When a man with painful cystic acne came to dermatologist Eva Rawlings Parker for help in a Nashville clinic, she couldn’t prescribe him doxycycline or minocycline, two medications she’d typically use to treat this condition. This is because the man was a roofer, says Parker, and these medications would have impacted his ability to tolerate heat. 

Parker’s patient was far from alone. Other common medications for physical health, like beta blockers, can impact people’s ability to handle heat. Many medications for mental health do, too.

Conventional wisdom tells people with conditions that make them unusually vulnerable to the sun, like the autoimmune disorder lupus, or are on medications that lead to heat sensitivity, to avoid staying outside when the sun is at its strongest.

“We know that workers have been dying because of chronic conditions that accumulate through heat stress over many years and decades that lead to shorter life spans.”

But for the one-third of US workers who must spend regular time outdoors, that advice bursts into flames. For some, such as farmworkers, hours and hours of heat exposure, with minimal or no reprieve, are just part of the job. Increasing heat waves and more frequent wildfires point to the need to find real solutions for outdoor workers—and highlight how labor and climate change are intertwined. 

Alongside heat waves getting worse and longer, which can trigger mental health episodes, more and more people are taking antipsychotic medications or antidepressants like SSRIs. Even before the toll of the Covid pandemic, the CDC estimated that more than one in eight adults took antidepressants. Since the beginning of the Covid-19 pandemic, SSRI prescriptions for adolescents and young adults has increased by 63 percent.

Edward Flores, faculty director of the Community and Labor Center at the University of California, Merced, specializes in the conditions of low-wage and immigrant workers in California. He says the need for heat safety policy reform is acute. “We know that workers have been dying,” Flores says, “because of chronic conditions that accumulate through heat stress over many years and decades that lead to shorter life spans.”

Parker, the dermatologist, is acutely aware of how heat can trigger or worsen skin problems. She is co-chair of the American Academy of Dermatology’s group on climate change and environmental issues, and was an author of a 2023 review on the ways climate change can contribute to dermatological issues, including triggering flares of conditions like hidradenitis suppurativa—which causes painful lumps deep in a person’s skin—and skin cancer.

“The skin is really probably our most climate-sensitive organ, also a very large and complex organ, and it’s really the major interface to the environment,” says Parker, who is also a Vanderbilt University Medical Center professor. Her experience with patients, many of whom are low-income and migrant workers, lets her see firsthand just how challenging giving practical health advice can be in a warming world. 

People’s core temperature can rise much more quickly on SSRIs, for instance, putting them at increased risk of heat stroke. And there’s the challenge, says Rupa Basu, a heat epidemiologist with the California Office of Environmental Health Hazard Assessment: “It’s really hard to monitor core body temperature.” 

Workers do have some legal rights to breaks and water, depending on the locale. California, Oregon, and Washington are the only states that mandate those breaks. And roughly half of crop farmworkers have no legal work authorization. That lack of legal status, and the threat of deportation, gives many workers reason to fear complaining about working conditions.

In July, the Occupational Safety and Health Administration proposed a new set of rules which would help protect more than 36 million workers from heat-related illness or death. The proposed OSHA rules would require employers to monitor their workers for heat exhaustion symptoms, provide adequate water and shade, designate break areas, and provide mandatory rest breaks, among other things. 

In one landmark 2022 farmworker health study that Flores, of the University of California, worked on, nearly half of workers interviewed said their employer had no heat-illness prevention plan—such plans are required by state law, and may soon be required federally—and one in six did not receive state-mandated rest breaks. When that lack of respite causes illness, many farmworkers are unlikely to see a doctor: 23 percent of those interviewed had not had a doctor’s visit in the past year, even at clinics tailored towards migrants.

23 percent of those interviewed had not had a doctor’s visit in the past year, even at clinics tailored towards migrants.

But enforcement, if the rules are implemented, will be a challenge. For one thing, as Flores explained, California has very few Spanish-speaking OSHA inspectors—and none that he’s aware of in the Central Valley, which supplies 8 percent of America’s total agricultural output. (89 percent of California agricultural workers speak Spanish as their primary language.) Nationwide, many accounts exist of inspectors arriving at a workplace without being able to speak workers’ main language.

Summers, meanwhile, are only going to get hotter. Without adequate regulation and enforcement, workers will keep dying in the heat. As Bill Field, director of AgrAbility, a Department of Agriculture program for disabled farmers, put it: “If you go to the racetrack, all the horses have multiple fans blowing on them…Why? Because we care more about the horses than we do the people.”

The adversity brought on by the climate crisis, Flores said, makes it “all the more important to safeguard workers’, outdoor workers’, health and well-being with improved standards and enforcement.”

Whether or not it is legally required, there are steps that employers can already take—but seldom do—to make outdoor working environments safer. “It could be things like increasing water breaks,” Basu said, “or putting up structures to increase shade.”

When the sun beats down on workers, clothes that protect against ultraviolet light can be a useful tool. Research suggests that UV-protective clothing is more effective in preventing skin damage, blocking 96 to 98 percent of the sun’s radiation—by comparison, a cotton shirt will only block around 80 percent. But these garments also tend to be more expensive—protective long-sleeve shirts can easily cost $50 or more. Field believes that employers should cover the cost of UV-protective clothing for exposed workers.

“If I’m a legitimate apple grower or a peach grower in New Jersey, and I’ve got to hire people,” Field said, “I need to be able to budget for them to all have hats and water bottles and things that are going to protect them while they’re in the field.” 

Those changes wouldn’t just benefit workers who are chronically ill—prolonged heat can disable and kill anyone. “When we’re thinking about public health messaging,” Basu adds, “it’s so important to say it’s not just people who you would think would be at high risk.” 

Last December, UNICEF reported that two and a half months into Israel’s offensive in Gaza, at least a thousand children lost one or both of their legs. As more Palestinians become disabled, their risks expand. A United Nations committee warned in May of “the disproportionate impacts on people with disabilities due to the destruction of hospitals, the cut-off of essential services, restrictions, [and] non-existing access to humanitarian assistance” amid the war waged in response to Hamas’s attack on October 7th.

One organization that is trying to help disabled Palestinians in Gaza is Humanity & Inclusion, an international Nobel Peace Prize-winning humanitarian group, which has operated in Palestine—both in Gaza and the West Bank—for nearly three decades. Since October, H&I has provided mobility devices to newly disabled Palestinians.

Their work has been treacherous—multiple H&I staff members have been killed and their office in Gaza City has been destroyed. In mid-June, H&I says the Israeli Defense Forces bulldozed their warehouse in Rafah, where medical supplies and mattresses had previously been stored. (In response to a request for comment on the destruction of H&I’s warehouse, a spokesperson for the Israeli Defense Forces did not deny the warehouse’s destruction, but said the IDF “follows international law.”) The Israeli army has also prohibited many medical devices from entering Gaza, claiming that these are “dual-use items”—that crutches or hearing aid batteries, for example, could have a military use. 

Mother Jones spoke to Noor Bimbashi, an advocacy officer for Humanity & Inclusion based in the West Bank about the challenges that disabled people in Gaza face, the impact of aid restrictions, and how those in the West Bank experience violence, too. 

This interview has been edited for length and clarity.

The number of amputees, including children who lost limbs in Israel’s offensive, has risen in Gaza since October. How has this changed the type of work that Humanity & Inclusion does? 

Back in 2022, the number of amputees was already high. At least 21 percent of households in Gaza had [a person with a] disability. We keep trying to compare this number with what’s happening right now.

The impeded access into Gaza is affecting our rehabilitation services. In order to sustain the well-being of amputees and persons with disabilities, we need more resources. And the shortage of electricity and fuel is impacting our operations.

One of the challenges I’ve heard from my colleagues recently is the fact that after the Rafah offensive our employees became scattered in different areas across the Gaza strip. Sometimes communication is difficult. The number of persons with disabilities, and how many families are in need of rehabilitation—or in need of assistive technologies like wheelchairs or crutches—is increasing by the day, and sometimes it’s difficult to keep up. But we’re trying our utmost best. 

In mid-June, H&I said the Israeli army destroyed a warehouse your organization had previously used in Rafah. How has the lack of viable warehouse space affected the services you have been able to provide? 

The offensive has forced us to suspend all activities for persons with disabilities across the whole governorate of Rafah. The loss of this warehouse made it impossible for us to stock items in Rafah, in the short term. And even after the end of the offensive, it’s going to take us a lot of time, which, of course, slows down our future assistance to persons with disabilities, especially in Rafah. 

In Gaza, even mild injuries are turning into permanent disabilities. “We’re hearing about people having their legs or arms amputated without anesthesia,” says an advocacy officer.

Even our warehouses in other areas sometimes it’s too difficult to reach them, or to find a proper warehouse, since more than 60 percent of buildings are destroyed in Gaza. 

Palestine has high rates of disability, including child amputees. Have you all been able to meet that demand of treating kids who are newly disabled? What obstacles stand in the way of getting these kids care? 

The nurses that we work with tell us how challenging it is, since they don’t have access to basic tools to treat patients. One of the nurses told me one of the biggest challenges is inability to follow up with patients because of displacement. One day they’re treating a person with a disability, and the next day they can’t find him or her, because they were ordered to evacuate to another place. 

The overcrowding in shelters hinders the execution of some of the rehab sessions. But I think the biggest challenge right now is displacement and scarcity of resources.

In Gaza, persons with disabilities have lost all chances for education, or for mental support. They’re the last ones to evacuate because some of them don’t even know that they have to evacuate, like those with hearing difficulties.

We keep calling for Israel to allow us to import some of the tools and resources that are considered “dual use,” but they’re not. So sometimes it’s difficult even to bring into Gaza wheelchairs, crutches, and hearing aids, because some of them are put on the dual use list. The problem is that we’re not even getting the list, so we don’t even know. 

There need to be thousands more prosthetics in Gaza. How does delaying getting an amputee a prosthesis negatively impact their quality of life? 

First, it affects their mental health. We’ve heard about confusion, anger management issues, because they’re unable to get the right treatment. And even mild injuries are turning into permanent disabilities. The situation in the hospitals is very bad. We’re hearing about people having their legs or arms amputated without anesthesia. It’s devastating. We try our best to find alternatives, but I don’t know what else can be done. 

Some children think that their legs might grow again. This is one of the saddest things that we hear on a regular basis, when talking to children. They tell us, we’re waiting for our legs to grow again. Sometimes, it’s difficult to explain that that’s not going to happen. 

That’s heartbreaking. How has the team in the West Bank, where you’re based, been supporting H&I members in Gaza?

At the beginning, we lost communication. It was really difficult. But right now, there are more than 40 employees in Gaza, and in the West Bank there are more than 30. We try to have joint projects together. But, you know, in the West Bank we aren’t allowed to enter Gaza. 

Our international staff are the ones who have entered Gaza. We send rehabilitation specialists, we send a lot of support from our headquarters in France, and other places, to enter Gaza to support. Sometimes we suspend movements due to the security situation. After the Rafah offensive, it’s been difficult to predict what’s going to happen—we don’t want our staff to be stuck. 

What challenges have you experienced in helping disabled people in the West Bank since October?

I can tell you, living there, that everything has escalated following the seventh of October. One of the biggest challenges is restriction of movement. We work not only in Ramallah, but also in Jenin, and Nablus, and Bethlehem. Palestinian refugee camps in the West Bank have been subjected to daily raids and incursions. So, sometimes we plan a field visit, or we plan to conduct a needs assessment in a certain refugee camp, but then the next day, we are unable to, because a new checkpoint has suddenly been erected, which prevents us from going there.

“Some children think that their legs might grow again. This is one of the saddest things that we hear on a regular basis.”

Another challenge is that settler violence has increased drastically. One of our local partners is a rehabilitation center in Jenin refugee camp. All of the infrastructure surrounding them has been completely destroyed. I cannot walk to the center, or go in a car to the center. The Israeli soldiers have been surrounding hospitals and rehabilitation centers, and they destroy the infrastructure around them. It’s becoming really, really difficult for persons with disabilities to continue their treatments or to access services that they need.

The situation is bad. We hope for the cessation of hostilities, and to have a ceasefire as soon as possible, so we will be able to operate as we should.