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Respiratory Medicine
Series Editor: Sharon I.S. Rounds

Lynn B. Gerald
Cristine E. Berry Editors

Health
Disparities in
Respiratory
Medicine
Respiratory Medicine
Series Editor:
Sharon I.S. Rounds

More information about this series at http://www.springer.com/series/7665

Lynn B. Gerald • Cristine E. Berry
Editors

Health Disparities
in Respiratory Medicine
Editors
Lynn B. Gerald, PhD, MSPH Cristine E. Berry, MD, MHS
Arizona Respiratory Center and Department Arizona Respiratory Center and
of Health Promotion Sciences Department of Medicine,
Mel and Enid Zuckerman College Division of Pulmonary
of Public Health Allergy, Critical Care and Sleep Medicine
University of Arizona College of Medicine
Tucson, AZ, USA University of Arizona
Tucson, AZ, USA

ISSN 2197-7372 ISSN 2197-7380 (electronic)

Respiratory Medicine
ISBN 978-3-319-23674-2 ISBN 978-3-319-23675-9 (eBook)
DOI 10.1007/978-3-319-23675-9

Library of Congress Control Number: 2015947791

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Humana Press is a brand of Springer

Springer International Publishing AG Switzerland is part of Springer Science+Business Media
(www.springer.com)
Contents

1 Introduction to Health Disparities and Respiratory Health ............... 1

Andrew Pleasant, Jennifer Cabe, and Richard H. Carmona
2 Health Disparities in Tobacco Smoking and Smoke Exposure ........... 9
Pebbles Fagan
3 Health Disparities Related to Environmental Air Quality .................. 41
Sonali Bose and Gregory B. Diette
4 Health Disparities in Occupational Exposures..................................... 59
Kenneth D. Rosenman
5 Health Disparities and Pulmonary Function Testing .......................... 79
Joseph H. Skalski, Rachele A. Gibson, Sarah A. Narotzky,
Hemang Yadav, and Paul D. Scanlon
6 Health Disparities as They Relate to Medication Adherence ............. 105
Sandra R. Wilson, Meghan Halley, and Sarah Knowles
7 Health Disparities in ARDS ................................................................... 135
Nancy Gonzalez Casanova, Jorge R. Navarrete, Hector Quijada,
Louise Hecker, and Joe G.N. Garcia
8 Social Disparities in Lung Growth and Respiratory Health ............... 147
Kelly J. Brunst and Rosalind J. Wright
9 Health Disparities in Asthma ................................................................. 173
Christian Bime
10 Health Disparities in Chronic Obstructive Pulmonary Disease ......... 189
Miriam Siegel, Jerry A. Krishnan, Jamie Lamson-Sullivan,
Scott Cerreta, and David M. Mannino
11 Health Disparities and Tuberculosis...................................................... 207
Eyal Oren

v
vi Contents

12 Disparities in Lung Cancer Outcomes .................................................. 237

Ching-Fei Chang, Gary S. Feigenbaum, and Michael K. Gould
13 Health Disparities in Critical Illness ..................................................... 265
Daniel Monroy Chaves and John Daryl Thornton
14 Health Disparities in Sleep-Related Breathing Disorders ................... 295
Jose S. Loredo
15 Health Disparities in End-of-Life Care ................................................. 325
Ann C. Long and J. Randall Curtis
16 Where Do We Go from Here? Improving Disparities
in Respiratory Health ............................................................................. 341
Juan C. Celedón, Gary Ewart, and Patricia W. Finn

Index ................................................................................................................. 355

Contributors

Christian Bime, M.D., M.Sc. Department of Medicine, Division of Pulmonary,

Allergy, Critical Care, and Sleep Medicine, College of Medicine, University of
Arizona, Tucson, AZ, USA
Sonali Bose, M.D., M.P.H. Division of Pulmonary and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD, USA
Kelly J. Brunst, Ph.D. Department of Pediatrics, Kravis Children’s Hospital at
Mount Sinai, New York, NY, USA
Jennifer Cabe, M.A. Canyon Ranch Institute, Tucson, AZ, USA
Richard H. Carmona, M.D., M.P.H., F.A.C.S. Canyon Ranch Institute, Tucson,
AZ, USA
Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson,
AZ, USA
Nancy Gonzalez Casanova, M.D., M.P.H. Department of Medicine, Division of
Pulmonary, Allergy, Critical Care and Sleep Medicine, College of Medicine,
University of Arizona, Tucson, AZ, USA
Juan C. Celedón Division of Pulmonary, Allergy and Immunology, Department of
Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh,
Pittsburgh, PA, USA
Scott Cerreta The COPD Foundation, Washington, DC, USA
Ching-Fei Chang, M.D. Division of Pulmonary, Critical Care, and Sleep Medicine,
University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
Daniel Monroy Chaves, M.D. Division of Pulmonary, Critical Care, and Sleep
Medicine, The MetroHealth Campus of Case Western Reserve University,
Cleveland, OH, USA

vii
viii Contributors

J. Randall Curtis, M.D., M.P.H. Division of Pulmonary and Critical Care

Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
Gregory B. Diette, M.D., M.H.S. Division of Pulmonary and Critical Care Medicine,
Johns Hopkins Hospital, Baltimore, MD, USA
Gary Ewart American Thoracic Society, Washington, DC, USA
Pebbles Fagan, Ph.D., M.P.H. Cancer Prevention and Control Program, University
of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
Gary S. Feigenbaum, M.D. Department of Internal Medicine, University of
Southern California, Keck School of Medicine, Los Angeles, CA, USA
Patricia W. Finn Department of Medicine, University of Illinois at Chicago,
Chicago, IL, USA
Joe G.N. Garcia, M.D. Senior Vice President for Health Sciences, Department of
Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine,
College of Medicine, University of Arizona, Drachman Hall, Tucson, AZ, USA
Rachele A. Gibson, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Michael K. Gould, M.D., M.S. Department of Research and Evaluation, Kaiser
Permanente Southern California, Pasadena, CA, USA
Meghan Halley, Ph.D., M.P.H. Palo Alto Medical Foundation Research Institute,
Palo Alto, CA, USA
Louise Hecker, Ph.D. Department of Medicine, Division of Pulmonary, Allergy,
Critical Care and Sleep Medicine, College of Medicine, University of Arizona,
Tucson, AZ, USA
Sarah Knowles, Ph.D., M.P.H. Palo Alto Medical Foundation Research Institute,
Palo Alto, CA, USA
Jerry A. Krishnan Breathe Chicago Center, Division of Pulmonary, Critical Care,
Sleep and Allergy, University of Illinois in Chicago, Chicago, IL, USA
Jamie Lamson-Sullivan The COPD Foundation, Washington, DC, USA
Ann C. Long, M.D., M.S. Division of Pulmonary and Critical Care Medicine,
Harborview Medical Center, University of Washington, Seattle, WA, USA
Jose S. Loredo, M.D., M.S., M.P.H. Department of Medicine, University of
California San Diego School of Medicine, San Diego, CA, USA
David M. Mannino, M.D. Department of Preventive Medicine and Environmental
Health, University of Kentucky College of Public Health, Lexington, KY, USA
Sarah A. Narotzky, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Contributors ix

Jorge R. Navarrete, M.D. Department of Medicine, Division of Pulmonary,

Allergy, Critical Care and Sleep Medicine, College of Medicine, University of
Arizona, Tucson, AZ, USA
Eyal Oren, Ph.D., M.S. Department of Epidemiology and Biostatistics, Mel and
Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
Andrew Pleasant, Ph.D. Canyon Ranch Institute, Tucson, AZ, USA
Hector Quijada, B.S. Department of Medicine, Division of Pulmonary, Allergy,
Critical Care and Sleep Medicine, College of Medicine, University of Arizona,
Tucson, AZ, USA
Kenneth D. Rosenman, M.D. Department of Medicine, Michigan State University,
East Lansing, MI, USA
Paul D. Scanlon, M.D. Division of Pulmonary and Critical Care Medicine, Mayo
Clinic, Rochester, MN, USA
Miriam Siegel Department of Preventive Medicine and Environmental Health,
University of Kentucky College of Public Health, Lexington, KY, USA
Joseph H. Skalski, M.D. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
John Daryl Thornton, M.D., M.P.H. Division of Pulmonary, Critical Care, and
Sleep Medicine and Center for Reducing Health Disparities, The MetroHealth
Campus of Case Western Reserve University, Cleveland, OH, USA
Sandra R. Wilson, Ph.D. Palo Alto Medical Foundation Research Institute, Palo
Alto, CA, USA
Rosalind J. Wright, M.D., M.P.H. Department of Pediatrics, Kravis Children’s
Hospital at Mount Sinai, New York, NY, USA
Mindich Child Health and Development Institute, Icahn School of Medicine at
Mount Sinai, New York, NY, USA
Hemang Yadav, M.B.B.S. Division of Pulmonary and Critical Care Medicine,
Mayo Clinic, Rochester, MN, USA
Chapter 1
Introduction to Health Disparities
and Respiratory Health

Andrew Pleasant, Jennifer Cabe, and Richard H. Carmona

A review of a 2014 report released by the Forum of International Respiratory

Societies makes the case for an increased focus on respiratory health crystal clear,
“the morbidity and mortality related to lung diseases is staggering. Hundreds of
millions of people are burdened with chronic respiratory conditions; four million
people die prematurely from chronic respiratory diseases each year. Respiratory
infections are the leading cause of death in developing countries [1].”
Most respiratory illnesses are avoidable. The cost of prevention—as is the case
with most chronic disease—is only a fraction of the cost of treatment. While
research is always important, we very often already know how to prevent the
millions of cases of chronic respiratory illness occurring around the world [2].
We hold a high value for basic research, but perhaps nowhere more than in
this arena is there a critically important need for applied research and informed
advocacy.
The leading respiratory diseases—where the most gain is likely—are chronic
obstructive pulmonary disease (COPD), asthma, acute respiratory infections,
tuberculosis, and lung cancer. The most fruitful areas for solutions are also very
well known and researched: the use of tobacco, indoor and outdoor air quality,
childhood immunizations, nutrition, and physical activity/exercise.
As is well demonstrated throughout this volume, access to better living conditions,
escape from poverty and unhealthy environments, and having hope for tomorrow

A. Pleasant, Ph.D. (*) • J. Cabe, M.A.

Canyon Ranch Institute, Tucson, AZ, USA
e-mail: [email protected]
R.H. Carmona, M.D., M.P.H., F.A.C.S.
Canyon Ranch Institute, Tucson, AZ, USA
Mel and Enid Zuckerman College of Public Health,
University of Arizona, Tucson, AZ, USA
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 1

L.B. Gerald, C.E. Berry (eds.), Health Disparities in Respiratory Medicine,
Respiratory Medicine, DOI 10.1007/978-3-319-23675-9_1
2 A. Pleasant et al.

are often least available to those who would benefit the most. These structural deter-
minants of health are not a mystery—we currently have the knowledge of how to
improve those. What the world lacks is the will. Our hope, and thus we are collabo-
rating on this introduction, is that collections of evidence and understanding such as
this volume will help create that will.
In this volume, you will explore complex connections between poor respiratory
health, the proximal causes, the social and environmental determinants that under-
pin those causes, and suggested solutions.
Following this introduction, in the remainder of this volume you can explore the
creation and possible responses to health disparities in regard to tobacco smoke
exposure, environmental air quality, occupational exposures, pulmonary function
testing, medication adherence, acute respiratory distress syndrome (ARDS), asthma,
COPD, tuberculosis, lung cancer, critical illness, sleep-related breathing disorders,
and end-of-life care.
First, Fagan offers insight into disparities associated with exposure to tobacco
smoke. Fagan writes, “Tobacco affects nearly every organ in the body [3] … Annual
indirect costs due to productivity losses are $150 billion [4] and medical expenses
range from $130 billion to $176 billion [4].”
Fagan accurately points out and relies on the history of reports on tobacco from
the U.S. Surgeons General—beginning with the first report now over 50 years ago
by Surgeon General Dr. Luther Terry. These reports have driven not only more sci-
entific research and significant changes in policy around the world but also helped
improve health literacy so people are better equipped to find, understand, evaluate,
communicate, and use information to make informed choices and change behaviors
in relation to their health and well-being [5, 6].
In Chap. 3, Bose and Diette take on issues of health disparities related to envi-
ronmental air quality. The pair explores disparities related to socioeconomic status,
race, gender, age, and place. While maintaining awareness that certain groups—
people in poverty, racial minorities, women, children, the elderly, those living in
developing rural areas, and inner-city residents—face an unfair burden of the
adverse effects, they also remain aware that “no one group can be ‘safe’ or immune
to the far-reaching nature of outdoor pollution as it sweeps across continents, nor to
the toxins emerging from the indoor environments that we create in our own homes
in which we purposefully seal ourselves.”
Chapter 4 takes a look at occupational exposures with a series of brief case stud-
ies on issues such as chromates, coke oven emissions, cotton dust in textile mills,
Navajo miners in uranium mines, rubber workers, exposure to silica in drilling and
mining, and work-related asthma. The chapter’s author, Rosenman, calls for
improvements in monitoring systems, including, “requiring the reporting of race in
the annual Bureau of Labor Statistics employer based survey on injuries and ill-
nesses; adding race as a core variable in worker compensation state data systems;
adding industry and occupation to the core module of the annual BRFSS survey
administered in the 50 states; and routinely collecting information about occupa-
tion/employer in medical records and making collection of such information a
1 Introduction to Health Disparities and Respiratory Health 3

requirement for future meaningful use incentives as part of the transition to elec-
tronic medical health records.”
In Chap. 5, readers will explore health disparities in the context of pulmonary
function testing. Skalski, Gibson, Narotzky, Yadav, and Scanlon explore disparities
related to access, language barriers, cultural variations among English speakers,
reference values for pulmonary function testing based on gender, age, height, and
ethnicity, and corrections based on self-reported race.
The authors of this chapter explore, in part, the two-sided nature of many
underpinning causes of health disparities—the failure of health care professionals
and systems to effectively communicate as well as the level of skills and abilities
in many of the populations they serve. In this context, the authors argue that “an
important aspect of lung function testing is that accurate testing is highly depen-
dent on patient performance.” While avoiding blaming the victims, the authors
conclude that “all of this makes PFTs more sensitive than many other medical
diagnostic tests to linguistic and cultural barriers that may exist between testing
personnel and the patient. Furthermore, for a patient to have access to accurate
PFTs, they must not only have access to a medical facility with equipment and
willingness to perform the PFTs but they must also have appropriately trained
technicians at that facility, assisted by translators when necessary, to perform max-
imal and error-free tests.”
In Chap. 6, Wilson, Halley, and Knowles explore health disparities as they relate
to medication adherence. They begin their focus by discussing disparities related to
characteristics of the health care delivery system, the physician/patient relationship,
disease and treatment regimen, and characteristics of the patient—such as age, gen-
der, health literacy, income, insurance, socioeconomic status, comorbidities, and
race and ethnicity.
As is true of discussions of disparities in general, medication adherence studies
often blame, or verge on blaming, the patients and even more frequently focus on
whether, not how, the medications were taken, while neglecting the demand side of
the equation coming from the health care system. That history is reflected in this
review of the literature to date in Chap. 6. Reflecting the state of disparities research
overall—which is the driver of the content of this book—the authors of this chapter
call for better measurement, better theory, and more equitable and practical research
and practice. We couldn’t agree more, but do suggest the argument can be taken
further in terms of the causative factors related to social determinants of health such
as health literacy, a focus on prevention versus documenting effects, and an even
stronger emphasis on identifying causes within the sick care system—the demand
side—versus placing such an emphasis on patients.
The next chapter shifts the focus to health care disparities in ARDS. Briefly
stated, ARDS is a life-threatening lung condition that prevents enough oxygen from
getting to the lungs and the blood. Casanova, Navarrete, Quijada, Hecker, and
Garcia highlight that further ARDS research studies focused on Latinos, African
Americans, Native Americans, and other minorities are needed to understand the
multifactorial causes associated with disparities. They conclude by pointing out the
4 A. Pleasant et al.

potential benefits from increased and continued studies focused on genomic and
epigenetic analysis of the risk factors underlying ARDS.
Chapter 8, written by Brunst and Wright, takes a look at the role of social stress
in asthma disparities. They suggest, “Social toxicity experienced as increased psy-
chological stress is likely a major driver of observed disparities in lung growth and
development and asthma, as well as a range of other respiratory conditions. Most
respiratory conditions likely share overlapping etiology; therefore, multiple mecha-
nistic pathways with complex interdependencies must be considered when examin-
ing the integrative influence of stress independently as well as the interaction of
social and physical environmental toxins in explaining the social patterning of
respiratory diseases. Because these factors tend to cluster in the most socially disad-
vantaged, this line of research may better inform the etiology of growing health
disparities increasingly documented for respiratory disorders.”
While we don’t disagree, we wonder if solutions to disparities might also be
discovered by looking at where they don’t exist, as well as where they do.
Communities and individuals suffering greater prevalence of disease are certainly
where researchers will identify disparities and their associations, but observing
where disease is not prevalent may be a better way to understand what changes need
to be put in place to prevent disparities from occurring at all.
Bime continues the focus on asthma by looking at disparities related to patient
factors, social and environmental factors, and factors related to health care systems
and health care professionals. Asthma is perhaps the quintessential example of
health disparities. Bime describes that situation very well and concludes with a call
for greater emphasis on “adequate representation of members of high-risk popula-
tions and minority investigators that should be involved in the research.”
The next chapter by Siegel, Krishnan, Lamson-Sullivan, Cerreta, and Mannino
focuses on health disparities in chronic obstructive pulmonary disease (COPD). The
authors point out the multitude of types of disparities in COPD that currently exist—
from death rates and frequency in various populations to perception of the disease.
They discuss disparities related to race and ethnicity, gender, age, genetic predispo-
sition, geographic residence and location of care, type of chronic illness, un- and
under-insured, work trajectory and unemployment, income inequality, and the
nature of critical care settings.
In Chap. 11, health disparities and tuberculosis (TB) become the central point of
interest. Oren argues that “as with many other diseases, the TB burden follows a
clear socioeconomic gradient, with the poorest at the most elevated risk.” For exam-
ple, Oren reports that “worldwide, one out of three persons is infected with M.
tuberculosis, with 1.5 million deaths due to TB… In the U.S.A., foreign-born per-
sons have case rates 11.5 times higher than U.S. -born persons, and among the U.S.
-born, the largest disparities are between blacks and whites; where TB rates in
blacks are 5.8 times greater than among whites, and distribution is geographically
heterogeneous, with California, Texas, New York, and Florida reporting half of all
TB cases in 2012.”
A true highlight of this volume is Chap. 12 by Chang, Feigenbaum, and Gould
that takes a definitive look at disparities in lung cancer outcomes. Taking a proactive
1 Introduction to Health Disparities and Respiratory Health 5

view and offering a series of practical and tangible recommendations to address the
issue, the authors set up the problem by arguing that “despite good intentions and
the passage of major legislation, significant social, economic, and cultural barriers
still persist that undermine access to appropriate health care for those at greatest risk
for lung cancer. Thus social revolution, rather than technological innovation, may
be the true answer to improving lung cancer mortality in America on a large scale.”
Taking a broad and holistic approach, Chang, Feigenbaum, and Gould assert that
“no matter what kind of modern miracles medicine may offer, the social paradigms
in America will ultimately define what kind of impact they achieve in regard to lung
cancer outcomes.” They suggest aggressive action to address tobacco prevention,
improvement of infrastructure and environments within poverty-stricken communi-
ties, universal health care, standardization of practices within health care, health
care professionals receiving training in cultural sensitivity, increased enrollment of
underrepresented populations in clinical trials, and a new appreciation of “the com-
plexity of lung cancer biology, including gender differences and genetic mutations,
leading to more targeted, effective, and personalized therapy.”
Health disparities in critical illness are the focus of the Chap. 13, offered by
Chaves and Thornton. As is true for much of this volume, this chapter paints a
detailed picture of the issue. The authors sum up the issue, accurately, by stating,
Race and ethnicity also continue to be used as poor substitutes for the true factors
that need to be identified including income, insurance status, location where health-
care was delivered, neighborhood of residence, and work trajectory. This not only
leads to false declarations, but it prevents the field from moving forward as it implies
that such factors and their associated outcomes are not modifiable.
Loredo offers in Chap. 14 a focus on health disparities in sleep-related breathing
disorders. For those looking for an in-depth introduction to the existing science of
sleep and sleep-related breathing issues, go no further. The case is made that while
the importance of sleep to health has only been recently recognized, the nature,
causes, and extent of disparities in sleep and sleep-related breathing disorders are
areas where more research is needed.
Health disparities in end-of-life care are the focus of Long and Curtis in Chap. 15.
The authors explore differences in end-of-life care across patient characteristics,
including gender; race and ethnicity; socioeconomic status; health literacy; and
members of the lesbian, gay, bisexual, and transgender community. It seems more
work may be needed to fully explore the extent of causes of disparities in this area
that may reflect the health care system and/or the patient and their family’s responses
to end-of-life issues. The authors conclude, “Cultural competence in end-of-life
care must be a priority for health care providers in order to improve communication
for nonwhite patients and their family members and ensure respect for informed
decisions that reflect patient and family preferences.”
Wrapping up this volume focusing on health disparities and respiratory health
issues, Celedón, Ewart, and Finn offer a chapter titled, “Where do we go from here?
Improving disparities in respiratory health.” The authors base their argument on the
all-too-well-known but under-addressed reality that “current health disparities are
not only morally unacceptable but financially unsound.”
6 A. Pleasant et al.

Causing that unwise and unsound approach is a lack of prevention of respiratory

health issues. The authors acknowledge that the modifiable risk factors for most
respiratory health issues are environmental and lifestyle risk factors—tobacco use,
air pollution, and occupation—and that those determinants are unevenly distributed
in society. To conclude, the authors call for true universal health care, more research,
a more diverse health care workforce, environmental justice, healthier lifestyles,
and advocacy.
There are two important issues, in our view however, that deserve further atten-
tion than they receive in the volume that follows. One is the importance of health
literacy as a solution. The second is a need for the scientific enterprise to begin not
only to embrace calls for more research but also to propose functional solutions and
responses to the social determinants of health.
Health literacy is being shown to be one of the strongest social determinants.
While the concept is mentioned in some—but far from all—of the chapters in this
volume, the idea is worthy of greater consideration in the realm of health disparities.
Respiratory illnesses may prove a key context in which to fully deploy the ability of
health literacy not as a diagnosis, but as a powerful tool of prevention. One issue this
volume, in its totality, makes perfectly clear is that in order to prevent and treat
respiratory illnesses, true partnerships must occur between health care professionals
and the individuals and communities they are striving to serve.
In this age, when we face shortages in qualified health care professionals, the
burden of addressing chronic diseases of all types will only succeed through forging
new partnerships between the public and the health care systems based on the best
practices of health literacy. Only then we can successfully transform our current
sick care systems into true health care systems focusing on prevention. The benefits
of that transition will be significant to all of the global community.
Finally, we close with a plea to all readers. Research is incredibly valuable—but
not when it sits on a dusty shelf for years before it is utilized. We fully embrace the
need for verification and building a body of evidence, but such a vast majority of
book chapters and journal articles simply conclude with a call for further research
that it is no wonder society does not give due heed to the lessons learned through
vigorous and reliable research. We hope that researchers will conclude with a call to
action and advocate for application of their findings. Furthermore, we hope that
readers will be inspired to implement evidence-based solutions derived from such
research.
Certainly, part of the know-do gap—the gap between what people know and
what they actually do to improve or maintain their health—has many explanations
and causes. We hope that the exceptional discussions in this text of the complex
scientific and social issues around pulmonary disease will inspire all of us to aggres-
sively translate what we know into effective and sustainable public health programs
that reduce morbidity, mortality, and cost while improving the quality of life for our
fellow citizens.
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