22 minute read
3 Findings
The following are findings that emerged from both the literature review and the stakeholder discussions. Gaps that stakeholders highlighted in South Africa’s existing response were especially interesting as they may provide opportunities for funders to implement important intersectoral programmes to improve health and climate related outcomes.
3.1 Climate vulnerability and adaptation (V&A) assessment
For most countries, the starting point for thinking through the vast topic of ‘climate change and health’ is to conduct a vulnerability and adaptation assessment.22,23 This assessment process and subsequent outputs helps stakeholders to unpack and understand the impact of climate change on health. The goal of the V&A assessment is to identify priority health risks and adaptation options to manage those risks. The identified priorities, and the data and information collected to inform the V&A assessment, can be used to select a first set of indicators.24 25 Guidance also exists at the healthcare facility level.26 27 A key output of these assessments is to produce Health National Adaptation Plans (HNAPs), aligned with the realities of the communities affected.
South Africa published its own National Climate Change and Heath Adaptation Plan 2014-2019. It was reported to us, however, that implementation was limited. A new plan, coordinated by the Environmental Health team within the NDoH, is currently in the pipeline. We understand that this latest iteration now includes a V&A assessment and is undergoing final review, formatting and sign-off by the Minister of Health.
While it was reported to us by some that there was a comprehensive consultative process, we also heard that engagement was not as wide-ranging or cross-sectoral as some may have hoped. The COVID-19 pandemic, political unrest, more pressing emergencies of extreme weather events and energy shortages, also meant that attention of senior policymakers was often diverted elsewhere.
In anticipation of a the new HNAP being approved and published, there may still be a need for additional technical assistance, support for coordination, and support to access additional funding, including finance that has been set aside for climate-related initiatives.
3.2 Climate-resilient healthcare infrastructure
It is fair to say that, on the whole, new health infrastructure in South Africa is developed with what could only be called a cursory consideration for climate resilience. This holds mostly true
22 World Health Organization (2021). Country Support on Climate Change and Health - Visual Guide https://www.who.int/publications/i/item/country-support-climate-change-health
23 World Health Organization (2021). Climate change and health: vulnerability and adaptation assessment https://www.who.int/publications/i/item/9789240036383
24 World Health Organization (2021). Quality Criteria for Health National Adaptation Plans https://www.who.int/publications/i/item/9789240018983
25 World Health Organization (2022). Measuring the climate resilience of health systems https://apps.who.int/iris/handle/10665/354542
26 World Health Organization (2020). WHO guidance for climate resilient and environmentally sustainable health care facilities https://www.who.int/publications/i/item/climate-resilient-and-environmentally-sustainablehealth-care-facilities
27 World Health Organization (2021). Checklists to assess vulnerabilities in health care facilities in the context of climate change https://apps.who.int/iris/handle/10665/340656 for both the public and private sectors who face different challenges, but both are required to operate in environments with shortages of two mission-critical elements – water and power.
3.2.1 Extreme drought and health services
The delivery of quality healthcare is inextricably linked to the availability of fresh, running water in a health facility. In 2017 the Western Cape experienced its most severe drought on record, with a day zero event28 a very real possibility for large metro areas like the City of Cape Town, and the local government instituting strict water restrictions and monitoring policies to drive down household and business consumption. The Western Cape Department of Health (WCDoH) was facing a situation where radical change in water usage had to happen or facilities may face the prospect of closure.
In discussions with Laura Angeletti-du Toit (Chief Director of Infrastructure and Technical Management) and Krish Vallabhjee (Chief Director of Strategy) at the WCDoH, they noted that many staff in the health facilities needed the shock of imminent closure in order for staff to mobilise and take action. Once sufficiently motivated, it then became easier to instil practices and procedures to reduce overall consumption. Some of these interventions included:
• Process management to reduce required instances of hand scrubbing
• Sourcing of alternative water sources and development of osmosis treatment plant
• Strong collaboration and communication between health services and health infrastructure teams
• Visualisation and clear communication on usage goals and targets.
The challenge for the WCDoH has been to ensure the behaviours instilled during the drought continue to ensure such shortages are avoided in the future. Continued monitoring, visual tools and behavioural insights (BI) have been key in securing good habits, but systemic change is also needed to ensure there is a platform to address climate-related challenges proactively, as opposed to relying on crisis management.
In December 2021, the Western Cape Departmental Climate Change Forum was created and includes representatives from different sectors and universities to investigate and prioritise interventions that assist in developing the province’s climate change resilience.
3.2.2 Energy efficient facilities: the effect of load shedding
South Africa has been battling power shortages for over 12 years, with the last two years recording the greatest number of days of rolling power-cuts; this is termed “load shedding” and is a preventative measure implemented by the national power utility Eskom to stabilise the power grid when it is unable to generate sufficient power supply to meet the country’s demands (see Figure 3)
It is therefore unsurprising that the issue of load-shedding dominates any dialogue around energy efficiency, as it has become part and parcel of doing business in an environment where power is not only scarce, but costly as well. Furthermore, rising temperatures due to climate change are likely to increase peak load demands during hotter summers and reduce outputs of power generating stations due to limited cooling capacities.29
It is rare that any new health facility development is undertaken without the potential loss of power from the national grid in mind. Mitigating measures such as the installation of diesel
28 “Day zero” refers to the first day when municipal water supplies would be largely turned off and residents would likely need to queue for daily water rations.
29 The World Bank Group (2021). Climate Risk Country Profile: South Africa https://climateknowledgeportal.worldbank.org/sites/default/files/country-profiles/15932WB_South%20Africa%20Country%20Profile-WEB.pdf generators and photovoltaic units with battery back-up have now become a standard requirement for uninterrupted operations across many facilities in the public sector and almost all hospitals in the private sector.
The use of back-up power solutions can be further supplemented with the installation of costeffective and energy-efficient electrical components, such as smart lighting and evaporative coolers, with smart metering to ensure areas of excessive power consumption can be identified and managed. The WCDoH noted that they had installed smart meters, donated by Microsoft, in a number of health facilities to monitor water and electricity usage.
*as of 11 July 2022
Figure 3: Annual days of loadshedding and gigawatt hours shed30
3.2.3 Environmental, Social and Governance
(ESG) considerations
While loadshedding has been a positive contributor to more households and businesses moving away from coal, back-up power solutions to ensure operations can continue uninterrupted are not informed by any overarching environmental regulation or mandatory ESG measures. It is also why the adoption of these interventions is often a “bare-minimum” exercise, as the installations need to meet strict cost/benefit thresholds, and long-term ESG return on investment is rarely considered.
This was explored in discussions with LTS Health, a laboratory design and capacity building company. Their clients initially like the idea of building to the maximum “green building” standards but tend to scale down the specifications to just power continuity once the upfront total cost is presented. Christian van Zyl, CEO of LTS Health, said that a compelling business case for the large-scale inclusion of energy-efficient components in a new build has yet to be developed. In his opinion, the solution has to be funding, as no one in Africa is going to undertake this extra work out of goodwill (although he noted the expertise already exists in South Africa) and governments are loathe to legislate it as they don’t want to create bottlenecks in critical areas such as health care delivery. Without legislation or funding, it is unlikely to ever become mainstream, and in most cases serious consideration to ESG goals is only considered if there is funding specifically earmarked for it.
30 Labuschagne H (2022). 2022 is already South Africa’s worst year for load-shedding with 170 more days to go. Mybroadband. https://mybroadband.co.za/news/energy/452132-2022-is-already-south-africas-worst-yearfor-load-shedding-with-170-more-days-to-go.html
This holds true most notably in facilities that are supported by private equity funds linked to foreign institutional investors or governments. Samaritan Healthcare, for example, are backed by the Summit Fund, which is comprised of several large European institutional investors, including British International Investment who have heavy mandates on the execution of their projects. Part of the fund’s mandate is to drive ESG measures within the greenfield projects they invest in. As such, Samaritan Healthcare have significant funding available to them for their new hospital builds to ensure there is “green-proofing” within the development, and the project’s performance is continuously monitored. Reporting to investors on ESG measures once the building is operational must be regular and linked to the project’s internal rate of return (IRR).
At the time of writing, there are no tax or other government incentives linked directly to the reduction in the use of fossil fuels, GHG emissions or the use of alternative power sources. It was noted by Samaritan that the lack of federal regulation on ESG measurables in South Africa is one of the factors that makes their projects executable, as additional requirements over-andabove the fund’s mandate would likely have a negative effect on the project’s IRR, and therefore would be unlikely to be funded in the first instance.
In our discussions with both LTS Health and Samaritan Healthcare, it was clear that infrastructure developers will only “go green” if there are earmarked funds or mandated ESG requirements. While government mandated ESG regulations are an important or even necessary step to encourage green building more widely, it may also disincentivise investment if strict requirements make funding less desirable. Therefore, these regulations need to be carefully aligned and utilise an investment case that shows compelling evidence for the longterm cost savings of green building. This investment case can be developed sooner in the absence of ESG regulations in order to stimulate progress in this space.
A thought piece by PWC South Africa from July 2022, in which representatives of eight healthcare subsectors were surveyed, found low priority given to environmental and climate related aspects of healthcare delivery 31 Its overall ESG finding is summarised as “The healthcare industry needs an increased focus on ESG initiatives and measurements”, further stating that “the impact of climate change and any mitigating actions taken by organisations rarely featured in the research.” Despite global ESG efforts in healthcare, 29% of the survey respondents reported having no ESG plan or focus for their organisation. Furthermore, there was a clear higher degree of importance given to the social and governance measures within the ESG plans, with the environment pillar being the only one to receive responses (6%) saying that it was not an important consideration
These results are unsurprising given the social and political environment of South Africa. It is currently recognised as the country with the highest level of income inequality, thus social development is a major priority, and corruption scandals are a common staple within political discourse, leading to calls for stronger governance frameworks across all sectors.
These findings corroborate the assertions of both LTS Health and Samaritan Health in terms of the low priority of the environmental and climate change-related aspects of healthcare delivery. Yogan Pillay, the Country Director of the Clinton Health Access Initiative (CHAI), said that there is still an unfair view of green infrastructure as “luxury”, but that there is increasing push towards “necessity”. In our discussion with James Irlam from the University of Cape Town, he noted that some engineers are championing a green agenda for hospitals, and more hospitals are being built with sustainable design principles in mind.
31 PwC South Africa (2022). South African Healthcare Reimagined: Industry Insights https://www.pwc.co.za/en/publications/south-african-healthcare-reimagined.html
3.2.4 Pandemic-resilient infrastructure
In addition to the climate considerations of energy and water, infrastructure will increasingly need to consider the risk of infectious disease transmission as climate change alters the landscape and interactions between humans, wildlife, and the environment, leading to increased opportunities for zoonotic diseases to infect humans. The frequency of pandemic events is predicted to increase in the coming decades, and the ‘slow-burn pandemic’ of antimicrobial resistance (AMR) threatens to render our arsenal of treatments ineffective. Similar to climate change, AMR is among the most pressing global threats, currently causing around 700,000 deaths annually. In our discussion with Gina Pocock from Waterlab, she raised the point that AMR is an important issue in South Africa particularly because of the number of immunocompromised people due to HIV/AIDS. Pandemic-resilient infrastructure will only become more important as the risk of new diseases emerging increases and effective treatments become more limited for an already at-risk population
Many infrastructure features that are impacted by climate change are also integral to infection prevention and control, such as water availability (clean drinking water, handwashing facilities), wastewater and solid waste management, and ventilation and air quality (mechanical ventilation, air filtration, air pollution). For example, vector-borne diseases such as malaria are predicted to increase as climate change could broaden the geographical distribution of the mosquito vector in South Africa, and therefore screens should be installed on openable windows to prevent mosquitoes and other insects from entering the building. Rodent-borne diseases are also an increasing concern with climate change, as they can be associated with flooding or damaged waste systems.
According to our stakeholder interviews, pandemic resilience features are not currently a consideration in building or retrofitting infrastructure. There is an opportunity to link some of these features with the increasing attention on climate resilience, as they are closely associated. Andrea Rother from University of Cape Town made the point that informal settlements and townships have drastically inadequate infrastructure to deal with health concerns including infection prevention and control.
3.3 Supply chain inefficiencies
A 2019 paper released by Health Care Without Harm in collaboration with Arup – “Health care’s climate footprint: How the health sector contributes to the global climate crisis and opportunities for action”32 – states that 71% of health care sector emissions come from the supply chain “through the production, transport, and disposal of goods and services, such as pharmaceuticals and other chemicals, food and agricultural products, medical devices, hospital equipment, and instruments”. Despite this, the supply chain is often not foremost in discussions relating to the impact of the health care sector on climate change.
Conversely, health care supply chains’ resilience has a high probability of being severely impacted as climate change makes extreme weather more frequent and more severe, disrupting logistics, infrastructure, transport, and suppliers. Extreme weather events will become increasingly likely to disrupt supply chains internationally and domestically, as was the case during the recent floods in KwaZulu Natal (KZN). It was warned that the escalating medicine supply crisis in KZN could affect the rest of the country as key distributors, wholesalers and pharmacies were impacted by the floods, as well as the health facilities that were damaged or destroyed. There is also a risk that increasing intensity or frequency of storms at sea can damage sensitive medical equipment during sea transport.
32 Karliner J, Slotterback S, Boyd R, Ashby B, and Steele K (2019). Health care’s climate footprint: How the health sector contributes to the global climate crisis and opportunities for action https://noharmglobal.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf
During the COVID-19 pandemic, medical supply chains were drastically disrupted as manufacturers and distributors worldwide struggled with the impacts of the pandemic. International supply chains were especially vulnerable to delays due to border closures and new measures imposed by governments. This has sparked renewed calls for domestic manufacturing and procurement, which also has a positive effect on reducing GHGs. Laura Angeletti-du Toit and Krish Vallabhjee at the WCDoH said that much of South Africa’s medical equipment is procured from overseas, especially China, and the transport of that equipment has a large carbon footprint; they would like to push the agenda for more local procurement and manufacturing of medical equipment. Local production of pharmaceutical ingredients could also negate the need to import many active ingredients, as is currently the case in South Africa.
Rob Botha, Chief of Party, Global Health Supply Chain - Technical Assistance at Guidehouse, said that there are many opportunities to improve efficiency and reduce waste and GHG emissions in the medical supply chains in South Africa. A significant inefficiency highlighted is the separate, parallel medical supply chains for the public and private health care sectors, which have different warehouses and deliveries. More direct delivery from the manufacturer or distributor, rather than using central storage warehouses, would shorten the supply chain and allow consolidation of the distribution network by combining deliveries to public and private facilities at the same time. Combined deliveries would mean fewer vehicles on the roads and less packaging material, though the drawback is that there is no backup in the event of a security issue. In addition, the veterinary and agricultural antimicrobial supply chains are almost entirely separate from human health supply chains, leading to further avoidable emissions in transport
The supply chain is not limited to distribution, but also includes the selection of medicines and medical devices, as well as the contracting and contract management of suppliers for these products. To curtail their supply chain emissions, health systems are considering putting pressure on their suppliers to move toward more sustainable practices. The NDoH (and in future the proposed NHI Fund) has major purchasing power and therefore the ability to influence suppliers in addressing their climate footprint through the contracting processes. In the UK, the National Health Service (NHS) requires its larger suppliers to report their greenhouse gas emissions through a standardised framework, benchmark them, and manage them with a goal of getting to net zero.
With respect to the selection of medical supplies, South Africa is currently developing the policy and processes for the routine implementation of Health Technology Assessment (HTA), with the introduction of the new Health Technology Assessment Methods Guide (funded through the FCDO) and a technical working group being set up to develop a national HTA strategy. There is currently international focus on whether the net impact on GHG emissions should be included routinely in these assessments. GHG accounting is not a recent phenomenon and at least some of the preconditions for ensuring the integration of the impact of GHG emissions into HEE/HTA have been met33 , and in principle, it appears that an HTA process could incorporate the impacts of GHG emissions into the decision-making processes when selecting medicines and medical devices.
This is particularly relevant when looking at the selection of single use devices (SUDs). As Mr Botha pointed out, there is extensive debate about SUDs and the reuse thereof. The reuse of these devices is increasing globally with both cost effectiveness and concern for the environment often being cited as reasons. In selecting devices for use in the health sector,
33 Pekarsky, B.A.K. The Inclusion of Comparative Environmental Impact in Health Technology Assessment: Practical Barriers and Unintended Consequences. Appl Health Econ Health Policy 18, 597
599 (2020). https://doi.org/10.1007/s40258-020-00578-5 consideration needs to be given to whether the devices have been tested for reuse or, at the very least, an evaluation has been done of the increased risk to patients
Another factor to be taken into consideration during both the selection and contracting processes, is the size of packages procured. Health facilities routinely waste millions of rands worth of medicines each year because the vials or packages are large and regulations prohibit them from being split between patients. Again the UK leads by example in that health facilities specifically order right-sized packages and only stock the amount of a medicine they need, to avoid having expired stock that must be disposed of.
Similarly, waste management of packaging material is an opportunity for improvement, as health facilities accumulate enormous amounts of waste from medical packaging. Suppliers could be motivated to rethink the type and quantity of packaging used, in particular cold chain packaging which contains polyurethane. According to Mr Botha, the South African government has pushed for patient-ready packs which reduces packaging material and costs, but these do still have secondary packaging. There is already an initiative to do away with secondary packaging of ARVs which could be expanded to other medicines. During the COVID-19 pandemic, a new measure was implemented in which the distributor remained responsible for the packaging material and took it back after delivering the goods, in order to reduce waste at the facility level and open the possibility to reuse certain packaging.
Overall, the NDoH does not currently include impact on climate in their supply chain processes, and a business case could be developed to provide the evidence base for the inclusion of these factors. There is opportunity to learn from the NHS in terms of how they have implemented sustainable strategies across the supply chain.
3.4 Wastewater surveillance and treatment
Wastewater surveillance is the monitoring of infectious or chemical agents in untreated sewage and can be used to track community spread of pathogens, identify threats such as antimicrobial resistance or toxic chemicals, and provide data for decision-making. This method can sample a community without requiring any action from individuals, making it a valuable tool for monitoring local trends. Many informal settlements in South Africa do not have sewer systems, and much of the waste flows into rivers; for these communities, information can be gained from river sampling upstream and downstream of the location. Gina Pocock, a specialist consultant at Waterlab, reported that this data is currently underutilised in terms of informing policy and decision-making.
Droughts and flooding present significant problems with sewers and wastewater treatment plants (WWTP), which were not historically designed for these events. When there is a water shortage, the higher proportion of solids in sewers causes blockages, and WWTP do not function normally. In areas where climate change is predicted to cause droughts, sewers should be designed with a steeper slope and wider corners to deal with these low-flow conditions.
According to Gina Pocock, funding is a significant barrier to improvement of wastewater systems. Management of existing WWTPs falls under local governments, including the budgets,
Case study: During the COVID-19 pandemic, wastewater surveillance has been used to track community spread of the SARS-CoV-2 virus in South Africa. The South African Medical Research Council (SAMRC) first conducted a proof-of-concept study in 5 WWTP, followed by more funding and extension of the study to additional WWTP once the methods showed positive results. An online dashboard for SAMRC’s wastewater surveillance research programme shows trends in monitored sites. The National Institute for Communicable Diseases (NICD) also has a dashboard displaying SARS-CoV-2 wastewater levels across numerous monitoring sites from their network of 10 testing laboratories.
SAMRC: https://www.samrc.ac.za/wbe/
NICD: https://wastewater.nicd.ac.za/ but money is not ringfenced for this purpose. Often WWTPs are not prioritised for funding and receive insufficient money for proper upkeep of facilities A large new WWTP would be funded by the national treasury.
The vast majority of WWTP in South Africa are not compliant with nationally recognised standards. In 2021, the Department of Water and Sanitation (DWS) re-launched the Green Drop Certification programme to audit wastewater networks and treatment works across the country, long after the previous report was published in 2013. The 2022 report shows that the state of wastewater systems has declined in the past decade, with a larger number of systems identified as critical (334/850), and fewer – alarmingly few – awarded the certification (22/850).34 WWTP often exceeded their design capacity, had ineffective disinfection equipment, and were generally non-compliant in treating sewage and sludge. Mr Senzo Mchunu, the Minister for Water and Sanitation, wrote that “It is of great concern that there are so many systems with scores below 31% [in critical condition], indicating a dismal state of wastewater management, posing a risk to both environment and public health.” If not addressed, this problem will only get worse with climate change as extreme weather events put additional strain on wastewater systems, threatening an already limited water supply with further contamination.
3.5 Antimicrobial resistance (AMR)
South Africa’s current National Action Plan for AMR, 2018-2024, was written and signed by the respective then-ministers of the NDoH and the Department of Agriculture, Forestry and Fisheries (DAFF). This document aimed to provide the strategic framework under which South Africa would tackle AMR using a ‘One Health’ approach. It also recognised the importance of AMR to South Africa, given its large immunocompromised population.
However, implementing the plan remains a challenge and ministerial leadership has changed. In 2019, the DAFF merged with the Department of Environmental Affairs (DEA) and two new departments were created – the Department of Forestry, Fisheries and the Environment (DFFE) and the Department of Agriculture, Land Reform and Rural Development (DALRRD) – further adding to challenges in coordination and coherence across sectors. From our stakeholder interviews, it was unclear if the multi-disciplinary intersectoral Ministerial Advisory Committee on AMR functions as set out.
Currently there is a mechanism to combine AMR data from both public and private human health facilities, led by the National Department of Health together with the National Institute of Communicable Diseases (NICD), to show a full heat map of AMR across the country Progress is being made to pass legislation to regulate the use of antimicrobial agents across all sectors (including in animals and in agriculture).
One cross-sectoral area identified through our discussion with Gina Pocock from Waterlab was the role for wastewater and river sampling for AMR, for both resistant organisms as well as antimicrobial by-products. Given the sampling that already takes place for COVID-19 and other infectious agents, there could be cost efficiencies to expand the scope of what is sampled. As noted, however, efforts should be coordinated through the relevant committee, involving both NDoH and DFFE.
Rob Botha from Guidehouse also noted that pharmaceutical waste may be getting washed into rivers in certain circumstances, which is a risk for the development of antimicrobial resistance. Most pharmaceutical waste must now go through incineration rather than being put in landfill, and pharmaceutical waste disposal organisations should theoretically be compliant with 34 Department of Water and Sanitation (2022). Green Drop National Report 2022. https://wisa.org.za/2022/04/01/green-drop-2022-report-release/ environmental regulations. However, retail pharmacies do not have contracts with the pharmaceutical waste disposal organisations, and their waste disposal is unregulated.
3.6 One Health and zoonoses
Climate change will alter the interactions between humans, wildlife, and ecosystems. Up to 75% of new or emerging infectious diseases in people are zoonotic in origin, meaning that they ‘jumped species’ from other animals to humans 35 With warming temperatures, many animals will shift their geographic ranges in the coming decades, and thousands of new contacts between different mammal species that haven’t met before are predicted to occur.36
These new encounters may lead to diseases jumping between species, which poses a risk for new diseases then spilling over into humans. Encounters between humans and wildlife will continue to increase due to habitat destruction and fragmentation, deforestation, agriculture and livestock farming encroaching into wildlife habitats, and expanding urbanisation. The consumption of bushmeat poses an additional threat in South Africa as another route that zoonoses may be introduced to human populations.
Adopting a One Health approach, which unites human health, veterinary/animal health, and environmental expertise, for surveillance of new and emerging disease threats in wildlife, livestock, and humans, will be crucial to identifying and containing zoonotic disease threats. This surveillance effort will require decentralised laboratories for animal and human pathogens, and cross-sectoral collaboration between professionals in human, animal, and environmental health.
3.7 Violence and gender-based violence
Violence claims around 1.25 million lives each year globally, with South Africa among the top 10 countries in the world for the highest homicide rate.37 The crime statistics published in July 2022 show an increase of 11.5% in cases of homicide in South Africa as compared to the previous quarter, especially among women and children.38 The release of these statistics coincided with the release of a United Nations Report which concluded that climate change is likely to increase gender-based violence 39 The report noted substantial and mounting evidence of an increase in gender-based violence following climate-induced disasters, “especially in the light of the pandemic and the extreme weather events that have hit the Global South over the last three years.”
Evidence increasingly indicates that the risk of interpersonal violence increases with higher temperatures. A study using monthly data from 2001-2012 from all police wards in South Africa
35 United Nations Environment Programme (2020). Preventing the next pandemic - Zoonotic diseases and how to break the chain of transmission https://www.unep.org/resources/report/preventing-future-zoonotic-diseaseoutbreaks-protecting-environment-animals-and
36 Carlson CJ, Albery GF, Merow C, et al. (2022). Climate change increases cross-species viral transmission risk Nature; https://www.nature.com/articles/s41586-022-04788-w
37 World Health Organization (2020). Global Health Estimates 2019: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2019 https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/gheleading-causes-of-death
38 South African Police Service (2022). Police Recorded Crime Statistics, Republic of South Africa: First Quarter of 2022/2023 Financial year (April and June 2022) https://www.saps.gov.za/services/downloads/April2022_23-presentation.pdf
39 United Nations Framework Convention on Climate Change: Subsidiary Body for Implementation (2022). Dimensions and examples of the gender-differentiated impacts of climate change, the role of women as agents of change and opportunities for women: Synthesis report by the secretariat https://unfccc.int/sites/default/files/resource/sbi2022_07.pdf showed that there were higher levels of violent crimes during periods of higher temperature 40 An article in the South African Medical Journal concluded that “Countries like SA, which already have high levels of violence and a rapidly warming climate, may be particularly vulnerable to this underappreciated consequence of climate change. There may be a considerable increase in the number of cases of homicide and other forms of violence per year should the mean temperature rise by 1°C”.41
Although the SAMRC are instigating studies examining the impact of recent climate disasters in South Africa on gender-based violence, this aspect of climate change and health is relatively under-researched given the direct and severe effects on both the physical and mental health of individuals and communities.
3.8 Driving behaviour change
The need for profound behaviour change in addressing climate change is well established. Changes are needed not only on an individual level, but also in consumer action and as members of communities and organisations, and of high-emitting groups.42 The need for wide scale interventions that address multiple drivers of and barriers to behaviour change was one of the issues that repeatedly came to the fore in interviewing different stakeholders.
The WCDoH noted that, despite continued messaging through posters and strategically placed signage requesting staff across all facilities to rationalise their water usage during the severe drought, there was not a noticeable change in staff behaviour until individuals were directly impacted by water rationing in the homes in 2017.
What has proved to be difficult, according to the WCDoH, is the maintenance of staff habits of rationing water use after the drought was perceived to be over. They have had some success in utilising measurement and visual tools showing energy reduction across all health facilities. Staff can see how their facility compares to others in terms of saving on electricity, which helps to promote awareness and motivate staff to improve behaviours through a ‘gaming’ element in competing with other facilities.
Caradee Wright, the Senior Specialist Scientist leading the Climate Change and Human Health Research Programme at SAMRC, noted that in order for people to change their behaviour and use new solutions (such as new technologies), the local context must be taken into account from the beginning. Well-intentioned solutions may fail to take hold because of a lack of consultation with the local community before implementation about how the solution fits practically into their daily lives.
Moving forward, it will be increasingly critical to acknowledge the importance of behaviour change interventions in all climate mitigation and adaptation strategies.
40 Bruederle A, Peters J, Roberts G (2017) Weather and crime in South Africa. Ruhr Economic Papers No 739. https://econpapers.repec.org/paper/zbwrwirep/739.htm
41 Chersich MF, Swift CP, Edelstein I, Breetzke F, et al. (2019). Violence in hot weather: Will climate change exacerbate rates of violence in South Africa? South African Medical Journal, 109(7): 447-449. http://www.samj.org.za/index.php/samj/article/view/12655/0
42 Whitmarsh L, Poortinga W, Capstick S (2021). Behaviour change to address climate change. Current Opinion in Psychology, Vol 42: 76-81. https://doi.org/10.1016/j.copsyc.2021.04.002
