Adapting to Climate Change: Public Health

Table of Contents

Summary ...................................................................................................................................................................... 1

Introduction ................................................................................................................................................................ 2

1. Overview ............................................................................................................................................................. 2

2. What is Public Health? .................................................................................................................................. 2

3. Monitoring Public Health ............................................................................................................................ 4

Impacts .......................................................................................................................................................................... 7

1. Heat Stress and Heat Waves....................................................................................................................... 7

2. Aeroallergens and Allergic Diseases.................................................................................................... 11

3. Changes in Endemic and Epidemic Infectious Diseases ............................................................. 14

4. Ambient Air Pollution ................................................................................................................................ 18

Specific Adaptations ............................................................................................................................................. 21

1. Heat .................................................................................................................................................................... 21

2. Aeroallergens and Allergic Diseases.................................................................................................... 23

3. Changes in Endemic and Epidemic Infectious Diseases ............................................................. 23

4. Ambient Air Pollution ................................................................................................................................ 24

Context ....................................................................................................................................................................... 25

Conclusions .............................................................................................................................................................. 27

References ................................................................................................................................................................ 29

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Adapting to Climate Change: Public Health

Jonathan M. Samet

Summary

he potential consequences of climate change extend to the health of the public, with warming
of the planet projected to have both positive and negative consequences that will vary
temporally and spatially. Climate change will not act to introduce new causes of morbidity and

mortality, but to change the distributions of factors that affect the occurrence of morbidity and
mortality. The time frames over which health consequences of climate change are anticipated to be
manifest are both immediate and longer term and, consequently, adaptation measures could
potentially reduce their impact. This paper addresses the projected health consequences of climate
change, reviewing the projected adverse effects, the diverse strategies that might mitigate these
effects, and the potential effectiveness of these strategies. It addresses temperature, aeroallergens
and allergic diseases, air pollution, and infectious diseases.

The methods for addressing the health consequences of climate change, as evident in this

review, are those of public health and disease control generally. The unique aspect of climate
change is its upstream driver. The consequences of climate change for health range from being
quite specific (e.g., heat waves) to general (e.g., increased exposure to air pollution) and from being
acute in nature (e.g., infectious disease outbreaks) to longer term (e.g., changes in allergic diseases
associated with shifts in aeroallergens). For some of the health consequences of climate change

such as emerging infections and heat waves

adaptation will take place through the routine

functioning of effective public health systems, if in place. Some, such as allergic diseases, will be
managed through routine medical care. And some, including increased emissions of air pollution,
will be addressed through regulatory mechanisms.

Recognition and quantification of the health consequences of climate change will be difficult,

given their lack of specificity. Risk assessment methods, including burden of disease estimation, will
remain central as a tool for estimating the need for implementation of adaptive strategies and for
quantifying their benefits.

Jonathan M. Samet, M.D., M.S. Professor and Chair, Department of Preventive Medicine and Director, USC Institute for

Global Health, Keck School of Medicine, USC/Norris Comprehensive Cancer Center. 1441 Eastlake Avenue, Room 4436, MS 44,
Los Angeles, CA 90033. Telephone: 323‐865‐0803. Fax: 323‐865‐0127

jsamet@usc.edu

. This report was prepared for the

Resources for the Future project on adaptation to climate change. For more information, see www.rff.org/adaptation.

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Introduction

1. Overview

The potential consequences of climate change extend to the health of the public, with warming

of the planet projected to have both positive and negative consequences that will vary temporally
and spatially. Climate change will not act to introduce new causes of morbidity and mortality, but to
change the distributions of factors that affect the occurrence of morbidity and mortality. The time
frames over which health consequences of climate change are anticipated to be manifest are
sufficiently slow to allow adaptive measures to come into play that may modulate the occurrence of
these effects.

This paper addresses the projected health consequences of climate change, reviewing the

projected adverse effects, the diverse strategies that might mitigate these effects, and the potential
effectiveness of these strategies. The review is qualitative and does not itself quantify the potential
health burden of these effects; such assessments have been reported and are reviewed. The
literature on climate change and health covered in this review was identified through searches of
the biomedical literature using PubMed. Additionally, references included in the 2007 report of the
Intergovernmental Panel on Climate Change (IPCC; Metz et al. 2007), the 2006 report of the Climate
Change and Adaptation Strategies for Human Health (Menne and Ebi 2006), and recent review
articles on climate change and health (Haines and Patz 2004; Patz et al. 2005; Haines et al. 2006;
McMichael et al. 2006; Frumkin et al. 2008) are reviewed.

This review begins with a discussion of the concepts and methods of public health, covering the

general strategies used to identify and manage threats to the health of the public and to
prospectively implement programs to improve the public’s health. Ongoing data collection to
monitor health status and disease occurrence is fundamental to these strategies, as is evaluation of
any interventions that are implemented. It draws on standard sources in public health (Teutsch and
Churchill 2000; Detels et al. 2004; Wallace 2008) and covers major health consequences of climate
change, including mortality associated with hot and cold temperatures, allergic diseases, air
pollution, and infectious diseases. It does not address hurricanes and other climate‐driven natural
disasters. Models support the potential for climate change to increase the frequency and severity of
such disasters, which may have dramatic public health consequences and necessitate responses at
the national and global levels (Metz et al. 2007). However, the potential consequences of such
disasters and the need for response mechanisms are already well documented.

2. What is Public Health?

Health, as defined by the World Health Organization (1948, 100), is “…a state of complete

physical, mental and social well‐being and not merely the absence of disease or infirmity.” The
definition is notable for its emphasis on well‐being. Public health refers to the approaches taken to
protect and improve the health of communities, in contrast to clinical medicine, which addresses the
health and disease of individuals. Prevention is fundamental to public health; primary prevention
involves the control of the causes of disease, whereas secondary prevention involves detection of
early cases of disease through screening and treatment at a stage at which cure is likely. Tertiary

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prevention is the domain of clinical medicine—treating patients with clinically manifest disease.
Frumkin and colleagues (2008, 435) have applied these disease control concepts to public health,
proposing that mitigation is analogous to primary prevention and that adaptation is comparable to
secondary and tertiary prevention, as it involves “…efforts to anticipate and prepare for the effects
of climate change, and thereby to reduce the associated health burden.”

The essential services of public health cover broad domains that are relevant to adaptation to

climate change (Table 1; American Public Health Association 2008). Frumkin and colleagues (2008)
match these functions to the anticipated consequences of climate change. These domains include
monitoring the health of the population and investigating health problems that occur in
communities. Communications and engagement are also essential, as is the maintenance of the
infrastructure and capacity for sustaining the core public health functions. Public health,
particularly in comparison to clinical care, has long been underfunded, and public health experts in
the United States have repeatedly voiced concern as to the size and competence of the public health
work force (Institute of Medicine and Committee on Assuring the Health of the Public in the 21st
Century 2002; Institute of Medicine et al. 2003). Health problems that can be addressed through
primary prevention remain as major, but remediable causes of morbidity and mortality and include,
for example, tobacco use, obesity and physical inactivity, sexually transmitted diseases, and
alcoholism and drug abuse (Mokdad et al. 2004). Globally, the status of public health is highly
variable, ranging from completely lacking in some less developed countries to being highly effective
in others (Beaglehole and Dal Poz 2003).

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Table 1. Essential Services of Public Health

Monitor

health status to identify community health problems

Diagnose and investigate

health problems and health hazards in the community

Inform, educate, and
empower

people about health issues

Mobilize

community partnerships to identify and solve health problems

Develop policies and plans

that support individual and community health efforts

Enforce

laws and regulations that protect health and ensure safety

Link

people to needed personal health services and ensure the
provision of health care when otherwise unavailable

Ensure

a competent public health and personal healthcare workforce

Evaluate

the effectiveness, accessibility, and quality of personal and
population‐based health services

10.

Research

for new insights and innovative solutions to health problems

Source: American Public Health Association n.d.

3. Monitoring Public Health

The health of a population can be gauged by a number of diverse indicators (Table 2; Etches et

al. 2006). The most basic is the overall mortality rate and the complementary projection of life
expectancy. In most of the more developed countries, cause‐specific mortality is also tracked. Other
key mortality indicators relate to pregnancy and the outcome of pregnancy. With regard to
incidence

—

that is, new cases of disease

—

the occurrence of some infectious diseases is tracked

through a variety of active and passive symptoms; of the chronic diseases (i.e., those with a lengthy
course), incident cases of cancer are tracked in the United States and some other countries, but
other major chronic diseases, such as coronary heart disease, are generally not.

Surveillance refers to the tracking of the health of a population, whether in general or for

particular indicators. The concept of surveillance was formalized by Langmuir (1963, 182), who
offered the following definition in a now‐classic 1963 paper in the New England Journal of Medicine:

Surveillance, when applied to a disease, means the continued watchfulness
over the distribution and trends of incidence through the systematic
collection, consolidation and evaluation of morbidity and mortality reports
and other relevant data.

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Surveillance involves more than passive collection of data; it is grounded in process, such that

the incoming data are analyzed and the findings reviewed and action is taken when needed (Figure
1; Teutsch and Churchill 2000). If intervention is undertaken, the continued monitoring provides a
way to track its consequences. Although surveillance is central to tracking the occurrence of
infectious illnesses, such as influenza and other respiratory pathogens, the same concepts are also
applied to diseases that occur over far longer time frames, such as cancer and coronary heart
disease.

Table 2. Selected Indicators of Population Health

Mortality

Total mortality rate
Cause‐specific mortality rates

Maternal mortality rate
Perinatal mortality rate
Infant mortality rate

Lifespan

Incidence

Infectious diseases
Cancer

Prevalence

Chronic diseases
Malnutrition
Overweight and obesity
Disease risk factors

Vaccination
Health care coverage

Source: Etches et al. 2006.

In the United States, the Centers for Disease Control and Prevention (CDC) has a broad set of

surveillance activities in place, including many that are housed in the National Center for Health
Statistics (CDC n.d. [a]; CDC n.d. [b]). The resulting extensive databases of spatial and temporal data
provide a major resource for planning potential surveillance activities related to climate change in
the United States. Additional databases are maintained at the regional, state, and local levels.
Analytical tools have also been developed that facilitate the scanning of these data for patterns
indicative of potential consequences of climate change or other factors.

One further type of tracking involves the periodic estimation of the burden of avoidable

morbidity and mortality. This type of estimation has been carried out at the national level in some
countries and at the global level through the Global Burden of Disease project, initially coordinated
by the World Health Organization (n.d.). The estimation uses the concept of population attributable

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risk to estimate disease burden and uses, as the comparison for a particular risk factor, the
expected amount of disease absent the exposure (Levin 1953). The burden depends on the
prevalence of exposure to the factor of interest and the risk associated with exposure; higher
prevalence and greater risk increase the estimated burden of disease. For cigarette smoking, for
example, the population attributable risk for lung cancer in the United States exceeds 80 percent,
implying that, absent smoking, these cases would not have occurred (U.S. Department of Health and
Human Services 2004). Burden estimates also address the combination of life lost and the extent of
useful life lost through the calculation of disability‐adjusted life years (DALYs) lost.

Figure 1. Modeling a Surveillance System

Source: Teutsch and Churchill 2000.

This approach of burden estimation has been extended to climate change (McMichael et al.

2004). Although they are inherently subject to great uncertainty, burden of disease estimates
provide an indication of the magnitude of anticipated impact and a way to compare the future
burden under various scenarios of mitigation and adaptation. The McMichael et al. (2004) report on
the burden of mortality and morbidity related to climate change includes estimates of the
attributable burden (in the past) and of the projected burden (for the future). The particular
difficulties of burden estimation in regard to climate change have been a topic of several
commentaries (Kovats et al. 2005; Campbell‐Lendrum and Woodruff 2006).

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Impacts

1. Heat Stress and Heat Waves

Heat Waves and Their Consequences

Temperature has long been associated with adverse effects on health and mortality. At the

extremes of temperature exposure, the well‐known clinical entities of hypothermia and
hyperthermia are well‐documented causes of death (Basu and Samet 2002). Hypothermia typically
affects persons at risk for unprotected exposure to cold because of socioeconomic status and
limited resources for space heating. Hyperthermia occurs among persons carrying out physical
activities when temperatures are high that lead to thermal stress as well as those who are
susceptible to heat because of limited adaptive capacity, such as the elderly and persons taking
certain medications that impair responses to thermal stress. Even in more developed countries,
deaths occur that are attributable to hypothermia and hyperthermia. In the United States, for
example, approximately 600 deaths from hypothermia (CDC 2004) and slightly fewer than 700
deaths from hyperthermia (CDC 2006)

occur each year.

The phenomenon of excess mortality during heat waves has been extensively documented and

is well recognized as a potential consequence of global warming arising from climate change (IPCC
2007). In recent decades, the dramatic epidemics of death associated with heat waves in Chicago in
1995 (Semenza et al. 1996) and in Europe in 2003 (Vandentorren et al. 2004; Kovats et al. 2006)
have alerted the public to the dangers of heat waves and led to protective actions by governments
and public health agencies. Moreover, warmer temperatures are associated with mortality even at
times when heat waves are not in progress (Basu and Samet 2002; Kovats et al. 2006). The
relationship between temperature and mortality has been characterized as “J‐shaped” (Figure 2),
such that mortality increases with both colder and warmer temperatures from some temperate
optimum at which it is lowest (Curriero et al. 2002; McMichael et al. 2008). The value of this
optimum temperature varies with average temperature, and hence latitude, as well as the extent to
which adaptive measures are available for acclimating to warmer or colder temperatures (The
Eurowinter Group 1997; Curriero et al. 2002; Kovats et al. 2006).

This J‐shaped relationship has implications for the potential overall effect of global warming

consequent to climate change on heat‐associated mortality. Warming would reduce the cold‐
associated mortality while increasing heat‐associated mortality, absent new adaptive measures
(Figure 2; Curriero et al. 2002). However, beyond the rise in average temperature, climate change is
also projected to increase the variability of temperature and the frequency of heat waves (IPCC
2007).

Heat is already associated with ongoing mortality. Temperatures above the optimum value can

be assumed to contribute to mortality. Estimates for Germany, for example, ranged from 5 to 10
percent in excess beyond the optimum for temperatures that were below the extreme (Kovats et al.
2006). Clear excesses of thousands of deaths during heat waves have been well documented (Basu
and Samet 2002; Kovats et al. 2006; IPCC 2007).

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Figure 2. Temperature–Mortality Relative Risk Functions for 11 U.S. Cities, 1973–1994

Notes: Northern cities: Boston, Massachusetts; Chicago, Illinois; New York, New York; Philadelphia,

Pennsylvania; Baltimore, Maryland; and Washington, DC. Southern cities: Charlotte, North Carolina;

Atlanta, Georgia; Jacksonville, Florida; Tampa, Florida; and Miami, Florida. °C = 5/9 x (°F – 32).
Source: Curriero et al. 2002.

The recent heat waves in Chicago and Europe are particularly informative for indicating the

vulnerabilities that contributed to remarkably high mortality during the episodes and for
identifying the subgroups within the population that are particularly susceptible. In Chicago, 465
deaths were certified as heat‐related over the period July 11–27, 1995 (CDC 1995). A case–control
study found strong associations between increased mortality and the presence of medical problems
and social isolation, whereas having an air conditioner and transportation were associated with
reduced mortality (Semenza et al. 1996). Mortality was also higher in neighborhoods that were less
socially cohesive (Klinenberg 2002).

The 2003 heat wave in Europe was dramatic for its scope and for the failure to recognize the

resulting mortality and to take action in a sufficiently timely way. Numerous analyses have been
reported on the mortality caused by the heat wave (see Kovats et al. 2006; IPCC 2007). France
experienced approximately 15,000 excess deaths, and the total for Europe was estimated at 35,000
(IPCC 2007). As was the case in Chicago, the at‐risk groups included the elderly, those living alone
and without social support, and the less advantaged (Poumadere et al. 2005). Inquiries in France

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identified failures that led to the tragic excess: inadequate surveillance, limited public health
capacity, and insufficient communication (Poumadere et al. 2005; IPCC 2007).

Evidence also suggests that the risk of heat‐related excess mortality has declined on longer time

frames. Carson and colleagues (2006) examined weekly mortality in London during the 20th
century and assessed temperature‐associated mortality over a period during which a major shift
occurred in the underlying causes of death and a progressive increase in the age of the population
and the proportion affected by chronic diseases. They found declines in susceptibility to death from
both cold and heat. They attributed this finding to a variety of factors related to social and
environmental conditions, behavior, and health care. Davis et al. (2003) examined heat‐related
mortality over the period 1964–1998 in the United States; they also found declining heat mortality,
which they attributed to a variety of adaptations, including the increased availability of air
conditioning. Barnett (2007) found that the association of warm temperature with cardiovascular
mortality during the summer declined substantially over the period 1987–2004.

Because the elderly and people with underlying chronic diseases are particularly susceptible,

the hypothesis has been advanced that the excess mortality associated with heat waves represents
only a brief advancement of the time of dying, a phenomenon sometimes referred to as mortality
displacement or harvesting. This same hypothesis has been advanced in interpreting the
associations found between daily mortality counts and air pollution concentrations on the same or
recent days. If such mortality displacement is prominent, a reduction in mortality would be
anticipated following the excess associated with the heat wave; analytical approaches have been
developed for assessing mortality displacement (Zeger et al. 1999; Zanobetti et al. 2000). For the
2003 heat wave in France, the extent of mortality displacement was found to be modest (Toulemon
and Barbieri 2008). A parallel analysis of heat‐related deaths in Delhi, São Paulo, and London, using
distributed lag models, found evidence of mortality displacement in London and a lesser indication
of this phenomenon in Delhi (Hajat et al. 2005); the pattern was intermediate for São Paulo.

Evidence is noticeably lacking on temperature‐associated mortality in the developing countries.

The ISOTHURM project examined the temperature–mortality relationship in 12 urban areas,
including several in low‐ and middle‐income countries (McMichael et al. 2008). The data from most
of the cities showed a J‐shaped relationship with temperature. In Delhi and Salvador, mortality did
not increase at colder temperatures, nor did an increase occur at hotter temperatures in Chiang Mai
and Cape Town.

Determinants of Severity

The impact of a heat wave varies with the magnitude of the thermal stress, the duration of the

episode, and the characteristics of the population affected. In general, models of the relationship
between temperature (or other indicators) and mortality show increasing mortality with increasing
temperature (for example, Curriero et al. 2002). Based on analyses of data from London, Budapest,
and Milan, Hajat et al. (2006) found a “heat wave effect,” such that mortality from a sustained
temperature elevation exceeds that predicted by the rise in temperature alone.

Population characteristics also determine the impact of heat waves. The elderly and persons

with underlying chronic diseases, such as coronary artery disease and congestive heart failure, are

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particularly at risk. Additionally, persons taking diuretics, certain agents used for blood pressure
control, and other drugs may have impaired cardiovascular responses to thermal stress, as may
obese persons. In the aging populations of the more developed countries, these at‐risk groups are
increasing in size and likely to continue to do so. Epidemiological analyses, described above, have
identified additional risk factors for mortality during heat waves, including lack of social support,
socioeconomic status, and housing characteristics. In urban areas, the “urban heat island”
phenomenon tends to increase the risk of mortality associated with heat waves (U.S. Environmental
Protection Agency, n.d. [b]; Buechley et al. 1972). Determinants of risk in less developed countries
have received little research attention.

Spatial and Temporal Distribution

Analyses included in the IPCC (2007) report make clear that increases in mean temperature will

be widespread and that variability will also increase, leading to the potential for more frequent and
severe heat waves. Most regions of the world will probably be affected. Although time trends of
heat wave–associated mortality are not clearly apparent, recent dramatic episodes, including
Chicago in 1995 and Europe in 2003, document that heat waves continue to have unabated impact.

Synthesis and Summary

Excess mortality during heat waves has long been documented. The present potential for heat

waves to cause substantial morbidity and mortality in cities, even in developed countries, has been
established by several dramatic events. The IPCC’s (2007) projections of rising temperatures and
increasing variability support the conclusion that there is a high probability of future climate
change–caused heat waves with excess mortality. The burden of climate change–attributable
cardiovascular disease mortality has been estimated for the various regions of the World Health
Organization and summarized for the world (Tables 3 and 4; McMichael et al. 2004). For
temperature variation (both hotter and colder temperatures) associated with climate change, an
estimated 12,000 cardiovascular disease deaths were advanced by climate change for the year
2000. This number, a global estimate, is much smaller than the actual numbers of excess deaths
during well‐documented heat waves; the estimate, however, refers to the burden of temperature‐
associated mortality from the effect of climate change on temperature and not to the consequences
of temperature itself.

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Table 3. Estimated Mortality (000s) Attributable to Climate Change in the Year 2000,

by Cause and Subregion

Subregion

Malnutrition

Diarrhea

Malaria

Floods

CVD

All causes

Total

deaths/million

population

AFR‐D

66.83

AFR‐E

109.40

AMR‐A

0.15

AMR‐B

3.74

AMR‐D

10.28

EMR‐B

5.65

EMR‐D

61.30

EUR‐A

0.07

EUR‐B

1.04

EUR‐C

0.29

SEAR‐B

7.91

SEAR‐D

65.79

WPR‐A

0.09

WPR‐B

2.16

World

166

27.82

Notes: CVD, cardiovascular disease; AFR, African region; AMR, Region of the Americas; EMR, Eastern

Mediterranean region; EUR, European region; SEAR, South‐East Asian region; WPR, Western Pacific region.
Source: McMichael et al. 2004.

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Table 4. Estimated Disease Burden (000s of DALYs) Attributable to Climate Change in the Year 2000,

by Cause and Subregion

Subregion

Malnutrition

Diarrhea

Malaria

Floods

All causes

Total

DALYs/million

population

AFR‐D

293

154

178

626

2185.78

AFR‐E

323

260

682

1267

3839.58

AMR‐A

11.85

AMR‐B

166.62

AMR‐D

324.15

EMR‐B

147.57

EMR‐D

313

277

112

748

2145.91

EUR‐A

6.66

EUR‐B

48.13

EUR‐C

14.93

SEAR‐B

117.19

SEAR‐D

1918

612

2538

2080.84

WPR‐A

8.69

WPR‐B

169

111.36

World

2846

1459

1018

193

5517

925.35

Notes: DALY, disability‐adjusted life year; CVD, cardiovascular disease; AFR, African region; AMR, Region of

the Americas; EMR, Eastern Mediterranean region; EUR, European region; SEAR, South‐East Asian region;
WPR, Western Pacific region.

Source: McMichael et al. 2004.

2. Aeroallergens and Allergic Diseases

Aeroallergens, Allergic Diseases, and Their Consequences

Aeroallergens

—

biological agents associated with allergic responses

—

are ubiquitous in indoor

and outdoor environments. Contact of these agents with the mucosal surfaces of the eyes and nose
causes allergic responses, as does inhalation into the lung. The two principal diseases associated
with aeroallergens are allergic rhinitis, also referred to as hay fever, and asthma. These are
prevalent diseases, affecting substantial proportions of children and adults (Avila‐Tang et al. 2008).
Both diseases are presumed to have a genetic basis as familial aggregation is well documented. In
spite of several decades of investigation, however, only modest progress has been made in
identifying the genes associated with allergic rhinitis, asthma, and allergy.

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The frequency of allergic rhinitis and asthma is tracked with periodic surveys using

questionnaires and other approaches. Such surveys have documented a remarkable and
unexplained rise of asthma and other allergic disorders in children. Prevalence estimates range up
to 20 percent for asthma, which tends to be more frequent in developed countries (Avila‐Tang et al.
2008). Multiple hypotheses have been offered with regard to the rise in childhood asthma, but
uncertainty remains as to the basis for the increase.

The development of asthma is broadly considered to be a consequence of gene‐by‐environment

interaction; that is, environmental exposures trigger the onset of disease in persons who are
genetically at risk. Aeroallergens may have a role in this triggering; exposure to the house dust mite,
for example, has been associated with earlier onset of wheezing in young children (Sporik et al.
1990). Aeroallergens are not considered to be a sufficient cause of asthma onset, absent underlying
genetic susceptibility.

Aeroallergens are well established as an exposure that can exacerbate asthma and trigger

attacks of allergic rhinitis. Numerous aeroallergens are found in outdoor air, particularly pollens
that can trigger allergic diseases. In the United States, pollen counts are routinely monitored
outdoors by the National Allergy Bureau (http://www.aaaai.org/nab), and the monitoring data are
communicated to the public. The levels of pollen in the air display strong seasonal patterns, with
peaks in the spring and fall. Indoor sources of aeroallergens include dogs and cats, rodents, and
house dust mites.

Determinants of Severity

Fortunately, allergic rhinitis and asthma are diseases that can be effectively managed in most

affected persons. A variety of medical management approaches are directed at controlling
symptoms and reducing the likelihood of exacerbations (Pearce et al. 1998; National Heart Lung
and Blood Institute and National Asthma Education and Prevention Program 2007; Avila‐Tang et al.
2008). The phenotypic severity of these diseases, particularly of asthma, is highly variable, and this
variation probably has both environmental and genetic bases. In addition to medications, asthma
severity may be lessened through environmental management strategies that reduce exposure to
indoor aeroallergens, tobacco smoke, and other types of indoor air pollution, and also by avoiding
pollutants in outdoor air by staying indoors.

For persons with allergic rhinitis and asthma, climate change might increase the risk of

exacerbation through altered local and regional pollen production. Warming has already caused an
earlier onset of the spring pollen season in the Northern Hemisphere (IPCC 2007). It may also
increase the duration of the pollen season, change the spatial distribution of vegetation, and
possibly alter pollen production (Beggs 2004; Beggs and Bambrick 2005; IPCC 2007). More
prolonged and intense exposure to aeroallergens could result in more severe disease and possibly
greater morbidity, and even mortality, from asthma. Beggs and Bambrick (2005) have proposed
that climate change could be contributing to the global rise in asthma as a consequence of greater
pollen exposure.

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Spatial and Temporal Distribution

Evidence suggests that climate change has already affected exposures of populations to

aeroallergens (IPCC 2007; Shea et al. 2008). Vegetation patterns have changed, and pollination is
occurring earlier for some species in some places. New species could potentially become successful
in additional areas, leading to exposures of populations to new antigens.

Synthesis and Summary

Evidence already suggests that patterns of exposure to aeroallergens have been altered by

climate change. Many people throughout the world have allergic rhinitis and asthma, diseases that
make them sensitive to aeroallergens. Lengthened periods of exposure and higher concentrations
are very likely to increase the frequency and severity of exacerbations. An increase in the incidence
of allergic diseases as a result of increased aeroallergen exposure is less likely.

3. Changes in Endemic and Epidemic Infectious Diseases

Epidemiological Aspects of Infectious Diseases

Worldwide, in both developed and developing countries, infectious agents remain a leading

cause of disease and death (Nelson et al. 2007). The numerous known infectious diseases differ in
their causative organisms, pathways of transmission, clinical manifestations, responses to therapy,
and outcomes. Vector‐borne diseases are of greatest concern with regard to potential adverse
consequences of climate change. The transmission of these diseases is conceptually described by
the “epidemiological triangle” (Figure 3), which captures the interplay between the agent, the
environment, and the vector. Environmental conditions that promote or extend the geographic
range of the vector increase the potential for infection by the agent. In addition to potentially
affecting vector‐borne diseases, climate change may also extend or change the geographic regions
in which an infectious agent is present. Climate change may affect both endemic disease (i.e.,
disease generally occurring in a population), and epidemic disease (i.e., disease occurring in excess
of the usual background). Epidemiological aspects of major infectious diseases were recently
summarized by Nelson et al. (2007).

Mathematical models of infectious disease transmission provide quantitative insight into the

potential for climate change to increase rates of vector‐borne diseases. The transmission of
infectious diseases has been characterized by the basic reproductive rate (R

) which describes the

number of new cases of infection arising from one case in a population of susceptible persons
(Rogers and Randolph 2006). Values above unity imply the possibility of epidemic disease; a value
of unity means that endemic disease will be maintained, and a value below unity means that the
disease will decline. Warming can increase R

through its effect on vector numbers, transmission

probabilities, and biting rates (Rogers and Randolph 2006). The geographic spread of vectors may
also be affected by the extension of their ranges resulting from warmer conditions. A number of
vector‐borne diseases are considered to be potentially sensitive to climate change (Table 5; Haines
et al. 2006).

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Waterborne and airborne diseases may also be affected by climate change. For diseases

transmitted by water, warming may enlarge the geographic area in which conditions are suitable
for the survival of disease‐causing organisms and for propagation of infection (Colwell 1996; Lipp
et al. 2002). Colwell and colleagues have set out a schema by which global climate change alters
patterns of cholera infections (Colwell 1996). The occurrence of waterborne infections has also
been linked to extreme weather events (Charron et al. 2004). To date, little emphasis has been
given to the possible impact of climate change on airborne infections. Increased air conditioning
and more time spent indoors, because of warming, might affect patterns for diseases that are
transmitted in indoor environments by droplets or by contact.

The potential impact of climate change on infectious diseases has been addressed through

modeling approaches as well as through the investigation of specific shifts in infectious disease
occurrence that could be attributed to climate change. Case studies of particular outbreaks and
changes in infectious disease occurrence in relation to climate indicators provide further evidence
of the role of climate change in altering patterns of infectious disease occurrence. For some agents,
such as malaria, there is substantial controversy as to whether warming will increase occurrence.
The case studies below exemplify the evidence used to link climate change to infectious diseases.

Cholera illustrates the complexity of understanding how climate change can alter the

occurrence of infectious diseases (Figure 4; Lipp et al. 2002). Multiple global cholera pandemics
have been documented; the seventh, which began in 1961, is still ongoing. The disease‐causing
organism, Vibrio cholera, is endemic and widely found in water. The present epidemic began with
the emergence of a new biotype, the El Tor biotype of V. cholerae 01, in Indonesia. In 1991, the
pandemic moved to South America with outbreaks along the Pacific coast. The occurrence of the
epidemic was linked to a plankton bloom that was driven by the El Niño Southern Oscillation
(ENSO). The planktonic copepod organism harbors the V. cholera organisms on its surface;
consequently, a higher concentration of plankton increases the dose of the infectious agent received
from water. A time‐series analysis of cholera in Bangladesh found a link with the ENSO
phenomenon (Rodo et al. 2002). Lipp and colleagues (2002) propose that climate change could
affect each step in their model for cholera transmission.

Checkley and colleagues (2000) carried out a time‐series analysis of temperature changes

associated with the ENSO and all hospital admissions for diarrhea in children in Peru. Over the
period 1993–1998 they found that the numbers of admissions were positively associated with
temperature and also with the ENSO, which had an effect on the admissions rate beyond that
expected from the temperature increase alone.

The IPCC (2007) report identified increased transmission of malaria as a potential consequence

of climate change, coming from the effect of warming on vector numbers and on geographic spread.
The potential for climate change to increase malaria is, however, still controversial in spite of
empirical and modeling‐based research. Loevinsohn (1994) published one of the initial time‐series
analyses based on data for Rwanda. Subsequently, there have been conflicting analyses of the
potential for climate change to increase the spread of malaria and to cause it to become endemic in
areas where it currently no longer occurs. The approaches in these conflicting publications are

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conceptually comparable, involving time‐series analyses to characterize the temperature–malaria
relationship and the use of biological transmission models to incorporate the effect of temperature
(Loevinsohn 1994; Sharp 1996; Epstein 1998; Haines 1998; Reiter 1998; Hales and Woodward
2003; Reiter et al. 2004). The sensitivity of findings to model assumptions indicates a need for more
robust data. The IPCC (2007) report acknowledged the complexity of interpreting the empirical,
time‐series analyses and called for more research.

Figure 4. Hierarchical Model for Environmental Cholera Transmission

Source: Lipp et al. 2002.

Changes in the epidemiological characteristics of a variety of other infectious diseases have

been examined in relation to climate change. Dengue transmission was addressed in the IPCC
(2007) report and in specific studies (see, for example, Cazelles et al. 2005). In Western Australia,
Woodruff et al. (2006) found that climate data predicted epidemics of Ross River virus disease,
which is spread by mosquitoes, with reasonable predictive value, particularly if data on mosquitoes
were incorporated into the model. Studies have also addressed tick‐borne disease (Lindgren and
Gustafson 2001; Ogden et al. 2008) and food‐borne disease (D'Souza et al. 2008).

Determinants of Severity

Many factors determine susceptibility to infection and the severity of the resulting illness,

including the risk of dying. In developed countries, key factors include age, immunocompetence,
presence of comorbid chronic diseases (e.g., coronary heart disease, chronic obstructive pulmonary

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disease, and diabetes), access to vaccines and medical care, and the quality of medical care
available. In developing countries, additional determinants of severity include general nutritional
status and specific micronutrient deficiencies, the level of sanitation, the availability of preventive
measures (such as bed nets and vector control), and the availability of health care and vaccinations.
In both developed and developing countries, large populations are at risk for more severe
infections and mortality.

Spatial and Temporal Distribution

Warming from climate change has the potential to affect the transmission of infectious diseases

across the globe. Although concern has been focused on countries with tropical, subtropical, and
temperate climates, one outbreak of Vibrio parahaemolyticus gastroenteritis on a cruise ship in
Alaska illustrates how warming can alter the spread of infectious organisms in colder climates
(McLaughlin et al. 2005). In this outbreak, passengers developed gastroenteritis from eating
contaminated oysters grown on a farm 1,000 kilometers north of the most northern point at which
the organism had previously been identified.

The diseases of potential concern with regard to global warming are ubiquitous throughout the

world. The time frames over which climate change could affect infectious diseases extend from
relatively short, as even the temperature rise to date has had apparent impact, to relatively long, as
continued temperature increases would be predicted to continue to alter vector distributions and
densities.

Synthesis and Summary

Infectious diseases remain a leading cause of death throughout the world. Climate change could

affect their frequency and distribution through multiple modes of transmission and diverse
pathways. Several case studies document that small increases in temperature can affect the
geographic distribution of infectious organisms and the occurrence of vector‐borne diseases. The
burden of premature mortality attributable to climate change for 2000 was estimated at 47,000 for
diarrheal disease and 27,000 for malaria; however, these estimates are highly uncertain and only
address two types of infection.

4. Ambient Air Pollution

Health Risks of Ambient Air Pollution

Climate change could potentially worsen air pollution, either directly, through increased

tropospheric (ground‐level) ozone production, or indirectly, through greater power plant emissions
as power generation increases to meet the demand for greater air conditioning capacity. Ozone
pollution is projected to increase because warmer temperatures increase ozone production (IPCC
2007). Ozone is a secondary pollutant, formed via sunlight driven photochemical reactions
involving precursor hydrocarbons and oxides of nitrogen. Warmer temperatures enhance the
chemical reactions that generate ozone. Under various scenarios, increases of several parts per
billion are projected over the next two decades (Dentener et al. 2006) up to a range of 10 to 30

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parts per billion by the end of this century (Wilson et al. 2007). Fossil fuel combustion
contaminates the atmosphere with the primary particles generated by combustion and with the
secondary particles formed from gaseous components of power plant emissions through complex
chemical and physical processes. Increased fossil fuel burning could also worsen particulate air
pollution, beyond predictions from climate change scenarios (Davis and Working Group on Public
Health and Fossil‐Fuel Combustion 1997; IPCC 2007).

The health risks of both ozone and airborne particles have been characterized with reasonable

certainty in epidemiological studies, with supporting evidence coming from in vivo and in vitro
toxicological research (Pope and Dockery 2006; World Health Organization 2006). Both ozone and
particulate matter (PM) air pollution have been associated with an increased risk of mortality in
time‐series studies of daily mortality (Samet et al. 2000; Bell et al. 2004; Pope and Dockery 2006),
and airborne particles have also been associated with an increased risk of dying on longer time
frames (Pope and Dockery 2006). Both types of pollution are also associated with morbidity,
including an increased risk for hospitalization (Dominici et al. 2006; Pope and Dockery 2006) and
other adverse outcomes (World Health Organization 2006). A quickly expanding body of evidence
links particulate air pollution to adverse cardiovascular effects (Brook et al. 2004).

Two analyses that link climate change model outputs to ozone concentrations have been

carried out for cities in the United States. Knowlton et al. (2004) projected the future increase in
ozone concentration for 31 counties of the New York metropolitan region. Considering the impact
of climate change alone on ozone concentration, they estimated a median 4.5 percent increase in
summertime ozone‐related, acute, all‐cause mortality for the 31 counties. Bell et al. (Bell 2007)
performed similar modeling for 50 cities in the eastern United States. They estimated the average
increase in the daily one‐hour maximum concentration as 4.8 parts per billion. Depending on the
concentration–response relationship used, the increase in ozone concentration corresponded to an
increase in daily, all‐cause mortality of 0.11 to 0.27 percent.

Several analyses have addressed particulate air pollution, considering the potential risks of

increased fossil fuel combustion and the benefits for health of reducing air pollution through
greenhouse gas mitigation (Davis and Working Group on Public Health and Fossil‐Fuel Combustion
1997; Cifuentes et al. 2001). Enhanced energy consumption based on fossil fuel combustion is
predicted to lead to a substantial increase in premature mortality (Davis and Working Group on
Public Health and Fossil‐Fuel Combustion 1997); in one scenario of business as usual leading to
increased exposure to PM air pollution, an additional 700,000 premature deaths were projected.
Correspondingly, in an analysis of four of the world’s major cities (Mexico City, New York City,
Santiago, and São Paulo), Cifuentes et al. (2001) predicted that reductions of ozone and particles
from mitigation would substantially reduce premature mortality.

Determinants of Severity

The risks of premature mortality and morbidity associated with exposure to ozone and PM air

pollution increase with concentration; the most recent studies do not provide a clear indication of a
threshold below which effects do not occur (U.S. Environmental Protection Agency 2006; World
Health Organization 2006).

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The factors determining responses to ambient air pollution have been studied extensively. As

for heat stress, a wide range of groups are considered to be at risk: infants and the elderly, persons
with chronic heart and lung disease, and the socially disadvantaged. Persons with greater potential
to receive high doses of inhaled pollutants are also considered at risk; these large populations
include those doing physical work or exercising outdoors when air pollution concentrations are
elevated (U.S. Environmental Protection Agency 2008).

In addition, air pollution and thermal stress may act synergistically: both affect largely the same

susceptible populations, and hot temperatures increase ozone production. Only a few studies have
explored synergism between these two environmental stressors. In Athens, the short‐term effect of
sulfur dioxide on daily mortality was independent of temperature over the period 1975‐1982
(Hatzakis et al. 1986). An analysis of mortality in Athens during a 1987 heat wave suggested
synergism of air pollution with higher temperature (Katsouyanni et al. 1993). Filleul and colleagues
(2006) examined the contributions of ozone and temperature to the excess mortality observed in
nine French cities during the 2003 heat wave. They estimated that both ozone and heat contributed
to the excess and that the relative contributions varied from city to city. Fischer et al. (2004)
published similar findings for the Netherlands during 2003 as well. Neither analysis tested for
synergism between ozone and temperature.

Spatial and Temporal Distribution

Air pollution is largely a problem in urban areas, where dominant sources include motor

vehicles, industry, and power generation. Additional pollution may occur from fuel combustion,
particularly biomass fuels, used for heating or cooking. In rural areas, emissions from these sources
may also lead to locally significant ambient air pollution (Smith 2006). With regard to the effects of
global climate change on ozone pollution, urban areas are of greatest concern; typically, ozone
pollution extends well beyond urban centers across surrounding areas.

Synthesis and Summary

The risks of ambient air pollution to health have been studied extensively. For the two

pollutants of concern with regard to global climate change—ozone and airborne PM—exposures
have been strongly and consistently associated with increased risks for excess mortality and for
morbidity. Effects are documented at levels that are prevalent throughout the major cities of the
world in both developed and developing countries.

Warming will increase summertime ozone production, leading to greater exposures unless

emissions of precursors are reduced. Particle levels may also increase, particularly if power
generation from coal‐fired power plants increases to support more air conditioning. Tools are
available to estimate the potential burden of disease associated with worsening air pollution, but
disentangling the contributions of climate change from those of other factors will not be
practicable.

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Specific Adaptations

1. Heat

Surveillance and Warning Systems

The needed tools for protecting people from heat stress are available. Temperature is readily

and widely measured, and the weather conditions that lead to dangerous heat stress can be
forecasted. The many epidemics of heat‐caused deaths have identified those who need to be
protected during heat waves, and there is a single stressor, heat, to be avoided. In fact, model heat
watch systems have been implemented and their impact evaluated (Ebi and Schmier 2005).

Kalkstein and colleagues (1995) established one model for such systems based on the

identification of weather conditions historically associated with increased mortality in a particular
location and then the prospective issuance of a warning when such conditions arise. The approach
uses exploratory and clustering statistical methods to identify synoptic conditions, oppressive air
masses, that have been linked to increased mortality. The anticipated occurrence of such conditions
triggers a protective response from public health and municipal authorities. In a 1996 paper
describing this approach for the city of Philadelphia, Kalkstein et al. (1996) suggested that the
implementation of this type of system may have reduced the impact of a heat wave in Philadelphia
during the summer of 1995.

A decade later, Sheridan and Kalkstein (2004) reported on the widespread application of this

approach in multiple cities in North America, Europe, and Asia. The underlying algorithm is set out
in Figure 5 (Sheridan and Kalkstein 2004). Its implementation requires certain data, the capability
to implement the synoptic classification system, and the capacity to implement a system of warning
and response. Measures that might be taken to protect the public include media announcements,
the activation of support networks, the implementation of a “heatline,” taking steps to protect
susceptible groups, and providing air‐conditioned shelters. Although evaluation is difficult, studies
in Philadelphia, Rome, and Shanghai indicate that this approach can reduce the mortality associated
with heat waves (CDC et al. 2004; Ebi et al. 2004; Tan et al. 2004).

Following the 2003 European heat wave, a heat watch and warning system, including a national

action plan, was implemented in France (Pascal et al. 2006). The system was based on an analysis of
data from 14 cities in France and used temperature alone, rather than the synoptic approach
advanced by Kalkstein and others. A heat wave in 2006 afforded the opportunity to assess the
effectiveness of the system (Fouillet et al. 2008). This event, the second most severe since 1950
after the 2003 heat wave, led to more than 2,000 excess deaths in France

—

this was 4,400 fewer

deaths than predicted based on the 2003 event. The evaluation documents that an effective
warning system can be rapidly implemented.

Housing and Air Conditioning

Housing style and the use of air conditioning can lessen the impact of heat waves. In a number

of studies, the availability of air conditioning has been shown to reduce the risk of mortality during
a heat wave. As a longer‐run strategy, increased use of air conditioning in homes would be expected

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2. Aeroallergens and Allergic Diseases

Surveillance and Warning Systems

In more developed countries, such as the United States, tracking is in place both for

aeroallergens and for the prevalence of allergic diseases, particularly asthma (American Academy
of Allergy Asthma & Immunology n.d.). The aeroallergen monitoring is sensitive to changes in
pollen and mold concentrations and to changes in their sources. Asthma surveillance remains
difficult, in part because of the variability of the phenotype of asthma, the changing classification
over time, and the potential for misclassifying other, minor conditions as asthma (Moorman et al.
2007). On the other hand, routine surveillance in the United States and in other countries has
identified variation in asthma mortality rates with several epidemic rises over the past 50 years as
well as the still unexplained rise in childhood asthma over the last several decades (Avila‐Tang et al.
2008).

Most cases of asthma and other allergic diseases can be treated, and symptoms limited, if

adequate medical care and treatment are available (National Heart Lung and Blood Institute and
National Asthma Education and Prevention Program 2007). On the relatively slow time frame over
which aeroallergen exposures may change, the medical care systems of many countries should be
able to accommodate increasing numbers of persons with these diseases; by contrast, in many
countries these disorders are untreated and are a substantial source of morbidity and even
mortality (Braman 2006; Pearce et al. 2007; Shea et al. 2008).

3. Changes in Endemic and Epidemic Infectious Diseases

Surveillance

Surveillance is the fundamental tool for identifying changes in the patterns of infectious disease

occurrence. In the United States, CDC maintains a variety of surveillance systems for specific
infectious diseases. Some are passive, relying on proactive reporting by health care providers and
facilities, whereas others are active, involving the collection of data through established systems
and networks. The World Health Organization tracks the occurrence of key infectious diseases on a
global basis. Absent effective surveillance

—

to detect outbreaks as well as more subtle, longer–time

frame changes

—

adaptation cannot be successful.

Examples of established and ongoing surveillance at local, national, and global levels include

those for HIV/AIDS and tuberculosis. For tuberculosis, the World Health Organization monitors not
only the occurrence of disease, but also the operational success with which therapy is delivered
(World Health Organization 2008). Notable, sentinel outbreaks are also likely to be detected;
examples include the outbreak of V. parahaemolyticus aboard the cruise ship in Alaska (McLaughlin
et al. 2005), the 2003 outbreak of severe acute respiratory syndrome (SARS) in countries of Asia
and elsewhere (Naylor et al. 2004), and the very recent outbreak of Chikungunya in Italy (Charrel et
al. 2007). In the future, such outbreaks are likely to occur more often in developed countries.

However, there may be barriers to establishing surveillance systems that extend across national

boundaries, even if they are needed to protect global public health. In the initial phase of the SARS

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epidemic in China, the scope of the epidemic was initially minimized and not revealed with
sufficient warning (Naylor et al. 2004). The alerting function that should be an element of an
effective surveillance system also failed. A case study of Hong Kong and Toronto also identified
difficulty in linkages of clinical and reference laboratories into data systems (Naylor et al. 2004). In
China, the failures in surveillance during the SARS outbreak were followed by a strengthening of
capacity of the China Center for Disease Control, documenting that surveillance capacity can be
addressed on a short‐term basis.

Nonetheless, access to surveillance data persisted as a barrier in avian influenza surveillance in

2006, three years after the SARS epidemic (Nature 2006; Normile 2006). An approach to solving
this problem was made with the Global Initiative on Sharing Avian Influenza Data (GISAID), a set of
principles for sharing samples and data (GISAID n.d.). The need for this type of approach was
evident, given the potential gravity of an avian influenza pandemic, and the key actors were moved
to take action.

Can current surveillance methods identify the potential consequences of climate change for the

occurrence of infectious diseases? Some reports of epidemics support this potential, at least for
sentinel outbreaks (e.g., McLaughlin et al. 2005). Unless implemented with sufficient sensitivity and
in vulnerable locations, changes in the zones of vector‐borne and waterborne diseases may not be
readily detected. Models of climate change and infectious diseases should be useful for guiding the
design of surveillance systems.

Public Health Responses

Public health responses can be effective in controlling specific disease outbreaks; recently, they

have proven most effective for controlling acute epidemics of disease, particularly those associated
with emerging infections, such as SARS. On longer time frames, the eradication of smallpox was
possible through a global initiative, and the delivery of curative therapy for tuberculosis has been
enhanced. Slow changes in endemic diseases are less likely to be addressed in a timely and ongoing
fashion.

Clinical Responses

Clinicians hold key roles, both in treating infectious diseases and in recognizing the occurrence

of sentinel cases that signal a possible outbreak. The first cases of AIDS, for example, were
recognized in the United States in 1981 because of the occurrence of a cluster of cases of
Pneumocystis carinii pneumonia in gay men with immunocompromise (CDC 1981). Clinicians are
an integral element of surveillance, a role they can better fill if they are alerted to the potential
consequences of climate change and the possibility of emerging infections.

4. Ambient Air Pollution

In many countries, air quality regulations or guidelines are in place, along with extensive air

quality management programs to control air pollution levels. The World Health Organization
provides guidelines for the major ambient pollutants; the 2006 revisions (World Health
Organization 2006) were more stringent than earlier versions as mounting evidence showed that

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contemporary levels of air pollution are associated with continued risk, particularly for the elderly
and for persons with chronic heart and lung diseases. A substantial proportion of the world’s
population is exposed to outdoor air pollutants at concentrations exceeding the World Health
Organization’s guideline values. In the most recent global burden of disease estimates, urban air
pollution, using PM

(coarse PM) as the surrogate, was estimated to cause about 3 percent of

mortality attributable to cardiopulmonary disease in adults, 5 percent of lung cancers, and 1
percent of childhood mortality from acute respiratory illnesses (Cohen et al. 2004). In this analysis,
many cities of the world were estimated to have PM

concentrations well above the current

standards of the U.S. Environmental Protection Agency (n.d. [a]) as well as the target values
proposed in the 2006 World Health Organization guidelines.

The anticipated changes in ozone, and possibly in PM, air pollution will happen on a relatively

long time frame, approximately over decades. During this same time period, increasing numbers of
motor vehicles are anticipated to be used in the major cities of the developing world, adding to the
potential for ozone production to increase. On the other hand, as petroleum supplies lessen and fuel
prices increase, the growth of motor vehicle use may be slowed, and efforts at conservation may
reduce emissions as well.

Ozone and PM are monitored routinely in an increasing number of cities; consequently, data

should be available on trends of these pollutants in the world’s major cities. Time–trend analysis
will probably be insufficiently sensitive for the identification of the specific contribution of climate
change, given the numerous determinants of concentrations of urban air pollution. On the other
hand, air quality management strategies will be directed at limiting the emissions of ozone
precursors and controlling primary particle emissions and contributors to secondary particle
formation. Strategies directed at the control of greenhouse gas emissions will also reduce ambient
air pollution (Davis and Working Group on Public Health and Fossil‐Fuel Combustion 1997). To
date in the United States and many countries of Europe, levels of the major urban and regional air
pollutants have dropped, showing that air quality management strategies can be effective (U.S.
Environmental Protection Agency n.d. [a]; World Health Organization 2006). Over the short term,
these same strategies should be effective in controlling air pollution concentrations. Longer‐run
predictions are made difficult by uncertainty around possibly rising power plant emissions

—

warming leads to the need for greater capacity for electricity for cooling

—

and because of potential

changes in the powering of motor vehicles.

Context

Numerous systems are in place to protect the public against threats to health, including

those threats predicted to take place consequent to climate change. The systems vary in levels of
organization—from local to global—and in their capacity, competence, and effectiveness (White
and Nanan 2008). These systems will represent the starting point in any effort to track and control
the health consequences of climate change. The occurrence of health outcomes potentially affected
by climate change reflects the intersection of multiple factors (Figure 6; IPCC 2007). These factors
are operative across multiple levels of societal organization, indicating that adaptation to the health

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consequences of climate change will necessarily engage agencies and institutions that extend from
the local to the global level.

Figure 6. Schematic Diagram of Pathways by Which Climate Change Affects Health, and Concurrent

Direct‐Acting and Modifying (Conditioning) Influences of Environmental, Social, and

Health System Factors

Source: IPCC 2007.

International health agencies, key to global approaches, have been classified as multilateral,

bilateral, nongovernmental, and other. The lead, multilateral organization for health is the World
Health Organization. Its reach is global, coordinated from its headquarters in Geneva to regional
and national offices; it maintains a variety of surveillance systems and responds to major acute and
chronic threats to health. There are many instances of collaboration between nations on matters of
health, often through a pairing of more developed and less developed countries. Nongovernmental
organizations are playing an increasing role in global public health, both by providing substantial
resources for disease control and through program implementation. In the specific example of
climate change, they may also motivate action, toward both mitigation and adaptation.

Examples already cited have challenged this global system to respond to far‐reaching public

health threats. There have been successes, and the example of smallpox eradication remains a

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model. SARS has been contained, and surveillance in China should identify further cases. Problems
with surveillance for avian influenza were identified and steps were taken to address them.

For public health problems on a longer time frame, reflecting global causes, responses have

been slower and less organized at the global level. In the example of cigarette smoking, an
extraordinarily potent cause of chronic diseases and death, unified action was not taken at the
global level until 50 years after firm evidence on smoking and lung cancer was published.
Researchers and tobacco control professionals had established networks, but the needed
institutional response at the global level was delayed, even though the root cause of the epidemic
was the multinational tobacco companies. The World Health Organization’s Tobacco Free Initiative
was established at the end of the 20th century, 100 years after smoking became widespread among
men in many countries. Now a global treaty, the Framework Convention on Tobacco Control,
addresses the root cause of the epidemic. Global tobacco control initiatives have been launched, and
surveillance systems are coming into place to address smoking among children and adults.

Conclusions

Much has been written on adaptation to climate change; books and reviews address not only

the means of adaptation but the policy context (Fussel 2007). The European Union funded the
Climate Change Adaptation Strategies for Human Health project to systematically assess adaptation
strategies for Europe (Menne and Ebi 2006). This extensive project charted the potential threats of
climate change to human health in Europe and addressed policy implications and the potential for
adaptation to mitigate these consequences. It is comprehensive in its coverage of the topic, but
evidence for the utility of this effort will be forthcoming only as the extent of its use by
decisionmakers plays out. The term climate change adaptation science has been used, implying a
formalism and the emergence of evidence‐based approaches (Fussel et al. 2006).

The methods for addressing the health consequences of climate change, as evident in this

review, are those of public health and disease control generally. A unique aspect of the health
consequences of climate change is that climate change is an extremely “upstream” driver (Figure 6).
The consequences of climate change for health range from being quite specific (e.g., heat waves), to
general (e.g., increased exposure to air pollution), and from being acute in nature (e.g., infectious
disease outbreaks), to longer‐term (e.g., changes in allergic diseases associated with shifts in
aeroallergens). For some of the health consequences of climate change

—

such as emerging

infections and heat waves

—

adaptation will take place through the routine functioning of effective

public health systems, if in place. Some, such as allergic diseases, will be managed through routine
medical care, and others, including increased emissions of air pollution, will be addressed through
regulatory mechanisms.

Across the public health community, views vary on the urgency of addressing the public health

consequences of climate change. All concur with the need for primary prevention

—

that is, slowing

climate change as quickly as possible. Some propose that the health sector needs to become more
proactively engaged in pushing for solutions and advancing strategies for adaptation (Haines and
Patz 2004; Menne and Bertollini 2005; Frumkin and McMichael 2008; McMichael et al. 2008). A

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recent issue of the American Journal of Preventive Medicine covers the medical dimensions of
climate change and sets out strategies for attempting to mitigate them. In introducing the issue,
Frumkin and McMichael (2008) comment on the need for a reorientation of public health
approaches to reflect the long time frame for action and the need for “systems thinking,” along with
“effective framing and communication” and proactive leadership.

Although the time frame over which climate change is anticipated to affect health is long, in fact

far longer than the time domains on which public health planning usually takes place, some steps
should be taken immediately. One such immediate step is to assess capacity and begin to address
gaps (Ebi 2009). A variety of stakeholders are involved, as described by Ebi (2009), and these
should be surveyed. Other actions should also be taken without delay. For example, places at risk
for heat events should have warning systems in place, along with programs to reduce the
consequences of thermal stress.

Will the health consequences of climate change be a useful lever for enhancing public health

data systems and capacity and for engaging health professionals in mitigating the health
consequences? At the national level, the projected risks of climate change may motivate the
enhancement of data systems and improved preparedness for addressing possibly more frequent
and more severe disastrous weather events. On the other hand, at more local levels, the threat of
climate change may appear remote, viewed in the context of pressing, local issues.

The recognition and quantification of the health consequences of climate change will be

difficult, given their lack of specificity. Risk assessment methods, including burden of disease
estimation, will remain central as a tool for estimating the need for the implementation of adaptive
strategies and for quantifying their benefits. Tracking the benefits of adaptation for the purpose of
accountability will probably prove difficult, given the multiplicity of factors affecting the health
outcomes of concern (Health Effects Institute 2003). At the national level, the government should
ensure the clear designation of the locus within the federal government that will track the health
consequences of climate change and assess the extent to which adaptation strategies are in place as
well as their effectiveness. Absent this monitoring function, there will inevitably be uncertainty as
to whether the right steps have been taken and whether they have worked.

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