Over the last decade, thousands of pharmacies have closed due to declining reimbursement rates for prescriptions, increased competition from online retailers and rising operational costs.^1,2  As a result, many areas have become what are known as “pharmacy deserts,” where residents must travel long distances to obtain their medications. An estimated one in seven people are affected,³ with an overwhelming number of closures landing in Black and Latino communities.

“Pharmacy deserts create real, tangible harm to patients and communities and are a growing public health concern,” says Jennifer Rodis, PharmD, FAPhA, associate dean and professor of clinical pharmacy at The Ohio State University College of Pharmacy in Columbus. She notes that the closures are causing greater health concerns for people who live in underserved areas. “When access to pharmacies dwindle, residents face significant barriers to obtaining essential medications and essential healthcare services,” Dr. Rodis says. Diminishing access to pharmacies takes an even greater toll on those with chronic diseases such as diabetes, for whom missed insulin doses can lead to life-threatening complications.

“If getting to the pharmacy becomes time-consuming or difficult, many patients may delay or go without necessary care,” says Angelina Tucker, PharmD, clinical director of Best Value Pharmacies in Fort Worth, TX, and managing network facilitator for Community Pharmacy Enhanced Service Networks (CPESN). She also points out that beyond filling prescriptions, pharmacists play a critical role in disease state education and counseling on medication management.

Below, experts discuss this concerning trend for this vulnerable population and ways to improve access to lifesaving drugs. 

An access crisis

The issue of disappearing pharmacies came to the government’s attention in 2014, when researchers found that one million Chicago residents—more than half of whom lived in predominantly Black neighborhoods—did not have proper access to independent or chain drugstores.⁴ Another study of the 30 most populous metropolitan areas confirmed that most pharmacy deserts were in Black and Latino communities nationwide.⁵ According to a 2025 survey, people living in metropolitan areas travel 53 minutes and 18 miles round-trip to get their prescriptions.⁶

Last year, an estimated 2,300 pharmacies shut their doors, and this year, Rite Aid’s bankruptcy has added more than 1,000 closures.⁷ Other chain stores, such as CVS and Walgreens, continued to shut down hundreds of stores. The rapid pace of disappearing pharmacies doesn’t appear to be abating, and there are signs that lower-income areas where people are under- or uninsured are feeling the brunt. Independent pharmacies, which tend to be located in urban settings, are at an even greater risk of closure. “The rising closures of independent pharmacies have a greater impact, since they often serve as the only option in minority communities,” says Dr. Tucker.

What’s causing independent pharmacy closures?

Pharmacy benefit managers (PBMs)—who negotiate drug prices for large health insurers—along with the difficulties resulting from complex payment systems are two factors “putting the squeeze” on independent pharmacies. “These pressures make it increasingly difficult for the pharmacy business model to remain financially viable,” Dr. Rodis explains. “They are responsible for slim-to-no profit margins for independent pharmacies, which creates barriers for patients obtaining medications,” Dr. Tucker says. As a result, many existing independents don’t stock or dispense certain drugs, including those for diabetes and obesity, because they lose money on them.⁸ At this writing, the U.S. Federal Trade Commission (FTC) has filed a lawsuit against the three biggest PBMs alleging inflated prices on drugs like insulin.⁹            

The role of public and private insurance companies’ PBM-negotiated contracts influences which medications are covered, the cost and where patients can get them filled, Dr. Rodis notes. And local pharmacies that rely predominately on Medicaid or Medicare for payment are more likely to close than other pharmacies

Implications for patients

When locations close, patients need to spend additional time and energy in finding another pharmacy, which can lead to decreased medication adherence and reduced outcomes.¹⁰ Patients in underserved areas aren’t just missing out on getting their medications—they're losing access to immunizations, preventive care, wellness screenings, medication management programs and over-the-counter products, Dr. Tucker says. Older adults (age 50 plus) who rely on their local pharmacy to fill essential drugs such as statins, beta blockers and anti-coagulants, also showed a decline in adherence after their local drug store closes.¹¹

And with fewer primary care practices in Black communities, pharmacists are often the only healthcare professional providing healthcare services. “Clearly, the lack of access to pharmacies puts these communities at a disadvantage for staying healthy,” Dr. Tucker says. 

How to bridge the gaps

“I encourage clinicians to have a conversation with patients living in a pharmacy desert about the best way to get their prescriptions, and to support legislative and regulatory policies and practices that help pharmacies remain or expand into underserved areas,” says Dr. Rodis. This year, a handful of federal bills has been introduced targeting PBM reform, and there is legislation pending in all 50 states aimed at reform measures that would help sustain pharmacies.¹² While proposals to help brick-and-mortar pharmacies are underway, clinicians should consider referring patients without access to the following for filling their prescriptions.

• Social workers. “Social workers are a wonderful and essential practitioner in providing access and referral for patients to a variety of services,” Dr. Rodis says. “While social workers can’t prescribe medication, they can provide critical support for patients in pharmacy deserts by connecting them to healthcare providers and navigating online resources.” They can also connect eligible patients with state- or pharmaceutical company-sponsored medical assistance programs that provide free or lower-cost medication, and help them access reliable transportation, such as community ride programs, for their medical appointments. All this improves treatment adherence and health outcomes, she says.

• Mail-order pharmacies. Most insurance plans offer mail-order services and potentially lower out-of-pocket costs for a 90-day supply of medications, Dr. Rodis says. “Mail-order can be convenient for patients with limited access to pharmacies, especially for those medications they take chronically,” she says. Patients should contact their insurance provider to set up this service. Once enrolled, mail-order pharmacies send delivery updates via text and emails. Remind patients to call you or the pharmacy after receiving their drugs to ask any safety and use questions: Most mail-order pharmacies have pharmacists on staff to take calls and answer questions.

Caveat: There can be the potential for delivery delays, which isn’t suitable for urgent medication needs, says Dr. Rodis. Patients should also be advised to set up orders at least two weeks before running out of medication to avoid delays unless refills are automatic.

• Digital pharmacies. More than 35,000 pharmacies actively operate over the internet, which patients can easily access through a Google search for a particular medication.¹³ These can be extensions of big chains and independent pharmacies, as well as those that operate exclusively online. Benefits include convenience and often cheaper access to drugs not covered by health insurance.

Caveat: Only about 5% of online pharmacies comply with U.S. pharmacy laws and practice standards, which puts patients at risk of buying unapproved, counterfeit or unsafe medicines outside the safeguards followed by licensed pharmacies, according to the U.S. Food and Drug Administration (FDA).¹³ For protection, the agency advises using online pharmacies that require a doctor’s prescription, and have a U.S.-based physical address with a licensed pharmacist on staff who can be contacted online or by phone. The National Association of Boards of Pharmacy also publishes a list of accredited digital pharmacies on its website nabp.pharmacy. “In general, patients should avoid digital pharmacies that have not been referred to them directly by their physician, pharmacist or other healthcare professional,” Dr. Rodis says.

• Telepharmacies. The COVID-19 pandemic accelerated the adoption of telehealth services, and telepharmacies are no exception. “Telepharmacies have an important role to play for underserved areas,” says Dr. Tucker. They allow pharmacists at brick-and-mortar locations to use audio and video links for remote patient interaction and provide services such as filling prescriptions, medication reviews and patient counseling. These services can be provided in various settings, including remote sites with pharmacy technicians and automated dispensing kiosks. Research also shows they can be a viable solution for improving patient access.¹⁴ A recent study on telepharmacy services delivered by pharmacists to patients with diabetes via virtual conferencing and telephone calls was shown to be effective for better glucose control and improved medication adherence.¹⁵

Caveat: Telepharmacy services are allowed in only 28 states, and pick-up kiosks are available in even fewer states.¹⁴ And most of those states have varying restrictions for use, such as maintaining up to a 20+ mile radius between the telepharmacy location and the nearest traditional pharmacy, which limits access.¹⁴

Community collaborations. Health fairs targeting underserved communities allow pharmacists to collaborate with other healthcare professionals and local organizations to provide a hub for screening and preventive education. “Clinicians can encourage patients to look for these opportunities as great resources for those with unmet needs in pharmacy deserts,” Dr. Rodis says.

Tucker participated in Community Connected, led by CPESN in Fort Worth, TX, an initiative that demonstrated how local stakeholders can work together to address health disparities. This initiative aimed to support a predominantly Black community in one of the city’s poorest areas, which has the lowest life expectancy in the state at 67 years—10 years lower than the surrounding ZIP codes, according to Dr. Tucker. “The first step was understanding the community and reaching out, since we had a pharmacy in the vicinity,” says Dr. Tucker.

Specialists who wish to volunteer their time can help educate people on diabetes management and healthy lifestyle choices. Clinicians can also help by referring patients to these community health initiatives, Dr. Tucker says. Check your local and state department websites for more information on community healthcare fairs in your area.

—by Linda Keslar

When patients of African or Caribbean descent present with diabetic ketoacidosis (DKA), clinicians might initially diagnose them with type 1 diabetes. But some of these patients could actually have ketosis-prone diabetes, also known as “Flatbush diabetes,” a distinct and often under-recognized condition that affects Sub-Saharan and Caribbean peoples.¹ It has since been recognized in Asian and Latino populations. DKA for type 2 diabetes got its nickname after it was first identified in the Flatbush neighborhood of Brooklyn, New York, in 1987.² It is a condition with unique diagnostic and treatment challenges that defies traditional classifications but also offers the opportunity for insulin-independence and long-term remission.

“These patients may have features similar to type 1 diabetes, but their autoantibodies are negative,” says Rachel Pessah-Pollack, MD, clinical professor, Division of Endocrinology, Diabetes & Metabolism, NYU School of Medicine, NYU Langone Health. “Those negative autoantibodies are not consistent with type 1 diabetes.” Kelly N. Wood, MD, FACE, who practices at Piedmont Physicians Endocrinology Fayette in Fayetteville, GA, adds, “Patients typically present with ketoacidosis, but they don’t have the typical features of someone with type 1 diabetes, like someone younger or leaner with a lower BMI.”

Below, experts discuss ways to diagnose and treat a form of diabetes that clinicians sometimes miss.   

Diagnostic clues and pitfalls

For clinicians, it’s crucial to include Flatbush diabetes in the differential when a patient presents with DKA—especially if a patient’s medical history and BMI suggest type 2 diabetes. Dr. Wood notes that the condition is atypical, which is why the diagnosis can be elusive. “When a patient presents with DKA and they don’t fit the typical type 1 diabetes patient, it’s a red flag,” says Dr. Wood.  Dr. Pessah-Pollack agrees: “If African American or Caribbean patients are discharged from the hospital, and they tell you that they were diagnosed with type 1 diabetes and presented in ketoacidosis, do a workup in your office to see if it suggests non-autoimmune diabetes such as Flatbush diabetes,” she advises. “This is especially important to do in individuals who are overweight or have obesity.”

Key diagnostic tools are autoantibody testing and beta-cell function markers. The recommended workup should check for autoantibodies commonly found in type 1 diabetes, including:³

• Glutamic acid decarboxylase 65 (GAD65)
• Islet antigen-2 (IA-2)
• Insulin autoantibodies
• Zinc transporter 8 (ZnT8; optional)

Measuring C-peptide levels can also help assess endogenous insulin production; however, experts note that timing is crucial.⁴ “The best time to check is at least a few weeks after hospitalization when there is resolution of ketoacidosis and the glucose levels have normalized—then you can see if there’s some recovery of beta-cell function,” Dr. Pessah-Pollack says. Dr. Wood adds: “Poor beta-cell function would be a C-peptide less than 1 ng/mL, and adequate beta-cell function would be above 1 ng/mL.”

Treat aggressively—then step back

Regardless of a patient’s background or suspected diabetes type, the immediate priority is stabilizing their DKA.⁵ Prompt and aggressive treatment is essential to preventing life-threatening metabolic disturbances and further complications.⁶ Once DKA has resolved, clinicians can begin the process of reevaluating the diagnosis and adjusting treatment accordingly. “Initiate insulin immediately, as if treating type 1,” advises Dr. Pessah-Pollack. “Then once they recover, you’re able to follow them and start to reduce doses if endogenous insulin secretion increases.”

Dr. Wood concurs, saying, “Because this type of diabetes is unknown at the time of presentation, all of these patients need to be treated for their DKA with IV insulin treatment in the ICU. Then, everyone needs to be on subcutaneous insulin.” Both doctors emphasize the importance of monitoring after discharge and recommend that medication adjustments be made incrementally. “They should be seen in the clinic one to three weeks after they’re discharged to check how their blood sugars are responding to their insulin regimen,” Dr. Wood recommends. “If the patient is consistently meeting those targets after that timeframe, their insulin can be cut in half.” Dr. Wood says clinicians should also follow up with the patient in a few weeks to see how they are responding. “If their blood sugars are still within target, or if they’re having low blood sugars, you can stop the insulin,” she notes.

Transition to non-insulin therapies

Once stable, many patients can discontinue insulin altogether and begin oral or non-insulin injectable therapies. “You can consider switching them over to an antihyperglycemic medication if they have endogenous insulin production—for example, metformin is often first-line if not contraindicated,” Dr. Pessah-Pollack says. “Some of these patients are good candidates for GLP-1 receptor agonists given the beneficial effects of weight loss and potential cardiometabolic benefits as well.” Dr. Wood also recommends metformin, citing its relatively low cost to patients and added utility in managing metabolic syndrome, and also recommends GLP-1 receptor agonists due to its cardiometabolic benefits. In addition, she says, “Pioglitazone has also been shown to preserve beta-cell function.”

Monitor for recurrence and
long-term care

Monitoring C-peptide levels and ketones during insulin withdrawal is crucial. “If someone develops ketosis once off their insulin, they should be put back on, and we shouldn’t try to take them off of it again,” Dr. Wood cautions. “If their blood sugars go above 200, we should check their urine for ketones.”

When it comes to assessing recovery of beta-cell function, Dr. Wood reiterates the importance of timing C-peptide measurements. “You should wait about 2 to 3 weeks before checking C-peptide because high levels of glucose are toxic to the beta cells. If you check someone right after DKA, they might have low C-peptide because of that,” she says.

Adopt culturally competent care

Care models must account for structural inequities, too. “Access to care is a key component of this,” Dr. Pessah-Pollack emphasizes. “You could get discharged from the hospital on insulin, and the type of insulin they give you isn’t covered.” Dr. Wood notes that there is a mistrust of the medical system, citing the historical mistreatment of Black patients and other racial and ethnic populations. “The patient sitting in front of you might have had their own experience with bias and racism in healthcare.” She suggests that simply acknowledging why the mistrust occurred can help clinicians address that barrier with their patients, as can relying on community educators to help rebuild trust.

Educate patients on insulin adherence

Clinicians should be aware of the potential for community misconceptions that interfere with treatment adherence. “A lot of people in different populations—especially if they’re used to seeing a family member have a negative experience on insulin—may be very much against insulin,” says Dr. Pessah-Pollack. “There’s a lot of stigma and denial in the Black community,” adds Dr. Wood. “There’s also a fear of starting insulin, especially with ketosis-prone diabetes. We need to explain to them that patients do come off insulin.”

Empower lifestyle interventions

Both experts acknowledge the vital role of dietary and lifestyle modifications as foundational to diabetes care—especially once patients stabilize from DKA and begin insulin tapering. Structured lifestyle interventions, including calorie-restricted, plant-based or low-carbohydrate diets combined with regular physical activity, lead to clinically meaningful improvements in glycemic control, weight and lipid levels.⁷ A landmark example is the Diabetes Prevention Program, which showed that losing just 7% of body weight through a low-fat, calorie-reduced diet and 150 minutes of moderate exercise reduced the risk of developing type 2 diabetes by 58%—outperforming even metformin in preventing disease progression.⁸

Equally important is approaching lifestyle guidance through a culturally sensitive lens. Food traditions run deep, and telling patients to simply eliminate staples isn’t realistic. “It’s not going to work to just say ‘don’t eat rice,’” Dr. Pessah-Pollack says. Dr. Wood echoes this approach, saying, “Patients can still eat their traditional foods, but maybe in moderation. Instead of frying certain things, maybe they can steam or boil them instead.”

—by Zoe Owrutsky  

A patient who trusts you enough to openly share their symptoms and adhere to your treatment plan helps you provide the best care possible. But when confidence in you is missing, ensuring the health of patients can be challenging. While building strong relationships with all patients is essential, a survey by the Kaiser Family Foundation found that Black patients are less likely to trust providers and do not believe that the healthcare system will “do what is right for them and their communities.”¹ Another survey by the Pew Research Center also shows that 55% of Black Americans have had negative experiences with doctors, including the need to speak up to get proper care and feeling as though the pain they reported was not taken seriously.²

“For Black communities, distrust in healthcare isn’t just a personal feeling; it’s an inherited, completely rational response to centuries of medical violence,” says Leon Nathaniel Rock, M.Ed., co-founder & CEO of African American Diabetes Association. “We’re not talking about isolated incidents here, but a systemic legacy of medical apartheid.”

Historical and ongoing experiences of racism and discrimination have contributed to this problem. The Tuskegee Syphilis Study, for example, performed between 1932 and 1972, involved observing what happened when syphilis is left untreated. The study was conducted on Black men 25 years of age or older, without their consent. Because these men didn’t receive treatment, some of their female partners contracted syphilis.³ “From forced experimentation during slavery to the horrific Tuskegee Syphilis Study and the exploitation of Henrietta Lacks, Black bodies have historically been exploited and dehumanized for medical advancement,” says Rock.

The skepticism brought about by the Tuskegee study resulted in a significant under-representation of Black individuals in clinical research, “depriving them of access to potentially life-saving interventions and the opportunity to benefit from advancements in medical science,” says Brandi Addison, DO, FACE, DABOM, endocrinologist and chair of the American Academy of Clinical Endocrinology Belonging, Leadership, Opportunity, Outreach and Mentorship (BLOOM) committee.

The case of Henrietta Lacks, a 30-year-old Black mother of five who was treated for cervical cancer in 1951, also fostered distrust by the Black community. Scientists at Johns Hopkins Hospital performed medical research on Lacks without her knowledge or consent. The experiment contributed to medical research in profound ways without recognition or renumeration for Lacks and her family, who continue to fight for ethical and financial justice.⁴

“This painful history, combined with ongoing systemic racism and implicit bias—where Black pain is often dismissed and our cultural practices ignored—creates a deep, wide chasm of mistrust,” says Rock.

How distrust harms patients

When people don’t trust their doctor, they may avoid visits and engaging in preventive care, notes Marie-Elizabeth Ramas, MD, a family physician and healthcare diversity advocate based in Nashua, NH. She says this contributes to a disproportionate burden of diabetes-related complications. Black Americans are three times as likely to end up hospitalized for diabetes-related complications, more than twice as likely to undergo diabetes-related leg or foot amputation, and more than three times as likely to have end-stage kidney disease.⁵ Moreover, non-Hispanic Black individuals were 40% more likely than non-Hispanic White people to die from diabetes.⁶

“If you don’t trust the system, you’re less likely to come back for A1C checks, kidney labs, eye exams or foot exams—the very visits that prevent catastrophic complications,” she says. It may also cause patients to decline insulin, statins and newer therapies such as GLP‑1 receptor agonists (GLP-1 RAs). Dr. Ramos adds that proper communication around why these medications are needed, what their side effects are or how costs will be handled, are often neglected. “Continuous glucose monitors, smart insulin pens, and patient portals can feel like surveillance instead of support if trust isn’t there,” she adds. “Chronic stress from racism and medical mistrust can also contribute to ‘weathering,’ accelerated biologic aging that worsens metabolic health and makes diabetes harder to control.”

Lack of diabetes preventive care results in Black patients turning to the emergency department. One study found that in 2021, ER visit rates by adults with diabetes were highest among non-Hispanic Black people (136.6 visits per 1,000 adults per year) compared to White people and Hispanic people.⁶

Ways to build trust

Repairing this schism within the Black community may take time, but it’s not insurmountable. The following are concrete steps clinicians can take to improve the clinician-patient relationship.

Refer patients to Black doctors

For non-Black clinicians who are finding it difficult to gain a patient’s trust, referrals to physicians of color are an appropriate next step. They can find Black doctors through online directories such as blackdoctorsusa.com or findablackdoctor.com. These platforms allow patients to search for doctors by specialty, location, and other criteria, and they often highlight doctors with shared backgrounds and experiences. Additionally, BlackDoctor.org includes a directory along with articles on finding culturally sensitive doctors. 

“Research consistently shows that minority patients experience better health outcomes when treated by healthcare providers who share similar cultural and demographic backgrounds,” says Dr. Addison. A Stanford University study confirmed that Black men who went to Black physicians were more likely to engage with them and agree to undergo preventive care like cardiovascular screenings and immunizations.⁷ “The failure to ensure diversity among healthcare providers creates significant barriers to care and exacerbates the lack of trust that many minorities, particularly Black Americans, have toward healthcare institutions,” says Dr. Addison.

Cultivate empathy

Approaching Black patients with humility, not defensiveness, and listening to their concerns can validate their experiences. Explain the diagnosis, options, side effects, costs and alternatives in plain language, says Dr. Ramas. “Make sure to align the plan to the patient’s goals, schedule, budget and cultural context,” she says. “Black patients with type 2 diabetes can, and do, achieve excellent outcomes. The responsibility to repair the relationship sits with the system and its clinicians, not with the patients who were failed by it.”

Embrace cultural preferences

Gaining an understanding of the beliefs, practices and values of the Black community can help improve care for Black patients, says Dr. Addison. “Healthcare professionals who can relate to patients on issues like food, family dynamics and physical activity are better equipped to build meaningful rapport,” she says.

And helping patients adapt food choices to make them healthier is a practical and impactful approach. For instance, collard and turnip greens are a staple in Black cuisine and Southern cooking, so encourage patients to add these or other preferred leafy greens to dishes whenever possible.⁸  You can also refer patients to a diabetes educator who can provide them with a personalized dietary plan and help them swap in healthier foods for less healthy foods.

Additionally, the organization Oldways offers free nutritional programs both in-person and online, such as the A Taste of African Heritage, which includes lessons on traditional herbs and spices, beans and rice, and more (oldwayspt.org). According to a peer-reviewed study in the Journal of Nutrition Education and Behavior, 98% of participants in this program reported heritage as a motivator for eating and living well. Other findings showed that participants significantly:⁹

• Increased consumption of fruits, vegetables, and greens
• Increased weekly exercise frequency
• Decreased weight, waist circumference and blood pressure

While guidelines recommend advising patients to engage in at least 150 minutes of exercise per week, connecting them with community programs like GirlTrek, a nonprofit organization for Black women that organizes walks across the country to promote physical activity, can help. Similarly, The African American Male Wellness Agency promotes physical activity through initiatives such as the National African American Male Wellness Walk, a 5K walk and run that serves as an awareness campaign for Black men's health.

—by Cathy Cassata

Special thanks to our medical reviewer:

Lenita Hanson, MD, FACE, CDCES, CPI
Hanson Diabetes Center, Port Charlotte, FL

Content reviewed by:

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