Climate Change and Health: Transcending Silos to Find Solutions

Annals of Global Health VOL. 81, NO. 3, 2015

ª 2015 The Authors. Published by Elsevier Inc. ISSN 2214-9996 on behalf of Icahn School of Medicine at Mount Sinai http://dx.doi.org/10.1016/j.aogh.2015.08.002

VIEWPOINT Climate Change and Health: Transcending Silos to Find Solutions

Catherine Machalaba, MPH, Cristina Romanelli, MSc, MA, Peter Stoett, PhD, Sarah E. Baum, Timothy A. Bouley, MD, Peter Daszak, PhD, William B. Karesh, DVM New York, NY; Montreal, Canada; and Washington, DC

Abstract BACKGROUND Climate change has myriad implications for the health of humans, our ecosystems, and the ecological processes that sustain them. Projections of rising greenhouse gas emissions suggest increasing direct and indirect burden of infectious and noninfectious disease, effects on food and water security, and other societal disruptions. As the effects of climate change cannot be isolated from social and ecological determinants of disease that will mitigate or exacerbate forecasted health outcomes, multidisciplinary collaboration is critically needed. OBJECTIVES The aim of this article was to review the links between climate change and its upstream drivers (ie, processes leading to greenhouse gas emissions) and health outcomes, and identify existing opportunities to leverage more integrated global health and climate actions to prevent, prepare for, and respond to anthropogenic pressures. METHODS We conducted a literature review of current and projected health outcomes associated with climate change, drawing on ﬁndings and our collective expertise to review opportunities for adaptation and mitigation across disciplines. FINDINGS Health outcomes related to climate change affect a wide range of stakeholders, providing ready collaborative opportunities for interventions, which can be differentiated by addressing the upstream drivers leading to climate change or the downstream effects of climate change itself. CONCLUSIONS Although health professionals are challenged with risks from climate change and its drivers, the adverse health outcomes cannot be resolved by the public health community alone. A phase change in global health is needed to move from a passive responder in partnership with other societal sectors to drive innovative alternatives. It is essential for global health to step outside of its traditional boundaries to engage with other stakeholders to develop policy and practical solutions to mitigate disease burden of climate change and its drivers; this will also yield compound beneﬁts that help address other health, environmental, and societal challenges. KEY WORDS adaptation, climate change, environmental change, global health, multidisciplinary collaboration, mitigation, prevention © 2015 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The authors declare they have no conﬂicts of interest. From the EcoHealth Alliance, New York, NY (CM, PD, WBK); Future Earth ecoHEALTH project, New York, NY (CM, PD, WBK); City University of New York School of Public Health, New York, NY (CM); Secretariat of the Convention on Biological Diversity, Montreal, Canada (CR); Loyola Sustainability Research Centre, Concordia University, Montreal, Canada (PS); Barnard College, New York, NY (SEB); World Bank Group, Washing- ton, DC (TAB). Address correspondence to W.B.K. ([email protected]). 446 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

INTRODUCTION water resources; the administration of vaccines and Over the course of the past decade, the hardening health support resources, particularly in rural locations, reality of anthropogenic climate change has demon- requires carbon-emitting transportation11; and public strated the need to understand its future effects health infrastructure, especially in developed countries, on health outcomes as well as the critical need for col- entails significant electricity usage12dall of which laboration across disciplines to find appropriate solu- increase greenhouse gas emissions and concomitantly tions that prevent, prepare, and respond to climate compound pressures on natural systems. change. As of 2000, climate change was directly Even for more linear causal linksdmortality and accountable for the loss of at least 5.5 million morbidity caused by extreme weather events and dis- disability-adjusted life years.1 The Intergovernmen- easedcomplexity reigns. The effects of climate tal Panel on Climate Change (IPCC) projected aver- change cannot be isolated from social and ecological age global temperatures will increase between 1.8C determinants of disease that will mitigate or exacer- 2 and 4C over the next century, and extreme weather bate forecasted health outcomes. Demographic fac- events and shifting patterns of disease are expected to tors, health status, culture or life condition, limited have significant effects on global disease burden, access to resources and services, and sociopolitical water and food security, and social con- conditions have been characterized as affecting vul- flictdalthough the extent and direction of these nerability to health effects of climate change.13 Geo- effects will be differentially felt.3-5 Given the com- graphically vulnerable regions, low-income plexity of social and environmental factors that influ- countries, and refugees are more likely to bear a ence disease and health outcomes, the precise degree higher burden of adverse effects. In this regard, of past and future effects on health is unclear; how- causal links may reinforce cyclical links between pov- ever, best estimates indicate that climate change erty and high health burden, whereas areas with will tip the scales of health outcomes unfavorably.6,7 higher human activity (land-use changes, urbaniza- The World Health Organization (WHO), for exam- tion, and rising populations) may motivate disease ple, estimated in the early 2000s that climate change trajectories and adverse health outcomes.4 was already accounting for 150,000 additional deaths Because of this complexity, multidisciplinary and globally (ie, deaths above the baseline) per annum. cross-sectoral collaboration will be critical to address This number has been updated such that compared health challenges related to climate change. This is with a future without climate change (for the year reflected in the literature; for example, the hundreds 2030) an additional 38,000 deaths annually are pro- of papers published relating to this topic (Web of jected due to heat exposure in elderly people, 48,000 Science search term [up to June 25, 2015] “health due to diarrhea, 60,000 due to malaria, and 95,000 AND climate change AND collaboration”) cover due to childhood undernutrition. This corresponds an expansive range of expected challenges, broad sec- to an additional 250,000 deaths per year for the years tors, and manifestations, including toxic algal 2030-2050dnot including all climate-sensitive blooms, food systems, pest control, built environ- health effects (eg, pollution, injuries, nonmalarial ment, remote-sensing technologies, health provider infectious disease, and others for which projection concerns, and environmental education. However, data is lacking).8 Direct health costs are projected emphasis has been placed primarily on vulnerabil- to increase from US$1.2 trillion to between US$2 ities, preparedness, adaptation, and resiliency. With and $4 trillion per year,8 and, when agricultural notable exceptions, the explicit reference to collabo- loss, damage due to extreme weather events, and ration aimed at outright prevention has been less decreased productivity are added, the estimated eco- prominent. nomic loss could reach 3.2% of global output.9 Collaboration is certainly pressing to address Many linear and nonlinear relationships exist both realized and near-term effects of carbon emis- between the environment and health, as anthropogenic sions and copollutants. However, less attention has activity influences health through a variety of ecosys- been given to the underlying drivers of climate tem and climate-mediated pathways. Causal pathways change to prevent, rather than only respond to, can also be reversed: societal needs related to health can health effects.14 Given that there is a critical 15- influence climate.10 For instance, health practices to 30-year window for greenhouse gas emissionsd themselves have a large carbon footprint. Nutritional with projections exceeding the “tipping point” for demands lead to land use change for agricultural stability if continued at current levels throughout expansion, increased carbon release, and pressure on that time frame, urgent action is required if we are Annals of Global Health, VOL. 81, NO. 3, 2015 Machalaba et al. 447 MayeJune 2015: 445– 458 Collaboration on Climate Change

Figure 1. Examples of the links associated with direct health impacts of climate change (black arrows) and those associated with the drivers of climate change (blue arrows). Activities taken by sectors contributing to climate change may also have other ecological impacts (eg, from human encroachment into forests). Other forces are occurring in parallel, simultaneously altering ecological and human dynamics. Global health must expand its scope to work with other sectors to find solutions that can prevent, prepare and respond to negative outcomes. NCD, noncommunicable disease. Figure adapted from reference 7. to transcend disciplinary silos to find solutions.7 burden in the region.15 Action will therefore likely Climate change is also occurring parallel to, and be most successful if it also addresses the underlying in combination with, other change pressures on contributors of global environmental change, and global health (Fig. 1), including widespread land- other major and related challenges, including loss use change, a global population expected to increase of biodiversity and infectious disease emergence.10 more than 30% by 2050,10 and globalization.15 To fully prepare for and respond to current and Such pressures often have geographic specificity; near-term challenges of climate change on health for example in Sub-Saharan Africa, increasing pop- and affected societies, a firm understanding of the ulation growth and demands on natural resources linksdand their differential effects based on differ- (including those leading to environmental degrada- ential socioeconomic conditionsdis needed.10 Fur- tion) coupled with regional exclusion from global thermore, to truly get ahead of long-term negative trade converge with climate-related agricultural pro- health outcomes, a more preventive approach will ductivity reduction and coastal flooding risks and an be neededdone that tackles upstream drivers in already disproportionately high infectious disease new and effective ways. We conducted a literature 448 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

review of pathways between climate change and killed more than 70,000 people across European health and drew on these findings and our collective countries19 and resulted in more than an estimated expertise to review opportunities for both adaptation US$14 billion in economic damages.20 (defined herein as adjustment strategies to reduce Although specific causal links between heat waves vulnerability to negative effects, also within the and morbidity have drawn less attention,21 chronic domain of preparedness and response) and mitiga- cardiovascular and respiratory conditions are pro- tion (prevention of effects) that demand genuine jected to increase, disproportionately affecting collaboration toward reducing global health risks vulnerable populations such as the elderly.22 Mor- posed by climate and other global environmental bidity exacerbated by geography, socioeconomic changes. The opportunities align with and empha- and occupational status will be especially problematic size the preventive measures of the recent recom- for already fragile economies. Projections suggest mendations put forth in the new Lancet that by the 2050s workdays lost due to heat could Commission on Climate Change report including reach 15% to 18% above the current baseline in near-term investments in research, monitoring and Southeast Asia, Central America, Oceania, and parts surveillance on climate change and health effects, of Sub-Saharan Africa, with as much as 20% of gross adopting mechanisms that facilitate intra- and domestic product in economic losses related to intergovernmental collaboration with an emphasis reduced productivity in Central America by 2080 on the extent to which additional global environ- without labor pattern adaptation.23 mental changes influence health outcomes, phasing Similarly, the total annual number of natural dis- out of coal-fired energy generation, and transition to asters doubled between 1980 and 2014,24 and of the human- and planet-healthy cities.7 245 disasters in 2009, 224 were weather-related and affected 55 million people, causing 7000 deaths and HEALTH OUTCOMES: IMPACTS AND comprising the majority (US$15 billion) of eco- DRIVERS OF CLIMATE CHANGE nomic damages attributed to natural disasters.25 Annual increases in the intensity of hydrological The outcomes of widely cited health effects related cycles worldwide will increase the frequency and to climate changed direct injury from extreme severity of flooding linked to heavy rain, cyclones, weather events, increased noncommunicable disease and rising sea levels.6 Populations in low-lying, (NCD) burden, increased burden of infectious dis- low-income regions without adequate protection eases, reduction of food and water security, and will be especially affected as a 2% to 5% increase in loss of other ecosystem services including access to the burden of diarrheal disease is anticipated to occur medicinal plantsd10,16 are likely to be both acute by 2020 due to increased heavy precipitation.26 and chronic, having significant effects on affected Although parts of the world will become wetter, communities. The wide scope of anticipated stake- other regions will become drier. The proportion of holders provides ready and necessary collaborative Earth’s surface in extreme drought could rise from opportunities for interventions, which can be differ- about 1% in 2015 to 30% by the end of this cen- entiated by addressing the upstream drivers leading tury.27 Between 1970 and 2008 in Africa alone, to climate change or the downstream effects of cli- although less than 20% of disaster occurrences mate change itself. Ideally, these will be in the form were associated with drought, they affected 80% of coordinated steps to effectively prevent climate- the continent’s population.25 Wildfires spurred by change drivers (ie, mitigation), although it will the 1997/1998 El Niño in Indonesia left 40,000 also be necessary to leverage these to prepare for hospitalized and an estimated loss of US$9.3 billion and respond to such pressures (ie, adaptation). in property, agriculture, and disrupted transport.28 Effects of Climate Change. Clear causal links between Estimated agricultural losses from the 1998-1999 climate change and human health due to the direct summer drought across the United States were on effects of extreme weather events have been widely the order of US$1.3 billion,29 and the 2015 ongoing reported.4,6,14,17 The deleterious effects of heat waves drought in California has resulted in serious eco- have already been realized over the past decade in nomic losses and spurred policy interventions. several countries,7 and they are generally projected to Extreme climate and weather have widespread increase in frequency and duration.2 The probability of implications for food, water and nutritional security, mega-heat waves, such as those experienced in Europe economic loss, and mental health. For example, if in 2003 and Russia in 2010, is estimated to increase 5- flood and droughts become more severe and fre- to 10-fold by 2050.18 The summer 2003 heat wave quent, especially in semiarid and subhumid areas, Annals of Global Health, VOL. 81, NO. 3, 2015 Machalaba et al. 449 MayeJune 2015: 445– 458 Collaboration on Climate Change

this will likely result in fluctuations in food produc- (RVF) and chikungunya virus over the past decade. tion. As much of this land is located in Sub-Saharan The largest RVF outbreak on record between 1997 Africa and part of South Asia, the poorest regions and 1998 corresponded to a strong El Niño result- with an already high level of chronic undernourish- ing in an estimated 89,000 possible human infec- ment will bear the largest burden of unstable food tions in northeastern Kenya and southern production.30 This is reflected in the IPCC Special Somalia.39 Reflecting the la Niña phase of the Report on Emission Scenarios and climate-change ENSO cycle, regional droughts in East Africa in scenarios where Sub-Saharan African will represent 2004 to 2006 aligned with the largest chikungunya 40% to 50% of global hunger by 2080, and in some epidemic on record.40 simulations will account for 70% to 75% of global It is likely that zoonoses (infectious diseases undernourishment.31 Other climate modeling has transmitted between animal and humans) can be estimated the number of undernourished people influenced by climatic changes affecting the behav- worldwide could increase from 40 to 170 million ior or movement of reservoir species due to shifts in by mid-century.2 resources, habitat range, or climate stress.4 In this There are many categories of infectious disease scenario, climate-induced changes in the proximity that show some degree of climate sensitivity. or frequency of reservoir and human interaction Although commonly broadly grouped as vector- would facilitate pathogen spillover between reservoir borne diseases (VBDs), zoonoses (emerging or and host leading to spillover and emergence of endemic), neglected tropical diseases (NTDs), and pathogens. Although there are few examples where water-borne diseases, the boundaries between the sufficient data have been collected or the correct disease types are not always clear or well defined. analyses undertaken to prove the case, future For example, some NTDs are VBDs and also research may be particularly fruitful in this field. waterborne; many diseases transmitted by vectors Warming temperature has increased schistosomiasis are also zoonotic. Vector-borne diseases are one of transmission from snails to humans in China by the most studied health challenges pertaining to cli- changing the “freeze line” that had previously pre- mate change.32 Although variation has been vented northward movement. Expanding hospitable observed for specific diseases, according to the UN environments for the parasite’s host means over Food and Agriculture Organization (FAO),33 20 million more people may be at risk by 2050.41 some regions reported expansion of vector range However, there are often other factors that have a due to rising temperaturesdthis has been noted key role in pathogen emergence, persistence, and with latitudinal and longitudinal shifts of tick- spread, some of which also are associated with borne encephalitis in Europe34 in addition to climate change drivers. mosquito-borne malaria in eastern Africa associated Drivers of Climate Change. The drivers of climate with a warming trend beginning in the 1970s.17 change do not act in isolation from other anthropo- Similar increases in malaria in southern Africa and genic pressures on our ecosystems. For example, South America35 have been associated with the deforestation leads to the loss of carbon sinks, fun- heavy rainfall of the El Niño Southern Oscillation damentally changes landscapes, and alters species cycle (ENSO). However, it should be noted that composition. Viewed as a “threat multiplier,” cli- other authors have disputed the influence of climate mate change can exacerbate existing and growing change on malaria distribution, suggesting that challenges, such as food security and food safety.42 other issues such as the spread of drug resistance This may complicate seemingly linear path- and effects of tightening or relaxing of control waysdhealth outcomes that appear to arise from measures are more significant factors determining climate change may emanate from shared upstream malaria risk.36 Based on minimal climate change drivers or arise from a mix of factors. scenarios, some African countries may see a 25% Such complexities can be seen with infectious increase in the number of malaria cases per 1000 diseases. Although climate change has been pro- people and more than a 20% increase in treatment jected to influence the distribution and behavior of costs.37 Similarly, modeling has projected the pathogens, reservoirs, and vectors, compounding expansion of transmission season and range for factors such as social, economic, and environmental mosquitoes carrying West Nile virus, especially in conditions (such as land use patterns and human the Canadian prairie provinces.38 activity) affect transmission pathways. Such uncer- El Niño patterns appear to have affected selected tainty reflects the difficulties in modeling the differ- VBDs and pathogens such as Rift Valley fever ential distribution of disease and the complex 450 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

interactions among disease, climatic, and socioeco- quality, and curtail some forms of obesity by influ- nomic determinants. Whether climate change is encing physical activity behavior. driven by or itself serves as one of several factors Environmental degradation associated with climate changing ecological dynamics, the extent to which change drivers can initiate a vicious cycle between vul- climate change influences infectious disease distri- nerable populations, especially those in low-income bution remains heavily debated.14 For example, countries, and their susceptibility to disease. The land-use change (eg, deforestation and other extrac- implications of land-use change for biodiversity loss tive industries) and agricultural intensification, both and the associated loss of ecosystem goods and services major contributors to greenhouse gas emissions, present deeper implications for social welfare. For rank among the leading drivers of recently emerging example, decreases in pollination services and reduced infectious diseases in humans from wildlife.43 access to wild foods may affect food and nutritional Factors often leading to or exacerbating climate security and livelihoods; a potential decline in access change,44 as well as natural events exacerbated by cli- to medicinal plants used by a large proportion of the mate change, also may increase the risk for NCDs. developing world as a source of primary health care For instance, extreme temperatures have resulted in may lead to negative health outcomes across indige- increased hospital admissions due to cardiovascular nous and local communities; inadequate nutrient and respiratory conditions. Air pollution has also cycling harms clean water sources and leads to soil ero- contributed to mortality and morbidity and is an sion and may contribute to the prevalence of water- increasing risk in developed and developing countries borne diseases, thereby decreasing ecosystem and alike.45 In a first study of its kind in the WHO Euro- community resilience to extreme weather events; and pean region, the overall annual cost of health effects biodiversity loss threatens access to natural resources and mortality resulting from air pollution, including with biomedical and pharmaceutical importance and estimates for morbidity costs, was estimated to weakens ecosystem integrity and resilience to climatic exceeded US$1.5 trillion (corresponding to 600,000 changes. All of these ecosystem services are also corre- premature deaths).46 Separately, the Organisation lated to quality of life, mental and physical health, and for Economic Co-operation and Development social welfare.10 (OECD) found that air pollution-related morbidities The scope of climate change, its underlying driv- and mortalities correspond to $1.7 trillion annually ers and health outcomes extends widely beyond in OECD countries, $1.4 trillion in China, and measurable disease burden and immediate mortality. $0.5 trillion in India. In 2012, around 80% of the For example, the IPCC projects climate change will 3.7 million deaths from outdoor pollution came as a increase the displacement of people and potentially result of stroke and heart disease, 11% from lung dis- their exposure and vulnerability to extreme weather eases, and 6% from cancers.47 Although not com- events, particularly in developing countries.51 This monly considered a pollutant with direct inhalation will modify risks for violent conflicts by amplifying effect on health, one analysis extrapolates that carbon well-documented drivers of conflicts such as poverty dioxide could result in more than 21,000 premature and economic shocks. Flow-on effects may include deaths per year globally related to ozone and air par- significantly increased risk for civil and political ticles effects.48 conflict over dwindling resources, and mental health Although the discussion of NCDs is often issues arising from trauma, displacement, conflict, limited to countries characterized by urbanization, and more limited access to natural resources used industrialization, and economic development, cli- for food, medicines, and cultural and spiritual fulfill- mate change appears to transcend disease patterns ment.52,53 Such challenges relate to defense and across country and income levels. In Delhi and peacemaking initiatives, with the US Department São Paulo, the incidence of chronic cardiovascular of Defense 2014 Climate Change Adaptation issues increased during heat waves.49 Although the Roadmap anticipating growing need for disaster discussion of NCDs is often detached from climate relief and humanitarian assistance abroad as well change public health actions, there are numerous as potential international instability coupled with co-benefits between the implementation of climate threats to operations and supply chains.54 The driv- control methods and its effect on the reduction of ers of climate change may themselves result in dis- NCD prevalence.7,10,45,50 Reduction of greenhouse placement of populations. The propensity for gas emissions through more sustainable transporta- climate change impacts and drivers to result in con- tion, building, and land use will ameliorate cardio- flict (and vice versa) provide an additional compel- vascular and respiratory disease with improved air ling call to action for global health.53 Annals of Global Health, VOL. 81, NO. 3, 2015 Machalaba et al. 451 MayeJune 2015: 445– 458 Collaboration on Climate Change

PREVENTION OPPORTUNITIES intricacies and causality from other factors. For example, climate change is commonly proposed as One route to addressing climate change risks is the reason for the expansion of vector range leading preparedness and response, such as coastal flooding to VBD. However, despite sensitivity to climate, safeguards and adaptive agriculture. Public health VBD spread may be more dependent on habitat loss may take a similar approach, preparing for and and social factors56dissues likely to increase responding to disease with stockpiling and emer- through large-scale land conversion to meet grow- gency measures and adaptation through vaccination ing food demands and expansion of human settle- or therapeutics. These scenarios are often expensive ments in the coming decades. Similarly, although and result in inefficient use of limited resources, as pathogen evolution is the focus of intense research, in the Ebola crisis in western Africa in 2014 to anthropogenic environmental changes are likely to 2015. Mitigation approaches, in contrast, can pre- have more profound implications for infectious vent negative outcomes and their financial losses, disease risk under climate change.57 New or more as well as yield co-benefits across sectors and help frequent human contact with other species, resulting to address multiple health threats related to environ- in some novel interactions, is facilitating pathogen mental change. spillover, leading to outbreaks. In some cases, adaptation will lead to further In addition to placing much-needed emphasis on environmental destruction, for example, in the preventing the ecological degradation and health form of agricultural changes that degrade freshwater outcomes associated with climate change drivers, quality.55 The dangers of anthropogenic environ- mitigation is also crucial for preventing social vul- mental change are not newly recognized, nor are nerability that could result from climate change. efforts to reduce anthropogenic climate change Societal disruption is typically associated with cata- associated with greenhouse gases. The year 2016 strophic events, such as emerging infectious disease marks the 20th year since the formation of the outbreaks and natural disasters. Climate change UN Kyoto Protocol aimed at a global commitment effects may worsen susceptibility to already weak to emissions reductions, but in that time overall structuresdsuch as the limited resilience of food greenhouse gas emissions have steadily increased.7 systems under pandemic scenarios.58 However, Thus, new and innovative approaches are urgently endemic or otherwise persistent disease concerns needed to prevent global environmental pressures can affect livelihoods, economic development, and including climate change. In addition to guiding other societal components. Climate-sensitive infec- adaptation to reduce health effects of climate tious diseases have been identified as an ongoing change, the health community can play a meaning- threat to the livestock industry. Despite their impor- ful role by catalyzing major systems changes toward tance to more than 1 billion livestock holders glob- infrastructure and practices that are focused on ally, and the substantial contribution of livestock for addressing the drivers of climate and other environ- global protein intake, investments in reducing vul- mental change. Multidisciplinary and cross-sectoral nerability related to climate-sensitive diseases collaboration and the full involvement of civil soci- remain limited.59 Upstream disease prevention in ety and local communities will be central to finding this realm, including through disease surveillance, effective solutions. risk mapping, and long-term risk projections, and Prevention at the Source. Considering the underly- early warning systems, can reduce risks to livelihood ing driver of outcomes provides useful information and decrease health vulnerability downstream.59 for prevention opportunities, including those that Adopting a Systems Approach. There is a wide can be prioritized across multiple sectors or to solve range of stakeholders whose health has been or multiple challenges. For example, although climate will be affected by ecological change, all of whom change is a causal contributor to both infectious dis- can and should be engaged in finding preventive ease emergence and biodiversity loss, all 3 share solutions that can yield co-benefits. An integrative many of the same underlying drivers (such as approach that fully acknowledges the complexities land-use change/habitat loss). Reversing the tra- of socioecological systems can help us more fully jectory of outcomes requires addressing these appreciate the interactions between each compo- underlying drivers, and determining the full scope of nent, and identify areas where intervention could major mitigating or exacerbating factors is impor- be synergistically beneficial. A One Health or eco- tant for improving understanding of disease ecology systems approach, which emphasizes the links dynamics; to look only at climate change could miss between human, animal, and environmental health, 452 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

provides a useful frame that can be used to begin help empower expanded stakeholder participation understanding and addressing connections.60 This by making population health outcomes of environ- is especially pertinent as other global changes mental changes more visible. Health professionals introduce pressures that may interface with climate can be role models by taking direct action to reduce change. For example, climate projections based on a their own carbon footprint and encourage their “business-as-usual” emission scenario suggest an colleagues and patients to do the same62: for overall expanded suitable habitat for Pteropus spp. example, by turning lights off in unused exam fruit bats, which serves as the reservoir for the rooms in their hospitals and clinics to reduce energy deadly Nipah virus.61 Although climate change consumption, educating patients or populations on itself will not enable cross-continental movement of the health benefits of using public or active trans- the bat, intentional or accidental introductiondfor port, exploring efficiencies with engineers to reduce example, through the international wildlife traded hydrocarbon plastics use and packaging, working may allow its change in distribution, potentially also with hospital administrators and facilities depart- facilitating disease emergence. Similarly, climate- ments to prioritize low-carbon energy sources, and induced changes in pathways for invasive alien implementing robust energy efficiency measures in species will harm local biodiversity and related health care facilities and institutions. As shown by human health services in many regions, such as with the strong voice of International Physicians for the the spread of the mountain pine beetle in North Prevention of Nuclear War, individual actions taken America; although most invasive species are relo- by health care providers can have a substantial col- cated due to human activities, their overall effect is lective effect. amplified under climate change. At the governmental level, Ministries of Health Life-cycle analysis is increasingly used in engi- should more systematically collaborate with other neering processes to assess material flows and Ministries such as environment, agriculture, or impact, usually in terms of physical persistence. transport to identify joint opportunities for coordi- Incorporating a more comprehensive framework nated action. Intragovernmental collaboration that shows all positive or negative effects, including (with cross-sectoral inputs) is also essential to the flows of financial inputs and outputs and any short- development of climate adaptation and resilience or long-term health gains, can at least make devel- indicators.10 Incentives for health professionals to opment project funding decisions more transparent engage with climate change and other environmen- and potentially help keep companies or funders tal change issues are limited but could be developed more accountable for anticipating and mitigating out on a health systems level, including through col- damages. As climate change and health data may laboration integrated into existing health frame- use different metrics and be paired with different works. The International Health Regulations assumptions, a common framework for generating (IHR) of the WHO, now in its second edition, rep- data may also lead to more united interpretations resents the main governance mechanism to promote of results, allowing for evidence-based decision public health security of member countries. Primar- making.10 ily focused on reporting and response at a country Levels of Collaboration. Health professionals work level to aid in preparedness, the capacity established in a range of settings, allowing for integration into by the IHR could be expanded to include proactive decision-making processes at many levels. Multi- approaches. Updates to the IHR could focus on dis- disciplinary, cross-sectoral, and intragovernmental ease prevention through risk reduction, including collaboration on climate change prevention, pre- public and community engagement and health edu- paredness, and response is not currently widely cation, and closer integration with environmental, employed in the health community, but progress agricultural, and other sectors to encourage multi- can be achieved within the current health domain. disciplinary understanding and solutions. Most At the institutional level, while training programs directly, for a number of diseases with strong links typically operate in siloes, academic institutions can to climate and weather, such as RVF, close working promote cross-training opportunities and invite relationships between national and local public researchers and practitioners from other disciplines health and weather services, as well as agricultural and settings to explore points of shared relevance to or wildlife entities where sentinel monitoring may initiate collaboration. Linking information resour- be possible, can help improve forecasting to enable ces, such as clinical decision support systems, local risk-reduction strategies. The US Department of disease reporting, and ecological trend data, may Defense and its partners have developed climate Annals of Global Health, VOL. 81, NO. 3, 2015 Machalaba et al. 453 MayeJune 2015: 445– 458 Collaboration on Climate Change

anomaly forecasting methods that provide weather- investments also promote cross-disciplinary imple- related disease projections (eg, El Niño conditions) mentation. Although goals 3 and 13 are specific to up to 8 months in advance, including areas of health and climate change respectively, all 17 goals heightened risk for specific infectious and NCDs directly or indirectly relate to health and ecological (such as expected respiratory illness associated with determinants or outcomes. For example, goal 7, to forest fires during drought events).63 This informa- “Ensure access to affordable, reliable, sustainable tion can help shape public health strategies and and modern energy for all”64 is critical for function- inform health providers for early detection or risk ing hospitals; as seen in the West Africa Ebola cri- mitigation of disease. sis, basic capacities are limited or nonexistent in Health professionals can also have meaningful parts of the world, plaguing health care delivery, participation in other domainsdand in addition to diagnostics, and reporting. Ad hoc health care sys- the many cross-cutting health impacts of climate tems capacity investments have been made in the and other environmental changes, the differing pri- region, but the expected future projects to build orities and political and economic dynamics across capacity in West Africa provide a ripe opportunity countries and regions make it crucial to engage in to ensure solar energy production or other sustain- multidisciplinary collaboration at many levels to able infrastructure (in terms of both low-carbon reinforce commitments and solutions to environ- and low ongoing costs). Similarly, under the head- mental change and health challenges. For example, ing of resilient, safe, and sustainable cities and the UN’s Joint Liaison Group of the Rio Conven- human settlements, proposed target b for goal 11 tions serves as a platform for biodiversity, desertifi- prescribes by 2020 “integrated policies and plans cation, and climate-change discussions and towards inclusion, resource efficiency, mitigation intended collaboration; engagement of additional and adaptation to climate change, resilience to dis- UN entities, including the WHO, FAO, and the asters, develop and implement. . . holistic disaster United Nations Framework Convention on Climate risk management.”64 Similarly, proposed goal 15 Change, could provide broader utility, especially if aimed at protecting, restoring, and promoting “sus- concrete integration occurs to enable a united voice. tainable use of terrestrial ecosystems, sustainably On a national level, UN and other intergovernmen- manage forests, combat desertification, and halt tal organization delegates can also mobilize across and reverse land degradation and halt biodiversity sectors, helping to routinize multidisciplinary poli- loss” is essential to the provision of multiple ecosys- cymaking and stimulate thinking on co- tem services that promote health and well-being.10 investments and co-benefits. For example, the Working from this frame can enable more proactive WHO, the Convention on Biological Diversity, risk analysis and planning around environmental, and the World Organisation for Animal Health social, financial, and health outcomes. Given their have representatives in most countries, many of catastrophic effect, emerging infectious diseases whom are based at national ministries, and most (such as severe acute respiratory syndrome, esti- state parties to these organizations have focal points mated at costing the global economy of US$30 bil- assigned to them; working groups could be formed lion or more and disruption of trade and travel),65 to identify common priorities in individual countries are a logical inclusion when considering disaster or regions that can facilitate synergies or higher level risks faced by society. liaison groups across these or other relevant organi- Coordination on natural resource planning, in zations could help to identify key priorities and which health aspects are currently limited or super- opportunities for effective action (Table 1). ficially incorporated, may be a particularly important National collaborative opportunities would be role for health professionals. For example, the UN especially timely as we transition toward the Sus- Reducing Emissions from Deforestation and Forest tainable Development Goals (SDGs).64 The Degradation program, which provides developing SDGs will build on the unfinished agenda of the nations with monetary incentives to preserve forest Millennium Development Goals, intended as a stra- areas, could be expanded with the help of health tegic direction for international development professionals to encompass health benefits or risks through 2030. Although the separate goals and of forest conversion or protection scenarios. Finan- detailed targets discussed to date appear to reinforce cial effects related to disease prevention and preser- a siloed approach, there are many potential areas of vation of other health-benefitting ecosystem services horizontal integration toward the creation of more could be quantified into forest valuations, allowing a sustainable and healthy societies, especially if fuller assessment of the public good and short- and 454 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

Table 1. Illustrative Opportunities for Multisectoral Collaboration to Inﬂuence and Protect Human Health in Light of Climate and Other Environmental Change* Commercial/ Industry Electricity Health Building Agriculture Transportation

Forestry Health, environmental, More efficient Selective logging Green space Biosecurity Consolidation and social effect machinery Sustainable forestry Density of Land of land use assessment Alternative sites development conversion Labor laws affecting Joint planning to supply chain prevent sprawl Retrofitting Transportation Solar/electric Increasing portion Active transit Increasing density Local suppliers transport of transport that of development Efficient Shipping runs on renewable Mixed land use shipping routes sources Increasing transportation density Agriculture Fuel-efficient Reduce energy needs Diversity and Composting/ machinery for food production nutritional value of community gardens Biodigesters cultivars Food safety practices Commercial/ LEED standards Efficient insulation Green buildings Building Recycled materials following LEED standards Health Carbon pricing Solar power Efficient cookstoves Electricity Renewable electricity Combining energy stores Microgrids Co-benefits Investment in underserved markets and shifts in industry standards Hospital and laboratory capacity Employee productivity and well-being Civic engagement Local businesses and tax base Ecosystem services critical to human and animal health and well-being

LEED, Leadership in Energy & Environmental Design * Opportunities can yield co-beneﬁts that span multiple sectors; decision making can thus consider ways to maximize positive outcomes for health.

long-term costs, financial gains or savings expected drought, waterborne disease, and water and food from land planning decisions and providing a com- security). Working together, health, ecological, mon platform for climate change mitigation and and other professionals can help assemble the exper- prevention of potential negative health effects asso- tise and information needed to understand the envi- ciated with deforestation. Multidisciplinary collabo- ronmental components that may influence disease ration in natural resource planning has utility for the risksdfor example, anticipating how factors such health community as means for developing as forest cover and soil quality affect water absorp- upstream intervention or reducing vulnerabilities tion and the resulting implications for flooding that may be influenced by climate change or its driv- and associated disease risks. ers. For example, decision making on water resource To promote science-driven decision making as well allocation will ideally involve diverse stakeholders, as research outputs with direct societal utility, including from public health, agriculture, energy, full-spectrum collaboration must also occur between and natural resource management sectors to antici- scientific communities and policymakers (which may pate and weigh benefits and adverse effects (eg, pos- represent governments, corporations, or the public itive or negative implications for sea shipping, empowered in decision making). This can occur in sev- irrigation access, energy generation, flooding and eral ways, including the coproduction of knowledge Annals of Global Health, VOL. 81, NO. 3, 2015 Machalaba et al. 455 MayeJune 2015: 445– 458 Collaboration on Climate Change

(eg, coordinated research question generation) and, preventive capacity could support development of where findings are not interpretable to direct action, needed renewable technologies such as solar micro- translating relevance to a given sector(s). For example, grids; building local capacity for installation and health scientists could take risk projection findings fur- maintenance could reduce cost and technological ther to calculate the cost of inaction or the gains of sol- barriers for uptake and use. Capitalizing on volun- ution scenarios or the scientific community could tary corporate collaboration may be highly fruitful; examine the cumulative health impacts associated as of 2012, 1.6% of publically traded companies with ecosystem alteration, and help to identify and held more than half of the market value globally, refine implementation strategies to address these chal- representing enormously powerful interests; gaining lenges in a more coordinated fashion. Even within the their collaboration in sustainable investments could scientific community itself, however, collaboration is lead to new industry standards.67 Finally, although not routine, despite potential research, understanding, a survey of company managers suggested only 27% and intervention efficiencies. To promote collabora- view climate change as a business risk,68 compelling tion across scientific disciplines and bridge research industry losses are at stake from broader ecological and policy oriented toward sustainability solutions, changes. For example, outbreaks of Marburg virus the Future Earth scientific platform was established in Eastern Africa, associated with human encroach- in 2014, merging international global change projects ment into wildlife habitat for natural resource representing atmospheric sciences, ecosystem services, extraction, prompted mine closures.69 Adding health, urbanization, and other disciplines. For this health to routine environmental and social impact model to be optimized, some baseline challenges will assessment processes for development projects need to be overcome: common metrics and data shar- can help identify and mitigate public health risks. ing systems do not currently exist, research invest- There are many opportunities for engagement ments typically are still oriented to single-discipline among those organizations already conscientious approaches, understanding of long-term trends is of the range of effects (positive and negative) that limited by the short-term nature of research funding, their investments may have. Multilateral develop- and (outside of clinical medicine) pathways are gener- ment banks and bilateral aid agencies may be ally not yet in place for wide-scale research-to-solution best positioned to lead here given their long processes. histories undertaking impact assessments and Industry and private-sector collaboration are also diverse expertise, including health. These assess- crucial for multidisciplinary solutions, but program- ments might include assessment of health in- matically, health organizations face resource challenges equities of disease burdenordisproportionate in raising awareness and combatting the ill effects health-related financial impact to certain popula- of fossil fuel-related pollution. For example, the tionsdinfrastructure or systems resiliency can WHO’s entire 2014-2015 approved budget also be assessed and improved to reduce vulnerabil- (US$3.98 billion) is a stark contrast to the almost ity of investments under climate change. Risks are $550 billion granted in annual global fossil fuel subsi- also highly relevant to reinsurance companies, as dies.66 The short-term societal focus on profits derived their clients increasingly face climate-related losses from fossil fuel extraction and consumption have over- that add to volatility of risk management. Rein- all represented a major barrier to stronger climate- surer Swiss Re has articulated that the severity of change regulation. In turn, the public sector has not flooding events will require public-private partner- developed an effective mechanism for protecting ships in addition to adaptation measures to tackle global public goods including disease prevention. upcoming challenges. Despite these incongruences, private-sector col- Prioritizing solutions across many sectorsdsuch laboration can be a crucial and high-yield opportu- as integrating environmental education in curricu- nity for global health engagement on climate change lum, expanding green energy investments through threats. Co-investments across sectors, or at least health grants, encouraging the development of citi- reinforcing ones, have practical value as well. zen science in civil society, and establishing industry Although typically applied to for-profit contexts, working groupsdcan help reduce redundancy we can consider the process of innovative disrup- and increases protection against volatile political sit- tion, which circumvents incumbents to effectively uations. Likewise, ensuring the full involvement of provide an alternative that catches an underserved local communities, who are in the first line of market or outperforms. Shifting a portion of global defense against ecosystem degradation and unsus- health investments from reactionary approaches to tainable use of resources and are those most affected 456 Machalaba et al. Annals of Global Health, VOL. 81, NO. 3, 2015 MayeJune 2015: 445– 458 Collaboration on Climate Change

when these resources are depleted, is equally critical Although we have focused on the importance of to the success of any prevention, preparedness and global health’s collaboration with other sectors, the response strategy that seeks to jointly optimize role of global health practitioners cannot be over- health outcomes. Moreover, systematic planning to stated for meeting complex societal challenges optimize co-benefits is also essential, and could such as climate change. Health can serve as a lever- have enormous cost savings from prevention of neg- aging point for other sectors concerned about global ative outcomes. For example, built environment environmental change; for example, ecological sci- modifications that encourage physical activity (eg, ences often state outcomes in abstract language, active transit) can help address obesity rates, and if expressing caveats and parameter limits in outputs using low-carbon alternatives, in the long term from theoretical models, tipping points, or measures may feed into measures for climate change con- such as parts-per-million greenhouse gas concentra- trol.70 Large-scale building investments may rely tions. In contrast, number of lives lost, quantitative on privatized investments, but the public sector impact to productivity, or visible signs of morbidity can take measures to require cross-sectoral land can be far more tangible to a community and use planning and project review and provide indus- individuals. try incentives, as well as the public infrastructure Global health professionals can help convey the required for successful business growth. need for “local solutions for global health” that address context-specific determinants of health CONCLUSION (eg, socioeconomic, environmental, behavioral) to promote successful implementation. However, to Benefits yielded from other sectors to human health foster these benefits for shared value, the global are already provided every day; for example, engi- health community must more actively engage other neers design sanitation systems that reduce the sectors to be more proactive in finding preventive prevalence of waterborne diseases through waste solutions, effectively broadening the scope of what removal and increase access to potable water, and constitutes public health. Doing so can yield consid- farmers (and pollination services) are essential to erable co-benefits from synergies that may also help sustaining food security and nutrition. However, address and prevent other current and future health these gains have typically been outside of the direct threatsdthe need is clear and pressing. purview of global health, with the latter largely emphasizing interventions when upstream systems ACKNOWLEDGMENTS fail (or do not exist at all) and a health risk emerges. Anthropogenic changes are placing novel or exacer- CM, WBK, and PD acknowledge the generous bating pressures on health that require complex sol- support provided by the DIVERSITAS-Future Earth utions; to fully address anticipated risks in a ecoHEALTH project and the PREDICT project of the United States Agency for International Development meaningful capacity, the global health community (USAID) Emerging Pandemic Threats program. The must embrace a focus on prevention of known and authors acknowledge the 2 anonymous reviewers for their potential health threats and develop coordinated, constructive comments that improved this paper, as well as coherent, and cross-sectoral strategies that are Virginia Porter for editorial assistance. All authors had a both representative of and adequately respond to role in the conceptual development of the paper, compiling the magnitude of the challenges that we face. background research, writing and reviewing the manuscript.

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