Cascading disasters and mental health inequities: Winter Storm Uri, COVID-19 and post-traumatic stress in Texas.

Previous research on health effects of extreme weather has emphasized heat events even though cold-attributable mortality exceeds heat-attributable mortality worldwide. Little is known about the mental health effects of cold weather events, which often cascade to produce secondary impacts like power outages, leaving a knowledge gap in context of a changing climate. We address that gap by taking a novel "cascading disaster health inequities" approach to examine winter storm-associated post-traumatic stress (PTS) using survey data (n = 790) collected in eight Texas metro areas following Winter Storm Uri in 2021, which occurred against the backdrop of COVID-19. The incidence of storm-related PTS was 18%. Being Black (odds ratio [OR]: 6.6), Hispanic (OR: 3.5), or of another non-White race (OR: 4.2) was associated with greater odds of PTS compared to being White, which indicates substantial racial/ethnic inequities in mental health impacts (all p < 0.05). Having a disability also increased odds of PTS (OR: 4.4) (p < 0.05). Having piped water outages (OR: 1.9) and being highly impacted by COVID-19 (OR: 3.3) increased odds of PTS (both p < 0.05). When modelling how COVID-19 and outages cascaded, we compared householders to those with no outages and low COVID-19 impacts. PTS was more likely (p < 0.05) if householders had a water or power outage and high COVID-19 impacts (OR: 4.4) and if they had water and power outages and high COVID-19 impacts (OR: 7.7). Findings provide novel evidence of racial/ethnic inequities and cascading effects with regard to extreme cold events amid the COVID-19 pandemic.