Impact of Environmental Determinants of Health on Access to Surgical Care

Infrastructure Damage

Disasters and extreme weather effects can have a significant impact on hospital infrastructure, causing damage to roads and health systems, resulting in hospital closures, and posing substantial potential to interrupt access to medical care, medications, and surgical care. Damaged infrastructure has been associated with forced evacuations and the closure of hospitals and health systems. ⁸ These closures may isolate patients from access to essential and time-sensitive treatments, continuity of medical care, medications, chemotherapy, radiation, and elective and urgent surgical care. ⁸ These disruptions are wide-ranging, including loss of power, decreased access to electronic medical records, and damage to operating rooms and patient care areas.^11,12 The loss of hospital services can exacerbate public health crises as essential healthcare delivery systems are unable to function effectively in the aftermath of these events. ¹² The resulting cascading effects of infrastructure damage, road closures, and hospital evacuations impact immediate surgical care and can have long-term implications for the community’s health.

Supply Chain Disruption

Loss of supply buildings and warehouses and damage to roads due to extreme weather events such as flooding, hurricanes, tornadoes, and other events cause an interruption in access to medical supplies, which can significantly impact the ability of the health system to provide adequate surgical care. ¹⁰ These implications are far-reaching with significant consequences. In 2024, Hurricane Helene struck the Southeast USA, resulting in significant supply chain disruptions, including significant IV fluid nationwide shortages, which impacted surgical care and dialysis across the United States.^10,13

Increased Trauma Burden

Extreme weather events have become increasingly frequent and intense, leading to a rise in traumatic injuries that may significantly strain an already overburdened healthcare system. Projectile-associated injuries have increased, as high winds and raging waters can result in dangerous projectiles that inflict harm. ⁵ Additionally, hazardous debris, such as fallen trees, shattered glass, and displaced building material, poses further risks and can cause serious injuries during and after the storm. ⁵ Healthcare facilities may also face challenges in managing the increased number of patients suffering from both acute and traumatic injuries, complicating their efforts to provide timely and adequate medical care. This may be further complicated by inadequate disaster preparedness plans by health systems, hospital infrastructure damage decreasing the ability to safely and effectively deliver healthcare services, supply chain disruptions, and damage to road infrastructure, which decrease the ability of healthcare personnel, hospital systems, and medications to be accessed.

Increased Preoperative Frailty

Climate change also affects preoperative frailty. Exposure to heat, wildfires, or other air pollution impacts cardiovascular and respiratory health, which impacts preoperative risk.^5,6 Air pollution from wildfires is associated with increased pollutants, particulate matter, and toxins, including benzene, formaldehyde, and polycyclic aromatic hydrocarbons (PAH), which increase respiratory and cardiovascular disease presentation, worsen preoperative frailty, and are associated with an increase in cancer incidence, including lung and breast cancer.^6,14,15 Exposure to particulate matter 2.5 worsens cardiopulmonary function, impacting preoperative frailty, anesthesia risk, and surgical recovery. ¹⁶ Additionally, loss of access to care due to flooding, infrastructure damage, or hospital evacuations worsens disease presentation for surgical patients. Flooding has also been associated with bacterial and viral water contamination, increasing foodborne and waterborne illnesses that impact overall frailty. ⁵

Impact on Mental Health

These catastrophic events not only disrupt physical environments and communities but also can have a significant effect on individual psychological well-being. The mental health impacts of these extreme weather impacts have been shown to persist for up to 15 years after the incidence of the disaster. ¹⁰ Individuals may experience a range of mental health issues as a result, including heightened levels of anxiety, profound depression, post-traumatic stress disorder (PTSD), and increased thoughts of suicide. ¹⁷ These psychological impacts can complicate medical and surgical recovery, strain community and public health resources, and affect overall quality of life. Adequate mental health support and intervention in the aftermath of extreme weather events is necessary. It is essential for all health systems to have disaster preparedness plans, including mental health resources and planning.

Forced Relocation/Evacuation

Extreme weather events such as hurricanes, wildfires, severe flooding, and extreme heat events may often lead to forced relocation of individuals and communities. ¹¹ This displacement can interrupt access to essential healthcare services such as routine and urgent surgical care and disrupt the continuity of care that patients rely on for effective management of their health conditions. ¹¹ When large populations are relocated urban centers and other medical facilities may become overwhelmed and overburdened by the sudden influx of patients requiring care. This increased demand may also strain available resources, including medical personnel, equipment, and space. Health systems must ensure that they have robust emergency preparedness and response strategies.

Vulnerable Populations

All populations are impacted by extreme weather and other environmental determinants of health. However, vulnerable populations are at a greater disadvantage and face barriers that can significantly hinder their access to necessary healthcare services, such as surgical services.^3,18 Patients with lower socioeconomic status, advanced age, children, and individuals with chronic health conditions may be least able to cope, relocate, or mitigate the impact of climate change. ¹⁹ These populations struggle with the direct effects of environmental changes. They may also encounter barriers that restrict their ability to seek or maintain access to surgical care and other medical services. Addressing the needs of these groups is critical in creating equitable health outcomes in the face of the increasing impact of environmental determinants of health.

Hurricanes Helene and Milton Impact Surgical Care in the Southeast US

Hurricane Helene, a category four hurricane on the Saffir–Simpson scale, made landfall in late September 2024 in Florida with extremely high winds and torrential rainfall. Hurricane Milton, a category five hurricane, made an inland landfall in October 2024. Helene moved inland over the following days in a north-easterly direction into Georgia and North Carolina. The impact on infrastructure due to Hurricane Helene was significant and continues to impact healthcare today. Baxter International North Cove facility, the largest manufacturer of peritoneal dialysis and intravenous fluids in the United States, was affected by Helene, unexpectedly halting production. ²⁰ Baxter International supplies approximately 60% of the intravenous fluids used in the United States. Helene’s supply chain disruption caused many hospitals and dialysis centers to face shortages of lifesaving care, affecting tens of thousands of patients.

In an effort to mitigate the negative impact, the FDA allowed the importation of products from five facilities outside the US, along with extending the expiry dates of some intravenous fluids by twenty-four months to help alleviate the shortfall.^21,22 Moreover, The American Kidney (AKF) Fund initiated a disaster relief program to provide grants to dialysis and post-transplant patients living in areas impacted by Helene. ²³

Hurricanes Helene and Milton significantly damaged domestic, commercial, and agricultural infrastructure. The impact on healthcare facilities was significant, with an immediate negative effect on the ability of healthcare facilities to provide care. Some facilities lost access to pressurized water, resorted to using oral rehydration solutions and Gatorade instead of intravenous fluids, and were forced to emergently evacuate staff and patients due to rising flood water levels. The impact of Hurricanes Helene and Milton resulted in significant traumatic injuries throughout the affected states. At least 227 people were killed during Hurricane Helene.^24,25

The infrastructure of some Georgia hospitals were directly impacted by the Hurricanes, affecting their ability to care for patients. For example, Wellstar in Augusta resorted to performing only emergency services due to the power shortages affecting Augusta, Georgia, which further impacted access to surgical care. ²⁶

Hurricane Sandy Increases Traumatic Injuries

Hurricane Sandy, a devastating tropical cyclone, struck the northeastern United States in October 2012 after impacting the Caribbean. Its record-breaking storm surge and high winds caused widespread devastation in New York City, with 43 reported deaths. ²⁷ The storm disrupted hospitals and other critical infrastructure, leading to significant health complications. Disasters like Hurricane Sandy can overwhelm healthcare systems, creating unique challenges for emergency surgical care, contributing to a rise in traumatic injuries, and increasing preterm birth rates. This report examines Sandy’s effects on emergency care and maternal and trauma outcomes to inform disaster preparedness.

As a result of power outages, failed generators, and extensive flooding from Hurricane Sandy, six acute-care hospitals in New York City were forced to evacuate over 6000 patients. ²⁸ While some facilities faced evacuation, others operated over capacity, reallocating staff and resources to manage the overflow of patients. ²⁹ The storm’s immediate toll on healthcare facilities led to a strain on emergency services, impacting medical and surgical care. Emergency departments saw a decrease in all-cause visits, likely due to patients’ inability to access care. However, there was an increased rate of ED visits for specific causes, including injury, poisoning, and skin and soft tissue infections. ³⁰

In addition to straining emergency surgical care, Hurricane Sandy brought a marked increase in traumatic injuries. According to a survey of individuals living in areas impacted by Hurricane Sandy, 75% reported more than one injury as a result of the storm. ³¹ While many injuries were directly related to the storm, others were secondary to evacuation and clean-up efforts. Additionally, there was an increase in tree-related injuries after the storm, both among tree-care workers and New York residents. ³² The rise in trauma-related emergencies further underscored the need for scalable disaster response plans in trauma centers to ensure adequate and effective care delivery during mass casualty events.

Moreover, Hurricane Sandy’s impact affected maternal health, with a notable rise in preterm births. Disasters of this scale can introduce multiple stressors, including displacement, psychological strain, and limited access to medical facilities. In New York City, emergency room visits for pregnancy-related complications increased by 6.3% following Hurricane Sandy. ³³ These complications included threatened or spontaneous abortion and threatened or early delivery. Prior studies have found an increase in preterm births in disaster-exposed areas, linking perceived stress in pregnant women with poor birth outcomes. ³⁴ These findings highlight the importance of integrating maternal and psychological support services into disaster preparedness plans to reduce risks associated with premature delivery.

Natural disasters like Hurricane Sandy expose vulnerabilities in healthcare systems due to the damaging infrastructure and overwhelming resources. Ensuring access to emergency surgical services during crises requires proactive disaster planning and improved infrastructure to meet the needs of patients and minimize adverse outcomes in affected populations.

Wildfires Impact on Preoperative Frailty

Wildfires are one of the most overt manifestations of the increasing impact of climate change on human life. While wildfires are known for their overt destruction of property, land, and life, a body of evidence is growing that investigates its subtle impacts on health, primarily cardiovascular and respiratory health. One primary concern of wildfires is smoke, which contains particulate matter (PM), a mixture of very solid particles and liquid droplets made of organic compounds, metals, sulfates, nitrates, and carbon. ³⁵ The US and Canadian governments have done assessments to indicate that exposure to a specific type of PM called PM_2.5 causes an increase in all-cause, cardiovascular, and respiratory mortality. ³⁵ Short-term exposure increases exacerbation of preexisting cardiovascular and respiratory conditions like asthma or COPD, changes in cardiac and lung functions, the deterioration of cardiovascular health, increased risk of lung cancer, and detrimental effects on lung development in children. In addition to PM_2.5, wildfire smoke contains other harmful compounds like CO and NOx. Although the pathophysiology of the impact of wildfire smoke on human health is not fully understood, it is theorized that pollutants cause the development of reactive oxygen species (ROS), leading to inflammation and endovascular dysfunction, causing downstream health issues. ³⁶ The current body of evidence shows a strong association between wildfire smoke and respiratory health issues, leading to an increase in physician visits and hospital admissions; however, there is less established data on wildfire smoke specifically regarding cardiovascular health, highlighting a need for further research. ³⁵

Wildfire smoke has been known to travel hundreds of miles, even to areas with little wildfire risk. A recent wildfire event that made substantial news was the Canadian Wildfires of 2023. Although the intensity of wildfires has been worsening, 2023 was notable due to the impact on the Northeast region of the United States. The 2023 Canadian Wildfire season was the most destructive up to that moment in Canadian history. ³⁷ This is attributed to Canada warming twice as fast as the global average due to the presence of extensive landmass located at higher latitudes. ³⁸ The extent to which wildfire smoke can travel was made apparent when large portions of the Northeastern region of the US were impacted by wildfire smoke from the Canadian Wildfires. One of the most notably impacted cities was New York City. A retrospective study found a positive association between increased ED visits for asthma exacerbations in NYC during the June 2023 season. ³⁹ This was seen in people between the ages of 5 and 64 and throughout all boroughs. With a growing body of evidence indicating the substantial impact of wildfire on long-term cardiovascular and respiratory health, it is imperative to understand the impact on surgical care. It has been long established that cardiovascular and respiratory conditions increase a patient’s perioperative mortality and morbidity. Therefore, as climate change continues to worsen the incidence and geographic impact of wildfires, surgeons must acknowledge the impact on the perioperative health of the patient population they serve. This includes an increased awareness that offering elective surgery during periods of the presence of wildfire smoke may lead to increased adverse outcomes.