Extreme heat puts diabetes patients at increased risk in border counties

Steven Jayme remembers a patient showing up to his diabetes education class with a giant cup of soft drink, but instead of a sugary soda, the patient was holding something unexpected: insulin on ice.

His car doesn't have air conditioning, which means he has to be outside for hours in temperatures that can reach 120 degrees, so he makes do with the resources he has on hand.

“Anything works,” says Jamie, a career nurse who has a doctorate in nursing science and now tells this story to diabetic patients who attend his classes at El Centro Regional Medical Center in Imperial County.

As heat waves hit across the country, medical researchers are warning that extreme temperatures and climate change are creating life-threatening problems for people with diabetes, with the risks especially affecting low-income communities. Medical experts in Imperial County, for example, have also expressed concern. The county has the highest diabetes incidence rate in California, and faces a combination of other factors that make diabetes management difficult, including extreme heat periods and the state's highest unemployment rate.

Diabetic patients enrolled in federal health insurance programs for low-income and older adults generally experience more complications if they live in areas exposed to extreme temperatures, according to a recent national study co-authored by Casey Boger, a researcher at the University of Pennsylvania's Center for Real-World Effectiveness and Safety of Therapeutics.

She also said studies like theirs that take into account the effects of climate change and health indicators have only recently begun, meaning more research is needed to look at the issue comprehensively.

“There's not enough data at this point to outline what everyone thinks they know,” Boger said.

Diabetes is a chronic disease that occurs when the body cannot control high blood sugar levels. The disease damages blood vessels and can cause damage to nerves and organs, leading to blindness, amputations and death.

In terms of medical factors, people with diabetes are more susceptible to heatstroke and dehydration, and may already suffer from other health problems, such as heart disease, which can be exacerbated by extreme heat.

“If your heart is not strong, you can easily suffer a heart attack,” says Dr. Majid Mani, a diabetic ophthalmologist in the Valley. “Mobility options are very limited unless you go for a walk early in the morning or late at night. Also, not everyone has access to a gym.”

More than 70 people have died from heatstroke in the Imperial Valley over the past three years. Local residents are still mourning the death of a 16-year-old girl who died late last month while running during a high school gym class. According to an online petition, the student collapsed after being made to run. Temperatures reached 112 degrees Fahrenheit that day. The incident remains under investigation.

Much of Imperial County is at sea level, and summer temperatures reach a high of 120 degrees Fahrenheit and rarely drop below 100 degrees. Projections suggest that the number of extremely hot days across Southern California will double over the next 50 years, with Imperial County leading the way.

A variety of socio-economic factors put residents at risk of poor health.

The county has one of the lowest physicians per capita rates in the state, and its poverty rate is nearly twice the state average. Residents report monthly air conditioning bills of about $400 to $500, a significant portion of their salary. The median income in Imperial Valley County is $53,900.

Meanwhile, insulin, a drug used to manage diabetes, remains out of reach for many people, and a recent federal policy capped the price for Medicare subscribers but not those with private insurance.

“Imagine if we could make $1,500 (a month) … can you imagine the impact that would have on our community?” said Guadalupe Heredia, who founded the El Centro Hospital Diabetes Education Center in the '80s.

More than half of the county's population relies on public health insurance, a vital but strained service for local health care providers, who make money by offering expensive services, many of which Imperial Valley Hospital cannot provide.

Heredia, who has diabetes himself and has worked in community education and advocacy for decades, said all of these factors combine to create complex problems that could have deadly consequences for his neighbors.

“That means you either have to pay rent, eat or buy medicine. Can you imagine that?” Heredia said.

Medical professionals in Imperial County link climate and socioeconomic status to health care challenges.

Frontline health care workers who support people with diabetes in the Imperial Valley say the challenges residents face range from the level of access to care to resources individual patients may have. A lack of specialists and facilities, as well as the high cost of living, are just a few of the barriers.

For many people living in Imperial County, diabetes is a part of daily life. Recent data shows that 17% of the county's population has been diagnosed with diabetes, compared to 11% statewide. The COVID-19 pandemic has placed additional strain on the local healthcare system while also raising awareness of the risks the disease poses for people with diabetes.

People with diabetes are more likely to develop serious complications from the virus. The pandemic, plus extreme heat and a lack of medical facilities, made the situation particularly tough in the valley. Local hospitals had to set up tents to treat patients.

“The temperatures in the Imperial Valley can get up to 120 degrees…can you imagine being in a tent?” Heredia said.

Mani explained that extreme heat can cause diabetics to become severely dehydrated, which can lead to a spike in blood sugar and stroke.

“The body tries to compensate by expelling the excess sugar, which results in severe dehydration,” Mani said. Many people die during the night or morning and their families don't know the cause of death, but high fever and diabetes could well have been to blame, Mani said.

When the pandemic hit, Heredia lost her brother, who, like her, had been a longtime diabetic. He was hospitalized for several weeks, returned home, and died in his sleep a month later from complications of diabetes and COVID-19.

“We were already struggling, but the pandemic just disrupted that,” Heredia said of the pandemic.

The pandemic has taken a toll on hospital finances, and for El Centro Regional Hospital, debt incurred from earthquake renovations has been an added stressor. Efforts are underway to combine resources at two area hospitals to better serve patients.

Financial issues have led El Centro Regional Hospital to close its obstetrics and pediatrics departments.

Diabetes programs have also been hit hard: Before the pandemic, the diabetes education program had five staff members; now, only two are working there.

Following Heredia's retirement, the education program has been run by Jamie, who has a PhD in nursing and is also diabetic, hails from the Imperial Valley, and focused her doctoral studies on ways to improve diabetes care in rural border communities.

“There are just too many sick people and not enough health care providers,” Jamie said, “so I think the high case ratio is a big issue in the valley.”

He said many patients are unaware of important, potentially life-saving information, such as how to use a glucose meter, a device that measures blood sugar levels.

“Many of the patients who come in say they don't even know how to use this equipment; no one has ever taught them how.”

His research focuses on why Hispanics are more likely to develop diabetes and how diabetes education can help reduce those numbers.

In the Valley, Latinos have a higher prevalence of diabetes than whites: In San Diego County, 9.2% of Latinos and 7.5% of whites have been diagnosed with diabetes, but in Imperial County the gap is larger, at 17.1% and 12.5%, respectively.

Like Heredia, Jaime has traveled to Washington, DC to advocate for her community and ask for resources to be focused on areas similarly affected as hers.

Imperial Valley Public Health says many of the diabetes-related hospitalizations in the region could be prevented if the standard of living improved overall.

This includes access to affordable housing, transportation, parks, cooling centers and climate-controlled exercise facilities.

It also means that children receive an education in a language they understand: Spanish, which is the first or only language spoken in many Imperial County homes.

“Finally, there are materials being published in Spanish that we can give to our patients,” Jaime says. “The only problem is, we need to make sure that our patients actually understand what they're reading.”

He says that means sitting down with them and spending hours talking to them, getting to know them and sharing his experiences.

It takes time, and Jamie says he's busier than ever these days caring for his patients.