Rita Kowalczyk sits in her office on the fourth floor of Aurora Lakeside Medical Center in Milwaukee, where the view of Lake Michigan would be beautiful if you had time to look at it. She doesn't. Her desk is covered in spreadsheets, vendor contracts, and a half-eaten sandwich from the cafeteria that's been sitting there since 11 AM. It's 4:47 PM on a Thursday in August 2034, and she's just gotten off a conference call about insulin supply allocations that went exactly as badly as she expected.
"Let me tell you how I spend my Thursdays now," she says, pulling up her calendar. "Morning meeting about backup generator fuel reserves. Lunch call about whether we can get antibiotics from the Dominican Republic since our Puerto Rico supplier is offline again. Afternoon arguing with finance about why we need to keep eight weeks of critical medications on hand instead of two. Then I go home and try to explain to my twelve-year-old why we're spending money on a portable AC unit for her bedroom instead of the summer camp she wanted."
She pronounces her last name slowly for the recording: "Ko-WAL-chick. Everyone gets it wrong. I've given up correcting people."
Rita came to healthcare supply chain management in 2027 after fifteen years in pharmaceutical sales. "I was good at it," she says. "Really good. Made decent money, traveled constantly, knew every hospital administrator in the Midwest. But around 2025, 2026, I started noticing things. Shipments delayed because of flooding in New Jersey. A manufacturing plant in India offline for three weeks. My biggest client—a hospital system in Louisiana—couldn't get IV fluids for two months after Hurricane Helene. I thought, somebody's going to need to figure this out. Might as well be me."
When you took this job in 2028, what did you think you were signing up for?
I thought I was going to be the person who made smart contingency plans and then mostly dealt with normal supply chain stuff. Like, we'll have backup suppliers, we'll keep extra inventory of critical items, problem solved. I was going to be the hero who prevented disasters, not the person constantly triaging which disaster to prevent.
That lasted about six months.
The first real wake-up call was February 2029. We had this polar vortex event—not as bad as the Texas freeze in '21, but bad enough. Our primary medical gas supplier's facility lost power for thirty-six hours. We're talking about oxygen, which, you know, pretty fucking critical in a hospital. We had enough in our tanks to last maybe forty hours if we rationed carefully.
I spent that whole time on the phone trying to find emergency supplies, calling in every favor I had, while our respiratory therapists were literally calculating which patients could be weaned off supplemental oxygen to stretch what we had.
We made it. Barely. And I realized: okay, this is the job now.
How has the supply chain actually changed since you started?
The big shift isn't that disasters happen—disasters always happened. It's that they happen constantly, and they compound. We used to have maybe one or two major disruptions a year. Now it's one or two a month.
Last year alone: flooding in Mumbai knocked out a major pharmaceutical manufacturing hub for seven weeks1. Heat waves in Arizona forced rolling blackouts that affected medical device sterilization facilities. Hurricane season ran from June through November instead of August through October, hitting three different ports we depend on. And that's just the big stuff. We also had dozens of smaller incidents—delayed shipments, damaged goods, suppliers going offline for a few days here and there.
The other thing is lead times. In 2025, we could order most supplies and get them in two weeks, maybe four for specialized items. Now? Twelve weeks is standard. Twenty-four for anything complex.
So we have to predict what we'll need six months out, which is basically impossible when you're also dealing with climate-driven health impacts that are genuinely new.
Like, we're seeing heat-related kidney disease in agricultural workers now2. Chronic kidney disease of unknown cause—CKDu. It's established in Central America, but we're starting to see cases here. How many dialysis supplies do I order for a condition that wasn't really in our patient population five years ago?
I'm making educated guesses based on incomplete data, and if I guess wrong, people die.
You mentioned arguing with finance about inventory. What's that tension like?
laughs bitterly
Oh, that's my favorite. So, traditional supply chain management is all about efficiency, right? Just-in-time delivery, minimal inventory, keep costs down. That's what I learned in sales. That's what every MBA program teaches. That's what our CFO still wants.
But just-in-time doesn't work when "time" becomes unpredictable. When your supplier might be offline for a week, or a month, or permanently because their facility got destroyed and they're not rebuilding.
So I'm pushing for what we call "strategic reserves"—basically, keeping months of critical supplies on hand instead of weeks. But that costs money. A lot of money. We're talking millions in inventory sitting in climate-controlled warehouses, taking up space, some of it expiring before we use it.
Finance sees that as waste. I see it as insurance.
Last month, I had a meeting where the CFO literally said, "Rita, we can't afford to prepare for every possible scenario." And I said, "Cool, which patients should I tell we can't treat when the next disruption hits?"
That didn't go over well.
The compromise we reached is that I can keep eight weeks of "Tier 1 critical supplies"—stuff like insulin, cardiac medications, antibiotics, surgical supplies—but only four weeks of everything else. Which means I'm constantly making Sophie's choice decisions about what counts as critical enough.
What does that calculation actually look like?
pauses, looks out the window
You want the real answer? I have a spreadsheet.
Column A is the medication or supply. Column B is how many patients need it. Column C is whether there are substitutes. Column D is how quickly someone dies without it. Column E is how many suppliers we have. Column F is how vulnerable those suppliers are to climate disruptions.
Then I assign weights to each factor and generate a priority score. The top hundred items get the eight-week inventory. Everything else gets four weeks or less.
Sounds rational, right? Very professional. Very data-driven.
Except I'm literally ranking human lives.
Insulin scores high because lots of patients need it, there are limited substitutes, and people die relatively quickly without it. But what about the medication that only twelve patients need, but those twelve patients absolutely die without it, and there's only one manufacturer, and that manufacturer is in a flood zone? That scores lower because it's only twelve people.
I think about those twelve people a lot. I know some of their names. I've met a few of them. And I've made a spreadsheet that says their lives are worth less than someone else's because the math doesn't work otherwise.
long pause
My daughter asked me last week what I do at work. I told her I make sure the hospital has the supplies doctors need. Which is true.
I didn't tell her that "making sure" means choosing who we're prepared to save and who we're not.
How do you live with that?
Some days better than others.
I have a therapist. I take Lexapro—which, ironically, I've made sure we have plenty of in stock because half the hospital staff is on SSRIs now.
But honestly? I think I live with it because the alternative is someone else making these decisions, and they might not have spent fifteen years learning this industry. They might not understand that the vendor promising the lowest price is also the one most likely to disappear when things get hard. They might not know which manufacturers are actually investing in resilience versus just saying they are in their marketing materials.
I'm good at this job. I hate that I'm good at this job, but I am. And I keep doing it because... shrugs ...someone has to.
Also, dark humor helps. My team has a running joke about "disaster bingo." Flooding in a manufacturing hub? That's the free space. Hurricane hitting a major port? Mark it off. Heat wave causing power outages? Check.
We're all deeply fucked up.
You mentioned your daughter. How does being a parent shape how you think about this work?
laughs
So I'm making life-and-death supply chain decisions at work, and then I come home and I'm supposed to be a normal mom. "How was school? Did you finish your homework? Please don't leave your wet towel on the bathroom floor."
But she knows something's wrong. Kids aren't stupid. She knows her friends' families are moving away. She knows we spent two weeks last summer at my sister's place in Duluth because Milwaukee was hitting 105 degrees and our AC couldn't keep up3. She knows the hospital where I work has a "cooling center" now where people can come during heat waves, and that's where she goes after school some days because it's safer than walking home in the heat.
Last month she asked me if we should move somewhere else. "Somewhere better," she said.
She's twelve. She shouldn't have to think about climate refuge.
I told her Milwaukee is actually pretty well-positioned compared to a lot of places. We have water. We're not on a coast. Yeah, we get extreme precipitation now and the infrastructure is struggling, but we're not Phoenix or Miami. This is one of the "good" places to be.
She looked at me and said, "If this is good, what's bad?"
I didn't have a great answer for that.
What do you wish you'd known when you started this job?
That it doesn't get easier.
I thought once we built up our reserves, once we diversified our suppliers, once we had good relationships with multiple vendors—I thought it would stabilize. That we'd reach some new equilibrium where yes, things are harder than they used to be, but we've adapted.
But it keeps accelerating. Every year the disruptions are more frequent, more severe, more overlapping. We adapt, and then we have to adapt to the adaptation not being enough.
I also wish I'd known how much of this job is emotional labor that has nothing to do with supply chain logistics. I spend hours every week managing people's expectations—explaining to doctors why we can't get the specific brand of surgical equipment they prefer, telling administrators why costs keep rising, reassuring staff that we're prepared for the next crisis even when I'm not sure we are.
And I wish someone had told me that doing this work well means living with permanent low-level dread. There's always another disruption coming. Always another shortage to prevent. Always another spreadsheet to update with new risk factors.
The door opens and a girl with dark hair in a ponytail sticks her head in
Girl: Mom, are you almost done? Ms. Rodriguez says the cooling center closes at six.
Rita: Twenty minutes, sweetie. I promise.
The girl disappears. Rita watches the door close
That's Zoe. She's applying to high schools next year. In Milwaukee, you can choose between different schools in the district. She wants to go to Riverside, which is a great school, really strong academics.
But Riverside is in a flood zone.
The basement flooded in 2031 and again in 2033. They've done some improvements, but the whole neighborhood is built on low-lying land near the river. With the extreme precipitation we're getting now...
So I'm looking at high schools and thinking about four-year flood probabilities. I'm thinking about whether the district will close schools in vulnerable areas and consolidate. I'm thinking about whether we should move to a different neighborhood, except the neighborhoods on higher ground are more expensive and farther from the hospital.
I'm thinking about all of this, and I'm also thinking: this is insane. I'm a supply chain director, not a hydrologist. I shouldn't have to factor climate risk into my kid's high school choice.
But I do. Because that's the world now.
What do you tell her about the future?
long pause
I tell her the truth, as much as I can. That things are hard and getting harder. That the climate is changing in ways that affect everything—where we live, what jobs exist, what normal life looks like. That she'll need to be adaptable and resilient and probably more careful about big decisions than my generation was.
I also tell her that people are working on solutions. That we're learning. That hospitals are getting better at this—we're not just reacting anymore, we're planning. Other cities are figuring things out too. Technology is improving.
pauses again
I don't know if I believe that last part. But I need her to believe it. She's twelve. She deserves to think she has a future.
The thing that kills me is that she's already making calculations I never had to make. She asked me last month about college—where she should think about going. Not what she wants to study. Where. As in, which parts of the country will be livable in 2040.
She's twelve years old and she's already thinking about climate refuge.
looks at her computer screen
I need to wrap up. I have a vendor call at five about backup suppliers for IV fluids, and then I need to get Zoe home before the heat advisory kicks in.
But here's what I want people to understand: this isn't some future scenario. This is now. I'm living it. Zoe's living it. Every hospital in the country is living some version of it. We're making impossible choices with inadequate resources, and we're doing it while pretending everything is under control because patients need to believe their hospital can take care of them.
And the really fucked up part? Milwaukee is one of the good places. We have resources. We have water. We have a community that mostly works together. I can't imagine doing this job in Phoenix or Miami or Houston.
stands up and starts gathering her things
Someone asked me at a conference last year if I thought healthcare supply chains would stabilize in the next decade. I said, "Define stabilize."
They didn't have a good answer.
Neither do I.