schools using classroom-based HEPA filter and school-wide integrated pest management (IPM) reported no significant impact on asthma symptom days.(43) The lack of impact reported is most likely due to the failure to reduce the settled dust allergen levels in the school. Despite the findings of this study, the school remains an important site where development of effective environmental interventions can potentially have an important impact on asthma.

Unconscious bias mitigation efforts

Mitigation efforts to combat person-level racism and unconscious bias, such as implicit bias and anti-racism workshops, webinars, and didactic instruction, have become more prevalent in recent years. A 2022 systematic review of all such interventions for healthcare workers identified 25 articles for inclusion into the review.(44) Overall, these interventions increased awareness of biases among subjects, though sustained reduction of implicit bias was more difficult to achieve. Of note, most of these studies were not performed in a clinical setting, did not include a control arm, and were not conducted among primarily asthma specialists.

Technology

Technological advances have had some success in improving the care of Black, Hispanic, and other underserved communities, where high use of mobile phones offer an opportunity for innovative interventions. These include telehealth visits (which can eliminate transportation and childcare needs for an office visit) and remote monitoring, among others. Studies performed specifically among Black and Hispanic asthma patients found that interventions such as tailored text messaging, video games, and Web-based systems improved outcomes such as asthma symptoms and quality of life, though the effects of health care utilization were typically not improved.(45) However, ensuring access to any technology-based intervention is an important consideration.

And what the future holds to decrease asthma-related health disparities

In the years since Unequal Treatment was written, it has become apparent that the Guidelines do not address all groups. Implicitly, the patients in asthma guidelines(46) are healthy except for asthma, not part of marginalized groups, not very old or very young, and not lacking financial resources and health care. Most of the research whose findings become part of recommendations for patients have only a small number of Black and Hispanic subjects, yet these are the groups with highest morbidity from asthma. Few of the researchers themselves come from underrepresented groups or live in conditions that T.D. and marginalized groups must face. Patients with comorbidities or history of tobacco use are not considered. Although limited literacy is mentioned, how to address patients with limited education or English language competency is not detailed.

How can the allergist-immunologists help? Table 1 describes resources for addressing disparities related to racial and ethnic institutional and structural inequities. These resources can be used to help create medical environments that better reflect the patient population. Specifically included are resources to judge self-understanding of biases, training to avoid implicit bias and racism, and recognize resources for improving diversity and inclusivity of the workforce and the patient pool. This table may help train healthcare workers to avoid implicit bias, and micro-aggressions. The AAAAI’s Chrysalis program referenced in the Table 1 has made a significant start.

Table 1 -.

Interventions to address Interpersonal, Institutional and Systemic Racism conducted at personal and institutional levels

Intervention	Resource
Awareness and Education: Identify your own biases Invest in Personal Education	The Harvard Implicit Association Test is an online and freely accessible assessment that measures attitudes and beliefs that people may be unwilling or unable to report. IAT measures the strength of associations between concepts (e.g., black people, gay people) and evaluations (e.g., good, bad) or stereotypes (e.g., athletic, clumsy). Individual data are reported back in real time. Identifying held racial and ethnics biases is an important first step(50). Selected Literature: The 1619 Project edited by Nicole Hannah-Jones and The New York Times How to be an Anti-Racist by Ibram X. Kendi The Sum of Us: What Racism Costs Everyone and How We Can Prosper Together by Heather McGhee
Training to create culturally inclusive medical environments. to promote anti-racism, to avoid Implicit Bias and recognize structural racism and inequity	The US Department of Health and Human ServicesNational Culturally and Linguistically Appropriate Services standards are a set of 15 action steps intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health and health care organizations to implement culturally and linguistically appropriate services(51). Numerous local and national anti-racism and anti-bias training and educational resources exist(52). A few examples include The Racial Equity Institute: The Groundwater Approach: https://racialequityinstitute.org/groundwater/ Diversity Science: https://www.diversityscience.org/dt_team/benjamin-reese/ Project Implicit Educational Services(53) Dr. Quinn Capers, How Clinicians and Educators Can Mitigate Implicit Bias in Patient Care and Candidate Selection in Medical Education(54)
Workforce Initiatives: Foster, support, and develop initiatives to increase health care and scientific workforce diversity	Sponsor and mentor students and trainees from racial and ethnic backgrounds under-represented in A/I. American Academy of Allergy Asthma Immunology Chrysalis Project https://www.aaaai.org/about/service-and-stewardship/chrysalis-project Having a diverse staff can increase understanding of cultural beliefs for multiple populations, thereby building a therapeutic alliance Allergists can partner with organizations like the National Medical Association, National Hispanic Medical Association, Association of American Indian Physicians at both the national and local chapter level to mentor students interested in careers in medicine and the allergy/immunology specialty Support initiates within your institution to increase researcher diversity National Institutes of Health Diversity supplements to support under-represented students and faculty in pursuing research careers (Funding Opportunity Announcement PA-21–071). National Institutes of Health Cluster Hiring Initiative through the Faculty Institutional Recruitment for Sustainable Transformation (FIRST) initiative(55)
Research Inclusion: Implement and participate in initiatives to increase racial and ethnic diversity among clinical and translational research participants	Overall increased scientific workforce diversity is an important intervention to increased diversity among research participants and to increase focused work in health disparities. Other tools and interventions include(56): Dedicated language access services Community engaged research practices Institutional investment and partnership with under-represented and historically marginalized communities (ideally before the topic of research is discussed) Prioritize participant access and experience in trial design
Advocacy efforts to address wealth inequity, environmental injustice, food insecurity, educational inequity, and overall structural drivers of asthma health disparities	Partner with medical societies and organizations who are currently leading advocacy efforts in areas such as: Diversity, Equity, and Inclusion: What Can a Journal Do?(57) American Academy of Pediatrics Policy Statement: The Impact of Racism on Child and Adolescent Health(58) Racism and Health in the United States: A Policy Statement From the American College of Physicians(59) Food Equality Initiative™ aims to improve health and end hunger in individuals diagnosed with food allergies through access to safe and healthy food(60). Work with state and national medical associations to ensure programs such as Medicaid offer access to services, medications and technologies that have been proven to improve asthma outcomes. For example, community members that can assist patients and their health care providers with communication and access to resources. Institutions and allergists can work to address wealth inequity at the individual and community level as a social determinant of health Ensuring that all staff receive a living wage Institutions can partner to offer financial planning seminars for patients and staff The Healthy Neighborhood, Healthy Families Initiative is a multiagency collaboration between Nationwide Children’s Hospital and local, community-based organizations to revitalize historically neglected neighborhoods
Environmental Interventions Social determinants of health contribute significantly to health disparities	Allergists can impact the burden of asthma through: Case managers – nurses or social workers to education about asthma and to enable access to social services Partnering with schools to aid with medication compliance Integrated pest management to reduce allergen burden Providing letters to patients advocating for apartment repairs such as moisture reduction
Technological interventions	Increase the use of telehealth visits when appropriate to overcome access barriers. Ensure and advocate for required broadband/technology for all to prevent the “digital divide” that may be an additional barrier and potentially worsen health disparities. Use of mobile technology tools, including monitoring systems to foster adherence and guide at home asthma management Digital educational interventions tailored for the challenges African American individuals may face
Volunteer to increase appropriate care	Urban and federally qualified health care centers often do not have access to spirometry, skin prick tests, nor asthma specialists. Allergists can partner with such institutions to provide services

While the table lists steps we can take now, there is still much more that needs to be done. We can ensure that office and lab personnel attend teaching sessions on understanding and avoiding implicit and structural racism. However, to be maximally effective the currently available implicit bias training workshops need further refinement and evaluation, perhaps with more robust inclusion of behavioral and/or learning theory. This is also true regarding the technological interventions.

In 2023 and beyond we must engage in advocacy to address structural racism within and beyond our practices. Whether the workplace is an office or a laboratory in a heterogeneous or homogeneous neighborhood, whether the setting is urban or rural, we can be advocates of health equity and engagement in our community. We must campaign and vote for local, state, and national programs that support adequate health care for all and provide programs that address social determinants of health. For example, one must advocate for equal and adequate funding of public schools so that the students and the teachers are diverse, and representative of the communities served and that educational resources and the quality of education is equitable. Because schools are funded locally and because there is local segregation, schools of children from underrepresented and low-income groups have been underfunded, depriving these children and future generations of opportunities. To increase the potential pipeline of future healthcare workers and scientists from underrepresented groups, the playing field must start with an equal footing.

There are multiple system-wide contributors to the social determinants of health including pollution, global warming, affordable childcare, efficient public transportation, and food insecurity. While some of these may seem a long way from the discipline of allergy and immunology, they all have significant contributions to asthma morbidity and mortality. Likewise, T.D.’s case at first does not seem relevant to allergy –immunology, but the problems he and his family face limit their health. Supporting law makers and decision makers willing to address these factors is an important step.

As allergist-immunologists we can improve our research relevant to under-represented groups in areas in which we are experts. For example, a recent systematic review of the effectiveness of indoor allergen reduction found inconclusive results in many studies.(47) More research is needed to understand how to design effective allergen interventions especially for under-served communities. We also need to partner with behavioral scientists to better understand the role of psychological stress on our patients and how to address stress in addition to addressing the root causes (e.g. structural racism) of this stress.

We can also volunteer by visiting under-served schools and community groups, providing lectures on asthma and allergic conditions, offering visits of our practices and laboratories, and introducing children to our careers. One recent study found that social capital (the strength of an individual’s social network and community) is associated with economic mobility.(48) Children with parents of low socioeconomic (SES) status who had more connectedness with individuals with higher SES were more likely to have upward income mobility.(48) We can provide our time, expertise, and services at clinics in underserved neighborhoods and communities. Urban areas often have inadequate physician coverage, and this may be even more pronounced among specialists.(49)

Eliminating structural racism and achieving health equity is a critical but essential task. However, it is not an unsurmountable goal with intentionality and persistence. We can individually and collectively make a difference in 2023 and beyond.

Abbreviations:

PCP

Primary care provider

NHAMCS

National Hospital Ambulatory Medical Care Survey

NAM

National Academy of Medicine

ETS

Environmental tobacco smoke

HEPA

High efficiency particulate air