Who carries the greatest burden?
The environmental justice framework applies directly here. Each of the groups below faces a mechanistically distinct vulnerability to water or food-related climate impacts.
Before expanding the cards: Name two populations you expect to appear here and briefly explain why each faces a specifically water or food-related climate vulnerability. Then explore the cards to check your thinking.
Higher surface-area-to-volume ratio increases dehydration risk from diarrheal illness. Growth-phase dependence on iron, zinc, and protein makes CO2-driven nutrient dilution disproportionately harmful: A child actively building tissue is harmed more severely by micronutrient depletion than an adult maintaining it.
Increased metabolic demand for iron, zinc, and folate intersects directly with the CO2 nutrient dilution pathway. Gestational malnutrition is associated with adverse birth outcomes including low birth weight and preterm delivery, and with altered fetal development that affects the child’s long-term health trajectory.
Income and nutrition are directly tied to harvest and catch, with no food system buffer. A single failed season due to drought or flood causes simultaneous economic and nutritional crises. Climate change is compressing the windows of agricultural and fisheries productivity.
Agricultural workers, particularly migrant and seasonal workers in regions like eastern Washington, face variable quality field water sources, creating waterborne disease exposure during both drought and flooding events. An additional vulnerability is the food access paradox: Workers who produce the food supply often face food insecurity themselves; a structural inequity rooted in the economic conditions of agricultural labor.
This group faces a compound exposure profile:
- Prior nutritional depletion during displacement.
- Disrupted water infrastructure
- Monotonous donated rations based on staple cereals that increase micronutrient deficiency risk.
- Limited healthcare access.
This population increasingly presents in high-income country clinics.
Food sovereignty—the right of a community to define its own food system and practices—is threatened when climate change disrupts traditional hunting, fishing, and harvesting. Standard food insecurity metrics measure caloric access but do not capture additional losses, which includes nutritional diversity, cultural continuity, and long-term health in ways that calorie counts alone cannot reveal.
Low-income urban households spend a high proportion of income on food, leaving little buffer against price shocks from climate-driven crop failures. Inadequate sanitation and wate-supply infrastructure amplify water-borne disease risk during flooding events, when sewage systems overflow into water supplies. During drought, reduced water pressure creates backflow contamination risk in piped supply systems.
Households are disproportionately reliant on private wells, which are not subject to EPA drinking water standards. Flooding can inundate well heads and introduce fecal pathogens into previously protected water supplies. During drought, declining water tables draw from bedrock containing naturally occurring arsenic, fluoride or manganese – the chemical contamination risk is distinct from the microbial one.
Living below the poverty line, American Indians and Alaska Natives face much higher rates of food insecurity than other impoverished adults—nearly 4 in 10 lack consistent access to a healthy diet.
These are among the findings of new research by Washington State University sociologist Justin Denney, which demonstrate that food insecurity—defined as “the lack of consistent access to food for an active, healthy lifestyle”—is a complex and varied problem across racial and ethnic groups. It suggests that a one-size-fits-all approach may be ill-suited to addressing the problem.
He performed a cross-sectional analysis of 37, 748 adults from the National Health Interview Survey, conducted by the Centers for Disease Control, from 2019–2023.
Denney said, “Food security is really powerfully related to health, and there are some pretty severe health disparities by racial and ethnic groups. By better understanding the state of food security across those racial and ethnic groups, we might get a little closer to understanding where some of these health disparities come from and what to do about them.”
Read the full article Food Scarcity by Racial and Ethnic Identity Among Lower-Income Adults at the American Public Health Association website.
The global structural dimension
The nations contributing least to cumulative greenhouse gas emissions bear a disproportionate share of the disease burden attributable to climate change. Subsistence farmers in drought-prone low-income regions, coastal fishing communities in low-lying nations, and Indigenous peoples whose traditional food and water systems are being disrupted face the greatest health consequences from a problem they have contributed to least. This injustice is not incidental — it reflects historical and ongoing structural inequities in global development, land access, and political representation. Clinicians working with migrant and displaced patients in high-income settings will increasingly encounter the health consequences of this pattern.
Incorporating global structure into clinical practice
Environmental awareness only translates into better patient care when it changes what you ask. Three additions to the standard social history—all evidence-based and actionable.
A validated 2-item screen derived from the USDA Food Security Module (Hager et al., Pediatrics 2010). A positive response to either question identifies food insecurity with good sensitivity. Endorsed for clinical use by the American Academy of Pediatrics and multiple health systems.
Patients are asked to answer the following 2 statements:
- “Within the past 12 months, we worried whether our food would run out before we got money to buy more.”
- “Within the past 12 months the food we bought just didn’t last, and we didn’t have money to get more.”
A single open question with targeted follow-up, directly addresses the mechanisms covered in this module.
- “What is your main source of drinking water, and how is sewage managed at your home?”
- Follow-up: “Has your water source changed recently? Any flooding or drought affecting it? Do you treat the water before drinking?”
For patients with a history of displacement, relocation, or agricultural livelihood. Connects environmental context to clinical presentation.
- What is the country or region of origin? Is there a recent relocation history?
- Is there a history of displacement due to flood, drought, or another climate event.
- Is there are history of agricultural livelihood or subsistence farming or fishing.
Put it into practice
One sentence instructions?
Patient: Gabriella
Gabriella is a 31-year-old woman who recently resettled from a flood-affected agricultural region. She presents with fatigue, hair loss, and impaired wound healing over four months. BMI 20.2. Her diet since arrival has been primarily donated grain-based foods.
Gabriella responds positively to the screen. Food insecurity is confirmed.
The symptom triad of fatigue, hair loss, and impaired wound healing is consistent with iron deficiency (fatigue, immune impairment) and zinc deficiency (hair loss, impaired wound healing, poor immune function). The displacement context from a flood-affected agricultural region, combined with a monotonous donated-grain diet, points to a nutritional picture compounded by the CO2 nutrient dilution effect on the staple grains she has been eating since resettlement.
Order:
- CBC
- Iron studies (ferritin, TIBC)
- Serum zinc
- B12
- Folate
Refer Gabriella to social work for food access support and referral to community food resources or Supplemental Nutrition Assistance Program (SNAP).
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