HOME ABOUT US INITIATIVES REPORTS NEWS AND EVENTS TOPPING INTERNS DONATE The Impacts of Climate Change on the American Rural Health Care System Home > Papers > The Impacts of Climate Change on the American Rural Health Care System Photo by Thomas Hawk/CC BY-NC 2.0 Noah Herfort | December 5, 2020 The world is currently ensnared in an unprecedented global pandemic. COVID-19, the disease caused by the novel SARS-CoV-2 virus, has not only infected millions around the globe, but has also precipitated an energized discussion over public health. The emerging public discourse, however, has largely failed to make connections to global climate change. This paper attempts to fill this gap by analyzing the impacts of climate change on the rural American health care system. More specifically, it investigates how two prominent impacts of climate change, extreme weather and increased disease incidence, will exacerbate the already brittle state of the American health care infrastructure. It also draws a sub-focus on Native Americans, a largely rural community suffering from comparably poor health outcomes and the ubiquitous weight of systemic racism. To demonstrate this, the paper will first provide an overview of rural health in the United States, highlighting key systemic issues as well as targeted shortcomings within the Native American health care system. From there, the essay discusses the impact of extreme weather on rural health infrastructure by honing in on the Southern Great Plains, an area whose already unforgiving climate will only intensify. The paper then analyzes climate-induced disease incidence by highlighting pre-existing and future struggles within the Native American community. It then finishes by offering remedial actions that would alleviate and fortify America’s ailing rural health infrastructure in the age of unmitigated global warming. Rural Health in the United States Socioeconomic Context The U.S. health care system, in general, is known for its exorbitant costs, low insurance rates, and mediocre health outcomes (Johns Hopkins, 2019; CMS, 2018; CDC, 2017a). These overarching issues, however, are intensified within rural America, especially in comparison to more affluent urban populaces (Warshaw, 2017). First and foremost, rural Americans tend to be older, poorer, and sicker than their urban counterparts (CDC, 2017b, p. 1). When compared with urban areas, rural populations have a lower median household income, a higher percentage of child poverty, fewer adults with a higher education, a low insurance rate for residents under the age of 65, and increased rates of mortality (NC RHRP, 2017). While it is difficult to tease out a conclusive dynamic, it is likely that rural America’s relative socioeconomic destitution is the reason for its worse health outcomes. Often, a lack of investment stifles economic opportunity and hinders the attainment of post-secondary education. This in turn can result in labor-intensive work and the development of unhealthy behaviors. It is likely that this type of slippery socioeconomic slope has disadvantaged rural America’s health care system and infrastructural capacity. Overarching Issues As a result of this socioeconomic deprivation, the rural American health system is weak and brittle. It is specifically plagued by three overarching challenges: physician shortages, far-away care facilities, and hospital closures. According to the North Carolina Rural Health Research Program (2017), there are 55.1 primary care physicians per 100,000 rural residents versus 79.3 primary care physicians per 100,000 urban residents. The juxtaposition is even more stark in mental health capacity, as there are only 35.1 mental health providers per 100,000 rural residents vis-á-vis 213.1 mental health providers per 100,000 urban residents. As Warshaw (2017) opines, rural doctors are “stretched thin,” leading to critical care gaps and comparatively worse health outcomes. It can be postulated that physician shortages are again linked to a lack of socioeconomic opportunity and the resulting difficulty of attracting top-level medical professionals. Corollary to this issue is the extreme distance at which many rural health facilities are located. Many rural residents live on secluded farms, ranches, reservations, and frontiers, making it difficult to find health care in their immediate area (Warshaw, 2017). Instead, they are forced to trek long distances for health care, a time-consuming endeavor that leads to unnecessary time off work and troublesome back-and-forth transportation (Warshaw, 2017). The lack of nearby health services can be a matter of life or death for many rural Americans, especially when confronted with an urgent medical emergency. This issue is also compounded by the aforementioned lack of physicians. It is not difficult to imagine a scenario where a rural American is forced to travel several hours for a check-up only to find that their appointment was abruptly cancelled due to staff shortages. A primary reason for shortage of nearby health services is the scourge of hospital closures in rural America. The North Carolina Rural Health Research Program (2020) estimates that 171 rural hospitals have closed since 2005, with 65 closing between 2015 and 2020. In fact, it appears as if this trend is only accelerating, as 2019 was the single worst year of the closure crisis with 19 rural hospitals ceasing operations (The Chartis Center for Rural Health, 2020, p. 1). Tantamount is the bleak future outlook, as 453 rural facilities of 1,844 rural hospitals are “vulnerable” to closure (The Chartis Center for Rural Health, 2020, p. 1). Hospital closures have been concentrated in the Southeast and Southern Great Plains, a region that has by and large refused to expand Medicaid under the 2010 Affordable Care Act (The Chartis Center for Rural Health, 2020, p. 2). Medicaid expansion has been shown to boost the bottom line of financially stressed rural health care facilities because it increases the number of insured amongst poor (and oftentimes unhealthy) residents and mitigates the financial losses of “charity care” (medical bills left unpaid) (Guth et al., 2020; Healthline, 2017). Refusal to adopt Medicaid expansion has thus hampered the financial viability of rural hospitals and underpinned the closure scourge. From a broader perspective, America’s rural health infrastructure can be described as scarce and under-equipped, a result of both direct policy choices and long-term socioeconomic decline. Poor Health Outcomes As a result of rural America’s relative socioeconomic deprivation and poor health care infrastructure, rural Americans suffer from comparatively poor health outcomes. While overall mortality rates have been declining nationwide, rural areas have experienced a much slower decrease (Warshaw, 2017). More specifically, rural mortality stands at 830.5 per 100,000 people while urban mortality is down to 704.3 per 100,000 people (CDC, 2017b, p. 1). Not surprisingly, the five leading causes of death in the U.S. – heart disease, cancer, unintentional injury, chronic lower respiratory syndrome, stroke – are higher in rural areas rather than urban areas (CDC, 2017b, p. 1). “Deaths of despair,” causes of death attributable to drugs, alcohol, or suicide, are also more highly concentrated in rural America. For example, opioid deaths are 45% higher in rural areas than urban areas, a substantial difference that bears testament to the economic hardship and corresponding ill health impacts in the rural U.S. Native American Health Care Native American health care is demonstrably worse off than the rest of the rural U.S. This is despite the fact that the U.S. government has a responsibility to provide basic services to Native Americans, not least adequate health care (Warne and Frizzell, 2014, p. 263). This is due to Native Americans’ “unique history” with the U.S., where the “exchange,” or rather brutal vanquishment of tribal lands, was based on the reciprocity of certain legal rights and concomitant financial obligations (Warne and Frizzell, 2014, p. 263). The web of treaties that resulted from the exploitation, death, and decline of native communities oftentimes include phrasing such as “promise of all proper care and protection,” which meant the de facto provision of basic services such as education and health care (Warne and Frizzell, 2014, p. 263). Thus, the Indian Health Service (IHS) was born, an agency within the Department of Human Health Services tasked with providing health care for Native Americans (IHS, 2019; ABA, 2018). Although the IHS technically satiates treaty responsibilities by covering more than 560 tribes, chronic underfunding by Congress has severely hampered its efficacy (Warne and Frizzell, 2014, p. 264). In fact, this lack of resources is not a new trend, rather it is an established practice dating back to when the last treaties were signed in 1871 (Warne and Frizzell 2014, p. 263). Native Americans subsequently suffer from centuries of exploitation and abuse, a systemic malaise which has become manifest in an under-funded and under-equipped health system. The most substantial legislative change came with the 1976 Indian Health Care Improvement Act, which not only established Urban Indian Health Programs but also expanded Medicare and Medicaid under the umbrella of the IHS (Warne and Frizzell 2014, p. 264). Medicare has thus become the main source of health care coverage, as Native American communities account for the highest national poverty at 27% (compared to 11% for Whites) (Warne and Frizzell 2014, p. 265; U.S. Census Bureau, 2013). While this is a welcome change, this legislation does not target the crux of the issue, namely the crippled IHS, which has been savaged by budget cuts and legal disrespect for the plight of Native American communities. As a result, Native Americans suffer from deficient health outcomes (IHS, 2019). In comparison to other Americans, Native Americans die at higher rates of chronic liver disease and cirrhosis, diabetes mellitus, unintentional injuries, homicide, intentional self-harm, and chronic lower respiratory diseases (IHS, 2019). More broadly, Native Americans born today have a life expectancy that is 5.5 years less than all U.S. race populations (73 years compared to 78.5 years), an incredulous gap that lends credence to the structural disadvantages foisted onto the Native American community (IHS, 2019). These structural shortcomings have laid the foundations for generational poverty, which is not least represented in the 28.6% rate of uninsured people amongst Native American communities (CDC, 2017c). Native American areas are also challenged by medical personnel shortages (ABA, 2018). While this is a general issue in rural America, it is particularly intense in Native American areas. This adequately encapsulates a larger phenomenon, namely that Native Americans are an underprivileged faction within the already disadvantaged general rural constituency. While rural America has had to wrestle with socioeconomic deprivation and a weak health care infrastructure, Native Americans are subject to the additional inequity of systemic racism, which has been firmly baked in the systems meant to support them. As such, it can be said that the Native American health care system is severely flawed and its infrastructure similarly dilapidated. The Impact of Climate Change on Rural Health Care Infrastructure Extreme Weather As was previously mentioned, rural populations suffer from socioeconomic deprivation and related poor health outcomes. According to the National Climate Assessment (2018a.), the “social, economic, and institutional contexts in which [rural communities] are embedded can further influence their individual vulnerabilities and collective capacity to communicate, cooperate, and cope with a climate disturbance event.” In other words, the structural disadvantages that currently afflict rural populaces will only exacerbate the impacts of climate-induced extreme weather. Chief among these structural disadvantages is an underfunded health care system, an undoubtedly crucial element in both climate resiliency and adaptation. Climate change can thus be described as a “perfect storm scenario” for rural American health care, as its current shortcomings will only worsen with continued intensive warming. This phenomenon is aptly evidenced in the Southern Great Plains, a rural region that stretches from Kansas to southern Texas (National Climate Assessment, 2018b). Even without anthropogenic warming, the Southern Great Plains are typified by an already unforgiving climate. The region’s inhabitants are often “at the mercy of some of the most diverse and extreme weather hazards on the planet,” such as hurricanes, flooding, severe hailstorms, tornadoes, relentless winds, heat waves, and drought (National Climate Assessment, 2018b). This hazardous climate already stresses existing infrastructure and socioeconomic systems, resulting in both human casualties as well as billions of dollars in property damage (National Climate Assessment, 2018b). Yet even though these climate stressors are well known, rural communities in the Southern Great Plains do not have the adequate funding to fortify their infrastructure and invest in climate resiliency (National Climate Assessment, 2018b). And, it must be noted, that these pervading issues are under a “normal” climate, or one that has not yet been subject to the predicted increase in global temperatures. The Southern Great Plains have also been particularly hurt by the cascade of rural hospital closures. Texas and Oklahoma alone have experienced 27 combined hospital closures since 2010, making the Southern Great Plains one of, if not the most impacted region in the country (The Chartis Center for Rural Health, 2010, p. 2). These closures are intimately tied to the aforementioned state-level hindrance of Medicaid expansion, evidencing how a lack of investment is damaging the Southern Great Plains infrastructural resiliency. This concentration of shuttered hospitals is particularly worrying when considering the predicted intensification of climate impacts (i.e. extreme weather) within the region. The National Climate Assessment (2018b.) estimates that future climate change will lead to an increase in average temperature (3.6-5.1C by the mid-21st century) as well as the frequency, duration, and intensity of extreme heat events. The National Climate Assessment (2018b.) also postulates that climate change will likely increase the “circumstances” conducive to extreme weather. The Southern Great Plains are thus teed up for a health care nightmare, as their infrastructural capacity is diminishing at the exact moment when it needs to be built up and fortified. Where are rural residents in the Southern Great Plains supposed to go when their closest hospital, which oftentimes is already an exorbitant distance away, is burned or flooded and they themselves need urgent care? The answer portends a host of dystopic scenarios, some of which have already become manifest in the early years of unencumbered global warming. Extreme Weather Case Study: The 2016 and 2017 Wildfires in Kansas and Oklahoma The 2016 and 2017 wildfires in Kansas and Oklahoma were amongst the largest in the region’s history, scorching over 400,000 acres of land and laying waste to countless rural communities (National Climate Assessment, 2018b). The inferno was fueled by near-perfect conditions, as 6 months of drought was preceded by bountiful rain and vigorous vegetative growth (The New Yorker, 2018). The entire region was thus replete with dried, tall prairie grasses, making it a veritable tinderbox awaiting nothing more than a diminutive spark. The conditions that preceded the fire are a telltale sign of climate change, as a hotter and wetter atmosphere leads to more vegetation growth (soon to be wildfire “fuel”) and more intense dry spells (The New Yorker, 2018). What resulted was a “megafire,” which tore through Kansas and Oklahoma and decimated both infrastructure and livelihoods. The intersection between rural health and climate change impacts (in this case a wildfire) was strikingly apparent in rural Ashland, Kansas. During the peak of the wildfire crisis, Ashland was threatened by a raging inferno (The New Yorker, 2018). Ashland’s volunteer fire department was the only thing standing between total destruction and survival (The New Yorker, 2018). However, in order to mitigate any potential casualties, Millie Fudge, the head of the county emergency-management operations, decided to evacuate Ashland and the nearby town of Englewood (The New Yorker, 2018). Fudge also gave explicit orders to evacuate the Ashland Health Center as well as the town’s nursing home (The New Yorker, 2018). One has to imagine that some patients may have been hospitalized and thus difficult to evacuate, not to mention that the elderly residing in the nursing home have challenged mobility. With a wildfire heading straight towards them, these desertions were likely panicked and disorderly. While Ashland itself was spared, this example offers a window into the future of rural American health care: hasty evacuations from under-equipped health facilities, and if luck has run out, destruction of health infrastructure and potential casualties. On the same day as the Ashland fire, the daughter of Englewood’s fire chief, Bernie Smith, was frantically trying to find care for her mother, whose severe asthma was triggered by wildfire smoke (The New Yorker, 2018). The situation was dire: either her mother received emergency care, or she would die (The New Yorker, 2018). So began a panicked hunt for a health care facility. First, Smith’s daughter told her to drive to a health care facility in the nearby town of Woodward, but the roads were blocked by fire (The New Yorker, 2018). Smith’s daughter then tried a clinic in the northwest town of Beaver, Oklahoma, only to find that the facility did not have the necessary medications (The New Yorker, 2018). While her mother was in desperate need of medical attention, Smith’s daughter tried a third option, a hospital in Perryton, Texas, but was again stymied by wildfire-induced powerline sparks (The New Yorker, 2018). As a last resort, Smith told his daughter to go to a facility in Liberal, Kansas even if it meant “[driving] through fire to get there” (The New Yorker, 2018). Smith’s daughter finally reached the hospital and his wife received life-saving treatment (The New Yorker, 2018). This crisis scenario, albeit anecdotal, elucidates how the acute shortcomings of America’s rural health infrastructure will be exacerbated in a warming world. Smith’s daughter was forced to drive exorbitant distances across the Southern Great Plains just to find a clinic. As was previously mentioned, health care facilities are few and far between in the rural United States. This scarcity can be life threatening when faced with an injury or urgent medical issue during a climate-induced extreme weather event. As this example demonstrates, the lack of rural health care facilities is only exacerbated by inaccessible infrastructure, such as roads rendered useless by flames or sparking powerlines. The future is subsequently ominous, as a health infrastructure already struggling to meet the needs of rural residents will be incapacitated by extreme weather. Disease Incidence Another climate-related impact is increased disease incidence. This stresses rural health infrastructure because it does not have the capacity to deal with the accompanying influx of patients with chronic illness. The diseases themselves are intimately linked to climate impacts. Air pollution, which is a direct cause of anthropogenic climate change, harms human health by increasing ground-level ozone and particulate matter, which in turn diminishes lung function, increases the risk of asthma, augments hospital admissions, and heightens the chance of premature death (CDC, 2020a.). Air pollution is already a deadly crisis, causing an estimated 4.2 million premature deaths per year (WHO, 2020). This prodigious death toll, and related health care burden, will only increase with rising carbon emissions and concomitant climate impacts. Climate-induced wildfires will also underwrite a litany of chronic health challenges (CDC, 2020b.). Wildfire smoke, which contains harmful particulate matter, carbon monoxide, nitrogen oxides, and various volatile organic compounds, reduces air quality both locally and downwind from fires (CDC, 2020b.). This smoke exposure increases respiratory and cardiovascular hospitalizations, emergency department visits, medication dispensation for asthma, bronchitis, chest pain, chronic obstructive pulmonary disease, respiratory infections, and medical visits for lung illnesses (CDC, 2020b.). It is difficult to imagine how the American rural health care infrastructure, which is under-equipped, under-funded, and scarce, will accommodate the crush of patients suffering from wildfire-induced respiratory illnesses. Precipitation extremes, a unique impact of climate change, will also lead to heightened disease incidence (CDC, 2020c). For example, waterborne disease outbreaks are oftentimes preceded by heavy rainfall events, evidencing the connection between climate and poor health (CDC, 2020c). Water intrusion (i.e. flooding) into buildings is also problematic, as the resulting damp, moldy environment manifests in poor indoor air quality and increases the prevalence of asthma and other respiratory tract symptoms, such as coughing and wheezing, pneumonia, and respiratory syncytial virus (RSV) pneumonia. This predicted increase in chronic illness will likely cripple the impoverished rural American health care infrastructure. Moreover, climate impacts pose an acute risk to pregnancy. A systematic review of studies analyzing 32,798,152 births found that there was a statistically significant association between heat, ozone, or fine particulate matter and dangerous pregnancy risks (Bekkar et al., 2020, p. 1). Four studies found that that high temperatures were tied to an increased risk of premature birth from 8.6% to 21%, while one study found that every temperature increase of 1 degree Celsius in the week before delivery corresponded with a 6% greater likelihood of stillbirth between the months of May and September (Bekkar et al., 2020, p. 6). These findings portend a host of issues for rural America’s health care infrastructure. In the instance of a dire heat wave and an uptick in emergency pregnancy complications, rural America’s under-staffed health system will likely buckle if not break. Not only would laboring mothers have to travel a long distance to get to a rural health care facility, but the facility could be short on medical personnel or equipment, or even out of power due to heat-induced grid blackouts. This projected increase in chronic illness will prove particularly harmful to Native Americans. As was previously stated, Native Americans already suffer from extreme adverse health impacts when compared to other American racial populaces (IHS, 2019). The IHS is also a particularly disadvantaged sector of the general rural health care system (Warne and Frizzell, 2014, p. 263). The combination of extant health disadvantages and a poor health infrastructure will likely be a lethal one, as climate change will only exacerbate levels of chronic illness and lead to a swell of patients poised to overload an already ailing health infrastructure. This reality is particularly cruel given the historic injustices that have plagued Native Americans, a systemic discrimination that has become imbricated in the systems meant to protect and care for them. This injustice is further compounded by the fact that Native Americans have done little to contribute to the climate crisis. In fact, their traditional, nature-based way of life is one that is inherently sustainable, especially when compared to the hyper-consumerist, carbon-intensive American lifestyle. Climate change is also intimately linked to the emergence of novel diseases. More specifically, climate influences emerging diseases in three ways. The first is via zoonosis, or the transfer of a virus, bacterium, or microorganism from an animal to a human (Lustgarten, 2020). Around 60% of new pathogens come from animals, roughly a third of which can be attributed to carbon intensive changes in land use, such as deforestation, farming, or resource extraction (Lustgarten, 2020). The second pathway is via vector-borne diseases, which are carried by insects like mosquitoes and ticks and transferred through human blood (Lustgarten, 2020). Mosquitoes and ticks, and by consequence vector-borne diseases, are on the rise due to the expansion of warmer weather and increased precipitation (Lustgarten, 2020). Due to this proliferation, disease-carrying mosquitoes will ultimately reach 500 million more people by the year 2050 (Lustgarten, 2020). The third process is the re-animation of old viruses (Lustgartern, 2020). Once sequestered to the Arctic cryosphere, these viruses are being released with the melting ice, raising the specter of a prehistoric plague (Lustgarten, 2020). The SARS-CoV-2 virus, which causes COVID-19, is inextricably connected to a changing climate. This virus emerged through the process of zoonosis, and more broadly, the carbon-rich encroachment into a previously sheltered, isolated woodland (Lustgarten, 2020). COVID-19 has proven to be a serious challenge to a uniquely unprepared and sclerotic U.S. health care system. Given the increased potential for emerging pathogens in a warming world, it is likely that COVID-19 will not be the last global pandemic. Future, potentially more deadly diseases will likely overload and decimate the U.S. health care system, especially its relatively disadvantaged rural sector. COVID-19’s devastating impact on rural America was acutely evidenced in Native American communities. The common COVID-19 precautions include handwashing with soap and water and social distancing. These two vital preventative measures, however, were virtually impossible on overcrowded Native American reservations with little or no running water (Schultz, 2020). For example, it’s estimated that 35-40% of the Navajo Nation does not have running water (Schultz, 2020). Not surprisingly, the Navajo Nation also had one of the highest deaths per capita in the entire U.S. (IHS, 2020). COVID-19 was also particularly devastating in Native American communities because of the infrastructural shortcomings of the IHS, which does not have the medical providers, equipment, or facilities to treat critical patients (Schultz, 2020). In fact, the IHS only has around 71 ventilators and 33 ICU beds at the 24 hospitals under its jurisdiction (Schultz, 2020). Future climate-influenced global pandemics will cause similar havoc and exacerbate the impoverished health care infrastructure of rural Native American communities. Conclusion This essay highlights how the climate change impacts of extreme weather and increased disease incidence will impact rural American health infrastructure. While the rural American health system is already under-funded, under-equipped, and infrastructurally scarce, climate change will only worsen these systemic shortcomings. Native American communities especially will suffer, as centuries of oppression and discrimination have made them a disadvantaged community in an already impoverished populace. There are, however, ways to improve the resiliency and capacity of the rural American health system. Recently, the Trump Administration issued an executive order that will expand rural access to telehealth services during the COVID-19 pandemic (The White House, 2020). This executive order will also bolster the health care communication infrastructure and provide financial incentives for hospitals to increase their quality of care (The White House, 2020; Diamond et al., 2020). While telehealth is an exciting innovation poised to ameliorate the issue of distance in rural health, it must be a part of rather than the keystone of the solution. Improving the American rural health system will require broad, sweeping legislation that augments Medicaid and Medicare (which prevents hospital closure), fully funds the IHS, and fortifies the structural resiliency of rural health centers. More broadly, improving rural American health will also require rapid carbon abatement and climate mitigation, a task which seems as far off as ever with climate denialist forces in the White House. A sustainable transition built on justice and equity will not only limit the unbridled impacts of anthropogenic warming but will also lift up rural communities and strengthen their disadvantaged health systems. About the Author Noah Herfort is an undergraduate at the University of St Andrews, where he studies International Relations and Sustainable Development. Noah is interested in climate change, politics, and writing, passions which came to the fore during his work with the U.S. State Department, research internship at the Climate Institute, and Editor-in-Chief role at a student-run environmental magazine. In the future, Noah plans on pursuing a Masters and gaining employment in the environmental-political sector. He can be contacted at noahherfort@icloud.com. References ABA (American Bar Association). (2018). Native Americans: A Crisis in Health Equity. 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