ArticlePDF Available

Abstract

Vulnerability and adaptation assessments can provide valuable input to foster climate-resilient health systems. However, these assessments often do not explore the potential health risks of climate change far outside the range of recent experience with extreme weather events and other climate-related hazards. Climate and health stress tests are designed to increase the capacity of health systems and related sectors to manage potentially disruptive climate-related shocks and stresses. Stress tests focus on hypothetical scenarios, during which it would be difficult for the health system to maintain its essential function of providing services to protect population health. The stress test explores approaches to effectively manage acute and chronic climate-related events and conditions that could directly impact health systems, and climate-related events in non-health sectors that can indirectly impact health outcomes and/or health system function. We provide detailed methods and guidance for conducting climate and health stress tests, centering on three primary activities: (1) preparing and scoping the stress test; (2) successfully conducting the stress test; and (3) communicating the results to key stakeholders to facilitate policy and programmatic reforms.
International Journal of
Environmental Research
and Public Health
Article
Stress Testing the Capacity of Health Systems to
Manage Climate Change-Related Shocks and Stresses
Kristie L. Ebi 1,2,3,* , Peter Berry 4,5, Katie Hayes 6, Christopher Boyer 1,3 ,
Samuel Sellers 1,3 , Paddy M. Enright 4,5 and Jeremy J. Hess 1,2,3,7
1
Center for Health and the Global Environment, University of Washington, 4225 Roosevelt Way NE Suite 100,
Seattle, WA 98105, USA; cboyer10@uw.edu (C.B.); sellers1@uw.edu (S.S.); jjhess@uw.edu (J.J.H.)
2Department of Environmental and Occupational Health Sciences, School of Public Health,
University of Washington, Seattle, WA 98105, USA
3Department of Global Health, Schools of Medicine and Public Health, University of Washington,
Seattle, WA 98105, USA
4Climate Change and Innovation Bureau, Health Canada, 269 Laurier Ave. West,
Ottawa, ON K1A 0K9, Canada; Peter.Berry@Canada.ca (P.B.); Paddy.Enright@Canada.ca (P.M.E.)
5
Department of Geography and Environmental Management, University of Waterloo, 200 University Avenue
W, Waterloo, ON N2L 3G1, Canada; pberry@uwaterloo.ca (P.B.); pmenright@uwaterloo.ca (P.M.E.)
6Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada;
katie.hayes@mail.utoronto.ca
7
Department of Emergency Medicine, School of Medicine, University of Washington, Seattle, WA 98105, USA
*Correspondence: krisebi@uw.edu
Received: 12 September 2018; Accepted: 22 October 2018; Published: 26 October 2018


Abstract:
Vulnerability and adaptation assessments can provide valuable input to foster
climate-resilient health systems. However, these assessments often do not explore the potential
health risks of climate change far outside the range of recent experience with extreme weather events
and other climate-related hazards. Climate and health stress tests are designed to increase the capacity
of health systems and related sectors to manage potentially disruptive climate-related shocks and
stresses. Stress tests focus on hypothetical scenarios, during which it would be difficult for the
health system to maintain its essential function of providing services to protect population health.
The stress test explores approaches to effectively manage acute and chronic climate-related events
and conditions that could directly impact health systems, and climate-related events in non-health
sectors that can indirectly impact health outcomes and/or health system function. We provide
detailed methods and guidance for conducting climate and health stress tests, centering on three
primary activities: (1) preparing and scoping the stress test; (2) successfully conducting the stress test;
and (3) communicating the results to key stakeholders to facilitate policy and programmatic reforms.
Keywords:
climate change; climate variability; health risks of climate change; health systems; health
workforce; stress test; vulnerability and adaptation assessments
1. Introduction
Climate and other global environmental changes are fundamentally altering our future.
Possible futures include a “hothouse earth” if self-reinforcing feedbacks result in continued warming,
despite reductions in greenhouse gas emissions [
1
]. Even stabilizing greenhouse gas emissions to
achieve the Paris Agreement goal of limiting warming to 1.5
C above pre-industrial temperatures is
projected to result in a significantly warmer future within the next few decades [
2
]. Climate variability
and change, including increasing temperatures, alterations in the hydrologic cycle, and increases in the
frequency and severity of extreme weather and climate events, are associated with a range of adverse
Int. J. Environ. Res. Public Health 2018,15, 2370; doi:10.3390/ijerph15112370 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018,15, 2370 2 of 16
health consequences. Impacts can be direct, such as illnesses and deaths from heatwaves and severe
storms; or can arise from indirect pathways, such as poor health outcomes associated with human
migration, ecosystem changes (e.g., vector-borne diseases), food insecurity, and economic decline [
3
5
].
Some impacts of climate change, such as effects on mental health (e.g., post-traumatic stress disorder,
anxiety, depression, violence, suicide) may occur in the short-term or extend over several years, with
associated implications for their management by health systems [5].
In addition to these climatic shifts, demographic changes (e.g., aging, migration), urbanization,
land use change, and other social determinants of health, will also change, with potential implications
for vulnerability to climate-related hazards [
6
]. All these changes will interact, with possible
amplifications of the challenges that individuals, communities, and health systems are projected
to face. Health systems include all facets of healthcare (e.g., acute care, chronic care, long-term
care, and mental healthcare), as well as all aspects of care delivery (e.g., workforce, care facilities,
supply chains, and pharmaceuticals), health governance and leadership, and health information and
technology, including surveillance and financing [7].
The focus of health adaptation to climate change has been on strengthening health systems
to better manage its impacts. The WHO Operational Framework for Building Climate Resilient Health
Systems describes the possible implications of climate change for the six building blocks of health
systems: leadership and governance, health workforce, health information systems, essential medical
products and technologies, service delivery, and climate and health financing [
7
]. This framework
was used, for example, to inform toolkits designed in the United States [
8
] and Canada [
9
], and by
the Pan American Health Organization [
10
] to increase the sustainability and resiliency of healthcare
facilities in the Americas [
11
]. While incremental improvements to modify current programs are
important first steps to increase resilience, they may lead to inadequate preparation of health systems
and overconfidence in their ability to manage multiple concurrent and synergistic climate-related
exposures outside the range of historic experiences, as expected with climate change.
These challenges are compounded for health systems struggling to manage the current health
risks of climate variability and change due to limited adaptive capacity [
3
], such as those in many low-
and middle-income countries. The Solomon Islands provides an example to illustrate the potentially
severe climate-related impacts and challenges for health systems. In that country, many health facilities,
including the only tertiary hospital in the country, are located on the seashore, with limited seawall
protection and at high risk of storm surges, flooding, and sea level rise [
12
]. A dengue outbreak in
2013, and flash flooding in 2014, illustrated the extreme weakness and vulnerability of the health
system and health facilities due to structural damage and increased patient demand. Following the
flooding event, 31 acute and subacute deaths were recorded, as well as a diarrhea outbreak that affected
8584 people. This resulted in a surge of inpatients that strained healthcare staff and depleted medical
supplies. Damage to the hospital and surrounding clinics, serving 26,000 people, led to the evacuation
of patients [
13
]. Without major adaptation measures—and, eventually, relocation—the majority of
facilities in the Solomon Islands will be inundated in the coming decades [14].
The extended timeframe associated with climate change necessitates a broader scope for risk
assessment and risk reduction efforts, increasing the time horizons for decisions. This results in
other dynamics within and outside the health sector becoming increasingly important. Health sector
capacity, particularly for highly vulnerable populations, will depend on poverty rates [
15
], healthcare
financing [
16
], and other policy choices [
17
]. Vulnerabilities will shift because of changes in climate as
well as migration, urban form, technology, and access to safe water and improved sanitation, among
other development trends [6,18].
To increase resilience to a relatively unexplored aspect of climate-related health risks—increases
in shocks and stresses with additional climate change—we propose conducting climate and health
stress tests, in conjunction with or following a vulnerability and adaptation assessment to identify and
prioritize interventions that promote climate-smart health systems and increase resilience.
Int. J. Environ. Res. Public Health 2018,15, 2370 3 of 16
2. Some Limitations of Vulnerability and Adaptation Assessments
Climate change and health vulnerability and adaptation (V&A) assessments are designed to
provide insights into current and projected future risks of climate variability and change, as well as
options for preparing for and effectively managing these risks [
19
]. Numerous health vulnerability and
adaptation assessments have been completed (e.g., [
5
,
20
,
21
]), with many more underway. Since climate
change and health is a relatively new issue for ministries and departments of health, and due to limited
human and financial resources for conducting V&A assessments and short planning cycles, these
assessments tend to focus on reducing vulnerability to current climate variability for a limited number
of climate-sensitive health outcomes. In response to these assessments, policies and measures are
being implemented to enhance local to national level preparedness within, for example, vector-borne
disease control programs.
V&A assessments are rarely comprehensive; a wide range of adverse health outcomes that are
expected to be exacerbated by the consequences of climate change are frequently not considered,
such as increases in mental health disorders or the population health impacts of migration [
22
].
The importance of considering mental health in assessments was illustrated by the lingering mental
health effects of the 2016 and 2017 western Canada wildfires that prompted the Canadian Mental
Health Association to create telephone help lines for people experiencing trauma and distress due
to the fires [
23
]. This support was particularly needed when British Columbia declared a state of
emergency as hundreds of wildfires raged throughout the province in summer 2018 [
24
]. The 2016 US
climate change and health assessment [
5
] included a chapter on mental health, and the next Canadian
assessment will include information on this issue.
Another limitation of V&A assessments is that guidance is not designed to identify climate
shocks and stresses outside the current range of experience that, alone or in combination with other
pressures, could undermine the effectiveness of health system functioning and impact health outcomes.
Existing guidance focuses on investigating the effectiveness, strengths, and weaknesses of policies and
programs aimed at reducing health risks from current climate variability and recent climate change [
19
].
V&A guidance does not include evaluation of the day-to-day challenges health systems may face in
realistic, but difficult to project, scenarios in an era absent of climactic stationarity. Further, tipping
points resulting from cumulative and/or compounding impacts are rarely considered. A climate and
health stress test provides an avenue to explore, in detail, what climate change shocks or stresses may
mean for the operational capacity of health systems.
3. Climate-Related Shocks and Stresses
Health systems regularly prepare for shocks and stresses (a shock is a single unpredictable
event and a stress is an ongoing hardship) not related to climate change, such as pandemics,
chronic human resource challenges, demographic changes (e.g., population aging), financial crises,
and others. Preparation for stresses tends to be distinct from preparation for shocks, because stresses
tend not to compromise function to the point that health systems functionality declines, although,
over time, the accumulated effects of stresses can make health systems more vulnerable to shocks.
Tipping points have been identified at which health systems begin to exhibit declining performance
under standard conditions, highlighting thresholds beyond which operational stresses undermine
essential functions [
25
]. By contrast, shocks necessitate a short-term reorientation of health systems
to optimize population health outcomes, rather than their usual focus (in care delivery settings) on
optimizing outcomes for individual patients [26].
Shocks and stresses differ in the burdens they impose relative to a system’s resilience and integrity,
with shocks generally more intense and short-lived. Examples of shocks include environmental,
climatic, or other types of events, such as floods, high winds, landslides, heatwaves or droughts, that
can impact health, damage critical public health infrastructure, and impede health system functioning.
By contrast, stresses can be beneficial to health systems through hormesis, which primes a system to
respond effectively to stress, or be damaging, depending on the net effects. Stresses are characterized
Int. J. Environ. Res. Public Health 2018,15, 2370 4 of 16
by continuous and compounding changes in environmental, climatic, or other types of factors (e.g.,
increasing desertification, multi-year declines in agricultural production, or chronic economic decline).
Shocks and stresses affect population health and health systems through myriad pathways, including
direct losses of lives, livelihoods, and infrastructure, and diverting funds from investments in social
and economic development to, for example, emergency relief and reconstruction.
The impacts of a shock or stress depend on the magnitude of the hazard, as well as the extent
of exposure of human and natural systems to the hazard, the susceptibility of those systems to harm,
and their ability to cope with and recover from exposure [
27
,
28
]. The record 2017 wildfire season in
British Columbia resulted in the temporary closure of 19 health facilities or sites, 880 patients evacuated
from facilities, over 700 health services staff displaced and $2.7 million in costs to Interior Health
Services for the response [
29
]. Shocks and stresses can also result in synergistic impacts that reverberate
throughout health and other key socioeconomic systems [
30
34
]. For example, persistent drought and
food insecurity in Syria, coupled with social-political and religious tensions, resulted in civil conflict,
mass displacement, and a public health crisis [35].
A further challenge is that many health systems operate with little to no surge capacity, which
is problematic in the context of growing risks from climate-related shocks and stresses, in both
low- and high-resource settings. For example, following Tropical Cyclone Pam in Vanuatu in 2015,
the destruction of healthcare infrastructure, combined with low numbers of healthcare personnel and
difficulties mobilizing resources and funds, significantly impacted the capacity of health services
to deliver curative and preventative services [
36
,
37
]. Similarly, addressing mental health after
climate-related disasters can be very challenging for some health systems [
38
]. After Superstorm
Sandy struck New York in 2012, the lack of access to care increased the odds of post-traumatic stress
disorder (PTSD), depression, and anxiety [
39
]. Emergency department crowding is a chronic stress that
severely limits capacity in the United States [
40
] and many other locations globally [
41
]; events such as
large wildfires, increasingly frequent with climate change, drive higher emergency department visit
rates for a range of conditions [
42
] in facilities which are often inadequately prepared for the surge,
with quality of care suffering as a result [43].
In response to the limitations of V&A assessments to effectively capture the potential challenges
of climate-related shocks and stresses, we propose to supplement these assessments with climate
change and health stress tests.
4. Conducting a Climate Change and Health Stress Test
Stress testing considers socioeconomic and political factors that can influence the extent of health
system vulnerability and factors that can affect demands on the system by impacting population
health. A stress test is designed to identify conditions under which it would be difficult for the health
system to maintain its essential function of providing services to protect population health and manage
climate-sensitive health outcomes, and to identify interventions that could maintain essential system
functions despite these shocks and stresses. A stress test focuses on acute and chronic climate-related
events and conditions, including those far outside the range of historic experience, that could directly
impact health systems and/or climate-related events and conditions in non-health sectors that can
indirectly impact health or health system function. This approach can be used to extend the analyses
and information gathered during the process of conducting a V&A assessment by leveraging the team,
stakeholders, information, and multi-sectoral analyses that ideally accompany a V&A assessment
process. The stress test can focus on one or more of the building blocks of health systems, with the aim
of improving system resilience, robustness, redundancy, and coordination [
7
,
44
]. By doing so, stress
testing may both inform ongoing and future V&A assessments, and provide scenario-based analyses
that may enhance stakeholder buy-in.
The climate change and health stress test can focus on shocks and/or stresses. The stress test
can be approached from the perspective of managing outbreaks of climate-sensitive health outcomes
(e.g., Zika, malaria), events that directly affect population health and health system functioning (e.g.,
Int. J. Environ. Res. Public Health 2018,15, 2370 5 of 16
extreme weather and climate events such as heatwaves, flooding, storm surges), impacts on other
sectors that affect health system function (e.g., cascading systems failures affecting power generation
and transmission, hydrometeorological disasters affecting healthcare supply chains), or events from
outside health systems that could indirectly affect population health and health system functioning
(e.g., large scale migration associated with drought). The following description has a greater focus
on shocks for illustrative purposes because these may be the most immediate need for health system
officials, but the approach can be modified to address potential climate-related stresses that could
compromise health system functioning.
The subsequent sections explain the stages of a climate change and health stress test, followed by
a discussion. The activities described in the stages are similar to and draw upon guidance developed
for gauging the climate resiliency of health facilities and for conducting V&A assessments [
11
,
19
].
Some activities, such as forming a stress test team, reviewing data and information, prioritizing health
issues, and communicating results, can be shared between a V&A assessment and a climate and health
stress test. The three basic stages in a stress test are as follows:
Stage 1: Prepare the climate change and health stress test. Preparing for a climate change and health
stress test includes forming the stress test team; reviewing the available data and information,
as well as collecting new data and conducting necessary modeling to inform the scenarios
developed; identifying priority health system functions and/or climate-sensitive health outcomes
for the stress test; developing hypothetical situations (scenarios) of shocks and stresses that form
the core of the stress test; and identifying stakeholders for inclusion in the exercise. Preparing the
stress test can benefit from linking with a completed climate change and health V&A assessment
or one being conducted in parallel. Ideally, the stress test includes multiple aspects of health
systems and services, including elements addressing all six building blocks of climate resilient
health services [7].
Stage 2: Conduct the stress test. Various stress testing modalities could be used, alone or in
conjunction. At a minimum, table-top or visioning exercises may be completed by the stress
test team in a workshop setting, in which the participants discuss the scenarios and evaluate
the extent to which health systems would likely be able to manage the shocks and stresses.
Additional modalities could be employed, including agent-based and systems dynamics modeling
to explore impacts in silico. Regardless of the approach(es) used, the team should review
the findings to identify additional resources, tools, and policies that, if made available, could
prevent adverse population health consequences associated with the hypothetical situations.
Recommended changes in policies and measures should be prioritized to increase the capacity
of communities and health systems to prepare for and manage the climate-related shocks and
stresses considered.
Stage 3: Communicate the results to key stakeholders. A summary report and other outreach materials
should communicate the results to key stakeholders. This report should include an overview
of climate and health risks and recommendations for actions, considering factors such as the
likelihood and timing of the shocks and stresses, competing demands, windows of opportunity to
build resilience based on current and planned projects, and stakeholder concerns and preferences.
5. Description of the Stages in a Climate Change and Health Stress Test
5.1. Stage 1: Prepare the Study
Decide the key issues on which to focus: To begin, the ministry of health, health department,
or other health administrative unit engaged with the stress test should decide which aspects of health
systems and services to include, such as focusing on the preparedness of facilities and infrastructure,
acute care and emergency department capacity, pharmacies, first responders, public health services,
and non-governmental organizations, such as the Red Cross/Red Crescent society. These choices will
inform decisions about which individuals should comprise the stress test team.
Int. J. Environ. Res. Public Health 2018,15, 2370 6 of 16
Form the stress test team: Ideally, the climate change and health stress test team should include specialists
(e.g., public health officials, doctors, nurses) knowledgeable about the health risks of climate change,
projections of climate change for the geographic region of interest, health system policies and programs
of relevance for climate change and health, policies, and programs in other sectors that could impact
population health, local and national plans (e.g., those affecting urbanization), and the local demographics
of particularly vulnerable groups. Team members could come from the ministry or department of health,
healthcare delivery organizations, universities, non-governmental organizations, and others. As local
context is critical, inclusion of participants with intimate knowledge of local health system disaster planning
and, crucially, actual disaster experience, is key. Including someone from the local meteorological service
would be very helpful to provide insights on the local or regional risks associated with specific types
of extreme weather events. Every situation is different, therefore, the team should utilize the specifics
of a given context, as well as aim to integrate with existing coordination mechanisms where possible.
For example, many countries have a climate change and health technical working group that could be
engaged in the process. The team should include the breadth and depth of expertise needed, without
becoming too large to be effective. Jurisdictions with specific climate hazards of concern to health systems,
for example, mental health impacts in rural, isolated, or northern communities, may require participation
of specialists, such as psychologists or social support workers.
Determining the stress test timeframe is key, as the type, magnitude, and frequency of
climate-related hazards, as well as the population structure, and issues such as land-use and insurance
coverage will vary considerably, depending on the time horizon. Other stipulations, such as the extent
of the disaster (which would affect the availability of aid) and impacts on other sectors (e.g., power
generation, transport, etc.) should also be determined.
Conduct a stocktake and review/generate data and information: In this step, the team gathers data
and information to inform the stress test. Stocktaking identifies relevant data, studies, reports,
or plans developed by the ministry of health and other organizations. Publications, documents,
and reports should be sought that provide details on recent climate-related shocks and stresses, and the
effectiveness of health systems in preparing for, and managing, associated morbidity and mortality.
For example, in the Vancouver Coastal Health jurisdiction of British Columbia, Canada, a scoping
report provided information on climate projections for the region, possible risks that threaten facilities,
and recommendations for taking adaptation actions in order to inform efforts to prepare facilities
for the impacts of climate change [
45
]. The stocktake and review should leverage efforts already
undertaken, particularly results from health V&A assessments and adaptation planning documents.
Examples of relevant information include (1) trends in temperature, precipitation, and extreme
events over recent decades; (2) national or subnational research on the health risks of climate change;
(3) national or subnational research on sectors that affect population health, such as the possible
impacts of climate change on water and food safety and security; (4) information about the health
system (e.g., number and types of specific health workers, number of hospitals and services offered at
each, frequency of stockouts, description of supply-chains, baseline health metrics, etc.); (5) information
on the spatial distribution of vulnerable groups, particularly those that are likely to need additional
assistance or ad hoc services in a disaster, such as those with electricity-dependent life-sustaining
devices at home, those on hemodialysis, those on opioid replacement therapy, and pregnant women,
among others; (6) information on health- and other insurance coverage, and on the capitalization
of the health system, as well as standing plans for rescue support including, but not limited to,
mutual aid agreements, emergency, and other sources of funding, and other needed support for
disaster recovery; and (7) recent national and subnational climate change and health V&A assessments.
Additionally, it may be advantageous to collect other information on physical infrastructure (structure
and vulnerabilities of the electricity grid, road networks, etc.) that may be vulnerable during extreme
weather events and which affect health systems. Appendix Asuggests guiding questions to identify
where impacts may occur today or in the future. Additional questions will arise based on specifics of
the local context.
Int. J. Environ. Res. Public Health 2018,15, 2370 7 of 16
Depending on the hypothetical situations (scenarios) of interest, it could be helpful to collect
additional data and/or conduct modeling to generate further details for the stress test. For example,
if the interest is in extreme events, then it could be informative to model possible increases in the
intensity of events in the tail of the distribution in mid-century. The modeling could also consider
where and when urbanization could increase, population aging, and other factors that could affect
vulnerability to the event.
Although access to data and other resources will improve the stress test, in low-resource situations,
it is possible to utilize realistic scenarios (e.g., based on events experienced in similar jurisdictions) in place
of those tailored specifically to the jurisdiction in question. In this sense, stress testing both increases the
accessibility of climate resilience analysis and may result in the buy-in necessary for senior decision-makers
to allocate resources needed for a broader V&A assessment or other forms of analysis.
Identify priority health system functions to be considered in the stress test: The stress test team will
identify a preliminary list of critical health system functions to consider in the stress test, including
measures of effective function, such as minimum number of healthcare professionals, access to essential
medical products (including supply chain needs), and financing needed. Health system functions of
potential interest include how to manage changes in the magnitude and pattern of climate-sensitive
health outcomes over the coming decades with additional climate change, such as increases in the
frequency, intensity, and duration of extreme weather and climate events, and the spread of infectious
diseases [
3
]. Informal interviews with ministry of health staff, researchers, and other experts may
identify other parameters of potential interest. General metrics of health system competency (e.g., daily
all-cause mortality rates, in-hospital mortality rates, and cause-specific morbidity and mortality
rates for vulnerable populations) are also important to consider because they provide generalizable
indicators that are not specific to particular hazards, and because they capture health effects on
populations that are not as directly affected. The stocktake will help with the other steps; for example,
information from recent national and local assessments will be useful in identifying priority health
system functions for the stress test, considered from the perspective of potential changes in the
components of risk: hazards, exposure, and vulnerability.
Develop desk-based hypothetical situations (scenarios) of shocks and stresses: The climate and health
stress test team should develop several possible hypothetical scenarios for consideration in the
workshop. These can range from relatively simple (e.g., heatwave outside historic experience during
which the power grid fails) to more complex scenarios, including, for example, interacting and
cascading events (e.g., heatwave coupled with wildfires that significantly affect air quality and also
affect agricultural productivity) and/or events that affect supply chains (e.g., flooding that limits the
ability to bring in needed supplies of medicines, food, and water, or the ability of affected individuals
to reach healthcare). The scenarios could be informed by events that occurred in the past or in other
regions. Basing the premise of the scenario in past real-world events, particularly those that took
place in similar countries and regions, may help increase engagement from local decision-makers.
Scenarios should be tailored to the region of interest, accounting for local factors that could affect the
magnitude and pattern of the hazard or response. However, they should also describe threats that
are beyond historic experience to account for possible future climate change impacts. The scenarios
should test the capacity of health systems to manage shocks and stresses projected with climate change
in the coming decades, with lower probabilities but more severe consequences. Real-world events
experienced in similar geographic settings and plausible, yet currently infrequent, events, may be used
in cases where high-quality data and modelling capacity are low.
Based on the selection of the aspects of health systems and services of interest in the stress test,
the scenarios should incorporate relevant information on the status and location of critical infrastructure
(e.g., the probability that the power grid could fail during a heatwave, putting additional people at risk) and
other factors that will affect the ability of the health system to manage the situation (e.g., a disease outbreak
that significantly increases emergency department visits, increases hospital admission rates, decreases
Int. J. Environ. Res. Public Health 2018,15, 2370 8 of 16
discharge rates, or stresses critical care capacity). A short description of each should be developed for
discussion during the climate change and health stress test workshop (stage 2).
Map stakeholders for inclusion in the stress test workshop: Strong partnerships, social networks,
and inclusiveness are key characteristics of resilience and are important facilitators of effective ad hoc
disaster response in the health sector [
46
]. A climate change and health stress test is an opportunity to
identify and strengthen connections among stakeholders. To be effective, the workshop should engage
a broad range of stakeholders, from local to national governments and civil society. These stakeholders
should include officials in charge of health system entities vulnerable to shocks and stresses, as well as
individuals who have decision-making roles in developing and implementing resilience-building strategies,
including for upstream drivers of population health. Other potential stakeholders include technical staff
at the ministry of health; representatives of healthcare facilities and medical clinics; representatives from
the mental health and long-term care sectors, pharmacists, health emergency managers, supply chain
workers, public health officials, emergency responders, and others. Additionally, it is generally desirable to
have representation from actors serving in national to local organizations and/or government initiatives
(e.g., public utilities/service providers, planning agencies, public-private agencies providing household
services, etc.); private sector officials (e.g., chambers of commerce, industry groups, etc.); NGOs and
community groups; and schools, universities, and research institutes. For health authorities with many
pressing priorities, it can be difficult to allocate the time and financial and human resources to undertake a
stress test. Including a broad range of stakeholders based on strong social networks and partnerships can
help address these challenges.
5.2. Stage 2: Conduct the Climate Change and Health Stress Test
The stress test will present and discuss the scenarios, as well as any necessary background
information to evaluate how well health systems and services could function during and after the
scenario. If other modalities, such as modeling, are used, the findings from these efforts also should
be discussed. These discussions should identify what additional resources, tools, and policies could
prevent or ameliorate adverse consequences for health system functioning or population health.
The discussions could also identify where collaborations could be strengthened, such as among
health authorities at different levels of government and among various sectoral partners, for example,
the ministry of health and electric and water utilities.
Together, the team conducting the stress test, the ministry/department of health, and other key
stakeholders, should draft the agenda and presentations, as well as identify the draft list of participants.
Including a relatively large number of participants in the workshop will facilitate information sharing
and more diverse discussions. The ministry/department of health and other government partners can
be helpful in disseminating invitations to key stakeholders. If particular key stakeholders are not able to
attend, then the stress test team should meet with these individuals separately to gather their insights for
the exercise.
The stress test workshop length depends on the need to provide participants with detailed
background and contextual information on climate change impacts on health and health systems and
on the hypothetical scenarios. The goal is to assess the extent to which the assembled actors could
manage real events based on the scenarios, and to identify what additional policies, capacity building,
and resources would be needed to effectively handle these situations. This is an opportunity for diverse
stakeholders to exchange views on risks that could constrain the health system from achieving its goals
to promote and protect healthy populations. The discussions can provide insights on what additional
information, resources, policies, programs etc. would be needed for the health system to be resilient
to the impacts of climate change. For example, the stress test workshop may highlight opportunities
for education on key issues of concern, such as the risks of heatwaves on mental wellness, or the
long-term psychosocial treatment needs related to trauma from extreme weather events. Appendix B
lists possible modules to include in stress test workshops, and Appendix Cprovides guiding questions
to facilitate discussions.
Int. J. Environ. Res. Public Health 2018,15, 2370 9 of 16
Examples of additional actions for health systems to manage shocks and stresses associated with
climate change are presented in Appendix D. There are several factors that participants should consider
when recommending which actions to undertake, including:
Necessity—which actions are most critical;
Timing—when a particular facility, program or other health system function may be vulnerable to
certain climate impacts and when particular actions should be taken in to prepare for and respond
to the timing of the hazard and other preparation and response activities;
Capacity—whether current surge capacity levels and available expertise are sufficient to handle
projected impacts, or whether these need to be increased;
Likely losses—expected increases in morbidity and mortality; facilities where adaptation is
prohibitively expensive and should not be undertaken; areas where programs or polices will need
to be reevaluated due to unavoidable impacts (e.g., health transportation and supply lines that
rely on ice roads); and contingent additional losses if mutual aid is not available); and
Costs—the economic, political, environmental, and social costs of taking actions to increase
resilience, whether they are manageable and how they compare to the costs of inaction.
Prioritizing actions and investments can be done through multi-criteria analyses, or risk-based
prioritization. More specific examination of whether the costs of adaptation warrant investment in specific
measures may use cost–benefit analyses or cost-effectiveness analyses [
19
]. The approach used will often
depend on the data, expertise, and timeframe available for the analysis and the needs of decision-makers.
For example, cost-effectiveness analysis would require robust information on the expected effectiveness
of the suite of adaptation options under consideration; this information may be limited, or not available.
The recommendations can be categorized into urgent and immediate actions (e.g., capacity building, data
collection, records management, social network development, etc.), medium- and longer-term actions
(new program development, infrastructure modifications or re-siting, etc.), and measures to strengthen
contingency planning for shocks and stresses, thereby reducing the vulnerability of the health system.
The recommendations should address specific climate-sensitive health risks, and include measures to
protect vulnerable communities, groups, or assets, in the context of low-carbon development.
Stress test participants should attempt to collectively agree on the major findings from the climate
change and health stress test, with respect to the ability of different elements of the health system to
manage the hypothetical scenarios, as well as additional policies, programs, and actions that could
increase their capacity to prepare for and manage the changes. Moreover, there should be discussion
of who should follow-up on recommended actions and on next steps for using the results to inform
policies to increase resilience to climate variability and change. Participants should also stipulate a
timeframe to reassess planning efforts going forward.
5.3. Stage 3: Communicate the Results to Decision-Makers and the Public
The climate and health stress test results and recommendations should be communicated to
decision-makers in health systems and to other stakeholders through, for example, a summary report
and other materials (e.g., policy briefs), taking into consideration the best mechanisms, opportunities,
and products to communicate the findings. For example, an investigation of critical public health
infrastructure vulnerabilities in California included a map showing the location of hospitals on California’s
coast, and current risks associated with a 100-year coastal flood event and future risk from projected sea
level rise [
47
]. Report recommendations should be informed by results from recent climate change and
health V&A assessments to provide additional insights into the timing and level of adaptation ambition,
taking into account factors such as the likelihood and timing of the threats, competing demands, windows
of opportunity based on current and planned projects, and stakeholder concerns and preferences.
The report also should discuss the limitations of the stress test. The analyzed scenarios are
hypothetical situations that, while outside the range of recent experiences, could still underestimate
the speed with which vector-borne diseases could change their range or the severity of future extreme
Int. J. Environ. Res. Public Health 2018,15, 2370 10 of 16
weather and climate events, and could overestimate the effectiveness of the health (or other) system
responses. The report should indicate how the results could be combined with the findings from other
studies, or integrated into future assessments, to maximize a health system unit’s understanding of
climate change threats and the opportunities to adapt.
As a component of the iterative management of the health risks of climate change, the stress
test should be repeated every few years, if possible, using the previously assessed scenario and
updated scenarios, to measure the extent to which preparedness is changing over time, and whether
resilience is increasing or decreasing relative to baseline indicators. Authors should discuss the
results and how they can be interpreted in the perspective of previous studies and of the working
hypotheses. The findings, and their implications, should be discussed in the broadest context possible.
Future research directions may also be highlighted.
6. Discussion
Even with ongoing mitigation efforts, there is a critical need for health adaptation, as highlighted
by realities of locked-in climate change and expected increases in the frequency and intensity of extreme
weather and climate events. Health authorities are increasingly responding to that need by taking
preventive actions to build climate-resilient health systems (e.g., assessments, global conferences,
research studies, partnership building) and the development of decision-support tools to support
adaptation (e.g., health facility resiliency tools) [11]. Health authorities also are beginning to monitor
progress towards resilience [
48
]. Climate change and health stress tests build upon these efforts,
exploring the extent to which each component of health systems is prepared to manage increases in
climate-related shocks and stresses in the context of other challenges—a key indicator of resilience.
Like many of the projected risks of climate change, impacts to health systems will not be felt equally
between or within countries. Areas with higher adaptive capacity and lower reliance on external support
or resources are likely to be more resilient [
3
]. Comparatively lower-resourced communities are likely
to be affected to a greater extent, and more susceptible to shocks and long-term stresses (e.g., rural and
remote health systems). Given the relatively minimal time and resources required to undertake a stress
test, it is a technique that is highly accessible to low-capacity health authorities in diverse regional contexts.
Information and data provided by an increasing number of climate change and health V&A assessments
at national and subnational levels will support robust stress test studies.
As health systems differ significantly within and among countries (e.g., health systems and
services serving a remote northern community vs those in a large city with a complex of health centers),
the scope and methods employed in stress test studies will need to be tailored to suit the needs of
decision-makers. Stress tests provide health authorities with the opportunity to examine the climate
resilience of specific components of health systems (e.g., health facilities, specific organizations or
departments) or interacting components (e.g., health facilities, integrated disease surveillance and
warning, pharmacies, community care, health insurance services). For this reason, the tool can be
used by decision-makers responsible for broad health system functions (e.g., a national ministry of
health) or specific components (e.g., a health facility). Health authorities conducting stress tests will
benefit through sharing of information about experiences in conducting workshops of different scope,
in different jurisdictions, and with different partners.
Stress testing utilizes tools familiar to key stakeholders that facilitate vulnerability assessments
and similar to methods employed by public health officials, risk-assessors, emergency managers,
and decision-makers. In many regions, scenario-based emergency management exercises are
mandatory components of all-hazard risk planning. Introducing or augmenting existing activities with
climate stress testing would add value to these efforts, and would enhance preparedness planning for
a climactically different and potentially more dangerous future. Stress testing should be part of efforts
to identify evolving hazards to health systems and to identify and address weak components, feeding
into ongoing all-hazards planning.
Int. J. Environ. Res. Public Health 2018,15, 2370 11 of 16
7. Conclusions
Climate change is increasing risks to the health and well-being of people in all countries.
According to the Intergovernmental Panel on Climate Change, health impacts are expected to increase
with further warming, putting millions more people at increased risk from heatwaves, food insecurity,
infectious diseases, water and air pollution, and poverty [
49
]. Tipping points in climate and social
systems that could result in very severe impacts on health are possible. Health services are a first
defense in preventing adverse health outcomes from climate change, and are critical for protecting
people by accurately diagnosing and treating illnesses and injuries when climate hazards strike.
They provide the foundation for individual and community level resilience to climate change.
The World Health Organization has called on health authorities to prepare for climate change risks
by building climate resilient health systems, with the urgency of such action increasing as the climate
continues to warm. Climate change and health stress testing supports strengthening health systems
by assessing and promoting effective and iterative risk management, while fostering engagement
across health departments, other sectors, and budgetary authorities. Stress tests can identify actions
and investments over the short- to longer-term, to increase the resilience of health systems using
a proactive, cost-efficient approach in the context of the upstream determinants of effective health
system functioning.
Author Contributions:
K.L.E. conceptualized climate stress testing of health systems in discussions and
collaborations with all authors. K.L.E. wrote the first draft of the paper, and all authors contributed to reviewing,
editing, and finalizing the paper. All the authors contributed substantially to the paper.
Funding: This research received no external funding.
Acknowledgments:
The authors would like to thank the reviewers, as well as the support and assistance of
Marci Burden.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A. Guiding Questions for Stage 1
Current burden of
climate-sensitive health outcomes
Are temperature and precipitation associated with the health outcome(s) or with the
transmission cycle(s) of interest in the area of interest? How important are the
associations to the current burdens of climate-sensitive health outcomes?
Is there evidence that infectious diseases have already changed their geographic
range or seasonality of transmission?
Do the number of cases of health outcomes of interest increase or decrease during
heatwaves, floods, droughts, and/or storm surges, or have these events affected the
transmission cycle? How important is the change?
Are there trends for the hazards, suggesting how climate change could affect the
burden of climate-sensitive health outcomes over the shorter term?
Which populations and regions are particularly vulnerable?
Future burden of climate-sensitive
health risks
How much might increasing temperatures and changing precipitation patterns affect
the magnitude and pattern of future burdens of the health outcome(s) of interest?
How important could this change be over the next few decades?
Could climate change alter the geographic range, seasonality, or intensity of
transmission of Lyme disease, dengue, and other infectious and re-emerging
diseases? Over what time period?
How could changes in the patterns of extreme events (heatwaves, droughts, floods,
extreme storms) affect the burden of climate-sensitive health outcomes? Over what
time period?
Based on projections, are health outcomes likely to become more or less sensitive to
climate change over time? Could climate change facilitate the emergence of health
outcomes that may need more attention? How could hotspots of health outcomes
change with climate change?
Int. J. Environ. Res. Public Health 2018,15, 2370 12 of 16
Environmental factors that could
affect population health, including
Availability of safe water
(quality and quantity)
Food security
Wildfires
Coastal erosion
Saltwater intrusion
To what extent do temperature, precipitation, other weather variables, and sea level
rise affect access to environmental services? How important is the association?
How could water supply and sanitation systems be affected by changes in
precipitation or salinization?
How could wildfires and coastal erosion, for example, affect access to environmental
services or electricity networks?
To what extent could changes in these environmental factors affect population
vulnerability to the risks associated with climate change?
Social and economic context,
including
Community services
Livelihoods
Social capital
Economic resources
Infrastructure
To what extent do temperature, precipitation, other weather variables, and sea level
rise affect social and economic factors? How important is the association?
How could climate change affect the future availability and level of community
services? Over what time period?
To what extent could changes in these socioeconomic factors affect population
vulnerability to the other risks associated with climate change? Over what
time period?
Health systems, including factors
such as
Ability to deliver services
Access to healthcare facilities
Supply chains, particularly
during extreme weather and
climate events
To what extent do temperature, precipitation, other weather variables, and sea level
rise affect the ability of health systems to deliver services?
Have extreme weather and climate events affected access to healthcare systems? How
important was the disruption?
Have extreme weather and climate events affected supply chains? How important
was the disruption?
Are mechanisms in place to mobilize resources (financial and human) during and
after extreme weather and climate events?
Geography and climate
Which regions could be affected by the climate-related hazard? Over what
time period?
Where are the most vulnerable populations for the health outcome(s) of
interest located?
Which ecosystems and other services are of importance? Over what time period?
Are there other factors of concern?
Appendix B. Possible Modules to Include in the Climate and Health Stress Test
An introduction explaining the broader context of the workshop, and demonstrating the
commitment of the ministry/department of health to the stress testing
Review of the ministry/department of health’s long-term goals and relevant plans
Background information relevant to the health risks of climate change
Review of vulnerability, adaptation, and capacity assessments, and of adaptation and mitigation plans
Introduction to the climate change and health stress test process and outcomes
Facilitated breakout group discussions on the extent to which the health system could manage
the hypothetical scenarios, such as changes in the geographic range, seasonality, or intensity of
transmission of climate-sensitive health risks with additional climate change, or changes in the
intensity of extreme weather and climate events
Group discussions on what actions and investments are needed in addition to current policies
and programs to reduce and manage increases in climate-sensitive health risks
Conclusions and next steps
Appendix C. Guiding Questions for Discussions at a Climate Change and Health Stress
Test Workshop
What is the level of effectiveness of current control programs to manage the burden of disease?
How likely could the programs adjust to manage changes in the geographic range, seasonality,
and intensity of transmission of, for example, infectious diseases? Or, how quickly could delivery
of health services and supply chains be established in case of an extreme weather and climate
event outside of historic experience?
Int. J. Environ. Res. Public Health 2018,15, 2370 13 of 16
Are there monitoring and surveillance systems that can provide place-based and timely
information? An example is collection and analysis of environmental data that could warn when
flooding events are expected, along with data on socioeconomic conditions so that vulnerable
regions and populations can be identified.
Are monitoring and surveillance data incorporated into strategic resource planning (financial,
infrastructure, medical personnel and training), distribution chains, disaster preparedness, etc.?
Does strategic planning consider climate change-related risks and their potential consequences?
Are memorandums of understanding in place with other ministries and departments to facilitate
timely access to data and information?
Does experience suggest the level of social capital in the community? Are there activities underway
in the community that could be extended to increase social capital?
Has there been an evaluation of climate-related risks to healthcare infrastructure, and of any
challenges to maintaining services in cases of epidemics or extreme weather and climate events?
If so, what were the implications of this evaluation?
Are there education and training programs that could easily incorporate the health risks of climate
variability and change?
Appendix D. Examples of Additional Actions for Health Systems to Manage Shocks and Stresses
Associated with Climate Change
Ensure incorporation of health risks into adaptation planning, to strengthen coordination and
collaboration across sectors
Strengthen surveillance, monitoring, and control programs to prepare for climate change-related
changes in the geographic range or seasonality of a disease
Develop early warning and response systems using environmental information to warn of
likely outbreaks
Provide training and capacity building for healthcare professionals to better manage health burdens
Project how climate-sensitive health outcomes or other risks (e.g., extreme weather and climate
events) could change under different scenarios of climate change and development at time periods
of interest (e.g., 2030s)
Consider how development choices could affect future health burdens, for example, the potential
consequences of planned urbanization for population vulnerability to flooding
Improve strategic planning and coordination of policies and programs across departments
Develop memorandums of understanding and collaborations with other organizations to ensure
timely access to and sharing of information and data
Support research to fill key knowledge gaps
References
1.
Steffen, W.; Rockström, J.; Richardson, K.; Lenton, T.M.; Folke, C.; Liverman, D.; Summerhayes, C.P.;
Barnosky, A.D.; Cornell, S.E.; Crucifix, M.; et al. Trajectories of the Earth System in the Anthropocene.
Proc. Natl. Acad. Sci. USA 2018,115, 8252–8259. [CrossRef] [PubMed]
2.
Seneviratne, S.I.; Wartenburger, R.; Guillod, B.P.; Hirsch, A.L.; Vogel, M.M.; Brovkin, V.; van Vuuren, D.P.;
Schaller, N.; Boysen, L.; Calvin, K.V.; et al. Climate extremes, land–climate feedbacks and land-use forcing at
1.5 C. Phil. Trans. R. Soc. A 2018,376, 20160450. [CrossRef] [PubMed]
3.
Smith, K.R.; Woodward, A.; Campbell-Lendrum, D.; Chadee, D.D.; Honda, Y.; Liu, Q.; Olwoch, J.M.;
Revich, B.; Sauerborn, R. Human health: Impacts, adaptation, and co-benefits. In Climate Change 2014:
Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the
Fifth Assessment Report of the Intergovernmental Panel on Climate Change; Field, C.B., Barros, V.R., Dokken, D.J.,
Mach, K.J., Mastrandrea, M.D., Bilir, T.E., Chatterjee, M., Ebi, K.L., Estrada, Y.O., Genova, R.C., et al., Eds.;
Cambridge University Press: Cambridge, UK, 2014; pp. 709–754.
Int. J. Environ. Res. Public Health 2018,15, 2370 14 of 16
4.
Watts, N.; Amann, M.; Ayeb-Karlsson, S.; Belesova, K.; Bouley, T.; Boykoff, M.; Byass, P.; Cai, W.;
Campbell-Lendrum, D.; Chambers, J.; et al. The Lancet Countdown on health and climate change: From
25 years of inaction to a global transformation for public health. Lancet 2018,391, 581–630. [CrossRef]
5.
U.S. Global Change Research Program (USGCRP). The Impacts of Climate Change on Human Health in the
United States: A Scientific Assessment; Crimmins, A., Balbus, J., Gamble, J.L., Beard, C.B., Bell, E., Dodgen, D.,
Eisen, R.J., Fann, N., Hawkins, M.D., Ziska, L., Eds.; U.S. Global Change Research Program: Washington,
DC, USA, 2016.
6.
O’Neill, B.C.; Kriegler, E.; Ebi, K.L.; Kemp-Benedict, E.; Riahi, K.; Rothman, D.S.; van Ruijven, B.J.;
van Vuuren, D.P.; Birkmann, J.; Kok, K.; et al. The roads ahead: Narratives for shared socioeconomic
pathways describing world futures in the 21st century. Glob. Environ. Chang. 2017,42, 169–180. [CrossRef]
7.
World Health Organization. Operational Framework for Building Climate Resilient Health Systems; World Health
Organization: Geneva, Switzerland, 2015.
8.
National Oceanic and Atmospheric Administration. U.S. Climate Resilience Toolkit. Available online:
https://toolkit.climate.gov/topics/human-health/building-climate-resilience-health-sector (accessed on
18 October 2018).
9.
The Canadian Coalition for Green Health Care. Climate Change Resiliency Mentoring. Available online:
http://greenhealthcare.ca/mentoring/#toolkit (accessed on 18 October 2018).
10.
Pan American Health Organization, World Health Organization. Smart Hospitals Toolkit.
Available online: https://www.paho.org/disasters/index.php?option=com_content&view=article&id=1742:
smart-hospitals-toolkit&Itemid=911&lang=en (accessed on 18 October 2018).
11.
Balbus, J.; Berry, P.; Brettle, M.; Jagnarine-Azan, S.; Soares, A.; Ugarte, C.; Varangu, L.; Prats, E.V.
Enhancing the sustainability and climate resiliency of health care facilities: A comparison of initiatives and
toolkits. Rev. Panam. Salud Pública 2016,40, 174–180. [PubMed]
12.
Solomon Islands Government. Solomon Islands National Health Strategic Plan 2016–2020; Solomon Islands
Ministry of Health and Medical Services: Honiara, Solomon Islands, 2016.
13.
Natuzzi, E.S.; Joshua, C.; Shortus, M.; Reubin, R.; Dalipanda, T.; Ferran, K.; Aumua, A.; Brodine, S.
Defining population health vulnerability following an extreme weather event in an urban Pacific island
environment: Honiara, Solomon Islands. Am. J. Trop. Med. Hyg. 2016,95, 307–314. [CrossRef] [PubMed]
14.
World Health Organization. Situation Report 3, Solomon Islands Flash Floods; World Health Organization
Western Pacific Regional Office: Manila, Philliphines, 2014.
15.
Peters, D.H.; Garg, A.; Bloom, G.; Walker, D.G.; Brieger, W.R.; Rahman, M.H. Poverty and access to health
care in developing countries. Ann. N. Y. Acad. Sci. 2008,1136, 161–171. [CrossRef] [PubMed]
16.
Atun, R.; De Andrade, L.O.M.; Almeida, G.; Cotlear, D.; Dmytraczenko, T.; Frenz, P.; Garcia, P.;
Gómez-Dantés, O.; Knaul, F.M.; Muntaner, C.; et al. Health-System reform and universal health coverage in
Latin America. Lancet 2015,385, 1230–1247. [CrossRef]
17.
Adler, N.E.; Glymour, M.M.; Fielding, J. Addressing social determinants of health and health inequalities.
JAMA 2016,316, 1641–1642. [CrossRef] [PubMed]
18.
Ebi, K.L. Health in the new scenarios for climate change research. Int. J. Environ. Res. Public Health
2014
,11,
30–46. [CrossRef] [PubMed]
19.
World Health Organization. Protecting Health from Climate Change: Vulnerability and Adaptation Assessment;
World Health Organization: Geneva, Switzerland, 2013.
20.
Berry, P.; Clarke, K.; Fleury, M.D.; Parker, S.; Brisbois, M.; Duncan, M.; Edmonds, N.; Jessiman, B. Human Health
in a Changing Climate. In Canada in a Changing Climate: Sector Perspectives on Impacts and Adaptation; Warren, F.J.,
Lemmen, D.S., Eds.; Government of Canada: Ottawa, ON, Canada, 2014; pp. 191–232.
21.
Levinson, M.; Whelan, M.; Butler, A. A Changing Climate: Assessing Health Impacts & Vulnerabilities Due to
Climate Change within Simcoe Muskoka; Simcoe-Muskoka District Health Unit: Barrie, ON, Canada, 2017.
22.
Hayes, K.; Poland, B. Addressing mental health in a changing climate: Incorporating mental health indicators
into climate change and health vulnerability and adaptation assessments. Int. J. Environ. Res. Public Health
2018,15, 1806. [CrossRef] [PubMed]
23.
Henning, C. Stressed and Tired? It May Be Lingering Mental Health Impacts from 2017 Wildfires.
CBC News. Available online: https://www.cbc.ca/news/canada/british- columbia/wildfires-2017-mental-
health-impacts-1.4764269?utm (accessed on 28 July 2018).
Int. J. Environ. Res. Public Health 2018,15, 2370 15 of 16
24.
Laanela, M.B.C. Declares State of Emergency as Hundreds of Wildfires Burn across Province. CBC News.
Available online: https://www.cbc.ca/news/canada/british-columbia/b-c-declares-state-of-emergency-
as-hundreds-of-wildfires-burn-across-province-1.4785983 (accessed on 15 August 2018).
25.
Kuntz, L.; Mennicken, R.; Scholtes, S. Stress on the ward: Evidence of safety tipping points in hospitals.
Manag. Sci. 2014,61, 754–771. [CrossRef]
26.
Kaji, A.H.; Bair, A.; Okuda, Y.; Kobayashi, L.; Khare, R.; Vozenilek, J. Defining systems expertise: Effective
simulation at the organizational level—Implications for patient safety, disaster surge capacity, and facilitating
the systems interface. Acad. Emerg. Med. 2008,15, 1098–1103. [CrossRef] [PubMed]
27.
Intergovernmental Panel on Climate Change. Managing the Risks of Extreme Events and Disasters to Advance
Climate Change Adaptation: A Special Report of Working Groups I and II of the Intergovernmental Panel on Climate
Change; Cambridge University Press: Cambridge, UK; New York, NY, USA, 2012.
28.
National Research Council. Climate and Social Stress: Implications for Security Analysis; National Academies
Press: Washington, DC, USA, 2013.
29.
Canadian Healthcare Facilities. Journal of Canadian Healthcare Engineering Society, In the Face of Fire,
Winter/Fall 2017. 2017. Available online: https://www.ches.org/ (accessed on 22 November 2018).
30.
Hosten, E.; Mehta, M.; Andre, E.; Rumman, K.A.; Van der Linden, D. Tuberculosis contact-tracing among
Syrian refugee populations: Lessons from Jordan. Confl. Health 2018,12, 25. [CrossRef] [PubMed]
31.
Diggle, E.; Welsch, W.; Sullivan, R.; Alkema, G.; Warsame, A.; Wafai, M.; Jasem, M.; Ekzayez, A.;
Cummings, R.; Patel, P. The role of public health information in assistance to populations living in opposition
and contested areas of Syria, 2012–2014. Confl. Health 2017,11, 33. [CrossRef] [PubMed]
32.
Blanchet, K.; Fouad, F.M.; Pherali, T. Syrian refugees in Lebanon: The search for universal health coverage.
Confl. Health 2016,10, 12. [CrossRef] [PubMed]
33.
Devakumar, D.; Birch, M.; Rubenstein, L.S.; Osrin, D.; Sondorp, E.; Wells, J.C. Child health in Syria:
Recognising the lasting effects of warfare on health. Confl. Health 2015,9, 34. [CrossRef] [PubMed]
34.
Strong, J.; Varady, C.; Chahda, N.; Doocy, S.; Burnham, G. Health status and health needs of older refugees
from Syria in Lebanon. Confl. Health 2015,9, 12. [CrossRef] [PubMed]
35.
Gleick, P.H. Water, drought, climate change, and conflict in Syria. Weather Clim. Soc.
2014
,6, 331–340.
[CrossRef]
36.
Government of Vanuatu. Second Phase Harmonized Assessment Report Vanuatu: Tropical Cyclone Pam;
Government of Vanuatu: Port Vila, Vanuatu, 2015.
37.
World Health Organization. Tropical Cyclone Pam: Vanuatu—Health Cluster Bulletin #4 19 April 2015;
World Health Organization Western Pacific Regional Office: Manila, Philliphines, 2015.
38.
Hayes, K.; Blashki, G.; Wiseman, J.; Burke, S.; Reifels, L. Climate change and mental health: Risks, impacts
and priority actions. Int. J. Ment. Health Syst. 2018,12, 28. [CrossRef] [PubMed]
39.
Ruskin, J.; Rasul, R.; Schneider, S.; Bevilacqua, K.; Taioli, E.; Schwartz, R.M. Lack of access to medical care
during Hurricane Sandy and mental health symptoms. Prev. Med. Rep.
2018
,10, 363–369. [CrossRef]
[PubMed]
40.
Love, J.S.; Karp, D.; Delgado, M.K.; Margolis, G.; Wiebe, D.J.; Carr, B.G. National Differences in Regional
Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health
Emergency? Disaster Med. Public Health Prep. 2016,10, 576–582. [CrossRef] [PubMed]
41.
Pines, J.M.; Hilton, J.A.; Weber, E.J.; Alkemade, A.J.; Al Shabanah, H.; Anderson, P.D.; Bernhard, M.;
Bertini, A.; Gries, A.; Ferrandiz, S.; et al. International Perspectives on Emergency Department Crowding.
Acad. Emerg. Med. 2011,18, 1358–1370. [CrossRef] [PubMed]
42.
Wettstein, Z.S.; Hoshiko, S.; Fahimi, J.; Harrison, R.J.; Cascio, W.E.; Rappold, A.G. Cardiovascular and
Cerebrovascular Emergency Department Visits Associated with Wildfire Smoke Exposure in California in
2015. J. Am. Heart Assoc. 2018,7, e007492. [CrossRef] [PubMed]
43.
Carter, E.J.; Pouch, S.M.; Larson, E.L. The Relationship Between Emergency Department Crowding and
Patient Outcomes: A Systematic Review. J. Nurs. Scholars. 2014,46, 106–115. [CrossRef] [PubMed]
44.
World Bank. Methodological Guidance: Climate Change and Health Diagnostic; World Bank: Washington, DC,
USA, 2018.
45.
Aubie Vines, G.; Murdock, T.; Sobie, S.; Hohenschau, D. Lower Mainland Facilities Management: Moving
towards Climate Resilient Health Facilities for Vancouver Coastal Health; Report Prepared for Vancouver Coastal
Health: Vancouver, BC, Canada, 2018.
Int. J. Environ. Res. Public Health 2018,15, 2370 16 of 16
46.
Adalja, A.A.; Watson, M.; Bouri, N.; Minton, K.; Morhard, R.C.; Toner, E.S. Absorbing Citywide Patient Surge
During Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations.
Ann. Emerg. Med.
2014,64, 66–73. [CrossRef] [PubMed]
47.
Heberger, M.; Cooley, H.; Herrera, P.; Gleick, P.H.; Moore, E. The Impacts of Sea-Level Rise on the California
Coast; California Climate Change Center: Sacramento, CA, USA, 2009.
48.
Ebi, K.; Boyer, C.; Bowen, K.; Frumkin, H.; Hess, J. Monitoring and Evaluation Indicators for Climate
Change-Related Health Impacts, Risks, Adaptation, and Resilience. Int. J. Environ. Res. Public Health
2018
,
15, 1943. [CrossRef] [PubMed]
49.
Intergovernmental Panel on Climate Change (IPCC). Summary for Policymakers. In Global Warming of
1.5
C. An IPCC Special Report on the Impacts of Global Warming of 1.5
C Above pre-Industrial Levels and Related
Global Greenhouse Gas Emission Pathways, in the Context of Strengthening the Global Response to the Threat of
Climate Change, Sustainable Development, and Efforts to Eradicate Poverty; Masson-Delmotte, H.O.V., Pörtner, D.,
Roberts, P.R., Shukla, J., Skea, P., Zhai, Y., Chen, S., Connors, M., Gomis, E., Lonnoy, R., et al., Eds.; World
Meteorological Organisation: Geneva, Switzerland, 2018.
©
2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
... 75 Identified vulnerabilities should be stresstested through realistic, regular drills done by experienced, credentialled emergency and disaster experts. 76,77 Health information systems should be created to inform the community (table 1). ...
Article
Full-text available
Increased frequency, intensity, and duration of wildfires are intensifying exposure to direct and smoke-related hazards in many areas, leading to evacuation and smoke-related effects on health and health systems that can affect regions extending over thousands of kilometres. Effective preparation and response are currently hampered by inadequate training, continued siloing of disciplines, insufficient finance, and inadequate coordination between health systems and governance at municipal, regional, national, and international levels. This Review highlights the key health and health systems considerations before, during, and after wildfires, and outlines how a health system should respond to optimise population health outcomes now and into the future. The focus is on the implications of wildfires for air quality, mental health, and emergency management, with elements of international policy and finance also addressed. We discuss commonalities of existing climate-resilient health care and disaster management frameworks and integrate them into an approach that addresses issues of financing, leadership and governance, health workforce, health information systems, infrastructure, supply chain, technologies, community interaction and health-care delivery, before, during, and after a wildfire season. This Review is a practical briefing for leaders and health professionals facing severe wildfire seasons and a call to break down silos and join with other disciplines to proactively plan for and fund innovation and coordination in service of a healthier future
Article
Increases in the frequency, intensity, and duration of extreme weather and climate events, such as heatwaves, droughts, fire weather, and flooding, are increasing the likelihood of compound and cascading events. The associated impacts are harming human health and well-being, ecosystems, livelihoods, and communities today, with larger impacts projected with additional climate change unless there are timely and significant investments in adaptation and mitigation. At this moment, risk management is not keeping pace with increasing risks. Investments in transdisciplinary research and implementation, accounting for barriers and capacities, is urgently needed.
Preprint
Full-text available
The potential death toll of worst-case extreme heat events is crucial for climate risk analysis and adaptation planning. We estimate this quantity for Europe using machine learning to calculate the intensity of historical heat waves if they occur at present or future global temperatures, combined with empirical exposure-response functions to quantify the resulting mortality. Each event is projected to generate tens of thousands of excess deaths. For example, if July 1994 or August 2003 meteorological conditions recur at the current global temperature anomaly of 1.5 °C, we project 14,000 or 17,300 excess deaths across Europe in a single week, respectively. At 3 °C, mortality rises to 26,800 or 31,500 per week. These death rates are comparable to peak COVID-19 mortality in Europe and are not substantially reduced by ongoing climate adaptation. Our results suggest that avoiding mass heat mortality in Europe will require significant and novel adaptation to heat.
Article
Experts expressed severe concerns over the possibility of increasing burden of infectious diseases as the planet’s climate began to change years ago. There have been increased rates of climate-related catastrophes and as global temperatures rise, emergence of certain viruses has become a serious concern. Vectors are susceptible to changing temperatures as they exhibit innate responses to thermal stress to increase survivability. Climate change impacts virus reservoirs, increasing transmission rates of vectors. Vector-borne diseases have already witnessed increasing numbers compared to before. Certain non-endemic areas are encountering their first-ever infectious disease cases due to increasing temperatures. Tick-borne diseases are undergoing transformations provoking a heightened prevalence. Food-borne illnesses are expected to increase owing to warmer temperatures. It is important to recognize that climate change has a multivariable impact on the transmission of viruses. With climate change comes the potential of increasing interspecies interactions promoting jumps. These factors must be considered, and an informed strategy must be formulated. Adaptation and mitigation strategies are required to curb these diseases from spreading. Despite significant evidence that climate change affects infectious diseases, gaps in research exist. We conducted this review to identify the potential role climate change plays in the emergence of new viruses.
Chapter
Planetary health is fundamental to the health of all beings on this earth. Climate change has direct implications on biopsychosocial aspects of humans’ health. This contribution introduces concepts of resilience relevant to promoting health of individuals, communities, and populations within a planetary health context. Additionally, it encourages reflection and action to strengthen resilience in the face of climate change-related implications and consequences, with recommendations for health professionals and beyond. Based on a consecutive literature review, inspired by Ziglio et al.’s work on resilience capacities, we are focusing on the development of the term resilience within the last decade, and are suggesting a nexus between resilience, engagement in meaningful, responsive, and anticipatory activities, and (planetary) health. An integrative interdisciplinary, occupation-based approach was taken to elaborate reciprocal transactions between resilience-related aspects, especially sense of belonging, self-efficacy, and human agency, as relevant on micro, meso, and macro-level. Conscious decisions in relatedness to planetary health, affecting occupational patterns and routines, may improve resilience on an individual, community, and system level. Attempts to promote resilience in the sense of wellbeing and health for all—as part of individual, community, population, global, and planetary health—are as well dependent on macro-level developments and players. Sense of place and belonging, ethical and strategical reasoning are pivot for decision makers in any context; this matter of fact emphasises the need for responsiveness, empathy, and wisdom for everybody and encouragement for meaningful doing in all levels and contexts.
Article
Full-text available
Purpose The interaction between urban development and climate change significantly impacts local public health services. Unfortunately, cities and involved institutions often fail to prioritize and integrate spatial planning when dealing with these unprecedented future challenges. This study aims to offer Health Integrative Climate Resilience and Adaptation Future (HICRAF), an innovative planning framework that systematically operationalizes future climate risks and their impact on local public health services. Design/methodology/approach HICRAF is developed based on the intermix of explorative and normative scenario planning approaches. Mixed methods of quantitative and qualitative techniques were applied to develop and operationalize the local climate adaptation scenarios through stakeholder participation. The framework demonstrates how different methods and scales (spatial and temporal) can be linked to exhibit climate risk outcomes of different future pathways. Findings The practicality of HICRAF was demonstrated in Khon Kaen city, where it bridged the gaps between global climate trajectories and local climate adaptation scenarios. It also highlights the need to consider intertwining spatial and systemic risks in local infrastructure operations. Although HICRAF has gained political buy-in and fostered the establishment of stakeholder discourse on climate-resilient futures, further research is needed to enhance its robustness and replicability. Originality/value This paper proposes a novel planning framework, HICRAF, that can systematically operationalize the future challenges of unprecedented climate change and urban development changes for the local public health service. The demonstration of HICRAF in Khon Kaen city provides empirical evidence of its implementability and upscaling potential.
Article
Full-text available
Climate change poses a range of current and future health risks that health professionals need to understand, track, and manage. However, conventional monitoring and evaluation (M&E) as practiced in the health sector, including the use of indicators, does not adequately serve this purpose. Improved indicators are needed in three broad categories: (1) vulnerability and exposure to climate-related hazards; (2) current impacts and projected risks; and (3) adaptation processes and health system resilience. These indicators are needed at the population level and at the health systems level (including clinical care and public health). Selected indicators must be sensitive, valid, and useful. And they must account for uncertainties about the magnitude and pattern of climate change; the broad range of upstream drivers of climate-sensitive health outcomes; and the complexities of adaptation itself, including institutional learning and knowledge management to inform iterative risk management. Barriers and constraints to implementing such indicators must be addressed, and lessons learned need to be added to the evidence base. This paper describes an approach to climate and health indicators, including characteristics of the indicators, implementation, and research needs.
Article
Full-text available
A growing number of health authorities around the world are conducting climate change and health vulnerability and adaptation assessments; however, few explore impacts and adaptations related to mental health. We argue for an expanded conceptualization of health that includes both the physiological and psychological aspects of climate change and health. Through a review of the global literature on mental health and climate change, this analytical review explores how mental health can be integrated into climate change and health vulnerability assessments and concludes with recommendations for integrating mental health within climate change and health vulnerability and adaptation assessments.
Article
Full-text available
We explore the risk that self-reinforcing feedbacks could push the Earth System toward a planetary threshold that, if crossed, could prevent stabilization of the climate at intermediate temperature rises and cause continued warming on a "Hothouse Earth" pathway even as human emissions are reduced. Crossing the threshold would lead to a much higher global average temperature than any interglacial in the past 1.2 million years and to sea levels significantly higher than at any time in the Holocene. We examine the evidence that such a threshold might exist and where it might be. If the threshold is crossed, the resulting trajectory would likely cause serious disruptions to ecosystems, society, and economies. Collective human action is required to steer the Earth System away from a potential threshold and stabilize it in a habitable interglacial-like state. Such action entails stewardship of the entire Earth System-biosphere, climate, and societies-and could include decarbonization of the global economy, enhancement of biosphere carbon sinks, behavioral changes, technological innovations, new governance arrangements, and transformed social values.
Article
Full-text available
Background In response to the influx of displaced Syrians since 2011, the Jordanian National Tuberculosis Program (NTP) implemented a specific Tuberculosis (TB) reduction strategy, including contact-tracing (CT). Contacts of all refugees diagnosed with pulmonary TB (PTB) were registered by the International Organization for Migration and screened for active & latent TB infection (LTBI) in 6 NTP centres. The objectives of this study were to assess prevalence of active TB and LTBI, risk factors for LTBI as well as program performance. Methods We performed a retrospective study among contacts (N = 481) of all PTB cases diagnosed between March 2011 and May 2014 (N = 76). CT was performed using verbal screening of TB-related symptoms, tuberculin skin test (TST) and chest X-ray. Results LTBI was diagnosed in 24.1% of contacts tested with TST while active TB was diagnosed in 2.1% of contacts. Main risk factors for positive TST included smear-positive index case (IC) (OR: 6.33) and previous TB infection in the family (OR: 4.94). Among children, the risk of LTBI was higher when their IC was a care-giving female (OR: 2.83). Prevalence of active TB was two times higher in children under five (U5 s) (5.3%) compared to adults (2.5%). Conclusion We found a high prevalence of active TB and LTBI among contacts of PTB cases in the Syrian refugee population, emphasizing the urgent need for host countries to implement CT strategies for refugees. Our results underscore the vulnerability of U5s and contacts of smear-positive IC highlighting the need for specific actions focusing on those groups.
Article
Full-text available
Background: This article provides an overview of the current and projected climate change risks and impacts to mental health and provides recommendations for priority actions to address the mental health consequences of climate change. Discussion and conclusion: The authors argue the following three points: firstly, while attribution of mental health outcomes to specific climate change risks remains challenging, there are a number of opportunities available to advance the field of mental health and climate change with more empirical research in this domain; secondly, the risks and impacts of climate change on mental health are already rapidly accelerating, resulting in a number of direct, indirect, and overarching effects that disproportionally affect those who are most marginalized; and, thirdly, interventions to address climate change and mental health need to be coordinated and rooted in active hope in order to tackle the problem in a holistic manner. This discussion paper concludes with recommendations for priority actions to address the mental health consequences of climate change.
Article
Full-text available
The Lancet Countdown tracks progress on health and climate change and provides an independent assessment of the health effects of climate change, the implementation of the Paris Agreement, and the health implications of these actions. It follows on from the work of the 2015 Lancet Commission on Health and Climate Change, which concluded that anthropogenic climate change threatens to undermine the past 50 years of gains in public health, and conversely, that a comprehensive response to climate change could be “the greatest global health opportunity of the 21st century”. The Lancet Countdown is a collaboration between 24 academic institutions and intergovernmental organisations based in every continent and with representation from a wide range of disciplines. The collaboration includes climate scientists, ecologists, economists, engineers, experts in energy, food, and transport systems, geographers, mathematicians, social and political scientists, public health professionals, and doctors. It reports annual indicators across five sections: climate change impacts, exposures, and vulnerability; adaptation planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and public and political engagement. The key messages from the 40 indicators in the Lancet Countdown’s 2017 report are summarised below.
Article
Full-text available
Destruction caused by natural disasters compromises medical providers' and hospitals' abilities to administer care. Hurricane Sandy was particularly devastating, resulting in massive disruptions of medical care in the region. This study aimed to determine whether a lack of access to medical care during Hurricane Sandy was associated with posttraumatic stress disorder (PTSD) symptoms and other mental health/substance abuse outcomes. A secondary aim was to examine whether having a chronic illness moderates those associations. Self-reported medical access and mental health symptomatology were obtained from New York City and Long Island residents (n = 1669) following Hurricane Sandy under the Leaders in Gathering Hope Together project (10/23/2013–2/25/2015) and Project Restoration (6/5/2014–8/9/2016). Multivariable logistic regressions were utilized to determine the relationship between lack of access to medical care and mental health outcomes. Of the 1669 participants, 994 (59.57%) were female, 866 (51.89%) were white, and the mean age was 46.22 (SD = 19.2) years old. Those without access to medical care had significantly higher odds of showing symptoms of PTSD (AOR = 2.71, CI = [1.77–4.16]), as well as depression (AOR = 1.94, CI = [1.29–2.92]) and anxiety (AOR = 1.61, CI = [1.08–2.39]) compared to those with access. Lack of access to care was associated with a 2.12 point increase in perceived stress scale score (SE = 0.63). The interaction between having a chronic illness and lack of access to medical care was not significantly associated with any outcomes. The findings emphasize the importance of making medical care more accessible to patients, both chronically and acutely ill, during natural disasters to benefit their physical as well as their mental health.
Article
Full-text available
Background: Wildfire smoke is known to exacerbate respiratory conditions; however, evidence for cardiovascular and cerebrovascular events has been inconsistent, despite biological plausibility. Methods and results: A population-based epidemiologic analysis was conducted for daily cardiovascular and cerebrovascular emergency department (ED) visits and wildfire smoke exposure in 2015 among adults in 8 California air basins. A quasi-Poisson regression model was used for zip code-level counts of ED visits, adjusting for heat index, day of week, seasonality, and population. Satellite-imaged smoke plumes were classified as light, medium, or dense based on model-estimated concentrations of fine particulate matter. Relative risk was determined for smoky days for lag days 0 to 4. Rates of ED visits by age- and sex-stratified groups were also examined. Rates of all-cause cardiovascular ED visits were elevated across all lags, with the greatest increase on dense smoke days and among those aged ≥65 years at lag 0 (relative risk 1.15, 95% confidence interval [1.09, 1.22]). All-cause cerebrovascular visits were associated with smoke, especially among those 65 years and older, (1.22 [1.00, 1.49], dense smoke, lag 1). Respiratory conditions were also increased, as anticipated (1.18 [1.08, 1.28], adults >65 years, dense smoke, lag 1). No association was found for the control condition, acute appendicitis. Elevated risks for individual diagnoses included myocardial infarction, ischemic heart disease, heart failure, dysrhythmia, pulmonary embolism, ischemic stroke, and transient ischemic attack. Conclusions: Analysis of an extensive wildfire season found smoke exposure to be associated with cardiovascular and cerebrovascular ED visits for all adults, particularly for those over aged 65 years.