When Laura arrived for her surgery, the hospital was almost completely empty. They’d sent everyone home, the nurse said when Laura asked where everyone was. Her surgery was one of only two the hospital had decided to schedule despite the lack of power and shortages in many supplies like IVs after Hurricane Helene hit the area.

Laura (we are using a pseudonym to protect her privacy) was diagnosed with an aggressive form of breast cancer just a month before the hurricane reached Asheville. “I [thought], it’ll just be some bad weather for a day or so and then it’s going to blow over a couple hours later and we’ll be fine,” she said. “Obviously that didn’t happen.”

After her neighborhood lost power, Laura sought out a satellite dish where people gathered to get a signal. She lost count of the number of times she tried to call the hospital. Eventually, a nurse was able to get in touch with her, but up until the night before her surgery was scheduled, neither Laura nor her surgical team had any clue whether the procedure would happen. At 2 a.m., the only time her phone was able to receive messages, she got the news that she should arrive at the hospital in less than six hours.

Laura had surgery in a generator-powered hospital a little over a week after the hurricane hit.

Many studies have shown that natural disasters worsen survival rates among cancer patients. “You can have the best health insurance, be at the best hospital, with the best prognosis of the tumor if you get your treatment, but then you don’t because of a climate event,” said Leticia Nogueira, a researcher at the American Cancer Society who studies how climate change and severe weather events affect cancer treatment.

These studies often focus on whether or not cancer patients receive their treatments, but even for someone like Laura, natural disasters still take their toll. In a recent study, Nogueira and colleagues found that in areas with active wildfires, patients recovering from lung surgery were kept in the hospital longer by two days on average, which can increase patients’ risk of infection and come with a hefty price tag, usually around $1,500 per day. Longer stays also use up already-limited hospital resources.

Still, physicians may delay discharging patients because of the risks of returning home. When Laura came back from the hospital, her house remained without power or water. Her surgical team was worried about keeping her incision clean to prevent infections. Neighbors were able to bring Laura sterile wipes and bottled water. “I took a gallon jug of water and poked holes in the cap, and that’s how I was taking my showers, because what else are you going to do?” she said.

Another neighbor who had heard about her surgery also set up a generator at her house. “It was enough that I was able to plug the refrigerator in and run a microwave, and then, you know, one light in the evening type of thing,” she said. “Without that, recovering from surgery would have been a whole lot harder.”

Nogueira and her colleagues are often asked how cancer patients and oncologists should respond in natural disasters, but despite being among the few researchers studying these issues, they also don’t have clear answers. “There are no guidelines,” Nogueira said. “There is nothing out there. No clinical guidelines, no emergency preparedness guidelines that say this is what you need to do.”

A previous study from some of the same researchers found that while every NCI-designated cancer center in the US has experienced a climate-related disaster in the past decade, very few have relevant emergency preparedness plans in place. NCI-designated cancer centers are also some of the most resourced hospitals in the country, so if anyone would be ahead of the curve, it would be these centers, Nogueira said.

Nogueira began studying climate disaster impacts on cancer patients during Hurricane Harvey, which swept across Louisiana and eastern Texas in 2018. Harvey brought unprecedented levels of rainfall, a growing issue among hurricanes due to warmer temperatures. “While we were working on the response, Maria hit Puerto Rico, and the same things we were struggling with, they were too,” Nogueira said, “so are we learning nothing every time this happens?”

Hiram Gay is a radiation oncologist at Washington University School of Medicine who grew up in Puerto Rico. When Hurricane Maria hit the island, colleagues began reaching out, asking how they could help. They first looked into bringing patients to hospitals in the mainland US but ran up against challenges such as transferring all the records and equipment for each patient’s highly individualized treatment plan—an issue Nogueira has also seen crop up repeatedly in disaster responses.

Gay and colleagues looked for other ways to help, but it wasn’t clear what the needs were, Gay said, in large part because the destruction was far greater than anything the island had previously experienced. “I’ve gone through hurricanes in Puerto Rico before,” Gay added. “Growing up, we would celebrate missing school for a week or two, and then we were back on our feet.” Hurricane Maria was not that.

In the aftermath, Gay worked with oncologists in Puerto Rico to assess the extent of the damage to health-care facilities that provide radiation therapy. This treatment is very difficult to continue through a hurricane as it needs to be administered on a regular schedule, sometimes daily, and requires massive amounts of power. A single radiation treatment can use up to 38 kWh, which is more electricity than the average American household uses in a day. Parts of Puerto Rico were without power for nearly a year, and while the majority of health-care facilities had access to diesel generators, obtaining fuel quickly became a challenge. Certain machines used for radiation therapy also require fresh, clean water for their cooling systems.

In these situations, cancer treatments are often deprioritized. Laura had been in touch with another surgeon who completely dropped off the map when the hurricane hit. The hospital that employed the surgeon had been much more severely damaged by the storm. Weeks later, as the area began to recover, a receptionist told her it was wise she already had the surgery because they were scheduling for three months out—a long wait for an aggressive tumor.

In mid-November, Laura had her first radiation treatments at that same facility, in a building next to the main hospital that still lacked running water. When she mentioned to the radiation technician that her treatments had been delayed, he said that even two months after the hurricane hit, they were still rescheduling missed appointments.

After Hurricane Maria, Gay helped put together a checklist of lessons learned. The measures range from preparing alternative cooling systems for the radiation machines to providing patients with USB copies of their medical records, which are often stored in the cloud and therefore inaccessible when the internet is down. When asked if health-care facilities on the island are now more prepared for the next severe hurricane, Gay said, “I certainly would hope so, but there are some things that are so profound that it’s really hard to prepare properly.”

Nogueira is also currently studying how hospitals are using knowledge from previous disasters to better prepare for future ones. “If we have a more coordinated way of sharing information, of sharing lessons learned, and best practices, then we could all be doing better,” she said. “We don’t need to wait for it to hit our facility and reinvent the wheel.”

But learning from these experiences requires health-care facilities to be open about the extent to which their operations were disrupted, which doesn’t always happen. In surveying the level of damage to clinics after Hurricane Maria, Gay encountered resistance. “People didn’t want to show that their practice was in bad shape,” Gay said.

Sharing this information is only becoming more important as more places face extreme weather events due to climate change. Hurricanes are growing in strength and affecting areas like Asheville that were once deemed “climate havens,”and wildfires are reaching farther into densely populated areas. CalFire, the state agency that manages wildfire response and prevention in California, recently released new maps that expand fire hazard zones, adding over 3,600 square miles of “high” and “very high” hazard areas where more than 3.7 million people live.

“People ask, ‘Where should I move? Where should I go to escape this?’ There is no escaping this,” Nogueira said. Not only are these disasters becoming inevitable, but climate impacts like air pollution also increase people’s risk of developing cancer. “I think at least once in our lives, we all are patients,” Nogueira added. The work of medical professionals centers on helping people through this inevitability. Now to do this effectively, they have to prepare for the inescapable effects of climate change too.