Social EM

Water, Fire, and Medicine: Why Environmental Justice Matters in EM

They say nature does not discriminate. Fire and water flows where it desires, chemistry and physics dictating the course of its spread. However, due to structural forces, these events will always leave the largest impacts on vulnerable communities.

In California in 2020, amber flames ravaged millions of acres, destroying homes, claiming lives, and compromising people's ability to breathe as the fire raced to consume Mother Nature.

Just as easily as fire can destroy everything in its path, so can water. As I watched the wildfires in my home state rage on, memories of living through the deluge of Hurricane Harvey in Houston, Texas, resurfaced. As a student working in the county hospital's ED, I became intimately acquainted with countless stories of suffering, tragedy, and resilience. 

"I was doing so well. I had a business. I had a home. Now I have nothing," a patient lamented, her eyes tightly scrunched close, attempting to block the nauseating memories of the hurricane. It was no use. Just as the waters continuously poured into her home, so did the visuals of her life belongings being swept away, damaged and lost by the never-ending inundation of murky brown waves.

Her documented chief concern - a fractured arm. After escaping from her flooded home, she fell down and injured herself. However, without medical insurance, she repeatedly put off seeking help until the pain became too much to bear. Yet, the physical affliction of her broken bone felt like the least of her worries, as she mourned the loss of not only her possessions, but also her future livelihood. How could her extraordinary trauma be adequately captured in a progress note?

"The shelters are all full. I don’t have anywhere else to go. Please let me stay here," another patient begged. He had already spent 2 years without a home, navigating the streets of the sprawling cityscape, while receiving only sporadic care from the ED for his mental and physical ailments. After seemingly persevering through the darkest of times, somehow everything became worse with that ill-fated weather forecast.

His listed chief concern - suicidal ideation and intent. Yet this psychiatric assessment did not come close to capturing the brunt of his experiences, consistently shut out by the very same institutions that were designed to help him, requirements and time constraints wielded as obstacles to prevent the provision of anything but short-term relief. How could years of societal marginalization, further exacerbated by catastrophe, be appropriately captured in a progress note?

They say nature does not discriminate. Fire and water flows where it desires, chemistry and physics dictating the course of its spread. However, due to structural forces, these events will always leave the largest impacts on vulnerable communities. Systemic racism and deep-rooted socioeconomic inequalities have created an enduring legacy that will continue to disproportionately harm low-income and minority communities. 

In Houston, the areas where more residents were non-Hispanic Black experienced greater flooding from Hurricane Harvey, in addition to neighborhoods where residents had higher rates of low socioeconomic status and limited English proficiency.1 The longstanding practice of redlining forced minorities to inhabit neighborhoods with the greatest flood risks. In the aftermath, households with lower incomes and disability status faced greater difficulties in recovering from the event, independent of any post-disaster assistance.2

The California wildfires similarly illustrated the inequitable distribution of healing. Incarcerated individuals are paid less than $2 an hour to become firefighters, endangering their own lives for the public.3 Families with insurance and disposable savings are able to rebuild their scorched homes and find hotels for temporary sanctuary. Others are forced to relocate out of the state, unable to find new jobs and affordable housing to replace what had been lost.4

Emergency medicine serves on the frontline of our communities, acting as the critical interface for individuals with the healthcare system. Climate change will continue to intimately impact EM by requiring close coordination with disaster response, while increasing the incidence of climate-sensitive diseases, including heat-related conditions, weather-related injuries, and vector-borne diseases.5

As a cornerstone of communities' public health infrastructure, it is critical that hospitals assist in the healing process after natural disasters, while recognizing that the resulting destruction from disasters will never be equal or just. Environmental catastrophes bring patients into the ED who are uniquely vulnerable, such as individuals without homes, the uninsured, and other marginalized populations. Health professionals should not only treat their medical conditions, but also connect these patients to resources to assist in the holistic recovery process through networks of social and community health workers. 

EM scholars have proposed recommendations for physicians and administrators to respond to climate change through 7 crucial areas of engagement:6 

  1. Clinical care strategies
  2. Building resilient EDs
  3. Public health engagement
  4. Disaster preparedness
  5. Mitigation efforts
  6. Research,
  7. Education

As these initiatives are implemented, it is critical that efforts are viewed with the lens of environmental justice, as the impact of these events are heavily mediated through systemic racism and inequality. In addition, medical institutions must continuously value engagement in advocacy, for both students and physicians, to help bolster these social issues in the public space.

With the ongoing climate crisis, the frequency and intensity of these natural disasters will continue at dramatic rates. EM cannot idly stand while our planet, and our patients, suffer as a result. We cannot merely splint the fracture and prescribe the antidepressants without also working to address the origins of our patients' suffering. 

With time, eventually the flood waters will recede, the flames will be extinguished, and the sky will clear. Yet, the consequences from these natural disasters will continue to persist in infamy. Fire ecology also teaches that wildfires are a necessary evil. The desiccation of the landscape clears the debris, returns nutrients to the soil, and makes way for new vegetation to thrive. Medicine is also undergoing its own wildfire, a reckoning with its history of racism and role in perpetuating disparities. However, with intentional change and continued momentum, we can ensure there is sustainable growth to create an environment even better than before.


  1. Chakraborty J, Collins TW, Grineski SE. Exploring the environmental justice implications of Hurricane Harvey flooding in Greater Houston, Texas. Am J Public Health. 2019;109(2):244-250.
  2. Griego AL, Flores AB, Collins TW, Grineski SE. Social vulnerability, disaster assistance, and recovery: A population-based study of Hurricane Harvey in Greater Houston, Texas. Int J Disaster Risk Reduct. 2020;51:101766.
  3. White D. Capitalism and California's Urgent Need to Reform the Prison Volunteer Program. Harv BL Law J. 2019;35:73.
  4. Fuller T, Turkewitz J, Del Real JA. Despair for Many and Silver Linings for Some in California Wildfires. New York Times. Published October 29, 2019. Accessed September 11, 2020. 
  5. Hess JJ, Heilpern KL, Davis TE, Frumkin H. Climate change and emergency medicine: impacts and opportunities. Acad Emerg Med. 2009;16(8):782-794.
  6. Sorensen CJ, Salas RN, Rublee C, et al. Clinical Implications of Climate Change on US Emergency Medicine: Challenges and Opportunities. Ann Emerg Med. 2020;76(2):168-178.

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