Hurricane Maria was the deadliest storm to ever strike Puerto Rico, claiming nearly 3,000 lives on the island after striking in September 2017. But most of those deaths did not occur during the storm; they occurred over the following months, as hospitals and clinics closed or provided minimal services, roads to hospitals remained cut off, and loss of electricity rendered many at-home medical devices inoperable.
“One-third of the deaths were attributed to delayed or interrupted health care,” according to a 2018 New England Journal of Medicine study that estimated post-hurricane deaths based on surveys of residents. In addition, the most frequently reported health care problems (not related only to deaths) were lack of access to needed medications (cited by 14.4% of households); loss of electricity for respiratory equipment (9.5%); closed medical facilities (8.6%); and fewer doctors (6.1%).
Hurricane Maria illustrates the particular health risks that climate change poses to people in coastal areas. Storms, floods, excessive heat, and higher tides cause immediate health risks, including illness from water contaminated by pathogens, drowning, getting hit by falling debris, and heat stroke. But a growing challenge in coastal areas is the longer-term impact, particularly on low-income and marginalized populations that lack the financial resources and other supports to overcome the obstacles of contaminated homes and water supplies, crippled transportation systems, and damaged health care systems.
“A hurricane lasts 24 to 40 hours,” says Cecilia Sorensen, MD, director of the Global Consortium on Climate and Health Education at Columbia University in New York. “The [increased] mortality and impacts on physical and mental health lasts for months, if not years.”
About 128 million people (40% of the U.S. population) live in counties along the Atlantic and Pacific oceans, Gulf of Mexico, or Great Lakes, according to the latest data from the National Oceanic and Atmospheric Administration (NOAA). Those counties are more racially and ethnically diverse than the rest of the country; groups other than non-Hispanic White accounted for 52% of the population in coastal counties in 2017 (the most recent year for which the U.S. Census Bureau released data), compared with 34% in counties not along coastlines.
In addition, coastal communities are more distressed and vulnerable than inland counties, according to economic and social support data analyzed by the U.S. Census Bureau. As reported by the bureau, the data — on such factors as standard of living, health, housing conditions, and transportation — are “important indicators of an area’s ability to withstand disasters and other challenges.”
University-based scientists and physicians are studying the risks and working with communities to explore ways to mitigate the damage and help residents adapt to the changing environment.
Health risks increase
The health risks that come with climate change are the result not just of extreme events, like storms, but also ongoing, gradual changes in temperature, precipitation, and the movement of water. Here are four ways those changes pose threats to people’s health in coastal communities:
Water supply contamination. The increasing frequency and severity of high tides and rain-induced floods is bringing more salt water from oceans, gulfs, and bays into the ground and water supplies of coastal communities. Floods and heavy rains also pick up chemicals from industrial sites and pesticides from farms, and transport them throughout the communities.
It happened this summer in Plaquemines Parish, Louisiana, where saltwater contamination of groundwater forced residents to buy bottled water for cooking and drinking for months afterward. The contamination is not the result of one weather event, but of the gradual effects of climate change; heat and drought severely reduced water levels in the Mississippi River, opening the way for salt water from the Gulf of Mexico to force its way further upstream into water sources that are used by homes and businesses.
Spreading sewage. Excessive water from floods and high tides also put incredible strains on the septic tanks of homes and businesses, setting off a series of reactions that can cause tanks to fail. Water that escapes those failed systems contaminates the surrounding ground with bacteria and pathogens, as explained by researchers in a project at the University of Maryland School of Public Health.
“Kids are coming down with rashes because they go outside,” stepping and playing through “these bacterial-rich waters” and soggy grounds around compromised septic tanks, says Cheryl Holder, MD, interim executive director of Florida Clinicians for Climate Action and retired associate dean of Diversity, Equity, Inclusivity, and Community Initiatives at Herbert Wertheim College of Medicine at Florida International University in Miami.
On the east coast of Virginia, community leaders are looking into how to deal with septic system failures induced by increasing levels of water intrusion.
“If a septic system goes out, I’m looking at 15,000 to 20,000 dollars to replace it,” says Andre Elliott, senior executive director of two YMCAs in the area and a participant in a University of Virginia (UVA) project that partners with eastern shore communities to study and address the impacts of climate change.
Such repair costs are beyond the means of many home and business owners in those areas. In the rural eastern shore area of Virginia, household income is half the state average and the poverty rate is twice the state average, according to Karen McGlathery, director of the Environmental Institute at UVA, which oversees the eastern shore climate project.
Mold growth. If a home gets flooded by heavy rains, a hurricane, or exceptionally high tides (which are increasing to nearly routine in some coastal areas), residents often remain in the home after the water recedes, even though the health threat continues to grow, literally. Mold that grows in walls, floors, and insulation causes illnesses from stuffy noses and itchy eyes to severe respiratory problems, such as intense asthma.
Two years after Hurricane Ida sent water pouring into homes along the southern, mid-Atlantic, and northeastern coasts, residents are still getting sick from mold, even to the point of hospitalization.
While middle- and upper-class homeowners might be able to replace their soaked walls, carpets, and insulation through insurance, savings, or loans, lower-income families are less likely to have those resources. In addition, Holder notes that many of those families are renters who cannot afford to find alternative housing, and “they’re not willing to turn in their landlords” for failing to make repairs, out of fear of losing their leases.
Algae growth. The heat, rising sea levels, and frequent storms associated with climate change set off reactions that feed the growth of algae (an aquatic plant), especially in slow-moving bodies of water such as lakes and marshes, as explained by the Environmental Protection Agency (EPA). Hotter weather raises water temperatures, which algae prefer. Stormwater runoff transports various nutrients (such as from agricultural pesticides) that further feed the growth. Rising sea levels infiltrate shorelines with new pockets of water that tend to be shallow and still — “conditions that are perfect for the growth of algae,” the EPA notes.
Different types of algae produce various toxins, which people absorb by eating contaminated fish, drinking from contaminated groundwater, swimming in contaminated waters, or breathing the air around polluted lakes. The health impacts, according to the National Institutes of Health, include skin rashes, respiratory problems, gastrointestinal illness, and neurological damage.
NOAA has identified dangerous algae blooms in all coastal regions of the country. One of the most prominent blooms has taken over half of the largest freshwater lake in the country: the 730-acre Lake Okeechobee in Florida. County and state officials have issued warnings for people to stay away from the algae-infested areas, which have been blamed for illnesses and even deaths in pets that splashed in the water, and sent people who’ve inhaled the toxins to the doctor.
Which brings up the challenge of getting to the doctor.
Less access to care
The disruptions to health care delivery that begin during a severe storm often continue long thereafter. In coastal areas, many people live far from medical facilities. The flooding of a road might close off their only easy way to get to a doctor’s office or hospital. Rescheduling a medical appointment can be particularly difficult: With public transit systems sparse along the coasts, many low-income residents have limited means of transportation, often depending on friends and relatives as available.
“It impacts continuity of care,” Holder says of severe weather. “Your chemotherapy, your eye treatments, all those are impacted.”
The long-term disruptions also make it difficult to get prescriptions renewed by doctors or filled by pharmacies, notes Sue Anne Bell, PhD, FNP-BC, an assistant professor at the University of Michigan (UMich) School of Nursing in Ann Arbor.
The disruptions also impede care providers from getting to patients. During and after severe weather events, home health care providers struggle to get to patients, workers struggle to get to hospitals, and clinics and hospitals sometimes shut down critical services. When Hurricane Sandy devastated the mid-Atlantic coast in 2012, Bellevue Hospital Center — New York City’s flagship public hospital — shut down for three months, and was not fully operational for many more. That had a major impact on low-income patients, says Sorensen of Columbia University.
“Bellevue is the major safety net hospital in the city,” Sorensen notes. “Where did those people [who would get care there] go?”
Other hospitals can take on some of the patients, she says, but “those hospitals actually aren't really equipped” with case managers and pathways to social services to fully serve less-resourced populations.
Along Virginia’s eastern shore, a severe snowstorm that struck the Delmarva Peninsula in 2018 did not shut down the local hospital, but it so severely blocked roads and entrapped vehicles that some health care workers couldn’t get to work. Farmers used their tractors and combine harvesters to clear roads, dig out stuck ambulances, and give nurses a ride to work.
Adapting to change
Ensuring access to health care amid climate change in coastal areas begins in doctors’ offices and extends throughout health care systems and local governments.
During routine visits, doctors can talk with patients about preparing for severe weather that might affect their health care. Among the questions suggested by Bell at UMich and McGlathery at UVA: Do you have a 7-day supply of medications? Do you have an evacuation plan? If you have medical equipment at home that uses electricity and the power goes out, do you have a generator or a place to go that has power? If roads flood and you can’t get to a doctor’s appointment on your own, who can help you get there?
On the hospital side, some health care systems in coastal areas are making significant changes to their campuses, equipment, and emergency plans. These include installing flood walls, moving power generators to higher floors, and buying tall trucks to get medical and support staff to and from work through high water. In addition, many frontline clinics are employing new strategies to provide care to underinsured residents in the wake of extreme weather events.
To help communities adapt to climate changes in order to keep people safe and healthy at home, it’s essential that health systems and universities partner with local residents and leaders, McGlathery says. The UVA project that she oversees is a multiyear effort that will work with communities on Virginia’s eastern shore to collect and analyze data about the impact of climate-related events, educate residents about those impacts, and explore solutions. Among the possible solutions are building public septic systems and digging deeper water wells, both of which would require government action and investment.
Holder, in Florida, says that coastal areas are feeling the impacts of climate change sooner and more severely than most other areas — and as a result, can lead the way in communities learning to adapt. Says Holder, “The solutions that come out of coastal areas can help other areas around the world.”