Reporter (Spring 2021): “So why were we caught so flatfooted when COVID hit? Why did we allow this to happen?”

Me: “Actually, scientists have been warning us about this pandemic for decades.”

Reporter (Spring 2021): “Did you ever think that COVID would hit the minority community so hard?”

Me: “Actually COVID follows the same pattern as most major diseases. We all knew it was going to strike minority and vulnerable communities the hardest.”

Reporter (Fall 2021): “Now that everyone has been vaccinated, can you take out your crystal ball and let me know what is another major event that will be coming in the future and which we can stop now before it decimates minorities and vulnerable groups?”

Me: “Interesting question, since we have not made much headway in any of the existing health disparities. But if you want to know one which actually has already insidiously started and which if we do nothing, will mushroom over the next decades, that is easy: Global Warming.”

On September 20, 2017, Category 4 Hurricane Maria made a direct hit on Puerto Rico, lashing it for 30 hours. The storm landed on an island that had already suffered over a century of economic humiliation by a colonial overseer. In 1898, the U.S. army invasion sought to “liberate” an island that had already won autonomy from Spain. Immediately, the local currency was devalued, bankrupting residents and allowing U.S. corporations to purchase most of the island at a steep discount. Twenty years later, island residents were given citizenship and immediately tens of thousands were drafted in WWI. The island’s most recent economic decline began in 1995, when President Clinton phased out corporate tax breaks for the island’s manufacturing sector, leading to widespread unemployment. A few years before that, a poorly thought out and underfinanced health reform had eliminated most public health facilities in favor or “privatization”. Highly inequitable federal Medicare and Medicaid funding meant the island had to fund an increasingly substandard privatized health system through debt. Then, vulture capital and hedge funds moved in. Within a few short years, the island was $150 billion in debt and unable to meet payments. As federal law did not allow the island to declare bankruptcy, in 2016, President Obama assigned a federal fiscal oversight board with dictatorial powers to ensure the debt was paid back.

With Hurricane Maria, Puerto Rico became a case study on how inequities in social determinants of health (SDH) place racial and ethnic minorities (as well as other disadvantaged groups) at increased risk of morbidity and mortality from not only acute and chronic health conditions, but also such natural disasters. The huuricane hit an island in which in which most SDH were already way past the red zone. It killed 3,000 people, making it the deadliest U.S. hurricane in over a century. Immediately afterwards, there were outbreaks of scabies, lice, and conjunctivitis in shelters. Lack of clean water also led to Leptospirosis outbreaks. Mental health effects as a result of degradation of livelihoods, homelessness, and relocation also had major impact. However, most deaths were due to the complete disruption of the island’s hospital and health care system. The hurricane destroyed much of what was already a very substandard system. Many persons with chronic illnesses having no access to care, medicines, dialysis, or inpatient care simply died.

In the immediate aftermath, President Trump went to his comfort zone of denying the death toll, praising his response to the hurricane, and demeaning and insulting island residents. Federal Emergency Management Agency leaders declared that the best solution was for the colony to become self-sufficient. And, as always, disaster capitalists and profiteers made out nicely from the island’s suffering. Such devastation had already been forewarned twelve years prior by another deadly hurricane: Katrina. That had been another stark example of what happens to minority communities long disadvantaged by SDH and hit by such predictable natural disasters. We also know that over the next decades, the proportion of such cyclones that reach Category 4 and 5 levels and will continue increase due to global warming.1

We also have robust data on other ways climate change will increasingly and disproportionately impact minority populations. African Americans are more likely to live in neighborhoods with few trees and more heat-trapping pavement. Blacks and Native Americans have 2-3 times higher mortality from heat-related deaths than whites. Lack of central air-conditioning has been shown to be a major driver of this inequity. Pregnant women’s exposure to extreme heat raises their risk of being hospitalized and black women are more severely impacted by this than white women. Latino children are twice as likely to die from asthma and nearly half of them live in counties with poor air quality. The effects of increased carbon dioxide on crop nutrient concentrations will exacerbate inequalities in zinc and iron deficiencies with disproportionate impact South East Asian and sub-Saharan African countries. By 2100, Hawaii and some Pacific islands will experience about one- to two-and-a-half-foot higher sea level rise when compared to global averages.3

As extreme weather and climate-related events continue to increase, they will impact SDHs, including the built environment, social ecosystems, air and water quality, and the transmission of disease through insects and pests. Most impacted will be populations that are least resilient, including older adults, children, low-income communities, and communities of color.2 President Biden’s initial step to rejoin the Paris Climate Accord is an anemic but necessary first step to reverse Trump’s disastrous record on climate change. Kamala Harris has pledged strong support for the Green New Deal aimed at weaning the United States from fossil fuels and curbing greenhouse gas emissions. Those of us in the health disparities field will need hold this new administration accountable for their bold vision for addressing health disparities, racial justice and most definitely climate change.

Reporter (2090): “So your NEJM paper shows that over the last 50 years, one billion premature deaths can be attributed to climate change. Why were we caught so flatfooted?

My Great grand child’s response: “Actually, scientists have been warning us about this for many decades”.

Reporter: “Did anyone ever think the minority community would be hit so hard?”

Response: “Yes. Just look up what they used to call SDH.”

Reporter: “Why did we allow this to happen?”

Response: “Actually, 70 years ago, people thought things would change with the 2020 election. Democrats had just taken control of the House, Senate and White House”

Reporter: “Democrats never even had the back bone to stand up the insurance and pharmaceutical industry to enact National Health Insurance. Did anyone seriously think they would stand up to the fossil fuel industry?”

Response: “Well, some of them used words like big bold change when they spoke about global warming. Some voters actually believed them. But just like health insurance, when elected the talk suddenly changed to slow incremental change, meeting half way, and reaching bipartisan compromises. But hey, this is America. For the last 300 years, regardless of party affiliation, it has been the interests of wall street, large corporations and the whims of the rich which have always comes first. This is the way.”


  1. Union of Concerned Scientists. Hurricanes and Climate Change. Published Jul 16, 2008. Updated Jun 25, 2019. Cited February 15, 2021. Available at:
  2. U.S. Global Change Research Program, 2018: Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, 1515 pp. doi: 10.7930/NCA4.2018.
  3. Carrasquillo O. Global warming and health disparities. Climate and health: The CLEO Institute’s 10th annual empowering capable climate communicators symposium. (individual references for each sentence available upon request from Dr. Carrasquillo). Presentation held November 20, 2020.



COVID-19, Health Equity, Medical Ethics, SGIM, Social Determinants of Health, Vulnerable Populations

Author Descriptions

Dr. Carrasquillo ( is a professor of medicine and public health and chief of the Division of General Internal Medicine at University of Miami, Miller School of Medicine.