Carbon Pollution Increases Health Inequities: Lessons in Resilience from the Most Vulnerable

Pan American Journal Review of Public Health

Carbon pollution increases health inequities: lessons in resilience from the most vulnerable

Kristie L. Ebi,1 Stephen B. Fawcett,2 Jerry Spiegel,3 and Horacio Tovalin4

Suggested citation Ebi KL, Fawcett SB, Spiegel J, Tovalin H. Carbon pollution increases health inequities: lessons in resilience from the most vulnerable. Rev Panam Salud Publica. 2016;40(3):181–85.

ABSTRACT Climate change is a social justice as well as an environmental issue. The magnitude and pattern of changes in weather and climate variables are creating differential exposures, vulnerabilities, and health risks that increase stress on health systems while exacerbating existing and creating new health inequities. Examples from national and local health adaptation projects highlight that developing partnerships across sectors and levels are critical for building climate-resilient health systems and communities. Strengthening current and implementing new health interventions, such as using environmental information to develop early warning systems, can be effective in protecting the most vulnerable. However, not all projected risks of climate change can be avoided by climate policies and programs, so health system strengthening is also critical. Applying a health inequity lens can reduce current vulnerabilities while building resilience to longer-term climate change. Taking inequities into account is critical if societies are to effectively prepare for and manage the challenges ahead.

Keywords Climate change; global warming; environmental risks; health vulnerability; disaster vulnerability; environmental exposure; United Nations Environment Programme.

Health inequities arise from a range of outcomes among those groups with lim- complex environmental problems, such environmental and socioeconomic factors, ited power and resources to avoid them as pesticides and sulfur compounds, that not from inevitable forces independent (1). These inequities are rooted in social are typically more short-lived than carbon of human control. That is, there are signifi- relationships and processes that suggest dioxide, and that were relatively easily cant and preventable differences in health opportunities to respond at different and successfully controlled (4). These ne- scales (2). Climate change is affecting hu- gotiations eventually led to the 1992 man and natural systems in ways that ex- adoption of the United Nations Frame- 1 Department of Global Health, University of Washington, Seattle, Washington, United States of acerbate existing and will likely create work Convention on Climate Change America. Send correspondence to Kristie Ebi, new health inequities (3). (UNFCCC), whose stated ultimate objec- email: [email protected] In the 1970s, national and international tive was the “stabilization of greenhouse 2 World Health Organization (WHO) Center/Work Group for Community Health and Development, organizations began to seriously consider gas concentrations in the atmosphere at a University of Kansas, Lawrence, Kansas, United the possible consequences of increased at- level that would prevent dangerous an- States of America. 3 Global Health Research Program, School of mospheric concentrations of greenhouse thropogenic interference with the climate Population and Public Health, University of British gases, particularly carbon dioxide, due to system” (5). Columbia, Vancouver, British Columbia, Canada. human activity. Subsequent negotiations In the 20+ years since, the possible con- 4 Occupational Health Graduate Program, FES Zaragoza, Universidad Nacional Autónoma de to reduce greenhouse gas emissions were sequences of climate change for human México, Ciudad de México, México. informed by earlier experiences with less and natural systems have become better

Rev Panam Salud Publica 40(3), 2016 181 Review Ebi et al. • Carbon pollution and health inequities understood, leading to a risk-based frame- CLIMATE CHANGE AS A SOCIAL and may be more vulnerable to the asso- work for managing the challenges ahead. JUSTICE ISSUE ciated consequences. As detailed in the assessments conducted At any particular concentration of by the Intergovernmental Panel on Cli- Climate change is intimately inter- atmospheric carbon dioxide, some re- mate Change and in national assessments, twined with equity, social justice, and sus- gions and sectors will experience signifi- changing temperatures and precipitation tainable development, especially evident cant risks that they perceive to be patterns associated with climate change at the macro level by the striking mis- unacceptable, while others will experi- are already causing adverse impacts on match between countries that historically ence little to no impacts (13). In general, human health and well-being, with risks and currently emit the most greenhouse wealthier countries that historically emit- projected to markedly increase during this gases and those that are particularly vul- ted more greenhouse gases are less vul- century (3, 6–8). The magnitude and pat- nerable to the consequences of climate nerable because they will have the tern of possible health risks associated change. Understanding this leads to a capabilities—financial resources, gover- with climate change depend not only on complex and nuanced perspective of so- nance, and other factors—to implement global average temperatures, but also on cial justice. proactive adaptation. Thus, addressing the status of the human and natural sys- Negotiations under the UNFCCC aim climate change is a matter of social tems being affected, their degree of under- to reduce atmospheric concentrations of justice. lying vulnerability, and their capacity to greenhouse gas emissions to prevent prepare for, respond to, cope with, and re- dangerous anthropogenic interference REDUCING VULNERABIILITY cover from exposure (9). That is, climate with the climate system by reducing at- TO CLIMATE CHANGE interacts with other environmental and mospheric concentrations of greenhouse socioeconomic drivers to increase (or de- gas emissions. The criteria for determin- Vulnerability in the context of climate crease) risk, affecting risk through multi- ing what was considered to be dangerous change is defined as the propensity or ple pathways that vary across spatial and were: allowing time for ecosystems to predisposition to be adversely affected temporal scales. Three entry points for adapt naturally; ensuring food produc- (9). Vulnerability is the summation of all preparing for and responding to the chal- tion is not threatened; and enabling eco- risk and protective factors that determine lenge of climate change and its health and nomic development in a sustainable whether an individual or subpopulation health equity impacts are: matter (5). These criteria are challenging is more likely to experience adverse to operationalize because they are not health outcomes (14). Factors determin- 1. Differential exposures to the hazards cre- easily quantified. Furthermore, the UN- ing vulnerability and resilience in a par- ated by a changing climate (e.g., ex- FCCC does not specify whether these cri- ticular location typically do not align in treme weather and climate events; teria should be considered on the global, one direction; each community and na- reductions in air quality; ecosystem regional, or national scales. And, while tion has a mix of factors that increase or changes that could facilitate water-, these criteria are important, other possi- decrease each. Reducing vulnerability food-, and vector-borne diseases chang- ble risks of climate change could have and increasing resilience are complemen- ing their incidence, geographic range, large-scale consequences; for example, tary strategies that enhance the capability and/or seasonality; and lower nutri- the availability of sufficient quantities of of a community to prepare for and cope tional quality and quantity of food); safe water in some areas; the impact of with climate variability and change. 2. Differential vulnerabilities/capabilities in changing patterns of extreme weather There is a wide range of factors that de- avoiding or protecting against harms and climate events; changes in the geo- termine vulnerability, from the geo- from exposure (e.g., a wide range of in- graphic range and incidence of climate- graphic, environmental, and demographic dividual and local to national factors sensitive health outcomes; sea level rise; situation of a country or region to its edu- from individual susceptibility, socio- and acidification of the oceans. cational, social, cultural, political, socioeconomic status, and housing condi- Climate change will result in some economic, institutional, and governmental tions to the capacity of health systems, countries experiencing much greater in- circumstances. In the health sector, addi- local to regional emergency response creases in temperatures and larger shifts tional factors determining vulnerability systems, and governance); and in precipitation patterns (11). The UN- include the health status of the popula- 3. Differential consequences related to FCCC recognizes certain regions are tion, and the quality, responsiveness, and geographic location, unequal access more vulnerable to climate change, in- availability of public health facilities and to resources, and other factors (e.g., cluding least developed countries, small other infrastructure (e.g., capacity to pre- higher deaths among marginalized island states, and areas with fragile eco- pare for and manage the consequences of groups with limited access to health systems. Just 20 countries are responsible changing weather patterns, laboratories) services) (10). for approximately 80% of annual green- (3). Because factors that increase vulnera- The objectives of this paper were to house gas emissions; with China, the bility often act on the local scale, social outline why climate change is a social European Union, India, the Russian Fed- participation is an important factor in justice issue; summarize and illustrate eration, and the United States being the building resilience. how reducing exposures and vulnerabil- largest emitters in 2013 (12). However, There is an abundance of literature on ity to climate change can address health these are not necessarily the countries the particular factors that increase health inequities; discuss examples of reducing that are and will experience the largest vulnerability to changing weather pat- vulnerabilities to climate change while shifts in weather patterns. The Arctic and terns. Individuals with higher levels of addressing inequities; and highlight that parts of Africa, Asia, and Latin America susceptibility and reduced ability to some inequities cannot be eliminated. are warming faster than most land areas, prepare for/cope with climate-related

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exposures include pregnant women, those REDUCING HEALTH equal opportunity and resources for pre- with chronic medical conditions, mem- VULNERABILITY TO ADDRESS paredness. Although there has not been bers of an under-represented or disadvan- INEQUITIES sufficient time since the completion of taged group, or those with impaired these projects to measure the extent to mobility and/or cognitive constraints Enhancing resilience, in part by re- which resilience was increased, there are (14). Geographic factors also are impor- ducing vulnerabilities, means increas- early indications of increased awareness tant, with those living in environmentally ing the capacity of nations, communities, and capacity, and specific interventions degraded areas and/or unplanned settle- and systems to cope with changing to address the health risks of climate ments often experiencing higher vulnera- weather patterns by responding to or re- change, suggesting improvements over bility because mechanisms for social organizing in ways that maintain their the baselines. protection are limited. Social and environ- essential function, identity, and struc- mental factors often interact, leading to ture, while also maintaining the capac- Country examples increased exposures, vulnerability, and ity to adapt, learn, and transform (9). adverse consequences in communities WHO defines a climate resilient health Because it appears that the geographic consisting largely of racial and ethnic mi- system as one that is “capable to antici- ranges of malaria and dengue fever are norities and people of low socioeconomic pate, respond to, cope with, recover changing, at least partially in response to status (15). from and adapt to climate-related shocks warmer temperatures, the Ministry of Among the most effective policies and stress, so as to bring sustained im- Health of the Royal Government of Bhu- and measures to reduce vulnerability provements in population health, de- tan developed collaborations with the and enhance capability in the near term spite an unstable climate” (16). national Hydro-Meteorological Service are those that improve basic public The number of vulnerable communi- to initiate an early warning system for health infrastructure, such as providing ties and areas that have used ingenuity, environmental conditions associated safe water and improved sanitation, en- resources, and capacity to increase re- with infectious disease outbreaks (20). At suring access to essential health care, silience and reduce inequities is grow- the beginning of the 3-year project, vil- increasing the effectiveness of disaster ing. Identifying, supporting, and lage health workers were aware of risk management, increasing social cap- learning from these examples can help changing weather patterns, even if un- ital, and alleviating poverty (3, 16). Ad- make more efficient use of scare re- aware of anthropogenic climate change. dressing health inequities is central to sources for managing climate change. Training of district health managers, ba- these activities. An example of how oc- One example for learning about build- sic health units, and village health work- cupational health policies can influence ing the resilience of health systems is ers resulted in very high awareness of health inequities comes from Mexico, the first 5 years of implementation changing weather and disease patterns; where 65%–70% of the population lives (2008–2013) of multinational health ad- of how climate change can exacerbate or in poverty (17). In this country, the aptation projects in Albania, Barbados, ameliorate current health burdens; and wealthiest 10% of the population has 37 Bhutan, China, Fiji, Jordan, Kazakh- of what interventions can reduce addi- times the income of the poorest 10%. stan, Kenya, Kyrgyzstan, Philippines, tional health burdens. A national inte- Annual work-related incidents in the Russian Federation, Tajikistan, and grated database will be developed to formal sector, approximately 35% of the Uzbekistan (20). include climate-related data that will working population, average approxi- Seven countries were included in the facilitate an understanding of the magni- mately 600 000 accidents, 6 000 illnesses, WHO/United Nations Development tude and pattern of climate-sensitive and more than 1 100 deaths (18). The Programme (UNDP) Global Environ- health outcomes. This understanding informal sector is much larger and com- ment Facility (GEF)-funded project, “Pi- will be used to reduce health inequities prises formal-sector workers without loting climate change adaptation to by focusing on the needs of the most benefits or health coverage and all infor- protect human health” (20). The project vulnerable. mal-sector workers including those in was designed to build capacity and pro- Given the increase in the frequency, small enterprises and family work- vide lessons, globally and nationally, in intensity, and duration of some extreme shops; no information about work-re- the design, implementation, monitor- events, and the significant (and prevent- lated incidents in this sector is available. ing, and evaluation of health adaptation able) associated health impacts, China, There is no government program that policies and measures. Its overall objec- Kazakhstan, Tajikistan, and the former offers social protection for informal tive was to increase the adaptive capac- Yugoslav Republic of Macedonia de- workers by, for example, minimizing ity of national health system institutions, signed and implemented heatwave workplace exposures and ensuring ac- including field practitioners, to prepare early warning and response systems. cess to healthy working conditions and for the health risks of climate variability The aim was to guide the issuance of health services. Furthermore, informal and change. warnings, particularly for the most vul- outdoor workers have higher exposures Most of these countries developed nerable, and outline response plans to to weather and related factors. In Mex- early warning systems to reduce health facilitate timely coordination of re- ico City, there are at least 60 000 individ- inequities by taking into account the sources and strategies in response to uals who work outdoors for long hours, needs of the most vulnerable, including heatwaves. In China, the system was with increased exposure to air pollut- addressing educational needs, designing developed with community collabora- ants (19) and heatwaves, which can in- messaging to be readily understood, tion to ensure effective messaging and crease cardiovascular events and heat strengthening surveillance programs to appropriate responses when a warning stroke. detect disease outbreaks, and ensuring is issued.

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In Indonesia, a special climate change emissions, improve air quality, enhance determinants of health, is increasing task force initiated countrywide efforts physical access to hospitals, improve stress on health systems, while exacer- on adaptation and mitigation with in- access to safe water, and improve safety bating existing and creating new health tersectoral actions among ministries, fa- conditions. inequalities. As such, climate change is a cilitating interactions and coordination humanitarian and social justice issue as at the national and local levels. An ex- SOME INEQUITIES CANNOT BE much as an environmental issue. Using a ample is the training kit for “Participa- ELIMINATED health inequity lens can increase the ef- tory Adaptation Climate Change fectiveness of interventions to address Transformation for Dengue Fever and Not all risks can be adapted to; for ex- the wide range of social and environ- Malaria” (PACCT for Dengue Fever and ample, melting permafrost, increased mental factors underlying vulnerability Malaria). This kit is being used to raise storm surges, and other climate-change to climate change. awareness and to support the work of associated risks are threatening the exis- Because no health policy or program communities in developing their own tence of villages in Alaska. In Newtok, was developed taking climate change into action plans for managing the risks, tak- Alaska, coastal erosion associated with account, there is much work to be done. ing into account the needs of the most permafrost melt resulted in inundation of There also are many opportunities to use vulnerable. the dumpsite in use in 1996, with the pos- efforts to prepare for and manage the Ecuadorian researchers, in collaboration sibility of releasing its contaminants into health risks of climate change to reduce with colleagues from Canada, are using a the environment (22). Given the current health inequities. Examples from national systems approach to investigate the sus- and projected amount of permafrost melt, and local health adaptation projects high- tainability and resilience of how food is with the associated loss of infrastructure, light that partnering with communities is produced and the wider set of pathways the village needs to be moved. Moving a important for building resilience because that can affect health equity. The project, village is challenging; doing so requires factors increasing vulnerability often act at “Food systems and health equity in an era approval of multiple federal and state local scales. Using environmental informa- of globalization: Think, eat and grow green agencies over and above the expressed in- tion to develop early warning systems can globally” has observed that “sovereignty” terest of the affected population. It is es- be effective in protecting particularly vul- is of much greater interest in the Spanish pecially challenging for small villages nerable individuals and communities from literature than in the English (21). Action that do not have the required expertise to climate-sensitive health outcomes. Because research projects underway in partnership comprehensively manage the application not all projected risks of climate change with local communities include examining processes, including resolving contradic- can be avoided, health system strengthen- the feasibility and benefits of linking local tions in requirements between agencies, ing is also critical for managing the risks. agro-ecological producers with institu- while assessing equitable options. More- Climate resilience needs to be proac- tional purchasing opportunities (e.g., over, the loss of social and cultural institu- tively built into health system strengthen- schools, public programs); and exploring tions can have psychosocial repercussions ing and should focus on the needs of the ways that greater sovereignty can be as- that reduce the community’s capacity to most vulnerable. This means explicitly in- serted by indigenous communities in set- manage changing conditions. corporating climate and sustainable devel- tings where growing/gathering of food Similar challenges are being observed opment when improving surveillance retains especially strong cultural meaning. in a range of contexts. For example, in systems, developing actions plans, ensur- In the Caribbean, several countries are small island nations, infrastructure such ing sufficient human and financial re- promoting a smart initiative to develop as roads, schools, and health care facili- sources, training and capacity building, resilient, climate-adapted, and more sus- ties is increasingly at risk due to rising and monitoring and evaluating progress. tainable health care facilities through the sea levels and increases in the magnitude Taking inequities into account is critical if application of interventions aimed at re- of storm surges. In countries experienc- societies are to effectively anticipate, pre- ducing vulnerabilities (personal commu- ing frequent extreme heatwaves, the pare for, and manage the challenges ahead. nication, David Latchman, Ministry of health impacts of thermal extremes affect Health, Wellness, and the Environment, worker productivity, as well as mortality Conflict of interests: None declared. St. Vincent and the Grenadines). The ini- and morbidity. tiative promotes public health strategies Disclaimer. Authors hold sole respon- to address climate change and reduce DISCUSSION sibility for the views expressed in the fossil fuel use. These activities would manuscript, which may not necessarily realize cost savings on health care and Climate change, interacting with the reflect the opinion or policy of the RPSP/ utility bills, reduce greenhouse gas wider environmental and social PAJPH and/or PAHO.

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RESUMEN El cambio climático es un asunto no solo ambiental, sino también de justicia social. La magnitud y naturaleza de los cambios observados en las variables de tiempo meteo- rológico y clima están llevando a exposiciones, vulnerabilidades y riesgos de salud La contaminación por diferenciales que incrementan la sobrecarga de los sistemas de salud y exacerban las carbono empeora las inequidades sanitarias existentes, a la vez que generan nuevas inequidades. Los inequidades sanitarias: proyectos nacionales y locales de adaptación al cambio climático para proteger la salud humana ponen de manifiesto que la creación de alianzas entre diferentes sec- enseñanzas de los más tores y en distintos niveles es fundamental para lograr que haya sistemas de salud y vulnerables sobre la comunidades capaces de recuperarse de los efectos del clima. El fortalecimiento de las capacidad de recuperación intervenciones de salud en curso y la aplicación de nuevas intervenciones, tales como el uso de información de tipo ambiental para crear sistemas de alerta temprana, pueden ser eficaces para proteger a los grupos más vulnerables. Sin embargo, no todos los riesgos previstos en relación con el cambio climático pueden evitarse por medio de políticas y programas climáticos, de manera que el fortalecimiento de los sistemas de salud también es fundamental. La aplicación de una óptica de inequidad sanitaria puede reducir las vulnerabilidades actuales y al mismo tiempo crear capacidad de recuperación frente a los efectos del cambio climático a más largo plazo. Si las sociedades han de prepararse para los retos que se avecinan y hacerles frente de una manera eficaz, es imprescindible que se tengan en cuenta las inequidades.

Palabras clave Cambio climático; calentamiento global; riesgos ambientales; vulnerabilidad en salud; vulnerabilidad ante desastres; exposición a riesgos ambientales; Programa de las Naciones Unidas para el Medio Ambiente.

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