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

Impact of ambient temperature on hospital admissions for cardiovascular disease in Hefei City, China

Many studies have quantified the hospitalization risk for cardiovascular disease (CVD) caused by temperature, but the results of most studies are not consistent. In this study, we evaluate the effect of temperature on CVD hospitalizations. We use a quasi-Poisson regression with a distributed-lag nonlinear model (DLNM) to evaluate the effect of temperature on CVD hospitalizations between July 1, 2015, and October 31, 2017, in Hefei City, China. We found that the cold effect and heat effect of temperature can impact CVD hospital admissions. Compared with the 25th percentile of temperature (10.3 °C), the cumulative relative risk (RR) of extremely low temperature (first percentile of temperature, 0.075 °C) over lags 0-27 days was 0.616 (95% CI 0.423-0.891), and the cumulative RR of moderate low temperature (10th percentile of temperature, 5.16 °C) was 1.081 (95% CI 1.019-1.147) over lags 0-7 days. Compared with the 75th percentile of temperature (25.6 °C), the cumulative RR of extremely high temperature (99th percentile of temperature, 33.7 °C) was 1.078 (95% CI 0.752-1.547) over lags 0-27 days, and the cumulative RR of moderate-high temperature (90th percentile of temperature, 29.0 °C) was 1.015 (95% CI 0.988-1.043) over lag 0 day. In the subgroup, the < 65-year group and male were more susceptible to low temperature; however, the ≥ 65-year group and female were more vulnerable to high temperature. The high temperature's impact on CVD hospital admissions was found to be more obvious in female and the ≥ 65-year group compared to male and the < 65-year group. However, the < 65-year group and men are more sensitive to low temperature.

Replacing meat with alternative plant-based products (RE-MAPs): protocol for a randomised controlled trial of a behavioural intervention to reduce meat consumption

INTRODUCTION

Reducing meat consumption could contribute towards preventing some chronic conditions and protecting the natural environment. This study will examine the effectiveness of a behavioural intervention to reduce meat consumption.

METHODS AND ANALYSES

Replacing meat with alternative plant-based product is a randomised controlled trial comparing a behavioural intervention to reduce meat consumption with a no intervention control condition. Eligible volunteers will be recruited from the general public through advertisement and randomised in a 1:1 ratio to receive no intervention or a 4-week intervention comprising the provision of free plant-based meat alternatives, written information on the health and environmental benefits of eating less meat, success stories of people who reduced their meat consumption and recipes. The primary outcome is the change in meat consumption at 4 weeks (T1) from baseline. Secondary and exploratory outcomes include changes in meat consumption at 8 weeks (T2) from baseline and changes from the baseline to both follow-up in other aspects of participants diet, putative psychosocial determinants of eating a low meat diet and of using meat substitutes and biomarkers of health risk, including blood lipid profiles, blood pressure, weight and body composition. Linear models will be employed to explore whether the changes in each of the aforementioned outcomes differ significantly between the control and intervention group. Qualitative interviews on a subsample of participants receiving the intervention will evaluate their experiences of the intervention and help to identify the mechanisms through which the intervention reduced meat consumption or the barriers preventing the intervention to aid this dietary transition.

ETHICS AND DISSEMINATION

The trial has been granted ethical approval by the Medical Sciences Interdivisional Research Ethics Committee (IDREC) of the University of Oxford (Ref: R54329/RE001). All results originating from this study will be submitted for publication in scientific journals and presented at meetings and through the media.

TRIAL REGISTRATION NUMBER

ISRCTN13180635;Pre-recruitment.

A survey of the choice of general anaesthetic agents in Australia and New Zealand

Strategies to reduce the adverse environmental costs of anaesthesia include choice of agent and fresh gas flows. The current preferences of Australian and New Zealand anaesthetists are unknown. We conducted a survey of Australian and New Zealand anaesthetists to determine the use of volatiles, nitrous oxide and intravenous anaesthesia, lowest fresh gas flow rates, automated end-tidal volatile control, and the rationales for these choices. The survey was answered by 359/1000 (36%), although not all questions and multiple responses within single questions were answered by all respondents. Sevoflurane was preferred by 246/342 (72%, 95% confidence interval (CI) 67%–77%), followed by propofol, 54/340 (16%, 95% CI 12%–20%), desflurane 39/339 (12%, 95% CI 8%–16%) and isoflurane 3/338(1%, 95% CI 0–3%). When asked about all anaesthetics, low-risk clinical profile was the most common reason given for using sevoflurane (129/301 (43%, 95% CI 37%–49%)), reduced postoperative nausea for propofol (297/318 (93%, 95% CI 90%–96%)) and faster induction/awakening times for desflurane (46/313 (79%, 95% CI 74%–83%)). Two-thirds (226/340 (66%, 95% CI 61%–71%)) of respondents used nitrous oxide in 0–20% of general anaesthetics. Low fresh gas flow rates for sevoflurane were used by 310/333 (93%, 95% CI 90%–95%) and for 262/268 (98%, 95% CI 95%–99%) for desflurane. Automated end-tidal control was used by 196/333 (59%, 95% CI 53%–64%). The majority of respondents (>70%) preferred sevoflurane at low flows. These data allow anaesthetists to consider further whether changes are required to the choices of anaesthetic agents for environmental, financial, or any other reasons.

Health psychology at the age of Anthropocene

This commentary argues that health psychology, as a scientific discipline, needs to address the negative consequences of Anthropocene by helping individuals, communities and health systems to produce proactive efforts and prepare effective responses strategies for climate change consequences. The commentary addresses the following questions: How to demarcate health psychology at Anthropocene age? What are the best mitigation and adaptation behaviors for health and environment? How to help the environmental migrants and future climate refugees? How to develop a more resilient and adapted health care systems? Should we be in and out of health psychology? In conclusion, health psychologists and academics have to move forward helping individuals, communities and health systems to radically develop lower-carbon lifestyles in a sustainable society.

The Future of Climate Epidemiology: Opportunities for Advancing Health Research in the Context of Climate Change

In the coming decades, climate change is expected to dramatically affect communities worldwide, altering the patterns of many ambient exposures and disasters, including extreme temperatures, heat waves, wildfires, droughts, and floods. These exposures, in turn, can affect risks for a variety of human diseases and health outcomes. Climate epidemiology plays an important role in informing policy related to climate change and its threats to public health. Climate epidemiology leverages deep, integrated collaborations between epidemiologists and climate scientists to understand the current and potential future impacts of climate-related exposures on human health. A variety of recent and ongoing developments in climate science are creating new avenues for epidemiologic contributions. Here, we discuss the contributions of climate epidemiology and describe some key current research directions, including research to better characterize uncertainty in climate health projections. We end by outlining 3 developing areas of climate science that are creating opportunities for high-impact epidemiologic advances in the near future: 1) climate attribution studies, 2) subseasonal to seasonal forecasts, and 3) decadal predictions.

Increasing Risks for Armed Conflict: Climate Change, Food and Water Insecurity, and Forced Displacement

The interrelated factors of climate change, decreased access to freshwater, and forced displacement are heightening the risk of armed conflict. Higher temperatures and extremes of precipitation are contributing to food and water insecurity, forced displacement, and sociopolitical tensions. Health professionals can help to address these problems through education, advocacy, and other activities that aim to mitigate and adapt to climate change and minimize the risk of armed conflict.

Imaginary Numbers of Climate Change Migrants?

Within the extensive scientific and policy discussions about climate change migrants, detailed analyses continue to highlight the lack of evidence thus far for climate change directly causing migration. To understand better how climate change might or might not lead to migration, this paper explores possibilities for developing a robust, repeatable, and verifiable method to count or calculate the number of people migrating or not migrating due to climate change. The discussion starts by examining definitions of “climate change” and “migration”, then looking at how to determine numbers of climate change migrants based on those definitions. These points lead to descriptions of the subjectivity and arbitrariness of the decisions needed for counting or calculating climate change migrants and non-migrants. While the scientific study of working out numbers of climate change migrants and non-migrants is challenging and interesting, especially due to its complexity, changing baselines alongside legitimate concerns about necessary assumptions lead to questions regarding the usefulness of the calculations for policy and action. Ultimately, labelling, counting, and calculating climate change migrants and non-migrants depend on political choices, so any numbers reached might not be scientifically robust. Improved understanding of people’s motivations for migrating and not migrating under different circumstances, including under climate change and perceptions thereof, would be preferable to a starting point assuming that climate change inevitably causes migration.

A narrative model for exploring climate change engagement among young community leaders

INTRODUCTION

Decades of widespread knowledge about climate change have not translated into adequate action to address impacts on population health and health equity in Canada. Research has shown that context-based perceptions and interpretations mediate engagement. Exploring climate change engagement involves inquiry into contextual experience.

METHODS

This qualitative study has employed narrative methodology to interpret the meaning of climate change among community leaders in Saskatoon, Saskatchewan, Canada, age 20-40 (n = 10). Climate change narratives were explored both structurally and thematically.

RESULTS

A model was developed to organize results and to describe concepts of fidelity and dissonance within participant narratives. Findings suggested that knowledge of climate change and personal motivation to act did not preclude narrative dissonance, which served as a barrier to a meaningful personal response. Dissonance can result where internal and external barriers mediate mobilization at moments in the plot: (1) moving from knowledge of the challenge to a sense of agency about it; (2) from agency to a sense of responsibility to choose to address it; (3) from responsibility to a sense of capacity to produce desirable outcomes despite contextual challenges; and (4) from capacity to a moral sense of activation in context. Without narrative fidelity, meaningful mobilization can be hindered.

CONCLUSION

A narrative model is useful for exploring climate change engagement and highlights opportunities for a population health approach to address the conditions that hinder meaningful mobilization. By framing climate change narratives with emotional and moral logic, population health framing could help young leaders overcome internal and external barriers to engagement.

Climate change: essential knowledge for developing holistic solutions to our climate crisis

Understanding anthropogenic climate change is essential for anyone working in the life sciences. Firstly because climate change has already started to impact the Earth biosphere and human health and these changes need to be documented and acknowledged. Secondly, many of the solutions to climate change, both mitigation and adaptation, will be through the life sciences, everything from massive reforestation and sustainable agriculture to preventing the spread of disease and protecting individual human health. Anthropogenic climate change is, therefore, one of the defining challenges of the 21st century, along with poverty alleviation, environmental degradation and global security. Climate change is no longer just a scientific concern but encompasses economics, sociology, geopolitics, national and local politics, law and health to name a few. Hence, to understand climate change fully then not only does one have to review the science but also the politics and geopolitics, which have created the issue and can provide the solutions. Climate change ultimately makes us examine the whole basis of modern society and ultimately asks questions about humanity's relationship with the rest of the planet.

The Sensitivity of Urban Heat Island to Urban Green Space—A Model-Based Study of City of Colombo, Sri Lanka

Urbanization continues to trigger massive land-use land-cover change that transforms natural green environments to impermeable paved surfaces. Fast-growing cities in Asia experience increased urban temperature indicating the development of urban heat islands (UHIs) because of decreased urban green space, particularly in recent decades. This paper investigates the existence of UHIs and the impact of green areas to mitigate the impacts of UHIs in Colombo, Sri Lanka, using UrbClim, a boundary climate model that runs two classes of simulations, namely urbanization impact simulations, and greening simulations. The urbanization impact simulation results show that UHIs spread spatially with the reduction of vegetation cover, and increases the average UHI intensity. The greening simulations show that increasing green space up to 30% in urban areas can decrease the average air temperature by 0.1 °C. On the other hand, converting entire green areas into urban areas in suburban areas increases the average temperature from 27.75 °C to 27.78 °C in Colombo. This demonstrates the sensitivity of UHI to vegetation cover in both urban and suburban areas. These seemingly small changes are average grid values and may indicate much higher impacts at sub-grid levels.

Climate change adaptation in South Africa: a case study on the role of the health sector

BACKGROUND

Globally, the response to climate change is gradually gaining momentum as the impacts of climate change unfold. In South Africa, it is increasingly apparent that delays in responding to climate change over the past decades have jeopardized human life and livelihoods. While slow progress with mitigation, especially in the energy sector, has garnered much attention, focus is now shifting to developing plans and systems to adapt to the impacts of climate change.

METHODS

We applied systematic review methods to assess progress with climate change adaptation in the health sector in South Africa. This case study provides useful lessons which could be applied in other countries in the African region, or globally. We reviewed the literature indexed in PubMed and Web of Science, together with relevant grey literature. We included articles describing adaptation interventions to reduce the impact of climate change on health in South Africa. All study designs were eligible. Data from included articles and grey literature were summed thematically.

RESULTS

Of the 820 publications screened, 21 were included, together with an additional xx papers. Very few studies presented findings of an intervention or used high-quality research designs. Several policy frameworks for climate change have been developed at national and local government levels. These, however, pay little attention to health concerns and the specific needs of vulnerable groups. Systems for forecasting extreme weather, and tracking malaria and other infections appear well established. Yet, there is little evidence about the country's preparedness for extreme weather events, or the ability of the already strained health system to respond to these events. Seemingly, few adaptation measures have taken place in occupational and other settings. To date, little attention has been given to climate change in training curricula for health workers.

CONCLUSIONS

Overall, the volume and quality of research is disappointing, and disproportionate to the threat posed by climate change in South Africa. This is surprising given that the requisite expertise for policy advocacy, identifying effective interventions and implementing systems-based approaches rests within the health sector. More effective use of data, a traditional strength of health professionals, could support adaptation and promote accountability of the state. With increased health-sector leadership, climate change could be reframed as predominately a health issue, one necessitating an urgent, adequately-resourced response. Such a shift in South Africa, but also beyond the country, may play a key role in accelerating climate change adaptation and mitigation.

Carbon footprint of self-selected US diets: nutritional, demographic, and behavioral correlates

BACKGROUND

A substantial portion of greenhouse gas emissions (GHGE) has been attributed to the food sector, but little is known about the association between the carbon footprint of individual self-selected diets in the United States and nutritional quality.

OBJECTIVES

The aims of this study were to assess the GHGE from individual self-selected diets in the United States and examine their association with nutritional quality of the diets, demographic patterns, and food-related behaviors.

METHODS

The dietary GHGE from US adults (>18 y, N = 16,800) in the 2005-2010 National Health and Nutrition Examination Survey (NHANES) were calculated by linking all foods consumed in their 24-h recall diets to our new database of food environmental impacts. Diets were ranked by GHGE/1000 kcal. Those in the top and bottom quintiles were compared on the US Healthy Eating Index (HEI) and on the amounts of specific nutrients known to be under- or overconsumed in the US population. Demographic and behavioral variables from the NHANES were also correlated to these dietary carbon footprints.

RESULTS

Diets in the bottom quintile accounted for one-fifth the total emissions (GHGE/1000 kcal) of those in the top quintile, yet had significantly higher (P < 0.001) HEI scores by 2.3 ± 0.7 points on a 100-point scale. These low-GHGE diets contained higher amounts of fiber and vitamin E and lower amounts of sodium and saturated fats, whereas high-GHGE diets contained higher amounts of vitamins A and D, choline, calcium, iron, and potassium. Low-GHGE diets had less meat, dairy, and solid fats, and more poultry, plant protein foods, oils, whole and refined grains, and added sugars.

CONCLUSIONS

Food patterns responsible for lower GHGE had a better overall diet quality and were more nutritious on several key dimensions, although not all. These results can inform dietary guidance and other policies that seek to address the goals of improved dietary intakes and reduced food-related emissions.

Parents' healthcare-seeking behavior for their children among the climate-related displaced population of rural Bangladesh

In Bangladesh climate change has contributed to a massive displacement of people. This study examines the effects of climate-related displacement, socioeconomic status, availability of healthcare providers and disease-related attributes on the healthcare-seeking behaviors of parents for their children. Using cross-sectional survey data from the parents of 1003 children aged under 15 who were ill in the four weeks prior to the interview, collected from 600 randomly-selected households in climate displacement-susceptible areas and 600 households in non-climate-displacement-susceptible areas in Bangladesh, we use multivariate logistic regression to identify the factors associated with parental healthcare-seeking behaviors. The results show that 15.5% of the children who had been ill receive either no care or curative care at home. Of those receiving care outside the home, only 22.1% are treated by trained providers. Climate-related displaced parents are significantly less likely to seek care or to use provider-prescribed care to manage children's illnesses. Areas lacking local healthcare providers, poorer households, females, child age and mild illness are also associated with a child being significantly less likely to be treated outside the home. The children of climate-related displaced parents are around half as likely as those of non-displaced parents to be treated by a trained provider. The local availability of medical doctors, cost of reaching a healthcare center, household income, type and severity of illness, child's age, and joint parental decision-making about care providers are also important predictors of the selection of trained healthcare providers for children. Thus, climate-related displacement affects the healthcare-seeking behaviors of parents for their children. Policy aimed at improving child health should address the socioeconomic disadvantage and access to healthcare of the displaced, the training of local untrained providers about Primary Health Care service provision, and the numbers of medical doctors in the displacement-prone areas.

Heat Waves Occurrence and Outdoor Workers' Self-assessment of Heat Stress in Slovenia and Greece

Changing patterns of heat waves are part of the global warming effect and the importance of changes is reinforced by their negative impact on society. Firstly, heat waves were analyzed in Brnik (Slovenia) and Larisa (Greece) in the period 1981–2017 to reflect the environment which workers are exposed to. Secondly, outdoor workers (70 from Greece, 216 from Slovenia) provided a self-assessment of heat stress. The heat wave timeline is presented as an effective way of illustrating long-term changes in heat waves’ characteristics for various stakeholders. In both countries, workers assessed as significant the heat stress impact on productivity (Greece 69%, Slovenia 71%; p > 0.05), and in Slovenia also on well-being (74%; p < 0.01). The main experienced symptoms and diseases were thirst (Greece 70%, Slovenia 82%; p = 0.03), excessive sweating (67%, 85%; p = 0.01), exhaustion (51%, 62%; p > 0.05) and headache (44%, 53%; p > 0.05). The most common way to reduce heat stress was drinking more water (Greece 64%, Slovenia 82%; p = 0.001). Among the informed workers, the prevalent source of information was discussions. Therefore, educational campaigns are recommended, together with the testing of the efficiency of mitigation measures that will be proposed on the Heat-Shield project portal.

Impact of heatwaves on daily outpatient visits of respiratory disease: A time-stratified case-crossover study

OBJECTIVES

This study aims to estimate the impact of heatwaves from July 2010 to October 2012 on daily outpatient visits for respiratory disease (RD) in Cangnan, China and identify vulnerable populations.

METHODS

The definition of heatwave was a period at least 3 consecutive days with maximum temperature exceeding 35 °C in this study. A time-stratified case-crossover design was conducted to examine the relationship between heatwaves and outpatient visits for RD. Patient data for the period from 2010 to 2012 were collected from the Third People's Hospital of Cangnan and daily meteorological data for the same period were collected from the China Meteorological Data Service Center. Data regarding the air pollution index (API), a composite indicator of air pollution, were collected from the Data Center of the Chinese Ministry of Environmental Protection. RD were identified based on the 10th revision International Classification of Diseases (ICD-10) codes (J00-J99). A conditional Poisson regression model was applied to examine the heatwave-RD association using the Relative Risk (RR) while adjusting for meteorological and air pollution factors including temperature, rainfall, wind speed, pressure, humidity, sunshine hours and API.

RESULTS

During the study period, 4 heatwaves occurred and a total of 1732 outpatient visits for RD were reported. Heatwaves increased the frequency of RD outpatient visits and the highest RR of total RD was 1.155% and 95% Confidence Intervals (95% CI) was 1.084-1.232 at Lag 0. For subcategories, heatwaves increased the risk of infectious RD (Lag 0: RR =1.182, 95% CI: 1.106-1.263) and decreased the risk of non-infectious RD ((Lag 6: RR =0.750, 95% CI: 0.568-0.990). Moreover, heatwaves showed adverse effects on acute upper respiratory infection (Lag 0: RR =1.306, 95% CI: 1.177-1.450). The RR of outpatient visits for RD was statistically significant in females (Lag 0: RR =1.161, 95% CI: 1.046-1.298), males (Lag 4: RR =1.161, 95% CI: 1.096-1.261), young people aged 4-17 years (Lag 0: RR =1.741, 95% CI: 1.524-1.990) and elders aged 65 years or older (Lag 5: RR =1.412, 95% CI: 1.111-1.794) during heatwaves.

CONCLUSIONS

Heatwaves had a significant harmful impact on daily outpatient visits for RD in Cangnan, especially for vulnerable population identified. These results can be used not only to strengthen the health education and protection of these vulnerable populations, but also to assist relevant organizations with developing intervention programmes and improving disease prevention and community care.

A Comparison of Neighborhood-Scale Interventions to Alleviate Urban Heat in Doha, Qatar

Recent evidence suggests that many densely populated areas of the world will be uninhabitable in the coming century due to the depletion of resources, climate change, and increasing urbanization. This poses serious questions regarding the actions that require immediate attention, and opportunities to stave off massive losses of infrastructure, populations, and financial investments. The present study utilizes microclimate modeling to examine the role of landscape features as they affect ambient temperatures in one of the fastest growing regions of the world: Doha, Qatar. By modeling three study sites around Doha—one highly urbanized, one newly urbanizing, and one coastal low-density urbanized—the research indicates that at the neighborhood scale, the most effective scenario was that of adding mature trees along the sides of roads. In the coastal study area, the model results estimated a maximum hourly air temperature reduction of 1.35 °C, and in the highly urbanized inland site, surface temperature reductions were up to 15 °C at 12:00. While other scenarios were effective at reducing air and surface temperatures, the mean radiant temperature was also increased or nearly neutral for most of the other scenarios. This result highlights the need to develop improved shading measures for pedestrian pathways and outdoor recreational areas, especially for highly urbanized inland areas in Doha and cities with similar climatic conditions.

Emergency department asthma diagnosis risk associated with the 2012 heat wave and drought in Douglas County NE, USA

BACKGROUND

Global climate change concerns are forcing local public health agencies to assess potential disease risk.

OBJECTIVE

Determine if risk of an emergency department asthma diagnosis in Douglas County, NE, was higher during the 2012 heatwave compared to 2011.

METHODS

Retrospective, observational, case-control design selecting subjects from 2011 and 2012 emergency department (ED) admissions. Risk was estimated by conditional logistic regression.

RESULTS

The asthma ED risk estimate was 1.23 (95%CI = 0.96-1.57) times higher in 2012 than 2011, for the same calendar period. Asthma ED diagnosis risk was 3.37 (95%CI = 2.27-4.17) times higher among subjects <19years old compared to older subjects, and 3.25 (95%CI = 2.63-4.02) times higher among African-Americans than non-African-Americans, adjusted for heatwave exposure. Absolute humidity appears inversely related to asthma diagnosis risk ( χ2 = 16.6; p < 0.001).

CONCLUSION

Asthma ED diagnosis risk was not significantly higher in 2012 compared to 2011. Risk was elevated among subjects less than 19years old, and among African Americans; adjusted for heatwave exposure.

Conceptualizations of climate-related health risks among health experts and the public in Ghana

One major area that has gathered public attention in relation to climate change is health risks. Studies into risk perceptions have acknowledged differences between public and expert knowledge. What is less known is how perceptions of climate change related health risk vary between the public and health experts and how these differentiated perceptions are shaped and modified by everyday complex climate change narratives from multiple actors, and contextual ecologies of social and physical spaces. A concurrent mixed-methods approach was used to elucidate climate change knowledge and awareness of climate-related health risks among health experts and the public. Qualitative and quantitative data were collected on community members (n = 927) and health experts (n = 99) in Savelugu-Nanton and Ada East Districts in Ghana. The results showed that both groups were likely to report climate change-related health concerns, of which disease was the top concern. However, differences exist in public and experts' perceptions of climate change health linkage. Community members were less likely to link climate change to health risks compared with health experts (OR = 0.02, p ≤ 0.000). The contrasting climate change health risk perceptions between health experts and the public adds to the literature on the health dimensions of global environmental change. The findings from this study highlight limited knowledge about climate change health related risks among the public. Hence, in building sustainable communities in light of persistent climate change impacts, it is crucial to improve climate change adaptation by implementing climate change sensitization programs. In addition, health infrastructure, decision-making and management should be strengthened for effective response to emerging climate-health risks in Ghana and similar contexts.

Climate change, migration and health systems resilience: Need for interdisciplinary research

Climate change is one of today's major challenges, and among the causes of population movement and international migration. Climate migrants impact health systems and how their ability to respond and adapt to their needs and patterns.  To date, the resilience of health systems in the context of climate change has barely been explored. The purpose of this article is to show the importance of studying the relationship between climate change, migration, and the resilience of health systems from an interdisciplinary perspective. Resilience is an old concept, notably in the field of psychology, and is increasingly applied to the study of health systems. Yet, no research has analysed the resilience of health systems in the context of climate change. While universal health coverage is a major international goal, little research to date focused on the existing links between climate, migration, health systems and resilience. We propose an interdisciplinary approach relying on the concept of health system resilience to study adaptive and transformative strategies to articulate climate change, migration and health systems.

Climate change, migration and health systems resilience: Need for interdisciplinary research

Climate change is one of today's major challenges, among the causes of population movements and international migration. Climate migrants impact health systems and how they respond and adapt to their needs and patterns. But to date, the resilience of health systems in the context of climate change has been little explored. The purpose of this article is to show the importance of studying, from an interdisciplinary perspective, the relationships between climate change, migration, and the resilience of health systems. Resilience is an old concept, notably in the field of psychology, and is increasingly applied to the study of health systems. Yet, no research has analysed the resilience of health systems in the context of climate change. While universal health coverage is a major international goal, little research has to date focused on the existing links between climate, migration, health systems and resilience. We propose an interdisciplinary approach relying on the concept of health system resilience to study adaptive and transformative strategies to articulate climate change, migration and health systems.

Perceptions of Local Environmental Issues and the Relevance of Climate Change in Nepal's Terai: Perspectives From Two Communities

The direct and indirect impacts of global climate change entail serious consequences for global biophysical and social systems, including the health, well-being and sustainability of communities. These impacts are especially serious for vulnerable groups in economically developing societies. While climate change is a global phenomenon, it is at the local level that impacts are most felt, and from where responses to climate change are enacted. It is increasingly urgent that communities possess the capacity to respond to climate change, now and in the future. Community representations of climate-relevant issues are critical to underpinning responses. Environmental representations do not directly reflect actual physical conditions but are interpreted through social and cultural layers of understanding that shape environmental issues. This paper investigates environmental and climate-relevant perceptions within two communities in the Terai region of Nepal; the city of Bharatpur and the village of Kumroj in Chitwan Province. Following mixed findings on levels of climate change awareness in Nepal, we set out to explore perspectives on the environment and climate change awareness by conducting 30 qualitative interviews with local people. The study found that issues linked to sanitation and cleanliness were most important in both communities, while reports of temperature and weather changes were less common and typically linked to local causes rather than climate change. Imagined futures were also closely related to current environmental issues affecting communities and did not discuss climate change, though temperature and weather changes were anticipated. However, when talk of climate change was deliberately elicited, participants displayed their awareness, though this was rarely linked to local conditions. We conclude that, in light of other pressing local issues, climate change is yet to penetrate the environmental representations of some communities and there is a need to address the disconnect between local issues and global climate change. Making climate change relevant at the local level by connecting to salient local issues and co-benefits comprises an important step in bridging the gap between more global awareness and its relevance more locally, particularly for communities at risk.

Impact of recent and future climate change on vector-borne diseases

Climate change is one of the greatest threats to human health in the 21st century. Climate directly impacts health through climatic extremes, air quality, sea-level rise, and multifaceted influences on food production systems and water resources. Climate also affects infectious diseases, which have played a significant role in human history, impacting the rise and fall of civilizations and facilitating the conquest of new territories. Our review highlights significant regional changes in vector and pathogen distribution reported in temperate, peri-Arctic, Arctic, and tropical highland regions during recent decades, changes that have been anticipated by scientists worldwide. Further future changes are likely if we fail to mitigate and adapt to climate change. Many key factors affect the spread and severity of human diseases, including mobility of people, animals, and goods; control measures in place; availability of effective drugs; quality of public health services; human behavior; and political stability and conflicts. With drug and insecticide resistance on the rise, significant funding and research efforts must to be maintained to continue the battle against existing and emerging diseases, particularly those that are vector borne.

Priority focus areas for a sub-national response to climate change and health: A South African provincial case study

INTRODUCTION

The intersection of health and climate change is often absent or under-represented in sub-national government strategies. This analysis of the literature, using a new methodological framework, highlights priority focus areas for a sub-national government response to health and climate change, using the Western Cape (WC) province of South Africa as a case study.

METHODS

A methodological framework was created to conduct a review of priority focus areas relevant for sub-national governments. The framework encompassed the establishment of a Project Steering Group consisting of relevant, sub-national stakeholders (e.g. provincial officials, public and environmental health specialists and academics); an analysis of local climatic projections as well as an analysis of global, national and sub-national health risk factors and impacts.

RESULTS

Globally, the discussion of health and climate change adaptation strategies in sub-national, or provincial government is often limited. For the case study presented, multiple health risk factors were identified. WC climatic projections include a warmer and potentially drier future with an increased frequency and intensity of extreme weather events. WC government priority focus areas requiring further research on health risk factors include: population migration and environmental refugees, land use change, violence and human conflict and vulnerable groups. WC government priority focus areas for further research on health impacts include: mental ill-health, non-communicable diseases, injuries, poisonings (e.g. pesticides), food and nutrition insecurity-related diseases, water- and food-borne diseases and reproductive health. These areas are currently under-addressed, or not addressed at all, in the current provincial climate change strategy.

CONCLUSIONS

Sub-national government adaptation strategies often display limited discussion on the health and climate change intersect. The methodological framework presented in this case study can be globally utilized by other sub-national governments for decision-making and development of climate change and health adaptation strategies. Additionally, due to the broad range of sectoral issues identified, a primary recommendation from this study is that sub-national governments internationally should consider a "health and climate change in all policies" approach when developing adaptation and mitigation strategies to address climate change.

An Assessment of Climate Change and Health Vulnerability and Adaptation in Dominica

A climate change and health vulnerability and adaptation assessment was conducted in Dominica, a Caribbean small island developing state located in the Lesser Antilles. The assessment revealed that the country's population is already experiencing many impacts on health and health systems from climate variability and change. Infectious diseases as well as food and waterborne diseases pose continued threats as climate change may exacerbate the related health risks. Threats to food security were also identified, with particular concern for food production systems. The findings of the assessment included near-term and long-term adaptation options that can inform actions of health sector decision-makers in addressing health vulnerabilities and building resilience to climate change. Key challenges include the need for enhanced financial and human resources to build awareness of key health risks and increase adaptive capacity. Other small island developing states interested in pursuing a vulnerability and adaptation assessment may find this assessment approach, key findings, analysis, and lessons learned useful.

How Local Health Districts can prepare for the effects of climate change: an adaptation model applied to metropolitan Sydney

Climate change adaptation can be defined as a form of risk management (i.e. assessing climate change-related risks and responding appropriately so that the risks can be pre-emptively minimised and managed as they arise). Adapting to climate change by hospital and community health services will entail responding to changing health needs of the local population, and to the likely effects of climate change on health service resources, workforce and infrastructure. In this paper we apply a model that health services can use to predict and respond to climate change risks and illustrate this with reference to Sydney's Local Health Districts (LHDs). We outline the climate change predictions for the Sydney metropolitan area, discuss the resulting vulnerabilities for LHDs and consider the potential of LHDs to respond. Three 'core business' categories are examined: (1) ambulance, emergency and acute health care; (2) routine health care; and (3) population and preventative health services. We consider the key climate change risks and vulnerabilities of the LHDs' workforce, facilities and finances, and some important transboundary issues. Many Australian health services have existing robust disaster plans and management networks. These could be expanded to incorporate local climate and health adaptation plans.

The Exposome and Asthma

This article on exposome and asthma focuses on the interaction of patients and their environments in various parts of their growth, development, and stages of life. Indoor and outdoor environments play a role in pathogenesis via levels and duration of exposure, with genetic susceptibility as a crucial factor that alters the initiation and trajectory of common conditions such as asthma. Knowledge of environmental exposures globally and changes that are occurring is necessary to function effectively as medical professionals and health advocates.

Mortality burden attributable to heatwaves in Thailand: A systematic assessment incorporating evidence-based lag structure

BACKGROUND

Available information on the acute and cumulative effects of heatwaves on cause-specific mortality in Thailand is scarce.

OBJECTIVES

To quantify the acute and cumulative effects of heatwaves on mortality in Thailand, and assess heatwave-related mortality burden.

METHODS

Thirty heatwave definitions were used and categorized into three groups: low intensity heatwaves (HW_low), middle intensity heatwaves (HW_middle), and high intensity heatwaves (HW_high). Time-series analyses were conducted to examine the acute and cumulative effects of HW_low, HW_middle, and HW_high on total and cause-specific mortality in 60 provinces of Thailand, incorporating an optimal lag for each cause and each province. Random-effects meta-analyses were performed to pool provincial estimates to national estimates for both acute and cumulative effects. Meta-regressions were conducted to identify the possible factors contributing to the spatial heterogeneity of heatwave vulnerability.

RESULTS

The cumulative effects of HW_low and HW_middle on total and cause-specific mortality were greater than HW_high. Both acute and cumulative effects of HW_low, HW_middle and HW_high on neoplasms and certain infectious and parasitic diseases were among the highest across all death causes. Effects of heatwaves on deaths from endocrine, nutritional and metabolic diseases appeared to be longer-lasting, and effects of heatwaves on deaths from ischaemic heart diseases and pneumonia occurred more rapidly. Northern and Central Thailand were the regions vulnerable to heatwaves, and proportion of elderly population was the major driver behind the spatial heterogeneity of heatwave vulnerability.

CONCLUSIONS

More attention needs to be paid to mild heatwaves. Future heatwave-related mortality burden due to neoplasms and infectious diseases in Thailand may increase as climate change continues.

Assessing Health Vulnerabilities and Adaptation to Climate Change: A Review of International Progress

Climate change is increasing risks to human health and to the health systems that seek to protect the safety and well-being of populations. Health authorities require information about current associations between health outcomes and weather or climate, vulnerable populations, projections of future risks and adaptation opportunities in order to reduce exposures, empower individuals to take needed protective actions and build climate-resilient health systems. An increasing number of health authorities from local to national levels seek this information by conducting climate change and health vulnerability and adaptation assessments. While assessments can provide valuable information to plan for climate change impacts, the results of many studies are not helping to build the global evidence-base of knowledge in this area. They are also often not integrated into adaptation decision making, sometimes because the health sector is not involved in climate change policy making processes at the national level. Significant barriers related to data accessibility, a limited number of climate and health models, uncertainty in climate projections, and a lack of funding and expertise, particularly in developing countries, challenge health authority efforts to conduct rigorous assessments and apply the findings. This paper examines the evolution of climate change and health vulnerability and adaptation assessments, including guidance developed for such projects, the number of assessments that have been conducted globally and implementation of the findings to support health adaptation action. Greater capacity building that facilitates assessments from local to national scales will support collaborative efforts to protect health from current climate hazards and future climate change. Health sector officials will benefit from additional resources and partnership opportunities to ensure that evidence about climate change impacts on health is effectively translated into needed actions to build health resilience.

Stress Testing the Capacity of Health Systems to Manage Climate Change-Related Shocks and Stresses

Vulnerability and adaptation assessments can provide valuable input to foster climate-resilient health systems. However, these assessments often do not explore the potential health risks of climate change far outside the range of recent experience with extreme weather events and other climate-related hazards. Climate and health stress tests are designed to increase the capacity of health systems and related sectors to manage potentially disruptive climate-related shocks and stresses. Stress tests focus on hypothetical scenarios, during which it would be difficult for the health system to maintain its essential function of providing services to protect population health. The stress test explores approaches to effectively manage acute and chronic climate-related events and conditions that could directly impact health systems, and climate-related events in non-health sectors that can indirectly impact health outcomes and/or health system function. We provide detailed methods and guidance for conducting climate and health stress tests, centering on three primary activities: (1) preparing and scoping the stress test; (2) successfully conducting the stress test; and (3) communicating the results to key stakeholders to facilitate policy and programmatic reforms.