Climate Change Impacts, Vulnerability, and Adaptation in the Health Sector Introduction Global temperatures have been increasing steadily since pre-industrial times due to the accumulation of greenhouse gases (GHG) in the atmosphere, mainly a result of anthropogenic activity (St. Louis and Hess, 2008). As a result of this climate change, there have been severe global impacts taking place in the form of extreme weather events (Klein, 2014). Health implications resulting from the mentioned weather events are, however, inequitably distributed; while GHG accumulations originate largely from wealthy/industrialized countries, the resulting burdens fall mainly on poor countries already suffering from poor health, and without sufficient capacity to deal with such events (St. Louis and Hess, 2008). As such, vulnerability in the face of climate change varies on different levels (individual to regional) and depends on a number of factors (Smith et al, 2014). Adaptation and mitigation, to be further expanded on throughout this paper, are both measures designed to deal with climate change and the subsequent extreme weather events (UNISDR, 2009). A threshold target for global warming has been set at 2ยบC; however, considering the events that have resulted from a 0.8ยบC increase to date, the immediate urgency for adaptive and mitigating measures that reduce population vulnerability is highlighted (Klein, 2014). The following sections expand on the concepts of climate change impacts, vulnerability, and adaptation with a focus on human/public health, emphasizing particularly on the nature of different impacts, their associated vulnerabilities, and general adaptation measures to address them. Finally, the paper will analytically explore some of the limitations to climate change adaptation in the health sector, before concluding with a general overview of the findings and brief suggestions on how the mentioned limitations might be addressed.
Impacts, vulnerability, and adaptation With the ongoing increase in global warming, mean temperatures are expected to increase between 1.4ºC and 5.8ºC (over pre-industrial conditions) by the end of this century (Haines et al, 2006). Such a temperature rise is expected to result in an increase in the frequency, intensity, and/or duration of extreme weather events, namely: heavy rainfall; heat waves/warm spells; droughts; storm surges; and sea-level rise (Revi et al, 2014). With the current 0.8ºC increase in global temperatures, such extreme weather events are already taking place globally, and are progressively getting worse (Klein, 2014). Due to this, a number of urban sectors (water, energy, transportation and telecommunication, infrastructure, and health) are undergoing – and will continue to undergo – considerable stresses due to such events (Revi et al, 2014). Climate change impacts refer to certain changes in a system caused by exposure to climate change, such as the mentioned extreme events; vulnerability, therefore, refers to a system’s susceptibility or inability to cope with adverse impacts of climate change, variability, and the resulting extreme weather events – it is a function of a systems exposure, sensitivity, and adaptive capacity (Schneider et al, 2007; IPCC, 2007). Factors that influence vulnerability include geographical location, current health status, age/gender, socioeconomic status, and public health systems – usually occurring in combination, not autonomously (Smith et al, 2014). In order to reduce vulnerability to climate change, adaptation and mitigation are typically applied measures (UNISDR, 2009). Mitigation refers to measures taken to reduce GHG emissions with the aim of reducing the frequency and intensity of climate-related impacts; whereas adaptation refers to the adjustment of natural/human systems in response to actual or anticipated climaterelated events in order to minimize harmful effects and exploit beneficial opportunities (IPCC, 2007). There are three pathways by which climate change can impact health: directly, or mediated through natural or human systems (Smith et al, 2014); the following sections expands on the three pathways, highlighting population vulnerability in relation to each.
Direct impacts Direct impacts of climate change are related to an increase in the frequency of extreme weather events, including heavy rain, heat, and drought (Smith et al, 2014). In order to further elaborate on the direct impacts of climate change and the associated vulnerabilities, a heat wave that struck France will be considered as an example, mainly due to availability of empirical data associated with the event. France was struck by a severe heat wave in 2003, during which, 14,802 mortalities were recorded and have been considered ‘likely’ attributable to the event (Haines et al, 2006). Through epidemiological studies related to the event, it was found that people aged above 75 years accounted for 80% of the extra deaths (Smith et al, 2014). Also, it has been suggested that due to a relatively mild influenza season from the previous year, more people may have been vulnerable/susceptible at the time the heat wave struck (Smith et al, 2014). Having considered this example, important observations can be made regarding vulnerability determinants; in particular, population susceptibility to harm in this particular event was a function of current health status and old age. This example also shows that even in developed countries, such as France, climate-related events can occur sporadically and have severe implications. Floods are also extreme events that impact populations ‘directly’ as a result of climate change. Although mortality is the only ‘direct’ health implication that can be statistically correlated to flooding, other related implications include hypothermia, infectious diseases, and mental health (Smith et al, 2014) – mediated through natural and human systems.
Impacts mediated through natural systems Climate change can also impact human/public health by means of natural eco-systems; examples include vector-borne and other infectious diseases, food- and water-borne infections, and poor air quality (Smith et al, 2014). Due to their common occurrence and sensitivity to
climate-related factors, vector-borne diseases (VBD) are the most thoroughly studied climateassociated diseases (Smith et al, 2014); as such, they will be studied with closer detail in this section. VBDs are human-contracted infections transmitted through biting, by blood-sucking arthropods (e.g. mosquitoes, ticks, etc.) (Smith et al, 2014). Two specific VBDs (malaria and dengue fever) will be considered here to further explore impacts and vulnerability in relation to such climate-sensitive diseases. Malaria
and
dengue
fever
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a
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infections/manifestations yearly, despite the fact that malaria control measures have advanced significantly over the last two decades (Smith et al, 2014). Dengue fever Dengue fever – the fastest spreading mosquito-borne viral disease (incidence rate increased by 30 times over the last 50 years) (WHO, 2013) – results in 390 million yearly infections worldwide, 96 million of which manifest with symptoms (Bhatt et al, 2013). Studies have shown that typhoons in Taiwan affect dengue fever and vector population, as heavy rainfall, high humidity, and water pooling provide fresh breeding sites for mosquitoes (Smith et al, 2014). Droughts have also been considered to influence dengue fever transmission as households tend to store water in containers, which also offer suitable breeding sites for mosquitoes (Smith et al, 2014). Malaria In 2010, there were approximately 216 million malaria episodes globally, resulting in 1.24 million deaths (WHO, 2010; Murray et al, 2012). Studies have shown that precipitation and temperature influence the abundance, distribution, and disease transmission of malaria in different ways (Smith et al, 2014). Socioeconomic factors and health interventions have also been found to be strongly influential in terms of malaria transmission (Smith et al, 2014).
Adaptive health control measures have reduced the proportion of the world’s population that is affected by malaria with time (Smith et al, 2014). Having studied these two specific VBDs that are influenced by extreme climate-related events, certain generalizations can be drawn in relation to population vulnerability. Vulnerability to such nature-related impacts depends on geographical location (extreme events vary according to location), socioeconomic status, and strength of public health system (availability of vaccinations/health control measures).
Impacts mediated through human systems The third pathway by which climate change can impact health is through human-related systems/institutions: nutrition, occupational health, mental health, and violence/conflict (Smith et al, 2014). Nutrition is the most heavily researched of the mentioned impacts (Smith et al, 2014), and will therefore be focused on in order to further elaborate on impacts and population vulnerability. Nutrition is a product of three factors – agricultural production, socioeconomic factors, and human diseases – all of which are influenced by climate change (Smith et al, 2014). One of the main implications of climate-related impacts on nutrition is that extreme events (floods, droughts, heat waves) affect the quantity and quality of agricultural harvests; as a result, this increases food prices, reduces food consumption and affects nutritional health (Smith et al, 2014). Studies have been carried out to further understand the relationship between climate change and nutrition, and found that climate change will have a negative impact on calorie availability per capita, childhood under-nutrition, and child deaths and DALYs lost related to under-nutrition in developing countries (Smith et al, 2014). Through the mentioned findings, it can be seen that factors such as age and socioeconomic status play an influential role in determining population vulnerability in relation to nutritional health.
Adaptation to climate change Having mentioned the different ways in which climate change can impact human health and the criteria determining population vulnerability, this section focuses on the adaptation measures that can be taken to address these concerns. Successful adaptation can substantially reduce the vulnerability of populations and the implications of climate change. Considering Bangladesh as an example, the country has been exposed to severe cyclones over the last 5 decades (Smith et al, 2014). Comparing the death tolls of Cyclone Bhola (1970, category 3 severity – 500,000 deaths) and Cyclone Sidr (2007, category 4 severity – 3,400 deaths), and considering the population grew by over 30 million during the same period, the effectiveness of good adaptation measures (achieved in this case through strong collaborative efforts between the local community and governmental/non-governmental organizations) are clearly visible (Khan, 2008; Mallick et al, 2005; Smith et al, 2014). Adaption measures can be incremental (improving health care/public health services without focusing on the potential climate change impacts), transitional (focusing less on addressing existing adaptation deficits and more on climate change – how it could affect health burdens and the effectiveness of adaptive interventions), or transformational (significant changes in systems) (Smith et al, 2014). The level/intensity of adaptive measures depends on the current burden of ill health (amount of death/disability in a population), success of current interventions, health burden projections, feasibility of implementation, external influences, and social, economic, and political context (Ebi et al, 2006). Health adaptation measures include improving public health/healthcare services, implementing policies, incorporating early warning systems, and involving other relevant sectors (Smith et al, 2014). While adaptation at all levels is important, incremental approaches taken improve basic public health/health care services are especially so, as the current health status of a population is potentially the most important indicator of climate change impacts on health in the future, and the costs of adaptation measures (Pandey, 2010).
Challenges to adaptation in the health sector Adaptation efforts are being applied globally in an attempt to address the health implications of climate change; however, these efforts do not always result in the desired/expected outcomes. This section focuses on some global adaptation efforts, and details some of the complications/limitations standing in the way of effective/sustainable implementation.
Funding and evaluation To achieve global health goals and improve the health status of those living in low- and middleincome countries, it is crucial to strengthen the healthcare system in the long-term (Accordia Global Health Foundation, 2010). Long-term adaptation involves building research capacity (and capacity-building in general), as it is one of the most effective/sustainable ways of pushing health and development forward (Accordia Global Health Foundation, 2010). Unfortunately, unlike emergency aid, long-term capacity building lacks immediate gratification (Accordia Global Health Foundation, 2010). As such, the ways by which success of capacity-building is quantified and evaluated should be improved; at the moment, success is measured paradoxically in relation to demand (the better it works, the less it’s needed) (Accordia Global Health Foundation, 2010). The urgency for more effective evaluation measures is evident in funding patterns for global health. Funding in global health has been increasing exponentially, quadrupling in sum over the last two decades (Accordia Global Health Foundation, 2010). However, in a rush to obtain quick/measurable results, funds are often invested in separate structures/interventions, as opposed to ways by which the weak health system could be strengthened, which could lead to more sustainable adaptation (Accordia Global Health Foundation, 2010). Institutions in low/middle-income countries – universities, research centers, health profession schools (those with the potential to strengthen the health system) – did not
see their funding increase proportionately to global health funding (Accordia Global Health Foundation, 2010).
Data limitations Relationship between climate change and health Sufficient evidence exists of the effects of weather/climate change on health; however, only a few studies exist focusing on the effects of climate change itself, linking certain impacts specifically to health implications (Smith et al, 2014). The reason for this is the scale by which climate change is defined – typically in decades (Smith et al, 2014). In order to obtain robust studies, the following would be required: extremely long-term data series on climate and disease rates, and information on other causative factors (established or potential), along with statistical analyses attributing changes in health states to the mentioned factors (Smith et al, 2014). However, long-term studies are often unattainable as when health risks are generally identified, health agencies are obliged to intervene immediately, nullifying the study (Smith et al, 2014). In circumstances where long-term health surveillance data is in fact available, interpretation of the data may be complicated due to changes in important health determinants over time, and ways by which diagnoses may be recorded (Haines et al, 2006). Disaster classification Challenges exist in obtaining health data as a result of disaster classification. Disasters are defined as “a serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources” (UNISDR, 2009:9). Disasters can be of varying sizes; however, it is important to note that larger disasters are often responsible for the highest number of deaths, whereas smaller ones often claim the largest economic losses – this is of particular importance to people living in ‘urban slums’
because smaller disasters are more frequently occurring, and cause populations to experience higher levels of vulnerability (Kovats et al, 2014). This information is important because EM-DAT (the only global disaster database including health impact data and allowing open access) only includes a disaster in their dataset if the following criteria have been met: 10 or more deaths, 100 or more affected, state of emergency declared, or international assistance is requested (Kovats et al, 2014). As a result of these criteria, ‘smaller’ disasters often occur while their health impact data goes unrecorded (Kovats et al, 2014). It is also important to note that EM-DAT reports primarily at a national-level, leaving very general and often incomplete sets of data in relation to disasters in urban slums (Kovats et al, 2014).
Future predictions In order to effectively prevent adverse health effects resulting from extreme weather events, it is important to have a strong understanding about the nature of the risk, and be familiarized with the evidence base for current health burdens (Kovats et al, 2014). While most attempts to quantify health burdens associated with climate change project a modest 2ºC limitation on mean global temperature increases over pre-industrial levels, research has shown that containing temperature rise to such limitations is doubtful (Smith et al, 2014). Studying global temperature predictions under different RCP (Representative Pathway Concentration) scenarios has shown that under a RCP2.6 scenario (assuming strong mitigation efforts), global temperature increases of at least 1.5ºC and 2.5ºC (over pre-industrial levels) are expected by mid- and late-century, respectively, especially at higher latitudes (IPCC, 2013). Considering the case of a business-asusual scenario (RCP8.5 – where current GHG emission trends remain unchanged by midcentury), it can be expected that global temperatures will rise by at least 2ºC and 2.5ºC (over pre-industrial temperatures) by mid- and late-century, respectively (IPCC, 2013). In addition, temperature rise in Antarctica and a 6-8ºC rise in the Arctic would contribute to sea level rise that would affect coastal cities globally (Revi et al, 2014). This poses a particular challenge
considering a linear relationship between global warming and the associated climate change impacts is not guaranteed; therefore, with the potentially exponential implications of a global temperature rise above the 2ยบC threshold, it is difficult to predict what climate change impacts will ensue, what their subsequent implications on health will be, and thus, what adaptation measures can be taken to address them (Smith et al, 2014).
Conclusion The impacts of climate change on human health can be severe and difficult to address. Having discussed the different types of impacts, levels of vulnerability and measures of adaptation in dealing with climate change impacts in the health sector, a number of restrictive obstacles have surfaced that stand in the way of effective adaptation. Amongst these obstacles were funding allocation, data limitations, and future predictions. In order to overcome these obstacles, certain factors need to be taken into consideration when implementing adaptation measures. Firstly, an emphasis should be placed on improving adaptation evaluation procedures and approaching climate change and its subsequent impacts holistically, taking into consideration both long- and short-term implications. This addresses the funding concern, as funding is currently predominantly allocated to interventions and measures that produce measurable results (e.g. vaccinations), while indirectly neglecting investments that would potentially contribute to longterm adaptation as well (e.g. investments in institutions and research facilities) (Accordia Global Health Foundation, 2010). Secondly, investments should also be allocated to strengthening the data collection capabilities in developing countries, where health data is not currently available, or available in sparse capacities. Finally, as future outcomes of climate change and the resulting implications on health are unpredictable and difficult to anticipate, efforts should be made to mitigate the impacts of climate change and keep temperature elevations within the 2ยบC threshold, if not below. While it is difficult to address all the complications present in adapting
the health sector to deal with climate change impacts, the conclusive suggestions mentioned should serve as a starting point in improving present health status and providing longevity.
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