Health Risks Due To Climate Change: Inequity In Causes And Consequences
The importance of equity and sustainability to community resilience have become major concerns for the global community. In 2015 three major international conventions (the 2030 Agenda for Sustainable Development,1 the Paris Agreement under the United Nations Framework Convention on Climate Change,2 and the Sendai Framework for Disaster Risk Reduction3) laid out the risks and opportunities over the coming decades to achieve resilient and sustainable communities. Health is central to all three agreements. The tragedies of the coronavirus disease 2019 (COVID-19) pandemic have reinforced the deep connections between population health and overall societal resilience. The pandemic is highlighting the centrality of effective public health and health care systems and the importance of reducing poverty, decreasing inequities, increasing universal health care, and promoting food and water security. Healthy populations and responsive health systems are central to the quality of life and the economic growth and development of any country. As COVID-19 powerfully illustrates, the costs of ill health include treatments and hospital admissions; lost work hours; and less tangible costs caused by pain and suffering and by burdens on one’s family and others in the community.4
Climate change has the potential to present analogous, if not more profound, challenges to population health and society. Without proactive actions to prepare for and manage climate change, the burdens of ill health are projected to increase during the coming decades, with sustained detrimental impacts.5 The greatest health harms will continue to be seen in populations where exposure and susceptibility are high and in countries that have contributed the least greenhouse gas emissions.5 Climate change invokes deep ethical concerns over equity in impacts and responsibilities. Just twenty countries are the source of more than 80 percent of all current greenhouse gas emissions, with more than 40 percent of emissions coming from China (28 percent) and the US (14 percent) alone.6 Historically, the US is responsible for more than 25 percent of all greenhouse gas emissions.6 Future inequities are expected to increase with additional climate change and with adaptation and mitigation options that, if not carefully designed and implemented, could further marginalize vulnerable populations.7
Concerted action is becoming an urgent priority. The environmental impacts of climate change are broadly apparent. Climate change is altering the mean and variability of weather variables and sea level rise, shifting many regions into new climate regimes. The Intergovernmental Panel on Climate Change concluded in 2019 that the mean land surface air temperature in 2006–15 was 1.53°C higher than it was in 1850–1900.8 There was considerable variability in regional warming, with hotspots in the Arctic, western Africa, South America, and Eastern Europe.
In this article we review the health risks of a changing climate from an equity lens, discuss the transformational resilience needed to prepare for and manage a very different future, and provide concluding comments.
Key Health Risks And The Need For An Equity Lens
There are a wide range of climate-sensitive health risks. Those discussed here include injuries and deaths from extreme events (for example, heat waves, storms, and floods), infectious diseases (including food-, water-, and vectorborne illnesses), and food and water insecurity. Other risks include the health impacts associated with drought and wildfires, and respiratory diseases associated with poor air quality. Health impacts associated with loss of livelihoods and conflicts over resources and migration are also of significant concern. With increasing information, estimated burdens in other areas (for example, mental health) also will likely increase.
Interactions between climate change and demographic, socioeconomic, and other factors, including inequities, will determine the future burden of climate-sensitive health outcomes.9 The health risks of climate change are and will continue to be distributed inequitably, with vulnerable populations and regions differentially affected. Some population groups (for example, older adults, people with chronic illnesses, people with mobility challenges, the poor and isolated, Black and Indigenous populations and other people of color, certain occupational groups, and women and girls) will suffer a disproportionate share of the impacts because of heightened physiological sensitivities, greater exposures, or less capacity to take protective actions.4 Effectively preparing for and reducing the burden of climate-sensitive health outcomes requires explicit attention to addressing inequities in the social determinants of health—the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
Extreme Weather And Climate Events
Interactions among the land, oceans, atmosphere, and cryosphere determine our climate. Climate change is altering how energy moves between these elements. Chemical energy in fossil fuels is transferred into kinetic energy used to produce power for humans, with byproducts that lead to enhanced solar energy retention in the atmosphere. The associated warming increases the frequency, intensity, and duration of some weather and climate events, such as heat waves, heavy precipitation, and droughts in some regions.8 Preventable injuries, illnesses, and deaths occur during and after extreme weather and climate events.10 Chronic medical and mental health conditions also can be adversely affected by extreme events and their aftermath. Further, as witnessed after recent hurricanes, these events can disrupt critical public health, health care, water and sanitation, and food distribution systems and adversely affect the health of the affected populations long afterward. In coastal regions and along major riverways, many hospitals and other facilities are located in places subject to flooding and storm surge.
Heat waves are the leading weather-related cause of death in the United States.11 Increased mortality from high ambient temperatures has been well documented worldwide,12 with additional health risks being increasingly identified, such as increased rates of preterm births, low birthweights, and stillbirths.13 High ambient temperatures also adversely affect the productivity and health of outdoor workers and workers in settings that are not climate controlled.14 The health consequences of exposure to high ambient temperatures are not evenly distributed either within or across societies.15
Multiple factors determine the incidence of climate-sensitive infectious diseases such as malaria, dengue fever, Lyme disease, West Nile virus, and diarrheal diseases. Environmental factors such as land use and climate change–related impacts on ecosystems can create, increase, or decrease suitable habitats for vectors, possibly leading to the geographic spread or contraction of associated diseases.7 Trade, travel, and other socioeconomic changes also can facilitate emerging or reemerging infectious diseases, in part through introduction from other regions.16 As the COVID-19 crisis illustrates, proactive investments in health systems are critical to ensuring preparedness and surge capacity when diseases emerge.
Temperature and precipitation are key determinants of where mosquitoes and ticks are active, and temperature also affects the replication rate of the pathogens they spread, such as dengue virus. Increasing temperatures could facilitate the spread of vectorborne diseases in some regions; other regions may become too hot or dry for disease transmission. Heavy precipitation can wash away vector breeding grounds, leading to temporary decreases in disease transmission. Changing weather patterns can interact with other factors, such as human behavior (for example, people moving to forested areas with increased risk for transmission of Lyme disease) and the effectiveness of health systems in reducing risks. El Niño events may provide insights into the extent to which climate change could alter infectious disease transmission.17 Risks at higher temperatures could increase or decrease, depending on regional climate change and disease ecology.18
For example, dengue fever is the most important arthropod-borne viral disease globally, and transmission is closely associated with ambient temperature. Incidence increased thirtyfold during the past fifty years to approximately 390 million infections annually.19 Half of the world’s population is at risk. The four serotypes of dengue are carried by two species of Aedes mosquitoes; the principal vector in the US is Aedes aegypti. During the past 110 years the global abundance of A. aegypti increased about 9.5 percent, with the largest increase (8.2 percent) over the past two decades in response to rapid warming.20 Under a low-greenhouse-gas-emission scenario, the average increase in mosquito abundance is projected to be 8.2 percent per 1°C warming over this century. Assuming high levels of greenhouse gas emissions, a 20 percent increase in mosquito abundance is projected, after which a slight decrease is anticipated as temperatures become too hot for this type of mosquito to thrive. Socioeconomic development also affects the projected abundance of A. aegypti. Poleward shifts of A. aegypti are expected by the end of the century if the mosquito tracks optimal temperature ranges, with increased risks of transmission threatening nearly a billion people with new exposure to dengue, Zika, chikungunya, and yellow fever.21
Food And Water Safety And Insecurity
This century also will be marked by increasing challenges to food and water security. After a prolonged period of decline, the number of people suffering from hunger worldwide increased from 797 million in 2016 to more than 821 million in 2018 (one of every nine people on the planet). The inclusion of people affected by moderate levels of food insecurity means that more than two billion people do not have regular access to safe, nutritious, and sufficient food, including 8 percent of the population in Northern America. In 2018, about 149 million children younger than age five were stunted, and 40 million were overweight. Climate variability and change, including extreme weather and climate events, are exacerbating these trends.22
Climate change threatens food security through its impacts on agriculture, food, health, and both sociodemographic and economic systems.8 Other environmental changes may amplify these impacts, such as biodiversity loss (including loss of pollinators), depletion of fisheries, soil degradation, and freshwater depletion. The impacts of climate change on agricultural yields, pests, and food prices and supplies are projected to have major implications for sustainable development, inequality, poverty eradication, and the achievement of the Sustainable Development Goals.8 Limiting warming to 1.5° C compared with 2° C is projected to result in smaller net reductions in yields of maize, rice, wheat, and potentially other cereal crops, particularly in sub-Saharan Africa, Southeast Asia, and Central and South America. Further, carbon dioxide, the main greenhouse gas driving climate change, is causing ocean acidification and reducing the nutritional quality of major cereal crops by decreasing concentrations of protein, micronutrients, and B vitamins.23 Livestock are projected to be adversely affected by rising temperatures, depending on the extent of changes in feed quality, spread of diseases, and water resource availability.8
Climate change interacts with other challenges related to land use and the depletion of productive ecosystems. For example, the dietary choices of humanity are changing.24 With rising affluence, people consume more meat and dairy products, increasing livestock demand and contributing to climate change through deforestation and methane production. Increasing affluence and urbanization also result in greater conversion of land to agricultural uses. In 2017, fish accounted for about 17 percent of total animal protein consumed globally, providing 3.3 billion people with almost 20 percent or more of their animal protein intake, primarily in low- and middle-income countries.25 With 60 percent of current fish stocks being harvested at maximum levels and 30 percent overfished, people who rely on fish as a critical source of food are vulnerable to food insecurity.26
Climate change during the twenty-first century is projected to reduce renewable surface water and groundwater resources significantly in most dry subtropical regions, intensifying competition for water across sectors such as urban, agriculture, and energy.27 In many regions, changing precipitation or melting perennial snow and ice are altering hydrological systems, reducing water quantity and quality. These changes can negatively affect human health through increases in waterborne diseases, as illustrated by studies from Africa and Asia showing that extreme events, such as floods, may exacerbate the risks for infectious diseases spreading through water systems.28
Coordinated regional and national strategies aimed at transformational resilience are best suited to the tandem needs of reducing vulnerability and limiting further dangerous climate change. This strategy should include parallel government policies and investments in social and health protections aimed at reducing inequities and investments in climate change mitigation and adaptation. Progress toward these goals has been somewhat limited, however, and synergies have not been realized.
Mitigation, or reductions in greenhouse gas emissions, is needed to reduce health risks over the longer term. Emissions come from many sources, including power plants, industrial processes, mobile sources, and agricultural activities. These sources emit a range of particles, gases, and precursors of pollutants that directly or indirectly affect health and increase the risk for a range of illnesses and premature deaths.29 Ambient air pollution from particulate matter and ozone causes approximately 4.5 million deaths worldwide annually.29 Therefore, reducing emissions from these sources would reduce pollutants that directly harm health and decrease greenhouse gas emissions, benefiting public health and offsetting mitigation costs.
Greenhouse gas emissions from the transportation sector are large, at approximately 23 percent of the global total, and are growing rapidly,30 becoming an even larger proportion of total emissions as more renewable energy is used in energy production. Transportation choices have multiple impacts on health. Traffic-related injuries, physical inactivity, air pollution, noise, and other issues are associated with car use, causing 185,000–330,000 premature deaths annually worldwide.31 The human and financial costs of morbidity and mortality from transportation-related inactivity are much broader and more substantial. Transportation policies are powerful opportunities to reduce related morbidity and mortality and simultaneously reduce greenhouse gas emissions. Increasing equitable access to public transit not only reduces emissions but also increases economic opportunity, access to health care, and access to healthy food.
Dietary change is also an important opportunity for generating health and climate co-benefits.32 Among foods, red meat results in the highest greenhouse gas emissions and is associated with higher levels of cardiovascular disease, stroke, type 2 diabetes, and some cancers.32 Diets containing mostly minimally processed plant foods, whole grains, and pulses (for example, beans and lentils) are associated with lower levels of noncommunicable disease and greenhouse gas emissions.
Mitigation ambition has flagged in the US under the Trump administration, but the health sector has a significant role to play, starting with reducing its own greenhouse gases from health care infrastructure. For example, the US health care system contributes 10 percent of the nation’s carbon emissions and 9 percent of harmful non–greenhouse gas air pollutants.33 The health sector can also raise awareness of the harms of climate change and of the benefits of mitigation activities described here.
Within the climate community, adaptation refers to the process of adjustment to actual or expected climate and its effects. In human systems, adaptation seeks to moderate or avoid harm or exploit beneficial opportunities.34
From the point of view of health services, adaptation priorities include a health workforce with the knowledge and tools to promote climate resilience; health information systems that support the effective management of the health risks of climate change, such as early warning systems; effective service delivery; and adequate financing, including attention to financing in other sectors (such as property insurance) to limit indirect health effects (for example, mental health effects of catastrophic household losses from extreme weather events).4 Synergies and trade-offs of actions in other sectors need to be considered.
In practical terms, adaptation in many contexts entails modifying existing programs and activities. Most climate-sensitive health risks are already sources of morbidity and mortality, and there are policies and programs in many countries for preventing and managing them. But these policies and programs were developed without considering climate change. Because most risks are projected to increase with each additional unit of warming,18 additional public health interventions are needed, including new programs in countries to which diseases could spread. The Centers for Disease Control and Prevention developed the BRACE framework (Building Resilience Against Climate Effects) to help health departments manage climate change health risks, including modeling to project risks, engaging all relevant stakeholders, and regularly updating models and risk management plans as new information becomes available.35
Early warning and response systems are important adaptation options. These systems can save lives and protect health care facilities in extreme events. Early warning and response systems for infectious diseases, based on temperature, precipitation, and other environmental data, can lead to early outbreak detection, providing more time for health systems to implement vector and disease control programs and increase public awareness, and thus reduce the magnitude of the outbreak.36 To be effective in a changing climate, early warning and response systems need to become more widespread; include reliable forecasts; and link to response measures aimed at health systems, communities, and individuals. Interventions need to be appropriate, effective, and within the lead time of the warnings, and they should prioritize the needs of the most vulnerable. These systems also need to explicitly incorporate into their operations how climate change is altering the seasonality and severity of changing extremes.37
Early warning and response systems also need to recognize and accommodate the increasing probability of connected extremes—for example, not just individual heat waves or severe storms, but multiple events occurring in sequence or concurrently in multiple locations.38 These connected and compound events are projected to constitute a greater proportion of future extremes, putting more people at risk and challenging the effectiveness of current early warning systems. Early warning and response systems should be embedded within broader action plans that include other interventions to reduce risk, such as heat mitigation plans to modify urban infrastructure to prepare for a warmer future.39 Nature-based solutions that harness protective effects from green (for example, parks) and blue (for example, bodies of water) spaces can protect against extremes and also contribute to population health.
Using an equity lens would facilitate moving beyond incremental adaptation to increase resilience and sustainability.
In some contexts, a different approach to adaptation will be required. Later in the century, at higher degrees of warming, and in climate change hotspots, interactions between existing hazards (for example, heat waves and wildfires) are likely to become pronounced, and new hazards (for example, sea level rise) will present unprecedented challenges. Thresholds may be crossed that could result in nonlinear responses, resulting in sudden, large increases in disease burdens or putting new populations at risk. Adaptation options focused only on current vulnerabilities might not be sufficient to protect against health risks from future and possibly more severe climate change.40,41 Successful adaptation in these contexts will require development, implementation, evaluation, and modification of interventions to increase their effectiveness in the face of ongoing climate and societal change. Using an equity lens would facilitate moving beyond incremental adaptation to increase resilience and sustainability.
Regardless of the context, key approaches to understanding and managing the health risks of climate change include conducting vulnerability, capacity, and adaptation assessments and developing the health component of national or regional adaptation plans.42 A vulnerability, capacity, and adaptation assessment provides evidence-based information on current associations between weather and climate and health outcomes, identifies vulnerable populations, projects future risks, and identifies opportunities to build resilient communities and health systems. The assessments identify and prioritize policies and programs to address the health risks of climate change. These assessments also help build needed partnerships across sectors, such as meteorological services, to obtain data and information needed for modifying current and implementing new policies and measures to prepare for additional climate change.
Progress on adaptation to date has been hobbled by negligible funding for health adaptation (which totals less than 0.5 percent of international climate adaptation finance), leading the 2018 Adaptation Gap Report to conclude that “there is a significant global adaptation gap in health, as efforts are well below the level required to minimize negative health outcomes.”43 Research funding for understanding and managing the health risks of climate change is even smaller.44,45
Climate variability and change are harming human health—primarily affecting the most vulnerable—and health risks associated with these changes are projected to increase with additional warming. Because climate-sensitive health risks are current sources of injuries, illnesses, and deaths, explicitly incorporating climate change into policies and programs in health systems and in ministries and departments responsible for the upstream drivers of health, such as water and agriculture, could avoid some of the projected morbidity and mortality. Health systems also will continue to need to manage increases in the burden of climate-sensitive health outcomes. Proactive and effective actions by health systems, in collaboration with health-determining sectors, can increase resilience as the climate continues to change, but substantial additional funding is required.
Kristie Ebi reports having received occasional support from the World Health Organization (travel), Green Climate Fund, and Global Commission on Adaptation.
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