By Laura Freeman
When you hear hoofbeats, don’t look for zebras. Every medical student has been reminded of that sage advice. However, considering how climate extremes are expanding the diagnostic possibilities for cases that may walk through a doctor’s door, a useful addendum comes from Sherlock Holmes. When you have eliminated the impossible, whatever remains, however improbable, must be the truth.
The truth these days is that even if your patient hasn’t been anywhere this summer, if it looks like malaria and acts like malaria, it just may be malaria.
“We’ve already had reports of community acquired malaria in both Florida and Texas, and Eastern Equine Encephalitis in Mobile,” epidemiologist and assistant professor at UAB School of Public Health and UAB Heersink School of Medicine Katia Bruxvoort, PhD said.
From those locations, we are only one Midwestern tourist stopover up I-65 from a mosquito biting the wrong person and going next door for dessert.
According to the NASA Goddard Institute for Space Studies, July 2023 was hotter than any other month in the global temperature record. Struggling shrubs and trees that survived a destructive winter cold wave are being burned into crispy fire fodder. In an ironic twist, extreme heat in the southern hemisphere near Australia has been pushing the jet stream up into the arctic circle. It returns to us, swooping down with one polar vortex after another and making food planting seasons anything but predictable.
“Not long ago, if we suspected Lyme disease, the first question was whether a patient had travelled north in regions where deer ticks were found. Now North Carolina is having an outbreak,” Bruxvoort said.
The North Carolina cases have proven that, given crowding, predator pressure, and the continuing search for food, water and a comfortable place to live, deer can walk south along the Appalachian trail and bring their ticks with them. That mountain chain ends with Red Mountain and Shades Mountain here in Birmingham.
Some local physicians are also puzzling ouat why patients who have never had allergies before are turning up in ERs in the middle of the night with life-threatening anaphylactic shock. Standard diagnostic rule of thumb previously said that food allergies act quickly, not several hours after dinner. Now local allergy specialists report seeing Alpha-Gal syndrome more frequently. Caused by sensitivity developed after a bite from a Lone Star tick, patients begin to react to red meat. That means no more steak or pork chops, and either going vegetarian or relying on poultry or fish.
Until recently, the southern limits of the Lone Star range was thought to be Tennessee. Given the number of hunters in North Alabama who are testing positive, that tick is also moving South.
“Temperatures and cycles of rainfall and drought are turning our area into a suitable habitat for a growing list of vectors that carry diseases that we rarely saw before,” Bruxvoort said. “New mosquitoes and ticks are moving into the area. Fleas can carry both infectious diseases and parasites. Now we are also seeing new fungal diseases.
“State health agencies are also monitoring closely for any signs of Zika, West Nile virus, Dengue fever, and the broad range of other vector-borne infectious diseases. Fortunately, we haven’t had any indication of Yellow Fever recurring in the U.S., but some public health specialists are urging close monitoring of ships that pass through the Panama Canal and other infected areas before docking at southern ports.”
Some of the recent heavy rains across the country that resulting in drowning deaths and casualties from high winds, the storms left standing water for mosquito breeding grounds. Where there was heavy runoff, there was also an increased risk for water-borne illnesses when septic tanks, trash dumps, stock yards and swamps flooded, and contaminated private wells and public water sources.
“Thankfully, modern sanitation has helped us avoid the cholera and typhoid epidemics of the old days, but there are plenty of strains of e-coli, rotavirus, and a huge number of other water-borne diseases and parasites that can cause extreme digestive distress and even death,” Bruxvoort said. “Our big vulnerability is that even here, in the affluent United States, we have some of the same problems with access to clean, safe water that are plaguing third world countries.
“We have to face the fact that with infectious diseases we are only as safe as our poorest residents. The great plagues have always tended to simmer in poor areas that don’t have as much access to treatment before they break out to infect the general public. Too many places in Alabama don’t have access to clean water and sanitation. That has to change before our luck runs out.”
Although fungal diseases are frequently associated with damp conditions, there is one that becomes a problem during drought. The fungus is soil-borne. When farmers and others inhale the dust, it begins to attack the respiratory system.
In June, the eastern half of the U.S. experienced just how bad the impact of hot, dry conditions can be over a broad area when smoke from Canadian wildfires overwhelmed northern and Midwestern doctors’ offices, affecting air quality as far south as Birmingham.
“It’s what western states have been dealing with for years. We’ve had our own smoke problems from dump fires that can’t be put out. People near the smoke can develop serious lung problems. It doesn’t take that much to put patients who have heart disease in real trouble. The effects on eyes and sinuses are pure misery,” Bruxvoort said.
Heat itself is the killer in too many cases. A Birmingham fire fighter tells the story of finding an elderly man dead with his face in the sink and water running. He had been too poor for air conditioning and too afraid of violence to open his windows or go to a cooling shelter.
Human bodies simply aren’t built to cope with the heat indexes we’re seeing. Adaptation takes time, and change is happening too quickly. Even workers who have braved outdoor heat in the past are finding themselves no match for heat stroke, dehydration and severe muscle cramps. Hospitals in Las Vegas are using body bags filled with ice to quickly cool tourists who misjudged what 112 degrees can do.
People in fragile health are particularly vulnerable, and chronic conditions that were stable can quickly become a crisis. Patients should be cautioned about staying cool and informed about cooling shelter options.
Before the jet stream makes its next northern detour and releases a polar blast, it might be helpful to review strategies for managing exposure, frostbite and the flood of respiratory infections that come when too many people have been sharing indoor spaces for too long.
“Health care providers can’t solve climate problems alone, but they can be mindful of related health issues and help their patients deal with them. We’re also depending on providers to be vigilant in monitoring and reporting any sign of infectious diseases that may be new to the area so public health can respond quickly,” Bruxvoort said.
One thing for certain is that nature is on the move, and we can all expect the unexpected. That includes bears that have been cooling off in Gulf Shores waters, in swimming pools and frolicking in back yards as near as Trussville. It also includes alligators that have been attacking people and their pets from golf course ponds as far north as Huntsville—which brings a whole new meaning to the term water hazard.
If the unexpected turns up at your door, remember: the definition of impossible isn’t what it used to be.