Climate change, Covid-19, preparedness, and consciousness.

The Schwartzreport tracks emerging trends that will affect the world, particularly the United States. For EXPLORE it focuses on matters of health in the broadest sense of that term, including medical issues, changes in the biosphere, technology, and policy considerations, all of which will shape our culture and our lives.

Perhaps it is because I research and publish the daily Schwartzreport. The many stories I have done on climate change have certainly sensitized me to what is happening. Maybe it's just curiosity, or maybe it's fear. Whatever the reason, as I travel now I find myself looking around and thinking: what will be the impact of climate change on this community? I notice how they are dealing with the homeless, because migration is going to be a big deal, so this trend is only going to get worse. What's the food situation like? How good are the bridges? How do they handle sanitation demands at large events? It is going to be a huge problem. And all of it impacts, most particularly, health care.

In the United States on 30 January 2020, a Thursday, the Centers for Disease Control confirmed the first human-to-human transmission of the virus in the country, a 60 year old man returning from Wuhan, China, the center of the outbreak. A few hours later The World Health Organization declared the fast-spreading outbreak a global health emergency.

A few hours later, President Trump closed the borders, quarantined hundreds of travelers who had just arrived in the U.S. and gave an interview. As quoted from CNBC: “President Donald Trump said the U.S. government was working closely with China to contain the coronavirus outbreak that has killed at least 171 people, predicting “a very good ending” for the United States.

“We are working very closely with China and other countries, and we think it's going to have a very good ending for us, that I can assure you,” Trump added U.S. officials believe “we have it all under control,” adding that it's a “very small problem in this country.”

Four days later 17,438 cases had been identified and there were 362 known deaths. Four days after that the virus, still centered in China, had infected 34,546 people by that time and killed 720 people worldwide.

You will be reading this several months after I write it, and so will know how this plays out. But the numbers alone aren't the point I am trying to make. It is that this virus in spite of all medical advances arose very quickly and has had worldwide effects. Just as the AIDs pandemic has infected 75 million and killed 32 million as of 2019; or the much smaller (worldwide) Ebola hemorrhagic fever African epidemic which killed 11,000. Certainly we have come a long way the Spanish Flu pandemic of 1918, the deadliest pandemic on record, which infected an estimated 500 million worldwide, roughly a third of the world's population, and killed 20 to 50 million, including and estimated 675,000 Americans.

What I am trying to show with these illustrations is that a century of experience and data has taught us these afflictions appear in spite of all the advances of medicine, and cannot be anticipated. The question that haunts my mind is, how would the United States handle such a pandemic outbreak if it occurred as the coronavirus did in China, just as some kind of major climate change crisis was also stressing the American healthcare system. Are we prepared? I don't think so, do you?

The reality is that not only America but the world is utterly unprepared for these outbreaks, and when one adds the migrations that climate change will compel things look very bleak indeed. The International Organization for Migration in Geneva is generally considered the best source on information on this issue, and their source is Oxford professor Norman Myers. He says that by 2050, which is to say just 30 years from now, “When global warming takes hold there could be as many as 200 million people overtaken by disruptions of monsoon systems and other rainfall regimes, by droughts of unprecedented severity and duration, and by sea-level rise and coastal flooding.”

This rise in migration trend is already underway. The United Nations reports, “The climate crisis is already having an effect: according to the Internal Displacement Monitoring centre, 17.2 million people had to leave their homes last year, because of disasters that negatively affected their lives. Slow changes in the environment, such as ocean acidification, desertification and coastal erosion, are also directly impacting people's livelihoods and their capacity to survive in their places of origin.”

But I want to focus on the America's internal migrations particularly. Just consider the internal migrants projected to abandon coastal cities and towns because of flooding due to sea rise.

A multi-university re. search team led by Caleb Robinson of Georgia Institute of Technology's School Computational Science and Engineering Department did the calculations (See Fig. 1 ) and projected that sea rise alone will make 13 million people internal migrants. The team's commentary is chilling, “The impacts of SLR (sea level rise) are potentially catastrophic. About 30% of the urban land on earth was located in high-frequency flood zones in 2000, and it is projected to increase to 40% by 2030 taking urban growth and SLR into account [14]. In the United States alone, 123.3 million people, or 39% of the total population, lived in coastal counties in 2010, with a predicted 8% increase by the year 2020. By the year 2100, a projected 13.1 million people in the United States alone would be living on land that will be considered flooded with a SLR of 6 feet (1.8 m).

Fig. 1

Shows all counties that experience flooding under 1.8 m of SLR by 2100 in blue and colors the remaining counties based on the number of additional incoming migrants per county that there caused by sea rise over the baseline.

“As oceans expand and encroach into previously habitable land, affected people—climate migrants—will move towards locations further inland, looking for food and shelter in areas that are less susceptible to increased flooding or extreme weather events….we argue that the comprehensive impacts of SLR on human populations, when considering migration, expand far beyond the coastal areas.”

Climate change, migration, and epidemics; what lessons should we draw from those trends? How prepared is America to deal them? Ask yourself: Where I practice how would the EMTs, clinics, hospitals, my practice itself, handle the stresses to come over the next three decades? Whether it is people fleeing, people in transit, or people arriving, how would sanitation, housing, healthcare, and food support be done where you live?

I want to argue that we as a nation are headed to a disaster of a proportion nationwide never experienced in our history. And it is occurring at the same time that the Illness Profit System that passes for healthcare in America is collapsing. Is this a political statement? Only in the sense that it is going to require politics to solve it. Let's put partisanship aside and just look at the objectively verifiable data starting with the demographic which is going to live through what is occurring.

We are an aging population. According to the U.S. Census Bureau in less that 20 years the old will outnumber the young for the first time in U.S. history. They report, “Already, the middle-aged outnumber children, but the country will reach a new milestone in 2034 (previously 2035). That year, the U.S. Census Bureau projects that older adults will edge out children in population size: People age 65 and over are expected to number 77.0 million (previously 78.0 million), while children under age 18 will number 76.5 million (previously 76.7 million).” So we are getting older and less vital. Also, lifespan in America has been going downward for the last three years, after more than a century of increasing steadily.

Steven Wolf of Center on Society and Health, Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond, and Heidi Schoonmaker of Eastern Virginia Medical School, Norfolk, teamed up to really climb inside of this life expectancy decline, and their report in JAMA should be a clock stopper. They found that, “US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (e.g., drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.”

And all of this is occurring in a nation whose healthcare system currently ranks, according the to the World Health Organization, a lowly 37th in the world. Far from preparing for climate change and what it means, the United States is going backwards, dismantling the fragile system it has.

Twenty percent of the people living in the United States live in what is defined as a rural area. Rural counties constitute approximately 97% of the land mass of America. About 20% of the population live in one of these counties – that's just under 66 million men, women, and children, although this population is skewed older; 17.5% are older than 65, compared to urban areas where that percentage is 13.8% In some states more than 50% of the older population lives in these rural areas.

So we have climate change coming on in rural areas where there is an older population that already requires more healthcare that average. So what is actually happening? Since the U.S. healthcare system places profit above health, hospitals are closing right and left (see Fig. 2 ) because they aren't profitable enough, and the Covid-19 crisis will show us what happens in such a healthcare system.

Fig. 2

Credit: navigant.

In 2016 about 41% of rural hospitals nationally operated at a negative margin, meaning they lost more money than they produced from operations. Texas and Mississippi had the highest number of economically vulnerable facilities, that year. Three years later, in 2019, more than 20% of our nation's rural hospitals, or 430 hospitals across 43 states were near collapse. At least 155 rural hospitals have closed since 2005.

I have been documenting this in these pages since 2005. Once the reality is faced that healthcare is calibrated to profit not wellbeing, it is easy to see why hospital corporations are closing rural hospitals. At present we have a situation where the healthcare system is disintegrating at the very time it is going to be most needed.

Think about those hospitals closing. Each time a rural hospital closes, there are tragic consequences for the local community and surrounding counties. While the medical consequences are the most obvious, there is also loss of sales tax revenue, reduction in supporting businesses such as pharmacies and clinics. There are also fewer professionals, including doctors, nurses and pharmacists, and fewer students in local schools.

David Mosley and Daniel DeBehnke, MD, studied this exact issue and reported: “The closing of a rural hospital often signals the beginning of progressive decline and deterioration of small rural towns and counties. Hospitals often serve as financial and professional anchors as well as source of pride for its small rural community. It also often means loss of other employers or inability to recruit new employers due to lack of nearby health care. When a rural hospital closes its doors, unemployment often rises, and average income drops.”

There are no nurses, doctors, pharmacists or ERs for local farmers, ranchers, growers and assorted men, women and children who love living and working in America's vast rural regions. Rural communities and rural citizens are often left with no options for routine primary care, maternity care or emergency care. Even basic medical supplies are often hard to find. Just think about one example of what would happen if 13 million Americans were on the move in desperation. Consider diabetes.

According to the Centers for Disease Control, in 2017 “More than 100 million U.S. adults are now living with diabetes or prediabetes.” The report found that in 2015, 30.3 million Americans – 9.4 percent of the U.S. population were diabetic. Another 84.1 million had prediabetes, a condition that if not treated often leads to type 2 diabetes within five years. And the numbers in 2020 are larger because they have been going up.

Assume for the moment equal distribution of diabetic sufferers amongst the internal migrants, although in actuality that will not be the case. Coastal Southern states, where climate change will particularly cause internal migration, have the highest diabetes rate in the country. But just assume equal distribution. If there are 13 million internal migrants, 9.4% would be over a million men, women, and children, 1222,000 to be exact. If you have been taking insulin for more than 10 years without it you probably wouldn't live no more than 10 days. Do you think all those migrants will be well stocked with the insulin they need? No neither do I.

If you live and practice in a city of a hundred thousand, or a town of 50,000, could your emergency rooms handle 10,000 or 5000 additional diabetics desperate, probably unable to pay for their daily insulin? Insulin is not optional. How would your city or town even set up the system to meet the demand? Would your pharmacies have enough on hand?

And it isn't just the diabetes; if people weren't getting their dosages regularly a whole range of serious health complications such as cardiovascular events, or kidney disease will arise and require care.

In this essay I have just touched on three aspects of the crisis humanity faces, pandemics, climate change, and diabetes. But that is a very partial list. To really get the full picture would require more than an essay; one would have to add: extreme weather events from hurricanes to heatwaves, the decline of life-sustaining ecosystems, food security and dwindling stores of fresh water. Each one of these alone poses a monumental challenge to humanity in the 21st century. Taken together as is likely to happen the situation becomes cataclysmic.

America is not prepared for any of this, not even close. How bad could it get. At the University of Massachusetts in Boston, at the Center for Governance and Sustainability a team led by the center's director Professor Maria Ivanova as that question. And their conclusion? Looking at the combination of variables they see affecting the world they said these factors, “have the potential to impact and amplify one another in ways that might cascade to create global systemic collapse.”

Erik Franklin, a researcher at the University of Hawaii's Institute of Marine Biology concurs, “Human society will be faced with the devastating combined impacts of multiple interacting climate hazards. They are happening now and will continue to get worse.”

If any group must lead the preparation fight to prepare us I think it must be America's healthcare professionals; the people actually on the line. However, comfortable you are. No matter how convinced you are that this chain of crises won't touch you, or that you can handle it, you won't, and you can't. Not with the infrastructure and illness profit system we have today.

I think a significant part of the budget now going to the military should be redirected into the rebuilding of a new system based on universality and fostering wellbeing. It is going to require a different consciousness. A different way of thinking. A different worldview. And just as they say, you either become part of the problem or part of the solution.