Energy, energy efficiency, and the built environment

The Mortality Effects of Winter Heating Prices

This paper examines how the price of home heating affects mortality in the United States. Exposure to cold is one reason that mortality peaks in winter, and a higher heating price increases exposure to cold by reducing heating use. Our empirical approach combines spatial variation in the energy source used for home heating and temporal variation in the national prices of natural gas and electricity. We find that a lower heating price reduces winter mortality, driven mostly by cardiovascular and respiratory causes. Our estimates imply that the 42% drop in the natural gas price in the late 2000s, mostly driven by the shale gas boom, averted 12,500 deaths per year in the United States. The effect appears to be especially large in high-poverty communities.

A Systematic Review of Associations between Energy Use, Fuel Poverty, Energy Efficiency Improvements and Health

Energy use in buildings can influence the indoor environment. Studies on green buildings, energy saving measures, energy use, fuel poverty, and ventilation have been reviewed, following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The database PubMed was searched for articles published up to 1 October 2020. In total, 68 relevant peer-reviewed epidemiological or exposure studies on radon, biological agents, and chemicals were included. The main aim was to assess current knowledge on how energy saving measures and energy use can influence health. The included studies concluded that buildings classified as green buildings can improve health. More efficient heating and increased thermal insulation can improve health in homes experiencing fuel poverty. However, energy-saving measures in airtight buildings and thermal insulation without installation of mechanical ventilation can impair health. Energy efficiency retrofits can increase indoor radon which can cause lung cancer. Installation of a mechanical ventilation systems can solve many of the negative effects linked to airtight buildings and energy efficiency retrofits. However, higher ventilation flow can increase the indoor exposure to outdoor air pollutants in areas with high levels of outdoor air pollution. Finally, future research needs concerning energy aspects of buildings and health were identified.

Hydrogenotrophs-Based Biological Biogas Upgrading Technologies

Biogas produced from anaerobic digestion consists of 55–65% methane and 35–45% carbon dioxide, with an additional 1–2% of other impurities. To utilize biogas as renewable energy, a process called biogas upgrading is required. Biogas upgrading is the separation of methane from carbon dioxide and other impurities, and is performed to increase CH₄ content to more than 95%, allowing heat to be secured at the natural gas level. The profitability of existing biogas technologies strongly depends on operation and maintenance costs. Conventional biogas upgrading technologies have many issues, such as unstable high-purity methane generation and high energy consumption. However, hydrogenotrophs-based biological biogas upgrading offers an advantage of converting CO₂ in biogas directly into CH₄ without additional processes. Thus, biological upgrading through applying hydrogenotrophic methanogens for the biological conversion of CO₂ and H₂ to CH₄ receives growing attention due to its simplicity and high technological potential. This review analyzes the recent advance of hydrogenotrophs-based biomethanation processes, addressing their potential impact on public acceptance of biogas plants for the promotion of biogas production.

City-scale energetics: window on adaptive thermal insulation in North American cities

Previous research demonstrated that cities are similar to individual mammals in their relationship between the rate of energy use for heating and outdoor air temperature (T_a). At T_as requiring heating of indoor living spaces, the energy-T_a plot of a city contains information on city-wide thermal insulation (I), making it possible to quantify city-wide I by use of the city as the unit of measure. We develop methods for extracting this insulation information, deriving the methods from prior research on mammals. Using these methods, we address the question: in North America, are cities built in particularly cold locations constructed in ways that provide greater thermal insulation than ones built in thermally more moderate locations? Using data for 42 small and medium-size cities and two information-extraction methods, we find that there is a statistically significant inverse relationship between city-wide I and T_10-year, the average city T_a over a recent 10-year period (range of T_10-year: − 11 to 26 °C). This relationship represents an energy-conserving trend, indicating that cities in cold climates have greater built-in thermal insulation than cities in warm climates. However, the augmentation of insulation in cold climates is only about half as great as would be required to offset fully the increased energy cost of low T_as in a cold climate, and T_10-year explains just 5–11% of the variance in measured insulation, suggesting that cities in North America vary greatly in the extent to which thermal insulation has been a priority in city development.

Diversity and Changes in Energy Consumption by Transport in EU Countries

The main purpose of this paper is to present the differences in the volume of energy consumption in transport in the EU (European Union) countries. The specific objectives aim to determine the directions of changes and the degree of concentration in the volume of energy utilized by the transport sector in EU states, showing various models in this area, to establish the association between energy absorption and the parameters of the economy and in the field of transport. All EU countries were selected for research by the use of the purposeful selection method as of 31 December 2018. The analyzed period covered the years 2004–2018. For the examination of data, grading data analysis was used as one of the methods of multivariate data analysis. Descriptive, tabular and graphic methods were used to present the results. Findings reveal that there is a general tendency to reduce total energy consumption in the EU countries. The same is the case of energy in transport. Only in 2016–2018 was there an increase in energy absorption in transport. The reason was the better economic situation in this period. Road conveyance is the most important factor in energy utilization (over 90%). The share of other modes of transport was very small. Economically developing countries were the fastest in increasing energy absorption in transport per capita. In turn, highly developed states recorded slight growth and were stable in this aspect. There was a close relationship between energy utilization in transport per capita and GDP per capita. The reduction of energy consumption in transport depends on changes in road haulage, e.g., the pace of introducing innovative energy-saving technologies in automotive transport.

The residential energy futures of Bhutan

It is expected that with the increase in population and modernization of any country, energy consumption would increase. Bhutan is a carbon-negative country and committed to remaining carbon-neutral. Thus, identifying energy-saving potential will increase energy efficiency and contribute to continue fulfilling this pledge for years to come. This study aims to find the energy-saving potential of Bhutan by analyzing future energy demand from the residential building sector using a scenario-based modeling tool called Long-range Energy Alternatives Planning (LEAP). The research was an integration of primary and secondary data calculations. Final energy-savings from Bhutan in 2040 by attaining the efficient scenario is estimated at 830 GWh. Overall, the result suggests that 53% final energy-savings can be achieved in 2040 from all end-uses and energy sources compared to the reference scenario. Cumulatively, 19 TWh final energy-savings can be achieved in the study period (2018-2040) from the efficient scenario while all basic energy needs are fully met in 2040. This result obtained would provide a reference for Bhutan's future energy planning and guidelines for policy-making. It would also provide policy recommendations about the scope of shifting to energy-efficient end-uses.

Anomalously warm weather and acute care visits in patients with multiple sclerosis: A retrospective study of privately insured individuals in the US

BACKGROUND

As the global climate changes in response to anthropogenic greenhouse gas emissions, weather and temperature are expected to become increasingly variable. Although heat sensitivity is a recognized clinical feature of multiple sclerosis (MS), a chronic demyelinating disorder of the central nervous system, few studies have examined the implications of climate change for patients with this disease.

METHODS AND FINDINGS

We conducted a retrospective cohort study of individuals with MS ages 18-64 years in a nationwide United States patient-level commercial and Medicare Advantage claims database from 2003 to 2017. We defined anomalously warm weather as any month in which local average temperatures exceeded the long-term average by ≥1.5°C. We estimated the association between anomalously warm weather and MS-related inpatient, outpatient, and emergency department visits using generalized log-linear models. From 75,395,334 individuals, we identified 106,225 with MS. The majority were women (76.6%) aged 36-55 years (59.0%). Anomalously warm weather was associated with increased risk for emergency department visits (risk ratio [RR] = 1.043, 95% CI: 1.025-1.063) and inpatient visits (RR = 1.032, 95% CI: 1.010-1.054). There was limited evidence of an association between anomalously warm weather and MS-related outpatient visits (RR = 1.010, 95% CI: 1.005-1.015). Estimates were similar for men and women, strongest among older individuals, and exhibited substantial variation by season, region, and climate zone. Limitations of the present study include the absence of key individual-level measures of socioeconomic position (i.e., race/ethnicity, occupational status, and housing quality) that may determine where individuals live-and therefore the extent of their exposure to anomalously warm weather-as well as their propensity to seek treatment for neurologic symptoms.

CONCLUSIONS

Our findings suggest that as global temperatures rise, individuals with MS may represent a particularly susceptible subpopulation, a finding with implications for both healthcare providers and systems.

Topological indexes and community structure for urban mobility networks: Variations in a business day

Topological analysis and community detection in mobility complex networks have an essential role in many contexts, from economics to the environmental agenda. However, in many cases, the dynamic component of mobility data is not considered directly. In this paper, we study how topological indexes and community structure changes in a business day. For the analyzes, we use a mobility database with a high temporal resolution. Our case study is the city of São José dos Campos (Brazil)-the city is divided into 55 traffic zones. More than 20 thousand people were asked about their travels the day before the survey (Origin-Destination Survey). We generated a set of graphs, where each vertex represents a traffic zone, and the edges are weighted by the number of trips between them, restricted to a time window. We calculated topological properties, such as degree, clustering coefficient and diameter, and the network's community structure. The results show spatially concise community structures related to geographical factors such as highways and the persistence of some communities for different timestamps. These analyses may support the definition and adjustment of public policies to improve urban mobility. For instance, the community structure of the network might be useful for defining inter-zone public transportation.

Energy Efficiency and Health Efficiency of Old and New EU Member States

Environmental protection and health issues have always been of great concern. This study employed modified Meta-Frontier Dynamic Network Data Envelopment Analysis to explore the environmental pollution effects from energy consumption on the mortality of children and adults, tuberculosis rate, survival rate, and health expenditure efficiencies in 15 old EU states and 13 new EU states from 2010 to 2014. We calculated the overall efficiency scores and technology gap ratios for each old EU and new EU states as well as the efficiencies of non-renewable energy, renewable energy, PM2.5, CO₂, labor, GDP, tuberculosis, child mortality, adult mortality, health expenditure efficiency, and survival efficiency at the health stage. The average annual overall efficiencies of the old EU states are higher than that of the new EU states. Whether in terms of energy efficiencies or health efficiencies, the inputs and outputs of the old EU states are always higher than that of the new EU states. Overall, developing countries in Eastern Europe are lagging behind in terms of energy and health efficiencies. At the same time, the efficiency of child mortality is lower than that of adult mortality, and the efficiency of PM2.5 is higher than that of CO₂ in both old and new EU states.

Energy, Poverty, and Health in Climate Change: A Comprehensive Review of an Emerging Literature

Household energy is increasingly vital for maintaining good health. Unaffordable and inadequate household energy presents adverse consequences that are amplified by poverty and a changing climate. To date, the connections between energy, socioeconomic disadvantage, and well-being are generally underappreciated, and household energy connection with climate change is under-researched. Building on the energy insecurity framework, this review explores literature related to household energy, poverty, and health in order to highlight the disproportionate burdens borne by vulnerable populations in adequately meeting household energy needs. This paper is based on a comprehensive review of books, peer-reviewed articles, and reports published between 1990 and 2019, identified via databases including JSTOR and PubMed. A total of 406 publications were selected as having potential for full review, 203 received full review, and 162 were included in this paper on the basis of set inclusion criteria. From the literature review, we created an original heuristic model that describes energy insecurity as either acute or chronic, and we further explore the mediators and pathways that link energy insecurity to health. In the discussion, we posit that the extant literature does not sufficiently consider that vulnerable communities often experience energy insecurity bundled with other hardships. We also discuss energy, poverty, and health through the lens of climate change, making the criticism that most research on household energy does not consider climate change. This evidence is important for enhancing research in this field and developing programmatic and policy interventions as they pertain to energy access, affordability, and health, with special emphasis on vulnerable populations, climate change, and social inequality.

Air Quality-Related Health Benefits of Energy Efficiency in the United States

While it is known that energy efficiency (EE) lowers power sector demand and emissions, study of the air quality and public health impacts of EE has been limited. Here, we quantify the air quality and mortality impacts of a 12% summertime (June, July, and August) reduction in baseload electricity demand. We use the AVoided Emissions and geneRation Tool (AVERT) to simulate plant-level generation and emissions, the Community Multiscale Air Quality (CMAQ) model to simulate air quality, and the Environmental Benefits Mapping and Analysis Program (BenMAP) to quantify mortality impacts. We find EE reduces emissions of NO _x by 13.2%, SO₂ by 12.6%, and CO₂ by 11.6%. On a nationwide, summer average basis, ambient PM_2.5 is reduced 0.55% and O₃ is reduced 0.45%. Reduced exposure to PM_2.5 avoids 300 premature deaths annually (95% CI: 60 to 580) valued at $2.8 billion ($0.13 billion to $9.3 billion), and reduced exposure to O₃ averts 175 deaths (101 to 244) valued at $1.6 billion ($0.15 billion to $4.5 billion). This translates into a health savings rate of $0.049/kWh ($0.031/kWh for PM_2.5 and $0.018/kWh for O₃). These results illustrate the importance of capturing the health benefits of EE and its potential as a strategy to achieve air standards.

Associations between Green Building Design Strategies and Community Health Resilience to Extreme Heat Events: A Systematic Review of the Evidence

This project examined evidence linking green building design strategies with the potential to enhance community resilience to extreme heat events. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method for a systematic review, it assessed the strength of the evidence supporting the potential for Leadership in Energy and Environmental Design (LEED®) credit requirements to reduce the adverse effects of extreme heat events and/or enhance a building’s passive survivability (i.e., the ability to continue to function during utility outages) during those events. The PRISMA Flow Diagram resulted in the selection of 12 LEED for New Construction (LEED NC) credits for inclusion in the review. Following a preliminary scan of evidence supporting public health co-benefits of the LEED for Neighborhood Development rating system, queries were submitted in PubMed using National Library of Medicine Medical Subject Headings Terms. Queries identified links between LEED credit requirements and risk of exposure to extreme heat, environmental determinants of health, co-benefits to public health outcomes, and co-benefits to built environment outcomes. Public health co-benefits included reducing the risk of vulnerability to heat stress and reducing heat-related morbidity and mortality. The results lay the groundwork for collaboration across the public health, civil society, climate change, and green building sectors.

The effect of the Winter Fuel Payment on household temperature and health: a regression discontinuity design study

Background

The Winter Fuel Payment (WFP) is a non-NHS population-level policy intervention that aims to reduce cold exposure and enhance the health and well-being of older adults. Labelling this cash transfer as ‘winter fuel’ has been shown to lead to increased household energy expenditure, but it is not known if this expenditure produces warmer homes or health benefits.

Objectives

First, the association between indoor temperature and health was established to identify the outcome measures most likely to be affected by the WFP. Then, whether or not receiving the WFP is associated with raised household temperature levels and/or improved health was assessed.

Design

Random and fixed effects regression models were used to estimate the link between ambient indoor temperature and health. A regression discontinuity (RD) design analysis exploiting the sharp eligibility criteria for the WFP was employed to estimate the potential impact of the payment.

Setting

The sample was drawn from the English Longitudinal Study of Ageing (ELSA), an observational study of community-dwelling individuals aged ≥ 50 years in England.

Participants

Analyses examining the association between household temperature and health had a maximum sample of 12,210 adults aged 50–90 years. The RD analyses drew on a maximum of 5902 observations.

Intervention

The WFP provides households with a member who is aged > 60 years (up to 2010, from which point the minimum age increased) in the qualifying week with a lump sum annual payment, typically in November or December.

Main outcome measures

Differences in indoor temperature were examined, and, following an extensive literature review of relevant participant-reported health indicators and objectively recorded biomarkers likely to be affected by indoor temperature, a series of key measures were selected: blood pressure, inflammation, lung function, the presence of chest infections, subjective health and depressive symptom ratings.

Data sources

The first six waves of the ELSA were drawn from, accessible through the UK Data Service (SN:5050 English Longitudinal Study of Ageing: Waves 0–7, 1998–2015).

Results

Results from both random and fixed-effects multilevel regression models showed that low levels of indoor temperature were associated with raised systolic and diastolic blood pressure levels and raised fibrinogen levels. However, across the RD models, no evidence was found that the WFP was consistently associated with differences in either household temperature or the health of qualifying (vs. non-qualifying) households.

Limitations

The presence of small effects cannot be ruled out, not detectable because of the sample size in the current study.

Conclusions

This study capitalised on the sharp assignment rules regarding WFP eligibility to estimate the potential effect of the WFP on household temperature and health in a national sample of English adults. The RD design employed did not identify evidence linking the WFP to warmer homes or potential health and well-being effects.

Future work

Further research should utilise larger samples of participants close to the WFP eligibility cut-off point examined during particularly cold weather in order to identify whether or not the WFP is linked to health benefits not detected in the current study, which may have implications for population health and the evaluation of the effectiveness of the WFP.

Funding

The National Institute for Health Research Public Health Research programme.

Public health air pollution impacts of pathway options to meet the 2050 UK Climate Change Act target: a modelling study

Background

The UK’sClimate Change Act 2008(CCA; Great Britain.Climate Change Act 2008. Chapter 27. London: The Stationery Office; 2008) requires a reduction of 80% in carbon dioxide-equivalent emissions by 2050 on a 1990 base. This project quantified the impact of air pollution on health from four scenarios involving particulate matter of ≤ 2.5 µm (PM2.5), nitrogen dioxide (NO2) and ozone (O3). Two scenarios met the CCA target: one with limited nuclear power build (nuclear replacement option; NRPO) and one with no policy constraint on nuclear (low greenhouse gas). Another scenario envisaged no further climate actions beyond those already agreed (‘baseline’) and the fourth kept 2011 concentrations constant to 2050 (‘2011’).

Methods

The UK Integrated MARKAL–EFOM System (UKTM) energy system model was used to develop the scenarios and produce projections of fuel use; these were used to produce air pollutant emission inventories for Great Britain (GB) for each scenario. The inventories were then used to run the Community Multiscale Air Quality model ‘air pollution model’ to generate air pollutant concentration maps across GB, which then, combined with relationships between concentrations and health outcomes, were used to calculate the impact on health from the air pollution emitted in each scenario. This is a significant improvement on previous health impact studies of climate policies, which have relied on emissions changes. Inequalities in exposure in different socioeconomic groups were also calculated, as was the economic impact of the pollution emissions.

Results

Concentrations of NO2declined significantly because of a high degree of electrification of the GB road transport fleet, although the NRPO scenario shows large increases in oxides of nitrogen emissions from combined heat and power (CHP) sources. Concentrations of PM2.5show a modest decrease by 2050, which would have been larger if it had not been for a significant increase in biomass (wood burning) use in the two CCA scenarios peaking in 2035. The metric quantifying long-term exposure to O3is projected to decrease, while the important short-term O3exposure metric increases. Large projected increases in future GB vehicle kilometres lead to increased non-exhaust PM2.5and particulate matter of ≤ 10 µm emissions. The two scenarios which achieve the CCA target resulted in more life-years lost from long-term exposures to PM2.5than in the baseline scenario. This is an opportunity lost and arises largely from the increase in biomass use, which is projected to peak in 2035. Reduced long-term exposures to NO2lead to many more life-years saved in the ‘CCA-compliant’ scenarios, but the association used may overestimate the effects of NO2itself. The more deprived populations are estimated currently to be exposed to higher concentrations than those less deprived, the contrast being largest for NO2. Despite reductions in concentrations in 2050, the most socioeconomically deprived are still exposed to higher concentrations than the less deprived.

Limitations

Modelling of the atmosphere is always uncertain; we have shown the model to be acceptable through comparison with observations. The necessary complexity of the modelling system has meant that only a small number of scenarios were run.

Conclusions

We have established a system which can be used to explore a wider range of climate policy scenarios, including more European and global scenarios as well as local measures. Future work could explore wood burning in more detail, in terms of the sectors in which it might be burned and the spatial distribution of this across the UK. Further analyses of options for CHP could also be explored. Non-exhaust emissions from road transport are an important source of particles and emission factors are uncertain. Further research on this area coupled with our modelling would be a valuable area of research.

Funding

The National Institute for Health Research Public Health Research programme.

The Lancet Countdown: tracking progress on health and climate change

The Lancet Countdown: tracking progress on health and climate change is an international, multidisciplinary research collaboration between academic institutions and practitioners across the world. It follows on from the work of the 2015 Lancet Commission, which concluded that the response to climate change could be "the greatest global health opportunity of the 21st century". The Lancet Countdown aims to track the health impacts of climate hazards; health resilience and adaptation; health co-benefits of climate change mitigation; economics and finance; and political and broader engagement. These focus areas form the five thematic working groups of the Lancet Countdown and represent different aspects of the complex association between health and climate change. These thematic groups will provide indicators for a global overview of health and climate change; national case studies highlighting countries leading the way or going against the trend; and engagement with a range of stakeholders. The Lancet Countdown ultimately aims to report annually on a series of indicators across these five working groups. This paper outlines the potential indicators and indicator domains to be tracked by the collaboration, with suggestions on the methodologies and datasets available to achieve this end. The proposed indicator domains require further refinement, and mark the beginning of an ongoing consultation process-from November, 2016 to early 2017-to develop these domains, identify key areas not currently covered, and change indicators where necessary. This collaboration will actively seek to engage with existing monitoring processes, such as the UN Sustainable Development Goals and WHO's climate and health country profiles. The indicators will also evolve over time through ongoing collaboration with experts and a range of stakeholders, and be dependent on the emergence of new evidence and knowledge. During the course of its work, the Lancet Countdown will adopt a collaborative and iterative process, which aims to complement existing initiatives, welcome engagement with new partners, and be open to developing new research projects on health and climate change.

Infants' indoor and outdoor residential exposure to benzene and respiratory health in a Spanish cohort

Benzene exposure represents a potential risk for children's health. Apart from being a known carcinogen for humans (group 1 according to IARC), there is scientific evidence suggesting a relationship between benzene exposure and respiratory problems in children. But results are still inconclusive and inconsistent. This study aims to assess the determinants of exposure to indoor and outdoor residential benzene levels and its relationship with respiratory health in infants. Participants were 1-year-old infants (N = 352) from the INMA cohort from Valencia (Spain). Residential benzene exposure levels were measured inside and outside dwellings by means of passive samplers in a 15-day campaign. Persistent cough, low respiratory tract infections and wheezing during the first year of life, and covariates (dwelling traits, lifestyle factors and sociodemographic data) were obtained from parental questionnaires. Multiple Tobit regression and logistic regression models were performed to assess factors associated to residential exposure levels and health associations, respectively. Indoor levels were higher than outdoor ones (1.46 and 0.77 μg/m³, respectively; p < 0.01). A considerable percentage of dwellings, 42% and 21% indoors and outdoors respectively, surpassed the WHO guideline of 1.7 μg/m³ derived from a lifetime risk of leukemia above 1/100 000. Monitoring season, maternal country of birth and parental tobacco consumption were associated with residential benzene exposure (indoor and outdoors). Additionally, indoor levels were associated with mother's age and type of heating, and outdoor levels were linked with zone of residence and distance from industrial areas. After adjustment for confounding factors, no significant associations were found between residential benzene exposure levels and respiratory health in infants. Hence, our study did not support the hypothesis for the benzene exposure effect on respiratory health in children. Even so, it highlights a public health concern related to the personal exposure levels, since a considerable number of children surpassed the abovementioned WHO guideline for benzene exposure.

Indoor Fungal Exposure and Allergic Respiratory Disease

A gathering body of evidence has repeatedly revealed associations between indoor fungi and initiation, promotion, and exacerbation of allergic respiratory disease. The relationship between the exposure and outcome are complicated by the difficulties in measuring both exposure and outcome, the multifactorial nature of the disease, and the wide range of potential confounders. New technologies are becoming available that may enable better measurement of exposure and tighter case definitions so as to build more confidence in the associations discovered. The growing strength of the evidence base will aid the design of future public health interventions and generate new hypotheses on the cause of the rapid increase in allergic respiratory disease prevalence.

The German Energiewende-a matter for health?

BACKGROUND

Germany's enormous transformation away from nuclear energy and fossil fuels towards a renewable and energy efficient system-called the Energiewende-is playing an essential role in Germany's economy and policymaking. This article summarises the current knowledge on possible health impacts of the Energiewende and describes the need and opportunities to incorporate health into energy-related policy.

METHODS

A structural model helped to narrow down specific topics and to conceptualise links between the Energiewende, the environment and health. A comprehensive literature search was conducted within policy documents and scientific databases with English and German language selections.

RESULTS

Of 7800 publications first identified only 46 explicitly related energy measures to health, of which 40 were grey literature. Notably, only 12% published by health authorities all others were issued by environmental, energy or consumer protection agencies, ministries or institutions.

CONCLUSION

Our study shows that health impacts of the German Energiewende are rarely explicitly addressed. An integration of a health perspective into energy-related policy is needed including the involvement of public health authorities. A health impact assessment can be a suitable tool to support and evaluate Energiewende-related developments from a health perspective.

Benefit or burden? Perceptions of energy efficiency efforts among low-income housing residents in New York City

Low-income households contend with high energy costs and poor thermal comfort due to poor structural conditions and energy inefficiencies in their homes. Energy efficiency upgrades can potentially reduce energy expenses and improve thermal comfort, while also addressing problematic issues in the home environment. The present mixed method pilot study explored the impacts of energy efficiency upgrades in 20 households in a low-income community in New York City. Surveys and interviews were administered to the heads of household in a variety of housing types. Interviews were also conducted with landlords of buildings that had recently undergone upgrades. Findings indicate that energy efficiency measures resulted in improved thermal comfort, enhanced health and safety and reduced energy costs. Participants reported largely positive experiences with the upgrades, resulting in direct and indirect benefits. However, results also indicate negative consequences associated with the upgrades and further illustrate that weatherization alone was insufficient to address all of the issues facing low-income households. Moreover, qualitative results revealed differing experiences of low-income renters compared to homeowners. Overall, energy efficiency upgrades are a promising intervention to mitigate the energy and structurally related challenges facing low-income households, but larger scale research is needed to capture the long-term implications of these upgrades.

Higher energy efficient homes are associated with increased risk of doctor diagnosed asthma in a UK subpopulation

INTRODUCTION

The United Kingdom (UK) has one of the highest prevalence of asthma in the world, which represents a significant economic and societal burden. Reduced ventilation resulting from increased energy efficiency measures acts as a modifier for mould contamination and risk of allergic diseases. To our knowledge no previous study has combined detailed asset management property and health data together to assess the impact of household energy efficiency (using the UK Government's Standard Assessment Procedure) on asthma outcomes in an adult population residing in social housing.

METHODS

Postal questionnaires were sent to 3867 social housing properties to collect demographic, health and environmental information on all occupants. Detailed property data, residency periods, indices of multiple deprivation (IMD) and household energy efficiency ratings were also investigated. Logistic regression was used to calculate odds ratios and confidence intervals while allowing for clustering of individuals coming from the same location.

RESULTS

Eighteen percent of our target social housing population were recruited into our study. Adults had a mean age of 59 (SD±17.3) years and there was a higher percentage of female (59%) and single occupancy (58%) respondents. Housing demographic characteristics were representative of the target homes. A unit increase in household Standard Assessment Procedure (SAP) rating was associated with a 2% increased risk of current asthma, with the greatest risk in homes with SAP >71. We assessed exposure to mould and found that the presence of a mouldy/musty odour was associated with a two-fold increased risk of asthma (OR 2.2 95%; CI 1.3-3.8). A unit increase in SAP led to a 4-5% reduction in the risk of visible mould growth and a mouldy/musty odour.

DISCUSSION

In contrast to previous research, we report that residing in energy efficient homes may increase the risk of adult asthma. We report that mould contamination increased the risk of asthma, which is in agreement with existing knowledge. Exposure to mould contamination could not fully explain the association between increased energy efficiency and asthma. Our findings may be explained by increased energy efficiency combined with the provision of inadequate heating, ventilation, and increased concentrations of other biological, chemical and physical contaminants. This is likely to be modified by a complex interaction between occupant behaviours and changes to the built environment. Our findings may also be confounded by our response rate, demographic and behavioural differences between those residing in low versus high energy efficient homes, and use of self-reported exposures and outcomes.

CONCLUSION

Energy efficiency may increase the risk of current adult asthma in a population residing in social housing. This association was not significantly modified by the presence of visible mould growth, although further research is needed to investigate the interaction between other demographic and housing characteristic risk factors, especially the impact of fuel poverty on indoor exposures and health outcomes.

STUDY IMPLICATIONS

A multidisciplinary approach is required to assess the interaction between energy efficiency measures and fuel poverty behaviours on health outcomes prior to the delivery of physical interventions aimed at improving the built environment. Policy incentives are required to address fuel poverty issues alongside measures to achieve SAP ratings of 71 or greater, which must be delivered with the provision of adequate heating and ventilation strategies to minimise indoor dampness. Changes in the built environment without changes in behaviour of domicile residents may lead to negative health outcomes.

Modifiable factors governing indoor fungal diversity and risk of asthma

Exposure to dampness and fungi in the home is a known risk factor for individuals with allergic asthma. Inadequate heating and ventilation may lead to dampness and concomitant increased exposure to spores of allergenic fungi such as Aspergillus and Penicillium. These fungi have been cultured from sputum of asthmatic and non-asthmatic individuals, and implicated in the initiation or exacerbation of asthma. Indoor environmental factors influence the presence and concentrations of fungal propagules and, in turn, risk of asthma outcomes. This review aims to identify modifiable risk factors in the built environment that have been shown to influence fungal composition indoors, and to examine this association with the risk of asthma development and/or exacerbation. A complex interaction between residential characteristics, the built environment and the behaviour of people regulate the diversity and concentrations of indoor fungi. Modifiable factors include build age, architectural design, level of maintenance, variations in construction materials, presence of pets, heating and ventilation patterns. Risk of fungal contamination and asthma outcomes are also influenced by low occupant awareness concerning potential health effects and socio-economic factors. Addressing these factors provides an opportunity to improve future housing interventions, though it is not clear how the built environment and occupant behaviours interact to modify the diversity of indoor fungi and resultant risk of asthma. A combination of housing improvements combined with awareness programmes and the alleviation of fuel poverty can be used to lower the allergen burden associated with damp homes. Further research is needed to identify factors that regulate the concentration and diversity of indoor fungi and how this may act as a modifier for asthma outcomes.

Indoor fungal diversity and asthma: a meta-analysis and systematic review of risk factors

BACKGROUND

Indoor dampness increases the risk of indoor fungal growth. A complex interaction between occupant behaviors and the built environment are thought to affect indoor fungal concentrations and species diversity, which are believed to increase the risk of having asthma, exacerbation of asthma symptoms, or both. To date, no systematic review has investigated this relationship.

OBJECTIVE

This review aims to assess the relationship between exposure to indoor fungi identified to the genera or species level on asthma outcomes in children and adults.

METHODS

Ten databases were systematically searched on April 18, 2013, and limited to articles published since 1990. Reference lists were independently screened by 2 reviewers, and authors were contacted to identify relevant articles. Data were extracted from included studies meeting our eligibility criteria by 2 reviewers and quality assessed by using the Newcastle-Ottawa scale designed for assessment of case-control and cohort studies.

RESULTS

Cladosporium, Alternaria, Aspergillus, and Penicillium species were found to be present in higher concentrations in homes of asthmatic participants. Exposure to Penicillium, Aspergillus, and Cladosporium species were found to be associated with increased risk of reporting asthma symptoms by a limited number of studies. The presence of Cladosporium, Alternaria, Aspergillus, and Penicillium species increased the exacerbation of current asthma symptoms by 36% to 48% compared with those exposed to lower concentrations of these fungi, as shown by using random-effect estimates. Studies were of medium quality and showed medium-high heterogeneity, but evidence concerning the specific role of fungal species was limited.

CONCLUSION

Longitudinal studies assessing increased exposure to indoor fungi before the development of asthma symptoms suggests that Penicillium, Aspergillus, and Cladosporium species pose a respiratory health risk in susceptible populations. Increased exacerbation of current asthma symptoms in children and adults were associated with increased levels of Penicillium, Aspergillus, Cladosporium, and Alternaria species, although further work should consider the role of fungal diversity and increased exposure to other fungal species.

Climate change and air pollution: Effects on pollen allergy and other allergic respiratory diseases

The observational evidence indicates that recent regional changes in climate, particularly temperature increases, have already affected a diverse set of physical and biological systems in many parts of the world. Allergens patterns are also changing in response to climate change and air pollution can modify the allergenic potential of pollen grains especially in the presence of specific weather conditions.

Although genetic factors are important in the development of asthma and allergic diseases, their rising trend can be explained only by changes occurring in the environment and urban air pollution by motor vehicles has been indicated as one of the major risk factors responsible for this increase.

Despite some differences in the air pollution profile and decreasing trends of some key air pollutants, air quality is an important concern for public health in the cities throughout the world.

Due to climate change, air pollution patterns are changing in several urbanized areas of the world with a significant effect on respiratory health. The underlying mechanisms of all these interactions are not well known yet. The consequences on health vary from decreases in lung function to allergic diseases, new onset of diseases, and exacerbation of chronic respiratory diseases. In addition, it is important to recall that an individual’s response to pollution exposure depends on the source and components of air pollution, as well as meteorological conditions. Indeed, some air pollution-related incidents with asthma aggravation do not depend only on the increased production of air pollution, but rather on atmospheric factors that favor the accumulation of air pollutants at ground level.

Associations between thunderstorms and asthma morbidity of pollinosis-affected people have also been identified in multiple locations around the world (Fig.1).

Cite this as D’Amato G, Bergmann KC, Cecchi L, Annesi-Maesano I, Sanduzzi A, Liccardi G, Vitale C, Stanziola A, D’Amato M. Climate change and air pollution — Effects on pollen allergy and other allergic respiratory diseases. Allergo J Int 2014; 23: 17–23 DOI 10.1007/s40629-014-0003-7

A factor clouding the problem is that laboratory evaluations do not reflect what happens during natural exposition.

Considering these aspects, governments worldwide, international organizations, and cooperations such as the World Health Organization (WHO) and the European Health Policy of the European Union (EU) are facing a growing problem of the respiratory effects induced by gaseous and particulate pollutants arising from motor vehicle emissions.

Assessing framing assumptions in quantitative health impact assessments: a housing intervention example

Health impact assessment (HIA) is often used to determine ex ante the health impact of an environmental policy or an environmental intervention. Underpinning any HIA is the framing assumption, which defines the causal pathways mapping environmental exposures to health outcomes. The sensitivity of the HIA to the framing assumptions is often ignored. A novel method based on fuzzy cognitive map (FCM) is developed to quantify the framing assumptions in the assessment stage of a HIA, and is then applied to a housing intervention (tightening insulation) as a case-study. Framing assumptions of the case-study were identified through a literature search of Ovid Medline (1948-2011). The FCM approach was used to identify the key variables that have the most influence in a HIA. Changes in air-tightness, ventilation, indoor air quality and mould/humidity have been identified as having the most influence on health. The FCM approach is widely applicable and can be used to inform the formulation of the framing assumptions in any quantitative HIA of environmental interventions. We argue that it is necessary to explore and quantify framing assumptions prior to conducting a detailed quantitative HIA during the assessment stage.

Air pollution: a potentially modifiable risk factor for lung cancer

Economic growth and increased urbanization pose a new risk for cancer development: the exposure of high numbers of people to ambient air pollution. Epidemiological evidence that links air pollution to mortality from lung cancer is robust. An ability to produce high-quality scientific research that addresses these risks and the ability of local health authorities to understand and respond to these risks are basic requirements to solve the conflict between economic development and the preservation of human health. However, this is currently far from being achieved. Thus, this Science and Society article addresses the possibilities of expanding scientific networking to increase awareness of the risk of lung cancer that is promoted by air pollution.

Climate change, air pollution and extreme events leading to increasing prevalence of allergic respiratory diseases

The prevalence of asthma and allergic diseases has increased dramatically during the past few decades not only in industrialized countries. Urban air pollution from motor vehicles has been indicated as one of the major risk factors responsible for this increase.Although genetic factors are important in the development of asthma and allergic diseases, the rising trend can be explained only in changes occurred in the environment. Despite some differences in the air pollution profile and decreasing trends of some key air pollutants, air quality is an important concern for public health in the cities throughout the world.Due to climate change, air pollution patterns are changing in several urbanized areas of the world, with a significant effect on respiratory health.The observational evidence indicates that recent regional changes in climate, particularly temperature increases, have already affected a diverse set of physical and biological systems in many parts of the world. Associations between thunderstorms and asthma morbidity in pollinosis subjects have been also identified in multiple locations around the world.Allergens patterns are also changing in response to climate change and air pollution can modify the allergenic potential of pollens especially in presence of specific weather conditions.The underlying mechanisms of all these interactions are not well known yet. The consequences on health vary from decreases in lung function to allergic diseases, new onset of diseases, and exacerbation of chronic respiratory diseases.Factor clouding the issue is that laboratory evaluations do not reflect what happens during natural exposition, when atmospheric pollution mixtures in polluted cities are inhaled. In addition, it is important to recall that an individual's response to pollution exposure depends on the source and components of air pollution, as well as meteorological conditions. Indeed, some air pollution-related incidents with asthma aggravation do not depend only on the increased production of air pollution, but rather on atmospheric factors that favour the accumulation of air pollutants at ground level.Considering these aspects governments worldwide and international organizations such as the World Health Organization and the European Union are facing a growing problem of the respiratory effects induced by gaseous and particulate pollutants arising from motor vehicle emissions.

Atopic dermatitis and indoor use of energy sources in cooking and heating appliances

BACKGROUND

Atopic dermatitis (AD) prevalence has considerably increased worldwide in recent years. Studying indoor environments is particularly relevant, especially in industrialised countries where many people spend 80% of their time at home, particularly children. This study is aimed to identify the potential association between AD and the energy source (biomass, gas and electricity) used for cooking and domestic heating in a Spanish schoolchildren population.

METHODS

As part of the ISAAC (International Study of Asthma and Allergies in Childhood) phase III study, a cross-sectional population-based survey was conducted with 21,355 6-to-7-year-old children from 8 Spanish ISAAC centres. AD prevalence, environmental risk factors and the use of domestic heating/cooking devices were assessed using the validated ISAAC questionnaire. Crude and adjusted odds ratios (cOR, aOR) and 95% confidence intervals (CIs) were obtained. A logistic regression analysis was performed (Chi-square test, p-value < 0.05).

RESULTS

It was found that the use of biomass systems gave the highest cORs, but only electric cookers showed a significant cOR of 1.14 (95% CI: 1.01-1.27). When the geographical area and the mother's educational level were included in the logistic model, the obtained aOR values differed moderately from the initial cORs. Electric heating was the only type which obtained a significant aOR (1.13; 95% CI: 1.00-1.27). Finally, the model with all selected confounding variables (sex, BMI, number of siblings, mother's educational level, smoking habits of parents, truck traffic and geographical area), showed aOR values which were very similar to those obtained in the previous adjusted logistic analysis. None of the results was statistically significant, but the use of electric heating showed an aOR close to significance (1.14; 95% CI: 0.99-1.31).

CONCLUSION

In our study population, no statistically significant associations were found between the type of indoor energy sources used and the presence of AD.

Aging, climate change, and legacy thinking

Climate change is a complex, long-term public health challenge. Older people are especially susceptible to certain climate change impacts, such as heat waves. We suggest that older people may be a resource for addressing climate change because of their concern for legacy--for leaving behind values, attitudes, and an intact world to their children and grandchildren. We review the theoretical basis for "legacy thinking" among older people. We offer suggestions for research on this phenomenon, and for action to strengthen the sense of legacy. At a time when older populations are growing, understanding and promoting legacy thinking may offer an important strategy for addressing climate change.

Improving health and energy efficiency through community-based housing interventions

OBJECTIVES

Houses designed for one climate and cultural group may not be appropriate for other places and people. Our aim is to find cost-effective ways to improve the characteristics of older homes, ill-fitted for New Zealand's climate, in order to improve the occupants' health.

METHOD

We have carried out two community randomised trials, in partnership with local communities, which have focused on retrofitted insulation and more effective heating and have two other studies under way, one which focuses on electricity vouchers and the other on housing hazard remediation.

RESULTS

The Housing, Insulation and Health Study showed that insulating 1,350 houses, built before insulation was required, improved the occupants' health and well being as well as household energy efficiency. In the Housing, Heating and Health Study we investigated the impact of installing more effective heating in insulated houses for 409 households, where there was a child with doctor-diagnosed asthma. Again, the study showed significant results in the intervention group; indoor temperatures increased and levels of NO(2) were halved. Children reported less poor health, lower levels of asthma symptoms and sleep disturbances by wheeze and dry cough. Children also had fewer days off school.

CONCLUSION

Improving the energy efficiency of older housing leads to health improvements and energy efficiency improvements. Multidisciplinary studies of housing interventions can create compelling evidence to support policies for sustainable housing developments which improve health.

Climate change, migration, and allergic respiratory diseases: an update for the allergist

Local climate changes can impact on a number of factors, including air pollution, that have been shown to influence both the development and attacks of allergic respiratory diseases, and thus, they represent an important consideration for the allergist. Migration involves exposure to a new set of pollutants and allergens as well as changes in housing conditions, diet, and accessibility to medical services, all of which are likely to affect migrants' health. This review provides an update on climate change, migration, and allergy and discusses factors for consideration when making recommendations for local allergy service provision and for assessing an individual patient's environmental exposures.

Will drivers for home energy efficiency harm occupant health?

The U.K. government has committed to an 80% reduction in carbon emissions by 2050, with housing accounting for 27% of total current emissions. There are several drivers both to reduce emissions from homes and to reduce fuel poverty, promoting a range of building and behavioural measures in homes. The health benefits of warmer homes in winter have been described, but there has been less consideration of the potential negative impacts of some of these measures. We examine the changes in U.K. homes, and the possible consequences for health. The main concerns for health surround the potential for poor indoor air quality if ventilation is insufficient and the possible risks of overheating in heatwave conditions. This paper notes a limited evidence base and the need for further research on the health effects of energy-efficient homes, particularly with regard to ventilation.

Public health benefits of strategies to reduce greenhouse-gas emissions: household energy

Energy used in dwellings is an important target for actions to avert climate change. Properly designed and implemented, such actions could have major co-benefits for public health. To investigate, we examined the effect of hypothetical strategies to improve energy efficiency in UK housing stock and to introduce 150 million low-emission household cookstoves in India. Methods similar to those of WHO's Comparative Risk Assessment exercise were applied to assess the effect on health that changes in the indoor environment could have. For UK housing, the magnitude and even direction of the changes in health depended on details of the intervention, but interventions were generally beneficial for health. For a strategy of combined fabric, ventilation, fuel switching, and behavioural changes, we estimated 850 fewer disability-adjusted life-years (DALYs), and a saving of 0.6 megatonnes of carbon dioxide (CO(2)), per million population in 1 year (on the basis of calculations comparing the health of the 2010 population with and without the specified outcome measures). The cookstove programme in India showed substantial benefits for acute lower respiratory infection in children, chronic obstructive pulmonary disease, and ischaemic heart disease. Calculated on a similar basis to the UK case study, the avoided burden of these outcomes was estimated to be 12 500 fewer DALYs and a saving of 0.1-0.2 megatonnes CO(2)-equivalent per million population in 1 year, mostly in short-lived greenhouse pollutants. Household energy interventions have potential for important co-benefits in pursuit of health and climate goals.

Effects of improved home heating on asthma in community dwelling children: randomised controlled trial

OBJECTIVE

To assess whether non-polluting, more effective home heating (heat pump, wood pellet burner, flued gas) has a positive effect on the health of children with asthma.

DESIGN

Randomised controlled trial.

SETTING

Households in five communities in New Zealand.

PARTICIPANTS

409 children aged 6-12 years with doctor diagnosed asthma.

INTERVENTIONS

Installation of a non-polluting, more effective home heater before winter. The control group received a replacement heater at the end of the trial.

MAIN OUTCOME MEASURES

The primary outcome was change in lung function (peak expiratory flow rate and forced expiratory volume in one second, FEV(1)). Secondary outcomes were child reported respiratory tract symptoms and daily use of preventer and reliever drugs. At the end of winter 2005 (baseline) and winter 2006 (follow-up) parents reported their child's general health, use of health services, overall respiratory health, and housing conditions. Nitrogen dioxide levels were measured monthly for four months and temperatures in the living room and child's bedroom were recorded hourly.

RESULTS

Improvements in lung function were not significant (difference in mean FEV(1) 130.7 ml, 95% confidence interval -20.3 to 281.7). Compared with children in the control group, however, children in the intervention group had 1.80 fewer days off school (95% confidence interval 0.11 to 3.13), 0.40 fewer visits to a doctor for asthma (0.11 to 0.62), and 0.25 fewer visits to a pharmacist for asthma (0.09 to 0.32). Children in the intervention group also had fewer reports of poor health (adjusted odds ratio 0.48, 95% confidence interval 0.31 to 0.74), less sleep disturbed by wheezing (0.55, 0.35 to 0.85), less dry cough at night (0.52, 0.32 to 0.83), and reduced scores for lower respiratory tract symptoms (0.77, 0.73 to 0.81) than children in the control group. The intervention was associated with a mean temperature rise in the living room of 1.10 degrees C (95% confidence interval 0.54 degrees C to 1.64 degrees C) and in the child's bedroom of 0.57 degrees C (0.05 degrees C to 1.08 degrees C). Lower levels of nitrogen dioxide were measured in the living rooms of the intervention households than in those of the control households (geometric mean 8.5 microg/m(3) v 15.7 microg/m(3), P<0.001). A similar effect was found in the children's bedrooms (7.3 microg/m(3) v 10.9 microg/m(3), P<0.001).

CONCLUSION

Installing non-polluting, more effective heating in the homes of children with asthma did not significantly improve lung function but did significantly reduce symptoms of asthma, days off school, healthcare utilisation, and visits to a pharmacist.

TRIAL REGISTRATION

Clinical Trials NCT00489762.

Children are likely to suffer most from our fossil fuel addiction

BACKGROUND

The periods of fetal and child development arguably represent the stages of greatest vulnerability to the dual impacts of fossil fuel combustion: the multiple toxic effects of emitted pollutants (polycyclic aromatic hydrocarbons, particles, sulfur oxides, nitrogen oxides, metals) and the broad health impacts of global climate change attributable in large part to carbon dioxide released by fossil fuel burning.

OBJECTIVES

In this commentary I highlight current scientific evidence indicating that the fetus and young child are at heightened risk of developmental impairment, asthma, and cancer from fossil fuel pollutants and from the predicted effects of climate disruption such as heat waves, flooding, infectious disease, malnutrition, and trauma. Increased risk during early development derives from the inherently greater biologic vulnerability of the developing fetus and child and from their long future lifetime, during which early insults can potentially manifest as adult as well as childhood disease. I cite recent reports concluding that reducing dependence on fossil fuel and promoting clean and sustainable energy is economically feasible.

DISCUSSION

Although much has been written separately about the toxicity of fossil fuel burning emissions and the effects of climate change on health, these two faces of the problem have not been viewed together with a focus on the developing fetus and child. Adolescence and old age are also periods of vulnerability, but the potential for both immediate and long-term adverse effects is greatest when exposure occurs prenatally or in the early years.

CONCLUSIONS

Consideration of the full spectrum of health risks to children from fossil fuel combustion underscores the urgent need for environmental and energy policies to reduce fossil fuel dependence and maximize the health benefits to this susceptible population. We do not have to leave our children a double legacy of ill health and ecologic disaster.

Climate change and local public health in the United States: preparedness, programs and perceptions of local public health department directors

While climate change is inherently a global problem, its public health impacts will be experienced most acutely at the local and regional level, with some jurisdictions likely to be more burdened than others. The public health infrastructure in the U.S. is organized largely as an interlocking set of public agencies at the federal, state and local level, with lead responsibility for each city or county often residing at the local level. To understand how directors of local public health departments view and are responding to climate change as a public health issue, we conducted a telephone survey with 133 randomly selected local health department directors, representing a 61% response rate. A majority of respondents perceived climate change to be a problem in their jurisdiction, a problem they viewed as likely to become more common or severe over the next 20 years. Only a small minority of respondents, however, had yet made climate change adaptation or prevention a top priority for their health department. This discrepancy between problem recognition and programmatic responses may be due, in part, to several factors: most respondents felt personnel in their health department--and other key stakeholders in their community--had a lack of knowledge about climate change; relatively few respondents felt their own health department, their state health department, or the Centers for Disease Control and Prevention had the necessary expertise to help them create an effective mitigation or adaptation plan for their jurisdiction; and most respondents felt that their health department needed additional funding, staff and staff training to respond effectively to climate change. These data make clear that climate change adaptation and prevention are not currently major activities at most health departments, and that most, if not all, local health departments will require assistance in making this transition. We conclude by making the case that, through their words and actions, local health departments and their staff can and should play a role in alerting members of their community about the prospect of public health impacts from climate change in their jurisdiction.

The economics of tackling climate change

Don’t leave health benefits out of the equation

Policies for accelerating access to clean energy, improving health, advancing development, and mitigating climate change

The absence of reliable access to clean energy and the services it provides imposes a large disease burden on low-income populations and impedes prospects for development. Furthermore, current patterns of fossil-fuel use cause substantial ill-health from air pollution and occupational hazards. Impending climate change, mainly driven by energy use, now also threatens health. Policies to promote access to non-polluting and sustainable sources of energy have great potential both to improve public health and to mitigate (prevent) climate disruption. There are several technological options, policy levers, and economic instruments for sectors such as power generation, transport, agriculture, and the built environment. However, barriers to change include vested interests, political inertia, inability to take meaningful action, profound global inequalities, weak technology-transfer mechanisms, and knowledge gaps that must be addressed to transform global markets. The need for policies that prevent dangerous anthropogenic interference with the climate while addressing the energy needs of disadvantaged people is a central challenge of the current era. A comprehensive programme for clean energy should optimise mitigation and, simultaneously, adaption to climate change while maximising co-benefits for health--eg, through improved air, water, and food quality. Intersectoral research and concerted action, both nationally and internationally, will be required.