Envy for-profit US healthcare? Check out this MD whose wife is a medical billing expert who spent over a year challenging an egregious billing error. After it all they still paid $1200. These are resourceful knowledgeable people who got taken for a ride.

— Raghu Venugopal MD (@raghu_venugopal)

— Dr. Raghu Venugopal, Toronto

A Plea for Sane Prices

I just read your story about the emergency room billing for a procedure that was not done (“A Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill,” Oct. 25). We too had a similar experience with an emergency room and a broken arm that was coded at a Level 5, and it was a simple break. No surgery needed, and it took them only 10 minutes to set and wrap the broken arm but charged us over $9,000. I disputed the charges, and it took six months to get them to reduce the bill but they never admitted that they coded a simple break incorrectly to jack up the price of the bill. If it had been a Level 5 issue, we would not have sat in the waiting room for six hours before being seen. It was a horrible experience, and I think ERs all over the nation are doing this to make up for the non-payers they treat every day. It is robbery.

— Terrence Campbell, Pocatello, Idaho

It would be great if the vaulted would clearly distinguish between the ED pro fee billing & hospital charges as it is not entirely clear here w/ in network svs.—Billing Expert Saved Big After Finding an Incorrect Charge in Her Husband’s ER Bill

— Ed Gaines (@EdGainesIII)

— Ed Gaines, Greensboro, North Carolina

As you said, CPT codes should always be examined. This case is probably more than “just an error.” As a retired orthopedic surgeon, chief of surgery, and chief of staff at a North Carolina hospital, I have seen care such as this coded exactly like this with the rationale that, “Hey, this was a fractured humerus and it was manipulated and splinted.” 24505 is correct IF that is the definitive treatment, which it was not here. Even code 24500 would indicate definitive treatment without manipulation. This was just temporary care until definitive care could be done later. It should be billed as a visit and a splint. The visit for this, if it was an isolated problem (no other injury or problems), would qualify only as a Level 2 visit. That frequently gets upcoded as well by adding a lot of non-pertinent family, medical, and social history and a complete physical exam (seven systems at least) and a whole lot of non-pertinent “medical decision making.” All of that should be documented in the medical records even if the hospital stonewalls on the CPT codes.

Look closely at medical records and you will find frequent upcoding, if you are familiar with the requirements for different levels of treatment.

— Dr. Charles Beemer, Arvada, Colorado

Never attribute to Baumol's cost disease that which is adequately explained by malice.

— Shashank Bhat (@shashank_ps)

— Shashank Bhat, San Francisco

A number of years ago, I was billed using a code that described a treatment that was not carried out. In similar fashion, I talked with my insurance company, which basically said it did not care whether the treatment took place or not as all it required was for a valid code to appear. I also contacted the Virginia Bureau of Insurance, which approves the various policies, and it said it had no jurisdiction over claims. I decided to let the hospital sue me for the disputed amount and defended myself in district court. Despite their attorney and four “witnesses,” the case was thrown out because the hospital was both unwilling and unable to justify the charges to the satisfaction of the judge. They did not want anybody in power to testify because of the questions they would have been asked, so they left it to people who were completely clueless. The takeaways from this were:

• Hospitals make up the numbers and leave them grossly inflated so they can claim that they are giving away care when they give discounts on the made-up numbers.
• Hospitals turn employees into separate billing entities so they can double-charge.
• Hospitals open facilities such as physical therapy in hospital locations because insurance companies will pay higher amounts when treatment is carried out in a hospital environment.
• Insurance companies and state insurance agencies do not act as gatekeepers to protect their clients/taxpayers.
• The insurance companies and the providers have a shared interest in the highest possible ticket prices and outrageous charges because the providers get to claim how generous they are with “unremunerated care,” and if the prices were affordable then they could not justify the high prices for insurance premiums and the allowed administration/profit share of 20% would be based on a far smaller amount.

In any other industry, this would have resulted in multiple antitrust suits. U.S. health care is a sad example of government, health care industry, and insurers all coming together against the interests of consumers. After this court case, I wanted to form a nonprofit to systematically challenge every outrageous charge against people who, unlike myself, did not believe or know how to defend themselves. If hospitals and other providers were forced to go to court to justify their charges on a systematic basis, pricing sanity would eventually prevail.

— Philip Solomon, Richmond, Virginia

The obvious solution to prosecute the hospital for fraud followed by a civil suit"A hospital charged nearly $7,000 for a procedure that was never performed"

— Barry Ritholtz (@Ritholtz)

— Barry Ritholtz, New York City

Patients as Watchdogs

Thank you for the article on Lupron Depot injections (Bill of the Month: “$38,398 for a Single Shot of a Very Old Cancer Drug,” Oct. 26). Last year, I was diagnosed with prostate cancer, though my case is not anywhere as severe as that experienced by Mr. Hinds.

Last month my urologist scheduled an MRI update for me at a facility owned by Northside Hospital Atlanta. At the suggestion of my beloved wife, I called my insurance company, UnitedHealthcare, to make sure the procedure was covered. Fortunately, it was. That being said, the agent from UnitedHealthcare mentioned that Northside Hospital’s fee was “quite a bit higher than the average for your area.” It was. Before insurance, the charge for an MRI at Northside was $6,291. I canceled the appointment at Northside and had the MRI done by a free-standing facility. Their charge, before insurance, was $1,234.

Every single encounter that I have with the health care system involves constant vigilance against price-gouging. When I have a procedure, I have to make sure that the facility is in-network,. that each physician is in-network, that any attending specialist such as an anesthesiologist or radiologist is in-network (and their base-facility as well). If I have a blood test, I have to double-check if the cost is included in a procedure or if it is separate. If it is a separate fee, I have to ensure that the analysis is also covered, and, if it is not, that it is not done through a hospital-owned facility but instead through a free-standing operation.

I have several ongoing conditions in addition to my prostate cancer — Dupuytren’s contracture, a rare bleeding disorder similar to thrombocytopenia, and arthritis. Needless to say, navigating our byzantine, inefficient, and profit-driven health care system is a total nightmare.

Health care in the United States has become so exceedingly outrageous. I cannot understand why it is not an issue that surfaces during election years or something that Congress is willing to address.

Again, thank you for your excellent reporting.

— Karl D. Lehman, Atlanta

Why capitalism without guardrails is a pipedream. Own the patent, control the pricing, and this is the result: $38,398 for a Single Shot of a Very Old Cancer Drug via

— Brian Murphy (@NorwoodCDI)

— Brian Murphy, Austin, Texas

I was a medical stop-loss underwriter and marketer for over 30 years. Most larger (company plans for 100-plus employees) are self-funded, meaning the carrier — as in this case, UnitedHealthcare — is supplying the administrative functions and network access for a fee, while using the employer’s money to pay claims.

Every administrator out there charges a case management fee, either as a stand-alone charge or buried in their fees. Either way, they all tout how they are looking out for both the employer and the patient.

Even if this plan was fully insured, wouldn’t it have been in the best interest of all parties when they became aware of the patient’s treatment (maybe after the first payment) to reach out to the patient and let them know there are other alternatives?

The question in these cases is who is minding the store for both the patient and the employer. The employer, the insurer, and the patient could have all saved a lot of money and pain, if someone from case management had actually questioned the first set of charges.

— Fred Burkacki, Sarasota, Florida 

I did a few rounds of Lupron in my 20s for severe , and I had to fight my insurance company to get approved. Now, this is how much it costs for some people.

— Amanda Oglesby 🌊 (@OglesbyAPP)

— Amanda Oglesby, Neptune, New Jersey

‘Bill of the Month’ Pays Off

I received a $1,075 refund on a colonoscopy bill I paid months earlier after listening to the KHN-NPR “Bill of the Month” segment “Her First Colonoscopy Cost Her $0. Her Second Cost $2,185. Why?” (May 31) and finding out the procedure should be covered under routine health care coverage. Thank you!

— Cynthia McBride, University Place, Washington

We have to close legal loopholes to make sure that cancer diagnostic procedures have the same insurance coverage as screening. Colonoscopies must be fully covered whether a polyp is found or not

— Erica Warner, ScD (@ewarner_12)

— Erica Warner, Boston

Removing Barriers to Benefits

In the story “People With Long Covid Face Barriers to Government Disability Benefits” (Nov. 9), you stated: “Many people with long covid don’t have the financial resources to hire a lawyer.” This is incorrect. When applying for disability, you don’t need financial resources. There are law firms that specialize in disability claims and will not charge you until you win your claim. And, according to federal law, those law firms can charge only a certain percentage of the back pay you would get once the claim has been won. Also, if you lose the claim, and the law firm has appealed as many times as possible, you don’t owe anything. Please don’t make it more difficult for those who are disabled with misinformation.

— Lorrie Crabtree, Los Angeles

People unable to work due to Long Covid are facing barriers to obtaining government disability benefits.

— Ron Chusid (@RonChusid)

— Ron Chusid, Muskegon, Michigan

Vaccine Injuries Deserve Attention, Too

I read your long-covid article with interest because many of the barriers and some of the symptoms faced by people with long covid are similar to those experienced by people with vaccine injuries. I’m really concerned about how there is even less attention and support for people who suffered adverse vaccine reactions.

Long covid and vaccine injuries are both issues of justice, mercy, and human rights as much as they are a range of complex medical conditions.

It’s nearly 20 months since someone I know sustained a serious adverse reaction, and it is heartbreaking how hard it has been for her to find doctors who will acknowledge what happened and try to help. There’s no medical or financial support from our government, and the Countermeasures Injury Compensation Program is truly a dead end, even as other countries such as Thailand, Australia, and the United Kingdom have begun to acknowledge and financially support people who sustained vaccine injuries.

I’ve contacted my congressional representatives dozens of times asking for help and sharing research papers about vaccine injuries, but they have declined to respond in meaningful ways. Similarly, my state-level representatives ignore questions about our vaccine mandate, which remains in place for state employees, despite at least one confirmed vaccine-caused fatality in a young mother who fell under the state mandate in order to volunteer at school.

There have been a few articles, such as …

… but no new ones have come to my attention recently, and it is concerning that the media and our political and public health leaders seem OK with leaving people behind as collateral damage.

Please consider writing a companion piece to highlight this need and the lack of a functional safety net or merciful response. My hope is that if long covid and vaccine injuries were both studied vigorously, new understanding would lead to therapeutics and treatments to help these people.

— Kathy Zelenka, Port Angeles, Washington

Given how long it took Congress to eventually approve "Agent Orange" and "Burn Pit" benefits for disabled veterans, it is at least a 15-20 year time frame and they don't have the backing or societal standing that veterans do.

— Matthew Guldin (@MRG_1977)

— Matthew Guldin, West Chester, Pennsylvania

More on Mammograms

The article “Despite Katie Couric’s Advice, Doctors Say Ultrasound Breast Exams May Not Be Needed” (Oct. 28) does a disservice to women and can cause harm. An ultrasound is saving my life. I had two mammograms with ultrasounds this year. Although the first mammogram showed one cyst that was diagnosed as “maybe benign,” I knew it wasn’t. Why? Because I could feel the difference. I insisted on a second, and sure enough a large-enough cyst that’s definitely malignant was found. I had breast surgery on Oct. 31, followed by radiation treatment and, if needed, chemotherapy later. This article will deprive other, less aggressive and experienced women who do not have health care credentials or a radiologist for a husband to be harmed by being lulled into complacency.

— Digna Irizarry Cassens, Yucca Valley, California

Why do some women with dense breasts get additional screening while others do not? ⁦⁩ explains. ⁦⁩

— Patricia Clark MD, FACS, FSSO (@patriciaclarkmd)

— Patricia Clark, Scottsdale, Arizona

Your article on breast cancer screening neglected to present the supplemental option of Abbreviated Breast MRI (AB-MRI). The out-of-pocket cost at many clinics ranges from $250 to $500. For a national listing of clinics that offer this supplemental screening option, please go to . For benefits, just Google “Abbreviated Breast MRI.”

— Elsie Spry, Wexford, Pennsylvania

Why didn’t more leave for safer havens during Hurricane Ian as recommended? ⁦⁩ rightfully suggests that learning why is critical as the population of older people grows and become more frequent.

— Donald H. Polite (@DonaldPolite)

— Donald H. Polite, Milwaukee

Preparation Plans for Seniors: All for One and One for All

At least 120 people died from Hurricane Ian, two-thirds of whom were 60 or older. This is a tragedy among our most vulnerable population that should have been prevented (“Hurricane Ian’s Deadly Impact on Florida Seniors Exposes Need for New Preparation Strategies,” Nov. 2).

Yes, coming together and developing preparedness plans is one way to protect seniors and avoid these kinds of tragedies in the future, but since this is not a one-size-fits-all situation, organizations that help seniors across the country must first look internally and be held accountable by making sure their teams always have a plan in place and are prepared to activate them at a moment’s notice.

During Hurricane Ian, I saw firsthand what can happen when teamwork and effective planning come together successfully to protect and prepare seniors with chronic health conditions like chronic obstructive pulmonary disease who require supplemental oxygen to breathe.

Home respiratory care providers and home oxygen suppliers worked tirelessly to ensure our patients received plenty of supplies to sustain them throughout the storm, and when some patients faced situations where their oxygen equipment wasn’t working properly inside their homes, staff members were readily available to calmly talk the patient through fixing the problem. After the winds receded, mobile vans were quickly stationed in safe spaces for patients or their family members to access the oxygen tanks and supplies they needed. If patients were unable to make it to these locations, staff members were dispatched to deliver tanks to their homes personally and check in on the patient.

Patients were also tracked down at shelters, and a team of volunteers was formed around the country to find patients who could not be reached by calling their emergency backup contacts, a friend, or family member. Through these established systems, we were able to remain in contact with all of our patients in Ian’s path to ensure their care was not impeded by the storm.

Organizations should always be ready and held accountable for the seniors they care for in times of disaster. I know my team will be ready. Will yours?

— Crispin Teufel, CEO of Lincare, Clearwater, Florida

Understanding the impact of on older people is critically important as the population expands and become more frequent and intense.

— Ashley Moore, MS, BSN Health Policy (@MooreRNPolicy)

— Ashley Moore, San Francisco

The Tall and the Short of BMI

I am amazed that in your article about BMI (“BMI: The Mismeasure of Weight and the Mistreatment of Obesity,” Oct. 12) you never mentioned anything about the loss of height. If a person goes from 5-foot-2 to 4-foot-10, the BMI changes significantly.

— Sue Robinson, Hanover, Pennsylvania

I've been against this since after gastric bypass surgery I got down to 164 pounds but at 5'7" BMI still considered me overweight. How an overreliance on BMI can stand between patients and treatment

— Steve Clark (@blindbites)

— Steve Clark, Lee’s Summit, Missouri

Caring for Nurses’ Mental Health

During the pandemic, when I read stories about how brave and selfless health care heroes were fighting covid-19, I wondered who was taking care of them and how they were processing those events. They put their own lives on the line treating patients and serving their communities, but how were these experiences affecting them? I am a mother of a nurse who was on the front lines. I constantly worried about her as well as her mental and physical well-being (“Employers Are Concerned About Covering Workers’ Mental Health Needs, Survey Finds,” Oct. 27). I was determined to find a way to honor and support her and her colleagues around the country.

I created a large collaborative art project called “The Together While Apart Project” that included the artwork of 18 other artists from around the United States. It originated during the lockdown phase of the pandemic, a time when we were all physically separated yet joined by a collective mission to create one amazing art installation to honor front-line workers, especially nurses. Upon its completion, this collaboration was recognized by the Smithsonian Institute, Channel Kindness (a nonprofit co-founded by Lady Gaga) and NOAH (National Organization of Arts in Medicine). After traveling around the Southeast to various hospitals for the past year on temporary exhibit, the artwork now hangs permanently in the main lobby at the University of Virginia Medical Center in Charlottesville, Virginia.

I wanted to do something philanthropic with this art project to honor and thank health care heroes for their dedication over the past two years. It was important to find a way to help support them and to ensure they are not being forgotten. Using art project as my platform, I partnered with the American Nurses Association and created a fundraiser. This campaign raises money for the ANA’s Well-Being Initiative programs, which support nurses struggling from burnout and post-traumatic stress disorder and who desperately need mental and physical wellness care. Fighting covid has taken a major toll on too many nurses. Some feel dehumanized and are not receiving the time off or the mental and physical resources needed to sustain them. Many are suffering in silence and have to choose between caring for themselves or their patients. They should not have to make this choice. Nurses are the lifeline in our communities and the backbone of the health care industry. When they suffer, we all suffer. Whether they work in hospitals, doctors’ offices, assisted living facilities, clinics or schools, every nurse has been negatively impacted in some way by the pandemic. They are being asked to do so much more than their jobs require in addition to experiencing greater health risks, less pay, and longer hours. Nurses under 35 and those of color are struggling in larger numbers.

The American Nurses Foundation offers many forms of wellness care at no charge. They rely heavily on donations to maintain the quality of their offerings as well as the ability to provide services to a growing number of nurses. I am an artist, not a professional fundraiser, and I have never raised money before. But I feel so strongly about ensuring that nurses receive the support and care they deserve, that I am willing to do whatever it takes to advocate and elevate these health care heroes.

The Together While Apart Project’s “Thank You Nurses Campaign” goal is $20,200, an amount chosen to reflect the numbers 2020, the year nurses became daily heroes. So far, I have raised over $15,500 through gifts in all amounts. For example, a $20 donation provides a nurse with a free one-hour call with a mental health specialist. That $20 alone makes a big difference and can change the life of one nurse for the better. The campaign has provided enough funding (year to date) to enable 940 nurses to receive free one-hour wellness calls with mental health specialists.

The online fundraiser can be found at .

— Deane Bowers, Seabrook Island, South Carolina

CEAPs, is it time to offer more services? Nearly 1/2 of employers (w/ 200 workers) report a growing share of workers using mental health services. Yet 56% report they lack providers for employees to access to timely care.

— EAPA (@EAPA)

— Employee Assistance Professionals Association, Arlington, Virginia

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The most recent horrific example was Hurricane Ian, the massive storm that in September smashed into Florida’s southwestern coast — a haven for retirees — with winds up to 150 mph and storm surges in some areas. , most of them in Florida. Of those who perished, two-thirds were 60 or older. Many and were found in their homes.

Why didn’t more older adults leave for safer areas, as authorities recommended? Understanding this is critically important as the population of older people expands and natural disasters become more frequent and intense with climate change.

“I think the story of Hurricane Ian that people will remember is the story of people who didn’t evacuate,” said Jeff Johnson, AARP’s Florida state director.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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Las partículas irritantes para los pulmones llegaban desde los bosques en llamas de California y se instalaban en el condado de Douglas (Nevada), donde viven casi 50,000 personas, lo que hizo que se advirtiera que la había alcanzado niveles peligrosos.

Esos niveles significaban que el aire era muy insalubre, lo suficientemente malo como para hacer saltar las alarmas sobre la salud inmediata de las personas y la cuestión sobre si el empeoramiento de la contaminación podría provocar problemas de salud a largo plazo. Estos riesgos aumentarán a medida que el cambio climático haga más frecuentes los incendios forestales, las sequías, las tormentas de polvo y las inundaciones en Estados Unidos y en el mundo.

Algunos se sienten impotentes.

“No hay mucho que podamos hacer al respecto”, dijo , presidente de la tribu Washoe de Nevada y California. Las tierras de la tribu se encuentran en la frontera entre California y Nevada, cerca del lago Tahoe, y se extienden hasta el condado de Douglas, a unas 60 millas al sur de Reno.

Los miembros de la tribu y otros residentes de la zona se encuentran entre los del país que este año experimentarán una mala calidad del aire debido a los incendios forestales. En septiembre, cuando el humo se asentó sobre Nevada, se emitieron relacionadas con los incendios en otros seis estados: California, Idaho, Montana, Oregon, Washington y Wyoming.

Quienes viven en el condado de Douglas están en mejor situación que en otras zonas afectadas. Los residentes del condado de Douglas deben conducir una media de 30 minutos para acudir al  neumólogo, el especialista del pulmón. Sin embargo, en otras partes del Oeste y del Alto Medio Oeste, los pacientes deben conducir una hora o más, según los , un sitio web que rastrea los precios de los medicamentos recetados y realiza investigaciones.

En concreto, el análisis descubrió que unos 5,5 millones de estadounidenses viven en los 488 condados en los que el tiempo de conducción hasta los neumólogos es de una hora o más. Gran parte de Nevada y amplias zonas de Montana se encuentran a esa distancia de los especialistas; son lugares que han sufrido recientemente incendios forestales que llenan el aire de humo y ceniza, lo que puede provocar problemas pulmonares o agravar los ya existentes.

Las alergias, el asma y otros problemas similares suelen ser atendidos por los médicos de atención primaria, pero los pacientes son cuando los problemas se complican en forma de asma grave, la enfermedad pulmonar obstructiva crónica (EPOC) o el enfisema.

Los muestran que el número de especialistas en enfermedades pulmonares en el país se redujo casi un 11% entre 2014 y 2019. La asociación, que tiene su sede en Washington, D.C., y representa a la comunidad académica de la medicina, señaló que la disminución podría no ser tan alta como parece porque algunos médicos están optando por practicar la atención crítica pulmonar en lugar de solo la neumología. Muchos de esos neumólogos trabajan en las unidades de cuidados intensivos de los hospitales.

Según el informe de GoodRx, en Estados Unidos ejercen unos 15,000 neumólogos. Sin embargo, vastas franjas del país tienen .

“Nuevo México tiene un neumólogo para toda la parte sureste del estado, sin contar Las Cruces, que está más cerca de El Paso”, dijo el doctor , neumólogo de Texas Tech Physicians.

Test, uno de los 13 neumólogos de la región de Lubbock (Texas), explicó que sus pacientes de Texas a veces conducen cuatro horas para una cita y que otras personas viajan desde “Nuevo México, Oklahoma, incluso el lejano oeste de Kansas”.

Es probable que el aumento de los incendios forestales y su intensidad requiera de más neumólogos.

“El cambio climático va a afectar a las enfermedades pulmonares”, afirmó el doctor , profesor de medicina pulmonar, de cuidados críticos y del sueño en la Facultad de Medicina de la Universidad de California-Davis, donde él y otros investigadores están estudiando los efectos de los incendios forestales. En su consulta de Sacramento, Kenyon explica que atiende a pacientes de las zonas más septentrionales de California, incluida Eureka, a cinco horas en coche de la capital del estado.

Los efectos a corto plazo de respirar humo son bastante conocidos. Las personas acuden a las salas de urgencias con ataques de asma, exacerbación de la EPOC, bronquitis e incluso neumonía, indicó Kenyon. Algunos presentan dolor en el pecho y otros problemas cardíacos.

“Pero tenemos muy poco conocimiento de lo que ocurre a largo plazo”, añadió. “Si la gente se expone durante dos o tres semanas a los incendios forestales durante dos o tres años, ¿se produce un empeoramiento del asma o de la EPOC? No lo sabemos”.

Los incendios liberan múltiples contaminantes, como dióxido de carbono, monóxido de carbono y sustancias químicas como el benceno. Todos los incendios envían partículas al aire. Los investigadores de la salud y los expertos en calidad del aire están más preocupados por las denominadas partículas 2,5. Mucho más pequeñas que un cabello humano, estas partículas pueden alojarse y se han relacionado con afecciones cardíacas y pulmonares.

El aumento de esas diminutas partículas se asocia a un mayor riesgo de muerte por cualquier causa, excluyendo accidentes, homicidios y otras causas no accidentales, hasta cuatro días después de la exposición de la población, según una reseña del de 2020.

La concentración de partículas finas es uno de los cinco indicadores utilizados para calcular el Índice de Calidad del Aire (ICA), un índice numérico y codificado por colores que se utiliza para informar al público sobre los niveles locales de contaminación del aire. El color verde denota una buena calidad del aire y se da si el índice total es de 50 o menos. Cuando la medición supera 100, la calidad del aire recibe una etiqueta naranja y puede ser mala para determinados grupos. Los niveles superiores a 200 obtienen una etiqueta roja y se consideran insalubres para todos.

Los organismos gubernamentales hacen un seguimiento de esos niveles, al igual que las personas que utilizan aplicaciones o sitios web para determinar si es seguro salir a la calle.

Cuando el ICA se eleva por encima de 150, la doctora Farah Madhani-Lovely, neumóloga, dijo que el Renown Regional Medical Center de Reno cierra su clínica de rehabilitación pulmonar para pacientes externos porque no quiere que los pacientes conduzcan hasta el hospital. Algunos pacientes del condado de Douglas optan por la atención cerca de casa, a una hora de distancia. “No queremos que estos pacientes salgan al exterior porque solo un minuto de exposición al humo puede desencadenar una exacerbación de su enfermedad crónica”, señaló Madhani-Lovely.

Smokey explicó que acudir a un neumólogo puede ser difícil para los miembros de la tribu Washoe, en particular para los que viven en el lado de California de la reserva. “No podemos encontrar especialistas para ellos”, dijo. “Acabamos derivándoles fuera y enviándoles a cientos de millas de distancia para recibir una atención que deberíamos poder proporcionar aquí”.

La contratación de especialistas en zonas rurales o ciudades pequeñas ha sido difícil durante mucho tiempo. Por un lado, un especialista puede ser el único en millas a la redonda, “por lo que tienen una tremenda carga en términos de cobertura y días libres”, indicó Test.

Otra preocupación es que los médicos tienden a formarse en ciudades más grandes y a menudo quieren ejercer en lugares similares. Incluso la contratación de médicos del pulmón en Lubbock, una ciudad de 260,000 habitantes en el oeste de Texas, es un reto, añadió Test.

“Me encanta Lubbock”, aseguró. “Pero le digo a quienes nunca han estado aquí: ‘Es realmente llana’. No entienden lo que es llano hasta que llegan aquí”.

En Nevada, en los días en que la calidad del aire es mala, los miembros de la tribu Washoe tratan de protegerse con purificadores de aire improvisados creados con ventiladores, cinta adhesiva y filtros de aire, explicó Smokey.

A largo plazo, Smokey y otros líderes tribales están presionando al Servicio de Salud Indio para que establezca un hospital de atención especializada en el norte de Nevada. El hospital de atención especializada más cercano para los miembros de la tribu Washoe está a más de 700 millas de distancia, en Phoenix.

Es difícil porque “hay una necesidad que deberíamos atender”, añadió Smokey. “Pero tenemos que luchar por ello. Y a veces esa lucha lleva años, años y años para conseguirlo”.

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The lung-irritating particles were blowing in from burning forests in California and settling in Douglas County, Nevada, home to nearly 50,000 people, that air quality had reached hazardous levels.

Those levels meant the air was very unhealthy, bad enough to raise alarms about people’s immediate health care needs and questions about whether worsening pollution could result in long-term health issues. People could increasingly face such risks as climate change makes wildfires, drought, dust storms, and floods more frequent across the U.S. and the world.

Some people simply feel powerless.

“There’s not much we could do about it,” said , chairman of the Washoe Tribe of Nevada and California. The tribe’s land straddles the border between California and Nevada near Lake Tahoe and extends into Douglas County, about 60 miles south of Reno.

Tribe members and other area residents are of people nationwide who this year will experience poor air quality because of wildfires. In September, as smoke settled over Nevada, air quality alerts were dispatched in six other states: California, Idaho, Montana, Oregon, Washington, and Wyoming.

Yet, by one measure, people who live in Douglas County are better off than those in some other hard-hit areas. Douglas County residents must drive 30 minutes, on average, for medical care from lung specialists called pulmonologists. In other parts of the West and Upper Midwest, however, patients must drive an hour or more, according to , a website that tracks prescription drug prices and conducts research.

Specifically, the research found that about 5.5 million Americans live in the 488 counties where drive times to pulmonologists are an hour or more. Much of Nevada and large parts of Montana fall into those gaps between specialists — places that have recently grappled with wildfires that fill the air with smoke and ash, which can cause lung problems or exacerbate existing ones.

Allergies, asthma, and similar issues are often handled by primary care physicians, but patients are when problems escalate — think severe asthma; chronic obstructive pulmonary disease, or COPD; or emphysema.

shows the number of pulmonary disease specialists in the U.S. dropped nearly 11% from 2014 to 2019. The group, which is based in Washington, D.C., and represents the academic medicine community, noted that the decline might not be as high as it appears because some physicians are opting to practice pulmonary critical care rather than just pulmonology. Many of those types of pulmonologists work in hospital intensive care units.

About 15,000 pulmonologists are practicing in the U.S., according to the GoodRx report. Yet vast swaths of the country have .

“New Mexico has one pulmonologist for the entire southeastern part of state, not counting Las Cruces, which is closer to El Paso,” said , a pulmonologist at Texas Tech Physicians.

Test, one of 13 pulmonologists in the Lubbock, Texas, region, said that his patients from within Texas sometimes drive four hours for an appointment and that other people travel from “New Mexico, Oklahoma, even far western Kansas.”

Increases in wildfires and their intensity will likely expand the need for pulmonologists.

“Climate change is going to affect lung disease,” said , a professor of pulmonary, critical care, and sleep medicine at the University of California-Davis School of Medicine in California, where he and are tracking the effects of wildfires. At his Sacramento practice, Kenyon said, he sees patients from far northern parts of California, including Eureka, a five-hour drive from the state capital.

The short-term effects of breathing smoke are pretty well known. People show up in emergency rooms with asthma attacks, exacerbation of COPD, bronchitis, and even pneumonia, Kenyon said. Some have chest pain or other cardiac concerns.

“But we have very little understanding of what happens over the longer term,” he said. “If people get two or three weeks of wildfire exposure for two or three years, does that lead to worsening of asthma or COPD? We just don’t know.”

Fires release multiple pollutants, including carbon dioxide, carbon monoxide, and chemicals like benzene. All fires send particles into the air. Health researchers and air quality experts are most concerned about tiny pieces referred to as particulate matter 2.5. Far smaller than a human hair, the particles and have been linked to heart and lung conditions.

Increases in those tiny particles are associated with a greater risk of death from all causes, excluding accidents, homicides, and other non-accidental causes, for up to four days after a population is exposed, according to a 2020 .

The concentration of fine particulate matter is one of five gauges used to calculate the Air Quality Index, a numerical and color-coded index used to let the public know about local air pollution levels. Green denotes good air quality and is given if the total index is 50 or less. When the measurement exceeds 100, the air quality gets an orange label and may be bad for certain groups. Levels over 200 get a red label and are considered unhealthy for everyone.

Government agencies track those levels, as do people who use apps or websites to determine whether it’s safe to go outside.

When the AQI rises above 150, Dr. Farah Madhani-Lovely, a pulmonologist, said Renown Regional Medical Center in Reno shuts its outpatient pulmonary rehabilitation clinic because it doesn’t want to encourage patients to drive in. Some patients from Douglas County opt for care near home, about an hour away. “We don’t want these patients exposed outside because just one minute of exposure to the smoke can trigger an exacerbation of their chronic disease,” Madhani-Lovely said.

Smokey said connecting with pulmonologists can be difficult for Washoe Tribe members, particularly those who live on the California side of the reservation. “We cannot find providers for them,” he said. “We end up referring them out and sending them hundreds of miles out of their way just to get care that we should be able to provide here.”

Recruiting specialists to rural areas or smaller cities has long been difficult. For one thing, a specialist might be the only one for miles around, “so there’s a tremendous burden in terms of coverage and days off,” Test said.

Another concern is that physicians tend to train in larger cities and often want to practice in similar places. Even recruiting pulmonary physicians to Lubbock, a city of 260,000 in West Texas, is a challenge, Test said.

“I love Lubbock,” he said. “But I tell people who have never been here, I say, ‘It’s really flat.’ They don’t understand flat until they get here.”

In Nevada, on days when the air quality is bad, Washoe tribal members try to protect themselves with makeshift air purifiers created from fans, duct tape, and air filters, Smokey said.

Longer term, Smokey and other tribal leaders are pushing the Indian Health Service to establish a specialty care hospital in northern Nevada. The closest specialty care hospital for Washoe tribal members is more than 700 miles away, in Phoenix.

It’s difficult because “there’s a need we should be taking care of,” Smokey said. “But we have to fight for it. And sometimes that fight takes years, years, and years to accomplish.”

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Hurricane Ian forced at least 16 hospitals from central to southwestern Florida to evacuate patients after it made landfall near the city of Fort Myers on Sept. 28 as a deadly Category 4 storm.

Some moved their patients before the storm while others ordered full or partial evacuations after the hurricane damaged their buildings or knocked out power and running water, said , president of the Florida Hospital Association, which coordinates needs and resources among hospitals statewide during a hurricane.

About 1,000 patients across five Florida counties were evacuated from hospitals for different reasons, Mayhew said, with one hospital moving patients after the storm tore part of its roof and deluged the ground floor. Other hospitals emerged with no structural damage but lost power and running water. Broken bridges, flooded roads, and lack of clean water all added to the challenge for some hospitals, Mayhew said.

And that’s before considering the need to help those injured in the hurricane and its aftermath.

“Climate shocks like hurricanes show us in the most painful way what we need to fix,” said Aaron Bernstein, interim director of the Center for Climate, Health, and the Global Environment, known as C-CHANGE, at the Harvard T.H. Chan School of Public Health.

As climate change of hurricanes, coastal cities threatened by rising sea levels from Miami to Charleston, South Carolina, have considered billion-dollar storm surge protection plans — from elevating homes to creating a network of seawalls, floodgates, and pumps to protect residents and infrastructure against powerful flooding from storms.

Some hospitals are fortifying buildings and elevating campuses. Others are moving inland, as they prepare for a future when even weak storms unleash flooding that can overrun facilities.

“They’re the front lines of climate change, bearing the costs of these increased weather events as well as the increase in injuries and disease that come with them,” said Emily Mediate, U.S. climate and health director for , a nonprofit that works with hospitals to prepare for climate change.

Yet even as hospitals prepare for extreme weather, Bernstein and a team of researchers at Harvard predicted in that many facilities along the Atlantic and Gulf coasts will face a suite of problems, even from milder weather events.

The study analyzed the flood risk to hospitals within 10 miles of the Atlantic and Gulf coastlines. In more than half of the 78 metropolitan areas analyzed, some hospitals are at risk of storm surge flooding from the weakest hurricane, a Category 1. In 25 coastal metro areas, half or more of the hospitals risk flooding from a Category 2 storm, which would pack winds of up to 110 mph. Florida is home to six of the 10 most at-risk metropolitan areas identified in the study, with the Miami-Fort Lauderdale-West Palm Beach region ranked as having the greatest risk of hurricane impact.

Researchers also considered the risk of flooding for roads within 1 mile of coastal hospitals during a Category 2 hurricane. That’s what happened on Florida’s western coast, where Hurricane Ian’s maximum sustained winds of 150 mph contributed to flooded roads and washed-out bridges.

All three hospitals in Charlotte County were closed during the storm. One reopened its emergency room the following day, and two were operational by Oct. 1.

In neighboring Lee County, the public hospital system was forced to partially evacuate three of its four hospitals, potentially affecting about 1,000 patients, after the facilities lost running water. As of Oct. 6, the county remained in a state of emergency and many roads and bridges were closed due to flooding and damage, according to the Florida Department of Transportation’s .

Several Florida hospitals on waterfront property have moved their essential electrical systems and other critical operations above ground level, elevated their parking lots and buildings, and erected water barriers around their campuses, including Tampa General Hospital, which has the only trauma center in west-central Florida.

Miami Beach is a barrier island where roads flood on sunny days during extremely high tides. Building to withstand hurricanes and flooding is a priority for institutions, said Gino Santorio, CEO of , which sits at the edge of Biscayne Bay.

Over the past decade, Mount Sinai has completed nearly $62 million in projects to protect against hurricanes and flooding. The projects were part of funded by the Federal Emergency Management Agency and state and local governments to fortify schools, hospitals, and other institutions.

“It’s really about being the facility of last resort. We’re the only medical center and emergency room on this barrier island,” Santorio said.

But Bernstein said the “Fort Knox model” of spending hundreds of millions of dollars on state-of-the-art hurricane-proof hospital buildings isn’t enough. This strategy doesn’t address flooded roads, transportation for patients ahead of a storm, medically vulnerable people in areas most at risk of flooding, emergency hospital evacuations, or the failure of backup power sources, he said.

Urging hospitals to fortify for more severe hurricanes and rising sea levels can feel overwhelming, especially when many are struggling to recover from pandemic-related financial stress, labor shortages, and fatigue, said Mediate, of the group Health Care Without Harm.

“Lots of things make it hard for them to see this is a problem, of course. But on top of how many other issues?” she said.

As Hurricane Ian approached the South Carolina coastline north of Charleston on Sept. 30, the city’s low-lying hospital district reported about 6 to 12 inches of water. “That’s much less than was expected,” Republican Gov. Henry McMaster said during a news briefing.

Though Hurricane Ian was a relatively minor weather event in South Carolina, it’s not unusual for Charleston’s downtown medical district to flood, making it dangerous and, sometimes, impossible for patients, hospital employees, and city residents to navigate surrounding streets.

In 2017, the Medical University of South Carolina ferried doctors across its large campus on from Hurricane Irma. One year later, the Charleston-based hospital system bought a military truck to navigate any future floodwaters.

Flooding, even after heavy rain and high tide, is one reason — one of three systems in Charleston’s downtown medical district — announced plans to eventually move Roper Hospital off the Charleston peninsula after operating there for more than 150 years.

“It can make it very challenging for people to get in and out of here,” said Dr. Jeffrey DiLisi, CEO of .

The hospital system sustained light flooding in one of its downtown medical office buildings from Ian, but it could have been much worse, said DiLisi. He also said that the downtown district is no longer the geographic center of Charleston and that many patients say it’s inconvenient to get there.

“The further inland, the less likely you’re going to have some of those problems,” he said.

Unlike Roper St. Francis, most coastal nonprofit and public hospitals have chosen to remain in their locations and reinforce their buildings, said , the president of the Safety Net Hospital Alliance of Florida and a former secretary of the state’s Agency for Health Care Administration, which regulates hospitals.

“They’re not going to move,” Senior said. “They’re in a catchment area where they’re trying to catch everyone, not just the affluent but everyone.”

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• Read de Marco’s “Children in Northern California Learn to Cope With Wildfire Trauma”

KHN Florida correspondent Daniel Chang discussed the Southern response to the monkeypox outbreak on C-SPAN’s “Washington Today” on Sept. 14.

• Read Chang’s “Southern States’ Lackluster Monkeypox Efforts Leave LGBTQ+ Groups Going It Alone”

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With her cat, Bodhi, in his carrier in the back seat, 80-year-old Diana Dimas, who doesn’t see well at night, kept her eyes glued to the rear lights of her neighbor’s Toyota. She and Magdalena Mulay had met a few years before at a bingo night in their sprawling retirement community on the outskirts of Santa Rosa. Both Libras, each with two marriages behind her, the two women soon became the sort of friends who finish each other’s sentences.

Now, for the second time in three years, they heard the alarms and fled together as fire consumed the golden hills of Northern California’s wine country.

“I thought, where on earth are we going to go?” recalled Dimas. She remembered that when the catastrophic Tubbs Fire hit back in 2017, people had sought refuge outside well-lit supermarkets, which had water and bathrooms. Which is how Dimas and Mulay and dozens of other seniors ended up spending the night of the most recent evacuation in the parking lot of the Sonoma Safeway.

At midnight, Mulay was trying to get comfortable enough to catch a few winks in her driver’s seat when her phone began to chirp. A friend was calling to wish her a happy 74th birthday.

The stories of that Sunday night — as a 20-acre fire started that morning merged with two other fires to become an 11,000-acre conflagration forcing tens of thousands from their homes in two counties — spotlight the challenges of evacuating elderly and infirm residents from the deadly wildfires that have become an annual occurrence in California. This year, the coronavirus, which is especially dangerous to the elderly, has further complicated the problem.

While the 2020 fire season will go down as the state’s biggest on record, rescuers have so far managed to avoid horrors on the scale of three years ago, when the firestorm that raced through California’s wine country killed 45 people. Almost all were over 65 — found in wheelchairs, trapped in their garages, isolated and hard of hearing, or simply too stubborn to leave. The same grim pattern emerged from the Camp Fire, which leveled the Northern California town of Paradise in 2018.

Assisted care homes in particular came under scrutiny after the 2017 fire, when ill-equipped and untrained workers at two Santa Rosa facilities abandoned two dozen frail, elderly residents as the flames closed in, according to state investigators. They concluded the seniors would have died in the flames had emergency workers and relatives not arrived at the last minute to rescue them.

“The problem is we don’t value elders as a society,” said Debbie Toth, CEO of Choice in Aging, an advocacy group. “If children needed to be evacuated, we’d have a freaking Romper Room stood up overnight to entertain them so they wouldn’t be damaged by the experience.”

The destructive effects of climate change in California have dovetailed with a rapidly graying population — which in a decade is projected to include 8.6 million senior citizens. That has fueled a growing demand for senior housing, from assisted care homes to swanky “active adult” facilities complete with golf courses and pools.

Proximity to nature is a major selling point of Oakmont Village, Dimas and Mulay’s upscale community of nearly 5,000 over-55s, which has everything from bridge games to cannabis clubs. But the woodlands and vineyards surrounding this suburban sprawl have put thousands of elderly citizens in hazardous wildfire zones.

“With seniors, there’s mobility issues, hearing issues — even the sense of smell is often gone in the later years,” said Marrianne McBride, who heads Sonoma County’s Council on Aging. Getting out fast in an emergency is especially challenging for those who no longer drive. In Sunday’s evacuation, some residents who followed official advice to call ride services had to wait hours, until 3 or 4 a.m., for the overtaxed vans.

Dimas and Mulay managed to scramble into their cars and get on the road shortly after 10 p.m., when a mandatory evacuation order went out for the thousands of seniors in Oakmont Village. But it was after midnight when residents of two Santa Rosa assisted care homes in the evacuation zone were shuffled onto city buses in their bathrobes, some with the aid of walkers. Off-duty drivers braved thick smoke and falling embers to ferry some of them to safety, only to spend hours being sent from one shelter to another as evacuation sites filled up fast because of social distancing rules designed to prevent the spread of COVID-19.

Other precautions, including masks and temperature checks, were followed. But health officials nonetheless voiced concerns that vulnerable people in their 80s and 90s — especially residents of skilled nursing homes, the source of most of Sonoma County’s coronavirus deaths so far — had been moved among multiple locations, upping their chance for exposure.

In the following days, shelters were fielding frantic calls from out-of-town relatives searching for their loved ones. “We were getting phone calls from Michigan, other places across the country, saying, ‘I’m trying to find my mother!’” said Allison Keaney, CEO of the Sonoma-Marin Fairgrounds, which sheltered several hundred horses, chickens, goats and llamas as well as displaced people.

By Wednesday afternoon, a few dozen evacuees remained at the shelters, mostly seniors without relatives or friends nearby to take them in, like Dimas and Mulay. The two women had left the Safeway lot and were sleeping on folding cots in a gym at the Veterans Memorial Building in Petaluma, an old poultry industry town dotted with upscale subdivisions.

This was their first time out and around other people since March, when the two friends had been planning a big night out to see Il Volo, an Italian pop group. Seven months later, the new outfits they bought for the concert still hang unworn in their closets.

“All we do since the shutdown is stay home and talk on the phone,” said Mulay, who spoke to a reporter while sitting next to her friend on a folding chair outside the shelter. “Now, with all these crowds — it’s terrifying.”

Dimas likened the pandemic followed by the fires to “a ball rolling downhill, getting bigger and bigger. And then there we were, with the flashing lights all around us and the cops shouting, ‘Go this way!’ ‘Keep moving!’”

Listos California — an outreach program, for seniors and other vulnerable people, run out of the Governor’s Office of Emergency Services — allotted $50 million to engage dozens of nonprofits and community groups around the state to help warn and locate people during disasters. (Listos means “Ready” in Spanish.)

In Sonoma and Napa counties, where the Glass Fire had destroyed at least 630 structures by late last week, the bolstered threat of wildfires in recent years has promoted new alert systems — including a weather radio that has strobe lights for the deaf or can shake the bed to awaken you.

But while counties are legally responsible for alerting people and providing shelter for them once they’re out, no public agency is responsible for overseeing the evacuation. Practices differ widely from county to county, said Listos co-director Karen Baker.

If Sonoma County has learned anything from the disasters of the past few years, it’s not to depend too much on any system in an emergency. “You’ve got to have a neighborhood network,” McBride said. “As community members, we have to rely on each other when these things happen.”

Early last week, word filtered through the shelters that the fire had consumed a triplex and two single-family homes in the Oakmont neighborhood, but firefighters had battled the blaze through the night with hoses, shovels and chainsaws and miraculously managed to save the rest of the community.

A week later, to their relief, Oakmont’s senior residents were allowed to return home. By then, Mulay had developed severe back pain. Dimas missed her TV.

Back in her apartment with Bodhi, Dimas noted with horror that the blaze had come close enough to her building to incinerate several juniper bushes and scorch a redwood just 2 feet away.

“The whole thing feels surreal, like ‘Oh, my God, did that really happen, or did I dream it?’” she said.

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• Read “In Debate, Pence and Harris Offer Conflicting Views of Nation’s Reality,” by the staffs of KHN and PolitiFact

KHN chief Washington correspondent Julie Rovner discussed Trump’s COVID-19 diagnosis on WFAE’s “Charlotte Talks” on Monday. She discussed the public’s right to know about the president’s health with Wisconsin Public Radio’s “Central Time” on Tuesday.

KHN correspondent Rachana Pradhan discussed COVID testing at the White House with Newsy’s “Morning Rush” on Tuesday.

• Read “Inside the Flawed White House Testing Scheme That Did Not Protect Trump,” by Pradhan, KHN Midwest correspondent Lauren Weber and KHN senior correspondent Liz Szabo.

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Last week, Hurricane Sally left a trail of watery devastation in Mississippi, Alabama and the Florida Panhandle, even as more storms brewed offshore.

All of that on top of the COVID-19 pandemic, which has .

The timing couldn’t have been better for the opening this month of the at UCLA’s Fielding School of Public Health.

Its mission is to work with policymakers and community groups to help safeguard human health against the ravages of climate change. The center was founded on the premise that the of climate change are already here and must be met with policies not only to slow the warming of the planet but also to help people adapt to its reality.

The center’s co-directors, Dr. Jonathan Fielding and Michael Jerrett, believe the clock is running out and we must quickly reduce the amount of carbon being pumped into the atmosphere to have any hope of preserving a viable planet.

“A lot of the predictions of what could happen with climate change have been wrong. But the predictions have been wrong in that they haven’t been catastrophic enough,” Fielding, a professor of medicine and public health at UCLA and former head of the Los Angeles County Department of Public Health, said in an interview last week.

Jerrett, a professor of environmental health sciences at UCLA’s who also participated in the interview, is the principal investigator on a study hypothesizing that long-term exposure to air pollution elevates the risk of severe COVID-19 outcomes. Other studies have yielded .

The following excerpts of the interview with Fielding and Jerrett were edited for length and clarity:

Q: Could the hazardous air quality from the wildfires burning across much of the West Coast fuel an increase in severe COVID-19 cases and deaths?

Jonathan Fielding: There’s a very good chance of that. There is no doubt the effects of air pollution on the lungs and other organs are substantial and contribute to people with chronic problems being more susceptible to the severe effects of COVID.

Michael Jerrett: When we have wildfire events like this, as people are exposed to these high levels of smoke, we see increases in those indicators of morbidity and mortality. And we’ve seen those effects for several lung diseases that have similarities to COVID, like pneumonia.

Q: How does climate change exacerbate the racial, ethnic and socioeconomic health disparities that are so prevalent in our society?

Fielding: You already have people who have a higher rate and burden of chronic illness. Just look at the rates of obesity, for example, as well as the rate of cardiovascular disease. Those are certainly exacerbated by increased heat and by where people can afford to live. A lot of people can only afford a place that’s going to have a lot of heat islands, it’s not going to be air-conditioned, it might not have much in the way even of public transportation.

Jerrett: If you look through very long periods of time, people who have more resources — whether that’s better social contacts or they’re more highly educated, or have higher incomes, or other factors that put them at a social advantage — have always been able to protect themselves from environmental risks better than people who lack those resources.

Q: Can you explain how wildfires affect mental health?

Jerrett: There’s emerging and increasingly convincing literature that shows air pollution is related to anxiety and depression. It’s thought that the change in the nervous system that seems to be stimulated by air pollution, and perhaps the vascular system changes, can affect brain function and lead people into a more depressive state. … Secondly, the loss of immediate surroundings that people are familiar with: So if you are used to looking out and seeing a beautiful forest, and you walk out and you look in your backyard and you see nothing but smoke, and the whole forest is gone, that can affect mental health.

Q: Can we expect to see pandemics more frequently?

Fielding: What I think most people are missing in discussing this issue is population growth. We’re increasing the interface between humans and other species that have viruses that may not affect them but very severely affect humans. So, that’s one issue. The second issue is that climate change is increasing the area where you have vectors that can thrive. So, for example, we’re going to wind up with mosquitoes that can transmit dengue fever and malaria in the U.S.

Q: You talk about the “health co-benefits” of programs that can help slow climate change while mitigating its impact on public health. What are some examples?

Jerrett: Some of the leading practices in terms of generating benefits involve, say, increasing the green cover. As we increase green cover, we absorb more carbon, so we’re going to reduce the risk of long-term climate change, but you can also have substantial health benefits from that. We know that the introduction of more vegetation generally lowers extreme heat, particularly in disadvantaged neighborhoods where they don’t have a lot of park space or a lot of trees. Another leading practice, where the Europeans are way ahead of us — but we do see signs of improvement across California, in places like Santa Monica — is promoting what’s known as active travel: to get people out of their cars and get them on a bicycle or walking for incidental trips or going to work. We get a benefit in terms of their increased physical activity, and we also reduce the amount of emissions.

Q: Are the climate changes we are already seeing permanent, or can they be halted or even reversed?

Jerrett: We’re already in what I would call a climate crisis. It’s elevating to a climate catastrophe, and that’s going to happen in the next 20 years. We still have a chance to pull back. If we don’t, then we’re going to start seeing massive species die-offs; it’s going to affect the ability of people all over the world to feed themselves. We’re going to have these extraordinary, extreme events like wildfires that are going to dwarf what we’ve seen in the past, and large portions of the planet may become uninhabitable.

Fielding: Here I would draw a parallel to COVID. Even though many of us predicted a pandemic, most people didn’t really believe it, the government didn’t prepare well for it, and we’re learning the same thing with climate change. The difference is we have a way, through vaccination and maybe drugs, to reverse what’s going on with COVID. We don’t know that we have the ability to do that with climate change. You have people politicizing it and calling it a hoax, and that, unfortunately, is very detrimental to what we all want, which is to have a habitable planet.

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As Hoopa’s fire chief and its pandemic team leader, Moon feared the impact of the blaze on the dense coniferous forests of the reservation, near Redwood National and State Parks, where 3,000 tribal members depend on steelhead trout and coho salmon fishing. He was even more terrified of a deadly viral outbreak in his tribe, which closed its land to visitors in March.

“We’re a high-risk community because we have a lot of diabetes, heart disease and elders that live in multigenerational homes. If a young person gets it, the whole household is going to get it,” Moon said.

Eventually, the three major blazes that burned nearly 100,000 acres around Hoopa were too much for the tribe’s 25-member fire team. Moon had no choice but to request help from federal wildland rangers and other tribal firefighters.

Native American tribes are no strangers to fire. Working with flames to burn away undergrowth and bring nutrients and biodiversity back to lands is an ingrained part of their heritage. But epidemics are also a familiar scourge. With the devastation that pathogens like smallpox and measles brought to Native populations following the arrival of Europeans, tribes are especially wary of COVID-19’s impact.

“When thinking about the potential of COVID-19 repeating history and wiping out entire communities and tribes, there is concern,” said Vernon Stearns, who as the fuels manager for the Spokane Tribe in eastern Washington is responsible for organizing controlled burns.

Some tribes have abandoned traditional fire suppression techniques, watching large swaths of land burn in order to protect a more fragile and essential resource: their people.

“The biggest fear the tribe had was COVID would hit our elders. And they are a very valuable resource of knowledge and connection to our ancestry and teaching of our ways to our children, who we also felt were at risk, and we obviously want to protect them,” said Ron Swaney, fire management officer for the Confederated Salish and Kootenai Tribes in Montana.

“I’ve seen how [the virus] has affected families close to me. I know the grief,” said Don Jones, fire chief of the Yakama Nation reservation in central Washington, where there have been at . “I’m not going to send sick people out to fight the fire. I’m not going to say, ‘Come on, guys, toughen up, go out there.’ Life takes precedence over that.”

Around the country, many tribes have full-time fire crews that traditionally aid one another and federal firefighters, sending out teams to help with blazes. But this year’s COVID-19 pandemic has pushed them to reconsider how much help they can give and receive in the face of encroaching infernos.

A Centers for Disease Control and Prevention found Native Americans and Alaskans were 3.5 times more likely than whites to test positive for the coronavirus. The rapid spread of the virus within tribes early in the pandemic led many reservations to aggressively control outside access. Casinos closed. Entrances to tourist areas such as lakes, hiking trails and fisheries were blocked off. Economically many tribes suffered, but COVID caseloads stabilized or declined.

The ongoing fire season is now threatening that progress.

Tribal families often live in multigenerational housing, sometimes in trailers or other small homes with no running water. Their isolated, tightknit communities can be sequestered from COVID-19 spikes in nearby towns but are ripe for an outbreak if the virus enters. Social distancing is a challenge on small, remote reservations. There may be only a single gas station or supermarket, where visiting fire crews would be likely to interact with the tribal population. Many tribes also lack strong internet connections, forcing fire crews to meet in person rather than stage briefings via Zoom, as federal crews have done elsewhere during the pandemic.

On the Flathead Reservation north of Missoula, Montana, COVID-19 hit the fire crew of the Confederated Salish and Kootenai Tribes before the fires did. A firefighter who came in direct contact with someone who was sick with the virus in early July took the tribe’s entire 12-person aviation team, consisting of an air attack plane and a helicopter crew, out of business for four days. While no fires were burning at the time, it was a worrisome wake-up call for Swaney.

“For a minute there, I really thought we would all be infected with COVID-19 and I was wondering who would be responding to the fires,” he said.

It was enough to convince Swaney that this year the tribe wouldn’t share any of its 60 firefighters with neighbors. It was a tough call because historically “in fire, when our neighbors need help, we go help,” he said.

At the end of July, Swaney had to accept help from nearly outside firefighters when lightning started a blaze in the mountains surrounding the bison-dotted grass valley his tribe calls home.

After the 3,500-acre Magpie Rock Fire was under control, Swaney learned that a federal wildland firefighter involved had tested positive for COVID-19 during his next assignment. He didn’t appear to have infected Swaney’s team, though four members have tested positive this season.

“We’ve had a lot of close calls,” he said.

Other tribes have sought to bolster their fire crews to do without the help of off-reservation teams. The Spokane Tribe in Washington earmarked it received from the CARES Act to hire an additional 10-person seasonal crew. It hoped to aggressively attack any fire and keep it small, thereby avoiding the need for outside firefighters who might also bring in the coronavirus, Stearns said.

The Yakama Nation, near the Oregon border, was still struggling with a coronavirus outbreak that had infected at least 6% of its population when fires started in July. The crews learned quickly that facing wildfire and a pandemic simultaneously would be an exercise in trade-offs.

Early in the effort, five fire crew members were taken off the line when several people got sick, leaving the 20 remaining members to make do. Federal firefighting is stretched thin as megafires consume vast areas of the West Coast — and other tribes were no help because they’ve restricted their fire teams’ movement to prevent COVID spread.

“We had no one else to call on. … It was pretty tough,” said Jones. “The stress level has gone up. You’re worried about exposure all the time.”

Ultimately, eight Yakama crew members tested positive for COVID-19. One of the firefighters who tested positive had already lost two family members to the virus. Another spread COVID-19 to a family member who ended up at the hospital on a ventilator but survived.

“Everyone in my program was affected one way or another,” Jones said. “Everyone lost somebody.”

The West’s brutal fire season is forcing tribes to concentrate on fires that start by lightning or accident, with no resources to give to prescribed burning.

“These fires are just gobbling up the ground,” said Jones. His tribe canceled the carefully controlled fires it normally conducts in September to avoid bringing together the large numbers of people needed to do them.

“Fires are just going to get bigger,” Jones said. “If we can’t do anything about it, we can’t do anything about it. We have to make sure everyone’s healthy first.”

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