The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health

Climate Change Related Depression, Anxiety and Stress Symptoms Perceived by Medical Students

Climate change has drastic consequences on human physical and mental health. However, research on the psychological effects of climate change awareness is still inconclusive. To examine the mental burden posed by climate change awareness and potential resilience factors, n = 203 medical students were surveyed about their awareness of the implications of climate change. Furthermore, well-established mental health questionnaires (PHQ-9, GAD-7, PTSS-10, PSQ-20) were presented twice, in their original form and in a modified version to specifically ask about the respective psychological burden regarding climate change. For identification of potential resilience factors, measures for attachment style (RQ), structural abilities (OPD-SF), and sense of coherence (SOC-13) were used. The results of our study suggest that medical students in Germany have an increased risk to suffer from mental health problems and predominantly experience significant perceived stress in regard to climate change. However, the reported stress does not yet translate into depressive, anxious, or traumatic symptoms. Climate-related perceived stress correlates negatively with potential resilience factors preventing the development of mental disorders such as attachment style, structural abilities, and sense of coherence.

Food insecurity and the risk of HIV acquisition: findings from population-based surveys in six sub-Saharan African countries (2016-2017)

OBJECTIVE

To assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa.

DESIGN

Nationally representative HIV impact assessment household-based surveys.

SETTING

Zambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia.

PARTICIPANTS

112 955 survey participants aged 15-59 years with HIV and recency test results.

MEASURES

Recent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month.

RESULTS

Overall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15-24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88).

CONCLUSION

SFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

The structure of the Clostridium thermocellum RsgI9 ectodomain provides insight into the mechanism of biomass sensing

Clostridium thermocellum is actively being developed as a microbial platform to produce biofuels and chemicals from renewable plant biomass. An attractive feature of this bacterium is its ability to efficiently degrade lignocellulose using surface-displayed cellulosomes, large multi-protein complexes that house different types of cellulase enzymes. Clostridium thermocellum tailors the enzyme composition of its cellulosome using nine membrane-embedded anti-σ factors (RsgI1-9), which are thought to sense different types of extracellular carbohydrates and then elicit distinct gene expression programs via cytoplasmic σ factors. Here we show that the RsgI9 anti-σ factor interacts with cellulose via a C-terminal bi-domain unit. A 2.0 Å crystal structure reveals that the unit is constructed from S1C peptidase and NTF2-like protein domains that contain a potential binding site for cellulose. Small-angle X-ray scattering experiments of the intact ectodomain indicate that it adopts a bi-lobed, elongated conformation. In the structure, a conserved RsgI extracellular (CRE) domain is connected to the bi-domain via a proline-rich linker, which is expected to project the carbohydrate-binding unit ~160 Å from the cell surface. The CRE and proline-rich elements are conserved in several other C. thermocellum anti-σ factors, suggesting that they will also form extended structures that sense carbohydrates.

Association between ambient temperature and cardiovascular disease hospitalisations among farmers in suburban northwest China

Cardiovascular disease (CVD) has become a severe public health and social issue in China. However, in northwest China, evidence on the association between ambient temperature and CVD hospitalisations in suburban farmers is somewhat limited. We collected CVD hospitalisations and meteorological data (2012-2015) in Zhangye suburbs and assessed the temperature-related risk and burden of admission by fitting a distributed lag nonlinear model to probe the relationship between ambient temperature and CVD hospitalisations among farmers in suburban northwest China. The results show that 23,921 cases of CVD admissions were recorded from 2012 to 2015. There was a "U-shaped" association between temperature and hospitalisations. Compared with the minimum admissions temperature (MAT) at 15.3 °C, the cumulative relative risk (RR) over lag 0-21 days was 1.369 (95% CI 0.980-1.911) for extreme cold temperature (1st percentile, -15 °C), 1.353 (95% CI 1.063-1.720) for moderate cold (5th percentile, -11 °C), 1.415 (95% CI 1.117-1.792) for extreme heat (99th percentile, 26 °C), and 1.241 (95% CI 1.053-1.464) for moderate heat (95th percentile, 24 °C). Female farmers were more susceptible to low and high temperatures than male farmers. Farmers aged ≥ 65 years old were more sensitive to low temperatures, while farmers aged < 65 years old were more sensitive to high temperatures. A total of 13.4% (3,208 cases) of the hospitalisation burden for CVD were attributed to temperature exposure, with the moderate range of temperatures accounting for the most significant proportion (12.2%). Ambient temperature, primarily moderate temperatures, might be an essential factor for cardiovascular-related hospitalisations among farmers in suburban northwest China.

An analysis of tax abuse, debt, and climate change risk in low-income and lower-middle-income countries

INTRODUCTION

Climate change is exacerbating a pre-existing child rights crisis. Lower- (low- and lower-middle-) income countries have borne 99% of the disease burden from the crisis, of which children under five carry 90%. In response, much of the recent global policy efforts focus on climate action. However, unsustainable levels of debt and tax abuses are draining countries of crucial revenue to handle the crisis. Like the climate crisis, these are primarily facilitated by entities domiciled within higher- (upper-middle- and high-) income countries. This paper aims to review these revenue leaks in countries where children are at the greatest risk of climate change to identify opportunities to increase climate change resilience.

METHODS

We compiled data on tax abuse, debt service and climate risk for all lower-income countries with available data to highlight the need for intervention at the global level. We used the Climate Change Risk Index (CCRI), developed by UNICEF. Additionally, we used figures for tax abuse and debt service as a percentage of government revenue.

RESULTS

We present data on 62 lower-income countries with data on revenue losses, of which 55 have CCRI data. Forty-two of these 62 countries (67.7%) are at high risk of lost government revenues. Forty-one (74.5%) of the 55 countries with CCRI data are at high risk of climate change. Thirty-one countries with data on both (56.4%) are at high risk of both climate change and revenue losses. Most countries at high risk of both are located in sub-Saharan Africa. This shows that countries most in need of resources lose money to arguably preventable leaks in government revenue.

DISCUSSION

Higher-income countries and global actors can adopt policies and practices to ensure that they do not contribute to human rights abuses in other countries. Highlighting the impact of a failing global economic model on children's economic and social rights and one which increases their vulnerability to the climate emergency could help drive the transition towards a model that prioritises human rights and the environment on which we all depend.

Diversity regained: Precautionary approaches to COVID-19 as a phenomenon of the total environment

As COVID-19 emerged as a phenomenon of the total environment, and despite the intertwined and complex relationships that make humanity an organic part of the Bio- and Geospheres, the majority of our responses to it have been corrective in character, with few or no consideration for unintended consequences which bring about further vulnerability to unanticipated global events. Tackling COVID-19 entails a systemic and precautionary approach to human-nature relations, which we frame as regaining diversity in the Geo-, Bio-, and Anthropospheres. Its implementation requires nothing short of an overhaul in the way we interact with and build knowledge from natural and social environments. Hence, we discuss the urgency of shifting from current to precautionary approaches to COVID-19 and look, through the lens of diversity, at the anticipated benefits in four systems crucially affecting and affected by the pandemic: health, land, knowledge and innovation. Our reflections offer a glimpse of the sort of changes needed, from pursuing planetary health and creating more harmonious forms of land use to providing a multi-level platform for other ways of knowing/understanding and turning innovation into a source of global public goods. These exemplary initiatives introduce and solidify systemic thinking in policymaking and move priorities from reaction-based strategies to precautionary frameworks.

Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data

OBJECTIVES

Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO₂ equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost.

DESIGN

We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO₂ equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis.

SETTING

Dutch respiratory healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs.

RESULTS

In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year.

CONCLUSIONS

In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

LAYERS: A Decision-Support Tool to Illustrate and Assess the Supply and Value Chain for the Energy Transition

Climate change mitigation strategies are developed at international, national, and local authority levels. Technological solutions such as renewable energies (RE) and electric vehicles (EV) have geographically widespread knock-on effects on raw materials. In this paper, a decision-support and data-visualization tool named “LAYERS” is presented, which applies a material flow analysis to illustrate the complex connections along supply chains for carbon technologies. A case study focuses on cobalt for lithium-ion batteries (LIB) required for EVs. It relates real business data from mining and manufacturing to actual EV registrations in the UK to visualize the intended and unintended consequences of the demand for cobalt. LAYERS integrates a geographic information systems (GIS) architecture, database scheme, and whole series of stored procedures and functions. By means of a 3D visualization based on GIS, LAYERS conveys a clear understanding of the location of raw materials (from reserves, to mining, refining, manufacturing, and use) across the globe. This highlights to decision makers the often hidden but far-reaching geo-political implications of the growing demands for a range of raw materials that are needed to meet long-term carbon-reduction targets.

Who tweets climate change papers? investigating publics of research through users’ descriptions

As social issues like climate change become increasingly salient, digital traces left by scholarly documents can be used to assess their reach outside of academia. Our research examine who shared climate change research papers on Twitter by looking at the expressions used in profile descriptions. We categorized users in eight categories (academia, communication, political, professional, personal, organization, bots and publishers) associated to specific expressions. Results indicate how diverse publics may be represented in the communication of scholarly documents on Twitter. Supplementing our word detection analysis with qualitative assessments of the results, we highlight how the presence of unique or multiple categorizations in textual Twitter descriptions provides evidence of the publics of research in specific contexts. Our results show a more substantial communication by academics and organizations for papers published in 2016, whereas the general public comparatively participated more in 2015. Overall, there is significant participation of publics outside of academia in the communication of climate change research articles on Twitter, although the extent to which these publics participate varies between individual papers. This means that papers circulate in specific communities which need to be assessed to understand the reach of research on social media. Furthermore, the flexibility of our method provide means for research assessment that consider the contextuality and plurality of publics involved on Twitter.

Addressing the environmental sustainability of eye health-care delivery: a scoping review

The demand for eye care-the most common medical speciality in some countries-is increasing globally due to both demographic change and the development of eye health-care services in low-income and middle-income countries. This expansion of service provision needs to be environmentally sustainable. We conducted a scoping review to establish the nature and extent of the literature describing the environmental costs of delivering eye-care services, identify interventions to diminish the environmental impact of eye care, and identify key sustainability themes that are not yet being addressed. We identified 16 peer-reviewed articles for analysis, all published since 2009. Despite a paucity of research evidence, there is a need for the measurement of environmental impacts associated with eye care to be standardised along with the methodological tools to assess these impacts. The vastly different environmental costs of delivering clinical services with similar clinical outcomes in different regulatory settings is striking; in one example, a phacoemulsification cataract extraction in a UK hospital produced more than 20 times the greenhouse gas emission of the same procedure in an Indian hospital. The environmental costs must be systematically included when evaluating the risks and benefits of new interventions or policies aimed at promoting safety in high-income countries.

The Changing Climate and Pregnancy Health

PURPOSE OF REVIEW

Climate change is the biggest public health threat of the twenty-first century but its impact on the perinatal period has only recently received attention. This review summarizes recent literature regarding the impacts of climate change and related environmental disasters on pregnancy health and provides recommendations to inform future adaptation and mitigation efforts.

RECENT FINDINGS

Accumulating evidence suggests that the changing climate affects pregnancy health directly via discrete environmental disasters (i.e., wildfire, extreme heat, hurricane, flood, and drought), and indirectly through changes in the natural and social environment. Although studies vary greatly in design, analytic methods, and assessment strategies, they generally converge to suggest that climate-related disasters are associated with increased risk of gestational complication, pregnancy loss, restricted fetal growth, low birthweight, preterm birth, and selected delivery/newborn complications. Window(s) of exposure with the highest sensitivity are not clear, but both acute and chronic exposures appear important. Furthermore, socioeconomically disadvantaged populations may be more vulnerable. Policy, clinical, and research strategies for adaptation and mitigation should be continued, strengthened, and expanded with cross-disciplinary efforts. Top priorities should include (a) reinforcing and expanding policies to further reduce emission, (b) increasing awareness and education resources for healthcare providers and the public, (c) facilitating access to quality population-based data in low-resource areas, and (d) research efforts to better understand mechanisms of effects, identify susceptible populations and windows of exposure, explore interactive impacts of multiple exposures, and develop novel methods to better quantify pregnancy health impacts.

An Examination of the Intersection of Climate Change, the Physician Specialty Workforce, and Graduate Medical Education in the U.S

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Workers and Climate Change: The Need for Academic–Industry Partnerships to Improve Agricultural Worker Health, Safety, and Wellbeing

Climate change will have negative consequences for human health worldwide. Agricultural workers are especially vulnerable to the health consequences of climate change. This communication demonstrates how a Total Worker Health® approach is utilized to protect Guatemalan agricultural workers from the negative health effects of climate change. DrPH researchers work alongside local partners to develop, implement, and evaluate climate adaptation strategies and other interventions to improve agricultural worker health, safety, and wellbeing. Training in public health ethics, communications, and leadership gives DrPH researchers the tools to help create successful academic–industry partnerships that increase local capacity and have sustainable public health impact.

Advocacy to support climate and health policies: recommended actions for the Society of Behavioral Medicine

Climate change poses serious threats to public health and is exacerbating health inequities. Policy changes are essential to mitigate climate change impacts on human and planetary health. The purpose was to describe recommendations by the Policy and Advocacy Subgroup of the Society of Behavioral Medicine (SBM) Climate Change, Behavior Change and Health Presidential Working Group (PWG). The Policy and Advocacy subgroup was comprised of experts in public health, climate policy, and health behavior change, who worked together to identify priorities and develop recommendations. We worked under the premise that building political will for climate policy action is the most urgent goal, and we recommended promotion of citizen advocacy for this purpose. Because citizen advocacy is a set of behaviors, SBM members can use behavioral science to identify and scale up interventions, working collaboratively with communities targeted for marginalization. Recommendations for SBM included establishing an organizational home for climate and health work, providing training and resources, engaging in climate advocacy as an organization, and networking with other organizations. Recommendations for a proposed SBM Climate and Health Committee, Council, or Special Interest Group included developing trainings and resources, seeking opportunities for networking and collaborations, and identifying a research agenda. Individual behavior changes are insufficient to address climate change; policy actions are needed. SBM and similar organizations can support their members to work in developing, evaluating, and scaling up advocacy interventions for action on climate policy to magnify the power of the health and medical sectors to protect planetary and human health.

Complex interlinkages, key objectives, and nexuses among the Sustainable Development Goals and climate change: a network analysis

BACKGROUND

Global sustainability is an enmeshed system of complex socioeconomic, climatological, and ecological interactions. The numerous objectives of the UN's Sustainable Development Goals (SDGs) and the Paris Agreement have various levels of interdependence, making it difficult to ascertain the influence of changes to particular indicators across the whole system. In this analysis, we aimed to detect and rank the complex interlinkages between objectives of sustainability agendas.

METHODS

We developed a method to find interlinkages among the 17 SDGs and climate change, including non-linear and non-monotonic dependences. We used time series of indicators defined by the World Bank, consisting of 400 indicators that measure progress towards the 17 SDGs and an 18th variable (annual average temperatures), representing progress in the response to the climate crisis, from 2000 to 2019. This method detects significant dependencies among the time evolution of the objectives by using partial distance correlations, a non-linear measure of conditional dependence that also discounts spurious correlations originating from lurking variables. We then used a network representation to identify the most important objectives (using network centrality) and to obtain nexuses of objectives (defined as highly interconnected clusters in the network).

FINDINGS

Using temporal data from 181 countries spanning 20 years, we analysed dependencies among SDGs and climate for 35 country groupings based on region, development, and income level. The observed significant interlinkages, central objectives, and nexuses identified varied greatly across country groupings; however, SDG 17 (partnerships for the goals) and climate change ranked as highly important across many country groupings. Temperature rise was strongly linked to urbanisation, air pollution, and slum expansion (SDG 11), especially in country groupings likely to be worst affected by climate breakdown, such as Africa. In several country groupings composed of developing nations, we observed a consistent nexus of strongly interconnected objectives formed by SDG 1 (poverty reduction), SDG 4 (education), and SDG 8 (economic growth), sometimes incorporating SDG 5 (gender equality), and SDG 16 (peace and justice).

INTERPRETATION

The differences across groupings emphasise the need to define goals in accordance with local circumstances and priorities. Our analysis highlights global partnerships (SDG 17) as a pivot in global sustainability efforts, which have been strongly linked to economic growth (SDG 8). However, if economic growth and trade expansion were repositioned as a means instead of an end goal of development, our analysis showed that education (SDG 4) and poverty reduction (SDG 1) become more central, thus suggesting that these could be prioritised in global partnerships. Urban livelihoods (SDG 11) were also flagged as important to avoid replicating unsustainable patterns of the past.

FUNDING

Engineering and Physical Sciences Research Council, UK Research and Innovation.

Global burden of chronic obstructive pulmonary disease attributable to ambient particulate matter pollution and household air pollution from solid fuels from 1990 to 2019

We aimed to estimate the spatiotemporal trends in the global burden of chronic obstructive pulmonary disease (COPD) attributable to both household air pollution from solid fuels (HAP) and ambient particulate matter (APM) from 1990 to 2019 and compared the possible differences between the burdens attributable to APM and HAP. The number of deaths, disability-adjusted life-years (DALYs), and years of life lost (YLLs) of COPD attributable to HAP from solid fuels and APM during 1990-2019 were extracted from the Global Burden of Diseases Study 2019. The proportion of YLLs in DALYs and average YLLs per COPD death were also calculated. Subgroup analyses by sex, age, and socio-demographic index (SDI) were conducted. The estimated annual percentage change (EAPC) was used to assess the temporal trend of age-standardized rate of mortality (ASMR) and DALYs (ASDR). Over the past 30 years, we observed a clear downward trend in COPD deaths attributable to HAP and an upward trend by 97.61% in COPD deaths attributable to APM. The global COPD burden attributable to APM in 2019 was higher than those due to HAP, except in low-SDI regions. For both HAP and APM, YLLs continued to predominate in DALYs of COPD, with an average YLLs per death of more than 10 years in different regions. The ASMR was higher in males and lower in high-SDI regions. The ASMR and ASDR attributable to HAP decreased globally in all age groups during 1990-2019, while those attributable to APM increased among people older than 80 years and in regions with lower SDI. Our study reveals an increasing trend in APM-attributable COPD burden over the past three decades. Comparatively, the global burden due to HAP decreased markedly, but it was still pronounced in low-SDI regions. Continued efforts on PM mitigation are needed for COPD prevention.

Cooling the City? A Scientometric Study on Urban Green and Blue Infrastructure and Climate Change-Induced Public Health Effects

Climate change causes global effects on multiple levels. The anthropogenic input of greenhouse gases increases the atmospheric mean temperature. It furthermore leads to a higher probability of extreme weather events (e.g., heat waves, floods) and thus strongly impacts the habitats of humans, animals, and plants. Against this background, research and innovation activities are increasingly focusing on potential health-related aspects and feasible adaptation and mitigation strategies. Progressing urbanization and demographic change paired with the climate change-induced heat island effect exposes humans living in urban habitats to increasing health risks. By employing scientometric methods, this scoping study provides a systematic bird’s eye view on the epistemic landscapes of climate change, its health-related effects, and possible technological and nature-based interventions and strategies in order to make urban areas climate proof. Based on a literature corpus consisting of 2614 research articles collected in SCOPUS, we applied network-based analysis and visualization techniques to map the different scientific communities, discourses and their interrelations. From a public health perspective, the results demonstrate the range of either direct or indirect health effects of climate change. Furthermore, the results indicate that a public health-related scientific discourse is converging with an urban planning and building science driven discourse oriented towards urban blue and green infrastructure. We conclude that this development might mirror the socio-political demand to tackle emerging climate change-induced challenges by transgressing disciplinary boundaries.

Tracking the impacts of climate change on human health via indicators: lessons from the Lancet Countdown

BACKGROUND

In the past decades, climate change has been impacting human lives and health via extreme weather and climate events and alterations in labour capacity, food security, and the prevalence and geographical distribution of infectious diseases across the globe. Climate change and health indicators (CCHIs) are workable tools designed to capture the complex set of interdependent interactions through which climate change is affecting human health. Since 2015, a novel sub-set of CCHIs, focusing on climate change impacts, exposures, and vulnerability indicators (CCIEVIs) has been developed, refined, and integrated by Working Group 1 of the "Lancet Countdown: Tracking Progress on Health and Climate Change", an international collaboration across disciplines that include climate, geography, epidemiology, occupation health, and economics.

DISCUSSION

This research in practice article is a reflective narrative documenting how we have developed CCIEVIs as a discrete set of quantifiable indicators that are updated annually to provide the most recent picture of climate change's impacts on human health. In our experience, the main challenge was to define globally relevant indicators that also have local relevance and as such can support decision making across multiple spatial scales. We found a hazard, exposure, and vulnerability framework to be effective in this regard. We here describe how we used such a framework to define CCIEVIs based on both data availability and the indicators' relevance to climate change and human health. We also report on how CCIEVIs have been improved and added to, detailing the underlying data and methods, and in doing so provide the defining quality criteria for Lancet Countdown CCIEVIs.

CONCLUSIONS

Our experience shows that CCIEVIs can effectively contribute to a world-wide monitoring system that aims to track, communicate, and harness evidence on climate-induced health impacts towards effective intervention strategies. An ongoing challenge is how to improve CCIEVIs so that the description of the linkages between climate change and human health can become more and more comprehensive.

Climate change and mental health research methods, gaps, and priorities: a scoping review

Research on climate change and mental health is a new but rapidly growing field. To summarise key advances and gaps in the current state of climate change and mental health studies, we conducted a scoping review that comprehensively examined research methodologies using large-scale datasets. We identified 56 eligible articles published in Embase, PubMed, PsycInfo, and Web of Science between Jan 1, 2000, and Aug 9, 2020. The primary data collection method used was surveys, which focused on self-reported mental health effects due to acute and subacute climate events. Other approaches used administrative health records to study the effect of environmental temperature on hospital admissions for mental health conditions, and national vital statistics to assess the relationship between environmental temperature and suicide rates with regression analyses. Our work highlights the need to link population-based mental health outcome databases to weather data for causal inference. Collaborations between mental health providers and data scientists can guide the formation of clinically relevant research questions on climate change.

Impacts of heat stress on global cattle production during the 21st century: a modelling study

BACKGROUND

Heat stress in animals is one of the major climate change impacts on domesticated livestock raised in both intensive and extensive production systems. At temperatures higher than an animal's thermoneutral zone, heat stress can affect liveweight gain, milk yield, and fertility. Animal welfare may also be negatively affected by heat stress even in the absence of effects on productivity, at least in the short term.

METHODS

We estimated the comparative statics change in the value of cattle milk and meat production from heat stress-induced losses at the global level, using climate scenario outputs for the middle (2045) and end of the century (2085). The loss estimates are based on bioenergetic equations that relate changes in dry matter intake (DMI) to both cold and hot, humid weather. DMI changes were estimated using CMIP6 climate data and linked to a global dataset containing information on livestock production systems, animal numbers, and region-specific and system-specific animal diets. Changes in DMI were converted to changes in milk and meat production and valued using early 20th century world prices (ie, constant 2005 US dollars).

FINDINGS

For a high greenhouse-gas emission scenario (SSP5-8.5), production losses from heat stress were estimated to amount to $39·94 billion (95% CI 34·39-45·49 billion) per year by the end of the century, or 9·8% of the value of production of meat and milk from cattle in 2005. For a low emission scenario (SSP1-2.6), the value of production losses was $14·89 billion (12·62-16·95 billion) per year, or 3·7% of 2005 value. In both scenarios, losses in most tropical regions were projected to be far greater than they were in temperate regions.

INTERPRETATION

Our results highlight the potential magnitude and extent of the adaptation efforts that will be necessary to combat the effects of increasing heat stress on cattle production during this century if food security challenges are to be minimised. Adaptations include switching to more heat-tolerant breeds and provision of shade, ventilation, and cooling systems.

FUNDING

CGIAR Trust Fund and bilateral donors.

Ecological Barrier Deterioration Driven by Human Activities Poses Fatal Threats to Public Health due to Emerging Infectious Diseases

The coronavirus disease 2019 (COVID-19) and concerns about several other pandemics in the 21st century have attracted extensive global attention. These emerging infectious diseases threaten global public health and raise urgent studies on unraveling the underlying mechanisms of their transmission from animals to humans. Although numerous works have intensively discussed the cross-species and endemic barriers to the occurrence and spread of emerging infectious diseases, both types of barriers play synergistic roles in wildlife habitats. Thus far, there is still a lack of a complete understanding of viral diffusion, migration, and transmission in ecosystems from a macro perspective. In this review, we conceptualize the ecological barrier that represents the combined effects of cross-species and endemic barriers for either the natural or intermediate hosts of viruses. We comprehensively discuss the key influential factors affecting the ecological barrier against viral transmission from virus hosts in their natural habitats into human society, including transmission routes, contact probability, contact frequency, and viral characteristics. Considering the significant impacts of human activities and global industrialization on the strength of the ecological barrier, ecological barrier deterioration driven by human activities is critically analyzed for potential mechanisms. Global climate change can trigger and expand the range of emerging infectious diseases, and human disturbances promote higher contact frequency and greater transmission possibility. In addition, globalization drives more transmission routes and produces new high-risk regions in city areas. This review aims to provide a new concept for and comprehensive evidence of the ecological barrier blocking the transmission and spread of emerging infectious diseases. It also offers new insights into potential strategies to protect the ecological barrier and reduce the wide-ranging risks of emerging infectious diseases to public health.

Climate Change and Medical Education: An Integrative Model

Medical schools face a challenge when trying to include new topics, such as climate change and health (CCH), in their curricula because of competing demands from more traditional biomedical content. At the same time, an understanding of CCH topics is crucial for physicians as they have clear implications for clinical practice and health care delivery. Although some medical schools have begun to incorporate CCH into curricula, the inclusion usually lacks a comprehensive framework for content and implementation. The authors propose a model for integrating CCH into medical school curricula using a practical, multistakeholder approach designed to mitigate competition for time with existing content by weaving meaningful CCH examples into current curricular activities. After the authors identified stakeholders to include in their curricular development working group, this working group determined the goals and desired outcomes of the curriculum; aligned those outcomes with the school's framework of educational objectives, competencies, and milestones; and strove to integrate CCH goals into as many existing curricular settings as possible. This article includes an illustration of the proposed model for one of the curricular goals (understanding the impacts of climate change on communities), with examples from the CCH curriculum integration that began in the fall of 2020 at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. The authors have found that this approach does minimize competition for time with existing content and allows mapping of content to existing curricular competencies and milestones, while encouraging a broad understanding of CCH in the context of individual patients, populations, and communities. This model for curricular integration can be applied to other topics such as social determinants of health, health equity, disability studies, and structural racism.

Food security and emerging infectious disease: risk assessment and risk management

Climate change, emerging infectious diseases (EIDs) and food security create a dangerous nexus. Habitat interfaces, assumed to be efficient buffers, are being disrupted by human activities which in turn accelerate the movement of pathogens. EIDs threaten directly and indirectly availability and access to nutritious food, affecting global security and human health. In the next 70 years, food-secure and food-insecure countries will face EIDs driving increasingly unsustainable costs of production, predicted to exceed national and global gross domestic products. Our modern challenge is to transform this business as usual and embrace an alternative vision of the biosphere formalized in the Stockholm paradigm (SP). First, a pathogen-centric focus shifts our vision of risk space, determining how pathogens circulate in realized and potential fitness space. Risk space and pathogen exchange are always heightened at habitat interfaces. Second, apply the document-assess-monitor-act (DAMA) protocol developing strategic data for EID risk, to be translated, synthesized and broadcast as actionable information. Risk management is realized through targeted interventions focused around information exchanged among a community of scientists, policy practitioners of food and public health security and local populations. Ultimately, SP and DAMA protect human rights, supporting food security, access to nutritious food, health interventions and environmental integrity.

Proxyeconomics, a theory and model of proxy-based competition and cultural evolution

Competitive societal systems by necessity rely on imperfect proxy measures. For instance, profit is used to measure value to consumers, patient volumes to measure hospital performance, or the journal impact factor to measure scientific value. While there are numerous reasons why proxies will deviate from the underlying societal goals, they will nevertheless determine the selection of cultural practices and guide individual decisions. These considerations suggest that the study of proxy-based competition requires the integration of cultural evolution theory and economics or decision theory. Here, we attempt such an integration in two ways. First, we describe an agent-based simulation model, combining methods and insights from these disciplines. The model suggests that an individual intrinsic incentive can constrain a cultural evolutionary pressure, which would otherwise enforce fully proxy-oriented practices. The emergent outcome is distinct from that with either the isolated economic or evolutionary mechanism. It reflects what we term lock-in, where competitive pressure can undermine the ability of agents to pursue the shared social goal. Second, we elaborate the broader context, outlining the system-theoretic foundations as well as some philosophical and practical implications, towards a broader theory. Overall, we suggest such a theory may offer an explanatory and predictive framework for diverse subjects, ranging from scientific replicability to climate inaction, and outlining strategies for diagnosis and mitigation.

Review: The impact of climate change awareness on children's mental well-being and negative emotions - a scoping review

BACKGROUND

Climate change is a threat to children's physical health, but there are also implications for mental well-being. Additionally, children may experience negative emotional responses stemming from an overarching awareness of the imminent threats to the planet due to climate change.

METHOD

Using a scoping review, we examined the impact of climate change awareness on children's mental well-being and negative emotions. Our aim was to identify and describe the existing literature and highlight priorities for future research. Three specific objectives guided the review: (1) to identify and provide an overview of research regarding the impact of climate change awareness on children's mental well-being and negative emotions; (2) to summarize and clarify the terminology related to climate change awareness and children's mental well-being and negative emotions; and (3) to make recommendations for areas of future research.

RESULTS

Thirty-three articles were included in a narrative synthesis. Many articles were reviews or editorials/commentaries. Of the empirical research, most were from Europe, North America, and Australia. The articles emphasized a large range of negative emotions that children felt about climate change, with anxiety and worry being the most researched and discussed.

CONCLUSIONS

The research on the impact of awareness of climate change on children's mental well-being and negative emotions is in its early phases. Efforts are needed to advance conceptual clarity and operationalize concepts. Additionally, there is a need for research into the impact of climate change awareness on children's mental well-being and negative emotions among a greater diversity of people and places. Existing studies provide an encouraging basis from which to develop future research.

"Land is everything, land is us": Exploring the connections between climate change, land, and health in Fort William First Nation

The myriad and cumulative impacts of climate change on land, communities, and health are increasingly evident worldwide. Throughout 2019 and 2020, Fort William First Nation and researchers at Lakehead University conducted a project to document and understand connections among climate change, land, and health from the perspective of Elders, knowledge keepers, and community members with close ties to the land. Fort William First Nation is an Anishinaabe community located on the shores of Lake Superior/Kitchigami in Northern Ontario and within Robinson-Superior Treaty territory. This paper describes the analysis of interviews with 22 community members. Two-Eyed Seeing, an approach that centers the working together of Indigenous and non-Indigenous knowledges and peoples and demands respectful relationship building, guided our project and analysis. Our analysis identified five themes: 1) observations and experiences of changes on the land, 2) lack of care and respect for Mother Earth as the root cause of climate change, 3) healthy land, healthy people, 4) youth and future generations, and 5) (re-)connecting with land and culture. 'All our Relations' is a thread woven across these themes emphasizing that climate change is understood and experienced through relationships and relationality. As concluding thoughts and reflections, we share three specific offerings of particular relevance to those engaging in climate change and health research and action with Indigenous peoples and communities. First, this research has highlighted the importance of explicitly centering land when exploring the links between climate change and health. Second, we reflect on the value of both the Two-Eyed Seeing approach and the Medicine Wheel in guiding climate change and health research. Third, we argue for an explicit focus on relationships and relationality in efforts aimed at understanding and addressing climate change.

'We have a plan for that': a qualitative study of health system resilience through the perspective of health workers managing antenatal and childbirth services during floods in Cambodia

OBJECTIVE

Health system resilience can increase a system's ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by exploring how public antenatal and childbirth health services in Cambodia have absorbed, adapted or transformed in response to seasonal and occasional floods.

DESIGN

A qualitative study using semi-structured interviews and thematic analysis and informed by the Dimensions of Resilience Governance framework.

SETTING

Public sector healthcare facilities and health departments in two districts exposed to flooding.

PARTICIPANTS

Twenty-three public sector health professionals with experience providing or managing antenatal and birth services during recent flooding.

RESULTS

The theme 'Collaboration across the system creates adaptability in the response' reflects how collaboration and social relationships among providers, staff and the community have delineated boundaries for actions and decisions for services during floods. Floods were perceived as having a modest impact on health services. Knowing the boundaries on decision-making and having preparation and response plans let staff prepare and respond in a flexible yet stable way. The theme was derived from ideas of (1) seasonal floods as a minor strain on the system compared with persistent, system-wide organisational stresses the system already experiences, (2) the ability of the health services to adjust and adapt flood plans, (3) a shared purpose and working process during floods, (4) engagement at the local level to fulfil a professional duty to the community, and (5) creating relationships between health system levels and the community to enable flood response.

CONCLUSION

The capacity to absorb and adapt to floods was seen among the public sector services. Strategies that enhance stability and flexibility may foster the capacity for health system resilience.

Global priorities for climate change and mental health research

BACKGROUND

Compared with other health areas, the mental health impacts of climate change have received less research attention. The literature on climate change and mental health is growing rapidly but is characterised by several limitations and research gaps. In a field where the need for designing evidence-based adaptation strategies is urgent, and research gaps are vast, implementing a broad, all-encompassing research agenda will require some strategic focus.

METHODS

We followed a structured approach to prioritise future climate change and mental health research. We consulted with experts working across mental health and climate change, both within and outside of research and working in high, middle, and low-income countries, to garner consensus about the future research priorities for mental health and climate change. Experts were identified based on whether they had published work on climate change and mental health, worked in governmental and non-governmental organisations on climate change and mental health, and from the professional networks of the authors who have been active in the mental health and climate change space.

RESULTS

Twenty-two experts participated from across low- and middle-income countries (n = 4) and high-income countries (n = 18). Our process identified ten key priorities for progressing research on mental health and climate change.

CONCLUSION

While climate change is considered the biggest threat to global mental health in the coming century, tackling this threat could be the most significant opportunity to shape our mental health for centuries to come because of health co-benefits of transitioning to more sustainable ways of living. Research on the impacts of climate change on mental health and mental health-related systems will assist decision-makers to develop robust evidence-based mitigation and adaptation policies and plans with the potential for broad benefits to society and the environment.

Air exchanges, climate change, and severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Results from a survey of the Society of Healthcare Epidemiology of America Research Network (SRN)

In this cross-sectional survey, we assessed knowledge, attitudes and behaviors regarding operating room air-change rates, climate change, and coronavirus disease 2019 (COVID-19) pandemic implications. Climate change and healthcare pollution were considered problematic. Respondents checked air exchange rates for COVID-19 and ∼25% increased them. Respondents had difficulty completing questions concerning hospital heating, ventilation and air conditioning (HVAC) systems.

Global implications of biodiversity loss on pandemic disease: COVID-19

Unpredictable climate changes and adverse effects on the planetary health due to environmental degradation have led to the rise of concerns regarding human wellness in the recent days. Coronavirus disease 2019 (COVID-19) is said to be originated from wildlife species and represents a significant threat to human health, social, food, and economic security. However, understanding the underlying factors behind the emergence is still rudimentary. This study has made efforts to understand the relationship between the drivers that causes the emergence of infectious diseases (EID). The recent biodiversity crisis that has a severe impact on planetary health is a new contributory factor for the emergence of COVID-19. The biodiversity crisis is an outcome of the land use and land cover (LULC) change, contributing to climate change. In the overall global LULC, 60% are associated with direct human activities and 40% indirect causes such as climate change. Climate change is one of the critical factors that induce landcover change, associated with increasing consumerism, environmental pollution, excessive livestock production, population explosion, and food production. Geospatial techniques provide a viable solution for monitoring the key drivers responsible for EID, such as climate characteristics, LULC, global land cover under food production, and locations affected by infectious diseases in the past. The study’s main objective is to discuss the possibilities of evolving novel solutions to approach the forecasting of emerging infectious disease spread and its mitigation, bridging the sectors and stakeholders, with due relevance to sustainable development goals (SDGs) and other dimensions from global to community levels.

Participação e transdisciplinaridade em Ecosaúde: a perspectiva da análise de redes sociais

Resumo A Ecosaúde usa abordagens participativas e transdisciplinares com o intuito de compreender as inter-relações entre os componentes dos sistemas socioecológicos e como estas interações influenciam a saúde das populações humanas. O objetivo do artigo é usar a Análise de Redes Sociais (ARS) para entender o papel das relações de colaboração entre os diversos atores envolvidos nos processos participativos e transdisciplinares em projetos de Ecosaúde. Apresentamos um conjunto de indicadores de ARS para caracterizar a evolução e a equidade de participação e diferenciar a inter e a transdisciplinaridade. A análise foi feita com base na rede de colaboração entre os atores da Iniciativa de Liderança em Ecosaúde para as Enfermidades Transmitidas por Vetores (ETV) na América Latina e Caribe. O processo participativo ficou mais intenso ao longo do projeto, com mais sujeitos envolvidos e um número crescente de colaborações. A cooperação entre os atores das ciências sociais, ambientais e da saúde é pouco equitativa; assim, predominam as ciências da saúde. Os poucos cientistas ambientais presentes estão, porém, ativamente envolvidos em colaborações interdisciplinares. A abordagem tem aplicação ampla para estudar a participação e a transdisciplinaridade em projetos sobre saúde e meio ambiente.

Participation and transdisciplinarity in Ecohealth: a social network analysis perspective

Abstract Ecohealth uses participatory and transdisciplinary approaches to understand the relationships between the components of socio-ecological systems and how these interactions influence the health of human populations. This article aims to use Social Network Analysis (SNA) to understand the role of collaborative relationships between the various actors involved in participatory and transdisciplinary processes in Ecohealth projects. We present a set of SNA indicators to characterize the evolution and equity of participation and to differentiate inter- and transdisciplinarity. The analysis was based on the collaboration network among the members of the Iniciativa Para el Liderazgo y Desarrollo del Campo de Ecosalud y Enfermedades Transmitidas por Vectores (ETV) en América Latina y el Caribe. The participatory process intensified throughout the project, with more individuals involved and increasing collaborations. Cooperation between members from social, environmental, and health sciences is unbalanced and health scientists predominate. The few environmental scientists are, however, actively involved in interdisciplinary collaborations. The proposed approach has wide application to study participation and transdisciplinarity in projects about health and environment.

A Study the Effect of Biodiesel Blends and the Injection Timing on Performance and Emissions of Common Rail Diesel Engines

This paper presents a study on the effect of the ratio of biodiesel and injection timing on the performance of diesel engines and their emissions. The research engine is a cylinder engine AVL-5402, simulated by software AVL-Boost. The simulated fuel includes fossil diesel and biodiesel blended with a replacement rate from 0% to 50%, with a simulation mode of 2200 (rev/min), at a rate of a 25%, 50% and 75% load. In this speed range, the engine has the lowest fuel consumption. The parameters to be evaluated are power, fuel consumption and emissions, based on the proportions of blended biodiesel. The results show that there is a relationship between the proportion of blended biodiesel, injection timing and the parameters of the engine. Specifically, the ratio of the biodiesel blend increases, injection timing tends to move closer to the top dead center (TDC), the tendency reduce engine power, fuel consumption increases, the emissions of CO and soot reduces, while NOx increases.

Presentation and evaluation of a modern course in disaster medicine and humanitarian assistance for medical students

BACKGROUND

Disaster medicine is a component of the German medical education since 2003. Nevertheless, studies have shown some inconsistencies within the implementation of the national curriculum, and limits in the number of students trained over the years. Recently, the SARS-CoV-2 pandemic and other disasters have called attention to the importance of training medical students in disaster medicine on a coordinated basis. The aim of this study is to present and evaluate the disaster medicine and humanitarian assistance course, which was developed in the University of Tübingen, Germany.

METHODS

The University Clinic for Anesthesiology and Intensive Care Medicine in Tübingen expanded the existing curriculum of undergraduate disaster medicine training with fundamentals of humanitarian medicine, integrating distance learning, interactive teaching and simulation sessions in a 40 h course for third-, fourth- and fifth- year medical students. This prospective and cross-sectional study evaluates the Disaster Medicine and Humanitarian Assistance course carried out over five semesters during the period between 2018 and 2020. Three survey tools were used to assess participants' previous experiences and interest in the field of disaster medicine, to compare the subjective and objective level of knowledge before and after training, and to evaluate the course quality.

RESULTS

The total number of medical students attending the five courses was n = 102 of which n = 60 females (59%) and n = 42 males (41%). One hundred two students entered the mandatory knowledge assessment, with the rate of correct answers passing from 73.27% in the pre-test to 95.23% in the post-test (t [101] = 18.939, p < .001, d = 1.88). To determine the subjective perception of knowledge data were collected from 107 observations. Twenty-five did not complete the both questionnaires. Out of a remaining sample of 82 observations, the subjective perception of knowledge increased after the course (t [81] = 24.426, p < .001, d = 2.69), alongside with the interest in engaging in the field of disaster medicine (t [81] = 7.031, p < .001, d = .78). The 93.46% of the medical students (n = 100) graded the training received with an excellent overall score (1.01 out of 6).

CONCLUSION

The study indicates a significant increase in students' understanding of disaster medicine using both subjective and objective measurements, as well as an increase interest in the field of disaster medicine and humanitarian assistance. Whereas former studies showed insufficient objective knowledge regarding disaster medical practices as well as subjective insecurities about their skills and knowledge to deal with disaster scenarios, the presented course seems to overcome these deficiencies preparing future physicians with the fundamentals of analysis and response to disasters. The development and successful implementation of this course is a first step towards fulfilling disaster medicine education requirements, appearing to address the deficiencies documented in previous studies. A possible adaptation with virtual reality approaches could expand access to a larger audience. Further effort must be made to develop also international training programs, which should be a mandatory component of medical schools' curricula.

Carbon Footprint of General, Regional, and Combined Anesthesia for Total Knee Replacements

BACKGROUND

Health care itself contributes to climate change. Anesthesia is a "carbon hotspot," yet few data exist to compare anesthetic choices. The authors examined the carbon dioxide equivalent emissions associated with general anesthesia, spinal anesthesia, and combined (general and spinal anesthesia) during a total knee replacement.

METHODS

A prospective life cycle assessment of 10 patients in each of three groups undergoing knee replacements was conducted in Melbourne, Australia. The authors collected input data for anesthetic items, gases, and drugs, and electricity for patient warming and anesthetic machine. Sevoflurane or propofol was used for general anesthesia. Life cycle assessment software was used to convert inputs to their carbon footprint (in kilogram carbon dioxide equivalent emissions), with modeled international comparisons.

RESULTS

Twenty-nine patients were studied. The carbon dioxide equivalent emissions for general anesthesia were an average 14.9 (95% CI, 9.7 to 22.5) kg carbon dioxide equivalent emissions; spinal anesthesia, 16.9 (95% CI, 13.2 to 20.5) kg carbon dioxide equivalent; and for combined anesthesia, 18.5 (95% CI, 12.5 to 27.3) kg carbon dioxide equivalent. Major sources of carbon dioxide equivalent emissions across all approaches were as follows: electricity for the patient air warmer (average at least 2.5 kg carbon dioxide equivalent [20% total]), single-use items, 3.6 (general anesthesia), 3.4 (spinal), and 4.3 (combined) kg carbon dioxide equivalent emissions, respectively (approximately 25% total). For the general anesthesia and combined groups, sevoflurane contributed an average 4.7 kg carbon dioxide equivalent (35% total) and 3.1 kg carbon dioxide equivalent (19%), respectively. For spinal and combined, washing and sterilizing reusable items contributed 4.5 kg carbon dioxide equivalent (29% total) and 4.1 kg carbon dioxide equivalent (24%) emissions, respectively. Oxygen use was important to the spinal anesthetic carbon footprint (2.8 kg carbon dioxide equivalent, 18%). Modeling showed that intercountry carbon dioxide equivalent emission variability was less than intragroup variability (minimum/maximum).

CONCLUSIONS

All anesthetic approaches had similar carbon footprints (desflurane and nitrous oxide were not used for general anesthesia). Rather than spinal being a default low carbon approach, several choices determine the final carbon footprint: using low-flow anesthesia/total intravenous anesthesia, reducing single-use plastics, reducing oxygen flows, and collaborating with engineers to augment energy efficiency/renewable electricity.

EDITOR’S PERSPECTIVE

The effect of deforestation and climate change on all-cause mortality and unsafe work conditions due to heat exposure in Berau, Indonesia: a modelling study

BACKGROUND

Previous studies focusing on urban, industrialised regions have found that excess heat exposure can increase all-cause mortality, heat-related illnesses, and occupational injuries. However, little research has examined how deforestation and climate change can adversely affect work conditions and population health in low latitude, industrialising countries.

METHODS

For this modelling study we used data at 1 km² resolution to compare forest cover and temperature conditions in the Berau regency, Indonesia, between 2002 and 2018. We used spatially explicit satellite, climate model, and population data to estimate the effects of global warming, between 2002 and 2018 and after applying 1·0°C, 1·5°C, and 2·0°C of global warming to 2018 temperatures, on all-cause mortality and unsafe work conditions in the Berau regency, Indonesia.

FINDINGS

Between 2002 and 2018, 4375 km² of forested land in Berau was cleared, corresponding to approximately 17% of the entire regency. Deforestation increased mean daily maximum temperatures by 0·95°C (95% CI 0·97-0·92; p<0·0001). Mean daily temperatures increased by a population-weighted 0·86°C, accounting for an estimated 7·3-8·5% of all-cause mortality (or 101-118 additional deaths per year) in 2018. Unsafe work time increased by 0·31 h per day (95% CI 0·30-0·32; p<0·0001) in deforested areas compared to 0·03 h per day (0·03-0·04; p<0·0001) in areas that maintained forest cover. With 2·0°C of additional future global warming, relative to 2018, deforested areas could experience an estimated 17-20% increase in all-cause mortality (corresponding to an additional 236-282 deaths per year) and up to 5 h of unsafe work per day.

INTERPRETATION

Heat exposure from deforestation and climate change has already started affecting populations in low latitude, industrialising countries, and future global warming indicates substantial health impacts in these regions. Further research should examine how deforestation is currently affecting the health and wellbeing of local communities.

FUNDING

University of Washington Population Health Initiative.

TRANSLATION

For the Bahasa translation of the abstract see Supplementary Materials section.

Awareness and attitudes towards sustainability and climate change amongst students and educators in nursing: A systematic integrative review protocol

Aim

This review identifies and synthesizes literature related to the awareness of and attitudes towards sustainability and climate change from the perspective of nursing students and educators.

Design

A systematic integrative review.

Methods

The review will follow the five stages outlined by Whittemore and Knafl: problem identification, literature search, data evaluation, data analysis and presentation. The data analysis will be based on inductive content analysis developed by Elo and Kyngäs. Principles of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) will also inform the review process.

Results

This review will offer insights about sustainability and climate change in relation to an important target population: the future nursing workforce and those educating its members. Findings might inform curriculum development, potentially contributing to a nursing profession that looks after the health of the planet and the health of the population inhabiting it.

The Impact of Natural Hazards on Older Adult Health: Lessons Learned From Hurricane Maria in Puerto Rico

OBJECTIVE

With natural hazards increasing in frequency and severity and global population aging, preparedness efforts must evolve to address older adults' risks in disasters. This study elucidates potential contributors to the elevated older adult mortality risk following Hurricane Maria in Puerto Rico through an examination of community stakeholder preparedness, response, and recovery experiences.

METHODS

In April 2018, qualitative interviews (n = 22) were conducted with stakeholders in 7 Puerto Rican municipalities. Interview transcripts were deductively and inductively coded and analyzed to identify salient topics and themes representing participant response patterns.

RESULTS

The hurricane's detrimental impact on older adult health emerged as a prominent finding. Through 6 months post-hurricane, many older adults experienced unmet needs that contributed to declining physical and emotional health, inadequate non-communicable disease management, social isolation, financial strain, and excess morbidity and mortality. These needs were predominantly consequences of lengthy public service gaps, unsafe living conditions, interrupted health care, and the incongruence between preparedness and event severity.

CONCLUSIONS

In a landscape of increasing natural hazard frequency and magnitude, a pattern of older adult risk has become increasingly clear. Study findings compel practitioners to engage in natural hazard preparedness planning, research, and policy-making that considers the multiple facets of older adult well-being.

Resilience of Communities in Puerto Rico Following Hurricane Maria: Community-Based Preparedness and Communication Strategies

OBJECTIVE

This study aimed to examine factors that may have contributed to community disaster resilience following Hurricane Maria in Puerto Rico.

METHODS

In April 2018, qualitative interviews (n = 22) were conducted with stakeholders in 7 Puerto Rican municipalities (9% of total). Transcripts were deductively and inductively coded and analyzed to identify salient topics and themes, then examined according to strategic themes from the Federal Emergency Management Association's (FEMA) Whole Community Approach.

RESULTS

Municipal preparedness efforts were coordinated, community-based, leveraged community assets, and prioritized vulnerable populations. Strategies included (1) multi-sectoral coordination and strategic personnel allocation; (2) neighborhood leader designation as support contacts; (3) leveraging of community leader expertise and social networks to protect vulnerable residents; (4) Censuses of at-risk groups, health professionals, and first responders; and (5) outreach for risk communication and locally tailored protective measures. In the context of collapsed telecommunications, communities implemented post-disaster strategies to facilitate communication with the Puerto Rican Government, between local first responders, and to keep residents informed, including the use of: (1) police radios; (2) vehicles with loudspeakers; (3) direct interpersonal communication; and (4) solar-powered Internet radio stations.

CONCLUSIONS

Adaptive capacities and actions of Puerto Rican communities exemplify the importance of local solutions in disasters. Expanded research is recommended to better understand contributors to disaster resilience.

Prenatal and Postnatal Household Air Pollution Exposures and Pneumonia Risk: Evidence From the Ghana Randomized Air Pollution and Health Study

BACKGROUND

Nearly 40% of the world's population is exposed daily to household air pollution. The relative impact of prenatal and postnatal household air pollution exposure on early childhood pneumonia, a leading cause of mortality, is unknown.

RESEARCH QUESTION

Are prenatal or postnatal household air pollution, or both, associated with pneumonia risk in the first year of life?

STUDY DESIGN AND METHODS

The Ghana Randomized Air Pollution and Health Study enrolled 1,414 nonsmoking, pregnant women before 24 weeks' gestation with prospective follow-up to the child's age of 1 year. We measured 72-h personal household air pollution exposures, indexed by carbon monoxide (CO), four times prenatally and three times postnatally. Weekly fieldworker surveillance identified ill-appearing children for physician pneumonia assessment. We used quasi-Poisson models to examine associations between prenatal and postnatal CO and physician-diagnosed pneumonia and severe pneumonia. Sex-specific effects were examined.

RESULTS

Of the 1,306 live births, 1,141 infants were followed up with 55,605 child-weeks of fieldworker surveillance. The estimated risk for pneumonia and severe pneumonia in the first year of life increased by 10% (relative risk [RR], 1.10; 95% CI, 1.04-1.16) and 15% (RR, 1.15; 95% CI, 1.03-1.28), respectively, per 1-part per million (ppm) increase in average prenatal CO exposure and by 6% (RR, 1.06; 95% CI, 0.99-1.13) per 1-ppm increase in average postnatal CO exposure. Sex-stratified analyses suggest that in girls, higher prenatal CO exposure was associated with pneumonia risk, while no association was seen in boys.

INTERPRETATION

Prenatal household air pollution exposure increased risk of pneumonia and severe pneumonia in the first year of life. Clean-burning interventions may be most effective when begun prenatally.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01335490; URL: www.clinicaltrials.gov.

Increases in extreme heat stress in domesticated livestock species during the twenty-first century

Anthropogenic climate change is expected to have major impacts on domesticated livestock, including increased heat stress in animals in both intensive and extensive livestock systems. We estimate the changes in the number of extreme heat stress days per year for animals raised outdoors that can be expected in the major domesticated animal species (cattle, sheep, goats, poultry, and pigs) across the globe during this century. We used the temperature humidity index as a proxy for heat stress, calculated using temperature and relative humidity data collated from an ensemble of CMIP6 climate model output for mid and end century. We estimate changes in the proportions of different livestock species that may be at increased risk of extreme heat stress under two contrasting greenhouse gas emission scenarios. Results are discussed in relation to changes in the suitability of different climate conditions for domesticated livestock during the current century. We find that by end century, extreme heat stress risk is projected to increase for all livestock species in many parts of the tropics and some of the temperate zones, and to become climatically more widespread, compared to 2000. Although adaptation options exist for both intensive and extensive livestock production systems, the increasing pervasiveness of extreme heat stress risk in the future will seriously challenge the viability of outdoor livestock keeping, particularly in the lower latitudes in lower and middle-income countries where the costs of adaptation may be challenging to address.

The Impact of Sustainability Goals on Productivity Growth: The Moderating Role of Global Warming

The objective of this paper was to gain novel insights into the complex relationships among Sustainable Development Goals (SDGs) in shaping productivity (GDP/capita) growth. Using dynamic panel regressions on data collected in 138 countries between 2000 and 2017, we found that rising temperatures negatively affect growth and mitigate the impact of other SDGs on growth. We also found that CO₂ emissions have a U-shaped relationship with growth; life expectancy negatively influences growth (positively moderated by rising temperatures), and food security positively impacts growth (negatively moderated by rising temperatures). This study highlights the difficulty of simultaneously implementing SDGs and elucidates novel research perspectives and policies to decrease the negative impacts of climate change on socio-economic and environmental well-being.

The Impact of Rainfall Variability on Diets and Undernutrition of Young Children in Rural Burkina Faso

Background: Climate change and consequent increases in rainfall variability may have negative consequences for the food production of subsistence farmers in West Africa with adverse impacts on nutrition and health. We explored the pathway from rainfall through diet up to child undernutrition for rural Burkina Faso. Methods: The study used data of a dynamic cohort with 1,439 children aged 7-60 months from the Nouna Health and Demographic Surveillance Site (HDSS) for 2017 to 2019. We assessed data on diets, height, weight, household characteristics, and daily precipitation (from 1981 to 2019). Principal component analysis was used to identify distinct child dietary patterns (Dietary Pattern Scores, DPS). These were related to 15 rainfall indicators by area to obtain a precipitation variability score (PVS) through reduced rank regression (RRR). Associations between the PVS and anthropometric measures, height-for-age (HAZ), and weight-for-height (WHZ), were examined using multi-level regression analysis. Results: Stunting (HAZ < -2) and wasting (WHZ < -2) were seen in 24 and 6% of the children. Three main dietary patterns were identified (market-based, vegetable-based, and legume-based diets) and showed mixed evidence for associations with child undernutrition. The RRR-derived PVS explained 14% of the total variance in these DPS. The PVS was characterized by more consecutive dry days during the rainy season, higher cumulative rainfall in July and more extremely wet days. A 1-point increase in the PVS was associated with a reduction of 0.029 (95% CI: -0.06, 0.00, p < 0.05) in HAZ in the unadjusted, and an increase by 0.032 (95% CI: 0.01, 0.06, p < 0.05) in WHZ in the fully adjusted model. Conclusion: Rainfall variability was associated with dietary patterns in young children of a rural population of Burkina Faso. Increased rainfall variability was associated with an increase in chronic undernutrition, but not in acute undernutrition among young children.