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    Rural Americans find little escape from climate change

    Farm work, geography, and health care gaps leave those who live in rural areas vulnerable to extreme weather. But research on the health impacts and effective prevention is thin.

    Farmer harvesting grapes on sunny day

    Editor’s note: This article is part of a series on climate change and health. Other articles in this series include stories on how extreme heat affects health, efforts to reduce greenhouse gas emissions in hospital cafeterias, and the impacts of extreme weather on coastal and underserved communities.  

    At a nursery outside St. Paul, Oregon, 38-year-old farm worker Sebastian Francisco Perez collapsed while moving irrigation pipes on a summer afternoon in 2021 when temperatures reached 104 degrees. Perez died of cardiovascular and respiratory failure caused by heat exhaustion and dehydration — a tragic demonstration of why agricultural workers in the United States are 35 times more likely than workers in other industries to die from heat-related causes.

    In the many rural areas of Wisconsin, doctors have been treating more cases of Lyme disease in recent years, as rising average temperatures make some northern regions of the nation more hospitable to the disease-carrying ticks, says Joel Charles, MD, a family physician in rural Soldiers Grove. The trend there is typical of the nation: A nonprofit health group’s analysis of insurance claims found that from 2007 to 2021, claims for Lyme disease in rural areas of the country increased by 357%.

    In Florida, a study that periodically collected blood and urine samples from farm workers over a 555-day span found that 81% were dehydrated after work and 33% showed acute kidney injury (AKI) on at least one workday. The study, led by researchers at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, found that each 5-degree increase in the heat index increased the odds of a worker having an AKI by 47%.

    Those experiences and findings illuminate some of the ways that severe weather events fueled by the changing climate are taking a toll on rural areas of the country. While more severe heat, storms, floods, and wildfires are affecting people just about everywhere, aspects of rural geography, economics, and lifestyle make its residents susceptible to those changes in particular ways.

    A study of emergency department visits over a six-year period in North Carolina found that “rural populations are especially vulnerable” to the heat, suffering heat-related illnesses at five to 10 times the rates of people in urban areas. The study, led by the University of North Carolina (UNC) at Chapel Hill, found the highest rates among 17- to 45-year-olds, which links to one of the highest risk factors: working in labor-intensive agriculture.

    So far, however, most of the research into the impact of climate change, along with efforts to mitigate the effects, have focused on urban areas, where populations are most dense. That leaves 60 million people — about one in every five Americans — living in rural areas for which there is little data on how climate change is affecting their health and how they can better adapt to those changes. Several universities are trying to fill the gaps.

    Rural areas vulnerable

    The death of Sebastian Perez in Oregon illustrates a fundamental reason that people in rural areas are so vulnerable to extreme weather events: They are far more likely than those in suburban and urban communities to work outdoors, in such jobs as farming, logging, and raising livestock. When extreme heat or wildfire smoke make the air they breathe unhealthy, outdoor workers cannot just move to an air-conditioned room to do their jobs or to take a rest break.

    “Agricultural workers in the United States are amongst the populations most vulnerable to the health impacts of extreme heat,” a recent University of Washington report noted. (This article explains how extreme heat affects the body.)

    If the workers do take breaks in the shade, or even stay home because of the heat, they might be giving up salary that they can ill afford to lose. Many farm workers do not get paid sick leave, and they are often paid based on how much they pick of a particular crop (known as a “piece rate”).

    “They’re very incentivized to keep picking and not slow down to take breaks,” says Charles E. Konrad, PhD, MS, director of the Southeast Regional Climate Center based at UNC and a lead author of the emergency department study.

    Here are other factors that make rural residents vulnerable to the effects of climate change:

    Poor health: Climate change in rural areas compounds health issues for a population that is already less healthy, on average, than the rest of the country. According to the Centers for Disease Control and Prevention, Americans living in rural areas are more likely than those in urban areas to die from the five leading causes of death in the United States: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke.

    One reason for these health challenges is the age of the population. “On average, rural residents are older and generally have worse health conditions than urban residents,” the General Accountability Office observes.

    Less health care: At the same time, rural residents typically have less access to health care than do people in cities and suburbs. Only 11% of physicians practice in rural areas, which account for most of the country’s “health professional shortage areas” as designated by the federal government. One reason for that shortage: More than 180 rural hospitals have closed since 2005, according to a recent analysis by the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill.

    As a result of the poor health conditions and scarce medical services in some communities, many frontline physicians in rural areas are so focused on the immediate health needs of their patients that mitigating the impact of climate change is not a priority when they are providing care.

    “They [doctors] say, ‘I know this is important, but we’re trying to get their diabetes under control, we’re trying to get them into prenatal care.’ So climate change is not seen as urgent,” says Linda McCauley, PhD, RN, dean of the Woodruff School of Nursing and a lead researcher on several studies about climate change impacts on farm workers.

    The same is true for some patients, especially those who struggle financially, even if they care about climate change. The poverty rate in rural areas stood at 14.4% in 2020, compared with 11.9% nationwide.

    “If you’re just trying to get by, you don’t have the luxury of worrying about climate change,” says Jennifer L. Barkin, PhD, MS, executive director of the Center for Rural Health and Health Disparities at the Mercer University School of Medicine in Macon, Georgia. “You’re worried about, ‘I’m pregnant. I need a car seat.’”

    Among farm workers, those who are foreign-born (which accounts for more than half) are especially unlikely to seek health care, researchers say, due to language barriers, lack of health insurance, and fear of being exposed as an undocumented worker.

    “A lot of these workers have never seen a health provider,” McCauley says.

    Rains and floods: Heavy rains and the resulting floods occur in all types of communities, but certain harms are more likely and severe in rural areas — as was seen when floods devastated rural communities in New York and Vermont in mid-July. Many rural communities are built around rivers that can overflow or in valleys where rainwater rushes down from hills and mountains. The surging waters contaminate household wells with fertilizers, pesticides, and animal waste from nearby farms; move through the single-family houses and mobile homes in which most people live (rather than higher up in apartments); wreck outdoor-based businesses, such as farms; and cut off access to work, family, and health care in places where there are few alternative routes around roads and bridges.

    “Lots of my patients get stuck” living in homes damaged by floods, because they can’t afford to move, Charles says. “It causes respiratory issues because of mold. It causes stress and worsening of infections” because of contact with contaminated water. “I have absolutely seen the mental health impacts: depression, anxiety, PTSD.”

    Pests and pesticides: Working outside exposes people to more disease-carrying pests like mosquitos and ticks, whose populations are expanding due to warmer and wetter climates. Also expanding are pests that harm crops and livestock, which the Environmental Protection Agency (EPA) notes cause some farmers to increase their use of pesticides, which in turn exposes their workers to those substances.

    “It could also put family members in danger if workers bring pesticide residues into their homes, such as on their skin, tools, and clothing,” the EPA reports. “Sprayed pesticides can also drift into communities and homes close to farms, increasing residents’ risk.”

    Efforts to cool down

    Projects based at several universities aim to mitigate the impact of climate change on rural residents.

    At the University of California (UC), Davis, staff from the Western Center for Agricultural Health and Safety (WCAHS ) routinely visit farms to talk with workers and employers about staying safe in the heat. The trainings — most of which are conducted in Spanish — cover the symptoms and health impacts of heat illness; how to provide sufficient shade, cool water, and breaks to workers in the fields; and the different impacts of water, energy drinks, coffee, and alcohol on the body during extreme heat.

    The trainers avoid medical jargon, instead “using terminology they [the workers] can relate to,” says Kent Pinkerton, PhD, director of WCAHS and professor of pediatrics at the UC Davis School of Medicine. “We talk about the importance of maintaining your car. You also have to maintain your body. You wouldn’t want to run your car without oil.”

    A trainer from the Western Center for Agricultural Health and Safety teaches farm workers about protecting themselves from extreme heat.
    A trainer from the Western Center for Agricultural Health and Safety teaches farm workers about protecting themselves from extreme heat.
    Courtesy University of California, Davis

    Other efforts have tested the impacts of providing protective clothing. In one of the studies that the School of Nursing at Emory University conducted in Florida, 78 agricultural workers wore some combination of a cooling bandana, and/or a cooling vest, or just their regular clothing. They also wore equipment to measure their core body temperatures and symptoms of heat-related illness. The result: Those who wore only the bandanas were the least likely to exceed the maximum core body temperature (38 degrees Celsius or about 101.4 degrees Fahrenheit) recommended by the National Institute for Occupational Safety and Health.

    Yet climate change education and protection efforts are nascent in rural America. In recent years, four states — California, Oregon, Washington, and Colorado — have enacted regulations requiring employers to take specified steps to protect outdoor workers as temperatures climb. Under Oregon regulations that took effect last year, when temperatures reach 80 degrees, employers must provide outdoor workers with an area of shade and enough cool water to drink 32 ounces per hour. Washington’s regulations make similar requirements and add more when temperatures reach 90 degrees, including a 10-minute rest period every two hours and “close observation to help identify employees showing signs of heat-related illness.”

    But training, laws, and gear are not enough to protect people from extreme weather if the advice gets tucked below other priorities. A study conducted by WCAHS several years ago found that farm workers “mostly know they should be drinking more water and resting frequently in hot weather, but they are not following through.” The main reason: “Workers are very aware their employer wants to have workers who can maximize productivity, no matter how hot the weather.”

    In Wisconsin, Charles knows it will take work to elevate the priority of climate change in rural areas. He has become a public advocate, doing media interviews and giving talks about the health impacts of extreme weather and how industries and governments can reduce carbon emissions.

    “It’s important for physicians to engage publicly” about climate change, says Charles, who serves on the board of an advocacy group, Healthy Climate Wisconsin. “We can make a huge impact. Physicians are trusted. We’re trusted primarily because we care.”