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J. van Hasselt
R. A. Chapman
KNOWLEDGE FOR ADAPTATION SERIES: 6
REGIONAL CLIMATE CHANGE PROGRAMME SOUTHERN AFRICA FEBRUARY 2012
Health and
Climate Change
Key linkages in southern Africa
SYNTHESIS REPORT
KNOWLEDGE FOR ADAPTATION SERIES: 6
Health and Climate
Change
Key linkages in southern Africa
SYNTHESIS REPORT
J. van Hasselt
R. A. Chapman
REGIONAL CLIMATE CHANGE PROGRAMME SOUTHERN AFRICA FEBRUARY 2012
RECOMMENDED CITATION
van Hasselt, J. & Chapman, R. A. 2012, Health and climate
change: key linkages in southern Africa. For the Regional
Climate Change Programme for Southern Africa (RCCP),
UK Department for International Development (DFID).
Cape Town: OneWorld Sustainable Investments.
Acknowledgements
Professor Akin Abayomi is acknowledged for his critical
review of the original manuscript.
The Regional Climate Change Programme
Southern Africa (RCCP)
The RCCP aims to contribute to the achievement of
southern Africa’s climate change adaptation needs,
socioeconomic development and poverty alleviation
objectives, including the Millennium Development
Goals.
By synthesising the relevant climate change science,
developing strategic research and strengthening
science-policy-governance-finance dialogue, the
RCCP will build an evidence base for appropriate
transboundary responses, strengthen the region’s
voice on international platforms and negotiations, and
enhance its ability to equitably access the necessary
finance for effective climate change adaptation.
The five-year Regional Climate Change Programme
of work (2009–2014) with Southern African
Development Community (SADC) partners on the
impact of climate change, aims to increase regional
participation in globally funded adaptation projects
and improving resilience. The RCCP has four
outputs, the first of which focuses on the scientific
basis for understanding climate change impacts in
southern Africa.
OneWorld • 2nd Floor • 4 Church Square • Spin Street • Cape Town • South Africa
Tel: +27-21-818-2900 • Fax: +27-866-739-437
info@oneworldgroup.co.za • www.oneworldgroup.co.za • www.rccp.org.za
DISCLAIMER:
This material has been funded by UKaid from the Department
for International Development. However, the views expressed
do not necessarily reflect the department’s official policies.
While reasonable efforts have been made to ensure that
the contents of this publication are factually correct, the
Department for International Development does not take
responsibility for the accuracy or completeness of its contents
and shall not be liable for loss or damage that may be
occasioned directly or indirectly through the use of, or reliance
on, the contents of this publication.
IMPLEMENTED BY:
Contents
Key messages .......................................................................................................iv
1. Introduction .................................................................................................. 1
1.1 Purpose of report ............................................................................................................................................1
2. Frameworks for assessment ............................................................................2
2.1 The 1st to 4th order conceptual approach ................................................................................................2
2.2 Impact of climate change on health ...........................................................................................................2
3. Overview of southern African climate change trends .......................................4
3.1 Increasing temperature ...................................................................................................................................4
3.2 Changing rainfall patterns ..............................................................................................................................4
4. Status of health and health-supporting systems .............................................5
4.1 Burden of disease ............................................................................................................................................5
4.2 Health systems .................................................................................................................................................6
5. Health effects of climate change .................................................................... 8
5.1 Water supply .....................................................................................................................................................8
5.2 Food security ...................................................................................................................................................9
5.3 Infectious organisms and vectors ...............................................................................................................10
5.4 Extreme weather events ...............................................................................................................................10
5.5 HIV/AIDS ........................................................................................................................................................ 11
5.6 Other health issues .......................................................................................................................................12
5.7 National, regional and international initiatives .......................................................................................12
6. Expected impacts and vulnerabilities in the development context ................. 13
6.1 MDG progress as a measure of resilience ................................................................................................14
7. Hotspots of specific vulnerability in southern Africa ..................................... 15
8. Assessing future conditions in the region and the impact on health .............. 18
9. International leadership and commitments ..................................................20
9.1 Decision support systems ........................................................................................................................... 20
9.2 Enhancing capacity ....................................................................................................................................... 22
10. Discussion ...................................................................................................23
10.1 Recommendations ........................................................................................................................................ 23
11. References ...................................................................................................25
Acronyms and abbreviations ..............................................................................28
IV
HEALTH AND CLIMATE CHANGE
Key messages
The Southern African Development Community (SADC) health sector is not sufficiently prepared
for the adverse public health impacts of climate change.
Climate change presents the greatest public health challenge of the future, and Africa is consistently
identified as the most vulnerable region in this regard. The health sector in the SADC is under-
capacitated and already strained by other health priorities such as the HIV pandemic and its numerous
complications, such as multidrug and extensively drug resistant tuberculosis (TB) as well as a number of
chronic diseases. TB is already placing further large demands on health system resources. Prioritisation
of health in National Adaptation Programmes of Action (NAPA) is low, with inadequate budget allocation
and superficial understanding of the health impacts of climate change. No comprehensive research
studies have been conducted on the health impacts of climate change in the SADC region, and few
studies appear to be underway. Existing literature draws on reasonable assumption although specific
diseases, particularly malaria, have been relatively well studied. Critical gaps in public health surveillance,
research, data collection and data availability are widely recognised. These are key to evidence-based
health adaptation response strategies and policies. A deeper understanding of the impact of climate
change on all levels of human health is critical for making progress towards the Millennium Development
Goals (MDGs). Those MDGs that relate specifically to health are directly threatened by climate change.
Notable gender and age-specific vulnerabilities to climate change also relate to MDGs 4 and 5.
Climate change threatens to worsen environmental and socioeconomic conditions, and exacerbate
health vulnerabilities in SADC.
SADC countries, especially the least developed countries, are vulnerable to the adverse health impacts
of climate change, with particular vulnerability in southern Mozambique, Malawi, Zimbabwe, Lesotho,
Swaziland, and southern Tanzania as identified using GIS-based risk and vulnerability mapping. However,
all SADC countries have highly vulnerable sub populations which currently experience high burdens of
diseases, including climate-sensitive diseases such as malaria and cholera, and malnutrition, which are
likely to be aggravated by expected climate change. Health systems are weak, thus an increased burden
of disease and poor health as a result of climate change will seriously challenge the limited human and
technical capacity of the region’s health services. Climate change environmental risks related to health
include: reductions in the availability of food and fresh water; risks of temperature and precipitation
extremes; disrupted health services and infrastructure following disasters; and more favourable and
unpredictable conditions for the transmission of infectious diseases. The most important impacts of
climate change on human health in southern Africa are likely to be those related to nutrition and water,
referring to both adequate quantity and quality of water. Extreme weather will add to the health stressors
and the burden of acute and chronic diseases and injury. Lack of access to adequate health care and
public health resources underpins current vulnerability. Unforeseen consequences in the nexus of animal,
human and environmental health, including new and emerging tropical diseases, have the potential to be
highly disruptive and may demand urgent diversion of substantial resources. Lost livelihoods, migration
and burgeoning informal urban settlement are all possible consequences of climate change in the region
which add to the socioeconomic drivers of disease, under conditions where housing, access to clean
energy and access to a safe environment are already under pressure. Informal urban settlement may
replace one form of climate vulnerability with another. The potential for political instability and even
conflict through competition for essential resources or as a result of migration and population pressure
would add to adverse socioeconomic circumstances with distal health consequences.
V
KEY MESSAGES
SADC ministers of health and environment have adopted a leadership position committed to
addressing climate change, emphasising adaptation in general and health adaptation measures in
particular.
At the Second Interministerial Conference on Health and Environment in Africa that took place in Angola
in 2010, African ministers of health and of environment committed to adopt the Joint Statement on
Climate Change and Health in Africa. Ministers’ prioritised provision of safe drinking water, sanitation
and hygiene services; management of environmental and health risks related to climate variability; vector
control; food safety and security; environmental health of children and women; health in the workplace;
and management of natural and human-induced disasters. Responding to these commitments, a joint
WHO UNEP technical team has drafted a framework for a comprehensive, integrated health sector
response for public health adaptation to climate change in Africa. The draft framework represents an
evidence based, systematic approach to lend structure and support at a technical level, to implement
government commitments regarding health and climate changes.
SADC countries should aim to minimise the adverse public health impacts of climate change, using
existing frameworks and agreed development goals wherever possible, for sustainable climate-
resilient health programmes.
SADC ministers of health participating in the 61st Session of the WHO Regional Committee for Africa
unanimously adopted the Framework for Public Health Adaptation to Climate Change. They committed
to immediately initiate its implementation by undertaking baseline risks and capacity assessment as
an immediate priority and to establish the existing population vulnerability to climate-sensitive health
risks, and the degree to which national health systems can respond effectively and manage these risks.
Recognising that individual countries have limited capacity to respond, ‘no regret’ priority health
adaptation response strategies should be identified and developed following baseline assessments, as
well as addressing critical capacity issues. Priority climate change health adaptation strategies can align
well with MDGs and prominently include investment in water and sanitation services, and addressing
undernutrition. This hybrid integrated approach will save lives now, increase resilience to future climate
change and address existing health challenges in ways that tries to accommodate the already limited
resources and capacity available. Suitably skilled people should drive collaborative regional efforts
such as data collection, research, surveillance and particularly actions on disaster planning, disaster
management and responses to unforeseen health consequences, such as new epidemics, disease
outbreaks and environmental refugees.
VI
HEALTH AND CLIMATE CHANGE
The greatest burden of climate change in southern Africa will be borne by women and children.
Outpatients at a clinic in a malaria endemic area in Angola.
© Zacharias/van Hasselt
1
In 2009 one of the world’s most respected medical journals,
The Lancet, commenced publication of a series of articles on
the health impacts of climate change (CC), concluding that
climate change is the biggest global health threat of the
21st century, putting “the lives and well-being of billions of
people at increased risk” (Costello et al., 2009).
Although entirely new health issues are possible in
future, the World Health Organisation (WHO) already
attributes substantial morbidity and mortality to CC
primarily through water and food insecurity, shifting
patterns of infectious diseases, and impacts of extreme
weather events (WHO, 2009a).
These challenges are already familiar in southern
Africa and the prospect of increasing disease burden
and pressure as a result of climate change are serious
cause for concern, based on existing and predicted
vulnerabilities in the region. CC has the potential to
severely affect the developmental goals and pathways of
the region, and add to existing stress on the health sector.
The Intergovernmental Panel on Climate Change (IPCC)
(Christensen et al., 2007) has identified southern Africa
as being highly susceptible to climatic induced impacts.
Significant changes in both precipitation and temperature
patterns are predicted across the region. These are likely to
alter the geographic range and incidence of vector-borne,
zoonotic, and food- and waterborne diseases, and the
prevalence of diseases associated with air pollutants and
aeroallergens. Specifically relevant for southern Africa, with
its high dependence on rainfed agriculture, is the increased
number of people at risk of malnutrition (Confalonieri et
al., 2007) due to decreased crop yields, livestock losses and
declining fish populations. If the frequency, intensity and
duration of extreme weather events, such as heat waves,
floods, droughts and windstorms increase as predicted
(IPCC, 2007b), this will affect millions of people each year,
damage critical public health infrastructure and livelihoods
and lead to economic dislocation and environmental
decline (PAHO and WHO, 2010).
Contemporary views of the impacts of CC on human
health consider key influences of climate on health
through the influence on vectors and pathways of disease,
e.g. malaria, dengue, cholera and other infectious diseases
(Campbell-Lendrum and Woodruff, 2006; McMichael et
al., 2003, in Young et al., 2010). Boko et al. (2007) has
identified many other factors that will also contribute to
and compound the impacts of current climate variability
and have negative effects on the continent’s ability to
cope with climate change. These include poverty, illiteracy
and lack of skills, weak institutions, limited infrastructure,
lack of technology and information, low levels of primary
education and health care, poor access to resources, low
management capabilities and armed conflicts. Additional
threats are exerted due to over exploitation of land
resources, population pressure, desertification and land
degradation – all compounding adverse environmental,
economic and social determinants of health.
Despite the major health implications posed by climate
change, public health has not yet identified its central role
in the climate debate. Reasons for this situation include
a lack of understanding of the health effects of climate
change and the strong focus on existing health crises.
Consequently, very little empirically-based material is
available. Although the health sector in southern Africa is
becoming increasingly engaged with CC issues, large gaps
of knowledge and awareness must be addressed. This is
in line with high level government participation and firm
political and legal commitments. However, a structured
and robust approach is required, that moves away from
traditional metrics and a compartmentalised approach to
specific diseases, and instead encompasses a policy and
strategic pathway that builds public health capacity as a
whole, and is integrated and supportive of other sectors.
1.1 Purpose of report
The purpose of this report is to describe the current and
predicted climate impacts on health in southern Africa,
present a view of health vulnerability to climate change,
identify risks and vulnerabilities, assess possible future
socioeconomic conditions in relation to future health
risk and vulnerability, and to identify priorities for action.
The report draws attention to proposed first steps which
should enable ‘no regret’ adaptive response strategies.
The report is one of a series of Knowledge for Adaptation
titles published by the Regional Climate Change Programme
(RCCP). This series is aimed at SADC decision and policy
makers and supporting their leadership in securing
government commitments (and support) in the climate
change and health context – including from influential
institutions and other key stakeholders in the health arena.
This synthesis draws from sources listed in the References
section. Of particular relevance is the report by Young et al.
(2010), commissioned by the RCCP, from which substantial
extracts have been drawn and are prominent in Section 4,
‘Status of health and health-supporting systems’, and in
Section 5, ‘Health effects of climate change’.
Finally, in the words of Margaret Chan, Director General
of the World Health Organization (2007):
“The health sector must add its voice – loud and clear… we
must fight to place health issues at the centre of the climate
agenda. We have compelling reasons for doing so. Climate
change will affect, in profoundly adverse ways, some of the
most fundamental determinants of health: food, air, water.”
1. Introduction
2
Many assessments associated with climate change have
taken a sector-based approach. However, this can inhibit
integration across sectors. Cross-sector appreciation is
critical when assessing responses in economic and social
systems to challenges posed by climate change, because
the interdependencies between these sectors are complex
and far reaching. One sector can act as an embedded driver
for another. Climate sensitivities are interconnected, and
a response to them requires integration for optimal effect.
Our assessment provides two frameworks for analysis,
which illustrate the cross-sector integration required to
address the challenges that climate change presents to
human health in the region.
2.1 The 1
st
to 4
th
order conceptual approach
The 1
st
to 4
th
order conceptual framework (Figure 1)
developed by the Regional Climate Change Programme
(RCCP), makes linkages between basic climate parameters
(1
st
order), resulting physical and chemical processes in
the physical and biotic environment (2
nd
order), leading to
ecosystem services and production potential (3
rd
order) and
finally informing social and economic conditions (4
th
order).
Dynamic feedbacks pathways exist between all the orders.
2.2 Impact of climate change on health
Human health is determined by the interaction of social
and environmental conditions (Figures 1 and 2). The
models illustrate the pathways between climate change
and adverse impacts on human health.
Climate is amongst the myriad factors that influence the
occurrence and range of human health determinants and
outcomes (Patz et al., 2005, in Young et al., 2010). Climate
and environmental factors are recognised as driving
forces on economic, social, political, and institutional
structures and their functioning, with important health
consequences.
The health impacts of climate variability and other
climate pressures can be broadly characterised into three
exposure types:
I. Direct impacts, which include morbidity and
mortality associated with direct exposure to hazardous
meteorological conditions, e.g. heat waves, floods, or
cyclones (1
st
order);
II. Indirect impacts, constituting the majority of climate-
related morbidities, are mediated by environmental
conditions which change the geographic range
and incidence of vector-, rodent-, water and food-
borne diseases and alterations in air pollution and
aeroallergen related diseases (2
nd
and 3
rd
order); and
III. Exacerbation of health conditions via economic,
resource, or social losses caused by climate change, that
affect health, or create economic barriers to health care,
food, or water (4
th
order).
2. Frameworks for assessment
Figure 1: 1st to 4th order conceptual approach developed by the Regional Climate Change Programme (RCCP)
1st order – basic
climate parameters
Impacts on flood generation,
soil water infiltration, erosion
rates, soil carbon status,
leaching rates
Air pollution intensity
2nd order – physical and
chemical processes
Crop/forest/livestock/fish
productivity changes, soil fertility,
moisture and carbon stocks
Changes to disease vectors and
pathways, pest lifecycles, biodiversity
3rd order – ecosystem services
and production potential
4th order – social and
economic conditions
1st
2nd
3rd
4th
Rainfall quantity, frequency, intensity
and timing
Temperature minimums, maximums and
durations above thresholds
Wind speeds
Impacts on food supplies, income, health
and disease prevalence
Impacts on infrastructure, energy supplies
Rates of disruption of economic activity &
social fabric
3
2. FRAMEWORKS FOR ASSESSMENT
Climate change
Increasing
temperatures
Changing rainfall
Climate variability
leading to
increasing
extreme events
Increasing
sea levels
Changing water
supply
Change in air
quality
Change in food
security
Effect on vectors
and infectious
organisms
Water insecurity
Poor water quality
Vectors, e.g.
mosquitoes and
snails
Contamination and
salt concentration
Pollutants
Airborne pollens and
spores
Loss of productive
farm land – crop
failure
Reduced sh
availability
Faster maturation of
infectious organisms
Zoonotic effects
Increased vectors/
pests
Infrastructural
Local environmental
conditions
Infrastructure and
logistics
Societal
Food availability
Income levels and
distribution
Population density
Social stability
Pre-existing disease
burden
Quality and
availability of public
health care
Adaptive policies
Quality and
availability of public
health care
Direct effects
Death, injury,
displacement, mental
health, heatstroke,
etc
Indirect effects
Effect on vectors and
infectious organisms
Infectious diseases,
e.g. water- and food-
borne diseases
Chronic diseases,
e.g. air pollution-
related impacts
Malnutrition
Mental health
Vulnerable groups
Health in women and
children
Climate change Environmental
effects Risk factors Modifying factors Health effects
Figure 2: The direct and indirect impacts of climate change on human health
Source: Adapted from SEAD, 2010 (Eisenberg, 2007 and McMichael, 2003)
Inadequate infrastructure poses a major challenge to the adequate delivery of health services across the region.
Disabled public health vehicles at a rural hospital.
© Zacharias/van Hasselt
4
Climate change has the potential to severely affect
the developmental goals of southern Africa, impacting
particularly on health. The Intergovernmental Panel
on Climate Change (IPCC) has identified this region as
being very susceptible to climate change and models also
project significant changes (IPCC, 2007a). A problem is
that Global Circulation Models (GCMs) do not provide
a coherent outlook for inter-annual variability of the El
Niño Southern Oscillation (ENSO) and Indian Ocean
Dipole (IOD) cycles and cannot predict the possible
number of cyclones that may develop.
3.1 Increasing temperature
Climate projections also indicate a further heating
with mean temperatures rising between 2.0 to 4.5 °C in
the next 50 years and even higher later in the century
(Fig 3a). In the nearer future, mean temperatures may
rise by 0.5 °C, indicated by increased hot days and nights.
These temperature excursions have debilitating effects
on human health and, when combined with other direct
and indirect health impacts, bring further challenges and
contribute to ill health and the burden of disease (BoD).
3.2 Changing rainfall patterns
Trends in mean rainfall across southern Africa are difficult
to detect and GCMs also differ on how rainfall may
change (IPCC, 2007a). What is much more evident is the
increasing variability of rainfall referring to timing and
duration. Trenberth et al. (2003) show that it is the nature
of the rainfall that is changing and not necessarily the
long-term mean. Convection-driven rainfall is becoming
more intense, but inter-rainfall period is also increasing.
The phenomenal impacts of climate change are wide-
ranging and highly complex, including anticipated and
unexpected impacts on human health. These changes are
experienced as an escalating variability in rainfall and
temperature extremes which bring a swathe of impacts at
varying scales, which ultimately influence the resilience,
adaptive capacity, livelihoods and poverty status of
vulnerable populations.
3. Overview of southern African climate
change trends
Temp response (%)
40°N
20°N
20°S
40°S
20°W 20°E 40°E 60°E
0°
0°
-50
-30
-20
-15
-10
-5
0
5
10
15
20
30
50%
Temp response (°C)
40°N
20°N
20°S
40°S
20°W 20°E 40°E 60°E
0°
0°
-1
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
4
5
7
10°C
Figure 3: Projected annual temperature and precipitation
changes in southern Africa from the multi-model MMD-
A1B simulations (A1B Special Emissions Scenario),
averaged over 21 models
Source: Christensen et al., 2007
5
Much of the existing medical and public health literature
related to climate comes from studies in the developed world.
However, health impacts of climate change will fall primarily
on low-income, poorly resourced and geographically
vulnerable populations (IPCC, 2007a) with sub-Saharan
Africa identified as especially vulnerable. “Although very
little research has been conducted on the present and future
impact of climate change on human health in southern
Africa, the population’s vulnerability stems from poverty,
high pre-existing BoD, fragmented health services, and water
and food insecurity” (Young et al., 2010). The health sector in
southern Africa is under-capacitated and already strained by
other health priorities such as the HIV pandemic.
The number of people living with HIV and on anti-retroviral
pharmaceuticals continues to grow. This trend is placing an
ever-increasing burden on health system resources, including
scarce human resources. Already the scale and intensity
of treatment is too low and below international standards.
While this has the effect of prolonging life, it also results
in sub-optimal recovery of individual immune status. The
burden of disease remains high and places a large demand
on the stretched public health system. The implication is
of a trend towards a chronically high need for health system
resources that has no obvious solution.
4.1 Burden of disease
Young et al., (2010) describe how the poor status of health
in southern Africa is due to a quadruple burden of disease,
and list the following:
• emerging infectious diseases, e.g. HIV/AIDS;
• old infectious diseases, e.g. tuberculosis (TB);
• chronic diseases, e.g. asthma, chronic obstructive
pulmonary disease (COPD), hypertension, ischaemic
heart disease and diabetes; and
• intentional and unintentional injury.
They also note (based on WHO 2009 data) that the
neonatal mortality rate is very high, ranging from 7 to
54/1 000 live births, infant mortality rate (IMR) from
14 to 116/1 000 live births, and maternal mortality ratio
from 15 to 1 400/100 000 live births (Table 1). Similarly,
in southern Africa, morbidity and mortality is also high.
Life expectancy at birth for both sexes is 52 years in
comparison to 80 years in high-income countries. The
healthy life expectancy at birth is 45 years, compared to
70 years in high-income countries (Young et al., 2010,
citing WHO, 2009). A healthy life expectancy at birth is
the average number of years that a person can expect to
live in ‘full health’, which accounts years lived in less than
full health due to disease or injury (Young, et al., 2010).
The burden of neglected tropical diseases (NTDs) in the
region is also substantial, and the impact on the health
system and degree of unpredictability as a consequence
of climate change cannot be overlooked. NTDs are the
most common conditions affecting the poorest 500
million people living in sub-Saharan Africa (SSA) (Hotez
4. Status of health and health-supporting
systems
Table 1: Mortality rates by cause for countries in southern Africa
Country
Neonatal
mortality rate
(per 1 000 live
births) (2004)
Infant mortality rate
(probability of dying between
birth and age 1 per 1 000 live
births) (2007)
Under-5 mortality rate
(probability of dying by
age 5 per 1 000 live
births) (2007)
Adult mortality rate
(probability of dying between
15 and 60 years per 1 000
population) (2007)
Maternal
mortality ratio
(per 100 000
live births)
Angola 54 116 15 8 347 1 400
Botswana 46 33 40 514 380
DRC 47 10 8 161 357 1 100
Lesotho 52 68 84 725 960
Madagascar 41 70 112 264 510
Malawi 26 71 110 544 1 100
Mauritius 9 15 17 157 15
Mozambique 35 115 16 8 498 520
Namibia 20 47 68 365 210
Seychelles 7 14 16 172 -
South Africa 17 46 59 520 400
Swaziland 40 66 91 618 39 0
Tanzania 35 73 11 6 472 950
Zambia 40 103 170 550 830
Zimbabwe 36 59 90 713 880
Source: WHO, 2009b
6
HEALTH AND CLIMATE CHANGE
and Kamath, 2009). For example, 31 million people in
the Democratic Republic of Congo (DRC) and 11 million
people in Angola are infected with hookworm, illustrating
the extent of the burden of NTDs in least developed
countries (LDCs). The effects that NTDs have on child
development, pregnancy outcomes and agricultural
worker productivity are substantial and impact on the
resilience and capacity of people to respond to additional
stress imposed by climate change.
Major additional factors in the high burden of disease
are the chronic high levels of malnutrition, HIV/AIDS,
malaria and TB. Multidrug and extensively drug resistant
tuberculosis (MDRTB and XDRTB respectively) is a serious
emerging health problem that will place very significant
extra strains on health system resources (WHO, 2011).
The disease is strongly linked to the HIV pandemic and
infections with MDRTB and XDRTB are usually related to
pre-existing HIV infection (WHO, 2011).
The percentage of underweight children aged <5 years
ranges from 6.1 to 36.8%, on the basis of malnutrition
and the prevalence of diarrhoeal diseases (WHO, 2009).
HIV prevalence among adults aged 15–40 is greater than
20% in the populations of some countries (Botswana,
Lesotho, Swaziland). Tuberculosis (TB) is similarly high
at 812/100 000 people (WHO, 2009). TB prevalence has
increased substantially in communities with the greatest
burden of HIV/AIDS.
Burden of disease information usually exists at country
level, allowing risk assessment that can attribute different
groupings of disease burden to different factors. The lack
of data in Africa means that other methods need to be used;
Campbell-Lendrum and Woodruff (2007), for example,
have applied a standardised comparative risk assessment
approach to assess the effects of climate change.
“In South Africa considerable work on the impact
of various risk factors on BoD has been studied by
the South African Comparative Risk Assessment
Collaborating Group (Bradshaw et al., 2007).
Some of the health outcomes are directly related
to those included by Campbell-Lendrum et al.
(2007). For southern African countries, WHO
has BoD data which are derived from few sources,
based on untested assumptions, and are unlikely
to be nationally representative. WHO BoD data
exists for 2002 and 2004 (WHO, 2006), and
updating these estimates is now in progress.”
(Young et al., 2010).
New data is expected in 2012 when the 2010 global
burden of disease study is released.
4.2 Health systems
With few exceptions, sub-Saharan African countries have
poor health care infrastructure and services, relatively
low per capita GDP and a low proportion of GDP (4.3
to 10.3%) spent on healthcare. The average per capita
GDP is 3 703 (PPP-US$), ranging from 434 (PPP-US$),
(Zimbabwe) to 15 498 (PPP-US$), (Botswana) (Table 2).
In 2001, African heads of state committed themselves to
the ‘Abuja Target’ which strives for countries to devote a
minimum of 15% of government funds to health in order
to address the massive burden of ill-health they face.
According to WHO (2009), only Tanzania and Botswana
have achieved this. Angola, Kenya, Lesotho, Nigeria, South
Africa, Swaziland and Zimbabwe are all in single figures.
The source of healthcare financing in sub-Saharan
Africa varies from country to country with some countries
significantly dependant on external funding, for example,
Mozambique and Malawi, and to a lesser degree, Tanzania
and Zambia (see Table 2) (WHO, 2009). In southern
Africa, total expenditure on health (% GDP) in 2006
ranged from 2.6 to 12.9% (WHO, 2009). Young et al.
(2010) note that not only is there a critical shortage of
healthcare workers, but they are also unevenly distributed
between countries and between the public and private
sectors within countries. To achieve enough coverage for
essential health interventions, Anyangwe and Mtonga,
(2007) estimate the health care workforce must be
increased by 140% to achieve a sufficient density and
coverage for a more sustainable health outcomes.
Workers per 1 000 populations
Europe
North America
Western Europe
Middle East
Global
S & Central America
Asia
Sub-Saharan Africa
12
10
8
4
2
0
6
Figure 4: Density of health workers in Africa compared to
other regions
Source: WHO, 2004
To achieve the MDGs, a high level forum on achieving the
health MDGs estimated the minimum workforce density
required at 2.5 health workers/1 000 (WHO, 2006). Only
six countries on the continent meet these criteria, with
the average at 0.8/1 000, significantly lower than the
world median of 5/1 000 (Figure 4).
7
4. STATUS OF HEALTH AND HEALTH-SUPPORTING SYSTEMS
Table 2: Economic and national health account data for LDCs in southern African countries
Country
GDP
(PPP-US$)
(billions)
(2010 IMF)
Per capita
GDP
(PPP-US$)
(2010 IMF)
Inflation,
average
consumer
prices (%)
(2010 IMF)
Total exp on
health as %
of GDP*
General
govt exp
on health
as a % of
total exp on
health*
Private exp
on health
as a % of
total exp on
health*
General
govt exp on
health as a
% of total
govt exp*
External
resources
for health
as a % of
total exp on
health*
Lesotho 3 1 299 4 8.2 68.2 31.8 8.2 30.4
Malawi 13 827 7 6.2 58.0 42.0 12.1 60
Mozambique 22 1 010 13 5.7 73.2 26.8 12.6 72.0
Swaziland 6 5 227 4 6.3 63.3 36.7 9.3 12.2
Tanzania 58 1 413 10 5.1 73.6 26.4 18.1 56.5
Zambia 20 1 512 9 4.8 53.0 47. 0 10.8 50.3
Zimbabwe 5 434 3 no data 38.4 61.6 no data 5.5
Source: WHO 2009b, with the exception of Zimbabwe (2001 data)
Southern Africa’s least developed countries spend an inadequate proportion of their low GDPs on health services, with
resultant overcrowding of poorly resourced facilities.
© Zacharias/van Hasselt
8
5.1 Water supply
Water is one of the key determinants of health and is
central to many of the adverse health impacts of climate
change in southern Africa. While climate change
can aggravate water insecurity (IPCC, 2007a), the
outlook for most countries in the region is mixed and
dependent on the model used. Water has several direct
and indirect effects on human health. Water supply of
poor quality is strongly associated with an important
range of disease-causing bacteria, protozoan parasites
and viruses. The Food and Agriculture Organisation
(FAO) of the United Nations regards water as a severe
constraint on socioeconomic development and
environmental protection at levels of internal renewable
water availability of less than 1 000 m
3
/capita. At levels
of water availability of less than 2 000 m
3
/capita, water is
regarded as a serious constraint and a major problem in
drought years. Water scarcity provides a measure of the
sensitivity of a given situation to drought. In situations
where the average availability of water per capita is low,
even slight variations can render whole communities
unable to cope and create disaster conditions
(FAO, 1993).
Water stress leads to competition for a scarce resource
and increases the risk of contamination by industrial,
mining and agricultural pollution as well as sewage.
Reduced quantity of available water not only impacts
potential food production but also hygiene. Basic
hygiene (personal and household), even using water
of sub-optimal quality, may reduce transmission of
enteric and respiratory pathogens (Luby et al., 2005).
Consequently strategic implications to health relate not
only to improving quality of water to communities, but
also to managing quantities and ensuring downstream
access. Impoverished communities, without access to
adequate reticulated water or facing water stress, are
motivated to store water. However, poor domestic water
storage containers are also implicated in contamination
with infective microorganisms and with the risk of
providing breeding sites for disease vectors such
as mosquitoes.
Community access to improved drinking water sources
ranges from 42% (Mozambique) to 100% (Mauritius)
and improved sanitation from 12% (Madagascar) to 94%
(Mauritius) (2006 data from WHO, 2009) (Table 3).
The lack of universal access to clean water increases
vulnerability to infectious diseases. Water-related health
problems linked to water scarcity are predicted to worsen
due to increased rainfall variability and high temperatures
(Dube and Chimbari, 2009).
Table 3: Southern African region: access to improved
drinking water sources and sanitation
Country Access to improved
drinking water
sources (%)
Access to improved
sanitation (%)
Angola 51 50
Botswana 96 47
DRC 46 31
Lesotho 78 36
Madagascar 47 12
Malawi 76 60
Mauritius 10 0 94
Mozambique 42 31
Namibia 93 35
Seychelles* – –
South Africa 93 59
Swaziland 60 50
Tanzania 55 33
Zambia 58 52
Zimbabwe 81 46
* Data not available
Source: WHO, 2009b
Change in rainfall results in an increased frequency and
severity of droughts in certain areas and floods in others.
Because water is closely linked to food production,
scarcity of water negatively impacts crop and pasture
yields, which can contribute to hunger and further
compound malnutrition. Shortage of water may also
lead to greater reliance on waste water recycling with the
attendant hygiene issues that presents. Gage et al. (2008)
note that droughts usually result in decreases in mosquito
populations and malaria transmission due to the reduced
number and quality of vector breeding sites. However,
receding water levels may also create optimal conditions
for vector breeding sites. Water scarcity also results in
higher concentrations of salt and chemical contaminants
in the water (McMichael, 2009).
GCMs project that rainfall intensity is likely to increase
significantly by 2075, increasing the likelihoods and
risks posed by flooding and erosion, as well as long-term
health-related effects of disease outbreaks and human
displacement (Patz, 2008; Dube and Chimbari, 2009).
Contamination of stormwater discharge by untreated
sewage pollutes water sources (Patz, 2008). According
to Schwartz et al. (2006) these disruptions and changes
in river flows can result in the spread of diarrhoeal
diseases, including salmonella, shigella and notably,
5. Health effects of climate change
9
5. HEALTH EFFECTS OF CLIMATE CHANGE
cholera-causing vibrio bacteria. Disrupted river flows
may contaminate community waters and increase risk of
bacterial, viral and parasitic infections. These waterborne
diseases include a number of bacterial induced
diarrhoeal illnesses (e.g. cholera), as well as viruses
(e.g. hepatitis) and protazoa (such as giardiasis and
cryptosporidiosis) (Patz, 2008). Citing Gage et al. (2008),
Young et al. (2010) note that vectors of disease-causing
pathogens such as malaria, dengue fever (dengue virus)
and bilharzia require open water to complete their life
cycles. The burden of vector-borne diseases is therefore
increased by climate factors such as temperature, rainfall
and humidity, which impact on distribution, increase
pathogen development within the vector, and their
concentration, transmission patterns and intensity and
outbreaks. Algal blooms in nutrient-enriched water
which contain cyano-bacteria and mycrocystin toxins
are an additional waterborne hazard that is emerging
across the region, particularly in South Africa but more
frequently in the less developed countries.
Rising sea levels increase the physical hazards of coastal
inundation, especially as a result of storm surge caused
by increasingly severe storms on the top of high tides
(McMichael, 2009). Damage to coastal infrastructure
(roads, housing, and sanitation systems) would pose direct
risks to health (see Section 5.3) (McMichael, 2009). The
low-lying coastal plains of the east coast of southern
Africa are at risk of inundation, and the Mozambique
Initial National Communication Report, 2003, identified
the Beira coast to be most vulnerable to sea level rise.
0
50
100
150
200
250
0
100
200
300
400
500
600
700
800
900
Rainfall Cholera cases
Number of cholera cases
Rainfall in mm
2003 2004 2005 2006 2007 2008 2009
Figure 5: Cholera outbreaks in Lusaka driven by the
changes in rainfall during the rainy season, showing the
strong association with short-term intense rainfalls
Source: WHO, 2011
5.2 Food security
The greatest impacts on human health in southern
Africa are likely to be those related to existing large scale
vulnerabilities such as water stress and undernutrition
(IPCC, 2007b). Changes in climate, such as increasing
temperatures and changed rainfall quantities and timing,
raise the risks of malnutrition. The WHO’s estimate of
disease burdens already attributable to climate change
in 2000 identified malnutrition as the pre-eminent
component of health loss (Campbell-Lendrum et al., 2007).
Most of that estimated loss (via premature deaths, stunting
and disabling infection) was in young children in developing
countries. Regional and global food yields are predicted to
be mostly negatively affected by climate change, especially
in Africa. This impact will however, be unevenly distributed.
Countries where both warming and reduced rainfall are
likely to occur are at greatest risk (McMichael, 2009).
Even under positive scenarios, indications are that crop
production in southern Africa will be adversely affected by
climate change (Kurukulasuriya and Mendelsohn, 2007;
Seo et al., 2008; Dube and Chimbari, 2009). Impacts are
likely to vary with soil type and crops grown (Dube and
Chimbari, 2009). A shortened growing season and lower
rainfall over most of the central and western land masses
of southern Africa, combined with rapid loss of moisture
due to warming, will further affect crop production in
these regions impacting subsistence farmers (Dube and
Chimbari, 2009).
The latest estimations from FAO are that 95 million
people in southern Africa are undernourished. Extracts
from a recent analysis of hunger and food security in
southern Africa (de Wit and Midgley, 2012) highlight
serious regional circumstances. Persistent high levels of
undernourishment, stagnant production and consumption,
increasing import dependence and declining terms of
trade, increase SADC countries’ vulnerability to shocks
that may disrupt food supplies or diminish the ability to
increase food consumption. According to the report, most
of the SADC member states are not reaching the minimum
calorie intake of 2 100 kcal/person/day, and several other
countries are dangerously close to this level. Worse still,
in almost half of all SADC countries, daily calorie intake
has declined compared to the early nineties (de Wit and
Midgley, 2012).
Declining water supply will reduce livestock production,
especially for subsistence farmers who are dependent on
surface water and rainfed pasture or grassland. Climate
change will also affect livestock production through
changing quantity, quality and cost of forage. Furthermore,
high temperatures and reduced water availability will
affect reproduction of cattle; affecting calving rates, milk
production and general body weight (Dube and Chimbari,
2009) impacting protein availability.
As a result of current crop and pasture failure, people in
countries such as Botswana are abandoning farming and
moving either to cities or bigger settlements in search
of economic opportunities (Oucho, 1995). Informal
urbanisation is associated with poorer housing conditions,
unemployment, mental health conditions, exacerbation of
chronic diseases, poor water and sanitation systems, and
predisposes the population to rapid spread of disease
especially during climate extremes such as floods. Rapid
urbanisation has led to the depletion of natural resources,
urban sprawls and physical infrastructure deficiencies,
as well as increased discharge of unprocessed wastes in
the environment. These have contributed to severe health
problems in many parts of the region.
Harley et al. (2006) write that marine life is likely to be
significantly affected by climate change. Fish populations
important to local coastal communities may migrate to
10
HEALTH AND CLIMATE CHANGE
to higher latitudes, away from warmer water, reducing
protein supplies and impoverishing livelihoods. Damage
to coral reefs by warmer water, CO
2
-induced acidification
and sedimentation from turbid rivers will exacerbate
the situation. The increase of the temperature of the
sea along the Mozambique Channel as a result of the El
Niño phenomenon will have negative impacts on corals,
which are an important part of the Mozambican marine
ecosystem and ecotourism. Warming affects the resurgence
processes responsible for transporting nutrients from the
deep layer of oceans, affecting the fisheries and thereby
having implications on income generation, malnutrition
and health (Dube and Chimbari, 2009).
5.3 Infectious organisms and vectors
The existence of surface water and high humidity encourages
mosquito breeding (Gage et al., 2008; McMichael, 2009).
Anopheline vectors of malaria favour small natural pools of
clean water, droughts therefore decrease vectorbreeding
sites and therefore populations, reducing the opportunities
for transmission (Gage et al., 2008). The effects of the
changing nature of precipitation on malaria transmission
are also co-dependent on the ecology of the vector species
(Gage et al., 2008). In Africa therefore it is likely that
the prevalence of Anopheles gambiae will be affected more
quickly than A. funestus which breeds on the edges of larger
bodies of water (Gage et al., 2008).
In Young et al. (2010), McMichael (2009) explains
that bacteria in food and nutrient-loaded water multiply
more rapidly in warmer conditions, and infectious agents
within mosquitoes (e.g. malaria plasmodium parasites
and dengue virus) also mature more quickly. These
findings are supported by studies in the UK, Australia
and Canada, which demonstrate a correlation between
short-term high temperatures and the rate at which
salmonella food poisoning occurs (Ebi et al., 2008).
Furthermore, the distribution of vectors changes as a
result of local warming; for example, the ascent of malaria
to higher altitudes in parts of eastern and southern Africa
(McMichael, 2009) and the northwards extension of the
water snail that spread schistosomiasis in eastern China
(Gage et al., 2008). In warmer conditions the numbers
of rodents, flies and other pests rise, and the risk of
malaria and other mosquito-borne diseases increases as
mosquitoes reproduce more efficiently and must feed
more often (Gage et al., 2008; McMichael, 2009).
Zoonotic diseases (those that extend from animals
into human populations) are affected by climate-related
changes in the density and movement of the ‘reservoir’
animal species e.g. Rift Valley fever in cattle (McMichael,
2009). In addition, temperature, rainfall and humidity
impact the vector distribution of tick-borne encephalitis
(Ixodes spp., ticks and flaviridae), and the development
and maintenance of pathogens, fecundity of the vector
(flea) and the distribution of plague (Yersinia pestis)
(Gage et al., 2008; Young et al., 2010).
Trypanosoma brucei gambiense/rhodesiense (human
African trypanosomiasis), or African sleeping sickness,
is endemic in 13 eastern and southern African countries
but represents less than 10% of reported cases (in central
and west Africa most are a result of T. b. gambiense) (WHO,
2010). Changes in distribution appear to be driven by
demographic and climate dynamics and climate change
and loss of tsetse habitat may be reducing disease
incidences in West Africa. Malawi and Zambia have
reported the most affected cases in recent years, with
less than 100 cases per year (WHO, 2010b). However, it is
suspected that the number of reported cases in southern
Africa is a fraction of the real number of infected people.
Controls of the disease are quite complex and national
health systems need to be strengthened to reduce
misdiagnosis, under-reporting and control systems which
include livestock, wildlife and vector management.
Leishmaniasis is caused by protozoan parasites transmitted
through the bites of sand flies. Of the three forms of the
disease (cutaneous, mucocutaneous and visceral), visceral is
the most prevalent in southern Africa (known as kala azar).
However, cutaneous leishmaniasis is known throughout
the western parts of southern Africa and it is reported
that co-infection of leishmaniasis with HIV is an emerging
and urgent problem, with frequent fatal outcomes (WHO,
2010b). The disease has particular gender and age-related
outcomes that are a result of socioeconomic and cultural
conditions. Epidemics can occur when large numbers of
people migrate to urban centres, where conditions can
favour explosive epidemics amongst densely populated non-
immune hosts (WHO, 2010b). The size of the problem is not
known due to under-reporting.
Onchocerciasis or ‘river blindness’ is caused by the filarial
worm Onchocerca volvulus which moves through the body
causing an inflammatory response in affected organs and
a variety of conditions, including blindness. It is endemic
in the northern countries of southern Africa, particularly
Angola, DRC, Malawi and Tanzania. The disease is controlled
to a certain extent by insecticide treatments and prevalence
is on the wane (WHO, 2010b). The number of simulium
(blackflies), which is the vector of onchocerciasis, decreases
during heavy rainfall when breeding sites may be washed
away (Opara et al., 2005). It is likely that rapidly varying
water levels reduce blackfly abundance by creating difficult
breeding conditions. Changes in climate, that increase river
flow variability, may decrease simulium life cycle completion.
5.4 Extreme weather events
Extreme weather and natural disasters are associated with
significant mortality and morbidity. There are indications
that there is increased tropical cyclone activity in the Indian
Ocean (Dube and Chimbari, 2009; INGC, 2009). Climate
hazards such as tropical cyclones, storm surges and sea level
rise have both short- and long-term effects on human health
and general livelihoods, which include, inter alia:
• death, injuries, destruction and loss of property
(including food stores) leading to sudden change in
community structures and family composition, with
resultant psychosocial disorders;
• increased susceptibility to infectious diseases due
to waterborne diseases, population displacement,
overcrowding, and shortage of food;
11
5. HEALTH EFFECTS OF CLIMATE CHANGE
• destroyed infrastructure and disrupted healthcare
services;
• decline in food security and increased malnutrition from
contaminated coastal land that makes soil unsuitable
for cultivation due to sea level rise (Government of
Seychelles, 2000, in Dube and Chimbari, 2009) and
disturbance of food distribution infrastructure;
• loss of tourism income; and
• increased geographical range of diseases, where
inundation and flooding extend into new areas.
5.5 HIV/AIDS
A crosscutting development issue is the HIV pandemic. Of
an estimated 34 million HIV infected individuals worldwide,
the vast majority are in sub-Saharan Africa. Southern Africa
is the most heavily affected region with reported adult
prevalence rates in several countries above 20%.
The extent of the pandemic and its consequent
demands have required mobilisation of resources on an
unprecedented scale. Scarce regional capacity has been
drawn into HIV/AIDS programmes, perhaps leading to
neglect of other areas of primary health care and public
health. A consequence of this effort is that excellent
programmes (and data) exist for HIV in many countries,
while comparatively few resources and monitoring is
available for a host of other diseases and illnesses of
epidemiological and public health importance.
While substantial progress has been made in addressing
the pandemic, climate change contributes additional
stress to a complex set of health determinants (poverty, lack
of social cohesion and survival strategies etc.) associated
with increased risk of contracting HIV and other sexually
transmitted infections (STI) (Mignone, 2002).
Population displacement through lost livelihoods and
dislocated communities following natural disasters and
extreme weather are examples of climate-related stressors
which may be relevant in the context of HIV prevention and
uninterrupted treatment. Social determinants of health
(poverty, social disruption, etc.) and basic livelihood
strategies drive HIV transmission. Climate change, with
its dynamic suite of influences, adds to these stresses
and increases the risk of spread. The direct link with the
HIV/AIDS pandemic comes with increased vulnerability
of immune-compromised patients to infectious disease,
including respiratory, waterborne and opportunistic
infections due to the impact of climate change on water
quantity and quality (see Section 5.3 for other important
implications for AIDS patients).
In turn, HIV/AIDS disproportionately impacts women,
increasing their vulnerability to climate-related health
problems, with consequent effects on family cohesion and
livelihoods. Vulnerability to infectious diseases is exacerbated
by depressed immunity and malnutrition, as above.
Namibia’s Review and Update of National Circumstances
(September 2009) includes a detailed analysis of the
impact of HIV/AIDS on the capacity of critical sectors to
respond to the challenges of climate change in Namibia.
Several publications have drawn attention to the negative
effects of the HIV/AIDS pandemic on the provision of safe
water supply and efficient resource management (Ashton
and Ramasar, 2001).
On the demand side, households providing home-based
care for AIDS patients have clearly recognised needs for
a safe and adequate water supply and sanitation services,
as priorities. WASH (water, sanitation and hygiene)
programmes are a well-recognised strategy to avoid
opportunistic infections in HIV infected individuals.
Home-based care requires more quality water than the 20
litres per capita per day that is considered ‘basic access’. A
Botswana case study showed households adequately caring
for HIV/AIDS patients exceeds normal consumption rates
by two to five times (Ngwenya and Kgathi, 2006).
Furthermore, access to water impacts livelihoods and
considerations such as the crucial importance of clean
water for infant feeding and food security (see Section 5.2).
As effective treatment is rolled out, HIV is increasingly
a chronic disease requiring long-term management.
Resource demands may therefore shift but will remain
substantial in the foreseeable future with large case
loads and ongoing needs to prevent new infections. The
pandemic will therefore continue to be a health priority,
which will demand and possibly compete with climate
change adaptation for allocation of adequate resources.
Health system strengthening (HSS) as an integrated
approach to health challenges then becomes essential
to avoid concentrations of capacity addressing only one
particular set of health problems. Perhaps in recognition
of this, the United States President’s Emergency Plan
for AIDS Relief (PEPFAR) – the largest foreign aid HIV
programme for Africa (The Economist, 2011) – is now
increasingly emphasising the importance of HSS.
The world has been changed by the pandemic. HIV/
AIDS is widely recognised as a development challenge
that requires a multi-sector response. Climate change
poses even more significant development problems, and
health adaptation responses similarly require multi-sector
involvement. Traditional health sector-specific responses
alone are unlikely to provide sufficient adaptive capacity
to meet the adverse health impacts of climate change, as
well as the ongoing needs of the HIV pandemic. Preventing
the spread of the pandemic remains a critical priority in
the region – for every individual in the region that goes
on treatment, two more are infected (The Economist, 2011).
The current demands that the pandemic places on the
health system, and the vulnerabilities it creates, will come
under additional pressure with dynamic wide-ranging
impacts of climate change on the region. Fundamentally
there are not enough resources in the region to address
these issues separately.
The response to the HIV pandemic has illustrated the
ability to mount an unprecedented scale response, and
key lessons regarding advocacy, education, awareness
and community based services may be applied to climate
change health impacts. Successful strategies to address the
HIV/AIDS pandemic need to be integrated to underpin
sustainable HSS, and so address existing vulnerabilities
and future risks to climate change. This includes planning
of programmes, human resources allocation and general
12
HEALTH AND CLIMATE CHANGE
capacity spread within the public health systems in response
to clear and substantiated priorities. Integrating the
specific needs of HIV and other disease programmes such
as malaria, with broader development to increase resilience
to climate change is necessary (Cohen et al., 2005).
5.6 Other health issues
Unexpected and entirely new health challenges are a
possible consequence of altered environmental conditions.
Large scale population displacement and migration may be
associated with unexpected disease outbreaks. The literature
indicates the possibility of new and emerging tropical
diseases, and an expected increase in zoonotic diseases. While
these conditions may not be the most likely or prominent
(quantitative) health impacts of climate change, unexpected
disease outbreaks can require significant resources and
demand deployment of scarce capacity. Disease outbreak
monitoring and response is an area of opportunity for
collaboration in the region as this requires particular skills,
and can allow for leveraged use and deployment of scarce
capacity, specifically outbreak response teams.
Young et al., (2010) note that chronic environmental
stress can result in mental health disorders, and that
displacement, loss of family members by disabling
injuries, post-traumatic stress disorder, impoverishment
or lost livelihoods through the consequences of climate
change can lead to anxiety and depression and/or suicide
(Berry et al., 2010). Mental health is under resourced
and neglected in Africa and it can be anticipated that
significant additional mental health burdens may occur.
5.7 National, regional and international
initiatives
Despite a rising number of research organisations
studying climate change in southern Africa, very few
are conducting explicit research on climate change and
health. Most of the work on climate change is primarily
adaptation focused and is being carried out through
networks based in Europe and the US, funded largely by
first world development agencies and academic grants
(Dube and Chimbari, 2009).
Dube and Chimbari (2009) identified a total of 36
networks based in southern Africa including: African
Technology Policy System (ATPS), Capacity Strengthening
of Least Developed Countries on Climate Change
Adaptation (CLACC), ZERO Zimbabwe, CARE Zimbabwe,
Global Network on Climate Change in Africa (in the process
of being formed), African Climate Change Fellowship
Programme (ACCFP), Climate Change Adaptation in Africa
(CCAA), Climate Systems Analysis Group at UCT and the
climate research group at Witwatersrand University that is
conducting research on climate change in southern Africa.
Faure (2009) further highlighted the fact that the
health sector has been overlooked in the region despite
the recognition of the impacts climate change will have
on it. Young et al. (2010) revisited the issue by identifying
a further 30 institutions undertaking climate change
research and of those only two explicitly integrated health.
The activities that have taken place include the modelling
of climate impacts on cholera outbreaks by CSIR in South
Africa, and Mash (2009) published an impact paper calling
for the health profession to respond to climate change as
opinion leaders, as professional bodies and as an industry.
Beyond the region there is international recognition of
the essential connection between climate change and
health as evidenced by leading medical schools founding
specific research units such as Harvard’s Centre for
Health and the Global Environment. However few, if any,
of the southern African Schools of Public Health have
curriculum content on climate change and health and no
readily identifiable research on the connections between
climate change and public health.
Standing water, poor sanitation and unremoved refuse contribute to hazardous conditions for
people living in unserviced informal settlements such as this one in Lusaka, Zambia.
© James Cumming/OneWorld
13
Southern Africa’s development is inextricably linked
to the region’s varied and unique climatic conditions
embedded within fragile social, economic and governance
contexts. Economic and human development is central
to the effort to reduce chronic poverty and vulnerability
of the poor. The adaptive capacity and resilience
of the region’s population to climate change is also
directly linked to achieving more appropriate levels of
development. In 2000 the United Nations created the
Millennium Development Goals (MDGs) to direct and
monitor development efforts across the globe for the
period 2000–2015, with the primary aim of advancing the
human condition. These were endorsed by 189 nations
and adopted as key commitments by all southern Africa
countries. Since 2008, the MDGs comprise eight goals,
21 targets and 60 indicators (Chapman et al., 2011). The
goals and objectives are underpinned by a strong health
focus with time-bound quantified benchmarks, and
serve as a useful barometer of development for southern
Africa and for assessing the capacity for improving health
indicators across the region. The achievement of the goals
is particularly critical for the seven LDCs within southern
Africa. These countries are characterised by widespread
poverty and human vulnerability, as well as weak financial
and human capacity to drive development.
The MDGs address the following measures of health:
• population access to basic human needs and key
determinates of health and vulnerability: access to
food, safe water, sanitation, health care and affordable
essential drugs;
• baseline population health status: under-five
nutritional status; under-five, infant and maternal
mortality; HIV prevalence amongst pregnant women;
TB prevalence and mortality; malaria prevalence and
mortality; and
• health care delivery and public health system
performance: proportion of one-year-old children
immunised against measles; births attended by skilled
personnel; population in malaria-risk areas using
effective malaria prevention and treatment measures;
TB cases detected and cured under directly observed
treatment short-course (DOTS).
To meet the MDG goals of providing access to clean and
affordable water, food, health services and energy services
for the poor, there must be sufficient supply of these
resources and services to meet the demand. The current
gap between demand and supply in southern Africa is
stark, most markedly evident in health services. The health
sector has three core MDGs (4, 5 and 6), with a close link
to one indicator in MDG8 (proportion of population
with sustainable access to affordable essential drugs)
and is implicit in MDG1 (nutrition) and MDG7 (access
to improved water and sanitation; indoor air pollution
from reliance on solid fuel combustion; peri-urban slum
conditions). Weak public healthcare systems in many
southern African countries are the biggest inhibitor
to achieving the MDGs and will need to be considered
a core focus for adaptation interventions in line with
climate change.
Assessments have been undertaken into the
achievement of MDG goals and are based on performance
and show that countries in sub-Saharan Africa (SSA) are
not achieving goals and in many cases there are no data to
monitor progress. The key shortfalls in SSA cluster around
MDG1 (poverty, unemployment and hunger), MDG4
(child mortality) and MDG5 (maternal mortality, which is
particularly slow to improve). HIV/AIDS and TB (MDG6)
remain debilitating health issues, with the latter showing
little improvement, and progress on MDG7 (sanitation,
safe water, conditions in slums) also slow. On the positive
side most countries in SSA are making good progress on
the goal of girls having access to primary school education.
Present trends indicate that the health-related goals are
the least likely to be met in SSA, despite the availability
of powerful drugs, vaccines and other tools to support
their achievement (Chapman et al., 2011). Current levels
of commitment fall short and significant targeted and
system-wide investments with systemic implementation
of sustainable solutions are needed to improve the
attainment of targets. Weaknesses in infrastructure and
governance need to be overcome to avoid squandering
resources. Chapman et al. (2011) carried out a detailed
analysis on four countries in southern Africa: Zambia,
Tanzania, Malawi and Mozambique. The United Nations
(UN) considers all four of these countries to be LDCs with
limited capacity to make the required progress on reaching
their MDG targets by 2015. Chapman et al. (2010) showed
that health targets are seemingly unattainable in these
countries. The burden of disease in the whole region is
such that even small increases in disease pressure linked
to climate change would severely impact the health of
already vulnerable populations. Women and children are
particularly vulnerable to climate change-related impacts
(see Section 5).
6. Expected impacts and vulnerabilities in
the development context
14
HEALTH AND CLIMATE CHANGE
6.1 MDG progress as a measure of resilience
The current status of low progress as illustrated by the
country analysis by Chapman et al. (2011) illustrates the
difficulty in achieving the MDG targets in these countries
starting from a very low baseline, with high levels of poverty.
Despite considerable progress in some LDCs, coming off
a low baseline means that improvements cannot be seen
as a good indicator of climate change resilience in the
health sector or as significant improvements in structures
needed for adaptation. Chapman et al. (2011) found that
even the target achievement in LDCs still leaves the system
highly vulnerable and does not result in good health
status, e.g. if the target is achieved, Malawi will still see
27% living in poverty and 14% of the country’s population
undernourished. However, many of the MDGs specifically
focused on health are well aligned to the health priorities
that need to be met to increase resilience to climate
related impacts.
Consequently the MDG structure and frameworks have
merit and need consideration in a policy and strategic
approach, as the existing indictor basis and capacity that
has focused on achieving these goals can be built upon to
integrate actions to address climate related vulnerabilities
in the health sector. While MDGs are not specific in how
they are to be achieved, they describe the most basic
human rights and support systems required for improving
the lives of a population, and the trends required.
While such MDG standards are taken for granted in the
developed world, achievement of minimum standards in
southern Africa remains an ongoing challenge (Chapman,
et al., 2011). In building specific climate related resilience
and adaptation interventions in the health sector in
relation to climate change, the 2015 achievement target
of the MDGs cannot be taken as the goal, and a trajectory
beyond 2015 would be more realistic.
The wide ranging and dynamic impacts of climate
change require a pragmatic, resource matched scalar
plan that looks to build sustainable capacity and is
focused on HSS as the overall goal. The focus of regional
capacity towards achieving the MDGs needs to be
aligned towards integrated health sector strengthening
approach. By focusing on an integrated health system,
the data collection and monitoring frameworks in line
with the MDGs can be tailored to produce a more robust,
reliable and practical data set to form pragmatic policy
interventions based on critical need across the region.
Increasingly frequent extreme weather events emphasise the importance of urban planning for exposed communities.
Storm damage in the Limete district on the outskirts of Kinshasa, DRC
© Delphin Bateko/Africa Media Online
15
A scaled and spatial approach to the issues in
southern Africa is needed in analysing the key impacts
climate change will have upon health. This requires
an empirically based spatial analysis that assesses
vulnerability to existing and predicted climate impacts.
Multiple frameworks for assessing vulnerability exist.
However, Christensen et al., (2007) provides an
authoritative framework. In the context of understanding
the impacts climate change will inflict on a spatial scale,
a suite of cumulative and compounding factors that
weaken systems vulnerability are needed. Christensen et
al., (2007) defines vulnerability as the degree to which
a system is susceptible to and unable to cope with the
adverse affects of climate change, including the context
specific risk variability and extremes.
Vulnerability is a function of the character, magnitude
and rate of climate change and variation to which each
individual country in the region is exposed. In this
light the sensitivity to this exposure differs both on a
biophysical level and in the context of health parameters,
specifically the adaptive capacity to integrate and adapt
to such stresses. Therefore the value of a spatially mapped
approach is that it clearly outlines the vulnerability to
climate change by combining exposure to risk factors
and the sensitivity to these factors, which comprises the
potential impacts of such risks. This risk is context specific
and looks at a particular hazard and its probability and
the cumulative risk based on the capacity to manage and
respond accordingly to those risks. Consequently assessing
the impacts of climate change on the health sector needs
to take a scaled approach that is both comprehensive in
time and spatial extent, as predicted impacts over a 20–40
year time span will differ significantly, and require timely
policy interventions to address future impacts.
Midgley et al. (2011) carried out a robust spatial analysis
of both the status quo (2008) and futures (2050) of climate
change using adaptive capacity, sensitivity and exposure as
the three primary metrics for overlay analysis, with a total
of 51 data layers depicting overall ‘hotspots’ of impacts.
Databases connected to health were strongly represented
and weighted in the overall analysis, illustrating health risk
and vulnerability and the adaptive capacity of countries in
the region.
The analysis of current vulnerabilities by Midgley et al.
(2011), utilising 2008 as the status quo, found that the
region’s most sensitive to climate risk follow the Afro-
montane belt and include Lesotho, Zimbabwe, Swaziland and
Malawi, followed by South Africa, Tanzania, Zambia and parts
of Madagascar. The countries follow the eastern seaboard
where droughts, floods and cyclones occur regularly, but
more arid regions towards the west are also exposed to risk.
This results in a broad latitudinal band of high exposure
across the sub-tropics (about 12–25°S). When sensitivity is
combined with exposure, Midgley et al. (2011) found that
Swaziland, Lesotho, Zimbabwe and Malawi, followed by
parts of Madagascar, Mozambique, Zambia and Tanzania to
be most vulnerable. The spatial data clearly illustrates the
heterogeneity across the SADC countries in their capacity to
adapt to climate variability and change.
This aspect of adaptation is specifically relevant to
health, as six key data layers included in the analysis have
an integral role in adaptive capacity of a country to react to
the additional stress climate change places on key health
indicators. When Midgley et al. (2011) applied an adaptive
capacity factor (to give an indication of vulnerability)
there was clear separation between areas where countries
have higher capacity (particularly Mauritius, South Africa,
Botswana and Namibia), and others with much lower adaptive
capacity (Mozambique, Madagascar, Malawi, in addition to
Zimbabwe, Lesotho and Swaziland). Zambia, Angola and
DRC emerged as intermediate. In-country heterogeneity
in adaptive capacity is also evident in the region. Some
countries, for example, Zambia, Angola, DRC and Tanzania
display highly differential results at a sub-national level, with
some parts of the country showing high vulnerability and
others lower vulnerability (Midgley et al., 2011).
The value of Midgley et al.’s analysis is the addition of
the futures analysis, including both predicted climate
changes and population data to give scenarios of predicted
vulnerable areas in 2050. The future ‘exposure’ category
showed a broadening of the high exposure latitudinal band
up to 30°S, and also extending into northern Angola and
the DRC. Five major clusters emerged as highly exposed
to climate change: 1) central Tanzania; 2) a large area
incorporating southern and central Mozambique, Malawi,
Zimbabwe and southern Zambia; 3) most of Madagascar;
4) southern and north-western Angola; and 5) southern
and particularly western DRC (Midgley et al., 2011).
The spatial analysis illustrates deepening and greater extent
of ‘hotspots’ highly vulnerable to climate change. These need
to be considered carefully in the context of their existing
public health structures and acute pressures at present. The
spatial analysis by Midgley et al. (2011) integrates key health
metrics, which have a significant impact on the adaptive
capacity of a country to climate change.
These health metrics include:
• Malnourishment in children under-5 (proportion
below the normal weight): spatially this layer indicates
balance or imbalance between people and their food
7. Hotspots of specific vulnerability in
southern Africa
16
HEALTH AND CLIMATE CHANGE
supplies. (This is considered one of the best indicators
of human poverty) (Center for International Earth
Science Information Network (CIESIN), Columbia
University, 2005.
• Health expenditure per capita (sum of public and
private expenditure in PPP-US$ divided by the mid-
year population): used in the analysis to indicate the
relative health levels of each country in the SADC
region. Health expenditure includes the provision
of health services (preventive and curative), family
planning activities, nutrition activities and emergency
aid designated for health, but excludes the provision
of water and sanitation (UNDP, 2007).
• Malaria incidence: integrated into adaptive capacity
utilising empirical epidemiological data.
• Tsetse fly habitat suitability: also integrated, as tsetse
flies are an important vector for disease in rural Africa.
• HIV prevalence: used to indicate the relative influence
of the disease among SADC countries (percentage of
people aged 15–49 years who are infected with HIV)
(UNDP, 2007).
• Access to improved water: used to indicate the
relative influence of disease among SADC countries.
This indicator gives the share of the population
with reasonable access (availability of at least 20
litres/person/day from a source within 1 km of his/
her dwelling) to any of the following types of water
supply for drinking: household connections, public
standpipes, boreholes, protected dug wells, protected
springs and rainwater collection (UNDP, 2007).
• Diet parameters: also included in the analysis as
countries with dietary diversity are considered less
sensitive to the effects of climate change (FAO, 2006).
The overall result of inclusion of these health indicators
into adaptive capacity needs to be analysed within the
overall context of vulnerability, especially considering
the predictions for 2050. Midgley et al. (2011) found
the inclusion of climate and population futures leads
to a broadening and intensification of problem areas in
southern and central Angola extending into northern
Namibia and western Zambia, as well as south-western
Figure 6: Predicted exposure to risk in 2050 considering health and food security status. Red indicates high levels of risk,
yellow indicates medium levels, blue indicates low levels.
Source: Midgley et al., 2011
17
7. HOTSPOTS OF SPECIFIC VULNERABILITY IN SOUTHERN AFRICA
Figure 7: Hotspots of climate vulnerability in the region predicted for 2050. This map combines considerations of
sensitivity, exposure to risk and adaptive capacity. Red indicates high levels of risk, yellow indicates medium levels, blue
indicates low levels.
Source: Midgley et al., 2011
Madagascar. The countries most highly impacted
are Zimbabwe, Malawi, Lesotho and Swaziland,
and substantial portions of Zambia, Mozambique,
Madagascar and Angola. Lower impacts emerged in the
southern and coastal areas of South Africa, and the
southern Namib Desert, in addition to currently less
impacted areas of northern Mozambique/southern
Tanzania, north-western Tanzania, northern Zambia,
north-eastern Angola and large parts of the DRC
(Figure 6).
By 2050 large extensions in future hotspots are evident
across southern and central Angola, and large parts of
southern and western DRC (the north-western parts of
southern Africa), owing to the lower adaptive capacity
of these regions combined with greater climate exposure
(Figure 6). As health indicators impact significantly on
overall adaptive capacity, it is these specific areas within
the region which need to be given special attention
with regards to their existing public health status and
preparedness. The analysis also found that central-
eastern regions (southern Zambia, Zimbabwe, Malawi,
southern and central Mozambique, Madagascar) remain
as hotspots, and the north-eastern hotspot regions
(northern Mozambique, Tanzania) become less intensive
(Midgley et al., 2011).
In summary, five major clusters of vulnerability to
climate change emerge and consequently need to
be considered contextually important with regard
to policy interventions. These areas are: 1) central
Tanzania; 2) a large area incorporating southern
and central Mozambique, Malawi, Zimbabwe and
southern Zambia; 3) most of Madagascar; 4) southern
and north-western Angola; and 5) southern and
particularly, western DRC.
18
Along with economic growth, population growth is a one
of the most powerful drivers of future socioeconomic
outcomes of a region (Hughes et al., 2010) The nature
of population growth, combined with the availability of
good quality food, water, clean energy and other aspects
of human development, will have powerful influences on
the state of health of future populations in the region.
These evolving demands may drive expanding economies
(Hughes et al., 2009). Consequently future economic
growth needs to fundamentally underpin a programmatic
approach to health system strengthening.
The International Futures (IFs) global modelling system
provides a valuable tool to assess the possible future
socioeconomic conditions of the countries of southern
Africa and what key drivers of their health outcomes may
be (Hughes et al., 2011). It builds on the work of the World
Health Organization’s (WHO) global burden of disease
(GBD) project, which has produced the only published
global forecasts of regional and cause-specific health
outcomes to date. GBD was not, however, designed to
produce integrated long-term future forecasts. Therefore,
when dealing with long-term climate change, long-term
forecasts of mortality and disease burden and a coherent
understand of population growth are essential for setting
current and future health system priorities (Hughes et al.,
2011).
Analytical results of the Base Case (IFs v6.38) for southern
Africa (Table 3) forecast that increased wealth and access to
resources will have a generally beneficial influence on the
status of human health in the region over the next 40 years.
This is despite strong population growth in most southern
African countries to 2050. IFs forecast that socioeconomic
development in southern Africa over the next 40 years
could be sufficient, under a ‘business-as-usual’ scenario, to
substantially reduce the number of malnourished children
(<5) in all countries with the exception of three, namely
DRC, Madagascar and Malawi (see Table 3).
The economies of these countries are largely agrarian
and there is a low level of economic diversity (CIA, 2012).
The levels of malnutrition in the DRC are forecast to
increase, despite increases in agricultural production
(based on modelling using IFs v6.38). Madagascar and
Malawi are likely to show no improvement in their
condition. In these three countries, the number of
people living on less than US$1.25 per day is expected
to nearly double. One of the key influences of climate
change on human health will therefore evolve through
its impact on food security and shocks to already
vulnerable populations. These projections by IFs indicate
an increasing vulnerability to climate shocks in some
countries from a nutrition point of view. This view is
supported by de Wit and Midgley (2012), writing that:
“Addressing the underlying, systemic causes of food
insecurity in southern Africa will go a long way towards
absorbing shocks brought about by expected increases in
climate variability, and longer-term climate changes.”
This modelling and scenarios approach is critical as a
complement to the SANA approach and adds valuable
empirical evidence to spatially based risk and vulnerability
evidence to guide on policy recommendation. It is the
trajectories and trends which the IFs predicts which
allows coherent scenarios to be formulated, and can allow
targeted interventions to facilitate a health strengthening
strategy to be promulgated.
8. Assessing future conditions in the
region and the impact on health
19
Table 3: IFS projections of some socioeconomic indicators over the period 2010–2050, history plus forecast
Country % Pop. change Agricultural
products
(% change mil.
tonnes)
Poverty
(<1.25$ /day)
Water use
(% of renewable
resources)
Diarrhoea
(Years life
lost – YLL)
Malnutrition
(children <5 yrs)
Angola 134 57 –100 113 –80 –54
Botswana 37 11 –61 31 –85 –57
DRC 17 8 114 89 16 0 –53 42
Lesotho 38 19 – 14 33 –85 – 70
Madagascar 152 10 9 113 137 –67 3
Malawi 158 16 9 99 162 –73 –1
Mauritius 9 68 –90 17 –67 –58
Mozambique 113 10 3 –95 111 – 98 –79
Namibia 76 25 –29 61 –80 –69
South Africa 14 17 –79 15 – 88 –72
Swaziland 55 16 –9 42 –85 –63
Tanzania 12 8 101 –97 119 – 97 –79
Zambia 140 62 –43 115 –80 –54
Zimbabwe 65 86 38 71 –58 –94
Source: Base Case IFs v6.38, Hughes et al., 2011
Modern diagnostic technologies play a vital role in combating pandemics. South African Health Minister Aaron
Motsoaledi inspects a new TB diagnosis tool, Prince Mshiyeni Hospital, Umlazi, South Africa.
© Rogan Ward/Africa Media Online
20
WHO features prominently in the region, from which
countries seek endorsement and direction in terms of
health goals, and whose work feeds directly into other
key environmental organisations such as UNEP and the
United Nations Framework Convention on Climate Change
(UNFCCC). WHO remains critically important in guiding
norms and standards of best practice for health in Africa.
WHO’s regional presence with national representatives in
each country, supported by regional centres and action
on advocacy and targeted programmatic action is also
unsurpassed in the region. At the 62
nd
World Health
Assembly (2009), a resolution on climate change and
health was passed including a work plan to scale up
WHO’s technical assistance to countries to assess and
address the implications of climate change for health and
health systems.
Based on health risk assessments at a global and national
level, WHO concluded that while the effects of sudden-
impact extreme weather events will have important
health consequences, slow-onset events related to climate
change are likely to have a much larger aggregate impact.
WHO has also consistently identified SSA as the world’s
most vulnerable region to the adverse health impacts of
climate change.
WHO (AFRO), working with UNEP, has been
instrumental in advocating for greater awareness and
commitment to addressing climate change in SSA. Effort
has been systematically aimed at securing leadership
commitment from all of Africa’s ministers of health and
environment to address climate change, emphasising
adaptation in general and health adaptation measures
in particular.
At the Second Interministerial Conference on Health
and Environment in Africa that took place in Angola in
2010, African ministers of health and of environment
committed to adopt the Joint Statement of on Climate
Change and Health in Africa. Ministers prioritised
provision of safe drinking water; provision of sanitation
and hygiene services; management of environmental
and health risks related to climate variability; vector
control; food safety and security; environmental health
of children and women; health in the workplace; and
management of natural and human-induced disasters.
Responding to these commitments, a joint WHO UNEP
technical team drafted a proposed framework for a
comprehensive, integrated health sector response for
public health adaptation to climate change in Africa.
The framework represents an evidence-based, systematic
approach to lend structure and support at a technical
level, to implement government commitments regarding
health and climate changes. In September 2011, at the
61
st
Session of the WHO Regional Committee for Africa,
all African ministers of health adopted the Framework
for Public Health Adaptation to Climate Change. They
committed to immediately initiate its implementation by
undertaking baseline risk and capacity assessments as an
immediate priority, to establish the current population’s
vulnerability to climate-sensitive health risks and the
degree to which national health systems can respond
effectively and manage these risks.
WHO and UNEP are promoting the deployment of an
essential public health package to enhance resilience
to climate change in developing countries. The package
provides a set of interventions for ‘climate-resilient’ HSS
in LDCs that include:
• comprehensive assessment of the risks posed by
climate variability and change in public health and
health systems;
• strengthening country’s capacity for the delivery of
preventive and curative interventions for the effective
management of identified climate-sensitive public
health concerns;
• preparedness for and response to public health
consequences of extreme weather events including
population displacement;
• research on local-level health effects of climate
change and on locally appropriate adaptation
measures;
• an integrated environment and health surveillance
system, including meteorological surveillance; and
• inter-sectoral coordination and health representation
in national and international development,
humanitarian, and climate policy forums.
9.1 Decision support systems
WHO provides access to important technical assistance to
assess vulnerability, needs and capacity. WHO’s Situation
Analysis and Needs Assessment (SANA) can be utilised as
a first step in a climate change prioritisation approach
to health by individual countries. The SANA places
ecosystems on which livelihoods depend at the centre
of the analysis and addresses an array of environmental
health determinants; the drivers that determine their
associated risk levels; and the management of these risks
(WHO, 2009b). The SANA tool adds further depth to the
process as it addresses national policies and legislation,
as well as technical and institutional capacities and
approaches to inter-sectoral coordination mechanisms
and resources.
9. International leadership and
commitments
21
9. INTERNATIONAL LEADERSHIP AND COMMITMENTS
A WHO vulnerability and adaptation assessment tool has
been developed as a next step to the SANA and enables:
• identification of the human health risks for current
climate variability and recent climate change, and
the public health policies and programmes to address
the risks;
• projection of future health risks and impacts;
• identification and prioritisation of policies and
programmes to address current and projected health
risks; and
• establishment of a process for monitoring and
managing the health risks.
The assessment is aimed at providing evidence of the
linkages between climate and health at a national level;
improving understanding of local and specific health risks
and vulnerabilities; identifying capacity constraints, and
to serve as a baseline analysis to monitor how health risks
may be influenced.
Outcomes of the vulnerability assessment (VA) and
SANA should provide coherent information on the scope
and magnitude of likely climate change health risks, and
therefore enable policy prioritisation and the development
of National Plans of Joint Action (NPJA). (Figures 7 and 8).
Process Categories
1. Establish a scaled strategic health-and-environmental alliance
2. Develop a rigorous updating process of national frameworks
3. Integrate objectives across sectors
4. Strengthen health and environmental institutional baselines
and cement partnership agreements
5. Support knowledge acquisition and analysis
6. Establish and strengthen systems of environmental
surveillance and monitoring
7. Institutionalise mechanisms for enforcing international
conventions and regulations
8. Set up regional, national and local monitoring and evaluation
mechanisms
9. Build capacity for robust assessment of current and future
health and environmental risks
10. Develop partnerships for targeted advocacy
11. Achieve balance in budgetary resource allocation for priority
programmes and key areas of risk
1. Advocacy
2. Policy
3. Regulations and legislation
4. Inter-sectoral coordination
5. Institutional arrangements
6. Organisational arrangements
7. Human resources
8. Financial resources
9. Research
Figure 7: Process of assessment and key output categories
Situation
Analysis &
Needs
Assessment
Country
status
Vulnerability
assessment Baseline
NPJA &
linkages
to MDG
indicators
Figure 8: Methodology for achieving a structured policy approach to health risks attributable to climate change
22
HEALTH AND CLIMATE CHANGE
The SANA process is underway, and completed in
several countries of the region. However the NPJA had
commenced in only one country as of 2011 (Table 4).
Table 4: Status of SANAs and NPJAs in sub-Saharan Africa
Country SANA status NPJA status
Started Completed Started Completed
Angola X
Botswana X
Congo X X
DRC X X
Lesotho X X
Madagascar X X X
Mozambique X
Seychelles X
Tanzania X X
Source: Adapted from Manga, 2011
The SANA is intended to feed directly into the development
of NPJA. The evidence base is used to define an overall
framework with indicators and direct linkages, through
an inter-sectoral analysis, on which to build a national
baseline. This also allows countries to be compared in
relation to the baseline and indicates how each country
ranks compared to the specific action points required to
achieve their set objectives and targets (WHO, 2009a).
This would feed into a coherent national and regional
approach to meeting established milestones on health
and environment, such as the MDGs.
In addition, WHO, UNEP and experts have analysed
various budget scenarios for the envisaged NAPA’s and have
estimated the minimum average cost that supplementary
activities for health adaptation programmes (for climate
change) would require per capita per year over five years,
as per Resolution AFR/RC61/R2 (WHO, 2011).
WHO is coordinating major pilot projects in 14
countries to generate the knowledge and capacity needed
to efficiently scale up climate change solutions. This feeds
into the objectives and work programmes of the UNFCCC,
where parties have committed to avoid adverse impacts
on ‘human health and welfare’ (Article 1, paragraph
1). However, it is worth noting that UNFCCC delegates
consider that health is relatively neglected compared to
the importance that it should have within climate change
negotiations (Singh et al., 2011).
9.2 Enhancing capacity
The key need and objective of the outcome of such
assessment is to encourage policy interventions that
are effective in preventative action of climate related
hazards. Enhanced capacity needs to focus directly on
assessing a partnership approach between NGOs, the
private sector, and national health systems to encompass
a robust planning and an analytical contribution to
national government plans. Effort needs to focus both
on longer term slow onset climate related variables, as
well as preparedness for rapid onset disasters. Complex
emergencies can rapidly materialise from extreme weather
events, resulting in huge health burdens and possible
humanitarian crises. WHO has proposed measures to
address these including:
• a multi-sectoral approach focused on health
emergency preparedness, early warning and health
action emergencies; and
• sustained effort in emergency preparedness to ensure
that interventions allows community recovery and a
level of stabilisation.
In 2010, an overview of health considerations in the NAPAs
for climate change in LDCs was conducted by WHO. This
revealed that most NAPA adaptation activities focused
on biodiversity and agricultural activities with health
not listed as a priority. Among others, Lesotho, Malawi
and Mozambique did not have health activities as part of
their NAPA at all, and these countries have populations
whose health, for a multitude of reasons, is particularly
vulnerable to climate change. Only 3% of all NAPA budgets
was allocated to health projects (Manga, 2010).
However, exceptions are also evident. In 2008,
the Namibian Ministry of Environment and Tourism
specifically commissioned a detailed study in preparation
of the Second National Communication (SNC) for the
United Nations Framework Convention on Climate
Change (UNFCCC). The study focused on health as a clear
priority, and drew detailed links between climate change
and current health challenges such as HIV, malnutrition,
and vector-borne diseases. Hopefully this study signals a
growing realisation that climate change fundamentally
threatens the health of society in the region.
Southern Africa is faced with innumerable social and
public health challenges that require attention but
rightly consume limited available resources. Linkages
between national, regional and international institutions
are essential in collaborating to deepen the scientific
understanding of climate related health issues; to build
capacity through training, and to ensure a coordinated,
prioritised research programme in the region, which
avoids duplicated effort. Climate change presents broad
development challenges, and therefore strategies and
cooperation need to be inter-sectoral, with ‘health’
participating and contributing to critical sectors such as
those mandated to achieve food and water security, and
in averting and managing disasters from climate extremes.
Frameworks for an integrated health sector response
have already been endorsed and can be responsibly used
as powerful tools to define climate change as a priority
public health issue in the region, and to drive for health
system strengthening as a key adaptation response.
This approach would support delivery of essential public
health services, an area that is overshadowed by pressing
issues such as HIV. Renewed effort and resources directed at
the fundamentals of public health, such as providing clean
water and sanitation, adequate nutrition, immunisation
programmes and integrated vector management are
immediately valid; would save lives now, and increase
resilience to climate change in future.
23
Urgent and targeted responses by a broad suite of
stakeholders engaged in health and development issues
in southern Africa are required to address the health
effects of climate change. Responses should address
issues at local, national and the regional scales. The most
robust approach requires a strengthening of public health
systems and raised awareness and advocacy are essential
to this effort. NAPA assessments already indicate the low
budget priorities of health and the scale of the impacts
already receives scant attention in the international
climate change negotiations process. However, this
situation provides opportunity for regional leadership in
championing the issue.
Risk and vulnerability analyses indicate that the most
severe climate changes will occur by 2050, in LDCs which
already have the weakest health systems and will therefore
be at greatest risk. SANAs and the socioeconomic
determinants of health in each country should be used
to prioritise health impacts and capacity requirements at
national and sub national levels. For those countries in
the region yet to address the issue, WHO has developed
applicable tools and guidelines, for example the
Framework for Public Health Response to Climate Change
which provides a basis for an initial policy response
and gives strategic direction for planning adaptation.
This framework has already been endorsed by all of the
southern African ministers of health.
Realising the above commitments requires that health
be integrated into a multi-sectoral response to climate
change and not operate as a ‘silo’, in isolation, as it all
too frequently does now. Shifts in policy are required. The
health sector needs to be sensitive to the need for multiple
sector involvement, and to collaborate on integrated
interventions. Likewise, health can provide motivation for
key sectors, most notably agriculture (food security) and
water, that have major, indirect human health impacts,
to embark on climate resilient strategies and adaptive
responses.
Less obvious links such as those between the HIV
pandemic and environmental factors illustrate that climate
change is a broad development issue. ‘No regret’ strategies
must be developed, and health system strengthening is
one of them. Policy interventions need to take a systems
approach. The competing priorities of existing disease
burden, especially from HIV, TB and malaria, (and the
effects of the widely extant malnutrition and the slow
progress on achieving the health-related MDGs), imply
that southern Africa will find the effects of climate change
severely challenging.
10.1 Recommendations
Advocacy: Greater awareness and understanding of the
health impacts of climate change is needed at regional
and national leadership levels to achieve government
commitment and support for suitable health adaptations.
Ministers of health, permanent secretaries, director
generals and directorates need to be targeted to raise
the level of understanding and relative priority of the
impending public health challenge imposed by climate
change, and be alerted to opportunities for inter-
sector, regional and international collaboration. Raised
awareness of health as a climate change priority needs to
be communicated to negotiators.
Baseline Situation Analysis and Needs Assessments
(SANAs): WHO has developed field-tested tools and
guidelines such as the Framework for Public Health
Response to Climate Change. This provides the basis
for an initial policy response and strategic direction for
health planning adaptation to climate change, such as
a National Adaptation Plan of Action (NAPA). Donors
should collaborate with the WHO and UN systems to
support countries on undertaking these baseline studies
and strategic plans where needed.
Public health*: Health systems and capacity, guided by
SANAs, need to be built not only to meet existing health
priorities but also to address the additional burdens
of disease which will be imposed by climate change.
Specifically, national health strategies must be orientated
to integrated HSS, as opposed to building concentrations
of capacity and resources around particular diseases.
Health surveillance and data collection: There is a
dearth of good public health data in the region with the
possible exception of South Africa. Investment in improved
public health surveillance and better health data is a widely
recognised need. Health reporting and public health data
analysis would assist in identifying and meeting current
needs, as well as recognising emerging health trends.
Research: More research needs to be done on climate
sensitive health conditions. Improved data (as above)
would greatly assist the scope and quality of research,
which should be coordinated among health institutions
10. Discussion
* Public health refers to the fundamentals of health systems, such as
providing clean water and sanitation, immunisation programmes,
maternal and child health, and health programmes specifically
aimed at protecting communities from environmental hazards.
24
HEALTH AND CLIMATE CHANGE
in the region. As a priority, existing large-scale regional
vulnerabilities to climate change (such as malnutrition),
and water related health issues should be targeted for
coordinated and collaborative research. Donor assistance
needs to target this need specifically, and encourage
international participation and skills transfer in the region.
Disease outbreak response: The region and national
governments require specific support for disease
outbreak responses. Appropriately rigorous epidemiolocal
studies and accessible reporting need to take place
during and after such events for effective intervention
and future prevention. Changes in environmental
conditions increasingly create unpredictable conditions
which may be conducive to infectious disease outbreaks.
These can be unexpected and therfore highly disruptive
and resource intensive. Specific skills and dedicated
resources are required at short notice for containing such
outbreaks, and as regional response team could leverage
such capability, it does not need to be duplicated in every
country.
Disaster planning and management: Sudden-and
slow-onset natural disasters of increasing frequency
and magnitude are an expected consequence of climate
change, with profound human health implications. All
countries in the region would benefit from multi-sector
planning at a national and sub- national level.
Promotive and preventive health care, including improved nutrition, are preconditions for community resilience.
A nurse demonstrates food gardening techniques at a project in Kwazondile Uphile, South Africa.
© Piper Collection/Africa Media Online
25
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AIDS Acquired Immune Deficiency Syndrome
BoD Burden of disease
CARE Cooperative for Assistance and Relief
Everywhere
CC Climate change
CCW Community care worker
CLACC Capacity Strengthening of LDCs for
adaptation to Climate Change
CSIR Council for Scientific and Industrial
Research, South Africa
DRC Democratic Republic of Congo
ENSO El Niño/La Niña-Southern Oscillation
ESD Education for Sustainable Development
FAO Food and Agriculture Organization
GCM Global Circulation Models
GDP Gross domestic product
GIS Geographic information systems
HELI Health and Environment Linkages
Initiative
HIV Human immunodeficiency virus
HSS Health system strengthening
IMF International Monetary Fund
INGC Instituto Nacional de Gestão das
Clamidades (National Institute for Disaster
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IOD Indian Ocean Dipole
IPCC Intergovernmental Panel on Climate
Change
LDC Least developed countries
MDG Millennium Development Goals
NAPA National Adaptation Programmes of Action
NGO Non-governmental organisation
NPJA National Plans of Joint Action
NTD Neglected tropical disease
PPP-US$ Purchasing Power Parity in US Dollar
PAHO Pan American Health Organisation
PEPFAR Presidents Emergency Plan for AIDS Relief
RCCP Regional Climate Change Programme
SADC Southern African Development Community
SANA Situation analysis and needs assessment
SSA Sub-Saharan Africa
TB Tuberculosis
UK United Kingdom
UNEP United Nation Environment Programme
UNFCCC United Nations Framework Convention on
Climate Change
USA United States of America
WHO World Health Organization
ZERO Zero Regional Environmental Organisation
Acronyms and abbreviations
Titles in this series
1. Climate Change Adaptation: An integrated approach for southern Africa
by W. Whande
2. Climate Risk and Vulnerability Mapping: Status quo (2008) and future (2050) for southern Africa
by S.J.E. Midgley, R.A.G Davies and S. Chesterman
3. Climate Change and the Millennium Development Goals: Case studies for southern Africa
by R.A. Chapman, S.J.E. Midgley, S. Chesterman, R. Spalding-Fecher and C. von der Heyden
4. Transboundary Water: Climate change and development impacts on southern African water resources
by G. Pegram, C. von der Heyden and R.A. Chapman
5. Hunger and Climate Change: An analysis of key variables in southern Africa
by M.P. de Wit and S.J.E Midgley
6. Health and Climate Change: Key linkages in southern Africa
by J. van Hasselt and R.A. Chapman
7. Energy Resources and Climate Change: Key transboundary vulnerabilities for southern Africa
by R. Spalding-Fecher and C. Fedorsky
8. Cities and Climate Change: Urban vulnerability and resilience in southern Africa
by R.A. Chapman and N. Sasman
9. Payment for Ecosystem Services: A climate change adaptation strategy for southern Africa
by S. Chesterman and E. Hope
RCCP Knowledge for Adaption Series
THE AUTHORS
James van Hasselt is a medical doctor, Executive Director
(Africa) of Safe Blood International and an independent
consultant.
Arthur Chapman is a hydrologist and climate change
specialist at OneWorld, and researcher for the RCCP.
CREDITS
The maps on pages 16 and 17 were produced by
Rob Davies of Habitat Info Ltd.
Series Editor: Andy Mason
Typesetting: Ink Design
Cover photograph: A rural hospital in northern Angola.
© Zacharias/van Hasselt.
Copyright © OneWorld 2011
All rights reserved. Apart from any use as permitted under
the Copyright Act, no part may be reproduced by any
process without prior written permission from:
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