Clinical Insights May 2023

Insights CLINICAL

CLIMATE CHANGE: AN IMPRINT ON HEALTH

May 2023

INTRODUCTION

Predicted to have a substantial detrimental impact on humanity, the changing climate is considered the largest single public health threat today. New and emerging health risks are expected, and several current health conditions could be negatively impacted.

A myriad of environmental disruptions is already affecting human health. Disruptions include sea-level rise, floods and drought, heat waves and wildfires, increased frequency and intensity of hurricanes and storms, and diminished air quality. Exacerbation of some disease processes is in play with more undesired health outcomes on the horizon. Scientists predict increases in heat-related illness, cardiovascular disease (CVD), asthma and other respiratory illnesses, zoonotic diseases (infections spread between animals and humans), and food-, water-, and vector-borne diseases.1

There were 396 disasters in 2019 worldwide, killing 11,755 people and affecting 95 million others. In 2022, costs for the United States (US) alone were at least $165 billion.2,3 Additionally, overlapping disasters occurring in the same season, such as wildfires in California and heat waves in the Northeast US have a substantial combined impact on an already stressed healthcare system.4

Historically, most of the analysis on climate change and health has focused on developing countries and disease impact in these regions. But the novel Coronavirus disease 2019 (COVID-19), which is zoonotic, demonstrates the impact of a global crisis.5

250,000 additional deaths per year

CURRENT STATE

Research has shown that rising temperatures and shifts in weather patterns are having major effects on the planet.7 Although the planet’s environment has fluctuated throughout time, influenced by multiple factors, such as evolutionary changes and solar cycles, scientists have unequivocal evidence of the link between human-caused carbon dioxide (CO2) emissions (responsible for a sharp rise in greenhouse gas concentrations) and temperatures which are accelerating these changes.8 Climate change will affect every human, although every human may not be affected in the same way. A host of factors will determine who is most at risk, including location, age, and socioeconomic factors.9

The World Health Organization (WHO) estimates between the years 2030 and 2050, climate change will cause

globally from malnutrition, malaria, diarrhea, and heat stress.6

Greenhouse gas concentrations have reached the highest levels in 2 million years, increasing the temperature to around 1.1°C (Celsius) warmer than the earth was in the late 1800s. The last decade was recorded as the warmest on record.10 To avoid catastrophic environmental changes, the Intergovernmental Panel on Climate Change (IPCC) estimates greenhouse gas emissions must be cut in half by 2030 and net zero emissions reached by 2050. Even if net zero emissions are met by 2050, the predicted sea level rise is estimated at 15 inches. Furthermore, in the worst-case scenario, failing to decrease CO2 emissions and doubling them would mean a sea level increase of 35 inches by the year 2100.11 Warmer temperatures have begun a cascade of wide-reaching environmental changes. These not only impact sea levels and melting polar caps, but greatly reduce biodiversity within the ecosystem, impacting human health and creating a more desirable environment for the propagation of diseases, including zoonotic diseases such as COVID-19.12,13

The National Climate Assessment Report, specific to climate change impacts in the US, is released every 4 years by the US Global Change Research Program (USGCRP) and provides a detailed view of present and future climate change consequences in the US. The fourth assessment released in 2018 projected a rise in air and water temperatures and more extreme events. These events will result in water- and food-borne diseases, heat-related deaths, increases in allergic diseases, and a change in the geographic range and distribution of disease-carrying vectors (insects and pests) around the country.14 The fifth report draft, made public for comment in November 2022, presents further warnings for the US if climate change measures were to go ignored. A final report is expected to be released in late 2023.15

The Intergovernmental Panel on Climate Change (IPCC), established in 1998, was created to assess, report, and make recommendations regarding the science of climate change. Since 1998 they have released 5 comprehensive assessment reports. The Fifth Assessment Report (AR5) was released in 2014 and provided the scientific recommendations for the Paris Agreement.16 On March 20, 2023, the IPCC released the AR6 Synthesis Report, which is based on the findings of three IPCC working group reports.17 The latest report concludes: "Greenhouse gas emissions have continued to increase, with unequal historical and ongoing contributions arising from unsustainable energy use, land use and land-use change, lifestyles and patterns of consumption and production across regions, between and within countries, and among individuals (high confidence)."18,19 Formal studies, along with a better theoretical understanding of what is happening, have determined an undisputable observation of warming lands, atmosphere, and oceans.20

In June 2022, the American Medical Association (AMA) declared climate change a public health crisis adopting policy during the Annual Meeting of its House of Delegates stating “the evidence is clear—our patients are already facing adverse health effects associated with climate change, from heat-related illness and injuries. Like the COVID-19 pandemic, the climate crisis will disproportionately impact the health of historically marginalized communities.”21

The impact on human health caused by environmental change disruptions, originating in the US and abroad, is forecasted to intensify already existing health issues and cause new health threats.22

KEY INFLUENCERS

One of the most critical steps in determining preparedness and creating healthcare solutions is accurately projecting the public health burden caused by climate change. As the increasingly complex intersection of climate change and health unfolds, agencies at the national and international levels are working in coordination to assess the threat and create climate change resilience strategies. The IPCC defines climate change resilience as "the capacity of social, economic and ecosystems to cope with a hazardous event or trend or disturbance, responding or reorganizing in ways that maintain their essential function, identity and structure as well as biodiversity in case of ecosystems while also maintaining the capacity for adaptation, learning and transformation."23 Select influencers in the public domain are outlined in the table below:

ORGANIZATION INITIATIVE

US Department of Health & Human Services (HHS)

National Institutes of Health (NIH)

Centers for Disease Control and Prevention (CDC)

World Health Organization (WHO)

Climate Adaptation and Resilience Plan announced in 2021

DETAILS

HHS partnering with 20 federal agencies to address climate change adaptation and resilience

Climate Change and Health Initiative Strategic Framework Research initiative on the health impacts of climate change

Climate and Health Program Supports state, tribal, local, and territorial public health agencies in climate change preparedness

Alliance for Transformative Action on Climate and Health (ATACH)

United Nations United Nations Environment Programme (UNEP)

World Meteorological Organization (WMO)

Climate Resilient Health Systems Initiative; COP26 Health Programme

The first human health program was presented at COP26. The program’s goal is to provide networking, support, and coordination access to existing climate change initiatives

Authoritative advocate for the global environment providing leadership and action for change

Provides climate change data to support evidence-based decision-making through multiple reports and collaborations with other agencies

The National Aeronautics and Space Administration (NASA)

HHS

World leader in climate studies

Provides scientific data to the global community: the public, policy, and decision-makers

The US Department of Health & Human Services (HHS) is playing a crucial role in addressing climate change as a public health threat, unveiling the Climate Adaptation and Resilience Plan in October 2021. The plan included the establishment of a new Office of Climate Change and Health Equity (OCCHE) which will address the effect of climate change on US health. The Climate Action Plan partners 20 federal agencies with the HHS to enhance resilience and adaptation to a changing environment. Partners include the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), the NIH, the CDC, the Substance Abuse and Mental Health Services Administration (SAMHSA), and others. The plan addresses the environmental emergency by outlining 8 different critical roles across the HHS and partnering agencies. These include public education, health and equity, cost-effective strategies, public healthcare system preparedness, vulnerable population impacts, and proper training in the context of healthcare and climate change.24

NIH

The National Institute of Health (NIH) is also positioned to expand its role in climate change and health. In 2010 the NIH along with the CDC and the Environmental Protection Agency (EPA) created the first federal climate change and health research needs assessment, A Human Health Perspective on Climate Change. In 2022 the NIH Climate Change and Health (CCH) Working Group produced the NIH Climate Change and Health Initiative Strategic Framework, a research initiative focusing on environmental change health impacts.25

WHO

The World Health Organization (WHO) is driving global action to protect human health from environmental change impacts through advocacy and partnerships, including working with the United Nations (UN) Environment Programme, the World Meteorological Organization (WMO), and the Climate and Clean Air Coalition (CCAC).26 During the 2021 United Nations Climate Change Conference (COP26), the COP26 Health Programme was launched, marking the first time a human health program was brought to the forefront of the climate change arena. The COP26 Health Programme is now called the Alliance for Transformative Action on Climate and Health (ATACH) and is a WHO-led program intending to provide networking, knowledge, best practice, and support and coordination access to already existing initiatives.27

NAM

In addition to the collaboration of government and public healthcare agencies, many non-profit organizations are driving public awareness and developing climate-resilient strategies. The National Academy of Medicine (NAM) started the Action Collaborative on Decarbonizing the US Health Sector (Climate Collaborative) in 2021.28 The program is a collaboration of public and private health system leaders gathering evidence and sharing solutions in a commitment to decarbonization to improve health equity.29 Moreover, NAM’s Grand Challenge on Climate Change, Human Health, and Equity (Climate Grand Challenge) is a global initiative to increase public awareness, system transformation, research and reduce its climate footprint, and become more climate change resilient.30

Advocates of environmental solutions in healthcare are also coming together to ensure policymakers, businesses, and health system leadership enact climate commitments and solutions that are in alignment with the Paris Agreement. The White House-HHS Health Sector Climate Pledge, launched by OCCHE in 2022, is a voluntary commitment to climate resilience and reduction in emissions. Over 100 organizations, including Prime Therapeutics/Magellan Rx Management, have signed the Pledge. Stakeholders included hospitals, health centers, insurance companies, pharmaceutical companies, and suppliers.31 Private employers are also doing their part to ensure preparedness. The Cleveland Clinic is assessing the projected climate-related health burden in an effort to commit to climate resilience.32

Collaborations were well observed during COVID-19 when partnerships between multilateral organizations were executed to slow the pandemic.33 COVID-19 offered insight into the collective vulnerability of a global crisis and provided tools to manage, both economically and socially, in preparation for the effects of climate change.

The goals outlined in the Paris Agreement will not be easily reached without the private sector, government, public agencies, and advocacy organizations working together to accelerate solutions. The emerging spirit of collaboration is observed in partnerships like the agreement between the US Agency for International Development (USAID) and NASA, who are working together to address problems in biodiversity conservation, climate change, disaster preparedness, weather forecasting, and energy and health issues.34 Additionally, included in the aforementioned NIH Climate Change and Health Initiative Strategic Framework, are initiative details regarding the organization’s plans to increase research activity and partnerships not only with traditional public health agencies (CDC and EPA), but with geoscience-focused agencies, non-health sectors, and private-public collaborations to understand better health outcomes and benefits of adaptation to environmental change.35

Vitally important to the climate resilient effort is the power of collaboration.

GLOBAL EFFECTS

The changing climate will have wide-reaching effects in the US and globally. Shifting weather patterns caused by these changes are already seen worldwide. These are just a sample of exposure pathways driving health outcomes.36

Extreme Weather

As temperatures rise worldwide so does the frequency of extreme weather patterns, creating major weather events, leaving a path of destruction, and often setting off cascading hazards. An example includes intense droughts, followed by large wildfires, followed by flooding, and mudslides.

Warming oceans have increased the intensity and frequency of hurricanes, typhoons, and cyclones. Since the 1980s, records indicate an increase in hurricane activity including stronger hurricanes as well as hurricanes that rapidly intensify. Global climate models predict hurricanes will continue to create higher storm surges due to rising sea levels and more intense rainfall.37 Additionally, rising temperatures and more moisture in the air are producing destructive storms on land, causing extreme rainfall and flooding. An increase in mortality can be linked to hurricanes, both directly and indirectly. A multitude of deaths occur due to injury and drowning, limited access to clean water, heat-related deaths caused by power outages, and loss of life-sustaining medical treatment due to suspended medical services at hospitals and treatment centers.38

Sea Level Rise & Flooding

Seas along the contiguous US coastline are expected to rise nearly 12 inches by 2050. More than 90% of greenhouse gases are absorbed by the oceans. Greenhouse gas emissions, melting glaciers and ice sheets are causing the warming and expansion of seas globally. The increase in intensity, frequency, and precipitation of coastal storms (hurricanes, tropical storms) combined with higher sea levels is expected to create moderate and major floods along coastal areas increasing exposure to health risks. The majority of coastal flooding deaths occur due to drowning, but deaths and injuries due to blunt trauma, motor-vehicle injuries, electrocution, and hypothermia are also possible. Additionally, after a flood occurs, waterborne disease outbreaks and mold are a concern, affecting healthy people and people living with chronic diseases (e.g., respiratory illness).39 In 2022, Florida recorded 29 illnesses and 4 deaths due to a flesh-eating bacteria (Vibrio vulnificus) caused by sewage overflow spilling into floodwaters from Hurricane Ian.40

Extreme Heat

In the past 40 years extreme levels of heat have more than doubled, and global temperatures are expected to continue to rise into the 21st century. Heat events can last weeks, and can also occur in succession, causing illness and resulting in significant increases in mortality. Heat-induced illness is a leading cause of weather-related death in the US.41 In Europe, 70,000 people died in 2003 because of an unprecedented 3-month heatwave.42

Not only do increased temperatures directly affect physical health, but they can also indirectly cause harm through the transmission of food- or water-borne illness, an increase in algae blooms, and decreased air quality. Moreover, extreme heat can negatively impact health services and infrastructure services including electricity, water, transportation, and productivity.43 The most vulnerable populations are infants and children, the elderly, pregnant women, outdoor and manual workers, the homeless, the displaced and poor, and those already dealing with compromised socioeconomic, physiological, and psychological issues.44 Urban heat islands (UHI) are even more susceptible to heat waves and are formed in large metropolitan areas due to increased numbers of people, transportation, and heat absorbing structures (buildings, sidewalks, and parking lots). Scientists are investigating the possible link between UHIs and global warming45. Although some populations are more vulnerable due to their geographical location or vocation, all populations will be affected.

Drought & Wildfires

As greenhouse gases and heat continue to rise, wildfires have also increased in number and ferocity, tripling the average number of annual fires in the western US and burning twice as many acres. Warmer shifts in the weather cycle, less rainfall, and melting snowpacks are all leading to less moisture in the ground causing extreme droughts and making vegetation more flammable.46 In 2020, during the state’s worst fire season on record, nearly 42% of the Californian population was exposed to a combination of extreme heat and smoke containing fine particulate matter.47 A study published in July 2022 revealed a significant positive association between the air pollution caused by the 2020 California fire and COVID-19 casualties.48

Air & Water Quality

Global Average Surface Temperature

Yearly surface temperature compared to the 20th-century average from 1880–2022. Blue bars indicate cooler-than-average years; red bars show warmer-than-average years.

NOAA Climate.gov “Climate Change: Global Temperature”. January 18, 2023. https://www.climate.gov/news-features/understanding-climate/climate-change-global-temperature

Access to clean air and water is a fundamental human necessity to support health and quality of life. Some of the most susceptible populations are children of developing ages and the elderly.49 Unfortunately, the degradation of air and water quality are another major concern regarding the changing climate. The increase in surface water temperature creates a more advantageous environment for microbes and algae to grow, not only contaminating drinkable water but the fish humans consume. Moreover, storm surges and flooding damage compromise water and sanitation systems allowing harmful contaminants to enter the drinking water system. Infrastructure weakness was demonstrated during Hurricane Katrina when most of the devastating damage resulted from unprecedented precipitation and failed levee systems causing massive flooding.50

Scientists have confirmed that the changing climate is also worsening air pollution problems. The change in weather patterns greatly influences the levels and locations of outdoor air pollutants including ground ozone (a chemical reaction between sunlight and pollutants and a major component of smog) and fine particulate matter. Further, airborne allergens have increased due to the overgrowth of plants producing higher CO2 levels. Outdoor changes also have a negative effect on indoor air quality. Poor air quality leads to a vast range of new health threats and the exacerbation of existing health conditions including asthma, lung cancer, chronic obstructive pulmonary disease (COPD), CVD, allergy sensitivity and disease, and premature death.51

HEALTH IMPACTS

As the results of climate change are felt worldwide, the effects on human health can be measured on both the physical and mental health spectrum.

Physical Health Impact

Cardiovascular Disease (CVD)

CVD is the leading cause of disease burden worldwide leading to disability and accounting for one-third of all deaths. High temperatures are linked to CVD-related mortality. A recent meta-analysis strengthens evidence of an increase in CVD risk associated with heat exposure due to the effect of environmental change on human health.52

The most vulnerable to heat-related CVD events continue to be older individuals, those with lower socio-economic status, and individuals with underlying illnesses, such as hypertension (HTN) and type 2 diabetes.53

Intensifying the CVD risk, the combination of high temperature and high concentrations of fine particulates in the air has been shown to triple CVD-related mortality rates. Even short-term exposure over a few hours to weeks can trigger CVD-related non-fatal and fatal events, including heart failure (HF), arrhythmia, strokes, and myocardial infarction (MI).54

Hypertension’s link to coronary artery disease (CAD) has long been established.55 A low-lying delta along the Ganges and Brahmaputra rivers facing or sitting behind the coastal zone in Bangladesh, is home to approximately 48 million people. In recent years an intrusion of saline water in the area spurred by the climate change effects of sea level rise, cyclonic events, and storm surges has resulted in higher levels

CDC. “Climate Effects on Health”. April 25, 2022.

of salt in the surrounding rivers, ponds, and groundwater depended on for drinking. This increase in saline has resulted in a higher incidence of HTN and a cause for alarm to ensure residents are warned about the increased risk.56

A study examining the effects of flood disasters and the prevalence of cardiovascular and cerebrovascular diseases analyzed data following a powerful and destructive typhoon that made landfall in Japan in 2019. Findings revealed there was not a substantial increase in the total number of CVD and cerebrovascular disease cases compared to 2017 and 2018. However, there was a significant increase in cases of unstable angina pectoris (UAP) at 1.5 and 2-months following the disaster, and HF, acute myocardial infarction (AMI), and cerebral hemorrhage cases increased in the 2 weeks immediately following the disaster. It was also determined that missed doses of medication and HTN at the time of hospitalization may have been risk factors for disaster-related HF.57

Heat-Related Illnesses

Extreme temperature events are becoming more frequent and intense, and the physiological effects on humans are wide-ranging.

Exposure to hotter-than-average temperatures over a short period alters the body’s ability to regulate temperature causing heat cramps, heat exhaustion, heat stroke, and hyperthermia. Heat stroke, the most serious heat-related illness, can be fatal or cause permanent disabilities if not treated promptly. Further, these extreme increases in temperature are known to worsen chronic conditions such as cardiovascular, respiratory, and cerebrovascular disease, kidney disorders, and diabetes-related illnesses.58

Varying by geography, some locations have a greater exposure risk to extreme heat. Most heat-related illness in the US occurs in the Southeast and Midwest. The older population, young children, individuals with pre-existing conditions or disabilities, pregnant women, outdoor workers, athletes, and those living in lower-income communities are most at risk.59 A systematic review of 57 studies revealed there is a significant relationship between heat, ozone, or fine particulate matter and adverse birth outcomes, including pre-term birth, low birth weight, and stillbirths.60 Some populations become more vulnerable when risk factors are combined. For instance, older individuals are less able to regulate body temperature and commonly live in US locales that offer milder climates projected to get hotter, combining two risk factors.61,62

Researchers looked at the impact of heatwaves on emergency department (ED) visits, admissions, and mortality in Australia, Botswana, the Netherlands, Pakistan, and the US. The results of the study demonstrated an association between ambient temperature and morbidity. Each region revealed an increase in ED visits when temperatures spiked and there was not sufficient time for individuals to acclimate to the increased heat. Heatwaves account for 55% of all natural-disaster-related deaths in Australia and cost the country $6.2 billion a year. Climate models in California predict cities such as Sacramento will experience 109 to 138 days of temperatures above 32°C (89.6°F) between 2070 and 2099, compared to only 58 days observed between 1961 and 1990.63

Lastly, evidence is emerging linking increased hospitalizations for mood and behavioral disorders to rising temperatures and extreme heat. Although the research is preliminary, studies suggest that increased aggression, impulsivity, frustration, and discomfort caused by rising temperatures may induce interpersonal violence.64

Infectious Diseases

According to a growing body of evidence, the worldwide risk for waterborne infections such as cholera, typhoid, and Escherichia coli (E. coli) is on the rise due to increases in temperature, heavy rainfall, flooding, and drought.65

One of the heaviest burdens of waterborne disease is a diarrheal disease. Diarrheal disease is the second leading cause of death among children 5 years old and under worldwide.66 Cholera outbreaks (which cause an acute diarrheal infection) have been closely associated with temperature rises (which accelerate the growth and reproduction of pathogens) and increased rainfall (which increases the risk of human contact with wastewater). An examination of hospital visits due to cholera between 1996 and 2002 in Bangladesh, showed a 14% escalation in cholera cases due to increases in rainfall, and in Zanzibar, East Africa, a 1° rise in temperature was associated with doubling cholera cases between 1997 and 2006.67 68

In August 2010, triathlon swimmers in Copenhagen, Denmark took part in a competition that coincided with an extreme rainfall event causing sewage systems to overflow into the sea adjacent to a large urban area. Out of the 838 swimmers, 42% self-reported illness associated with unintentionally swallowing contaminated water. This was a sharp increase relative to the same event held in 2011, when 931 swimmers competed and only 8% reported illness, demonstrating an extreme rainfall event could contaminate water and lead to illness. Climate change models predict increasing extreme rainfall events and subsequent flooding could intensify human health risks.69

Even small changes in precipitation could have negative health impacts on low-income countries with poorly developed healthcare and sanitation systems. Although high-income countries are less vulnerable due to modern infrastructure minimizing contaminated water contact, they may still experience health impacts. According to the IPCC reports (with “very high confidence”) if climate change continues as projected, increased risks of food- and water-borne diseases can be expected.70 71

Respiratory Illness

Data reports by the World Health Organization (WHO) show that nearly 99% of the global population breathes air that contains high levels of pollutants; those suffering the most are low- middle-income countries.72 Respiratory health can be markedly affected by changes in the environment leading to the promotion of new respiratory illnesses, or the exacerbation of already existing respiratory illnesses. Due to increases in CO2 concentration levels, plants have enhanced their photosynthesis capabilities and reproduction cycles allowing more production of pollen and allergens. Climate change has also caused the proliferation of mold spores from frequent heavy rains, storms, and floods. Moreover, there are higher concentrations of ground-level ozone and particulate matter in the air from increased temperatures, droughts, and wildfire smoke.73 These environmental changes have all led to an upsurge in breathing problems including increased hospitalizations for COPD, pneumonia, asthma, allergies, and other issues 74

As CO2 levels and air temperatures continue to rise, the quality of life could deteriorate in patients with COPD. A study of patients with COPD that were monitored via continuous telemonitoring found that heat stress aggravates COPD symptoms, including individuals’ clinical status, lung function, and exercise capacity. The study concluded that telemonitoring reduced the exacerbation frequency of COPD, and along with traditional and appropriate care, should be administered during prolonged heat exposure.75 The warming climate has also caused pollen seasons in the US to begin an average of 20 days earlier than in 1990. Studies show that US pollen amounts have increased by nearly 21% between 1990 and 2018, with the greatest increases in the mid-west and Texas.76 Species that bloom in early spring responding to warmer weather are most pronounced and are a major trigger for symptoms. Further, there is a link between air pollution caused by vehicle emissions, urbanization, and its direct effect on the increased allergenicity of pollen. People with asthma are particularly sensitive to pollen as well as changes in the weather. Both can trigger an asthma attack.77 In 2016 an unprecedented event occurred in Victoria, Australia when thousands of people developed breathing problems due to a thun-

derstorm that kicked up extreme amounts of grass pollen. The event resulted in 9,909 ED visits and 10 deaths. Thunderstorm asthma is theorized to be triggered by a combination of strong winds and a high concentration of allergens.78

Furthermore, natural disasters such as Hurricane Katrina can have devastating effects on residents dealing with chronic conditions (e.g., asthma). In the aftermath of Katrina, medical records were missing, there were lapses in health insurance, and several primary care clinics, pharmacies, and even New Orleans’ main healthcare provider, Charity Hospital, closed permanently, creating a serious disruption in care. Following Katrina, overall morbidity increased by 12.6%.79 Before the storm hit New Orleans, the city was already dealing with the challenges of poverty and a high incidence of asthma among inner-city minority children. In response to the disaster and the critical needs of those affected, a program was created to offer solutions to healthcare access challenges through the Health & Education Alliance of Louisiana (HEAL) which now provides comprehensive healthcare services for school-aged children in need.80

Vector-borne & Zoonotic Diseases

Vector-borne Disease

Vectors (fleas, ticks, and mosquitos) are cold-blooded animals (commonly arthropods) that spread pathogens causing disease, and they thrive in warmer temperatures. Seasonal shifts in North America, bringing warmer summers and shorter winters, have extended vector transmission allowing more infections over time and causing greater risk from ticks and mosquitos. North Americans are at risk of contracting Lyme disease, dengue fever, West Nile virus disease, Rocky Mountain spotted fever, plague, and tularemia. Chagas disease, Chikungunya, and Rift Valley fever viruses are also vector-borne pathogens not currently found in the US, but are considered a health threat.

Lyme disease is the most common vector-borne disease in the US. The CDC reports approximately 35,000 confirmed cases per year, however, they assume many cases go unreported. Increased temperatures were identified as the key environmental factor in establishing Lyme disease in southern Canada, where rapid spread has recently occurred.81,82

Malaria is the biggest killer of vector-borne diseases. Malaria, which is transmitted to humans through the bite of an infected mosquito, remains the most studied and deadly climate-sensitive vector-borne disease causing more than 600,000 deaths in Africa in 2020. The transmission of malaria was shown to be influenced by an increase in precipitation in Cote d’Ivoire, Africa, located in the sub-Saharan region, where malaria is endemic and 90% of all malaria deaths occur. Researchers are looking for ways to develop an early warning system predictive of drought versus rain weather patterns which are related to increases in mosquito breeding and transmission of disease.83 Further, temperature increases of 0.2°C have contributed to the spread of the disease into higher elevations in Columbia and Ethiopia.84

As reported by the IPCC, the incidence of vector-borne diseases has increased in the past few decades and is expected to continue to increase during the next 80 years. Warming temperatures and changes in precipitation, including flooding and drought, impact the life history of vectors and pathogens. Depending on adaptability and other variables, some vectors may not carry the same pathogens they once did, or they may carry new pathogens. What is known is changes in the incidence of vector-borne diseases are associated with changes in the local environment. In the future, alterations in the geographical range, seasonal distribution, and abundance of vector-borne diseases, including novel pathogens, are predicted.85 86

Zoonotic Disease

Zoonoses, defined by the WHO as “diseases and infections that are naturally transmitted between vertebrate animals and man” have emerged due to globalization, international trade, land-use changes, and from the changing climate.87 88 Zoonoses-related disease accounts for over 200 diseases including rabies, avian flu, Ebola virus, and most recently COVID-19. Nearly 75% of emerging infectious diseases originate from animals. People with homes in tropical locales are disproportionately affected and the impact between developed and non-developed countries is quite different due to disease control and

pharmaceutical treatment access variances. An increase in zoonotic diseases has been observed in recent years due to warmer temperatures creating more favorable living and reproductive conditions for vectors and pathogens.

Diseases confined to one area are now spreading to locations previously unaffected.89,90 An increase in Hantavirus, which is transmitted from rodents to humans via inhalation of rodent excreta, was reported in the US and was linked to El Nino-related weather patterns. Additionally, vector-borne diseases such as malaria, lymphatic filariasis, and dengue fever are found in previously non-endemic regions of Nepal.91,92

Mental Health Impact

Climate change-related illness does not only cause physical illness but also impacts mental health. Extreme weather, polluted air, damaged food, and lack of water negatively influence mental well-being. An analysis in 2020 looking at climate change and anxiety found that anxiety related to the changing environment may pose a threat to mental health.93 Eco-anxiety is a relatively new term defined by the American Psychological Association "as a chronic fear of environmental doom ranging from mild stress to clinical disorders."94 Anxiety may manifest as generalized worry about a perceived environmental threat, or it could stem from already existing anxiety-related pathologies. Additionally, some people experience constructive worry which calls them to take action and may have positive consequences on the environment.95

When disasters and extreme events occur, they can trigger a new mental health issue or cause a pre-existing condition to resurface. There is considerable documentation of the negative mental health repercussions following extreme climate change events.96 Some mental health impacts are immediate and severe, such as the loss of a loved one or a traumatic personal injury, while other impacts are indirect and show up gradually including changing temperatures, rising sea levels forcing migration or changes in the availability of transportation or health services.

Chronic mental health impacts may manifest in the days and weeks following the acute trauma. Examples of shock symptoms after an extreme event, include depression, stress, anxiety, post-traumatic stress disorder (PTSD), suicide symptoms, and substance abuse. Individuals affected by Hurricane Ike, which hit Galveston, Texas on September 13, 2008, were shown to suffer from both decreased mental health wellness (resilience across multiple mental health conditions) and decreased general wellness (resilience across mental health, physical health, and role functioning). Resilience as defined in this study "as low levels of symptoms or problems in a given outcome over time, with minimal elevations that are limited to the time period during the disaster and its immediate aftermath."97 Disparities also play a vital role in mental health outcomes following a disaster. Household income, sex, and racial and ethnic minority status are important factors affecting impact as was observed in the aftermath of Hurricane Katrina.98

A meta-analysis of 36 studies identified between 7% and 40% of study subjects exhibited some type of psychopathology following such events. These included phobic, somatic, alcohol or drug impairment, and depression. The highest prevalence rate was anxiety. In the wake of Hurricane Katrina, 1 in 6 people was diagnosed with PTSD, and 49% of people living in areas affected developed anxiety or a mood disorder such as depression.99 A survey also revealed suicide and suicidal ideation more than doubled among the 334 individuals who participated.100

Furthermore, studies have found that climate change can influence intergroup relations and lead to violence. This may be due to competition for scare resources, or due to people of different backgrounds being forced to interact in the wake of a disaster.101

HEALTHCARE SYSTEMS IMPACT

Hospitals and clinics are finding themselves on the front lines of climate change, providing care for patients who are affected by the increasing incidence of hurricanes, wildfires, heat waves, and other environmental disasters. Extreme events can lead to overcrowding in hospitals, power outages, hospital shutdowns, and disruptions in the supply chain, limiting the ability to obtain ample critical medications or life-saving medical devices. Climate change affects every part of the healthcare system including the quality and accessibility of services.

Not only are healthcare accessibility and quality affected, but the financial burden of extreme events is posing a challenge. Healthcare systems carry a heavy burden of public health responsibility in times of crisis. As millions of people become sicker every year due to climate change, healthcare costs rise drastically. A 2012 study of 10 climate-related events in the US revealed that health-related costs reached $10 billion, including hospital admissions, ED visits, lost wages, and other medical costs.102,103 In 2015 several International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes were added to the ICD-10-CM to properly diagnose and document environmental exposure to water pollution (Z77.111), air pollution (Z77.110), soil pollution (Z77.112), and other environmental pollution (Z77.118).104

Initiatives

A global climate change adaptation and mitigation gap have been identified in the healthcare sector. While many healthcare systems may have disaster plans in place, they do not have plans in place specifically designed to confront the implications climate change will bring. The National Academy of Medicine (NAM) created a multiyear global initiative to work towards the improvement and protection of human health, well-being, and equity. The Climate Grand Challenge outlines 4 main strategic goals:105

Certain environmental change-related impacts could be mitigated by creating climate-resilient systems that include preparation, response, and recovery plans that apply to the risks specific to the communities in which they serve. For example, locales that may be most impacted by extreme events such as heat waves or hurricanes could become more climate-resilient with these systems in place.106 Healthcare systems are recognizing the threat, and some have already experienced firsthand the devastating impact natural disasters can have on infrastructure. Hurricane Sandy, 2012, forced New York University (NYU) Langone Medical Center to evacuate more than 200 patients when buildings filled with water and generators failed due to storm surge. Scenarios such as this have increased the call to action, prompting hospitals and medical centers to develop plans to manage acute climate shocks, and find strategies for adaptation and climate resilience.107,108

Healthcare Professionals

Healthcare professionals (HCPs) can experience the mental and physical impact of climate change more intensely than the general population. They often find themselves at the intersection of caring for patients, themselves, their own families, and their homes during a natural disaster or extreme event which can lead to burnout, commonly seen during the COVID-19 pandemic. In the wake of the recognized demand and unprecedented health risks environmental change will bring, there is an urgent request by health associations, government agencies, and health professions schools to add climate change training to medical school curricula and prepare physicians for the impending challenge.109 The American College of Physicians (ACP) published a position paper in 2016 regarding climate change and health, including a list of policy recommendations that outlined a reduction in greenhouse emissions, adopting climate-resilient practices, advocation of policy, physician education, and government-provided research to mitigate the human health effects of climate change.110

"Communicate the climate crisis as a public health and equity crisis"

"Catalyze the health sector to reduce its climate footprint and ensure its resilience"

"Develop a roadmap for systems transformation"

"Accelerate research and innovation at the intersection of climate, health, and equity"

In 2019 the AMA adopted a policy to establish a curriculum to teach physicians and medical students about climate change and its health impacts.111 Harvard Medical School (HMS) recently announced the integration of climate change into the medical school curriculum. As well, Emory School of Medicine will make climate change a formal part of its curriculum and Stanford Medical is working on an integration plan.112 113 Additionally, the American Association of Colleges of Nursing (AACN) is considering the inclusion of climate change and planetary health in the AACN Essentials, which outlines and defines curriculum and competencies in nursing education.114 115 A climate change fellowship at Harvard and Columbia’s Global Consortium on Climate and Health Education (GCCHE) signal the burgeoning movement.116,117 Although not widespread, climate change education for HCPs is gaining traction and is frequently advocated by HCPs and students alike.

The impacts of environmental change could render healthcare systems unprepared if adequate plans are not developed. Climate change disasters threaten to overwhelm local health systems at a time when they are already under extreme stress.

EQUITY

Communities and nations will not feel the health impacts of climate change the same. Variances will greatly depend on individuals’ and communities’ vulnerability and climate resilience. Socioeconomics, age, race, pre-existing health conditions, living conditions, and the ability to access health resources will all drive experience and exposure to the effects of climate change.

Geographical Location

Geographical location will certainly influence who is impacted. Those living in vulnerable areas such as coastal communities, flood plains, and wilderness-urban interface areas susceptible to wildfires are at an elevated risk. Socioeconomically disadvantaged communities that are not able to respond or adapt as quickly due to a lack of modern infrastructure will experience greater challenges. For example, during the 1995 Chicago heatwave,

739 people died mainly due to a lack of working air conditioners or access to air conditioning locations to cool.118 The elderly, children, communities of color, pregnant women, individuals with disabilities, and those with pre-existing conditions all face a disproportioned risk.119,120

Lower-Income Groups

Further, lower-income groups and people of color who have been forced into more affordable areas such as flood zones and heat islands due to structural racism are likely to confront more barriers. Evidence shows that lower-income populations face barriers within bureaucratic systems to access housing or aid following a disaster. Barriers include a lack of aid program awareness, lack of transportation to go to disaster assistance centers, and overall uneasiness dealing with these systems.121

Ensuring Health Equity

Although research indicates industrialized nations are mainly responsible for climate change, it is low-income developing countries that will bear the largest burden.122 A major milestone was reached at the 2022 United Nations Climate Change Conference (COP27) when world leaders agreed to fund developing countries already experiencing extreme climate events.123 Some of the countries most vulnerable are those where poverty rates are high and government resources are low. In the event of extreme weather, there are few funds to rebuild. Additionally, the most vulnerable struggle to protect themselves against future disasters. Although developing countries have begun initiating climate adaptation plans, many are simply outpaced by the increased intensity and frequency of extreme weather events. For example, the Caribbean had a record-breaking number of storms in 2020, including 30 tropical storms and 6 major hurricanes. Adaptation plans were developed for category 4 hurricanes, but not category 5 hurricanes which are becoming more common.124

Climate programs are working to ensure equity is at the forefront of creating solutions so all people can share the benefits of climate-resilient efforts. In the US, the Office of Climate Change and Health Equity (OCCHE) is working with HHS and other agencies to ensure health equity in 3 major ways:125

US

impacts of climate change, especially those most vulnerable"

"Enhancing the sustainability and climate resilience of the US health system"

"Addressing underlying health disparities by identifying and promoting ways in which actions to address climate change can also improve social determinants of health" 1 2 3

The CDC developed a 5-step process, Building Resilience Against Climate Effects (BRACE), designed to help communities as health officials prepare for the health effects of climate change. To supplement BRACE, the CDC is also collaborating with the American Public Health Association (APHA) to create the Climate Change and Health Playbook: Adaptation Planning for Justice, Equity, Diversity, and Inclusion. The comprehensive resource was created to support public health departments and adaptation planners as they incorporate justice, equity, diversity, and inclusion into their climate and health programs.126

The Notre Dame-Global Adaptation Initiative (ND-GAIN) Country Index summarizes a country’s vulnerability to climate change and other global challenges in combination with its readiness to improve resilience. It aims to help governments, businesses, and communities better prioritize investments for a more efficient response to the immediate global challenges ahead.

Per ND-GAIN, the initiative "brings together over 74 variables to form 45 core indicators to measure the vulnerability and readiness of 192 UN countries from 1995 to the present (due to data availability, ND-GAIN measures the vulnerability of 182 countries and the readiness of 184 countries)."127

"Protecting the health of all people in the

from the

Top Five:128

Overall ND-Gain Index

“A country’s ND-GAIN index score is composed of a Vulnerability score and a Readiness score.”

Readiness

“Readiness measures a country’s ability to leverage investments and convert them into adaptation actions. ND-GAIN measures overall readiness by considering 3 components –economic readiness, governance readiness, and social readiness.”

Vulnerability

“Vulnerability measures a country’s exposure, sensitivity, and ability to adapt to the negative impact of climate change. ND-GAIN measures the overall vulnerability by considering vulnerability in six life-supporting sectors –food, water, health, ecosystem service, human habitat, and infrastructure.”

REGULATORY & LEGISLATIVE TRENDS National & International Legislation

In the US there has been a strong debate over climate change for many years. The Clean Air Act became a federal law in 1963 and the Clean Water Act followed almost 10 years later in 1972. Today there are 17 laws and 19 policies in effect in the US.129 In 1992 countries joined an international treaty, signing the United Nations Framework Convention on Climate Change (UNFCCC) in an effort to reduce global temperatures and manage climate change effects. In 1997 the Kyoto Protocol was adopted but was not ratified until 2005. The agreement is based on the principles of the UNFCCC but only obligates participation from developed countries, recognizing they are mainly responsible for the current state of climate change.130 The 2015 Paris Agreement builds on the foundation of the previous framework established under the Convention and aims to advance and intensify the actions required to create a sustainable and low-carbon future.131

On January 27, 2021, under a directive by President Biden [Executive Order 14008 section 222(d)], the Secretary of HHS established an Office of Climate Change and Health Equity (OCCHE) to address climate change and health impacts. The office is working in coordination with non-government organizations, academia, business, industry, and state, local, tribal, and territorial governments in pursuit to establish a central working conglomerate creating strategic solutions for environmental justice and equitable health outcomes.132 Shortly following the launch, OCCHE attended COP26 and joined the COP26 Health Progamme.

Most recently, the US passed the Inflation Reduction Act in August 2022, which includes nearly $370 billion in climate change and clean energy investment over the next 10 years, marking the largest and most ambitious piece of legislation to be approved by Congress.133 The bill includes but is not limited to, a program to reduce methane emissions, $135 billion in clean energy tax credits, $60 billion allocated for environmental justice, $21 billion to assist rural communities and US farmers, and $2.6 billion to help coastal regions prepare for sea-level rise and extreme storms.134

State Legislation

State governments are creating plans to combat the crisis. Vermont created a climate council, Rhode Island enacted a climate law to lower emissions, and Maine released a Climate Action Plan to lower emissions and make communities more climate resilient.135 California has some of the nation’s toughest climate laws; in September 2022, the state enacted an aggressive plan to cut pollution, aiming to achieve carbon neutrality by 2045 and 90% clean energy by 2035.136 In 2021 Hawaii became the first state to declare a climate emergency through a non-binding resolution passed by the state legislature calling for immediate and statewide action. Hawaii has set a goal of becoming carbon-neutral by 2045.137,138

Public Health Emergency (PHE)

Over the last 18 years, 119 public health emergencies (PHE) have been declared in the US. Declarations include multiple states following Hurricane Katrina, multiple states following Hurricane Sandy, during the 2017 Zika virus outbreak, and a national declaration in January 2020 in response to the emergence of COVID-19.139 Under section 319 of the Public Health Service (PSH) Act, the Secretary of the Department of Health and Human Services (HHS) may determine if a disease or disorder presents a public health PHE or that a PHE (including significant outbreaks of infectious disease or bio-terrorist attacks) otherwise exists. Directives under the declaration include deployment of national disaster medical system teams, funds to aid PHE preparedness, hospital preparedness and regional health care emergency preparedness, and assisting the CDC in response and preparedness to an infectious disease emergency.140

Given the far-reaching impact of the climate challenge, both the public and private sectors have a role to play in ensuring adaptation planning and implementation are achieved. The release of the IPCC’s AR6 Synthesis report confirms the urgent need for response and preparedness to minimize the threat to human health and loss of life.

1963

US Clean Air Act

1997

Kyoto Protoco

2022

US Inflation Reduction Act

1972 US Clean Water Act

1992 United Nations Framework Convention on Climate Change (UNFCCC)

2021

2015 Paris Agreement

PREPAREDNESS SOLUTIONS

Office of Climate Change and Health Equity (OCCHE) established

COP26 Health Programme launched

Many public, non-profit, and private sectors are actively working to anticipate and assess climate impacts.

The NIH is partnering with communities all over the world to develop research infrastructure and a workforce to gather relevant knowledge.141 The CDC is utilizing public health experience and expertise to assist state, local, and tribal health departments prepare and respond to health effects caused by climate change.142 In addition, they are building frameworks and programs such as BRACE and the Climate Change and Health Playbook to evaluate impact to ensure a just and equitable approach.143 The WHO has developed the WHO Global Strategy on Health Environment and Climate Change with a vision of eliminating the disease burden caused by unhealthy environments.144 The UN Environment Programme (UNEP) stands in the center of the action, battling climate change on a variety of platforms, including working with governments, civil society, and private sector, and empowering communities to develop adaptation programs to become more climate resilient.145

As healthcare systems look to public health organizations, government, and private companies to guide and inform on climate change and disaster resilience strategies in the US, the takeaways are varied and complex with many overlapping segments and industry-specific guidance. The WHO recommends the following operational framework for building climate-resilient health systems:146

» Leadership and governance

» Vulnerability capacity and adaptation assessment

» Health and climate research

» Management of environmental determinants of health

» Emergency preparedness and management

» Healthcare workforce

» Integrated risk monitoring and early warning

» Climate-resilient and sustainable technologies and infrastructure

» Climate-informed health programs

» Climate and health financing

Weatherproofing Life-Saving Drugs

In addition to climate resilient preparedness for healthcare systems, another important component is weatherproofing life-saving and essential drugs. In 2017 when Hurricane Maria hit Puerto Rico the damage was massive. Drug manufacturers in Puerto Rico make up 13 of the world’s top-selling brand-name drugs, including Baxter International, which makes up 43% of the US supply of intravenous (IV) solutions. Methotrexate, made in Puerto Rico and used to treat childhood leukemia, reported shortages of the drug in all 5 of its manufacturing facilities following Maria. In retrospect, the FDA issued a statement in 2018 that included guidance around the difficulty of predicting such shortages caused by natural disasters. The agency recommended companies become proactive and create backup lines ensuring facilities and raw material suppliers are prepared when issues arise to prevent future shortages. The FDA also stated it would work collaboratively with the pharmaceutical industry and government agencies to prevent shortages.147 Although there were many drug shortages during COVID-19, the FDA subsequently issued guidance during the pandemic to add additional measures to mitigate drug shortages including prioritizing reviews of drug applications and adding manufacturer reporting requirements in response to drug shortages.148 149 Drug shortages can pose a challenge to public health. Ongoing work seeks to gain better insights into the supply chain and increase its resilience.150

Our Toolkit

Preparedness solutions can mitigate access issues to medications during emergencies.151 The following healthcare readiness toolkit for extreme environmental challenges can be utilized by patients, payers, pharmacies, and prescribers.

Patients

1. Have an emergency supply of prescription medications and needed over-the-counter (OTC) medications.

2. Keep a current list of all prescription and OTC medications, including dosage instructions and known allergies.

3. Weatherproof medications by keeping them in a waterproof insulated container (resealable plastic bag in a cooler, etc.) and at the required optimal temperature.

4. Have phone numbers, apps, and websites for your pharmacy benefit manager (PBM), pharmacy, and prescriber handy.

5. Set up a patient portal with the provider and pharmacy.

Payers

1. Proactively monitor the drug supply chain for potential disruptions.

2. Create timely member/provider communications when relevant (but do not cause alarm).

3. Know the supply source and access to different suppliers through communication with supply chain partners–specialty and mail-order pharmacies, wholesalers, and manufacturers so they can share related actions.

4. Closely follow regulatory approvals and policy developments impacting supply.

5. Temporarily waive formulary tools to facilitate access in times of disaster. Examples include down tiering, changing preferred/non-preferred status, and generic substitution. Apply flexibilities such as waiving or limiting prior authorization (PA), quantity limits (QL), and day supply restrictions. However, day supply flexibilities must be balanced with preservation of supply and to minimize hoarding and stockpiling (as observed during COVID-19).

6. Waive home delivery restrictions.

7. Use technology as a tool to minimize risk. Examples include virtual reality (VR) for simulation and to provide solutions for payers. Use of drones for delivery of medications to avoid patient exposure during extreme weather or environmental events.

8. Create backup staffing plans.

9. Prepare for future emergency events by holding practice drills and simulations for environmental disasters (climate, weather, etc.) including medication access, claims processing, and testing of communication and information technology (IT) systems.

Pharmacies

1. Extra supply on hand for “essential medications” for impacted health conditions.

2. Considerations for “specialty medications” to ensure appropriate cold chain/storage/handling, avenues for provider-administered drugs, and ultimately appropriate access for patients.

3. Prepare for future emergency events by holding practice drills and simulations for environmental disasters (climate, weather, etc.) including medication access, claims processing, and testing of communication and information technology (IT) systems.

4. Create a backup staffing plan and paper prescription plan due to possible power or internet outages.

Prescribers

1. Use of telehealth and home visits when available and appropriate for patient continuity of care and safety of staff.

2. Stay alert for federal and/or state policies impacting prescribing changes and scope during disasters.

3. Create a backup staffing plan.

4. Create an emergency plan including collaboration with local hospitals, health systems, and pharmacies.

5. Develop a paper or manual backup process for electronic health records (EHR) including processing orders and sending prescriptions during possible power or internet outages.

OUR PERSPECTIVE

We are guided by four primary tenets of practice for environment and health, including awareness, education access, and preparedness.

Awareness Education Access Preparedness

awareness for all stakeholders including, patients/caregivers, payers, pharmacies, and prescribers

formal and hands-on training in medical education for future and current HCPs through health professions schools, real-world courses, experience, and continuing education

appropriate and equitable patient access to essential and life-saving medications during extreme environmental conditions

preparedness for stakeholders and communication/ resilience plans to act during environmental challenges

SUMMARY

The changing climate is predicted to be detrimental to human health. Climate change has evolved from theory to tangible science, yet it remains complex and challenging to fully determine the scope in which human health will be affected.

According to scientists, these changes will be a long-term threat to human life. Long after CO2 emissions are reduced, surface air temperature will continue to rise for nearly a century or more. New health threats will emerge, and pre-existing health conditions will worsen, placing an already strained healthcare system in possible peril if action is not taken. The partnerships of government agencies, private companies, academia, researchers, and advocacy organizations are vital in the steps to create and implement plans for education, adaptation, and resilience. Climate change will affect everyone, although all individuals may not be affected in the same way. Historically marginalized communities will be disproportionately impacted. Health impacts will be determined by the vulnerability of the populations affected and their ability to prepare and adapt. Climate and health vulnerability assessments will be required to plan and prioritize the welfare groups with health and social inequities. Expected to adversely affect public health in multiple ways, a fully integrated action plan formulated with effective responses is crucial for individuals and healthcare systems to become climate resilient.

Building operational climate-resilient frameworks and systems are key for preparedness for all stakeholders – hospitals, health systems, payers, prescribers, patients, pharmacies, communities, and local governments. Weather-proofing life-saving and essential medications are an important part of preparedness solutions to mitigate access issue during extreme environmental challenges.

The changing climate will have a far-reaching impact to human physical and mental health. Climate resilience and preparedness solutions are needed to adapt and create a cultural shift in healthcare.

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The content in this publication represents evidentiary literature regarding climate change and health impacts. However, it is not written by climate scientists and is not an exhaustive selection of available data. This publication is not a substitute for professional medical advice. For questions regarding any medical condition or if you need medical advice, please contact your healthcare provider.

©2023 Magellan Rx Management, LLC, a Prime Therapeutics LLC company. All rights reserved. The content of this publication may be used or reproduced for noncommercial purposes provided that any such use or reproduction is made with the following attribution statement: “Clinical Insights, Climate Change: An Imprint on Health. ©2023 Magellan Rx Management, LLC, a Prime Therapeutics LLC company. Used with permission.” MRX1436_0523.