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The Survival of "Global Health" - Part Six: The Climate Connection

Posted on by Laurie Garrett

From monster cyclones in the Indian Ocean to droughts across the Indian continent and glacial disappearances in the Andes the world is transforming. The Global Health community need not debate the relative onus fossil fuel burning carries for this, but it is necessary to acknowledge that dramatic climate change is unfolding, and human beings, and the livestock and crops upon which they depend, are dying.

Masked against pollution in Beijing this January.

Masked against pollution in Beijing this January.

Unfortunately, global health leadership and the academic public health community either make no note of climate change beyond rhetoric, or cite the issue as reason to enhance funding for specific health programs.

In the documents prepared for this week’s 66th World Health Assembly in Geneva only two mentions of climate change can be found. In a paragraph regarding the “transformation of relative power of the State” the issue “climate change” is listed as one of several that cannot be resolved without public/private collaboration. And in a section addressing sustainable development it is noted that, “Addressing the relationship between health, climate change and other major environmental factors such as air pollution will be of growing importance in coming years.”

But a host of crises related to Global Health present themselves as the planet’s CO2 levels rise. The Global Health community’s key focus in climate debates has been on the likely impact rising temperatures and rainfall will have/are having on vector populations, particularly mosquitoes. Of all likely outcomes of a 2 degree Celsius mean rise in global temperatures the health corollary that has received the most rigorous attention in public health circles is malaria. For about a decade public health experts have warned that planetary warming would allow disease-carrying mosquitoes to thrive at higher altitudes, and increases in flood and monsoon activities would enhance breeding opportunities for the insects. Both assertions have proven correct, and the phenomena are now unfolding. For example, Madagascar in 2012 experienced record numbers of malaria illnesses and deaths amid changing climate conditions. And an East African survey has demonstrated vast increases in mosquito terrain due to warming in mountainous regions. Recent discovery of malaria in Alaskan birds has startled the research community. The resurgence of malaria to southern Europe, decades after its eradication from the region, has also spawned concern.

The combination of austerity-imposed cuts in mosquito control programs in Greece and shifting climate have ushered the return of malaria to that country, decades after is eradication. Dengue Fever, a mosquito-carried viral disease that can present in deadly hemorrhagic form, has emerged in Portugal for the first time in nearly a century, and can be found in many locations worldwide where it either has never previously been seen, or has reemerged after a long hiatus.

Cholera vibrio is carried by a number of microscopic sea creatures such as copepods, which thrive in organically contaminated warm waters. As sea levels rise, and mean temperatures go up, cholera and other dysentery-causing microbial diseases are emerging in temperate regions, and the seasonality of the disease is extending into once-colder months of the year.

Many scientific agencies around the world have made long lists of microbial diseases that they believe are likely to surge in new locations or with different seasonality as the world warms. Some of these lists have been published by the World Health Organization, the U.S. CDC, and national health agencies. Such lists are useful in a general sense, but not specifically, as the complexities of climate change are so great that no particular locale can be predicted to have more rain, more snow, less water or any other narrow trend relevant to range and behavior of disease vectors.

Already proving to be of far greater consequence are climate-associated violent storm events and heat waves.

In 2012 global warming trends followed the high side of prior projections, hastening the pace of ice melting and atmospheric effects well beyond UN projections. Many scientists now predict that the Arctic will be free of ice in summer months, perhaps before 2016. As ice melts from the Arctic and glacial regions of the world the albedo refractive effect, bouncing heat off the planet and into the atmosphere, is reduced, and acidic fresh water pours into the saline oceans. The pH interaction, temperature mixing of water systems, and escalating water precipitation have a combined, but poorly understood, impact on promotion of violent weather events, as well as sea level rise. The summer of 2012 saw record melt of Arctic ice systems, exceeding the ice disappearance rates forecast by the United Nations.

All over the world glacial systems were stressed and melting rapidly, with direct impact on river systems. Amid shifting weather patterns and rising atmospheric temperatures droughts hit most of North America and the Indian Subcontinent in 2012, and violent storms were recorded in many regions. There is increasing evidence linking sea warming with hurricane activity in the Atlantic region. Insurance companies are no longer waiting for more scientific evidence: The link between climate change and violent weather is, from their corporate perspective, a done deal.

In late October 2012 Hurricane Sandy swept through the Caribbean and Atlantic, at its peak covering more than 1,000 miles of the North American coastline, making it the largest storm system in recorded history. More than 250 people lost their lives during the storm, which caused more than $65 billion in immediate damage. The longer term economic toll of Sandy, including reconstruction of power grids, infrastructure and homes, has not yet been fully tallied.

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Hurricane Sandy demonstrated that rising sea levels and climate change hold dire implications for coastal cities and for national security. Though there is considerable debate among modelers regarding Hurricane Sandy and the role climate change played in its generation, most of the argument is about relative contributions of various facets of CO2-induced planetary change, not whether or not climate change is playing a role at all. There is strong evidence that the storm was fueled by 2012 record warming of Atlantic sea surfaces. Climate modelers felt sadly vindicated when damage from Sandy – particularly the extent of storm surge and flooding – followed almost perfectly a 2007 forecast. Following Sandy the New York Times asked, “Is This The End?”

CO2 levels are rising far more sharply than forecast, and hit record heights in 2012. A World Bank report released in 2012 predicts a 4 degree Celsius global temperature rise would displace hundreds of millions of coastal residents and severely damage food supplies. Even a less gloomy temperature forecast, imagining merely a 1.5 degree rise, would force coastal displacement of some 6 million Americans, alone. Adaptation to climate change in North America will require spectacular infrastructure spending. For much of the world, especially the Pacific Islands nations, the only adaptive response may be migration, abandoning countries all together. The costs of adaption are already being felt, largely in emergency responses. The World Bank estimates the annual toll is $1.2 trillion – a number derived before Hurricane Sandy slammed the eastern seaboard of North America.

Hospital and emergency resilience after 2005 Hurricane Katrina, Sandy and other severe weather events shows few medical facilities are prepared to withstand prolonged flooding, loss of electrical power, or large scale surges in trauma patient numbers. WHO warns that health systems will be taxed all over the world by climate-induced storms, rich and poor alike. World Bank President Jim Kim announced willingness in 2012 to entertain proposals linking adaptation to climate change with global health issues and HIV programs.

Rising sea levels, violent storms and catastrophes constitute the most obvious challenges to health systems, particularly in poor countries with vast sea level populations, such as Bangladesh. But an equally devastating impact on human health may come from heat, itself.

Shifting heat and salinity patterns are altering the marine ecology that directly impacts fisheries, and the food Pacific Island nations, Japan and many Indian and South China Sea populations rely upon. Shifting salinity is directly affecting drinking water, and therefore human health and agriculture, in much of the world. The ocean ecologies are changing so rapidly and dramatically that scientists cannot parse the relative weight of the causes: Over-fishing, pollution and waste dumping, changes in salinity/acidity, temperature shifts, churning storms and a long list of other complex contributors. From a human health perspective the issue is less causality than the absolute loss of sea-derived food, coupled with the sewer-like ecology of many coastal waters, in which a range of microbes may thrive.

Heat, coupled with drought, may constitute a “new normal” across much of the Indian Subcontinent. Monsoons have come later annually, temperatures have risen, and extreme drought has shattered agricultural production in parts of India, Pakistan and Bangladesh.

For human beings the insidious effect of heat, per se on the body may be the most under-appreciated cause of elevated deaths associated with climate change. In 2012 the U.S. space agency NASA showed that the world has experienced a steady increase since 1951 in the volume and severity of severe heat events with temperatures sustained at levels that are above safe tolerance for human beings. While temperatures vary on a classic bell-shaped curve, NASA found that the median of that curve has shifted toward higher extremes every year. The heat is tolerable with air conditioning, but the cooling systems devour fossil fuels, contributing still more to the planetary CO2 burden.

Air conditioning is not an option for most of the planet’s poor and elderly. In 2003, when Europe experienced a record-breaking sustained heat wave, France lost more than 11,000 people to heat stroke, most of them elderly individuals abandoned to their fates by vacationing younger family members. The episode was a source of shame for France.

In 1995 a 50-day heat wave killed 692 people in Chicago, mostly poor, African-American and/or elderly. A third of the New Orleans deaths during and after Hurricane Katrina were due to heat stroke, disproportionately experienced by elderly individuals.

A recent Harvard School of Public Health study found that elderly individuals that have underlying chronic ailments are the most likely to perish under high heat conditions. Through analysis of Medicare records the Harvard group found a direct correlation between a 1 degree Celsius increase in temperature and a 2.8 to 4.0 percent greater risk of mortality, varying according to the individual’s underlying medical condition. Overall, the researchers concluded that for every degree increase in the average peak summer heat in the U.S., 10,000 senior citizens will perish. In a sense their work offers a dose/response curve between climate change and one type of human mortality.

The Global health community has not responded to the challenge of climate change in a meaningful manner. Beyond explicative work, health advocates and their multilateral agencies have steered clear of climate debates, spent little financial or intellectual capital in confronting the problem, and provided virtually no concrete agenda for health system and population adaptation to severe weather, heat or other likely outcomes of rising CO2 levels.

What good is a spanking new hospital and clinic infrastructure today if its basement is below sea level? How much capital will be wasted erecting medical services that will be inundated in a cyclone or hurricane, or be unable to provide services for days or weeks due to power failures? State or private provision of “health” is about a great deal more than medicines, doctors and buildings.

I have been chewed out over the years by leading health advocates for raising the climate change specter. Typically I am accused of being alarmist, or of pushing global health into areas of scientific uncertainty. There is a desire to keep health away from squabble over fossil fuels, energy and CO2.

It reminds me of the late 1980s. The Global Program on AIDS team inside the WHO – before the then-Director General eliminated HIV/AIDS programs – issued a forecast on the AIDS pandemic. Later folded into a large book, AIDS in the World, by Jonathan Mann et al, the prediction imagined a world in which millions of people, in all sorts of societies, would waste away and perish from the new virus. It spoke of “millions” when the official case counts for HIV patients were still reported in the thousands. It compared HIV to the Black Death. It predicted that all over the world the most marginalized, least socially accepted populations would be devastated by the new disease. A Summit was called in London, attended by most of the nations’ ministers of health, in which broad declarations of concern and urgency were issued.

And to the shock and dismay of the organizers, especially Mann, the world either turned a deaf ear to the shocking forecasts, or condemned them as exaggerated claims, aimed at garnering financial resources. Among the loudest cries of disdain came from advocates of other health priorities, dismissing the looming AIDS threat, condemning it as a “Western” disease or “homosexual” ailment, and insisting that directing significant resources to HIV would hurt other, more important health causes.

Bonus Blog Post Tomorrow: Patents and Potential Pandemics

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