Growing up in rural Louisiana, my first medical education was from Bobbee, the woman next door who diagnosed and treated most things with astonishing accuracy given her lack of formal education. While she only finished sixth grade and preferred Cajun French to the English that was forced upon her, she taught me how to clean and bandage wounds, splint limbs, and most importantly, how care for people. I carried her lessons throughout medical school and training. Within 6 months of being a new attending physician, my dad called me because Bobbee’s husband was having a stroke. I called ahead to the ED and instructed them to get a non-contrast head CT and fly him to me in New Orleans, regardless of the findings. A burn he’d gotten weeks earlier while working on his car became infected, leading to MSSA endocarditis and subsequently inferior left M2 stroke.

He spent months in the neurointensive care unit. Ultimately, he was able to have significant recovery including neurorehabilitation and aortic valve replacement. Now, 12 years later, he’s independent with moderate aphasia and only complains that his visual field cut keeps him from driving. Without the team in the neurointensive care unit, he would have died. And had my dad not known what I do for a living, he would not have made it to a neurointensive care unit.

While we should all help our neighbors, access to neurocritical care should not be dependent on luck and who lives next door like it was for Bobbee’s husband. We need dependable systems and infrastructure that anticipates the needs of all who need acute neurological care, whoever they are and wherever they may be.

I tell you this not to claim a particular authority or to gain praise for a success story, but because I think it matters who is in the room when we talk about healthcare disparities. I am a public school-educated white woman from a rural community in the South. My obstacles have not included racial bias, religious persecution, or the fear and horrors faced by immigrants today.  I have colleagues and patients whose stories carry that weight too. Because of my experiences and upbringing, I brought my full intersectionality and perspective alongside my colleagues when founding HEARD. Disparity does not have a single face. It has many. All of us who have contributed to the HEARD Center are driven by the principle of neurocritical care and educational access for all and are working to overcome the barriers that stand in the way.

Infrastructure: The Foundation of Equity

Equitable neurocritical care depends on infrastructure. Access infrastructure includes hospitals, transfer networks, telemedicine and regional referral pathways that connect patients in rural or under‑resourced areas to specialists. Coverage infrastructure comprises public insurance programs like Medicaid and Medicare and the broader safety‑net funding that allow millions of Americans to seek emergency neurological care without financial ruin. Knowledge infrastructure refers to the research, training and workforce development that generate the evidence base and expertise our field relies on. When any of these pillars weakens, disparities widen. Today all three are under strain.

Access Infrastructure: Rural and Urban Deserts

Roughly one in five Americans lives in a rural area, and access to specialized neurological care remains profoundly uneven. Rural America is still predominantly non‑Hispanic White. About 35 million White residents constitute 76 % of the rural population. That should not obscure the diversity of rural communities or suggest that geography protects anyone from inequity. Rural patients with stroke, traumatic brain injury or other neurocritical conditions often face longer times to treatment and lower rates of proven interventions because hospitals lack neurointensivists, stroke neurologists or 24‑hour neurosurgical coverage. Stabilizing and transferring a patient adds hours; in neurocritical care the early hours affect outcome.

The problem is compounded by the wave of rural hospital closures. Between 2013 and early 2020, more than 100 rural hospitals closed. Residents who had relied on these facilities had to travel an average of about 20 miles farther for common services such as inpatient care and roughly 40 miles farther for specialized services [1]. Counties where hospitals closed already had fewer doctors than counties without closures, and the number of physicians per capita continued to decline after closures[2]. For communities with limited transportation, an extra 20 or 40 miles can be insurmountable. A similar phenomenon occurs in urban neighborhoods lacking designated stroke centers or neurointensive units, where transportation barriers and fragmented referral networks produce delays. Geography shapes access differently across the country, but the underlying issue is the same: when the infrastructure connecting patients to neurocritical expertise is uneven, outcomes follow the map.

Access deserts are also about workforce. Rural hospitals often struggle to recruit and retain neurosurgeons, neurologists and critical care nurses. Over the past decade, the number of neurologists practicing in rural counties declined, even as population need increased. Telemedicine fills part of the gap, but many rural hospitals still lack reliable broadband or the resources to implement tele-neurology programs. HEARD’s community engagement pillar is not an afterthought. It recognizes that the patient’s journey begins long before arrival at a neuro ICU. It depends on whether communities recognize the signs of neurological emergencies, trust the health‑care system enough to seek help and have a pathway that connects them to expertise. Building telemedicine and transfer networks in rural Louisiana and Mississippi, for example, has allowed us to see patients like Bobbee’s husband daily. Bridging rural and under‑resourced regions with neurocritical care is one of our explicit strategic commitments.

Coverage Infrastructure: Financial Foundations

Safety‑net insurance programs are the financial backbone of care for millions of Americans who would otherwise have none. Any significant reduction in public coverage does not result in abstract budget savings; it translates into patients who arrive later, sicker and with fewer resources. In neurocritical care, those decisions are measured in disability and death.

According to the Centers for Medicare & Medicaid Services, non‑Hispanic Whites constituted about 43 % of Medicaid and CHIP enrollees in 2020. A larger share of enrollees were Hispanic (27 %) or non‑Hispanic Black (21 %). These programs therefore serve a diverse population; they are not “for other people.” Cuts to Medicaid or CHIP would disproportionately harm children, people with disabilities and low‑income families across all racial and ethnic groups. Similarly, about 71.8 % of Medicare beneficiaries are White. With roughly 67 million people enrolled in Medicare as of 2024, that means tens of millions of White Americans rely on these programs. Gutting safety‑net insurance would disproportionately harm the very communities many assume are insulated from inequity. It would also worsen the financial strain on hospitals and clinics that provide uncompensated or under‑compensated care.

Coverage infrastructure is not just about eligibility; it is about adequacy. Insurance status influences the likelihood of calling an ambulance, agreeing to a transfer, completing rehabilitation or refilling medications, all steps critical to outcomes of neurocritical care patients. Research shows that Medicaid expansion is associated with increased access to stroke care and better outcomes, while states that did not expand Medicaid continue to see higher rates of uninsured stroke patients arriving in emergency departments. Without stable coverage, patients may decline transfer to a higher‑level center or leave against medical advice because they cannot pay. In neurocritical care, the cost of delayed or incomplete care is measured in lost function and premature mortality. When policymakers debate the cost of safety‑net programs, they rarely account for the cost of failing patients.

Knowledge Infrastructure: Research, Collaboration and Workforce

The therapies and protocols used in neurocritical care exist because of decades of biomedical research and training. Federal investment in research has long been the engine behind advances in our field. When grants become unpredictable or funding contracts, investigators face an unstable environment in which to build programs. The effects are not immediate but emerge years later when new treatments are never developed and questions remain unanswered.

The researchers most vulnerable to funding instability are often those whose work is most urgently needed: early‑career investigators, scientists from under‑represented backgrounds and those studying health disparities. They operate on the thinnest margins, making them the first to lose support in a contraction and the last to recover. Workforce diversity is not a “nice‑to‑have”; it correlates with better patient outcomes and broader research perspectives. A neurocritical care workforce that does not grow to reflect the diversity of the patients it serves will perpetuate inequities.

Knowledge infrastructure also includes the pipelines that train neurointensive care professionals. Clinician‑scientists must have protected time and support to pursue research questions that arise from bedside care. Funding cuts often translate into heavier clinical loads and fewer opportunities to develop new expertise. Mentorship networks, travel grants for conferences and cross‑institution collaborations are all part of the infrastructure that keeps our field vibrant. International partnerships, whether through joint trials, exchange programs or shared registries, accelerate innovation and improve generalizability. When geopolitical tensions strain these relationships, our ability to test new interventions and learn from diverse populations is compromised. The COVID‑19 pandemic reminded us how quickly global cooperation can translate basic science into bedside practice. We should not take that cooperation for granted.

This Is Not Someone Else’s Problem

It is tempting to file these concerns under “policy issues” and return to the bedside. We are busy clinicians, and the ICU does not pause for geopolitics. But denying the weight of these systemic pressures is a disservice to our patients and to our profession. If safety‑net insurance programs are cut, patients do not vanish; they appear later and sicker in the emergency departments and academic medical centers that remain open to them. If research funding contracts and the pipeline of investigators narrows, we will all practice with a less complete evidence base a decade from now. If the neurocritical care workforce fails to diversify, patients from marginalized communities will continue to receive systematically different care. These are not problems for “other” patients alone; they threaten the integrity of our field.

The mission of the Neurocritical Care Society is to advance care worldwide. The mission of the HEARD Center is to close health‑care gaps within that larger aspiration. These are not separate agendas; they are the same commitment, expressed at different scales. HEARD was built, in part, to address the rural problem directly, but our work necessarily spans the pillars of access, coverage and knowledge. We see our role as linking clinicians, researchers, policymakers and communities in a coordinated response to emerging threats.

Standing Strong: Actions We Can Take Now

I am not asking for outrage. I am asking for action—deliberate, sustained, and proportionate to the stakes.

Integrate equity into the work you are already doing. Listen to your patients, their families and stories. The complexities of our field require integration into the social and cultural norms for each of our patients. Data has supported patients matched with providers of the same demographics have better outcomes. Why? Because they listen longer. Providers who do not share the same demographics must listen even longer to understand the complexities of barriers to care and cultural norms that may be influencing your work. Ask the questions your current practice may not be asking: Who is not reaching me? Who is arriving too late, or not at all? What does my institution’s data look like when disaggregated by race, insurance status, zip code? When thinking of growth strategies for your practice, think about those who are not represented and find them.

Encourage others to do this work. For those of us in academic medicine and training the next generation of practitioners, encourage trainees to consider service as part of their job search. Many in healthcare start out their careers wanting to help others but as we get jaded, we start to think of this as naïve. For me, the hometown community hospital serves as the perfect example. Several of our former residents have decided to start a private practice group together and with our support, have worked to develop a primary stroke center. They care for those they can and send us the more complex cases. For me, there is nothing more rewarding than celebrating their successes.

Support HEARD directly. The HEARD Center is building the infrastructure—research programs, mentorship pathways, community education, workforce pipelines—that this moment demands. We cannot do that work without the engagement of the broader NCS community. Mentoring a trainee from an underrepresented background, contributing to or amplifying our research, participating in community engagement efforts, or simply making HEARD’s work visible within your institution: these are concrete actions with concrete effects.

Conclusion

Members of this Society carry enormous responsibility. You have seen what happens when a patient arrives too late, without coverage, from a community that did not know help was possible. There is always someone in some community who has been forgotten. I grew up in a place where people did not expect the health‑care system to work for them. I became a physician because I believed it could and should. I still do. I co‑founded HEARD because belief is not enough without the foundational structures to support it. The environment we are in now is testing those structures, but it also clarifies something important: the work of equity in neurocritical care is not optional, peripheral or someone else’s responsibility. It is ours. It has always been ours.

The HEARD Center welcomes collaboration, mentorship partnerships and community engagement from Neurocritical Care Society members across all career stages and practice settings. Together we can ensure that access, coverage and knowledge remain the pillars upon which equitable neurocritical care is built and protected. Now and forever.