One of the seldom-discussed consequences of climate change is the increasing danger around zoonotic disease: infectious diseases that can jump from one animal species to another. While the scientific term zoonoses might not be familiar to the average person, recent history has proven that no one can escape the consequences of viral pandemics. We entered this decade with a world shut down due to SARS-CoV-2, considered a zoonotic disease because of its possible roots in China and Southeast Asian bat populations. The latest virus to break into the general consciousness and spark fear across the world is an Andes strain of the Hantavirus, followed by a resurgence of Ebola in central Africa. Both viruses are zoonotic in nature with high lethality rates. For Americans, the risk posed by these two diseases in particular may feel lower because of the federal government’s ability to isolate cases and halt incoming travel from particular regions. However, Americans are not immune to diseases spread by and between animals. As humans increasingly expand our geographic reach, encroach on untouched natural territories, and interact more closely with animal populations, we will continue to encounter novel zoonotic diseases that pose devastating threats to the human body. 

This is a global risk with potential for drastic local consequences. But it is also an opportunity for individual and collective action because the risks associated with zoonotic disease are not limited to the biological effects. Widescale outbreaks and global pandemics cause major global economic disruption. From supply chain issues, to workforce gaps and material shortages, society hinges on the assumption that people can work and any delays are remedied quickly. When these assumptions break down, few are sheltered from the economic and social consequences. 

Health Implications of Pathogens in a Changing Climate

It is no secret that our air, water, and soil is being poisoned by human activity and this has health implications. We pump greenhouse gasses into the atmosphere, dispose of harmful chemicals into our waterways, and dump toxins into our soil. These choices will continue to damage environmental and eventually human health. As the population’s general health declines, zoonotic disease becomes easier to spread. Consequently insurance prices will rise to account for the higher frequency in care required for citizens throughout their lifespan. Respiratory illness, waterborne disease, mosquito-borne illnesses, fungal infections, and tick-borne diseases are all predicted to increase with climate change. The sooner we act to address these risks and increase system resilience ahead of time, the better society will fare in the long run. 

One example familiar to Americans is habitat changes in the tick genus. Ticks are ectotherms, meaning their bodies don’t maintain a consistent internal temperature, so they are particularly sensitive to environmental temperature shifts. When average temperatures rise, they can expand north into historically colder climates and up into higher elevations. Furthermore, higher temperatures can expedite biological processes, with evidence showing that life cycles can decrease from three years to two. This creates more ticks, which yields a higher likelihood of contact with humans, and a greater risk of vector-borne zoonotic disease spread. 

In order for a tick to become an infected vector, it must feed on an animal carrying the bacteria. Scientists believe infrastructure development and fragmentation of forests are contributing to higher rates of infected tick bites. Notably, as forests become smaller due to human activity, rodent predator numbers decrease while rodent populations increase. When rodent numbers rise, so does the likelihood of a tick feeding on an infected mouse. Because habitats are not closed systems, a change for one animal or species will often cause cascading effects for the organisms around them.

Expanding on the issue of mice, which is often mentioned alongside the tick conversation, is how their biological processes are hastening with the changing climate. Conditions like warm autumn, mild winters, and early spring temperatures have afforded mice the potential to yield three additional litters each year. A single mouse can produce 50 to 100 mice a year, and each female can reproduce only six weeks after birth, so further acceleration could trigger exponential population growth. Similarly to the tick example; the more mice you have in an area, the higher the likelihood that infected individuals will come into contact with humans. 

Lastly, mosquitos are also vectors for zoonoses. Across the globe, humans have contended with mosquitos spreading disease like West Nile, Dengue Fever, and Malaria. In 1914, the United States Public Health Service (USPHS) received funds from Congress to address malaria throughout the country. Major advancements were made in 1933 with the inception of the Tennessee Valley Authority, which inspired an organized malaria control program. By the 1940s, Malaria Control in War Areas (MCWA) was established to control outbreaks in U.S. military bases and to address infected soldiers returning home. The CDC, established in 1946, stemmed from MCWA, so much of its early work was centered around malaria elimination. In the 1950s, the disease was essentially eliminated in the U.S.. 

Solutions are Slippery

However, the solutions we prescribe don’t always have the intended effect. Once in a while, a prescription meant to protect humans can be co-opted for personal or economic gain. Other times, communities may realize that a new tool performs far better than those currently in use for things like farming, hunting, and irrigation. In the case of African mosquitos specifically, the mid-2000’s saw nets being transformed from a protective barrier to fishing equipment that far out-performed any of the resources available at the time. This demonstrates how there are tangential consequences of viral zoonoses due to the potential ripple effects that can come from efforts to mitigate their presence. 

The zoonotic diseases that humans contend with will increase in frequency, duration, and severity. Studies show a strong correlation between extreme weather, particularly heavy rainfall events, and zoonotic disease outbreak. For example, there is a link between climactic patterns and plague levels in the western United States, with a warmer and wetter climate leading to an increased number of human cases. Additionally, H1N1 influenza virus concentration in the air was substantially higher during the period of Asian Dust Storms (ADS) compared to the normal days, as particulates can get trapped in soil and then spread with high winds. Pathogens have adapted to the changing climate as well, which means they are becoming resistant to conventional treatments. Furthermore, as climates change, diseases that used to be localized to areas like the tropics have spread worldwide. All of this creates a perfect storm for zoonoses to thrive, threatening humans across the globe.

Individual and Collective Action Can Be Proactive and Protective

The potential increased rate and spread of novel and re-emerging diseases around the world is a huge issue to address. To begin, governments across the globe should focus on creating opportunities to reinforce detection and monitoring activities in areas where human-animal interaction is occurring. Particular attention should be paid to historical regions where outbreaks are common. 

In Congress, Sen. Baldwin introduced bill S. 4451 that would establish a “Wildlife Health Coordination and Zoonotic Disease Program” jointly administered by the Fish and Wildlife Service and the Administrator of the Animal and Plant Health Inspection Service. According to the bill text, the purpose of this program would be two-fold; first to improve coordination between Federal, State, and Tribal partners on wildlife health issues. Second would be to “support communication, planning, and capacity building efforts to address emerging and ongoing national, State, and regional wildlife health concerns.” Intentional oversight can catch spillover events early, but that isn’t enough for a long term solution. 

While we continue to research systems-level environmental and policy prescriptions to address zoonoses as a whole, there are easy behaviors that everyone should adapt to protect themselves from threats at home. 

For example, when traveling, investigate all planned excursions that will put you in close proximity to wild animals. Ensure that you, or the tour agency, is aware of any PPE requirements and/or best safety practices. Take precautions seriously at home too. Data submitted through a smartphone app as a part of tick species research found that “people don’t take the same protective measures in their yards as they would if trekking into the woods. Yet while an urban backyard might have fewer ticks overall, there’s still risk.” Protective measures like wearing long pants, applying bug spray, and limiting contact with insects and small animals will reduce risk in your own yard. Little fuzzy friends may be adorable, but that does not mean you should go out of your way to play, touch, or have close contact with them if it can be avoided. Quarantine and seek medical attention if you experience atypical or unusual conditions. Lastly, within your immediate proximity, practice good hygiene practices. Clean your house, don’t touch or pick up stray animals, and make sure you use gloves and proper disinfectants when handling things like animals or animal droppings.

Lastly, citizen science projects and public awareness campaigns are a great place to start educating others and inspiring change locally. Empowering community members to get involved with local government can be the first step. 

A great example of community action toward vector-control is happening in my own city of Washington, DC. In March 2026, a simple listserv discussing the mass amounts of mosquitos in the Capitol Hill neighborhood grew into a local task force. Now called the Itty Bitty Mosquito Committee, the group engages in source reduction, community education, native habitat investment, and coordination with city agencies to holistically reduce the mosquito populations in their area without spraying harmful pesticides. They were inspired by a similar program in nearby Maryland; the University Park Community Mosquito Control. While mosquitoes in the U.S. are less likely to transmit dangerous diseases than those found in tropical regions, there are still hundreds of cases of West Nile Virus and Dengue across the country each year. Reducing the mosquito population overall will  reduce the number of infected mosquitoes, which lessens the risk of being bitten by an individual carrying a pathogen. Community task forces like these can move the population toward a goal without the institutional barriers and costs associated with traditional governmental routes. Zoonotic diseases may be on the rise but we have the tools and knowledge to reduce some of the risks.

Imagine trying to solve a public health crisis without knowing which communities are being hit hardest. We are moving closer to that reality. In recent months, concerning patterns have emerged that threaten to unravel decades of progress in how the federal government collects and reports race and ethnicity data. 

The near-complete elimination of gender identity from future data collection was the first wave of widespread reductions to demographic data since January 2025. We think race and ethnicity is likely to be the second. And while the administration’s approach to gender identity was done in one sweeping executive order, race and ethnicity data are being eroded from several directions.

The erosion began with the removal of information related to diversity, equity, and inclusion (DEI), including topics like health equity and cultural competence, in response to executive orders. Then agencies began walking back their intent to implement the modernized race and ethnicity standards that were a decade in the making. The Office of Management and Budget repeatedly pushed back deadlines for implementation plans. Now, race and ethnicity questions are beginning to be removed entirely from data collections, with stated justifications ranging from legal interpretations and paperwork burden to shifting policy priorities.

The growing threat to the availability and quality of race and ethnicity data has dire public health consequences. It narrows our visibility into who is getting sick, who is dying, and whether the people who need help are getting it. Let’s take a closer look at what these losses could look like.

Our nation’s common denominator

Our nation has collected race and ethnicity data in every census since 1790. Yet a draft Commerce Department rule is under review that would end race and ethnicity data collection in the 2030 Census. The draft rule also excludes undocumented immigrants and H-1B visa holders. The justification for the change is “to protect from any distortions created from the inclusion of personal questions.” Regardless of justification, ending the collection of race data will have far-reaching consequences, especially on America’s health.

Health data depend on the census in a critical way. Imagine only knowing that in 2023, around 85,000 Black Americans and 520,000 White Americans died of heart disease, without knowing how many total Black and White Americans were alive in 2023. If you read those counts alone, heart disease may look like a significantly worse problem for White Americans. We need the denominator from the census,¹ the total number of people in each group. Black Americans die from heart disease at a rate 21% higher than White Americans—the highest of any racial group in the country. Without the denominator, we cannot compare one group to another or know if the number of deaths are rising or falling over time. 

This issue reaches beyond health statistics. Federal programs, like at HHS, use census counts to distribute funding. For example, some tribal grant programs rely specifically on the census American Indian or Alaska Native category to allocate funding. If you change what the census counts, then you change where the money can help most. 

The census is the cornerstone of the federal statistical system, and changes to questions in the census often propagate across federal data collections. With the Census Bureau punting on the timeline for adopting the new race and ethnicity categories, and now possibly pulling race data completely out, health-related data collections are likely to follow suit. Removing race and ethnicity from federal forms and surveys would leave the country unable to measure who is getting sick and dying at higher rates, unable to direct prevention programs to the communities carrying the heaviest burden, and unable to tell whether any of it is working as intended. 

While race and ethnicity remain intact in these datasets (for now), the next three examples make clear what is at stake. If demographic data like race and ethnicity are removed, some of the most vulnerable populations would be endangered: new mothers, people experiencing chronic diseases, and those experiencing addiction, to give just a few examples.

Maternal Mortality

The National Vital Statistics System (NVSS) compiles birth and death certificates from every state, giving the federal government its most complete picture of who dies and how, including who dies during or shortly after pregnancy.

The numbers reveal a persistent racial disparity. In 2023, for every White mother lost to pregnancy-related causes, more than three Black mothers lost their lives.This racial disparity has existed for more than 100 years. Health systems use race-stratified data to see the big picture: identify which mothers face the highest risk, put in place interventions like blood pressure monitoring and faster hemorrhage response, and then assess whether those protocols actually narrowed the disparities. An intervention can lower the overall death rate while leaving the disparity untouched, or even widening it, and without race data, no one would know. If NVSS stops collecting or reporting race data, we will no longer be able to see if we are closing that gap.

Diabetes

The Behavioral Risk Factor Surveillance System (BRFSS) conducts an annual nationwide survey tracking chronic diseases and health behaviors in every state, giving health departments a county-by-county picture of where health issues, like diabetes, are concentrated. Respondents also report their race and ethnicity, which gives insight into which populations carry the heaviest health burden.

Diabetes does not fall evenly. American Indian and Alaska Native adults develop diagnosed diabetes at nearly twice the rate of white adults. Black and Hispanic adults also face significantly higher rates. Diabetes drives kidney failure, blindness, and amputation, and costs the country more than $400 billion a year. 

The lifestyle change program behind the National Diabetes Prevention Program can cut the risk of developing type 2 diabetes by about a third in people who are at risk, but it does not work equally well for everyone. Without the data showing which communities have higher rates of diabetes, prevention resources flow to whoever is easiest to reach, which is rarely the people who need them most.

Overdoses

The State Unintentional Drug Overdose Reporting System (SUDORS) collects information on fatal overdoses from 49 states and the District of Columbia. It records race and ethnicity for each death along with the circumstances surrounding it: whether a bystander was present, whether anyone administered naloxone, whether the person had been in treatment before. That combination of data can be turned into a prevention plan.

This matters because overdose deaths fall unequally across racial groups than almost any other health issue. American Indian and Alaska Native adults face the nation’s highest overdose death rate at nearly double that of White adults (65 vs. 33 per 100,000). Meanwhile, overdose deaths among Black adults rose to roughly 49 per 100,000 in 2023, nearly 50% above the rate for White adults, even as the national rate fell 4 percent. That decline belonged almost entirely to White adults. Without race data, the drop looks like progress for everyone, and prevention may ease off or continue to not reach the communities where deaths are still climbing.

Implications for Data Policy

With less than four years until the next decennial census, we must keep a close eye on all demographic data, especially race and ethnicity. The census sets the de facto standard for how federal agencies, as well as state and local governments, collect data across thousands of forms as surveys. As goes the census, so goes the rest of the statistical system.

If race and ethnicity are removed from the decennial census, it would set a precedent that extends far beyond 2030, making it easier for other agencies to do the same. This is bigger than a singular elimination of race and ethnicity questions. It could accelerate the second wave of widespread reductions to demographic data, leaving public health officials with even less information to deliver better health outcomes for all Americans. 

Removing race and ethnicity data does not make health disparities go away. It merely makes them harder to find, harder to measure, and harder to fix.

Colorado faces a projected shortage of more than 2,400 physicians by 2030, alongside the growing shortage nationwide, particularly in rural and certain underserved urban communities. Meanwhile, as of 2017, there were an estimated 3,000 immigrants in Colorado with healthcare-related degrees in jobs that do not utilize their training, 2,000 of whom received their training outside the United States. Many immigrants, including physicians with extensive experience in their countries of origin, are unable to practice without policy changes and/or support in navigating licensing requirements. Colorado has already invested in solutions. HB22-1050, enacted in 2022, created two pathways for internationally trained physicians — a clinical readiness program (CRP) that prepares international medical graduates (IMGs) for U.S. residency and an expanded re-entry license for internationally trained physicians (ITPs) — individuals who have completed postgraduate training and hold a foreign medical license. The CRP has produced real results, including a 100% residency match rate, all in rural and underserved communities. But CRP grant funding is expiring, the re-entry pathway has not yet been utilized, and a critical third pathway — supervised provisional licensure — remains absent from Colorado statute despite having been enacted in 24 states and two territories.¹ This memo calls on the incoming Governor to complete the architecture that HB22-1050 began and strengthen implementation of all three pathways through data assessment, interagency coordination, private funding, and outreach to ITPs and employers. Together, these actions can help close documented gaps in health services for communities with the greatest need.  This is an opportunity for the Colorado government to deliver by maintaining rigorous physician standards while eliminating unnecessary barriers to practice.

Challenge and Opportunity

Colorado is entering a healthcare workforce crisis decades in the making, at a moment when the state’s capacity to respond through traditional pipelines is shrinking. Colorado faces an estimated shortfall of 2,400 physicians by 2030, consistent with national projections of a shortage of 86,000 physicians by 2036.² The needs align with the state’s most vulnerable communities: rural counties, primary care, mental health, and obstetrics face the deepest gaps, with some eastern regions reporting ratios as high as 5,600 residents per primary care provider; and the vast majority of Colorado’s 64 counties contain at least one federally designated health professional shortage area. Colorado’s residency pipeline is insufficient to meet statewide needs. 

Meanwhile, demand is accelerating, especially for older adults who require more care. For the first time, more Coloradans are over 60 than under 18, and by 2030, roughly 20 percent of the population will be 65 and over, with many living in the rural communities where physician access is most acute.

HB22-1050, enacted in 2022, established a framework for activating the state’s immigrant physician workforce by creating a program to help IMGs enter a U.S. residency and a pathway to gain licensure through a competency assessment. The bill envisioned that IMGs needing additional training and assistance, such as provided through a residency, could access the CRP program. Those that did not need additional training could access a streamlined path to full and unqualified licensure through the re-entry pathway. However, the bill did not provide a pathway for those who may benefit from additional supervision but who do not need a full residency. Since HB22-1050 became law, other states have enacted a provisional pathway for this purpose. This path does not lower standards — it creates a supervised, employment-linked route to demonstrate equivalency. It is the missing piece in Colorado’s framework to ensure pathways to licensure for all incoming international talent. It is also the piece with the most potential to scale, since it is employer-driven. (See Table 1.)

Navigation and Support — IMG Assistance Program. Threading across all three pathways listed above³ is the IMG Assistance Program, which connects individual IMGs to whichever pathway they are best positioned to enter through career coaching, credential evaluation, and USMLE preparation support. Without this connective tissue and support structure, even a broader set of pathways will be inaccessible to immigrants with underutilized healthcare credentials currently living in Colorado and even more in the region.

Research by More in Common found that healthcare workers are among the most broadly supported immigration categories among Americans across the political spectrum⁴. This proposal is a workforce competitiveness initiative: it addresses a documented shortage with a tested, supervised pathway. New policy that translates into lifesaving services for Colorado communities would be a clear win for the new governor.

Plan of Action

Recommendation 1. Commission an assessment of physician and policy gaps and crosswalk with information on international medical graduates in Colorado.

Colorado’s physician shortage data exists, but is incomplete for policymaking. Aggregate shortage statistics — doctor-to-patient ratios, HRSA Health Professional Shortage Area designations — tell us where gaps exist in general terms, but do not tell the incoming administration which specific locations and specialties face the most acute near-term hiring needs, or which segments of the IMG population in Colorado are closest to practice-readiness. Without this crosswalk, it is difficult to effectively target efforts to fill physician workforce gaps.

The incoming Governor should direct Colorado’s Department of Public Health & Environment (CDPHE) and Department of Labor & Employment (CDLE), in coordination with the Office of New Americans (ONA), the Colorado Rural Health Center, the Department of Health Care Policy and Financing (HCPF), and the Department of Regulatory Agencies (DORA) to publish a physician workforce gap assessment within 90 days. Building on existing data, the assessment should map shortage areas by county, specialty, and care setting; document unfilled physician positions by metrics such as time-to-fill and applicants-per-posting; and identify and prioritize rural and frontier counties with the most acute needs. Simultaneously, CDLE’s Global Talent Survey and other data sources should be used to produce an updated estimate of the IMG and ITP populations in Colorado, their degree of practice-readiness, and which licensing pathway — CRP, re-entry, or provisional — each segment is best positioned to enter. 

The assessment should also analyze the ITP evaluation criteria for the provisional pathway, including by reviewing and building upon the existing evaluation criteria used in the re-entry pathway. Prior outreach generated interest in assisting Colorado to build out this specific pathway for ITPs (rather than having the same criteria used for evaluations of U.S.-trained doctors seeking re-entry), but the assessment plan should ground-truth the viability, costs, and potential scale.  

This assessment will serve as the evidentiary backbone for the action plan and will allow the administration to set measurable targets and create a monitoring and evaluation framework: how many IMGs and ITPs to activate, in which specialties, and in which communities, over a defined timeline. The assessment should be conducted with input from health systems, rural hospital associations, the Colorado Medical Society, and others, and should be completed in time to inform the 2027 legislative session.

Recommendation 2. Build on HB22-1050 by amending Article 87 of the CO Revised Statutes to authorize the Colorado Medical Board to grant provisional licenses to qualified international medical graduates.

Colorado is one of fewer than half the states in the country that do not yet authorize a supervised provisional licensure pathway for ITPs. 24 states and two territories — including Arkansas, Illinois, Florida, Louisiana, Massachusetts, Washington, and Wisconsin — have enacted versions of this pathway, and the list is growing. Colorado’s current framework requires both IMGs and ITPs to either complete a U.S. residency program (highly competitive, with very few slots successfully allocated to them) or navigate the re-entry license, which has not yet been underutilized in part due to the high cost in time and dollars. The result is that many qualified physicians already living in Colorado cannot practice.⁵

The incoming Governor should work with legislative champions to amend HB22-1050 in the 2027 session to authorize the Colorado Medical Board to issue provisional licenses to qualified ITPs. To be eligible, an applicant would need to: hold a current or recently active foreign medical license in good standing; demonstrate substantially equivalent postgraduate training; hold ECFMG certification; have passed USMLE Steps 1 and 2; demonstrate English proficiency; and secure a full-time offer of employment from a sponsoring healthcare entity — including hospitals, Federally Qualified Health Centers (FQHCs), rural health clinics, or medical practices — that agrees to provide supervision and periodic competency evaluation. The provisional license would be valid for two to four years. Upon passing USMLE Step 3, receiving a positive evaluation from the supervising physician or medical director, and maintaining good standing, the license would convert to a full, unrestricted license.

A new provisional pathway would maintain current standards by ensuring strict eligibility criteria followed by an extended evaluation period — it creates supervised, assessment-based routes to demonstrate equivalency. The provisional license increases the pool of potential applicants because it allows physicians to earn income while practicing under supervision, while they work toward a full license. The bill should explicitly prioritize placement and retention in rural counties, primary care shortage areas, and/or facilities serving Medicaid populations, and also include guidance on supervision, employer eligibility, malpractice coverage, reporting, discipline, patient safety, and conversion to the full license. Placement in rural and underserved areas could be incentivized by prioritizing the assessment of provisional license applications for those with job offers in rural and underserved areas, among other measures. 

Recommendation 3. Collaborate with healthcare employers, philanthropies, and impact investors to create revolving fund, loan, and scholarship programs that sustain alternative licensure pathways for physicians across all three pathways, with incentives for doctors to work in rural and underserved areas.

Given Colorado’s budget challenges and competing funding priorities, support for alternative pathways must be sustainable with philanthropic and private support, rather than relying on ongoing state appropriations. The CRP and IMG Assistance Program created by HB22-1050 were funded through state appropriations that are now expiring. Without a durable, privately capitalized financing mechanism, programs that have produced strong results will fail. The costs IMGs face on the path to licensure are substantial and prohibitive for many candidates: ECFMG certification, USMLE preparation and testing fees, credential evaluation, and living costs during non- or low-income training periods.

The Governor should direct a senior advisor (see Recommendation 5) to convene a working group in the first 90 days of the initiative, including health systems, rural hospitals, philanthropic funders, assessment providers, and impact investors, to design a revolving and loan fund structure. The blended-capital revolving fund — seeded with public and philanthropic dollars and replenished by loan repayments and employer contributions so it needs no recurring appropriations — should build on past lessons from successful models of State Revolving Funds and CDFIs, including the in-state precedent of the Denver Regional TOD Fund, and Minnesota’s grants for IMG residencies, which apply the concept directly to internationally trained physicians. The fund could include an allocation for grants and incentives for ITPs to serve in rural and underserved areas; where there are persistent physician gaps, incentives could also be offered to ITPs from other states who commit to working in an underserved area in Colorado for a specific term. The fund should draw on three primary sources of private and non-state capital.

Healthcare employer co-investment. Hospitals, health systems, rural health clinics, and FQHCs that hire ITPs through the provisional licensure pathway — and that currently spend significantly on temporary (locum tenens) coverage — are the natural anchor funders. The per-year cost of a locum tenens physician routinely exceeds $150,000; co-investment in the talent pipeline is substantially cheaper and produces a permanent hire rather than a temporary fill. Employers who place ITPs through the provisional licensure pathway should contribute a defined amount per placement back into the fund, creating a self-reinforcing cycle as the pipeline scales.

Philanthropic capital. Colorado philanthropies with missions aligned to health equity, workforce development, and immigrant integration are natural partners: the Colorado Health Foundation, the Denver Foundation, the Denver Health Foundation, the Rose Community Foundation, and national health funders such as the Milbank Memorial Fund and the Commonwealth Fund.

Impact investment and loan programs. Loan programs that allow individuals to finance their own path to licensure — with repayment structured around physician income once practicing — can support candidates who have the credential profile but lack upfront capital. Loan repayment and/or other financial incentives tied to rural or shortage-area service commitments can further align individual financial incentives with community needs.

A note on the Rural Health Transformation Program (RHTP). Colorado has secured up to $1 billion in federal RHTP funding over five years to strengthen health systems across the state’s 52 rural and frontier counties. While this initiative does not require RHTP funds, it can help Colorado meet the workforce goals RHTP is designed to achieve. The administration should engage the CO Department of Public Health and Environment to explore whether rural placement of ITPs can be recognized within Colorado’s RHTP implementation plan as a workforce strategy. This is not simply a funding ask: it is an opportunity to demonstrate to the Centers for Medicare and Medicaid Services that Colorado has an implementation-ready plan for activating the physician workforce in rural communities.

Recommendation 4. Launch employer outreach to build a pipeline of sponsoring institutions and connect IMGs and ITPs to available pathways.

A provisional licensure pathway is only as effective as the employer network ready to use it. The incoming administration should start building that network as soon as possible, so that willing sponsors are identified and the business case is established to support the bill and its implementation.

The Governor should direct a senior advisor (see Recommendation 5) to launch a targeted employer engagement campaign, working through the Colorado Hospital Association and the Colorado Rural Health Center as primary conveners. The campaign should identify health systems, rural hospitals, rural health clinics, and FQHCs willing to serve as sponsoring employers and make the business case directly; someone who becomes a permanent hire is substantially cheaper than a temporary physician and produces durable workforce gains. The shortage assessment commissioned under Recommendation 1 should drive targeting, concentrating outreach in the specialties and geographies where employer gaps are most acute.

In parallel, Colorado’s Office of New Americans, in partnership with stakeholders, should reach IMGs and ITPs through trusted community channels — immigrant-serving organizations, refugee resettlement networks, and professional associations — to map the eligible population and connect candidates to whichever pathway they are best positioned to enter.⁶ A single state-maintained landing page consolidating all pathway options, eligibility criteria, and contact points should be established to simplify navigation for both applicants and employers. Progress should be reported annually on the number of employer sponsors identified, individuals contacted, and candidates who entered each pathway.

Recommendation 5. Direct a senior advisor in the Governor’s office to sustain momentum through the 2027 legislative session and work with the legislature to create a statutory position in CDLE to coordinate longer-term implementation across agencies.

The four recommendations above require sustained coordination across at least five state agencies — CDPHE, CDLE, ONA, HCPF, and DORA/the Medical Board — as well as ongoing engagement with the legislature, health systems, immigrant-serving organizations, and philanthropic funders. Colorado’s current institutional arrangement has no single point of accountability for this work. Without a named senior official in the incoming Governor’s office with explicit responsibility for the health workforce (whose larger portfolio could be broader health or workforce issues), implementation could fragment across agencies and lose momentum.

The senior advisor should have explicit authority to coordinate across CDPHE, CDLE, ONA, HCPF, and DORA;⁷ convene the medical workforce coalition described above; and serve as the administration’s lead point of contact for legislative champions on the provisional licensure bill. The Governor and legislature should evaluate whether a more durable governance structure — a statutory position in CDLE that liaises with the Governor’s office, a permanent medical workforce function within CDPHE,⁸ and/or a statutory health workforce commission — is warranted to carry the initiative beyond a single administration.⁹

Conclusion

Colorado does not need to wait for the next generation of medical school graduates to begin closing its physician shortage. The workforce is already here — trained, experienced, and ready to serve the communities that need them most. The five recommendations in this memo build on the foundation Colorado established with HB22-1050, completing the architecture the legislature began with a provisional licensure pathway, a durable financing model, and the institutional leadership to drive it across the finish line.

The 2027 legislative session opens January 11. The incoming Governor has a narrow and favorable window to act — with cross-partisan support, a ready coalition, and peer states that have already proven the model works. A successful physician pathway also lays the groundwork for extending provisional licensure to nurses, behavioral health professionals, and others facing similar barriers. The race for talent is here and this initiative is a win that can jumpstart the Governor’s workforce leadership.

I’ve spent most of my career at the intersection of climate change and human health. During my 15 years in federal service, I helped build the scientific foundation for the government’s work on climate and health, stewarding the health work of the U.S. Global Change Research Program and directing the NIH’s Collaborating Centre for Environmental Health Sciences. In 2021, I took on a new challenge, establishing and leading the Health and Human Services (HHS) Office of Climate Change and Health Equity (OCCHE), to guide HHS and the whole-of-government strategy on climate and health. It was both the best opportunity of my professional life and the hardest thing I’ve ever done.

At OCCHE, we worked to meet that challenge with the relevant federal government levers. We built the country’s first seasonal health forecast, the Climate and Health Outlook, so communities could see hazards like heat and wildfire smoke before they arrived. We supported Centers for Medicare and Medicaid Services in enabling health systems to use microgrids as emergency backup power, opening the door to scaling clean energy. We launched the HHS-White House Health Sector Climate Pledge that drew commitments from 900 hospitals. We ran dozens of webinars to help the nation’s rural and safety net hospitals learn how to access vital Inflation Reduction Act funding. None of it was the whole answer, especially because we were never given sufficient resources for the work that needed to be done, but all of it showed that the capabilities and coordination were worth having.

OCCHE no longer exists. It was eliminated, along with much of the federal infrastructure built to address climate’s health threats. I won’t pretend that was easy to experience. But I have been in this field long enough to know that its most stubborn obstacle is not any single administration. It is attention, recognition, and political will. We need to build a durable coalition that can fight for sustained progress.

Ask people what worries them most right now, and they’ll say the cost of living and their livelihoods, not climate change. But those concerns are not separate. The heat that sends someone to the emergency room, the smoke that keeps a child home from school, the drought that drives up food prices, the storm that knocks out the power of a rural clinic: these are the moments when climate change stops being an abstraction and starts costing people money, time, and their health. This summer, none of that has been hypothetical. During the hottest month the country has ever recorded, towns across Washington fled from wildfires, combined heat and smoke waves across the Midwest and East Coast made it deadly to be outside, and critical water sources along the Colorado River hit their lowest levels ever.

When we lead with those costs, and with solutions that bring them down, we reach people who would never call themselves climate voters. A family whose home is weatherized stays cooler in a heat wave and pays less every month in energy bills. We too often treat health, climate and cost reductions as competing priorities. Done well in our space, they are one and the same investment.

The work has not stopped despite federal headwinds. States and local governments, health systems, researchers, community organizations, philanthropies, and private-sector partners are making progress on decarbonization and resilience, often more creatively than before. When I talk with them, I rarely hear a shortage of ideas or commitment. I hear about a shortage of cross-sector collaboration and resources. There is a need to bring stakeholders across the country together to co-develop a shared sense of priorities, identify better ways to collaborate, and articulate a practical strategy for building national capacity that can outlast any one office or administration. 

That is why I’ve taken on a new effort at the Federation of American Scientists, in partnership with the Aspen Global Change Institute’s Climate Reserve, to strengthen America’s climate-health capacity. We are bringing together leaders to look honestly at where the climate and health field stands and where we can accelerate progress together. We will map where capabilities have been diminished, identify the state, local, and private-sector models worth scaling, and build a shared strategy for coordinated action. That means taking on some of the hardest pieces: building trust amidst groups with different perspectives, identifying opportunities where political will, capacity and impact align, and creating a pipeline of sustainable funding for work at the climate and health nexus. 

I believe by working together, we can reduce pollution from a health system responsible for roughly 8.5 percent of U.S. greenhouse gas emissions, strengthen the resilience of hospitals, community clinics, and nursing homes, support the health and social services workforce, restore the data and early-warning systems that let us anticipate risk, and direct investment toward building healthy, thriving communities. And in the process we can reduce operating expenses for health care facilities and improve the health of everyone in the country.  These are the capabilities a changing climate demands of us, and they are well within our reach.

OCCHE was a beginning, not a finished model. We need to define the capabilities the nation needs to protect health in a changing climate, and to make sure they exist and can be used, wherever they ultimately live. America has extraordinary expertise in climate and health. The work ahead is to turn that expertise into coordinated national capacity and into the connections that make it useful when a community needs it most.

If your organization is working on climate and health, I would like to hear from you. This is a moment for building, let’s do it together.

Can you estimate someone’s cancer risk from the air they breathe? Not exactly. Every person has different genetics, lifestyles, occupations, and environmental exposures that change over time. Air pollution varies from day to day, season to season, and even block to block. But scientists can make remarkably reliable estimates of a neighborhood’s cancer risk based on the type and amount of toxic air pollution.

After a year-long delay, this April, EPA released the latest air toxics data, which only included raw air data downloads. This year, for the first time in nearly 25 years, the air toxics data did not include cancer risk estimates. 

Without a public explanation or opportunity for input, one of the nation’s most important environmental health datasets has quietly gone dark. 

The disappearance of EPA’s cancer risk data continues a broader trend under this administration of environmental, public health, and other government datasets becoming less available, less complete, or more difficult to access.  

What’s Changed?

For the 2021 data (this most recent release), only raw air emissions and concentration data are available for download. Previously, the EPA also produced detailed explanations and a mapping tool that made the data easier to discover, understand, and use. Additionally, they included cancer risk estimates to help translate data and complex scientific models into information the public could understand. 

Now, if users want to understand cancer risk from air pollutants, they will need to download and analyze detailed air concentrations of nearly 200 toxic air pollutants for more than 8 million individual locations. 

Researchers and geospatial data professionals can navigate government databases, process large datasets, and build custom analyses or maps. Everyone else relies on easy-to-use websites, interactive maps, and plain-language explanations to understand the environmental conditions affecting their communities. 

Data hidden behind obscure downloads may satisfy a technical definition of transparency, but they do little to promote public understanding, meaningful community engagement, or actions to save lives.

Why Cancer Data Matter

Cancer affects nearly every family in the country, and the United States has one of the highest cancer incidence rates in the world. Understanding where people face higher exposure to cancer-causing pollutants is a key step toward reducing preventable risks.

Most people have no easy way of knowing what hazardous pollutants are being released into the air around their homes, schools, or workplaces. Air toxics are often invisible, odorless, and linked to health effects that can take years or even decades to develop. EPA’s cancer risk estimates gave communities, local governments, researchers, and others a way to identify areas where cancer risks from air pollution may be elevated and where action or additional monitoring might be needed. 

History of Cancer Risk Data

The Clean Air Act lists nearly 200 toxic air pollutants known to cause cancer or other serious health effects, and requires reporting of these emissions by facilities. Amendments in 1990 directed the EPA to establish risk standards for any source emitting a cancer-causing pollutant that poses a lifetime risk of cancer of more than one-in-a-million.

EPA began publishing nationwide cancer risk estimates from hazardous air pollutants in 2002 with the first release of the National Air Toxics Assessment (NATA). These cancer risk estimates took hazardous air pollutants information from across the country (using facility emissions, vehicles, and other pollution sources), and combined them together with atmospheric modeling and toxicological research, making the data easier for the public to understand and use. This dataset became a core component of EPA’s mapping applications and was incorporated into numerous federal, state, academic, and community tools. Like any national-scale model, the NATA cancer risk data had limitations. It relied on emissions inventories, many of which were self-reported by industry, and modeled pollution levels for some locations, rather than direct air monitoring. It could not fully capture localized conditions or cumulative exposures, and the results often lagged several years behind current conditions. But public feedback on those limitations also inspired continuous improvements. 

Over time, EPA scientists improved the quality of the pollution data, updated what scientists know about the health effects of toxic chemicals, and made the models more accurate. In 2022, the agency rebranded the program as the Air Toxics Screening Assessment or AirToxScreen, making the data more accessible and actionable through a dedicated mapping platform. With EPA having done the heavy lift of creating cancer risk estimates, other organizations can incorporate them into local processes. For example, New Jersey’s Environmental Justice, Mapping, Assessment, and Protection Tool (EJMAP) uses cancer risk data to help evaluate the cumulative impacts of facilities before approving or renewing permits.

Communities Impacted by Air Pollution-Related Cancer

Perhaps nowhere are both the strengths and limitations of these EPA data more apparent than in Louisiana’s Cancer Alley. This 85-mile industrial corridor along the Mississippi River contains one of the highest concentrations of petrochemical facilities in the United States, accounting for roughly one-quarter of the nation’s production. Residents have spent decades raising concerns about pollution and unusually high cancer rates. Here, some communities experience estimated lifetime cancer risks from toxic air pollution up to 50 times higher than the national average, and more than 47 times higher than EPA’s acceptable cancer risk benchmark. These findings have helped draw national attention to environmental justice concerns and have even prompted international human rights scrutiny. 

At the same time, Cancer Alley demonstrates why screening and mapping tools alone are not enough. AirToxScreen is based largely on emissions inventories and modeling assumptions. It cannot fully account for cumulative exposures across multiple pathways, capture every emission event, or reflect neighborhood-scale differences that can vary dramatically within a city. Similar concerns have been raised by communities along the Houston Ship Channel, Chicago’s industrial corridors, and other heavily burdened areas across the country. 

For these communities, data like AirToxScreen’s cancer risk estimates are an essential first step, but need to be accompanied by direct air monitoring, epidemiological research, or community-based science. And data need to be tied to action, such as strong environmental enforcement, in order to reduce Americans’ exposure to cancer-causing chemicals.

Additional Issues and Concerns

The disappearance of EPA’s cancer risk estimates comes at a time when protections against hazardous air pollutants are also under increasing pressure. The current administration has proposed rolling back or reconsidering several air toxics regulations, including standards for pollutants such as ethylene oxide, one of the largest contributors to cancer risk from industrial emissions. 

At the heart of many of these proposals is a broader debate over what level of cancer risk should be considered acceptable and how that risk should be calculated. Loosening these standards does not reduce the amount of pollution in the air or the health risks facing nearby communities. Instead, it changes how those risks are defined and regulated. Combined with the loss of publicly available cancer risk estimates, these policy changes make it more difficult for communities to understand, communicate, and respond to the environmental health risks they face. 

What’s the Data Policy Angle?

For more than two decades, EPA scientists steadily improved these estimates despite chronic underfunding, changing regulations, and shifting political priorities. Those challenges have only intensified with the dismantling of EPA’s Office of Research and Development and the erosion of scientific capacity across the agency. 

EPA’s cancer risk data, though imperfect, has been an indispensable resource for researchers studying environmental disparities, journalists uncovering pollution hotspots, regulators prioritizing inspections, and communities advocating for cleaner air. 

Now, the cancer risk estimate data so many depend on has disappeared. There was no public notice, no opportunity for public comment, and no consultation with one of several terminated scientific federal advisory committees. 

The lack of public engagement is a policy problem.

The Open Government Data Act (OGDA), signed by President Trump in his first term, and subsequent OMB Guidance in M-25-05 include explicit requirements that agency data stewards engage with public stakeholders to understand the value of federal data, and ways it could be improved to better serve the needs of the American people.

OGDA and M-25-05 also unambiguously state that agencies:

• shall assist “the public in expanding the use of public data assets”; and
•  “must provide adequate notice when initiating, substantially modifying, or terminating significant information dissemination products.”

The disappearance of EPA’s cancer risk data is just the most recent signal that the current patchwork of federal data policies is increasingly unprepared to address the challenges and opportunities facing our nation.

These are exactly the types of issues that the FAS Data Policy Institute is taking on, because cancer risk does not go away when the data disappear.

Cancer risk does not disappear because the data does.

It’s here! After months of delay, the council tasked by President Trump to review the Federal Emergency Management Agency (FEMA) released its final report earlier this month. 

If you’re not a disaster policy nerd like we are, here’s some quick background.

Up until the founding of FEMA in 1979 under President Jimmy Carter, disaster response in the United States was largely disorganized and reactive. The agency has since gone through several major updates. Passage of the Robert T. Stafford Act in 1988 established the formal mechanism for disaster declarations and federal disaster response, while in the years following the 9/11 attacks FEMA transitioned from an independent cabinet agency to part of the newly established Department of Homeland Security. 

Recently, FEMA has come under intense scrutiny from the second Trump administration for being seen as ineffective, bureaucratic, and in some cases politically biased against him. While FEMA has had issues in the past related to delayed response times and survivors receiving aid (and criticism with how it handled Hurricane Maria), reports show that many of these issues may be related to an increase in major disasters due to climate change, as well as a lack of regular training, sufficient funding, and adequate staffing – rather than structural issues with the agency. In addition, traditionally “red” states (like Texas, Louisiana, and Florida) typically receive more FEMA funding due to the amount of disasters they experience, so claims of political bias are largely unfounded. 

Yet when Trump took office for the second time, there were calls to get rid of FEMA altogether. However, after pushback from citizens and lawmakers and several major disasters, the aforementioned council has opted to avoid recommending completely dismantling the agency. Instead, the council proposes major changes to the way FEMA operates (the council repeatedly refers to a “transformed agency”), via ten general recommendations. Here’s our quick snapshot of the good, the bad, and the ugly of these recommendations, with more detail below:

• The Good: An emphasis on mitigation and streamlining the application process for disaster survivors, along with a focus on getting money to states and survivors quicker.
• The Bad: Shrinking and privatizing most of the National Flood Insurance Program (NFIP), while slashing overall federal funding for disaster response and recovery.
• The Ugly: An unrealistically short timeline for implementing recommendations in the report, as well as a reductionist approach to how disasters enact damage.

Also, a quick note on the United States’ approach to disasters: there is generally an overemphasis on acute economic impacts, and not what they do to systems as a whole long-term. As many disaster researchers will tell you, while hazards can be natural, disasters are not. Disasters are the result of hazards adversely impacting people and their communities due to decisions that increase vulnerability and risk exposure. If we limit our approach to disaster recovery to include only economies and infrastructure, we’ll tend to overlook other critical factors, like public health, social connection, and community wellbeing, that contribute to these vulnerabilities. Just because a house has been rebuilt or power has been restored does not mean recovery has been achieved. Before we implement sweeping changes to the agency responsible for disaster response, it’s important that we as a nation consider this in our approach to disasters.

With that aside, onto the deeper dive into the good, the bad, and the ugly of the review council’s report.

The Good

First, the council re-emphasizes FEMA’s core mission of “[reducing] the loss of life and property and [protecting] the Nation from all hazards”, with the guiding principle of disaster response being “locally executed, state or tribally managed, and federally supported”. This is in line with the survivor-led response approach that many local recovery groups have recommended. Communities have the local knowledge and boots-on-the-ground presence needed to ensure that recovery efforts are appropriate for their situations and contexts, but often lack the funding to implement tailored solutions. The council suggests that FEMA strengthen regional coordination, which could in turn support community- and survivor-led response. 

Another positive is the council’s emphasis on rapid mitigation and hardening support to increase efficiency and prevent damage from future disasters. This includes modernizing the federal disaster response by implementing the National Resilience Strategy and updating flood risk information and land use to prevent building in flood plains, both common-sense solutions that can prevent the worst damage from disasters before they even occur. They additionally recommend a two-phase program that would replace the Hazard Grant Mitigation Program (HGMP) with a new program designed to more rapidly distribute federal funding to states (the first 5% of federal funds within the first 30 days following a disaster declaration, followed by an additional 10% within six months). The council calls this new program the “Refined Risk Reduction” Program (R3P), and could potentially address issues survivors have brought up with administrative burden around disaster aid, such as by modifying the Individual Assistance Program and consolidating relief applications into a single direct payment program. There are also specific relief allocations for renters (who often get left out of recovery discussions), including the equivalent of three to six months of rent.

Finally, a recommendation could be either positive or negative (depending at least partially on the details of implementation) is changing how surviving homeowners get reimbursed for individual assistance, including how the amounts are calculated. Currently, home repair assistance payments are capped at $25,000 and based on loss estimates, regardless of property value. The council suggests changing this cap to no more than 15% of the home valuation (so a home valued at $250,000 would qualify for a maximum payment of $37,500), but expanding the purpose of such payments to cover everything from home repairs to funeral costs – i.e., requiring the payments to stretch further than they do currently. Another issue is that FEMA funding has been found to favor wealthier individuals, and basing funding on home valuation has the potential to further drive disparities in aid. Supplemental funding opportunities and/or proactive aid and assistance for lower-income families could potentially reduce this risk.

The Bad

Perhaps the most concerning recommendation of the council is its call for a “lean FEMA workforce”. While the council is less aggressive overall in demanding FEMA staffing reductions than previous drafts (and now just calls for a strategic review of requirements to “determine appropriate staffing levels”), further staffing reductions could exacerbate issues we’re already seeing with FEMA from previous personnel cuts. Disaster survivors have also condemned further FEMA staffing cuts. The council also suggests adjusting how insurance rates are calculated under the National Flood Insurance Program (NFIP) and shifting more flood insurance policies to private markets, which could prohibitively increase premiums, decrease regulation, and lead to more uninsurance and underinsurance in risk-prone areas unless there are appropriate safety measures in place. 

Finally, the council recommends decreasing the overall federal share of disaster assistance funding from 75–100% to 50–75% of costs, with states expected to cover the rest. Many states do not have resources to cover the difference – at least in the near term. With a sufficient transition period, though, more heavily weighting state responsibility for disaster aid may increase sustainability in the long term given that the Disaster Relief Fund repeatedly runs low on funds, and that there are concerns with fund depletion as disasters continue to increase in frequency and severity. Another concern is the council’s prioritization of “high performing states”. While this would encourage more states to have hazard mitigation plans in place, it could result in biased decision-making that would favor certain states, and may leave states with fewer financial resources or rare disaster occurrence with less support when it’s most needed.

The Ugly

The biggest overall issue with the council’s suggestions is that they recommend a 2–3 year timeline for states and tribal governments to prepare their fiscal and physical resources to lead disaster response efforts (rather than relying on FEMA). This is an unrealistic timeline, as many states do not currently have sufficient emergency management resources, legislation to establish and support relief funding, or identified revenue streams to pay for the increased cost-share for states. And on top of that, some state governments (like Texas) only meet every two years, making the 2-3 year timeline impossible. Another issue with the council is the apparent bias in its makeup. While it did include representatives with leadership and emergency management experience from hard-hit states like Florida, Texas, Louisiana, Mississippi, and Virginia, there was a notable lack of members from other disaster-prone parts of the country, like California.

Another problem is the council’s recommendation of using a parametric insurance program to replace FEMA’s current Public Assistance Program (the main funding source for community-level disaster recovery). Parametric insurance is a type of insurance where payments are disbursed almost immediately following certain trigger events, and while it has demonstrated potential in rapidly distributing funds after certain hazardous events, there are too many variables to feasibly consider replacing the entire Public Assistance Program in 2-3 years. For example, the council includes an example of determining payment amounts by hurricane category (e.g.,: a Category 2 hurricane would disburse less funds than a Category 4). However, hurricane categories are based on wind speed alone, and hurricanes with weaker winds can still do extensive damage through other means, like storm surge and rainfall (Hurricane Ike in 2008 and Hurricane Harvey in 2017 are two such examples). These complexities would have to be accounted for when establishing the thresholds of a parametric insurance framework, and without rigorous pilot testing, runs the risk of over or underpaying states following disasters.

One final concern is the council made no mention whatsoever of the BRIC (Building Resilient Infrastructure and Communities) grant program. This absence from the report likely means BRIC is not a priority for current leadership, despite it being one of the largest sources for proactive mitigation funding for states and communities. BRIC has been the subject of much consternation following its abrupt cancellation in April of 2025 and its later reinstatement in March of 2026 (following a lawsuit from several states). However, there is now a heavy focus on “shovel-ready projects” (i.e. physical infrastructure projects that have already been planned out). While this sounds good for efficiency, as we noted earlier, not all infrastructure critical to community wellbeing and recovery is physical and “shovel-ready”. Things like social and public health infrastructure are just as important for disaster recovery, but tend to be overlooked in recovery efforts. In limiting BRIC funding to these types of projects, states and local governments will be unable to be truly proactive in their mitigation efforts to prevent future damage from disasters. 

Conclusion

The review council’s recommendations are not as bad as they could have been and FEMA’s continued existence seems to be safe (for now). Indeed, many of the recommendations could yield positive results, especially when it comes to reducing the burden and obstacles that survivors face in getting help. However, some of the recommendations (like using parametric insurance methods, reducing state assistance, and attempting to implement sweeping changes over a fast 2–3 year timeline) could pose problems for states, communities, and survivors, and a longer transition period with pilot testing will be needed to ensure these changes happen efficiently and effectively. 

2025 was a costly extreme weather year. January kicked off with the Palisades and Eaton wildfires, which caused an estimated 31 deaths in Los Angeles County and billions of dollars in economic damages. Texas experienced some of its worst flooding in decades in July, resulting in the deaths of more than 100 people, many of whom were children staying at an overnight summer camp. In October, flooding in Alaska led to at least one person’s death and the displacement of more than 1,500 others as whole villages were inundated from the remnants of Typhoon Halong. 

However, even though 2025 is over, the effects of these disasters are not. 

There is considerable interest from both sides of the political aisle in reforming FEMA. The reform conversation has largely focused on where responsibility for disaster response should sit – with the federal government, or with the states? But from a public health perspective, we should be talking about something even more important: our hyperfocus on short-term disaster effects that causes us to neglect the longer-term needs of disaster-affected survivors and communities.

Disasters create ripple effects on health that can extend into the months, years, and even decades after fires are put out, winds die down, and floodwaters recede. While these effects are hard to precisely measure, they are undeniably potent. Official data, for instance, indicate that hurricanes and other tropical cyclones cause an average of 24 deaths per storm. That number is too high – every death is a tragedy – but it pales in comparison to the 7,000 – 11,000 deaths that studies estimate actually come from storms’ longer-term consequences.

With extreme weather events becoming ever-more common, there is a national and moral imperative to rethink not just who responds to disasters, but for how long and to what end. This issue brief presents an overview of the ways in which disasters affect public health and well-being in the long term, as well as suggestions for disaster governance reform viewed through a public health lens.

Disasters impose sustained effects on physical and mental health

The evidence is clear: disasters cause suffering that persists long after national attention turns elsewhere. The same study cited above also found that the adverse health effects of hurricanes and other tropical cyclones were most pronounced in infants under the age of one almost two years after a given storm. If you do the math, this means the storms continued to increase the infants’ risk of death despite them not having even been conceived at landfall, suggesting that the true damage from hurricanes (and likely other natural hazards) comes from the stress they put on families and communities. This doesn’t just apply to infants, but other vulnerable groups, such as older adults. For example, older adults who lived through Superstorm Sandy had higher risks of cardiovascular disease and all-cause mortality five years after the storm had passed. 

Why do exposures to extreme weather events have these long-term health impacts? More research is needed, but so far at least three likely pathways have been identified.

Disasters can expose survivors to hazardous conditions that increase their risk of chronic illnesses. For example, hazardous particles from wildfire smoke can settle into people’s lungs and negatively affect lung function for years, which is especially dangerous when individuals have pre-existing respiratory conditions like asthma or COPD. This decreased lung function has been shown to last at least two years after the wildfire for some individuals. Individuals living in high-risk areas where wildfires frequently occur may never get the chance to fully recover. 

The physical damages from a disaster to the built and natural environments that surround survivors can become hazardous to human health. For instance, when disasters knock out power during a heatwave or cold snap, individuals can be exposed to dangerous temperature extremes. Heatwaves alone can increase the risk of chronic kidney disease, and can even make the body age faster, while those who have experienced heat illness and heat stroke are at risk of organ damage, including damage to the brain. Other disasters can spread harmful toxins. Floodwaters often contain hazardous waste from runoff and sewage system overflow, increasing the risk of illness in the months following the flood. Homes and businesses that flooded are also at risk of growing toxic mold, especially in warm and humid environments (like the hurricane-prone Southeast United States). What is especially challenging about mold is that it can be difficult to detect and can persist for years unless treated, leading to families living in toxic environments without ever knowing it. Exposure to mold increases the risk for various diseases and health problems, including asthma attacks and infections, and are particularly concerning for sensitive individuals, like those who are immunocompromised. Similarly, when wildfires burn houses, vehicles, and other infrastructure, this releases toxic ash and other debris into the air for hundreds of miles, contaminating the lands and waters of communities for years. Airborne toxins released during wildfires can settle on indoor surfaces and in heating, ventilation, and air conditioning systems. These harmful exposures can contribute to serious long-term health conditions like cardiovascular and respiratory diseases and cancer. 

Living through a disaster and then navigating a byzantine recovery landscape can contribute to chronic stress that takes a toll on mental and physical health. Several studies suggest that exposure to disasters increases the risk of mental health challenges like depression, anxiety, and post-traumatic stress, affects people of all age groups, including children, and can last for years. One study found that survivors of Hurricane Katrina were still dealing with post-traumatic stress symptoms twelve years later. Poor mental health can lead to poor physical health in the long term (such as an increased risk of chronic diseases and premature death), as people deal with the toll chronic stress can have on the body. This stress can also increase risk of cognitive decline and dementia, and considering that chronic stress is common among disaster survivors, it’s no wonder that wildfires, hurricanes, and heat waves have all been found to be associated with cognitive decline and dementia too.

Disasters disrupt healthcare delivery and operations

Access to healthcare, including going to doctor’s appointments, getting prescription refills, and receiving specialty treatment (like chemotherapy or dialysis), is critical for keeping people healthy and maintaining quality of life. Unfortunately, disasters often displace people from their homes, communities, and from the healthcare services they depend on. For many people, displacement after a disaster is permanent. These people must then navigate entirely new environments, find new healthcare providers, and become re-established with the medical system all the while securing a place to live, meeting their other needs, and dealing with the stress of losing their life as they knew it. Medical care often falls to the wayside in the chaos of disaster recovery, leaving survivors vulnerable to worsening health conditions over time.

Disasters often displace people from their homes, communities, and from the healthcare services they depend on. Take for instance, these flooded homes adjacent to the Red River in North Dakota, via Wikimedia Commons

Even if displacement is only temporary, when residents return to their homes and communities they may find that their healthcare options no longer exist, as disasters can disrupt or destroy entire healthcare systems. Damaged clinics and hospitals may be temporarily or permanently shut down, creating healthcare “deserts” that lack sufficient healthcare infrastructure to treat people. Rural areas are particularly vulnerable to these disruptions, as they already face limited budgets and fewer resources – leaving less “cushion” to absorb disaster impacts. Disasters can also disrupt supply chains, impacting the quality of medical care for entire regions. This occurred when Hurricane Helene flooded one of the major medical IV suppliers in the United States, leading to IV shortages at healthcare facilities that persisted even months after the hurricane. 

Disasters drive housing insecurity

Having an affordable and stable place to live is one of the most important social determinants of health. Access to housing that is safe, clean, and sheltered from the elements can affect everything from risk of hospitalization, the number of medications someone takes, mortality, and overall quality of life. Unfortunately, housing is also one of the most vulnerable and deeply personal domains to be affected by disasters. Many are forced to flee from fires, floods, high winds, or other dangerous conditions presented by natural hazards, and people can be displaced from their homes for months or years at a time – or even permanently. This displacement is associated with numerous mental and physical health issues, including risk of death. And as insurance premiums continue to increase or insurance companies withdraw from states altogether because of the increasing frequency and intensity of disasters, homeowners may be unable to afford property insurance altogether in the near future, further reducing the chances of ever being able to return home. 

Even for those who could return home, the cost of recovery may be too prohibitive. For wildfire survivors, many insurance companies do not include smoke damage testing and remediation costs under their policies, and even some plans that cover smoke damage may refuse to remediate, which can cost thousands of dollars out-of-pocket. For flood survivors, mold can be difficult to detect and may require the services of a professional cleaner, which can be prohibitively expensive. Even if someone has flood insurance through the National Flood Insurance Program (NFIP), mold remediation is not typically covered, creating barriers for people trying to make their homes healthy to live in again. If someone’s insurance plan covers mold remediation, many plans make exceptions if action to prevent mold growth is not taken in the immediate days after the flood, which can pose a problem for those blocked from returning under emergency orders. These policy barriers result in survivors having to either relocate away from their homes and communities, or continue to live in unsafe conditions that can chronically affect their health.

Opportunities for Action

Our nation needs policies that understand and address the true public health effects of disasters over the months and years after the disaster is technically “over”. Opportunities for action include:

Update how health impacts are measured. Tracking of health impacts from disasters is generally limited to the direct impacts of disasters (i.e., injuries and deaths, like drownings from floods and smoke asphyxiation from wildfires). Few official data sources capture the indirect effects of disasters that take more time to manifest. Impact assessments should include epidemiological methodology that can capture these indirect effects, such as excess death calculations, to begin to truly understand and quantify the extent of disasters on peoples’ health.

Reinstate disrupted grants and other funding for health research relevant to disasters. Recent budget cuts, terminated grants, and increased hostility towards public health threaten our ability to understand – and therefore effectively address – the health impacts of disasters. Policymakers should reinstate such funding, and look for opportunities to prioritize research related to the longer-term and often overlooked impacts.

Invest in the physical resilience of healthcare infrastructure. Investments in the physical resilience of healthcare infrastructure (such as the installation of hurricane-proof glass, flood barriers, air filtration systems, etc.) strengthens disaster resilience and reduces the overall health impacts of disasters in the short and long terms. Studies show that these investments pay off in the long run, with every dollar dedicated to resilience yielding multiple dollars in avoided societal costs – and providing strong justification for state and federal resources to catalyze and support such investments.

Strengthen medical supply chains. The Strategic National Stockpile (SNS) provides a critical reserve of essential medical equipment, buffering health supply chains against disruptions from events like disasters. Congress should act to increase the SNS, particularly in locations that could provide rapid response of medical provisions to disaster-affected areas, and ensure that key medical suppliers are adequately prepared for future disasters.

Help with housing. One of the most efficient and effective means of disaster recovery is ensuring survivors have access to stable, safe, and healthy housing. One way to achieve this is by creating a centralized agency or entity (such as the Joint County-State Housing Task Force established in the wake of the 2025 Los Angeles wildfires) to handle housing-specific needs from disasters and for those displaced. At the federal level, this could look like integration of housing-relevant capabilities and authorities across agencies such as the Federal Emergency Management Administration (FEMA, particularly FEMA’s National Flood Insurance Program), the Department of Housing and Urban Development, and the Small Business Administration. Other options could include streamlining access to housing relief funds (such as by creating a consolidated hub for applications for assistance), creating pre-approved resilient home designs that can be fast-tracked for permitting and construction, and establishing well-defined responsibilities for remediation efforts, including cleaning of contaminated lands and homes. (Note: many of these issues are addressed in the proposed FEMA Act of 2025.)

Support on-the-ground efforts. Federal and state agencies can support nonprofit rapid response teams (such as SBP) equipped with cleaning and rebuilding supplies. These teams can be rapidly organized and deployed to mitigate physical damage from disasters, making it faster and safer for survivors to return home. As these teams often include members of affected communities, they often have a deep understanding of what the needs of survivors truly are, enabling more efficient use of resources. 

Conclusion

Disaster survivors want reform – but drastically reducing FEMA’s workforce without investing in any new disaster-response capabilities isn’t the type of reform they want. Rather, survivors are looking for leaders to institute more holistic disaster-governance strategies that include efforts to minimize long-term negative impacts, instead of the drop-in/rapid withdrawal pattern historically demonstrated. If we are to make (and keep) Americans healthy, then it’s time to make sure considerations for the long-term health needs of disaster survivors are being met, even after the winds, floods, and fires are gone. 

Despite spending over 17% of GDP on health care, Americans live shorter and less healthy lives than their peers in other high-income countries. Rising chronic disease and mental health challenges as well as clinician burnout expose the limits of a system built to treat illness rather than create health. Addressing chronic disease while controlling healthcare costs is a bipartisan goal, the question now is how to achieve this shared goal? A policy window is opening now as Congress debates health care again – and in our view, it’s time for a “whole health” upgrade.

Whole Health is a proven, evidence-based framework that integrates medical care, behavioral health, public health, and community support so that people can live healthier, longer, and more meaningful lives. Pioneered by the Veterans Health Administration, Whole Health offers a redesign to U.S. health and social systems: it organizes how health is created and supported across sectors, shifting power and responsibility from institutions to people and communities. It begins with what matters most to people–their purpose, aspirations, and connections–and aligns prevention, clinical care, and social supports accordingly. Treating Whole Health as a shared public priority would help ensure that every community has the conditions to thrive. 

Figure 1. Whole Health from Framework to Practice.

Whole Health is a systems framework that aligns health care, public health, and community & social systems to create the conditions for well-being. Guided by five principles–People-Centered, Upstream-Focused, Equitable & Accountable, Comprehensive & Holistic, and Team Well-Being–the framework is put into practice through models such as the VHA Whole Health System, which centers on Meaning and Purpose and operates through three core functions: Empower, Equip, and Care.

(Adapted from the National Academies of Sciences, Engineering, and Medicine, Achieving Whole Health, 2023, and the Department of Veterans Affairs, Office of Patient Centered Care and Cultural Transformation, 2019).

Challenge and Opportunity

The U.S. health system spends over $4 trillion annually, more per capita than any other nation, yet underperforms on life expectancy, infant mortality, and chronic disease management. The prevailing fee-for-service model fragments care across medical, behavioral, and social domains, rewarding treatment over prevention. This fragmentation drives costs upward, fuels clinician burnout, and leaves many communities without coordinated support.

At this inflection point in our declining health outcomes and growing public awareness of the failures of our health system, federal prevention and public health programs are under review, governors are seeking cost-effective chronic disease solutions, and the National Academies is advocating for new healthcare models. Additionally, public demand for evidence-based well-being is growing, with 65% of Americans prioritizing mental and social health. There is clear demand for transformation in our health care system to deliver results in a much more efficient and cost effective way.

Veterans Health Administration’s Whole Health System Debuted in 2011

Whole Health offers a system-wide redesign for the challenge at hand. As defined by the National Academies of Sciences, Engineering, and Medicine, Whole Health is a framework for organizing how health is created and supported across sectors. It integrates medical care, behavioral health, public health, and community resources. As shown in Figure 1, the framework connects five system principles—People-Centered, Upstream-Focused, Equitable & Accountable, Comprehensive & Holistic, and Team Well-Being–that guide implementation across health and social support systems. The nation’s largest health system, the Veterans Health Administration’s (VHA), has demonstrated this framework in clinical practice through their Whole Health System since 2011. The VHA’s Whole Health System operates through three core functions: Empower (helping individuals define purpose), Equip (providing community resources like peer support), and Clinical Care (delivering coordinated, team-based care). Together, these elements align with what matters most to people, shifting the locus of control from expert-driven systems to shared agency through partnerships. The Whole Health System at the VHA has reduced opioid use and improved chronic disease outcomes.

Successful State Examples

Beyond the VHA, states have also demonstrated the possibility and benefits of Whole Health models. North Carolina’s Healthy Opportunities Pilots extended Medicaid coverage to housing, food, and transportation, showing fewer emergency visits and savings of about $85 per member per month. Vermont’s Blueprint for Health links primary care practices with community health teams and social services, reducing expenditures by about $480 per person annually and boosting preventive screenings. Finally, the Program of All-Inclusive Care for the Elderly (PACE), currently being implemented in 33 states, utilizes both Medicare and Medicaid funding to coordinate medical and social care for older adults with complex medical needs. While improvements can be made to national program-wide evaluation, states like Kansas have done evaluations that have found that the PACE program is less expensive than nursing homes per beneficiary and that nursing home admissions decline by 5% to 15% for beneficiaries. 

Success across each of these examples relies on three pillars: (1) integrating medical, behavioral, social, and public health resources; (2) sustainable financing that prioritizes prevention and coordination; and (3) rigorous evaluation of outcomes that matter to people and communities. While these programs are early signs of success of Whole Health models, without coordinated leadership, efforts will fragment into isolated pilots and it will be challenging to learn and evolve.

A policy window for rethinking the health care system is opening. At this national inflection point, the U.S. can work to build a unified Whole Health strategy that enables a more effective, affordable and resilient health system. 

Plan of Action

To act on this opportunity, federal and state leaders can take the following coordinated actions to embed Whole Health as a unifying framework across health, social, and wellbeing systems.

Recommendation 1. Declare Whole Health a Federal and State Priority.

Whole Health should become a unifying value across federal and state government action on health and wellbeing, embedding prevention, connection, and integration into how health and social systems are organized, financed, and delivered. Actions include:

• Federal Executive Action. The Executive Office of the President should create a Whole Health Strategic Council that brings together Veterans Affairs (VA), Health and Human Services (e.g. Centers for Disease Control and Prevention, Centers for Medicare and Medicaid (CMS), and Health Resources and Services Administration (HRSA)), Housing and Urban Development (HUD), and the U.S. Department of Agriculture (USDA) to align strategies, budgets, and programs with Whole Health principles through cross-agency guidance and joint planning. This council should also work with Governors to establish evidence-based benchmarks for Whole Health operations and evaluation (e.g., person-centered planning, peer support, team integration) and shared outcome metrics for well-being and population health.
• U.S. Congressional Action. Authorize whole health benefits, like housing assistance, nutrition counseling, transportation to appointments, peer support programs, and well-being centers as reimbursable services under Medicare, Medicaid and the Affordable Care Act health subsidies.
• State Action. Adopt Whole Health models through Medicaid managed-care contracts and through CDC and HRSA grant implementation. States should also develop support for Whole Health services in trusted local settings such as libraries, faith-based organizations, senior centers, to reach people where they live and gather.

Recommendation 2. Realign Financing and Payment to Reward Prevention and Team-Based Care.

Federal payment modalities need to shift from a fee-for-service model toward hybrid value-based models. Models such as per-member-per-month payments with quality incentives, can sustain comprehensive, team-based care while delivering outcomes that matter, like reductions in chronic disease and overall perceived wellbeing. Actions include:

• Federal Executive Action. Expand Advanced Primary Care Management (APCM) payments to include Whole Health teams, including clinicians, peer coaches, and community health workers. Ensure that this funding supports coordination, person-centered planning, and upstream prevention, such as food as medicine programs. Further, CMS can expand reimbursements to community health workers and peer support roles and standardize their scope-of-practice rules across states.
• U.S. Congressional Action. Invest in Medicare and Medicaid innovation programs, such as the CMS Innovation Center (CMMI), that reward prevention and chronic disease reduction. Additionally, expand tools for payment flexibility, through Medicaid waivers and state innovation funds, to help states adapt Whole Health models to local needs.
• State Action. Require Medicaid managed-care contracts to reimburse Whole Health services, particularly in underserved and rural areas, and encourage payers to align benefit designs and performance measures around well-being. States should also leverage their state insurance departments to guide and incentivize private health insurers to adopt Whole Health payment models.

Recommendation 3. Strengthen and Expand the Whole Health Workforce. 

Whole Health practice needs a broad team to be successful: clinicians, community health workers, peer coaches, community organizations, nutritionists, and educators. To build this workforce, governments need to modernize training, assess the workforce and workplace quality, and connect the fast-growing well-being sector with health and community systems. Actions include:

• Federal Executive Action. Through VA and HRSA establish Whole Health Workforce Centers of Excellence to develop national curricula, set standards, and disseminate evidence on effective Whole Health team-building. Further, CMS should track workforce outcomes such as retention, burnout, and team integration, and evaluate the benefits for health professionals working in Whole Health systems versus traditional health systems.
• U.S. Congressional Action. Expand CMS Graduate Medical Education Funds and HRSA workforce programs to support Whole Health training, certifications, and placements across clinical and community settings.
• State Action. As a part of initiatives to grow the health workforce, state governments should expand the definition of a “health professional” to include Whole Health practitioners. Further, states can leverage their role as a licensure for professionals by creating a “whole health” licensing process that recognizes professionals that meet evidence-based standards for Whole Health.

Recommendation 4. Build a National Learning and Research Infrastructure.

Whole Health programs across the country are proving effective, but lessons remain siloed. A coordinated national system should link evidence, evaluation, and implementation so that successful models can scale quickly and sustainably.

• Federal Executive Action. Direct the Agency for Healthcare Research and Quality, National Institutes of Health, and partner agencies (VA, HUD, USDA) to run pragmatic trials and cost-effectiveness studies of Whole Health interventions that measure well-being across clinical, biomedical, behavioral, and social domains. The federal government should also embed Whole Health frameworks into government-wide research agendas to sustain a culture of evidence-based improvement.
• U.S. Congressional Action. Charter a quasi-governmental entity, modeled on Patient-Centered Outcomes Research Institute (PCORI), to coordinate Whole Health demonstration sites and research. This new entity should partner with CMMI, HRSA and VA to test Whole Health payment and delivery models under real-world conditions. This entity should also establish an interagency team as well as state network to address payment, regulatory, and privacy barriers identified by sites and pilots.
• State Action. Partner with federal agencies through innovation waivers (e.g. 1115 waivers and 1332 waivers) and learning collaboratives to test Whole Health models and share data across state systems and with the federal government.

Conclusion

The United States spends more on health care than any other nation yet delivers poorer outcomes. Whole Health offers a proven path to reverse this trend, reframing care around prevention, purpose, and integration across health and social systems. Embedding Whole Health as the operating system for America’s health requires three shifts: (1) redefining the purpose from treating disease to optimizing health and well-being; (2) restructuring care to empower, equip, and treat through team-based and community-linked approaches; and (3) rebalancing control from expert-driven systems to partnerships guided by what matters most to people and communities. Federal and state leaders have the opportunity to turn scattered Whole Health pilots to a coordinated national strategy. The cost of inaction is continued fragmentation; the reward of action is a healthier and more resilient nation.

This memo produced as part of Strengthening Pathways to Disease Prevention and Improved Health Outcomes.

In 1942, the United States formally began the Manhattan Project, which led to the production, testing, and use of nuclear weapons. In August 1945, the United States dropped two nuclear weapons on Japanese cities, killing around 200,000 people by the end of 1945 and leaving survivors with cancer, leukemia and other illnesses caused by radiation exposure. While this was their only use in wartime, states have detonated nuclear weapons many times since for testing purposes, producing radioactive fallout. Many U.S. nuclear weapons production activities, including the mining of uranium and testing of the weapons themselves, have occurred outside of the continental United States. Notably, explosive testing in the Pacific islands and ocean spread radioactive fallout to Marshallese, Japanese, and Gilbertese people, forcibly displacing entire communities and producing intergenerational illnesses. 

Much of the scholarship surrounding the effects of nuclear weapons on environmental and human health is framed within a potential detonation scenario. For example, studies have shown that even a regional nuclear war would cause millions of immediate deaths and trigger a “nuclear winter,” a shift in the climate that would disrupt agricultural production, thus killing hundreds of millions more through starvation. Additionally, in 2024, the United Nations General Assembly voted to create an independent scientific panel to study the health, environmental and economic consequences of nuclear war. While such research is crucial for understanding the consequences of nuclear weapons use, nuclear weapons are built, maintained, and deployed everyday, impacting communities at every stage even before detonation. Studying only the predictive futures of the use of a nuclear weapon in war is insufficient in understanding nuclear weapons’ holistic humanitarian impact. According to former Secretary of Defense Lloyd J. Austin III, “The heart of American deterrence is the people who protect us and our allies. Here at STRATCOM, you proudly stand up—day in and day out and around the clock—to defend us from catastrophe and to build a safer and more peaceful future. So let us always ensure that the most dangerous weapons ever produced by human science are managed with the greatest responsibility ever produced by human government.” Nuclear deterrence theory contends that a retaliatory nuclear strike is so threatening that an adversary will not attack in the first place. Thus, nuclear advocates often suggest that these weapons protect American citizens and the U.S. homeland. This report demonstrates, however, that the creation and sustainment of the nuclear deterrent harms members of the American public. As the United States continues nuclear modernization on all legs of its nuclear triad through the creation of new variants of warheads, missiles, and delivery platforms, examining the effects of nuclear weapons production on the public is ever more pressing.

Extreme heat is a major occupational hazard with far-reaching impacts on the national economy as well as worker health and safety. Extreme heat costs an estimated $100 billion per year in lost productivity, and causes an average of at least 3,389 heat-related injuries and 33 heat-related fatalities annually – numbers that are likely vast undercounts. To protect workers, Congress must mandate a federal heat standard, retain federal workers with expertise in heat stress management strategies, and establish Centers of Excellence to support research, training, and sector-specific mitigation strategies. Through investments in infrastructure for heat safety, Congress can save lives, protect the economy, and enhance resilience nationwide.

Heat-Related Risks are Heightened in Many Work Environments

Extreme heat puts workers of all types at risk: OSHA has documented hospitalizations and heat-related deaths in close to 275 industries. Some work environments present extreme heat risk, particularly those involving high exposures to the outdoors and limited access to cooling. With roughly one in three U.S. employees regularly working outdoors, a large share of the workforce is at elevated risk during summer months. Indoor workers also face high exposure, especially in kitchens, warehouses, manufacturing plants, and other poorly ventilated environments because heat and humidity easily build up in enclosed spaces without adequate air flow and climate-control. 

Business and Economic Impacts of High Heat Exposure in the Workplace 

On top of the $100 billion in direct annual losses, high temperatures are also linked to increased healthcare costs for employers and workers’ compensation claims, with claim frequencies rising by up to 10% during temperature extremes. Some industries are more exposed than others; for example, agriculture, construction, and utility companies face twice the risk of incurring increased healthcare claims due to extreme weather and other environmental conditions. This growing number of claims increases companies’ experience modification rates, which insurers use as a key factor for calculating higher future premiums. Higher premiums translate to greater insurance and overall operating costs, which is especially burdensome for small and low-margin businesses. Despite all these risks, many employers continue to underestimate the financial burden of extreme heat and other weather-related health impacts. 

Many Military Personnel and Federal Workers Face Above-Average Risks of Heat-Related Illness

Military personnel, federal law enforcement officers, border patrol officers, wildland firefighters, federal transportation workers like railroad inspectors, and postal employees are all in positions that require long, labor-intensive hours outdoors, raising the risk for heat-related illness. In 2024, heat-related illnesses were among the top five most reported medical events among U.S. active duty service members. Without consistent standards in place to protect these workers from extreme heat, military and other federal operations will continue to be vulnerable to disruption and reduced workforce capacity.

Advancing Solutions: Establish a Strong Federal Heat Standard and Sector-Specific Centers of Excellence for Heat Workplace Safety

To begin to address heat-related injuries and illnesses in workplaces, OSHA in 2022 established the National Emphasis Program (NEP) on Outdoor and Indoor Heat-Related Hazards, which remains in effect until April 2026. As of 2025, OSHA reports that this NEP has conducted nearly 7,000 inspections connected to heat risks, which lead to 60 heat citations and nearly 1,400 “hazard alert” letters being sent to employers.

However, in the absence of a federal mandate for effective heat safety practices, most workplaces rely on voluntary guidance that is not tailored to specific job conditions, backed by consistent data, or subject to enforcement. This puts both workers and businesses at risk. OSHA’s proposed Heat Injury and Illness Prevention rule would be a critical step forward to establishing common-sense baseline protections. According to the agency’s projections, compliance with this standard could prevent thousands of heat-related illnesses and deaths. The projected benefits from reduced fatalities, illness, and injury amount to $9.18 billion per year. Importantly, this action has broad public backing: 90% of American voters support the implementation of federal protections from extreme heat in the workplace. 

Congress should act swiftly to ensure OSHA finalizes and enforces a strong, evidence-based heat standard. To do this effectively, it is essential that funding for experts at the National Institute for Occupational Safety and Health (NIOSH) is retained in the FY26 budget request, as these critical workers develop criteria for recommended standards on occupational heat stress. These experts have been impacted by reductions in force at NIOSH, and as of July 2025 have not been brought back by the agency.

Some employers have raised concerns about the technical and financial feasibility of the proposed rule. To address these concerns, Congress should pair regulation with practical support by creating federally funded, sector-specific Centers of Excellence (CoEs)for Heat Workplace Safety. These Centers would develop and implement evidence-based solutions tailored to different work environments, such as agriculture and construction. The CoE approach includes comprehensive data collection at worksites that form the basis of occupational safety and health protocols best practices and policies to enhance productivity, prevent injury and illness, and ensure a return on investment. Once strategies are developed, CoEs implement them, track their impact, and work with workers, employers, and cross-sector partners to ensure long-term success.

By leveraging advanced technology, predictive analytics, and continuously updated industry standards, CoEs can help modernize OSHA regulations and make them more aligned with current workplace realities that go beyond simple compliance or post-injury responses.  Federal agencies and other industries with sizable workforces that receive government contracts are key places to develop best practices, technologies, and public-private partnerships for these interventions, all while reducing fiscal risk to the federal government.  

Artificial intelligence (AI) is transforming industries, driving innovation, and tackling some of the world’s most pressing challenges. Yet while AI has tremendous potential to advance public health, such as supporting epidemiological research and optimizing healthcare resource allocation, the public health burden of AI due to its contribution to air pollutant emissions has been under-examined. Energy-intensive data centers, often paired with diesel backup generators, are rapidly expanding and degrading air quality through emissions of air pollutants. These emissions exacerbate or cause various adverse health outcomes, from asthma to heart attacks and lung cancer, especially among young children and the elderly. Without sufficient clean and stable energy sources, the annual public health burden from data centers in the United States is projected to reach up to $20 billion by 2030, with households in some communities located near power plants supplying data centers, such as those in Mason County, WV, facing over 200 times greater burdens than others.

Federal, state, and local policymakers should act to accelerate the adoption of cleaner and more stable energy sources and address AI’s expansion that aligns innovation with human well-being, advancing the United States’ leadership in AI while ensuring clean air and healthy communities.

Challenge and Opportunity

Forty-six percent of people in the United States breathe unhealthy levels of air pollution. Ambient air pollution, especially fine particulate matter (PM_2.5), is linked to 200,000 deaths each year in the United States. Poor air quality remains the nation’s fifth highest mortality risk factor, resulting in a wide range of immediate and severe health issues that include respiratory diseases, cardiovascular conditions, and premature deaths.

Data centers consume vast amounts of electricity to power and cool the servers running AI models and other computing workloads. According to the Lawrence Berkeley National Laboratory, the growing demand for AI is projected to increase the data centers’ share of the nation’s total electricity consumption to as much as 12% by 2028, up from 4.4% in 2023. Without enough sustainable energy sources like nuclear power, the rapid growth of energy-intensive data centers is likely to exacerbate ambient air pollution and its associated public health impacts.

Data centers typically rely on diesel backup generators for uninterrupted operation during power outages. While the total operation time for routine maintenance of backup generators is limited, these generators can create short-term spikes in PM_2.5, NO_x, and SO₂ that go beyond the baseline environmental and health impacts associated with data center electricity consumption. For example, diesel generators emit 200–600 times more NO_x than natural gas-fired power plants per unit of electricity produced. Even brief exposure to high-level NO_x can aggravate respiratory symptoms and hospitalizations. A recent report to the Governor and General Assembly of Virginia found that backup generators at data centers emitted approximately 7% of the total permitted pollution levels for these generators in 2023. Based on the Environmental Protection Agency’s COBRA modeling tool, the public health cost of these emissions in Virginia is estimated at approximately $200 million, with health impacts extending to neighboring states and reaching as far as Florida. In Memphis, Tennessee, a set of temporary gas turbines powering a large AI data center, which has not undergone a complete permitting process, is estimated to emit up to 2,000 tons of NO_x annually. This has raised significant health concerns among local residents and could result in a total public health burden of $160 million annually. These public health concerns coincide with a paradigm shift that favors dirty energy and potentially delays sustainability goals.

In 2023 alone, air pollution attributed to data centers in the United States resulted in an estimated $5 billion in health-related damages, a figure projected to rise up to $20 billion annually by 2030. This projected cost reflects an estimated 1,300 premature deaths in the United States per year by the end of the decade. While communities near data centers and power plants bear the greatest burden, with some households facing over 200 times greater impacts than others, the health impacts of these facilities extend to communities across the nation. The widespread health impacts of data centers further compound the already uneven distribution of environmental costs and water resource stresses imposed by AI data centers across the country.

While essential for mitigating air pollution and public health risks, transitioning AI data centers to cleaner backup fuels and stable energy sources such as nuclear power presents significant implementation hurdles, including lengthy permitting processes. Clean backup generators that match the reliability of diesel remain limited in real-world applications, and multiple key issues must be addressed to fully transition to cleaner and more stable energy. 

While it is clear that data centers pose public health risks, comprehensive evaluations of data center air pollution and related public health impacts are essential to grasp the full extent of the harms these centers pose, yet often remain absent from current practices. Washington State conducted a health risk assessment of diesel particulate pollution from multiple data centers in the Quincy area in 2020. However, most states lack similar evaluations for either existing or newly proposed data centers. To safeguard public health, it is essential to establish transparency frameworks, reporting standards, and compliance requirements for data centers, enabling the assessment of PM2.5, NOₓ, SO₂, and other harmful air pollutants, as well as their short- and long-term health impacts. These mechanisms would also equip state and local governments to make informed decisions about where to site AI data center facilities, balancing technological progress with the protection of community health nationwide.

Finally, limited public awareness, insufficient educational outreach, and a lack of comprehensive decision-making processes further obscure the potential health risks data centers pose to public health. Without robust transparency and community engagement mechanisms, communities housing data center facilities are left with little influence or recourse over developments that may significantly affect their health and environment. 

Plan of Action

The United States can build AI systems that not only drive innovation but also promote human well-being, delivering lasting health benefits for generations to come. Federal, state, and local policymakers should adopt a multi-pronged approach to address data center expansion with minimal air pollution and public health impacts, as outlined below. 

Federal-level Action

Federal agencies play a crucial role in establishing national standards, coordinating cross-state efforts, and leveraging federal resources to model responsible public health stewardship. 

Recommendation 1. Incorporate Public Health Benefits to Accelerate Clean and Stable Energy Adoption for AI Data Centers

Congress should direct relevant federal agencies, including the Department of Energy (DOE), the Nuclear Regulatory Commission (NRC), and the Environmental Protection Agency (EPA), to integrate air pollution reduction and the associated public health benefits into efforts to streamline the permitting process for more sustainable energy sources, such as nuclear power, for AI data centers. Simultaneously, federal resources should be expanded to support research, development, and pilot deployment of alternative low-emission fuels for backup generators while ensuring high reliability.

• Public Health Benefit Quantification. Direct the EPA, in coordination with DOE and public health agencies, to develop standardized methods for estimating the public health benefits (e.g., avoided premature deaths, hospital visits, and economic burden) of using cleaner and more stable energy sources for AI data centers. Require lifecycle emissions modeling of energy sources and translate avoided emissions into quantitative health benefits using established tools such as the EPA’s BenMAP. This should:
  • Include modeling of air pollution exposure and health outcomes (e.g., using tools like EPA’s COBRA)
  • Incorporate cumulative risks from regional electricity generation and local backup generator emissions
  • Account for spatial disparities and vulnerable populations (e.g., children, the elderly, and disadvantaged communities)
  • Evaluate both short-term (e.g., generator spikes) and long-term (e.g., chronic exposure) health impacts
• Preferential Permitting. Instruct the DOE to prioritize and streamline permitting for cleaner energy projects (e.g., small modular reactors, advanced geothermal) that demonstrate significant air pollution reduction and health benefits in supporting AI data center infrastructures. Develop a Clean AI Permitting Framework that allows project applicants to submit health benefit assessments as part of the permitting package to justify accelerated review timelines.
• Support for Cleaner Backup Systems. Expand DOE and EPA R&D programs to support pilot projects and commercialization pathways for alternative backup generator technologies, including hydrogen combustion systems and long-duration battery storage. Provide tax credits or grants for early adopters of non-diesel backup technologies in AI-related data center facilities.
• Federal Guidance & Training. Provide technical assistance to state and local agencies to implement the protocol, and fund capacity-building efforts in environmental health departments.

Recommendation 2. Establish a Standardized Emissions Reporting Framework for AI Data Centers

Congress should direct the EPA, in coordination with the National Institute of Standards and Technology (NIST), to develop and implement a standardized reporting framework requiring data centers to publicly disclose their emissions of air pollutants, including PM₂_.₅, NOₓ, SO₂, and other hazardous air pollutants associated with backup generators and electricity use.

• Multi-Stakeholder Working Group. Task EPA with convening a multi-stakeholder working group, including representatives from NIST, DOE, state regulators, industry, and public health experts, to define the scope, metrics, and methodologies for emissions reporting.
• Standardization. Develop a federal technical standard that specifies:
  • Types of air pollutants that should be reported
  • Frequency of reporting (e.g., quarterly or annually)
  • Facility-specific disclosures (including generator use and power source profiles)
  • Geographic resolution of emissions data
  • Public access and data transparency protocols

State-level Action 

Recommendation 1. State environmental and public health departments should conduct a health impact assessment (HIA) before and after data center construction to evaluate discrepancies between anticipated and actual health impacts for existing and planned data center operations. To maintain and build trust, HIA findings, methodologies, and limitations should be publicly available and accessible to non-technical audiences (including policymakers, local health departments, and community leaders representing impacted residents), thereby enhancing community-informed action and participation. Reports should focus on the disparate impact between rural and urban communities, with particular attention to overburdened communities that have under-resourced health infrastructure. In addition, states should coordinate HIA and share findings to address cross-boundary pollution risks. This includes accounting for nearby communities across state lines, considering that jurisdictional borders should not constrain public health impacts and analysis.

Recommendation 2. State public health departments should establish a state-funded program that offers community education forums for affected residents to express their concerns about how data centers impact them. These programs should emphasize leading outreach, engaging communities, and contributing to qualitative analysis for HIAs. Health impact assessments should be used as a basis for informed community engagement.

Recommendation 3. States should incorporate air pollutant emissions related to data centers into their implementation of the National Ambient Air Quality Standards (NAAQS) and the development of State Implementation Plans (SIPs). This ensures that affected areas can meet standards and maintain their attainment statuses. To support this, states should evaluate the adequacy of existing regulatory monitors in capturing emissions related to data centers and determine whether additional monitoring infrastructure is required.

Local-level Action

Recommendation 1. Local governments should revise zoning regulations to include stricter and more explicit health-based protections to prevent data center clustering in already overburdened communities. Additionally, zoning ordinances should address colocation factors and evaluate potential cumulative health impacts. A prominent example is Fairfax County, Virginia, which updated its zoning ordinance in September 2024 to regulate the proximity of data centers to residential areas, require noise pollution studies prior to construction, and establish size thresholds. These updates were shaped through community engagement and input.

Recommendation 2. Local governments should appoint public health experts to the zoning boards to ensure data center placement decisions reflect community health priorities, thereby increasing public health expert representation on zoning boards. 

Conclusion

While AI can revolutionize industries and improve lives, its energy-intensive nature is also degrading air quality through emissions of air pollutants. To mitigate AI’s growing air pollution and public health risks, a comprehensive assessment of AI’s health impact and transitioning AI data centers to cleaner backup fuels and stable energy sources, such as nuclear power, are essential. By adopting more informed and cleaner AI strategies at the federal and state levels, policymakers can mitigate these harms, promote healthier communities, and ensure AI’s expansion aligns with clean air priorities.

This memo is part of our AI & Energy Policy Sprint, a policy project to shape U.S. policy at the critical intersection of AI and energy. Read more about the Policy Sprint and check out the other memos here.

46 million rural Americans face mounting risks from temperature extremes that threaten workforce productivity, raise business operational costs, and strain critical public services. Though extreme heat is often portrayed in research and the media as an urban issue, almost every state in the contiguous U.S. has rural communities with above-average rates of vulnerability to extreme heat. To protect rural America, Congress must address extreme heat’s impacts by repairing rural health systems, strengthening the preparedness of rural businesses, and hardening rural energy infrastructure.

Extreme heat exacerbates rural communities’ unique health vulnerabilities

On average, Americans living in rural areas are twice as likely as those in urban areas to have pre-existing health conditions, like heart disease, diabetes, and asthma, that make them more sensitive to heat-related illness and death. Further compounding the risk, rural places also have larger populations of underinsured and uninsured people than urban areas, with 1 in 6 people lacking insurance. 

Limited healthcare infrastructure in rural places worsens these vulnerabilities. Rural areas have higher shortages of healthcare professionals who provide primary care, mental health, and dental services than urban areas. Over the last decade, 100 rural hospitals have closed, and hundreds more are vulnerable to closure. Finally, many rural communities do not have public health departments, and those that do are underfunded and understaffed. Because public health systems and healthcare professionals are the first responders to extreme heat, rural residents are severely underprepared. 

Congress should provide flexible resources and technical assistance to rural hospitals to prepare for emerging threats like extreme heat. Additionally, Congress should continue to enable the U.S. Department of Agriculture and the Department of Health and Human Services to provide loans or grant assistance to help rural residents retain access to health services and improve the financial position of rural hospitals and clinics. And because Medicaid expansion correlates with better rural hospital financial performance and fewer closures, Congress should invest in Medicaid to protect rural healthcare access.

Extreme heat puts rural businesses and workers at risk

Rural economic health relies on the outdoors (e.g., recreation tourism) and outdoor labor (e.g., agriculture and oil and gas extraction). Extreme heat in many of these places makes it dangerous to be outside, which impacts worker productivity and local business revenues. Indoor workers in facilities like manufacturing plants, food processing, and warehouses also face heat-related safety threats due to the presence of heat-producing machines and poorly ventilated buildings with limited cooling. These facilities are rapidly growing components of rural economies, as these sectors employ almost 1 in 5 rural workers. 

Simple protections like water, rest, shade, and cooling can improve productivity and generate returns on investments. But small-to-medium rural enterprises need support to adopt affordable cooling systems, shade and passive cooling infrastructure, and worker safety measures that reduce heat-related disruptions. Congress should help rural businesses reduce heat’s risks by appropriating funding to support workplace heat risk reduction and practical training on worker protections. Additionally, Congress should require OSHA to finalize a federal workplace heat standard.

Extreme heat threatens rural energy security

When a power outage happens during a severe extreme heat event, the chance of heat-related illness and death increases exponentially. Extreme heat strains power infrastructure, increasing the risk of power outages. This risk is particularly acute for rural communities, which have limited resources, older infrastructure, and significantly longer waits to restore power after an outage.

Weatherized housing and indoor infrastructure are one of the key protective factors against extreme heat, especially during outages. Yet rural areas often have a higher proportion of older, substandard homes. Manufactured and mobile homes, for example, compose 15% of the rural housing stock and are the one of the most at-risk housing types for extreme heat exposure. When the power is on, rural residents spend 40% more of their income on their energy bills than their urban counterparts. Rural residents in manufactured housing spend an alarming 75% more. Energy debt can force people to choose between paying for life-saving energy or food and key medications, compounding poverty and health outcomes. 

To drive the energy independence and economic resilience of rural America, Congress should support investments in energy-efficient and resilient cooling technologies, weatherized homes, localized energy solutions like microgrids, and grid-enhancing technologies.