Climate Migration And The Future Of Health Care
Illustration by Brett Ryder
At first, the connection between the two women wasn’t obvious. Both were new to our practice—first-time patients at a primary care clinic in a public hospital system in New York, one of the busiest cities in the world. One, Ms. S., was a petite, round-faced woman in her early thirties. She came with her seven-year-old son and concerns about belly pains. She spoke in Spanish, her words laced with an accent that was distinct enough for me to notice but not to place but that would identify her to the exact town of her childhood for those who knew. With her son happily distracted by a handheld video game, she described her symptoms, their time course, triggers, and alleviating factors. We also discussed her financial concerns as a woman working two jobs to make ends meet; her housing insecurity as an unregistered subletter in an overcrowded apartment complex; and her worries about her son, who was struggling in a school that did not offer strong courses in English as a second language. For primary care physicians, being able to elucidate these social determinants is often as important as being able to perform advanced diagnostic maneuvers or identify subtle exam findings.
The second woman, Ms. M., was older, impossibly tall and impeccably dressed, with a deeply furrowed brow that communicated to me the seriousness of her visit. Ms. M. had come from a small community in Northeast Africa and spoke a language so uncommon that there was only one certified interpreter in our entire language service’s network who spoke it. I watched as she and the translator spoke—familiar, almost intimately—and as the three of us established a rapport, I could see her brow unfurrow the smallest bit. Ms. M. suffered from years of back pain, and after a failed surgery in her home country, she was seeking care in our clinic. As I performed her physical exam, we discussed her family history, her children’s health, her favorite things about New York, and what she missed most from home.
These women, two strangers, could not have been more different. They represented the spectrum of patients our public clinic cared for and I was privileged to meet in the course of my work. So it wasn’t until I got to my usual screener on immigration that the connection between them became apparent.
“Do you have any concerns about your immigration status or documentation that you would like to discuss with me or our legal team?”
They did.
Both, it turned out, were looking for asylum. In the course of their care, I would learn that both of their lives had been turned upside down by climate change.
The Legal Clinic
I had no formal teaching in migrant health in medical school, despite training in a part of the country with some of the largest and most vibrant migrant communities. As a result, when I began my work in the New York City public hospital system, I felt poorly prepared to care for patients with needs related to immigration. But when rumors began circling in 2018 that the US Immigration and Customs Enforcement (ICE) agency was targeting our patients for arrest and deportation, my clinic made efforts to educate and prepare its providers. We offered education on topics related to screening and medical care provision for migrant patients, built community resources and references, and expanded the hours of our volunteer legal clinic. Because of this effort, I was able to regularly screen and refer my patients for migrant health–specific needs, including the need for legal services regarding asylum seeking.
When I asked Ms. S. for details, her story came slowly. She asked if someone could watch her son while she talked, as she didn’t want to risk retraumatizing him. She spoke of gang violence in her community, exacerbated by systematic resource extraction by international agricultural conglomerates and a lack of economic and infrastructure investment by the government in rural areas like hers. She spoke of financial destitution, the frighteningly high incidence of HIV/AIDS, and the loss of children to treatable bacterial infection caused by contaminated drinking water. Her voice was so soft that I almost missed what she said had finally driven her to leave for the US. Tierra fallida. The land had failed.
Ms. M. recounted the events of her emigration in pragmatic terms (or at least her interpreter did). She was a member of an ethnic minority in her country, whose people were abandoning their community after a contract with a UN organization to provide water for agricultural support had failed. Years of recurrent drought and extreme temperatures coupled with resource mismanagement had rendered the land around her town unable to support farming, and with the erosion of the agricultural base, the towns in the area were in economic collapse. When the doctor treating her back pain closed his practice and left, she knew it was time to leave, too.
Both of these women had, in some way or another, been forced to leave their homes. They were escaping violence, economic collapse, and the lack of access to crucial health care. But they had also been driven by environmental pressures that had made their homes unlivable and their lives unsafe. The connection—across continents, languages, ages, and myriad other differences—was striking. In my evaluation, both of these women needed support to navigate the complexity of the US immigration system, and both had cases to be considered for asylum. But this was not something I was prepared to address. So, in addition to a mammogram for Ms. M. and routine vaccinations for Ms. S., I referred them both to our free legal clinic.
A few weeks later I called the legal clinic office to check on the status of my referrals. The woman on the other end of the line was a volunteer, one of a handful of legal professionals who took time from their paid work to help meet the legal needs of our patients. She was not familiar with my cases but took the time to pull up their documents. On the other end of the line, I could hear the squeaking of old file cabinets opening and the shuffling of paper records being parsed and reviewed.
When she returned to the line, the woman informed with saddened resignation me that my patients were not eligible to apply for asylum. Her tone hinted that this was not the first time she had shared such news.
“Why not?” I asked.
She paused. “They are climate migrants.”
The Privilege Of Asylum
According to the Department of Homeland Security, a refugee is “a person outside his or her country of nationality who is unable or unwilling to return to his or her country of nationality because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.” An asylee, on the other hand, is a person who meets the definition of refugee and is either already living in or seeking to come to the US. When I learned that neither of my patients would qualify for legal support in their quest for asylum, I was despondent. These women had trusted me, shared their personal stories of grief and suffering, and were relying on me for the help that I had promised. Their stories were compelling, credible, and worthy of further advocacy by someone better informed and equipped than I. Where had it gone wrong?
In 1948, after the end of World War II, the United Nations General Assembly signed the Universal Declaration of Human Rights, outlining the “rights and fundamental freedoms” applicable to all human beings. Three years later, international leaders elaborated on the particular case of those who had been forcibly expelled from their homes as a consequence of the war and its aftershocks: The 1951 UN Convention Relating to the Status of Refugees formally defined the term refugee and outlined the conditions under which individuals had rights (and nations, responsibilities) related to asylum. In the US, Congress incorporated these definitions and provisions in the Refugee Act of 1980. Much of how the international community identifies and protects refugees has existed unchanged since then.
Currently, there is no international legal framework to address the impacts of climate change or associated environmental disasters such as extreme weather events on migration. And while international organizations like the World Bank and the UN Refugee Agency acknowledge “climate migrant” as an official designation for those whose migratory patterns are influenced by environmental changes, they have stopped short of using the term “climate refugee.” As a result, there are no explicit legal or judicial protections for those fleeing environmental disasters, and asylum does not apply.
The lack of explicit language to protect those affected by climate change is compounded by the fact that it is often difficult to identify extreme environmental conditions as the primary driver of forced migrations. While those seeking asylum are often able to point to a key identifying characteristic of themselves or their communities that triggered persecutorial action by others (such as being a member of a minority political group or having a particular religious affiliation), it is much harder for individuals or communities to point to environmental causes of forced migration as reasons for “fear of persecution.” This is despite the fact that these communities are often targets of environmental exploitation specifically because their minority status has left them neglected or underrepresented in policies or programs that affect their homes, livelihoods, and health.
Ms. S., for example, had come from a country experiencing years of decreasing crop returns as the result of worsening drought, extreme temperatures, and soil erosions from heavy flooding. In addition to natural phenomena such as El Niæo and resource misuse by multinational agricultural conglomerates in coffee, fruit, and palm oil, these disastrous weather changes have been attributed to the effects of climate change (climate modeling from ProPublica, the New York Times Magazine, and the Pulitzer Center estimates that in the next thirty years more than thirty million migrants from Central America could make their way to the US as the result of climate changes; a similar report by the World Bank in 2018 put that number at seventeen million). However, because Ms. S.’s most immediate reasons for leaving her country were cited as the violence and insecurity she faced when forced to move to an urban environment in her country, it was not apparent that climate change played a role. Only when her whole story was taken into account did it become clear that the principal cause of her migration had been the failure of her farm. And that had been driven by climate change.
Primary Care And Climate Change
In primary care we are witnessing, often without even knowing it, the effects that climate change and associated extreme weather events are having on our patients.
Recently, a frustrated colleague shared the story of a patient, an elderly man and lifelong city resident who suffered with chronic obstructive pulmonary disease (COPD). At a recent appointment, the man complained that he couldn’t breathe during the summer because the city was so hot but he couldn’t open a window because the pollution from a nearby highway triggered his reactive lungs.
“What I am supposed to do?” my colleague asked, shaking his head. “Recommend he invest in better AC? Tell him to move? He can’t afford that. So I looked up local cooling tents, reminded him to clean his units to prevent legionella, and made sure he’s got refills on his inhalers.”
In urban areas, extreme heat events are compounded by dense and crowded living environments and outdated infrastructure, which make for poor air movement and quality and ineffective cooling. This places the elderly, people with limited mobility, and people with underlying respiratory and cardiovascular diseases at increased risk for what the Centers for Disease Control and Prevention identifies as “temperature-related death” and illness. These events have increased in frequency, and severity, over the past several years. But extreme weather–related events are not the only climate-related changes that pose health risks. Research suggests that in the next twenty to fifty years nearly one in two Americans will experience a significant decline in the quality of their environment. And while almost four million of us may wind up living in an “extreme zone”—characterized by environmental factors inhospitable to normal life—the rest of us may experience something less obvious but just as devastating.
In the Northeast, for example, there are concerns regarding the quality of drinking water and the potential for increases in waterborne illnesses for large populations, as a result of contamination from soil erosion and agriculture runoff from increased flooding. In the Midwest, warm winters are expected to increase populations of pests, particularly disease-carrying mosquitoes, which not only change infectious disease risks for communities but will lead to increased used of potentially harmful pesticides. In the Southwest, food insecurity and malnutrition may be exacerbated as the result of agricultural runoff, chemical waste exposure, and waterborne pathogens infecting local plant, meat, and fish processing plants. In all of these places, the mental health effects of climate change may weigh heavily, resulting in a secondary health crisis. These issues may also result in sizable migrations of people within the United States to areas of more environmental stability or predictability (internal migration as the result of climate change is known as climate displacement).
All of the health impacts of climate change can manifest in a clinic visit. But in medicine we are struggling with how to talk about that. Often, this is due to concerns about “bringing politics” into the clinic. The detrimental impact of humans on our environment has become one of the most charged topics of conversation, and many physicians worry about jeopardizing their patient-provider relationships by discussing it. But politics is only part of it. As primary care physicians and social medicine doctors, my colleagues and I have confidently and competently discussed everything from abortion to sex trafficking to voting with our patients. So what else is going on?
One reason may be a knowledge gap. As doctors, we have dedicated our lives to the pursuit of learning and are charged with sharing that learning with our patients. But how can we teach what we do not know? A 2018 review from the Center for Climate Change Communication at George Mason University revealed that although both patients and providers identified climate change as an area of potential harm to health, few people were able to list specific health impacts of climate change; providers reported low self-assessed knowledge and high need for further information and training. At the same time, studies of Canadian and US medical schools showed an average of zero curriculum hours dedicated to teaching about the health impacts of climate change (and, given the demanding schedules and competing time requirements of residency training, it is likely that graduate medical education is no better than medical school is in this regard).
This leaves us to fend for ourselves when searching for information on the relationships between health and the environment, and to wade through the morass of misinformation, speculation, and politicization that comes with it. All of which means we are poorly prepared to have critical conversations with our patients about the role of climate change on their health.
Soon We May All Be Climate Migrants
In August 2020 the impacts of climate change in the US were made horrifically apparent. We watched as wildfires tore through the American West, destroying thousands of lives and millions of acres. Environmental scientists across the country maintained that the conditions precipitating the wildfires—such as warmer and drier woodlands and declining autumn rain—were due, at least in part, to the effects of humans on our climate.
We also saw the health consequences of the disaster. Medical centers in California, Oregon, and elsewhere saw upticks in primary care and emergency department visits for respiratory complaints, but also headaches, nausea, and mental health concerns like anxiety and depression, all of which were attributed to the effects of the fires. Providers got booster courses on managing burns, smoke, and heat injuries. Tens of thousands of residents were advised to stay indoors for days at a time to avoid potential exposure to harmful smoke and particulate matter. And, in the end, thousands made the decision to leave their homes.
The US public hospital system cares for a disproportionate number of undocumented and migrant populations, and we are starting to recognize climate migration as a driver of immigration among our patients. But public hospitals will not be the only frontiers where this new health crisis will manifest; as things get worse, even the most privileged will seek care for the health consequences of environmental destruction. As health care providers, we must be ready. More education is needed to train providers to adequately identify, diagnose, and treat the sequelaeof climate change and extreme weather events. We must incorporate climate change education into patient care and talk with those whose health may be affected. On a deeper level, we must acknowledge that a commitment to climate justice activism is an integral part of not only primary care but all of medicine. And we must work, in collaboration with local, national, and international leaders, to ensure that patients and communities affected by climate change are not disproportionately harmed by regressive or isolationist migration policies, exclusionary health practices, or other forms of discrimination.
That Life Was Gone
I did not see Ms. M. in clinic again. In primary care, we often talk about the joy one feels in establishing long-term caring relationships with patients. Less often do we mention those we lose along the way. Strangers, briefly becoming something more, only to fade again to anonymity.
Ms. S. continued to come to our clinic for care, despite not being eligible for asylum. I diagnosed her with an H. pylori infection, and after a course of antibiotics and acid suppression treatment, her belly pains improved. But they did not disappear entirely, and as we worked to identify and address her health needs, we both appreciated the role her past traumas played. We tried cognitive behavioral therapy, and I referred her to mental health services to help her more thoroughly process her past experiences. At our last visit I learned that she had sent her son back home. Financial constraints, coupled by the fact that he was undocumented, had forced her hand. I asked her if he had returned to the family farm. She smiled sadly and shook her head. That life was gone.
