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thebmj
BMJ
2017;359:j5117 | doi: 10.1136/bmj.j5117 1
ANALYSIS
Climate change: health effects and response
inSouth Asia
Banalata Sen and colleagues call for urgent and inclusive action to address health impacts
ofclimate change in South Asia
E
xtreme weather events such as
cyclones, flooding, and heat
spells in South Asia have drawn
attention to the effect of climate
change on human life and our
lack of preparedness. Rapid urbanisa-
tion and industrialisation coupled with
high population density contribute to
emission of greenhouse gases, in par-
ticular carbon dioxide (CO
2
), which lead
to a rise in temperature. This has altered
precipitation patterns and led to a rise in
sea levels.
1
The fifth assessment report of
the Intergovernmental Panel on Climate
Change (IPCC) notes that key risks for the
region are widespread damage to human
life, infrastructure, and livelihoods from
riverine, coastal, and urban flooding;
heat related mortality; and drought
related water and food shortage causing
malnutrition.1
The 2015 Lancet Commission on
Health and Climate Change concluded
that although climate change was the
biggest public health threat of the 21st
century, tackling it could be the greatest
global health opportunity.2 All South
Asian countries have ratified the Paris
agreement, committing to monitor
and reduce greenhouse gas emissions
and develop systems to respond to the
effects of climate change.3 However,
climate change is not yet given priority in
countries’ health agendas. The eect on
the poorest and most vulnerable in society
is also often neglected in the climate
change discourse.
We examine the health eects of climate
change in South Asian countries and
current strategies to address these, and
recommend an inclusive approach to
climate change adaptation planning in the
region.
How health is affected by extreme weather
events
The complex topography of the region,
including high mountains, plains, long
coastlines, and low lying islands, increases
its vulnerability to extreme weather events
(table 1). The recent flash floods in Nepal,
Bangladesh, and India, reportedly the
worst in 100 years, claimed more than
1400 lives, damaged over 7000 schools,
submerged a third of Bangladesh, and led
to food insecurity for nearly half a million
Nepalese people.11
A rise in the sea levels and melting
glaciers pose greater risk of flooding in
the coastal plains. A mean sea level rise of
15-38 cm is projected along India’s coast
by 2050.
1
The region of the Bay of Bengal,
comprising the coast of Bangladesh and
eastern coast of India, has witnessed a
20% increase in cyclonic events because
of the rise in sea levels and increasing
sea surface temperature.18 These events
cause displacement of populations, loss
of livelihood, and mental health problems,
with urban slum, rural, vulnerable, and
marginalised populations being worst
aected.
The fifth deadliest heatwave in recorded
history affected large parts of India and
Pakistan in 2015 and claimed around 3500
lives.
19
Heat stress can cause dehydration,
acute heat illnesses such as heat
exhaustion, and heat stroke, and exacerbate
cardiovascular and respiratory diseases.
20
Extreme heat can worsen the already poor
air quality observed across South Asia, and
lead to respiratory illnesses.2
Indirect health effects
The change in temperature and associated
increase in the severity and frequency of
precipitation events has altered the distri-
bution of diseases. Areas that were previ-
ously non-endemic for certain infections
are now at risk. Although the region has
made substantial progress in malaria con-
trol, another mosquito-borne disease—den
-
gue—is now a major public health problem.
Increased rainfall and flooding are pre-
cursors for waterborne diseases such as
cholera, typhoid, and diarrhoeal diseases.
Lower socioeconomic groups tend to be
more vulnerable to these diseases.
Unpredictable rainfall patterns and
temperature fluctuations have led to crop
failures. Loss of cultivable land because
of droughts and salt water intrusion from
rising sea levels is likely to aggravate food
insecurity in a region already grappling
with high rates of undernutrition among
children.21 In Nepal and the mountains
of India, increased temperature and
diminished snowfall followed by rapidly
receding glaciers have depleted water
reservoirs.11-13 Added to food insecurity is
the threat of nutritional insecurity as rising
carbon dioxide emissions tend to make
staple food crops less nutritious.21
Livelihood is also affected in the
largely agriculture based economies of
the region.21 Droughts and crop failures
have led to large numbers of suicides
among farmers in central India. Loss
of productivity is a concern during the
hottest and wettest months of the year.
Simulations from South East Asia predict
that in 2050, more than half the afternoon
work hours will be lost because of the
need for rest breaks.
22
Economic loss from
climate change is projected to be largest in
the agricultural and energy sectors and in
coastal areas.23
Health system preparedness
Vulnerability of healthcare facilities to
extreme weather events disrupts the deliv-
ery of healthcare services, especially during
emergencies.
24 25
With overburdened public
health infrastructure most countries in the
region are underprepared to manage the
health risks of climate change. Emergency
preparedness and early warning systems
for disease and vector surveillance are in
place in most countries. However, climate
change has not been adequately addressed
in the disaster planning process. The US
Department of Health and Human Services
(HHS) has developed a sustainable and cli-
mate resilient healthcare facilities toolkit.
26
Efforts are underway by groups like the
global network HealthCare Without Harm
to strengthen resilience of healthcare facili-
ties in the region, beginning with Nepal and
India.27
The 2016 Paris agreement calls for
countries to implement mitigation and
adaptation strategies (box 1), supported
by global cooperation to enhance capacity
and financing as well as transfer of
environmentally sound technologies to
developing countries to enable sustainable
KEY MESSAGES
•
South Asia is vulnerable to extreme
weather events and ill health resulting
from climate change
•
Adaptation strategies with a clear
focus on health must be prioritised
•
Community participation and decen-
tralised initiatives to address the
effects of climate change must be
fostered
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2017;359:j5117 | thebmj
ANALYSIS
development.28 Countries are expected
to formulate and implement national
adaptation plans (NAPs) in accordance
with guidelines from the United Nations
Framework Convention for Climate Change
(UNFCCC). The objective of these plans is to
identify medium and long term adaptation
needs and to develop and implement
appropriate initiatives.
Adaptation efforts in South Asia have
been fragmented, without a strong
link between national climate change
strategies and existing disaster risk
reduction, agricultural, health, and other
relevant policies. The WHO South East Asia
Regional Office (WHO-SEARO) reviewed
national health policies of member states
and found that, although health features
in their climate action plans, there is little
or no integration of climate change into
health policies (table 2).
29
This stems from
a lack of conceptual understanding of the
detrimental health eects of climate change.
As part of the Paris agreement, countries
must monitor and evaluate the impact of
adaptation activities.
31
As yet, none of the
South Asian countries have a system for
monitoring and evaluation. Information
gaps, capacity, and resource constraints
have been identified as limiting factors.31
Community participation is vital
Unequal distribution of resources such
as clean air, water, housing, and public
spaces aects local capacity to cope and
poses challenges for disaster risk man-
agement and adaptation.32 Certain popu-
lations, such as poor, marginalised, and
homeless people, are disproportionately
vulnerable to the eects of climate change.
The UN framework convention calls for all
sectors of society to be included in devel-
oping national adaptation plans in order
to reduce the underlying causes of vulner-
ability.
Countries in the region vary in how well
they tackle social inequity in their action
plans. Problems that aect vulnerable and
poor populations directly, such as forest
degradation, the eect of dams, depletion
of natural resources, and urban transport
and planning, are not given enough
attention.33 Most South Asian countries
have patriarchal social structures, and
because the health eects of climate change
are not gender neutral, adopting a gender
sensitive lens in adaptation planning will
help tackle existing inequities.
India’s plan states the protection of the
poor and vulnerable sections of society as
its first principle.34 It stipulates that local
communities must be involved in decision
making and implementation but does not
set out how this will be achieved.33 On
the other hand, Nepal’s local adaptation
plans provide a framework for a bottom-up
approach to planning that is inclusive,
responsive, and flexible. This process is
expected to take into consideration the
needs and resources of vulnerable people,
including the knowledge, skill, and
practices of the local communities and
stakeholders.35
In recent years, increasing attention
has been given to building community
resilience to respond to these problems.
24
Considering the geographical, cultural,
Table1 | Summary of health risks posed by climate change and climatic variability in South
Asian countries4
Country Health risks from climate change
Afghanistan5Increased incidence of waterborne diseases such as cholera, typhoid, diarrhoea, and ascariasis because
of droughts, flooding, and rise in temperature
Increased incidence of vector-borne diseases such as malaria and leishmaniasis due to rise in
temperature and flooding
Illnesses associated with cold weather due to frost and cold spells
Ocular, respiratory, and skin diseases due to change in monsoon and strong winds
Bangladesh Diarrhoeal diseases from temperature change and extreme weather events. Studies find that a 1°C rise in
temperature increased diarrhoeal incidence rates by 5.6%6
Vector-borne diseases such as dengue and leishmaniasis are rising due to increase in temperature
Deaths, injuries, and psychosocial stress due to extreme weather events such as floods, cyclones, storm
surges, droughts, and heat waves
Bhutan Death and injuries due to glacial lake outburst floods, landslides, and flash floods
Vector-borne diseases such as malaria, dengue, Japanese encephalitis, and chikungunya; waterborne
diseases; and respiratory diseases
India Mortality and morbidity related to heat stress
Vector-borne diseases such as malaria, dengue, Japanese encephalitis, leishmaniasis
Waterborne diseases due to flooding. Diarrhoeal incidence in north India is expected to increase by
13.1% by 20407
Respiratory diseases due to poor air quality
Deaths, injuries, and psychosocial stress due to extreme weather events. Of the 7516 km long coastline,
almost 5700 km is prone to cyclones and tsunamis8
Undernutrition due to food insecurity caused by droughts
Maldives Annual rainfall and number of rainfall days is decreasing; temperatures are increasing in the northern part
and decreasing in the southern part, and sea levels are projected to increase by 0.40 to 0.48m by 2100.9
These make the low lying archipelago vulnerable to storm surges, tsunamis, heavy rains and flooding,
tidal waves, and dry spells
Incidence of dengue, chikungunya, scrub typhus along with newly emerging diseases such as Zika virus
infection10
Waterborne diseases such as diarrhoea and typhoid due to unsafe water and poor sanitation
Mental health problems and injuries due to extreme weather events
Damage to healthcare facilities located in coastal areas
Undernutrition due to the effect of flooding or drought on agriculture
Nepal Combined effects of increased temperature and diminished snowfall followed by rapidly receding glaciers
have resulted in depletion of water available for drinking, livestock, and irrigation11 13
Waterborne and foodborne diseases, cardiorespiratory diseases, malnutrition, injuries, and mental
illness
A recent report shows that for a 1°C increase in ambient temperature, the incidence of diarrhoeal
diseases rose by 4.39% and for a 1 cm increase in rainfall the incidence of diarrhoeal diseases rose by
0.28%14
Warmer temperatures have led to an expansion in the range of vectors. Mosquito vectors of malaria,
chikungunya, and dengue and lymphatic filariasis and Japanese encephalitis can now be found at
2000 m above mean sea level in Nepal.9 Zika virus threat is emerging in Nepal and the high altitudes
of the Hindu Kush Himalayan region.15 A study conducted in two malaria endemic districts shows that
a 1°C increase in minimum and mean temperatures increases malaria incidence by 27% and 25%,
respectively16
Pakistan17 Morbidity and mortality from extreme weather events
Melting glaciers in the Himalayas threaten river flows, increased frequency and severity of monsoons and
cyclones, and saline intrusion
Increase in geographical range and incidence of vector-borne diseases
Increase in cardiovascular and respiratory diseases, waterborne diseases, malnutrition, and heat stress
Sri Lanka Mortality and morbidity from increased flooding due to sea level rise, increased risk of vector-borne
diseases such as malaria and dengue, and heat related diseases
Box 1: Adaptation and mitigation
strategies for climate change
• Mitigation strategies include actions
to limit greenhouse gas emissions—for
example, reduced fossil fuel combustion
and use of mass transit, cycling, or
walking instead of private vehicles
• Adaptation strategies include public
health measures to manage the risks,
already present or expected, from
climate change. These range from early
warning systems for impending weather
changes and enhanced infectious disease
surveillance to longer term actions such
as remodelling urban settlements to make
them less vulnerable to extreme events
and new modes of farming
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ANALYSIS
and social diversity in the region,
frameworks for disaster mitigation and
building climate resilience must be
informed by local knowledge and practice.
Understanding how communities use
their resources and recover from the
damage from climate threats will be
important to help people plan for, and
rebound from, climate disasters. For
example, the Maldives is inherently
vulnerable to climate and other natural
hazards because of its geographical
characteristics. Its communities have dealt
with climatic variability for centuries,
and indigenous local knowledge and
practices are time tested and align with
local needs and priorities.24 The people
have developed ways to adapt their
everyday lives to be flood resilient through
practices such as cage culture for fish
farming, “floating gardens” for vegetable
cultivation, disaster resilient shelters, and
“floatingclasses” for children aected by
floods.
Decentralised adaptation strategies
that are locally driven and flexible are
more likely to work than a one size fits
all approach. Box 2 provides an example
of a climate adaptation strategy in which
decentralised planning, coordination of
stakeholders, and community outreach
helped respond to extreme heat events.
Becoming better prepared
Climate change adaptation strategies must
be prioritised in the health agenda. At pre-
sent, the climate narrative in the region
lacks a strong focus on population health
and wellbeing. The health sector has an
important role in raising awareness of the
health eects of climate change among the
general public. As a first step, countries
must aim to establish their national adap-
tation plans and monitoring and evaluation
systems in line with global frameworks.
Political will is essential for coordinated
and sustained action across sectors. Pub-
lic health and basic science research on
climate change and associated diseases
must be encouraged.
Programmatic strategies alone are
insufficient to strengthen resilience to
climate change. Steps to close the gaps
in preparedness to manage the health
risks of climate change will need to take
account of the social vulnerabilities of
local communities. Representatives of these
communities must be part of the decision
making process for designing the region’s
adaptation strategies, and their lived
experiences and knowledge should inform
local, national, and regional responses to
climate change (box 3).37
With common social, cultural, and
demographic features, countries in
South Asia have much to gain through
Table2 | Health in national adaptation plans for climate change in South Asia29
Country Actions
Bangladesh Adaptation and mitigation strategies feature in the country’s climate change action plan, but there is
little integration into health policies. Research, education, and community based programmes are being
conducted at the intersection of climate and health
India The national action plan on climate change and health drafted by the Ministry of Health and Family Welfare
will address raisingawareness of the effects of climate change on human health among the general
population, healthcare providers and policy makers; strengthen the capacity of the health system to respond
to climate sensitive illnesses and diseases, perform situational analysis to strengthen preparedness and
response to cope with adverse health effects of climate related disasters; assist states to assess their health
vulnerabilities in the context of climate change and build capacities to address these; develop partnerships
with stakeholders in the private sector, civil society, and related government department to ensure that
health is appropriately represented in the climate change agenda; strengthen monitoring, surveillance, and
research capacity with regard to impact of climate change on human health; and develop a mechanism to fill
the gap in the evidence based health policy
Maldives Initiatives to enhance institutional and technical capacities to work on climate change and health are under
way. However, a detailed action plan has not been formulated. A low emission, climate resilient development
programme is being piloted to support local level development planning and service delivery, with the aim of
creating greater community ownership and sustainability
Sri Lanka The national plan recognises health as one of nine sectors identified as most vulnerable to climate change.
Additionally, studies on climate change and vector control are being carried out. Climate change is also
included in the nutrition policy. Training and awareness sessions for public health staff are also conducted
Bhutan Health features prominently in the national adaptation plan as a standalone as well as a cross-cutting theme.
Adaptation priorities for the health sector include ensuring safe drinking water, controlling vector-borne
diseases, strengthening disaster management and preparedness, improving surveillance systems, building
climate change and health research capacity, and reducing nutritional effects. The costs and timelines have
not been defined
Nepal The country’s national climate change policy identifies public health as one of the most vulnerable sectors.
The policy encourages sector-wide collaboration and integration of climate change in all relevant sector
plans30
Pakistan Climate change policies will assess the health vulnerabilities and build capacities of communities; measures
to address climate impacts on health will be incorporated into national health plans; education and training
on climate change related health issues for stakeholders and climate related extreme event preparedness,
monitoring of disease outbreaks, and forecasting systems are to be upgraded to protect public health
Afghanistan National action plan recognises health as a vulnerable sector. Mainstreaming of climate change
considerations into the healthsector are considered necessary to make medical experts and hospitals
climate ready to respond to potential new risks and diseases, and to increase public awareness of the health
risks of climate change so people can take measures to protect their health
Box2: Adapting to extreme heat in India36
Over 1000 people died in the city of Ahmedabad in western India after a major heat wave
in 2010 saw temperatures reach 47°C. To avert this in the future, the municipal corporation
together with public health experts, civic society groups, and other stakeholders prepared
a heat action plan, which was piloted in 2013. The plan aims to increase preparedness,
disseminate information, and coordinate response to reduce health effects of extreme heat
episodes on vulnerable populations. It has four key components:
• Build public awareness and community outreach on the risks of heat waves and measures to
prevent heat related deaths and illnesses
• Initiate an early warning system and interagency coordination to alert residents on potential
high and extreme temperatures
• Strengthen capacity among healthcare professionals to recognise and respond to heat
related illnesses
• Reduce heat exposure and promote adaptive measures such as identifying vulnerable areas
and improving access to solutions to alleviate the threat.
The actions have reduced mortality in the hottest months of the year in the city. The plan is
being replicated in other parts of India and being considered for implementation by other
countries in the region that experience similar high temperatures.
Box3: Key recommendations for adaptation
planning to address vulnerabilities37
• Assess the vulnerabilities, needs, and
capacities of stakeholders
• Give attention to the poorest, most
vulnerable groups, especially women and
marginalised communities
• Design and implementation of processes
and actions must be driven by a local
response and community participation
• Engage diverse stakeholders to bridge
the gap between local and traditional
knowledge with scientific knowledge
• Address both the immediate and long
term effects of climate change
• Locally inclusive bottom-up approaches
should complement the top-down
mobilisation of resources
ANALYSIS
4 doi: 10.1136/bmj.j5117 |
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2017;359:j5117 | thebmj
collaboration and exchange of ideas on
policies, research, interventions, and
monitoring strategies. Scientists, health
professionals, and advocates on climate
change must try to come together to create
a regional platform for action and advocacy
on climate change.
Contributors and sources: The authors have diverse
expertise in the area of health impacts of climate
change including policy (BS, MD, ATL) and research
(UG, MD). This article is based on our experience and
review of relevant peer reviewed articles, scientic
reports, national level data sets, monographs, and
policy documents identied through searching PubMed
central, Google Scholar, Mendeley, and the World
Health Organization (WHO) websites of South Asian
member countries (Afghanistan, Bangladesh, Bhutan,
Maldives, Nepal, India, Pakistan, and Sri Lanka).
Competing interests: We have read and understood
BMJ policy on declaration of interests and have no
relevant interests to declare.
Provenance and peer review: Commissioned;
externally peer reviewed.
Banalata Sen, adviser1
Meghnath Dhimal, senior research ocer2
Aishath Thimna Latheef, national professional ocer3
Upasona Ghosh, senior research ocer4
1Centre for Environmental Health, Public Health
Foundation of India, Gurugram, India
2Nepal Health Research Council, Kathmandu, Nepal
3World Health Organization Country Oce, Male,
Maldives
4Indian Institute of Health Management Research,
Jaipur, Rajasthan, India
Correspondence to: B Sen banalata.sen@ph.org
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