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Review
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
1
The 2018 report of the Lancet Countdown on health and
climate change: shaping the health of nations for centuries
to come
Nick Watts, Markus Amann, Nigel Arnell, Sonja Ayeb-Karlsson, Kristine Belesova, Helen Berry, Timothy Bouley, Maxwell Boykoff, Peter Byass,
Wenjia Cai, Diarmid Campbell-Lendrum, Jonathan Chambers, Meaghan Daly, Niheer Dasandi, Michael Davies, Anneliese Depoux,
Paula Dominguez-Salas, Paul Drummond, Kristie L Ebi, Paul Ekins, Lucia Fernandez Montoya, Helen Fischer, Lucien Georgeson, Delia Grace,
Hilary Graham, Ian Hamilton, Stella Hartinger, Jeremy Hess, Ilan Kelman, Gregor Kiesewetter, Tord Kjellstrom, Dominic Kniveton, Bruno Lemke,
Lu Liang, Melissa Lott, Rachel Lowe, Maquins Odhiambo Sewe, Jaime Martinez-Urtaza, Mark Maslin, Lucy McAllister, Slava Jankin Mikhaylov,
James Milner, Maziar Moradi-Lakeh, Karyn Morrissey, Kris Murray, Maria Nilsson, Tara Neville, Tadj Oreszczyn, Fereidoon Owfi, Olivia Pearman,
David Pencheon, Steve Pye, Mahnaz Rabbaniha, Elizabeth Robinson, Joacim Rocklöv, Olivia Saxer, Stefanie Schütte, Jan C Semenza,
Joy Shumake-Guillemot, Rebecca Steinbach, Meisam Tabatabaei, Julia Tomei, Joaquin Trinanes, Nicola Wheeler, Paul Wilkinson, Peng Gong*,
Hugh Montgomery*, Anthony Costello*
Executive summary
The Lancet Countdown: tracking progress on health and
climate change was established to provide an independent,
global monitoring system dedicated to tracking the health
dimensions of the impacts of, and the response to, climate
change. The Lancet Countdown tracks 41 indicators across
five domains: climate change impacts, exposures, and
vulnerability; adaptation, planning, and resilience for
health; mitigation actions and health co-benefits; finance
and economics; and public and political engagement.
This report is the product of a collaboration of 27 leading
academic institutions, the UN, and intergovernmental
agencies from every continent. The report draws on
world-class expertise from climate scientists, ecologists,
mathematicians, geographers, engineers, energy, food,
live stock, and transport experts, economists, social and
poli tical scientists, public health professionals, and
doctors.
The Lancet Countdown’s work builds on decades of
research in this field, and was first proposed in the 2015
Lancet Commission on health and climate change,1
which documented the human impacts of climate
change and provided ten global recommendations to
respond to this public health emergency and secure the
public health benefits available (panel 1).
The following four key messages derive from the Lancet
Countdown’s 2018 report:
1 Present day changes in heat waves, labour capacity,
vector-borne disease, and food security provide early
warning of the compounded and overwhelming impact
on public health that are expected if temperatures
continue to rise. Trends in climate change impacts,
exposures, and vulnerabilities show an unacceptably
high level of risk for the current and future health of
populations across the world.
2 A lack of progress in reducing emissions and building
adaptive capacity threatens both human lives and the
viability of the national health systems they depend
on, with the potential to disrupt core public health
infra structure and overwhelm health services.
3 Despite these delays, a number of sectors have seen
the beginning of a low-carbon transition, and it is
clear that the nature and scale of the response to
climate change will be the determining factor in
shaping the health of nations for centuries to come.
4 Ensuring a widespread understanding of climate
change as a central public health issue will be crucial
in delivering an accelerated response, with the health
profession beginning to rise to this challenge.
Climate change impacts, exposures, and vulnerability
Vulnerability to extremes of heat has steadily risen since
1990 in every region, with 157 million more people
exposed to heatwave events in 2017, compared with 2000,
and with the average person experiencing an additional
1·4 days of heatwaves per year over the same period
(indicators 1.1 and 1.3). For national economies and
household budgets, 153 billion hours of labour were lost
in 2017 because of heat, an increase of more than
62 billion hours (3·2 billion weeks of work) since 2000
(indicator 1.4). The direct eects of climate change extend
beyond heat to include extremes of weather. In 2017,
a total of 712 extreme weather events resulted in
US$326 billion in economic losses, almost triple the total
losses of 2016 (indicator 4.1).
Small changes in temperature and precipitation can
result in large changes in the suitability for transmission
of important vector-borne and water-borne diseases.
In 2016, global vectorial capacity for the transmission of
the dengue fever virus was the highest on record, rising
to 9·1% for Aedes aegypti and 11·1% for Aedes albopictus
above the 1950s baseline. Focusing on high-risk areas
and diseases, the Baltic region has had a 24% increase
in the coastline area suitable for epidemics of Vibrio
cholerae, and in 2016, the highlands of sub-Saharan Africa
saw a 27·6% rise in the vectorial capacity for the
transmission of malaria from the 1950 baseline
(indicator 1.8). A proxy of agricultural yield potential
shows declines in every region, with 30 countries having
downward trends in yields, reversing a decades-long
trend of improvement (indicator 1.9.1).
Published Online
Month date, 2018
http://dx.doi.org/10.1016/
S0140-6736(18)32594-7
*Co-chairs
Institute for Global Health
(N Watts MA, I Kelman PhD,
N Wheeler MSc), Institute for
Environmental Design and
Engineering
(Prof M Davies PhD), Institute
for Sustainable Resources
(P Drummond MSc,
Prof P Ekins PhD, J Tomei PhD),
Department of Geography
(L Georgeson PhD,
Prof M Maslin PhD), UCL Energy
Institute (I Hamilton PhD,
T Oreszczyn PhD, S Pye MSc),
Centre for Human Health
and Performance, Department
of Medicine
(Prof H Montgomery MD),
and Office of the Vice-Provost
(Research)
(Prof A Costello FMedSci),
University College London,
London, UK; Air Quality and
Greenhouse Gases Programme,
International Institute for
Applied Systems Analysis,
Laxenburg, Austria
(M Amann PhD, G Kiesewetter
PhD); Department of
Meteorology (Prof N Arnell PhD)
and School of Agriculture,
Policy, and Development
(Prof E Robinson PhD),
University of Reading, Reading,
UK; Institute for Environment
and Human Security, UN
University
(S Ayeb-Karlsson PhD);
Department of Public Health,
Environments, and Society
(K Belesova PhD, J Milner PhD,
R Steinbach PhD,
Prof P Wilkinson FRCP),
Department of Infectious
Disease Epidemiology
This version saved: 13:30, 26-Oct-18
18TL4101_Watts
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THELANCET-D-18-04101R1
S0140-6736(18)32594-7
Embargo: November 28, 2018—323:30 (BST)
Doctopic: Review and Opinion
Review
2
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
(R Lowe PhD), and Department
of Population Health
(P Dominguez-Salas PhD),
London School of Hygiene &
Tropical Medicine, London, UK;
Sydney School of Public Health,
Sydney Medical School,
University of Sydney, Sydney,
Australia (Prof H Berry PhD);
Health and Climate Change
Unit, World Bank, Washington,
DC, USA (T Bouley MD);
Cooperative Institute for
Research in Environmental
Sciences (M Boykoff PhD),
History and Society Division
(L McAllister PhD), and Centre
for Science and Technology
Policy Research
(O Pearman MEM), University of
Colorado Boulder, Boulder, CO,
USA; Epidemiology and Global
Health Unit, Department of
Public Health and Clinical
Medicine (Prof P Byass PhD,
M O Sewe PhD, M Nilsson PhD,
Prof J Rocklöv PhD), Umeå
University, Umeå, Sweden;
Department of Earth System
Science, Tsinghua University,
Beijing, China (W Cai PhD,
Prof P Gong PhD); Department
of Public Health and the
Environment, WHO, Geneva,
Switzerland
(D Campbell-Lendrum DPhil,
L F Montoya MSc, T Neville MSc);
University of Geneva, Geneva,
Switzerland (J Chambers PhD);
Department of Environmental
Studies, University of
New England, Biddeford, ME,
USA (M Daly PhD); School of
Government and Society,
University of Birmingham,
Birmingham, UK
(N Dasandi PhD); Centre
Virchow-Villermé for Public
Health Paris-Berlin, Université
Sorbonne Paris Cité and
Université Paris Sorbonne,
Paris, France (A Depoux PhD,
O Saxer MA, S Schütte PhD);
Department of Global Health
(Prof K Ebi PhD) and Centre for
Health and the Global
Environment (J Hess PhD),
University of Washington,
Washington, DC, USA;
Department of Psychology,
Heidelberg University,
Heidelberg, Germany
(H Fischer PhD); International
Livestock Research Institute,
Nairobi, Kenya (D Grace PhD);
Department of Health Sciences,
University of York, York, UK
(Prof H Graham PhD);
Universidad Peruana Cayetano
Heredia, Lima, Peru
(S Hartinger Peña PhD); Health
Decreasing labour productivity, increased capacity for
the transmission of diseases such as dengue fever,
malaria, and cholera, and threats to food security provide
early warning of compounding negative health and
nutrition eects if temperatures continue to rise.
Adaptation, planning, and resilience for health
Global inertia in adapting to climate change persists, with
a mixed response from national governments since the
signing of the Paris Agreement in 2015. More than half of
global cities surveyed expect climate change to seriously
compromise public health infrastructure, either directly,
with extremes of weather disrupting crucial services, or
indirectly, through the overwhelming of existing services
with increased burdens of disease (indicator 2.2).
Globally, spending for climate change adaptation
remains well below the $100 billion per year commitment
made under the Paris Agreement. Within this annual
spending, only 3·8% of total development spending
committed through formal UN Framework Convention
on Climate Change (UNFCCC) mechanisms is dedicated
to human health (indicator 2.8). This low investment in
Panel 1: Progress towards the recommendations of the 2015 Lancet Commission on health and climate change
In 2015, the Lancet Commission made ten policy
recommendations. Of these ten recommendations,
the Lancet Countdown is measuring progress on the following:
Recommendation 1: invest in climate change and public
health research
Since 2007, the number of published articles on health and
climate change in scientific journals has increased by 182%
(indicator 5.2).
Recommendation 2: scale up financing for climate-resilient
health systems
Spending on direct health adaptation as a proportion of total
adaptation spending increased in 2017 to 4·8% (£11·68 billion),
which is an increase in absolute and relative terms from the
previous year (indicator 2.7). Health-related adaptation spending
(including disaster response and food and agriculture) was
estimated at 15·2% of total adaptation spend. Although this
national-level spending is increasing, climate financing for
mitigation and adaptation remains well below the US$100 billion
per year committed in the Paris Agreement (indicator 2.8).
Recommendation 3: phase out coal-fired power
Coal consumption remains high, but continued to decline in
2017, a trend which is largely driven by China’s decreased
reliance and continued investment in renewable energy
(indicators 3.2 and 3.3). The Powering Past Coal Alliance
(an alliance of 23 countries including the UK, Italy, Canada,
and France) was launched at the 23rd Conference of the Parties
to the UN Framework Convention on Climate Change (UNFCCC)
in December, 2017 (COP23), committing to phase out coal use
by 2030 or earlier.
Recommendation 4: encourage city-level low-carbon
transition to reduce urban pollution
In 2017, a new milestone was reached, with more than 2 million
electric vehicles on the road, and with global per-capita
electricity consumption for road transport increasing by 13%
from 2013 to 2015 (indicator 3.6). China is responsible for more
than 40% of electric cars sold globally.
Recommendation 5: establish the framework for a strong
and predictable carbon pricing mechanism
Although a global carbon pricing mechanism has seen limited
progress, the proportion of total greenhouse-gas emissions
covered by national and regional instruments is increasing from
a low base. In 2017, 13·1% of greenhouse-gas emissions were
covered, a proportion that is expected to increase to 20% in
2018, with the implementation of the Chinese National
Emissions Trading Scheme (indicator 4.9).
Recommendation 6: rapidly expand access to renewable
energy, unlocking the substantial economic gains available
from this transition
Globally, 157 GW of renewable energy was installed in 2017,
more than twice as much as the 70 GW of fossil fuel capacity
that was installed (indicator 3.3), which advanced mitigation
efforts and improved local air quality. This trend was mirrored
by a 5·7% increase in the number of people employed in
renewable energy in 2017, which reached 10·3 million jobs
(indicator 4.4). From 2000 to 2016, the number of people
without connection to electricity fell from 1·7 billion to
1·1 billion (indicator 3.4).
Recommendation 9: agree and implement an international
treaty that facilitates the transition to a low-carbon
economy
In response to the USA’s announcement of its intention to
withdraw from the Paris Agreement, the great majority of
countries provided statements of support for the agreement,
reaffirming their commitment to hold global average
temperature rise to well below 2°C. Nicaragua and Syria have
both since signed the Paris Agreement. The UNFCCC requested
the development of a formal report to be delivered at COP24
(December, 2018), which is designed to provide
recommendations on how public health can more
comprehensively engage with the negotiation process.
Recommendation 10: develop a new, independent
collaboration to provide expertise in implementing policies
that mitigate climate change and promote public health,
and monitor progress over the next 15 years
The Lancet Countdown is a growing collaboration of
27 partners, committed to an iterative and open process of
tracking the links between public health and climate change.
In 2018, the Wellcome Trust announced its intention to
continue funding the collaboration’s work, supporting ongoing
monitoring across its five domains up to 2030.
Review
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
3
and Environment International
Trust, Nelson, New Zealand
(T Kjellstrom PhD); School of
Global Studies, University of
Sussex, Falmer, UK
(Prof D Kniveton PhD); Nelson
Marlborough Institute of
Technology, Nelson,
New Zealand (B Lemke PhD);
University of North Texas,
Denton, TX, USA (L Liang PhD);
Asia Pacific Energy Research
Centre, Tokyo, Japan
(Lott M PhD); The Centre for
Environment,
Fisheries, and Aquaculture
Science, Weymouth, UK
(J Martinez-Urtaza); Institute for
Analytics and Data Science,
University of Essex, Essex, UK
(Prof S J Mikhaylov PhD);
Preventive Medicine and
Public Health Research Centre,
Iran University of Medical
Sciences, Tehran, Iran
(M Moradi-Lakeh MD); European
Centre for the Environment and
Human Health (K Morrissey PhD)
and Medical School
(D Pencheon BM), University of
Exeter, Exeter, UK; Faculty of
Medicine, School of Public
Health, Imperial college
London, London, UK
(K Murray PhD); Iranian Fisheries
Science Research Institute,
Agricultural Research,
Education, and Extension
Organisation, Tehran, Iran
(F Owfi PhD, M Rabbaniha PhD);
European Centre for Disease
Control and Prevention, Solna,
Sweden (J Semenza PhD); WHO-
WMO Joint Climate and Health
Office, Geneva, Switzerland
(J Shumake-Guillemot DrPH);
Agricultural Biotechnology
Research Institute of Iran,
Agricultural Research,
Education, and Extension
Organisation, Tehran, Iran
(M Tabatabaei PhD);
and Physical Oceanography
Division, Atlantic
Oceanographic and
Meteorological Laboratory,
National Oceanic and
Atmospheric Administration,
Miami, FL, USA (J Trinanes PhD)
Correspondence to:
Dr Nick Watts, Institute for
Global Health, University College
London, London WC1N 1EH, UK
nicholas.watts@ucl.ac.uk
For the Lancet report see
https://www.thelancet.com/
climate-and-health
and for more on the
accompanying materials see
www.lancetcountdown.org
adaptive capacity is magnified in specific regions around
the world, with only 55% of African countries meeting
International Health Regulation core requirements for
preparedness for a multihazard public health emergency
(indicator 2.3).
Mitigation actions and health co-benefits
Multiple examples of stagnated mitigation eorts exist,
with a crucial marker of decarbonisation—the carbon
intensity of total primary energy supply—remaining un-
changed since 1990 (indicator 3.1). A third of the global
population, 2·8 billion people, live without access to
healthy, clean, and sustainable cooking fuel or technolo-
gies, which is the same number of people as in 2000
(indicator 3.4). In the transport sector, per-capita global
road-transport fuel use increased by 2% from 2013 to 2015,
and cycling comprises less than 10% of total journeys
taken in three quarters of a global sample of cities
(indicators 3.6 and 3.7).
The health burden of such inaction has been immense,
with people in more than 90% of cities breathing
polluted air that is toxic to their cardiovascular and
respiratory health. Indeed, between 2010, and 2016, air
pollution concentrations worsened in almost 70% of
cities around the globe, particularly in low-income and
middle-income countries (LMICs; indicator 3.5.1). In
2015 alone, fine particulate matter (ie, atmospheric
particulate matter with a diameter of less than 2·5 µm
[PM2·5]) was responsible for 2·9 million premature
deaths, with coal being responsible for more than
460 000 (16%) of these deaths, and with the total death
toll (from other causes including particulates and
emissions such as nitrogen oxide) being substantially
higher (indicator 3.5.2). Of concern, global employment
in fossil-fuel extractive industries actually increased by
8% between 2016, and 2017, reversing the strong decline
seen since 2011 (indicator 4.4). At a time when national
health budgets and health services face a growing
epidemic of lifestyle diseases, continued delay in
unlocking the potential health co-benefits of climate
change mitigation is short-sighted and damaging for
human health.
Despite this stagnation, progress in the power
generation and transport sectors provide some cause for
optimism, with many positive trends being observed
in the 2017 report,2 and which continue in the present
2018 report. Notably, coal use continues to decline
(indicator 3.2) and more renewable energy was installed
in 2017 than energy from fossil fuels (indicator 3.3).
However, maintaining the global average temperature
rise to well below 2°C necessitates wide-reaching
transformations across all sectors of society, including
power generation, transport, spatial infra structure, food
and agriculture, and the design of health systems. These
transformations, in turn, oer levers to help tackle
the root causes of the world’s greatest public health
challenges.
Finance and economics
About 712 climate-related extreme events were res-
ponsible for US$326 billion of losses in 2017, almost
triple the losses of 2016 (indicator 4.1). Crucially, 99% of
the losses in low-income countries remained uninsured.
Indicators of investment in the low-carbon economy
show that the transition is already underway, with con-
tinued growth in investment in zero-carbon energy, and
growing numbers of people employed in renewable
energy sectors (indicators 4.2 and 4.4). Furthermore,
investment in new coal capacity in 2017, was at its lowest
in at least 10 years, with 2015 potentially marking a peak
in coal investment. Correspondingly, global subsidies for
fossil fuels continued to decrease, and carbon pricing
only covers 13·1% of global greenhouse-gas emissions, a
number that is expected to increase to more than 20%
when planned legislation in China is implemented in
late 2018 (indicators 4.6 and 4.7).
However, the rise of employment in fossil fuel in-
dustries in 2017 reversed a 5 year downward trend, and
will be a key indicator to follow closely.
Public and political engagement
A better understanding of the health dimensions of
climate change allows for advanced preparedness, in-
creased resilience and adaptation, and a prioritisation of
mitigation interventions that protect and promote human
wellbeing.
To this end, coverage of health and climate change in
the media has increased substantially between 2007, and
2017 (indicator 5.1). Following this trend, the number of
academic journal articles published on health and climate
change has almost tripled over the same period
(indicator 5.2). These figures often follow internationally
important events, such as the UNFCCC’s Conference of
the Parties (COP), along with temporary rises in mentions
of health and climate change within the UN General
Debate (UNGD; indicator 5.3). The extended heatwaves
across the northern hemisphere in the summer of 2018,
might prove to be a turning point in public awareness of
the seriousness of climate change.
2017 saw a substantial rise in the number of medical
and health professional associations actively respon-
ding to climate change. In the USA, the US Medical
Society Consortium on Health and Climate represents
500 000 physicians. This organisation follows the forma-
tion of the UK Health Alliance on Climate Change,
which brings together many of the UK’s royal medical
and nursing colleges and major health institutions.
Organisations like the European Renal Association–
European Dialysis and Transplant Association and the
UK’s National Health Service (NHS) are committing to
reducing the contributions of their clinical practice emis-
sions. The NHS achieved an 11% reduction in emissions
between 2007, and 2015. Several health organisa tions have
divested, or are committing to divest, their holdings in
fossil fuel companies, including the Royal Australasian
Review
4
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
College of Physicians, the Canadian Medical Association,
the American Public Health Association, and the World
Medical Association (indicator 4.5).
Given that climate change is the biggest global health
threat of the 21st century, responding to this threat, and
ensuring this response delivers the health benefits avail-
able, is the responsibility of the health profes sion; indeed,
such a transformation will not be possible without it.
Progress on the recommendations of the 2015 Lancet
Commission
The 2015 Lancet Commission1 made ten global recom-
mendations to accelerate the response to climate change
and deliver the health benefits this response could oer.
A summary of the progress made against these recom-
mendations using the 2018 Lancet Countdown’s indicators
is presented in panel 1. Here, global leadership is
increasingly provided by China, the EU, and many of the
countries that are most vulnerable to climate change.
Introduction
A rapidly changing climate has dire implications for every
aspect of human life, exposing vulnerable popula tions
to extremes of weather, altering patterns of in fectious
disease, and compromising food security, safe drinking
water, and clean air (figure 1).3 These impacts exacerbate
transnational and intergenerational inequality, and com-
promise many of the national and global public health
imperatives that doctors, nurses, and allied health pro-
fessionals have dedicated their lives to. The health,
economic, and social implications of climate change
provide enough justification for the rapid acceleration of
mitigation and adaptation eorts, and clearly, success fully
achieving the UN Sustainable Development Goals (SDGs)
is dependent on a robust response to climate change.
At the broadest level, maintaining the global average
temperature rise to well below 2°C necessitates the
following: a complete decarbonisation of power gener ation
away from fossil fuels, reversing a trend that began
with the industrial revolution; a reorientation towards sus-
tainable global food and agricultural systems; a rethinking
of the structure and function of spatial infrastructure and
cities, and methods of transport within and between them;
the safeguarding of other planetary boundaries and the
reversal of deforestation and land-use change trends; and
profound changes in the methods of delivery of health
care.4–7 These wide-reaching interventions are linked with
numerous public health priorities, providing opportunities
Reduced
agricultural
productivity
Bacterial
diarrhoea
Undernutrition Impact on
mental health
Cardiovascular
disease
Harmful
algal blooms
Vector-borne
disease
Greenhouse
gas emissions
Climate change
Ocean acidification Other air pollutants
(eg, particulates)
Raised average and extreme temperatures
Altered rainfall patterns Sea-level rise
Ozone
increase
Particulate
pollution
Pollen
allergenicity
burden
Extreme weather
Flood Heatwaves Drought Fire
Reduced fishery
and aquaculture
productivity
Reduced
physical work
capacity
Biodiversity
loss, ecosystem
collapse, pests
Social mediating
factors
Loss of habitation
Poverty
Mass migration
Violent conflict
Other social
determinants of
health
Respiratory
disease
Figure 1: The pathways between climate change and human health
Review
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
5
to improve breathing conditions for 90% of the global
population exposed to polluted air, tackle the root causes of
obesity, physical inactivity, and poor diet, alleviate social
inequalities and promote social inclusion, improve work-
place environments, and increase access to health care and
other social services.1
Taken as a whole, the form and pace of the world’s
response to climate change will shape the health of
nations for centuries to come.
The Lancet Countdown: tracking progress on health and
climate change is an international, politically-independent
collaboration that exists to monitor this global transition
from threat to opportunity. The partner ship brings
together 27 leading academic institutions and UN and
intergovernmental agencies from every continent, with
expertise from climate scientists, ecolo gists, mathe-
maticians, geographers, engineers, energy, food, livestock,
and transport experts, economists, social and political
scientists, public health professionals, and doctors.
This 2018 report tracks 41 indicators of impact and
progress across five domains: climate change impacts,
exposures, and vulnerability; adaptation planning and
resilience for health; mitigation actions and their health
co-benefits; economics and finance; and public and
political engagement (panel 2).
A global monitoring system for health and climate change
For the public health profession, monitoring and tracking
have long been essential tools and are important in
understanding and diagnosing the problem in ques-
tion, predicting its future impact, identifying vulnerable
populations, developing and prioritising responses, and
evaluating interventions.
A good indicator should be based on a credible link
between public health and climate change, should be
sensitive to changes in the climate, and less sensitive to
non-climate explanations, its data should be available
and reproducible across temporal and geographical
scales, and the indicator should provide actionable
informa tion to guide policy in a timely manner.8 The
Lancet Countdown has adopted an iterative and open
approach to the development of indicators of the links
between climate change and public health. The Lancet
Countdown’s 2016 report9 launched a global consultation,
seeking input on what can and should be tracked, with a
final set of indicators presented in its 2017 report.2 These
indicators were based on the aforementioned criteria and
the collaboration’s time and resource constraints.2,9
This 2018 report provides an additional year of data
and presents the results of 12 months of work, further
de veloping and improving the methods and data sources
for each indicator. These improvements include the
following adjustments: first, new methods were used to
measure indicators that captured changes in labour
capacity, future projections of dengue fever (an important
climate-sensitive disease), terrestrial and marine food
security, climate information provided to health services,
Panel 2: The 2018 Lancet Countdown indicators
Climate change impacts, exposures, and vulnerability
• Indicator 1.1: vulnerability to the heat-related risks of climate change
• Indicator 1.2: health effects of temperature change
• Indicator 1.3: health effects of heatwaves
• Indicator 1.4: change in labour capacity
• Indicator 1.5: health effects of extremes of precipitation (flood and drought)
• Indicator 1.6: lethality of weather-related disasters
• Indicator 1.7: global health trends in climate-sensitive diseases
• Indicator 1.8: climate-sensitive infectious diseases
• Indicator 1.9: food security and undernutrition
• Indicator 1.9.1: terrestrial food security and undernutrition
• Indicator 1.9.2: marine food security and undernutrition
• Indicator 1.10: migration and population displacement
Adaptation, planning, and resilience for health
• Indicator 2.1: national adaptation plans for health
• Indicator 2.2: city-level climate change risk assessments
• Indicator 2.3: detection, preparedness, and response to health emergencies
• Indicator 2.4: climate change adaptation to vulnerabilities from mosquito-borne
diseases
• Indicator 2.5: climate information services for health
• Indicator 2.6: national assessments of climate change impacts, vulnerability,
and adaptation for health
• Indicator 2.7: spending on adaptation for health and health-related activities
• Indicator 2.8: health adaptation funding from global climate financing mechanisms
Mitigation actions and health co-benefits
• Indicator 3.1: carbon intensity of the energy system
• Indicator 3.2: coal phase-out
• Indicator 3.3: zero-carbon emission electricity
• Indicator 3.4: access to clean energy
• Indicator 3.5: exposure to ambient air pollution
• Indicator 3.5.1: exposure to air pollution in cities
• Indicator 3.5.2: premature mortality from ambient air pollution by sector
• Indicator 3.6: clean fuel use for transport
• Indicator 3.7: sustainable travel infrastructure and uptake
• Indicator 3.8: ruminant meat for human consumption
• Indicator 3.9: health-care sector emissions
Finance and economics
• Indicator 4.1: economic losses due to climate-related extreme events
• Indicator 4.2: investments in zero-carbon energy and energy efficiency
• Indicator 4.3: investment in new coal capacity
• Indicator 4.4: employment in renewable and fossil-fuel energy industries
• Indicator 4.5: funds divested from fossil fuels
• Indicator 4.6: fossil fuel subsidies
• Indicator 4.7: coverage and strength of carbon pricing
• Indicator 4.8: use of carbon pricing revenues
Public and political engagement
• Indicator 5.1: media coverage of health and climate change
• Indicator 5.2: coverage of health and climate change in scientific journals
• Indicator 5.3: engagement in health and climate change in the UN General Assembly
• Indicator 5.4: engagement in health and climate change in the corporate sector
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the quality and comprehensiveness of health adaptation
plans, and global access to clean energy. Second, expanded
geographical and temporal coverage was applied for
indicators that captured mortality from air pollution
(atmospheric particulate matter with a diameter of less
than 2·5 µm [PM2·5]) by sector, active transport uptake,
employment in low-carbon industries, and engagement
from governments, the scientific community, and the
media in health and climate change. Third, new indicators
were added, including indicators of vulnerability to
extremes of heat, exposure to flood, exposure to drought,
transmission suitability for malaria and pathogenic Vibrio,
adaptive capacity to vector-borne disease, and corporate
sector engagement in health and climate change. And
fourth, proposals were made for future indicators looking
to capture the mental health eects of climate change and
the preparedness of the health-care infrastructure.
Every year until 2030, these indicators will be developed
and improved, taking into account new methods, data
sources, and resources as they become available. To this
end, the collaboration continuously invites input from
experts and academic institutions willing to support the
further development of the analysis presented in this
report.
Health and climate change in 2017
This report presents 41 indicators of progress in health
and climate change, with global-level and regional-level
results and analyses for each indicator. Detailed metho-
dological descriptions, data sources, and discussion are
included in the appendix, which has been developed as
an essential companion to the main report.
In 2017, several concerning trends continued, with
vulnerable populations being subjected to 157 million
heatwave-exposure events, and 153 billion hours of labour
being lost because of rising temperatures, which re-
presents substantial increases from baseline levels (in-
dicators 1.3 and 1.4). Vectorial capacity for the transmission
of dengue fever virus continued to rise, with 2016 being
the most suitable year for transmission from Aedes aegypti
and Aedes albopictus since the 1950 baseline was studied.
The carbon intensity of the total primary energy supply
(TPES) remained static at 55–57 tCO2/TJ (the emission at
which the TPES has been since 1990; tCO2/TJ is a carbon
intensity metric that estimates the tonnes of CO2 for
each unit of total primary energy supplied), and
2·8 billion people still lived without access to healthy,
clean, and sustainable cooking fuels and technologies
(indicators 3.1 and 3.4).
However, clear signs of progress both within and beyond
the health profession’s response to climate change have
been observed. Health systems’ adaptive capacity remained
robust, and the WHO newly elected Director General listed
health adaptation as among the agency’s top priorities.
TPES from coal-fired power continued to decline, with
more than 20 countries (including the UK, Canada, Mexico,
and France) committing to unilateral coal phase-out
(indicator 3.2). Renewable energy continued to grow
rapidly, with 157 GW of new capacity installed (an increase
from 143 GW in 2016), compared with 70 GW of fossil fuel
capacity (indicator 3.3). Health institutions, including the
American Public Health Association, Medibank Australia,
and the Hospitals Contribution Fund of Australia,
announced their commitment to divest from fossil fuels,
with funds totalling $33·6 billion (indicator 4.5). The USA’s
announcement of its intention to withdraw from the Paris
Agreement contrasted with the formation of a new alliance
of US medical associations (including the American
Medical Association, the American College of Physicians,
and the American Academy of Paediatrics) representing
500 000 clinicians, dedicated to tackling climate change.
The data presented in the Lancet Countdown’s 2018
report2 provide ongoing reason for cautious optimism,
with the continuation of important trends signalling the
beginning of a broader transition. Despite these trends,
substantially faster progress is required across the full
range of indicators over the coming 5 years to meet the
commitments made under the Paris Agreement.
Section 1: climate change impacts, exposures,
and vulnerability
Introduction
This first section provides insights into the impact of
anthropogenic climate change on human health, tracking
its many pathways (figure 1). These indicators follow
numerous mechanisms and causal pathways, looking to
describe underlying population vulnerabilities, human
exposures, and ultimately, the health impacts that result
from a changing climate. This narrative approach,
built around quantitative indicators, allows the explicit
exploration of the extent to which climate change is
compromising public health globally.
The methods, data sources, and indicators selected for
this year’s Lancet Countdown report have been sub stantially
improved. Several new indicators have been developed,
including metrics on vulnerability to heat exposure
(indicator 1.1), exposure to flood and drought (indicator 1.5),
and the climatic suitability for trans mission of malaria and
pathogenic Vibrio species (indicator 1.8). Methods and data
sources have also been updated and improved, with more
sophisticated analysis being done on labour capacity loss
due to rising tempera tures (indicator 1.4) and the health
implications of declin ing marine and terrestrial primary
food productivity (indicator 1.9).
Indicator 1.1: vulnerability to the heat-related risks of
climate change
Headline finding: rising ambient temperatures place vulnerable
populations at increased risks across all WHO regions.
Populations in Europe and the East Mediterranean are
particularly at risk, with 42% and 43% of their populations
older than 65 years vulnerable to heat exposure
Increasing temperatures as a result of climate change will
continue to expose vulnerable populations to additional
See Online for appendix
For more on the Medical Society
Consortium on Climate
and Health see
https://medsocietiesforclimate
health.org/
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7
heat-related morbidity and mortality, including heat
stress, cardiovascular disease, and renal disease.2 Adults
aged more than 65 years are particularly vulnerable, as
are individuals with underlying cardio vascular diseases,
dia betes, and chronic respiratory diseases, and those
living in urban areas.10–12 These exact factors are used,
with equal weighting, to develop an index of vulnerability
to current and future heat exposure as a result of climate
change.
In all regions of the world, the proportion of populations
vulnerable to heat exposure is rising. Europe and the
eastern Mediterranean show markedly higher vulner-
ability than Africa and southeast Asia, a finding that is
most probably the result of a more elderly population
living in urban areas in these regions. In addition,
demographic transitions in LMICs show accelerating
upward trends in the prevalence of non-communicable
diseases, especially in southeast Asia, where vulnerability
has increased by 3·5% since 1990 (appendix).
This heat vulnerability index was compiled using data
from the Global Burden of Disease (GBD) for trends in
disease prevalence, and the Inter-Sectoral Impact Model
Intercomparison Project for GDP, population densities,
and demographics.13 Full details of the methods, data
sources, and figures for this new indicator can be found
in the appendix.
Indicator 1.2: health effects of temperature change
Headline finding: the mean global temperature change to which
humans are exposed is more than double the global average
change, with temperatures rising 0·8°C versus 0·3°C
The rising vulnerability to heat-related risks of climate
change (indicator 1.1) is mirrored by greater human
exposures to higher temperatures. In 2017, although
the global mean temperature increase relative to the
1986–2005 reference period was 0·3°C, the increase in
human exposure temperature (the temperature increase
in populated zones) was more than double at 0·8°C
(figure 2). This continues an accelerating trend globally,
which was identified in the Lancet Countdown’s previous
report.2
The methods and data sources for this indicator remain
unchanged, and are described in full in the 2017 Lancet
Countdown report2 and in the appendix, with data sourced
from the European Centre for Medium-Range Weather
Forecasts (ECMWF).14
Indicator 1.3: health effects of heatwaves
Headline finding: in 2017, an additional 157 million
heatwave exposure events occurred globally, representing an
increase of 18 million additional exposure events compared
with 2016
The strong upward trend noted in the 2017 Lancet
Countdown report,2 with notable peaks in heatwave
exposure observed in 2010, and 2015, continues in this
2018 report. On average, each person was exposed to an
additional 1·4 days of heatwave from 2000 to 2017
(compared with the 1986–2005 baseline). Furthe rmore,
in 2017, an additional 157 million exposure events
occurred (one exposure event being one heatwave
experienced by one person), 18 million more than in
2016 (figure 3). This increase in population exposure
to heatwaves continues to directly risk the health
of exposed populations, but also indirectly (for in-
stance, through food insecurity resulting from livestock
exposure to heatwaves).
The methods and data sources (the ECMWF)14 for this
indicator are described in the 2017 Lancet Countdown
report2 and in the appendix.
Indicator 1.4: change in labour capacity
Headline finding: in 2017, 153 billion hours of labour
(3·4 billion weeks of work) were lost, an increase of
62 billion hours lost relative to 2000
Rising temperatures are a key risk for occupational
health, with temperatures regularly breaching physio-
logical limits, making sustained work increasingly
dicult or impossible.15 This indicator highlights the
disproportionate impact of climate change and its
eects on labour capacity in vulnerable populations,
2000 2002 2004 2006 2008 2010 2012 2014 2016
0·0
0·2
0·4
0·6
0·8
Mean warming (°C)
Year
Population weighted
Area weighted
Population exposure trend
Global trend
Figure 2: Mean summer warming relative to the 1986–2005 average
For more on the Inter-Sectoral
Impact Model Intercomparison
Project see https://www.isimip.
org/
2000 2002 2004 2006 2008 2010 2012 2014 2016
0
50
100
150
200
Change in the number of heatwave
exposure events (millions per
year)
Year
Change relative to 1986–2005 average
1986–2005 average
Figure 3: Change in the number of heatwave exposure events (with one
exposure event being one heatwave experienced by one person) compared
with the historical average number of events (1986–2005 average)
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with a greatly improved method (as described by
Kjellstrom and co-workers)15 being deployed to calculate
this indicator compared with the previous report. This
method assigns work-fraction loss functions to dierent
activity sectors in accordance with the power typically
expended by a worker performing that activity; labour
loss is calculated as a function of the Wet Bulb Globe
Temperature. Total global hours of labour loss are
calculated by factoring in the working popula-
tion distribution and the distribution of activities across
sectors in dierent countries. Labour is divided into
three sectors: service (metabolic rate of 200 W), in-
dustry (300 W), and agriculture (400 W), all of which
were calculated under the assumption that the worker
was in the shade. As with indicators 1.2 and 1.3,
weather data were obtained from the ECMWF;14 details
of the method and datasets used can be found in the
appendix.
In total, 153 billion hours of labour were lost in 2017,
an increase of 62 billion hours relative to the year 2000;
notably, 80% of these losses were in the agricultural
sector (appendix). The areas most aected by these
changes are concentrated in already vulnerable areas in
India, southeast Asia, and sub-Saharan Africa, and South
America (figure 4).
Indicator 1.5: health effects of extremes of precipitation
(flood and drought)
Headline finding: changes in extremes of precipitation exhibit
clear regional trends, with South America and southeast Asia
among the regions most exposed to flood and drought
This new indicator maps extremes of precipitation
globally and is divided into two components—drought
and extreme rainfall. The change in the mean number
of severe droughts has been mapped for 2016 (appendix).
This indicator highlights increased exposure in large
areas of South America, northern and southern Africa,
and southeast Asia, with many areas experiencing a
full 12 months of drought throughout the year. Pro-
longed drought remains one of the most dangerous
environmental determinants of premature mortality,
resulting in reduced crop yields, food insecurity, and
malnutrition (which in turn leads to life-long stunting,
wasting, and eventually death when experienced by
young children).3 The spread of water-borne disease,
reduced availability of potable water, and migration as a
result of reductions in arable and habitable land often
com pound to further wear away at the resilient capacity
of populations.16
Meteorological drought trends can be used to track
potential population exposure.17 The World Meteorological
Organization (WMO) recommends the use of the
Standard Precipitation Index (SPI) to characterise
meteorological droughts around the world, in which a
severe drought is defined as periods when the SPI is less
than –1·5.18,19 A full description of methods and other data
sources (the ECMWF)14 can be found in the appendix.20
Floods and extreme precipitation also have severe
health implications, and 15% of all deaths related to
natural disasters are due to floods.21 In addition to im-
mediate injury and death from flood water, longer-term
impacts on health include spread of infectious disease
and mental illness, both of which are exacerbated by
the destruction of infrastructure, homes, and liveli-
hoods.22,23
The second component of this new indicator maps
extreme rainfall events, as a proxy indicator of flood risk.
In the 2015 Lancet Countdown report by Watts and
20 40 60 80 100 120
Mean change in hours lost
per person per year
Labour loss at activity level 400 W, mean change 2000–17 relative to baseline
Figure 4: Mean change in total hours of labour lost at the 400 W activity level over the 2000–17 period relative to the 1986–2005 baseline
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9
coworkers,1 flood risk was estimated for 2090 by defining
a flood event as a 5 day precipitation total exceeding the
10 year rainfall level (a level of rainfall only expected
once every 10 years) in the reference period. This method
has been adapted here to produce extreme rainfall trends
from 2000 to 2016. An extreme rainfall event is defined
as commencing when the 5 day rolling sum of daily
total precipitation exceeds the 10 year return level in
the 1986–2005 reference period, and ending when
precipi tation drops below this value. The return
values and events were calculated using the European
Research Area-Interim daily precipitation dataset from
the ECMWF.14 Exposures were calculated as the sum of
people at a location multiplied by the number of events
at that location, measured in person-events. A full
account of the methods and data can be found in the
appendix.
As with drought, changes in extreme heavy rain vary
regionally, with particularly important increases in ex-
treme heavy rainfall events evident in South America and
southeast Asia (appendix). Here, regional trends are
more significant than global trends, reflecting the varying
nature of climate change depending on the geographical
region studied.
Indicator 1.6: lethality of weather-related disasters
Headline finding: Annual frequencies of floods and extreme
temperature events have increased since 1990, with no
clear upward or downward trend in the lethality of these events
Providing global estimates of human exposure, mor-
bidity, and mortality associated with extreme weather
events is fraught with methodological complexities and
gaps in reliable data. Projections suggest that, if left
unmitigated, climate change is ex pected to result in an
additional 1·4 billion drought-exposure events per year
and 2 billion flood-exposure events per year by the end
of the century.1 These projections are borne out in
recent history, with clear increases in the annual
frequencies of flood and temperature anomalies over
the past 25 years. Although trends within regions and
income groups have been important in the lethality of
weather-related disasters, no clear trend is seen at the
global level, with the exception of a slight decline in the
absolute numbers of people aected by floods.
Governments and national health services are
increasingly adapting to extreme weather events and
climate change with impress ive results (section 2).
These adaptation interven tions and broad development
initiatives present a plaus ible explanation for the results
identified in this report. Crucially, indicator 4.1 makes
clear that health and human wellbeing is aected
indirectly through the economic and social losses that
result from such events.
Indicator 1.6 makes use of the same methods and data
sources (the Emergency Events Database)24 as those
described in the 2017 Lancet Countdown report2 and in
the appendix.
Indicator 1.7: global health trends in climate-sensitive
diseases
Headline finding: although global health and development
interventions have resulted in some impressive improvements
in human health and wellbeing, mortality from
two particularly climate-sensitive diseases, dengue fever and
malignant skin melanoma, is still rising in regions most
susceptible to both diseases
Climate change interacts directly and indirectly with a
wide variety of disease processes, ultimately acting as a
force multiplier for many of the existing challenges faced
by the global public health community. Drawing out
mortality estimates for climate-sensitive diseases calcu-
lated by the GBD helps to elucidate these macro trends
over time (figure 5).13 Climate change’s role in influencing
these trends will vary depending on disease process,
geography, and demographic profile of aected regions
and populations.
The reference category (all-cause mortality) shows
a strong decrease in mortality rates in Africa, and a
substantial reduction in southeast Asia. The number of
deaths caused by diarrhoeal diseases also show marked
decreases, especially in Africa. By contrast, mortality from
dengue fever disease is clearly increasing rapidly,
especially in regions most susceptible to its spread—
southeast Asia and the Americas. Mortality rates for
malignant melanoma, which notably has a decadal delay
from exposure to death and is associated with exposure to
ultraviolet radiation, have increased markedly in Europe,
the Americas, and the Western Pacific. The methods used
to measure this indicator are described in full in the 2017
Lancet Countdown2 report and in the appendix.
Indicator 1.8: climate-sensitive infectious diseases
Headline finding: in 2016, global vectorial capacity for the
transmission of dengue virus was the highest on record, rising
to 9·1% above the 1950s baseline for A aegypti and
11·1% above the baseline for A albopictus
Changing climatic conditions are a key determinant for
the spread and impact of many infectious diseases.
Understanding how climate change is altering the
environmental suitability for disease vectors, pathogen
replication, and transmission is crucial to understanding
the consequences for human exposure. The 2017 Lancet
Countdown2 analysis on dengue virus is expanded here
to include a seasonal analysis of dengue fever and global
analysis of pathogenic Vibrio species and malaria. The
second component of the indicator analyses publication
trends of climate-change infectious-disease research.
Vectorial capacity is a measure of the capacity for
vectors to transmit a pathogen to a host and is influ-
enced by vector, pathogen, and environmental factors.
Compared with the 1950s baseline, climatic changes
have increased global vectorial capacity for dengue virus
in the 2010s (2011–16 average) by 7·8% for A aegypti and
9·6% for A albopictus (figure 6). For both vectors, 2016
was the most suitable year on record. In addition, the
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seasonal dynamics of vectorial capacity for dengue virus
for both vectors have lengthened and strengthened
(appendix). Model pro jections suggest this rise will
continue for both vectors in step with greenhouse gas
emissions (appendix). The contribution of mobility and
globalisation to the expansion of the dengue virus vector
and dengue disease burden is important to note,
alongside the impact of climate change.
Turning to water-borne infectious diseases, in regions
with suitable salinity conditions, a consistent associ-
ation between sea-surface temperature (SST) anomalies
and cases of pathogenic Vibrio infections has been
reported.25–27 In 2018, a Vibrio indicator has been added
to track the environmental suitability of coastal regions for
Vibrio infections on the basis of SST and salinity.
This indicator was developed for Vibrio species that
are pathogenic to humans, including Vibrio
parahaemolyticus, Vibrio vulnificus, and non-toxigenic
Vibrio cholerae (non-O1 and non-O139 serogroups).
Vibrio-caused illnesses (vibriosis) include gastroenteritis,
wound infections, and septicaemia, and can be trans-
mitted in brackish marine waters. A clear trend of rising
suitability to Vibrio infections is observable globally
(notably in the northern hemisphere), with 2017 being a
particularly abnormal year of decreased suitability
(figure 7A). The percentage of coastal area suitable for
Vibrio infections in the 2010s has increased at northern
latitudes (40–70°N) by 3·5% compared with the 1980s
baseline. Over the same period, in two high-risk focal
regions, the Baltic region and northeastern USA, increases
of 24·0% and 27·0%, respectively, were observed in
the area of coastline that was suitable for infections
(figure 7B, C). Similarly, the number of days suitable per
year has almost doubled in the Baltic region, extending
the highest risk season by around 5 weeks (figure 7B).
A second new indicator addresses the changing
suitability for the transmission of malaria. The indicator
focuses on environmental suitability for Plasmodium
falciparum (African continent) and Plasmodium vivax
(other regions), the two dominant parasites causing
disease worldwide. The indicator shows significant
changes in suitability in highland areas of Africa, with
suitability increasing by 20·9% in the 2010s compared
with the 1950s baseline (figure 8), and with 2016 being
the fourth most suitable year (after 2002, 1997, and 2006)
since the beginning of the time series (27·7% rise
compared with the 1950s baseline). The expanded
methods for all disease indicators are in the appendix.
The final component of this indicator tracks research
and published literature on climate change and infec tious
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
0
5
10
V
ectorial capacity percentage
change from the 1950 baseline
Year
Aedes aegypti
Aedes albopictus
Figure 6: Changes in global vectorial capacity for the dengue virus vectors
Aedes aegypti and Aedes albopictus since 1950
1990
1995
2000
2005
2010
2016
0
5
10
15
20
Deaths per 100
000 people
Year
500
750
1000
1250
Deaths per 100
000 people
Exposure to forces of nature
All causes
1990
1995
2000
2005
2010
2016
0
25
50
75
100
Year
0·5
0
1·0
1·5
2·0
1990
1995
2000
2005
2010
2016
0
1
2
3
Year
0
50
100
1990
1995
2000
2005
2010
2016
0
20
10
30
40
50
Year
0·5
1·0
1·5
2·0
African region
Eastern Mediterranean region
European region
Region of the Americas
South-East Asia region
Western Pacific region
Malaria
Dengue fever
Malignant skin melanoma
Diarrhoeal diseases
Protein-energy malnutrition
Environmental heat
and cold exposure
Figure 5: Global trends in all-cause mortality and mortality from selected causes as estimated by the Global Burden of Disease 201713 for the 1990–2016
period, by World Bank regions
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11
diseases. Overall, the number of publications in the
previous 12 months remains high compared with
historical numbers, with a slight decrease in 2017
(75 publications) from a peak in 2016 (89 publications).
A clear majority of papers continue to report on positive
associations (appendix).
Indicator 1.9: food security and undernutrition
1.9.1: terrestrial food security and undernutrition—headline
finding: 30 countries are experiencing downward trends in crop
yields, reversing a decade-long trend that had previously seen
global improvement. Yield potential is estimated to be declining
in every region, as measured by accumulated thermal time
Worldwide, more than sucient food is produced to feed
the global population. The causes of food insecurity
and under nutrition are hence both complex and multi-
factorial, driven by factors beyond total food availability.28,29
However, food production is already being compromised
by extremes of weather that are predicted to become more
frequent and extreme; yield potentials are de creasing
globally, and many countries are already experiencing
falling yields.30,31
A multilevel indicator is presented in this report, linking
climate hazards and trends, crop yields and harvests, and
undernutrition. Overall trends are tracked using globally-
aggregated and country-level data, highlighting the extent
to which negative impacts of climate change outweigh
potential positive impacts on national nutrition and food
security through varietal breeding, improved farming
practices, and reductions in poverty.
First, global grain potential is represented by current
and future predictions of crop growth duration for maize
(appendix), which acts as a proxy for yield potential, and
in turn, food security. Reductions in crop growth duration
for maize in each region suggests declining maize yield
potential in each region and globally (figure 9, appendix).32
Second, the number of countries for which yields are
trending downwards is tracked. This number fell from
56 to 32 between 2000, and 2010, but has scarcely
decreased since, reaching 30 in 2016. For some countries,
where the yield gap (the dierence between actual
and maximum potential yield) is small, falling yields
reflect the negative eects of climate change already
outweighing any technological improvement.33 The third
component of this indicator tracks under nutrition,
aggregated at a global scale. Although pre valence and
AGlobal
Latitude
1982 1987 1992 1997 2002 2007 2012 2017
6
9
12
15
Coastal area suitable for
Vibrio outbreaks (%)
Year
Northern Tropics Southern
BBaltic region
Suitability metric
1982 1987 1992 1997 2002 2007 2012 2017
6
0
9
12
15
Suitability for Vibrio outbreaks (%)
Year
Days per year Percent of coast
CNortheastern USA
1982 1987 1992 1997 2002 2007 2012 2017
20
30
40
50
60
Coastal area suitable for
Vibrio outbreaks (%)
Year
Figure 7: Change in suitability for pathogenic Vibrio outbreaks as a result of changing sea surface temperatures
Figure 8: Environmental suitability for malaria transmission from 1950 to 2016, grouped by continent and
elevation
1950
1960
1970
1980
1990
2000
2010
3
4
5
6
7
8
Average number of suitable months
Year Year Ye ar
Africa
Elevation
Asia Latin America
1950
1960
1970
1980
1990
2000
2010
1950
1960
1970
1980
1990
2000
2010
High
Low
Figure 9: Change in crop growth duration relative to the 1961–90
accumulated thermal time, as a proxy for maize yield
The dashed line represents the average crop growth over the period of 1961–90,
and the solid black line represents an 11-year moving average.
1960 1980 2000 2020
–15
–9
–3
3
9
15
Accumulated thermal time days
Year
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absolute numbers of under nutrition have declined over
the past decade, a reversal of this trend and consequent
rise in undernutrition is evident in recent years.
The methods and data sources used for this indicator
have been improved on and expanded substantially since
the 2017 Lancet Countdown report,2 to incorporate potential
crop yield and actual crop production data,34 and are
presented in full in the appendix; additional figures for this
analysis are also available in the appendix.
1.9.2: marine food security and undernutrition—headline
finding: SST has risen substantially in 16 of the 21 key fishing
basins that were analysed, resulting in coral bleaching in many
of these basins and threats to marine primary productivity
being expected to follow
The indicator on marine food security has been further
developed since the 2017 Lancet Countdown report.2
21 basins have been analysed, selected for their geo graph-
ical coverage and importance to marine food security.34 A
multilayered indicator is tracked for each basin, monitoring
changes in SST and subsequent coral bleaching from
thermal stress (abiotic indicators), alongside per-capita
capture-based fish consumption (biotic indicator).
The data presented is sourced from NASA35 and the
US Environmental Protection Agency,36 with all methods
described in full in the appendix.
Between 2003, and 2015, SST rose in 16 of the 21 basins
analysed, rising by 1·59oC globally in 2015 compared with
1950 (figure 10; appendix). Rising SST coincides with an
increase in coral bleaching thermal stress (increased
stress and risk of bleaching to corals resulting from
prolonged rising temperatures) across many of these
basins, further threatening marine primary productivity
and a key source of protein for many populations. A full
breakdown of coral-bleaching thermal stress by basin is
provided in the appendix.
Indicator 1.10: migration and population displacement
Headline finding: climate change is the sole contributing factor
for thousands of people deciding to migrate and is a powerful
contributing factor for many more migration decisions worldwide
Measuring the net migratory impact of climate change
will always be one of the most methodologically complex
aspects of this indicator. This complexity is in large part
due to the multiple factors that comprise any individual
or community’s decision to migrate, as described by the
extensive migration and mobility literature. Attribution
of forced migration or non-forced migration to climate
change is complicated by the fact that the scarcity of
support mechanisms to deal with climate change is
typically more influential on population dynamics than
climate change itself. Attributing health outcomes to
migration-related decisions or the absence of such
options is another dicult step, although the forthcoming
Lancet Commission on Migration and Health is
elucidating aspects of the health eects of migration.
In the appendix, reanalyses of the work done in the 2017
Lancet Countdown report2 can be found, and follows the
definitions, scoping, and method described by Watts and
co-workers. A lower bound of several thousand people are
now migrating with climate change as the sole contributing
factor. Future projections are highly uncertain because of
challenges in projecting how society, technology, and
politics will change over the coming decades. Nonetheless,
in the absence of planning and inter ventions, several
hundred million people could end up being vulnerable to
forced migration, with climate change as the sole
contributing factor. To improve estimates, further research
suggestions are summarised in the appendix.
Conclusion
This section presents indicators on the vulnerability,
exposure, and impact of climate change for human health.
Overall, these indicators provide clear evidence of the
existing health eects of climate change. Notably,
vulnerability to heat has increased across all regions,
exposures to heatwaves have risen further, vectorial
capacity for disease vectors continues to increase, and
terrestrial and marine food-security threats have grown.
The regional health impacts of climate change and health
vary by geography, as shown clearly in the indicators on
flood and drought, highlighting the need for more detailed,
national-level, and local-level analyses. The indicators
presented in this section will therefore continue to be
improved, with important developments already in place.
Work on the development of a proxy indicator for the
crucial, and under-researched area of mental health and
climate change also continues, with preliminary national-
level results now being available.
Climate change aggravates risks to mental health and
wellbeing when the frequency, duration, intensity, and
unpredictability of weather-related hazards change.2 The
resultant weather eects increase the number of people
exposed or re-exposed to extreme events, and their
–0·40
–0·20
0
0·20
0·40
0·60
0·80
1·00
1·20
1·40
Changes in sea surface
temperature (°C) from 2003 to 2015
Germany
Peru
Nigeria
Mauritania
Kenya
South Korea
Chile
Australia
Brazil
Greece
Pakistan
Oman
Italy
UK
Canada
Haiti
Portugal
Iran
Saudi Arabia
Indonesia
Cuba
Figure 10: Changes in sea surface temperature (oC) for countries adjacent to and reliant on key Food and
Agricultural Organization fishing basins from 2003 to 2015
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13
consequent psychological problems, with suicide an
extreme manifestation of trauma.37,38 Because of their
rapidly growing frequency, duration, and intensity, heat-
waves are of particular concern, with strong evidence
linking their occurrence to increases in population
distress, hospital psychiatric admissions, and suicides.39–42
Less obvious eects of weather-related hazards can be
especially perilous, creating food shortages, home less ness
and displacement, and damaging public infra structure,
power and connectivity, agricultural land, and sacred
places.43 These pressures can impair social cohesion,
undermining crucial supports for mental health. Recent
analysis examining the relationship between hot years and
the incidence of suicide in Australia has been provided
(appendix).44
The adaptation and mitigation eorts of governments
and health professionals clearly matter immensely in
establishing the scale of the eventual health impacts of
climate change. Progress in these two areas, and on the
economic, financial, and political context on which they
depend, is the focus of the remainder of this report.
Section 2: adaptation, planning, and resilience for
health
Introduction
With the observed and future health impacts of climate
change becoming increasingly evident, and emission
trajectories committing the world to further warming,
accelerated adaptation interventions are needed to safe-
guard populations’ health. As the 2030 agenda shows,45
strategies to improve community resilience are often
linked to poverty reduction and broader socioeconomic
development imperatives, creating the possibility of no-
regret scenarios.1
The health sector should be at the forefront of adaptation
eorts, ensuring health systems, hospitals, and clinics
remain anchors of community resilience. This under-
recognised, yet growing area of practice, is the focus of
this section. The data are incomplete, providing more
insight into adaptation than resilience, and predominantly
allow for process-based indicators. However, several
indicators have been improved on since 2017: qualitative
analyses of the content and quality of national adaptation
strategies and vulnerability and adaptation assessments in
the health sector are included to complement previous
quantitative findings (indicators 2.1 and 2.6), and health-
specific adaptation questions were included in survey
tools and questionnaires for climate services (indicators 2.2
and 2.5). In addition, this year’s report includes a new
indicator assessing adaptive capacity to vector-borne
disease (in dicator 2.4). The indicators presented in this
report show an overall trend of increased uptake of
adaptation measures. However, although adaptation
activities may have increased, they do not guarantee
resilience against future climate change, and hence eorts
to adapt to climate change must be redoubled. This
increase in eorts is largely dependent upon sucient
spending on adaptation (indicator 2.7), funding availability
for adaptation (indicator 2.8), and an improved under-
standing of how to most eectively deliver resilience
within health systems.
Indicator 2.1: national adaptation plans for health
Headline finding: in 2015, 30 of 40 countries responding to the
WHO Climate and Health Country Survey reported having
national health adaptation strategies or plans approved by their
respective health authority
This indicator tracks the policy commitment of national
governments on health adaptation to climate change.
Revised data, based on the biennial WHO Climate and
Health Country Survey will be presented in the 2019 Lancet
Countdown report. In the interim, a qualitative analysis of
16 national health adaptation strategies and plans is
presented. Of note, as the most current and available
country strategies and plans were collected for this Review,
the documents included might not correspond exactly to
those reported in the 2015 survey findings.2 A full
description of the methods used in this qualitative review
can be found in the appendix.
Of the 16 national health adaptation strategies or plans
that were reviewed, only six were identified as being the
formal health component of a National Adaptation Plan
(NAP) of the UNFCCC process, referred to as an
H-NAP.46
The goal of a national health adaptation strategy or
plan should be to build the resilience of the existing
health system. Encouragingly, three quarters of the
countries (12 of 16) had established institutional
arrangements to integrate climate change adaptation
planning into ex isting health-related planning pro-
cesses. Almost all countries (15 of 16) prioritised their
most crucial climate-sensitive health outcomes in the
national health adapta tion strategy or plan. Water-borne,
food-borne, and vector-borne diseases were the most
widely considered climate-sensitive health outcomes,
followed by direct injuries and deaths due to extreme
weather events (figure 11). Nearly two thirds of countries
(10 of 16) outlined adaptation measures to address
specific health eects, particularly for integrated risk
monitoring, early warning, and climate-informed health
0 2 4 6 8 10 12 14 16
Water-borne and food-borne diseases
Vector-borne diseases
Direct injuries and death*
Nutrition and food security
Respiratory diseases
Non-communicable diseases
Heat stress
Other health outcomes
Mental health
Number of countries
Figure 11: The climate-sensitive health outcomes prioritised by 16 countries in their national health
adaptation strategies and plans
*Direct injuries and deaths due to extreme weather events.
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programmes. Yet less concrete measures were proposed
for mental health, non-communicable diseases,
respiratory diseases, and heat stress. Most countries (12
of 16) detailed a monitoring and evaluation process for
the implement ation of their strategy or plan with ten of
these countries proposing specific indicators for each
adaptation activity.
Indicator 2.2: city-level climate change risk assessments
Headline finding: of the 478 global cities surveyed, 65% have
either already completed or are currently doing climate-change
risk assessments, with 51% of cities expecting climate change to
seriously compromise their public health infrastructure
More than 50% of the world’s population live in cities,
generating 80% of global GDP and consuming 60% of
energy. Cities’ independent political and legal status
often aords them flexibility in developing a compre-
hensive adaptation response to climate change. This
indicator captures both the extent to which cities have
developed their own climate-change risk assessments,
and their own perception of the vulnerability of their
public health infrastructure to these threats.
Globally, 48% of cities had completed a climate-change
impact assessment, with 17% currently in progress. As
part of these assessments, 51% of cities identified public
health infrastructure as being particularly vulnerable to
climate change, and as needing additional and rapid
intervention. Global inequalities in the capacity to do
such assessments are evident, with only 25% of cities in
low-income countries doing so, as compared with 57% of
cities in high-income countries (appendix). Regional
trends are similarly correlated with development.
Data for this indicator are sourced from the Carbon
Disclosure Project’s 2017 survey of 478 global cities, and
the indicator is described in full in the 2017 Lancet
Countdown report2 and in the appendix.
Africa
Americas
Eastern Mediterranean
Europe
Southeast Asia
Western Pacific
WHO regions
2010
2011
2012
2013
2014
2015
2016
2017
20
40
60
80
100
Capacity score
Year
2010
2011
2012
2013
2014
2015
2016
2017
Year
CD
20
40
60
80
100
Capacity score
AB
Figure 12: International Health Regulations capacity scores by WHO regions
(A) Human resources capacity score. (B) Surveillance capacity score. (C) Preparedness capacity score. (D) Response capacity score.
For more on CDP cities and
regions data see
https://data.cdp.net/
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Indicator 2.3: detection, preparedness, and response to
health emergencies
Headline finding: despite a previous marked increase,
a substantial decline in national international health regulation
capacities, relevant to climate adaptation and resilience, was
observed in most WHO world regions in 2017
In total, 85% of WHO Member States responded to the
2017 International Health Regulations (IHR) monitoring
questionnaire47 (see panel 6 of Watts and co-workers2 for
details). Overall capacity scores have decreased for all four
capacities in 2017 compared with 2016, including human
resources (–9·9%), surveillance (–5·3%), preparedness
(–8·5%), and response (–7·8%). We present the progress
in capacity scores from 2010 to 2017 by WHO region
(figure 12).
The first of these capacities, human resources, has seen
the most heterogeneous change across WHO regions
(figure 12A). Two regions showed an increase in their
capacity score, Africa (11·8%) and Europe (7·1%), whereas
the remaining regions showed a decrease in their capacity
score—the Americas (–15·9%), the eastern Mediterranean
region (–8·0%), southeast Asia (–16·6%), and the Western
Pacific region (–21·3%).48 All regions showed a decrease in
surveillance capacity score (figure 12B), with Africa the
region showing the greatest decrease (–8·4%), followed by
the eastern Mediterranean region (–8·1%), the Americas
(–6·7%), southeast Asia (–6·5%,), Europe (–1·2%), and
the Western Pacific region (–1·1%).46 All regions except for
Africa have seen a decrease in their preparedness capacity
score;49 the African region main tained its capacity score
from 2016 (figure 12C). The greatest decrease occurred in
southeast Asia (18·3%), followed by the Western Pacific
(12·1%), the eastern Mediterranean region (6·9%), the
Americas (5·3%), and Europe (4·9%). Similar to
surveillance capacity, all regions showed a decrease in
their response capacity score (figure 12D), with the
greatest decrease occurring in the eastern Mediterranean
region (–12·6%), followed by southeast Asia (–11·1%), the
Americas (–10·2%), Africa (–6·8%), the Western Pacific
(–3·3%), and Europe (–2·4%).50 Importantly, these figures
are aected by a substantial improvement in reporting
(appendix).
Indicator 2.4: climate change adaptation to
vulnerabilities from mosquito-borne diseases
Headline finding: globally, improvements in public health have
reduced vulnerability to mosquito-borne diseases, with a
28% fall in global vulnerability observed from 2010–16
As indicator 1.8 makes clear, climate change is already
contributing to changing patterns of burden of disease
from vector-borne illnesses, such as dengue fever and
malaria. Robust public health adaptation strategies can
help to reduce these risks. This new indicator is the first
in a set of indicators that are in development, assessing
adaptive capacity to specific climate-related risks. The
indicator maps the preparedness and response capacity
of governmental institutions to prevent, prepare for,
cope with, and recover from climate change impacts.
Using a process-based mathematical model, relevant
country-level core capacities (drawn from the WHO IHR,
describing states of surveillance and response to
infectious disease outbreaks) were inversely related to
the hazard of being exposed to the dengue vector
A aegypti.51
The index combines estimates of risk of exposure to
A aegypti that a population could face, with the adaptive
capacity of the public health system. Improvements
in relevant areas of core capacity over the study
period translate into increased adaptive capacity
(decreased vulnerability) to mosquito-borne diseases.
The largest decrease in vulnerability was observed in
the Western Pacific and the Americas. The only region
to experience an increase in vulnerability was the
eastern Mediterranean. Importantly, as exposures to
climate-sensitive diseases change (indicator 1.8), the
existing adaptive capacity reported here might be
threatened, and thus vulnerability to such diseases could
increase in future. The data and methods for this new
indicator are described in full in the appendix, in which
figures are also available.
Indicator 2.5: climate information services for health
Headline finding: the national meteorological and hydrological
services of 53 countries report providing climate services to the
health sector
This indicator has been enhanced since 2017, with the
original survey now replaced by the WMO Country
Profile Database integrated questionnaire.52 Not only
does this questionnaire provide greater insights into the
nature of the provision of climate services to the health
sector than previously, it also allows for continuous
updating of this indicator. A snapshot of responses as of
May, 2018, were used; the methods and data for this
indicator are presented in full in the appendix, and a full
list of the countries reporting to provide climate services
to the health sector is included.
Of the 55 national meteorological and hydrological
services of WMO member states providing climate
services to the health sector, 14 were from Africa, 11 from
the Americas, four from the eastern Mediterranean,
18 from Europe, three from southeast Asia, and five from
the Western Pacific. Furthermore, services from
47 countries provided additional detail on the status
of climate service provision to the health sector:
ten countries reported to have initiated engagement with
the health sector, 13 reported to be undergoing health
sector needs definition, seven reported to be co-designing
climate products with the health sector, 14 reported that
tailored products are accessible to the health sector, and
three reported that climate services are guiding the
health sector’s policy decisions and investments plans.
For the remaining countries, whether they did not
respond to this section of the survey or whether they are
not providing services is unknown.
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Indicator 2.6: national assessments of climate change
impacts, vulnerability, and adaptation for health
Headline finding: in 2015, more than two thirds of the countries
that responded to the WHO Climate and Health Country Survey
reported to have done a national assessment of climate change
impacts, vulnerability, and adaptation for health
To design a comprehensive health adaptation plan to
eectively respond to climate risks and reduce adverse
health outcomes, a thorough assessment of a country’s
potential health impacts, vulnerability, and adaptation
needs is crucial.53 Similar to indicator 2.1, revised data from
the WHO Climate and Health Country Survey is not
available for this report. In the interim, WHO did a
qualitative analysis of the nature and quality of 34 national
assessments. A brief summary is presented here, with
methodological details presented in the appendix. Of note,
because the most recent and available country assessments
were collected for this Review, the assess ments that are
included might not correspond exactly to those reported in
the 2015 survey findings.
More than two thirds of countries that did the national
assessments (26 of 34) anticipated the integration of the
assessment findings into their national climate-change
adaptation strategy, and planned to use the assessments to
provide evidence-based policy options for health systems
and public health. 31 countries evaluated to some extent
the adaptive capacity of their health sector, with the
highest number of countries assessing adaptive capacity in
the areas of programmes (28 countries), infrastructure
(28 countries), and human resources (25 countries).
By comparing the countries’ assessments of vulnerability
and adaptive capacity with their proposed adaptation
measures, we showed that 23 countries had a corresponding
needs-to-actions translation, according to the established
criteria for the analysis (appendix). Detailed specifications
of how adaptation measures would be implemented,
however, were often absent, and resource constraints, data
availability, and capacity continue to be factors limiting the
scope and coverage of national assessments. Mirroring
national adaptation actions, capturing and better under-
standing how in dividual health systems are preparing and
adapting to climate change is equally important (panel 3).
Indicator 2.7: spending on adaptation for health and
health-related activities
Headline finding: globally, spending on adaptation for health
is estimated to be 4·8% (£11·68 billion) of all adaptation
spending, and health-related spending is estimated to be
15·2% (£32·65 billion)
This indicator tracks global adaptation spending on health
(spending directly within the formal health-care sector)
and health-related spending (spending in health care,
disaster preparedness, and agriculture). Such spending
can sub stantially reduce the mortality associated with
climate-related disasters, and monitoring this expenditure
over time is important (panel 4). Using the Adaptation
and Resilience to Climate Change (A&RCC) data reported
last year,54 health adaptation spending was shown to
increase by 8·2% in 2016–17 compared with 2015–16. This
percentage increase is larger than the change in total
adaptation spending over the same period (5·01%).
Globally, relative health-adaptation spending has grown
slightly from 4·6% for all adaptation spending estimated
by the A&RCC dataset in 2015–16 to 4·8% of all spending
in 2016–17 (a percentage change of 3·1%). For the wider
health-related values, relative spending increased from
13·5% to 15·2% of total A&RCC spending grouped by
World Bank income group, the highest percentage change
in health adaptation spending was in lower middle-
income countries followed by low-income countries,
although the dierences at this level of aggregation are
small (figure 13).55 Grouped by WHO region, the highest
percentage change is observed in Europe and southeast
Asia. However, noting the much lower spending in low-
income countries is important, because despite large
percentage changes, the total spending in low-income
countries is still far too low to meet their needs.
Panel 3: Health system climate change risk assessment,
preparedness and resilience
Future iterations of the Lancet Countdown will aim to
understand the extent to which individual hospitals and
health systems are adapting to climate change. A regular
survey done as part of the Health Care Climate Challenge is
attempting to gather such information. Although the data do
not have sufficient global coverage and annual
reproducibility, they provide some insight into the measures
taken at the health system level, and could potentially
represent a promising source for a future indicator.
Participants include health centres, hospitals, and health
systems, answering questions related to climate-change risk
assessment and preparedness activities. Respondents to the
survey are currently only based in the USA, the UK, Australia,
Brazil, France, Canada, New Zealand, and South Africa,
with the vast majority being in high-income countries.
Participants also represent the most engaged health systems,
introducing an element of bias into any analysis. Both
adaptation engagement (respondents who have completed a
vulnerability and adaptation assessment), and adaptation
activity (respondents who have begun to implement
preparedness activities) provide potentially useful sources of
data for future analyses.
Although the level of engagement rose somewhat between
2015, and 2016, adaptation activity is much lower, with only
57% of health systems, 22% of hospitals, and 20% of health
centres having developed a plan to address future health-care
service delivery needs resulting from climate change. Within
this sample, these results suggest that there may be more
capacity to undertake risk assessments than to plan and
implement adaptation activities, or may suggest a delay
between risk assessment and risk reduction efforts.
For more on the Health Care
Climate Challenge see https://
noharm-global.org/
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Indicator 2.8: health adaptation funding from global
climate financing mechanisms
Headline finding: the amount of adaptation funding falls short
of the commitments made in the Paris Agreement, with just
$472·82 million of adaptation funding for development in
2017; only 3·8% of the funding in 2017 was allocated for
health adaptation
This indicator makes use of the same data source
(Climate Funds Update)56 and methods as those described
in the 2017 Lancet Countdown report.2 The past 12 months
saw the approval of a new health-adaptation programme
in east Asia and the Pacific to scale-up health system
resilience in Pacific Island Least Developed Countries. At
$17·85 million, this project was the only health-focused
project to be approved in 2017, and represented 3·8% of
the total 2017 adaptation spending for development
($472·82 million), far less than the annual $100 billion
for adaptation eorts by 2020 promised at the 2010
Cancun Agreements under the UNFCCC (appendix).57
Conclusion
The data presented in section 2 suggests that health
professionals and health systems are increasingly
considering and responding to the health eects of
climate change. There appears to be more and earlier
engagement in higher-resource settings than low-
resource settings, although there is evidence of adapta-
tion activity in health sectors across the develop mental
and geographic spectrum. There is evidence of health
adaptation occurring incidentally, through broad de-
velopment initiatives, such as IHRs (indicator 2.3 and
2.4), and directly through specific climate-change adap-
tation initiatives (indicators 2.1, 2.2, and 2.6). Although
absolute preparedness remains low, most trends
followed in this report are moving in the right direc-
tion, and when vulnerability has been tracked, risks
related to climate change appear to be decreasing.
Despite this positive trend, absolute funding available
for health adaptation remains particularly low, limiting
further progress on this issue. Furthermore, powerful
technolo gical and financial limits to adaptation exist,
and these necessitate a joint focus on mitigation as
part of the global response to climate change.3
Measuring health adaptation and resilience to climate
change presents numerous methodological challenges,
with most available metrics being proxy indicators
of progress. These measures must be interpreted with
caution and applied to climate change, rather than solely
in their original context. This section has worked to
present findings of indicators for adaptation assess-
ments, planning, implementation, and financing.
Section 3: mitigation actions and health
co-benefits
Introduction
This section presents evidence relating to climate change
mitigation and associated near-term consequences for
health. The health impacts of climate change, and
communities’ ability to adapt to it, both depend on the
success of global mitigation eorts. But mitigation also
has more immediate co-benefits arising from the changes
in harmful exposures (eg, reductions in particle air
pollution) and health-related behaviours that mitiga tion
actions entail. Therefore, the pace of the low-carbon
transition establishes the degree to which such benefits
are realised.
The changes since the 2017 Lancet Countdown report2
mostly reflect continuing trends or modest incremental
shifts. A shift of investment towards clean energy tech-
nologies continues to occur, with accelerating growth in
new low-carbon power generation (indicator 3.3) and a
downward trend in global demand for coal (indicator 3.2).
However, global energy-sector carbon emissions remain
largely unchanged (indicator 3.1) and ambient air pollution
remains generally poor (indicator 3.5), with estimated
contributions of dierent sectors to PM2·5-attributable
Panel 4: Deaths from climate-related disasters versus
health spending
The number of people killed in climate-related disasters is a
function of the strength of the climate hazard, the exposure
of the population to the hazard related to the number of
people in the hazard location, and the underlying
vulnerability of the population. Governments can reduce
deaths to climate-related disasters through disaster
preparedness measures, such as early-warning systems and
via enhanced health services for those affected by a disaster.
Although generally countries with higher GDPs (gross
domestic products) have lower numbers of disaster fatalities
than countries with lower GDPs, this relationship does not
necessarily hold when also accounting for the number of
people exposed to climate hazards (appendix).
Instead, a clear relationship exists between deaths per capita
from climate-related disasters and per-capita health national
spending. Countries that spend more on health tend to have
fewer deaths from such disasters than countries that spend
less. Although health spending (per capita) is related to GDP
(per capita), the relationship is not one to one (appendix).
Most notably, when ranking countries by the percentage of
GDP that is spent on health, for the first three quartiles of
countries, a decrease in deaths per capita from disasters
related to climate hazards can be seen as the percentage of
GDP increases. This finding would appear to support the
notion that as governments allocate more of their GDP to
health spending per capita, they decrease the number of
deaths (per capita) from climate-related disasters for all
countries, except those in the highest percentage of the
health spending quartile. This raises serious questions as to
which elements of health spending are most effective at
reducing climate-related disaster deaths; for example,
whether preparedness or primary health or response have the
greatest role in minimising mortality.
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mortality presented in indicator 3.5.2. The number of
electric vehicles purchased has increased, but the electricity
they use is still largely derived from fossil fuels
(indicator 3.6), and they account for only a very small
fraction of the vehicle fleet.
Indicator 3.1: carbon intensity of the energy system
Headline finding: since 1990, the carbon intensity of TPES has
remained static with no reduction at 55–57 tCO2/TJ
This year’s report includes 4 years of additional data
compared with the 2017 Lancet Countdown report,2 and
shows that the global trend in carbon intensity remains
broadly unchanged. This means an ever-widening gap
from the required path of rapid reduction towards zero
emissions by 2050 to fulfil the Paris Agreement, which
would require a decline in carbon intensity approximately
equivalent to an average reduction of 1·0–1·6 tCO2/TJ
per year.
Carbon intensity remains high despite the continued
growth of renewable electricity (indicator 3.3), and the
decrease in coal demand (indicator 3.2), in large part
caused by the growth in use of other fossil fuels, such as
oil and natural gas, has continued apace, especially in the
rapidly growing economies of Asia (figure 14). Growth in
renewables still has a long way to go before it begins to
influence global carbon intensity enough to decrease
these trends, because renewables account for only 24% of
total electricity generated, of which 16% is hydroelectricity.
In final energy terms, these sources only met 4·5% of the
global demand in 2015.58
CO2 emissions appear to have levelled o from 2014
(figure 14); however, analysis by the Global Carbon
Project suggests that emissions have begun rising again,
with a projected 1·5% increase between 2016 and 2017.58
This rise, due to stronger economic growth in China
and other developing regions, highlights that further
0
5000
10
000
15
000
A&RCC spending (m)
A
0
2·5
5·0
7·5
Percentage change in A&RCC spending (%)
B
0
5
10
Percentage of total in A&RCC spending (%)
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
2015–16
2016–17
C
0
5
10
15
Health A&RCC spending per capita (£)
D
Fiscal year Category
Fiscal year
World Bank income grouping
Low Lower-middle Upper-middle High-income
World Bank income grouping
Low Lower-middle Upper-middle High-income
Fiscal year
Health
Health-related
Figure 13: Health and health-related A&RCC spending for financial years 2015–16 and 2016–17
(A) Total health and health-related A&RCC spending (in millions of pounds). (B) Percentage change in health and health-related A&RCC spending from 2015–16 to
2016–17. (C) Percentage of health and health-related A&RCC as a proportion of total spending. (D) Health and health-related A&RCC per capita (in pounds).
A&RCC=adaptation and resilience for climate change.
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19
structural change in the energy system is needed to
safeguard gains. In addition to the incentives provided
from demands for clean energy investment, policies are
also needed that incentivise suppliers into a timely
transition out of existing fossil-based infrastructure.59
The methods and data sources58 for this indicator are
described in full in the 2017 Lancet Countdown report2
and in the appendix.
Indicator 3.2: coal phase-out
Headline finding: since 2013, coal use has declined, resulting
largely from reductions in coal consumption in China, enhanced
efficiency in coal-fired power generation, and continued increase
in use of shale gas in the USA. In 2016, this downward trend
continued; however, preliminary data suggest coal consumption
might increase slightly in 2017and 2018
Accelerating the downward trend in coal demand will be
crucial to meeting the climate goals embodied in the Paris
Agreement. For example, to meet the 1·5°C warming-
limit target, coal use needs to be at 20% of 2010 usage by
2040, or around 30 EJ (figure 15).60 Although there is
optimism that coal consumption can be substantially
reduced, particularly in China, the question is whether
this reduction can be achieved quickly enough to meet
climate goals, and whether this overall trajectory will also
follow for countries with high growth demand.61 For
example, growth in India in 2016 was of 2·4% (a decrease
from previous years), but consumption in member states
of the Association of South East Asian Nations, where coal
has a small but growing role in electricity production,
increased by 6·2% in 2016. Furthermore, estimates
suggest a 1% increase in coal use in India in 2017.62
If coal phase-out can be sustained, this decrease in coal
consumption is likely to have important air pollution
co-benefits (indicator 3.5), which in turn help oset the
policy costs of mitigation.63,64 Crucially, renewable genera-
tion has become increasingly cost-competitive, with
auctions in India placing solar power as the cheapest
available form of electricity generation.65,66
Strong political momentum for the phase-out of coal
has also occurred since the 23rd COP to the UNFCCC
(COP23) in December, 2017, with many countries (eg,
the UK, France, and Canada) pledging to phase-out
coal use, forming the Powering Past Coal Alliance.67
Furthermore, 20 additional countries committed to
phase-out the use of coal-fired power generation by
2030 at the most recent UN climate summit, with a few
countries, including France, Italy, and the UK, aiming
to phase-out coal earlier than 2030.68 Other countries
have included coal reduction targets in their nationally-
determined contributions of the Paris Agreement.69 For
instance, Indonesia has stated that coal will make up no
more than 30% of its energy supply by 2025, and 25%
by 2050. Such commitments are crucial given that coal
demand continues to increase, particularly across Asia
(figure 15); of the 60 GW of new coal plants installed
globally in 2017 (100 GW in 2015), two thirds were in
India and China.70 Additional figures and details are
available in the appendix.
Indicator 3.3: zero-carbon emission electricity
Headline finding: in 2017, 157 GW of renewable energy was
installed (143 GW in 2016) compared with 70 GW (net) of
fossil-fuel capacity installation, continuing the trend reported
in 2017
The low-carbon electricity sector is thriving, with strong
prospects for displacing fossil fuels, such as coal, in the
electricity generation sector because of its cost-
competitiveness. Globally, this increase in low-carbon
electricity generation is playing out with much more
investment in renewable than fossil fuel-based capacity,
with the number of renewable capacity installations in
2017 being more than double that of fossil fuel capacity.
USA
1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015
10 0
20 5
30 10
40 15
50 20
60 25
70 30
80 35
tCO2/TJ (TPES)
Gigaton CO2 (energy combustion)
Year
Southern AsiaSoutheastern Asia
North and western Europe
Global energy-related CO2Global China
Figure 14: Carbon intensity of TPES for selected regions and countries, and global energy-related CO2
emissions
tCO2/TJ=total CO2 per terajoule of energy. TPES=Total Primary Energy Supply.
China
Southeastern Asia
Southern Asia
USA
North and western Europe
Other
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Global TPES coal (EJ)
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Figure 15: TPES coal use in selected countries and regions and global TPES coal
EJ=exajoule. TPES=Total Primary Energy Supply.
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Approximately 30% of global electricity generation is
from zero-carbon sources, with the majority coming
from hydropower and nuclear power. In 2015, 5% of
global electricity generation was from so-called new
renewables (solar and wind power), rising from 0·5% in
2000. This growth is particularly evident in the USA,
China, northwest Europe, and India, all of which are
expanding their renewables deployment (figure 16A and
C). The increasing share of renewable generation either
displaces fossil fuel gener ation or meets a portion of new
demand growth, reducing the need for investment in
fossil fuels (figure 16B and D). The data and methods for
this indicator are reported in the 2017 Lancet Countdown2
and the appendix.71
Indicator 3.4: access to clean energy
Headline finding: the number of people without connections to
electricity decreased from 1·7 billion in 2000 to 1·1 billion in
2016, and many countries will achieve electricity for all by
2030, with the greatest gains to be seen in east Asia and
southeast Asia. Conversely, more than 2·8 billion people still go
without healthy, clean, and sustainable cooking fuel or
technologies, the same number as in 2000
The reduction in the number of people without access to
electricity from 1·7 billion in 2000 to 1·1 billion in 2016,
is primarily due to an increase in new connections made to
a centralised grid, although modest gains continue for
decentralised grids or microgrids. Most new access was
achieved using electricity generated with fossil fuels,
highlighting a key challenge in moving towards a
decarbonised energy system. Much of this growth has
been driven by coal-generated power stations in China,
India, and southeast Asia; at 37%, coal remains the main
fuel used in global electricity production.58 Although strong
economic, health, and social benefits come from increased
use of electricity, costs (such as exacerbated outdoor
ambient air pollution and greenhouse gas emissions)
will vary depending on how electricity is provided
(indicator 3.5). The residential sector’s energy mix has
changed over 15 years alongside access to electricity, which
has been driven largely by fossil fuel generation. The
complicated nature of the relationship between energy
access and health is fraught with local synergies and
tradeos (panel 5).
Access and use of clean fuels and technologies for
cooking has seen limited improvement since 2000, and
in several countries negative trends have been observed
as the access gap increases. Access to clean cooking
remains a continuous problem, with around 3 billion
people (1·9 billion in developing Asia and 850 million in
0
200
400
600
800
1000
1200
1400
1600
Low-carbon generation (TWh)
A
0
0·1
0·2
0·3
0·4
0·5
0·6
0·7
Share of low-carbon generation
Share of renewable generation
(excluding hydropower)
B
1990 20152010200520001995
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50
100
150
200
250
300
Renewable generation
(excluding hydropower ;
TWh)
Year
C
1990 20152010200520001995
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0·02
0·06
0·04
0·08
0·10
0·12
0·14
Year
D
China
Southeastern Asia
Southern Asia
USA
North and western Europe
Figure 16: Renewable and zero-carbon emission electricity generation
(A) Electricity generated from zero-carbon sources. (B) Share of electricity generated from zero-carbon sources. (C) Electricity generated from renewable sources
(excludring hydropower). (D) Share of electricity generated from renewable sources (excluding hydropower). TWh=terawatt hours.
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21
sub-Saharan Africa) without clean cooking fuel or
technologies in 2016, exposing vulnerable popu lations to
high amounts of harmful indoor air pollution, estimated
to cause 3·8 million deaths per year.73 Biomass remains the
single largest fuel source in the residential sector, which
outlines the challenge of access to clean and modern fuels.
The appendix provides further details and a figure on the
proportional national share of energy types for the
residential sector for selected countries.74
Indicator 3.5: exposure to ambient air pollution
An estimated 7 million people die each year from air
pollution, and 4·2 million of these deaths are a result of
ambient air pollution.75 Much of this pollution is related
to combustion processes, which would be substantially
reduced by the achievement of climate-change mitigation
targets to phase-out dependence on fossil fuels. Rural
areas are not spared, facing important health burdens
caused by air pollution from agricultural practices and
household fuel use.
3.5.1: exposure to air pollution in cities—headline finding: from
2010 to 2016, air pollution concentrations have worsened in
almost 70% of cities around the globe, particularly in LMICs.
Populations in 90% of cities are subjected to air pollution
concentrations that are higher than WHO’s guideline of
10 µg per m3
Trends in urban concentrations of fine particulate matter
(PM2·5) between 2010, and 2016, were analysed by the
Data Integration Model for Air Quality for 308 globally
representative cities of the Sustainable Healthy Urban
Environments (SHUE) database.76,77 Annual average
concentrations of PM2·5 increased in 208 (67·5%) of these
cities and decreased in 100 (32·5%) cities, with an average
increase of 3·6 µg per m³ per year (unweighted by
population; figure 17). The number of cities in which the
concentrations of fine particulate matter were higher than
WHO’s annual guideline of 10 μg per m³ increased from
254 (82·5%) to 268 (87·0%).
These estimates are consistent with those of 4000 cities
covered by the most recent update of WHO’s air pollution
database.78 Concentrations in the majority of cities
remain much higher than recommended targets,
especially in LMICs,79 which in part reflects the slow pace
of change towards a low-carbon world.
3.5.2: premature mortality from ambient air pollution by
sector—headline finding: in 2015, ambient air pollution
resulted in more than 2·9 million premature deaths globally
from fine particulates alone. Coal use accounts for
approximately 16% of air pollution-related premature
mortality globally, making its phase-out a crucial no-regret
intervention for public health
Indicator 3.5.2 reports premature mortality from ambient
PM2·5, attributed to individual emission sectors by region.
This indicator is derived from calculations with the
Greenhouse Gas Air Pollution Interactions and Synergies
model, which calculates emis sions of all precursors of
PM2·5 with a detailed breakdown of economic sectors and
fuels used. Underlying activity data are based on statistics
by the International Energy Agency (IEA).80
Emissions and concentrations correspond to the year
2015, and are calculated from updated statistics of the
World Energy Outlook 2017.81 The geo graphical coverage
has been expanded since the 2017 report to global
coverage, and the breakdown has been refined to quantify
contributions from coal combustion in all sectors
(figure 18). Although the analysis is done by country,
results are aggregated by region for clarity.
The contribution of individual sectors to total air
pollution-related premature mortality varies regionally,
but numerous sources contribute in each region. Large
contributions come from the residential sector (much from
Panel 5: Energy, health and the Sustainable Development
Goals
The 2030 UN Agenda for Sustainable Development is a
comprehensive global plan of action for people, the planet,
and prosperity, comprised of 17 sustainable development
goals (SDGs) and 169 targets to be achieved by 2030.
SDG number 7 aims to ensure access to affordable, reliable,
sustainable, and modern energy, and provides an example of
a goal that delivers supporting infrastructure that underpins
the achievement of other SDGs.
In recognition of these interactions, analysis of efforts to
achieve SDG number 7 and the delivery of the 169 targets
reveals evidence of 143 synergies and 65 tradeoffs.72 There are
many interdependencies between energy and SDG number 3
on health (ensure healthy lives and promote wellbeing for all
at all ages), including evidence of synergies with eight of
13 targets, and tradeoffs with five targets. Synergies exist, for
instance, with target 3.2 (end preventable deaths of children
and newborn babies). Access to electricity supports using
medical equipment at health centres, ensuring good surgery
and delivery conditions for prenatal and neonatal care and for
storage of medical supplies. However, there are potential
tradeoffs for which, for example, electricity access (target 7.1)
is provided with non-carbon neutral sources, with probable
detrimental effects on human health through air pollution
(targets 3·4 and 3·9) and climate change (SDG number 13).
The SDGs provide an important opportunity to realise the
positive interactions between goals, such as energy and
health, and to minimise the negative outcomes. However,
these relationships are often context-specific, requiring
consideration of how actions to achieve one SDG may
reinforce or undermine progress towards another. For energy
and health, the needs will differ according to scale—
for instance, communities cooking with firewood will require
different solutions than cities dealing with high
concentrations of ambient particulate matter from wood
burning from heating homes.
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solid fuel, such as biomass and coal, and kerosene used
for household heating and cooking), industry (the
dominant contributor in east Asia), electricity generation,
transport, and agriculture (from burning of agricultural
waste and secondary inorganic aerosol formation). Coal is
a key target for early phase-out because this type of fuel is
particularly polluting with regards to both CO2 and
particulate matter. Coal is mainly used in electricity
generation, industry, and (in some countries) households.
In total, exposure to ambient air pollution is estimated
to have contributed to almost 3 million premature deaths
globally (almost 2 million in Asia, 130 000 in the
Americas, more than 300 000 in Africa, and almost
500 000 in Europe) in 2015. On average, more than
460 000 premature deaths are related to coal combustion
globally (about 16% of all premature deaths due to
ambient air pollution); this proportion rises to about
18% of premature deaths in Asia. Regional contributions
vary from 9% in southeast Asia, 14% in south Asia,
almost 30% in China, and more than 40% in Mongolia,
indicating large potential for direct health benefits of coal
phase-out. China and India are particularly aected, with
an estimated 911 000 premature deaths in China and
525 000 in India being caused by ambient air pollution;
coal accounts for 204 000 of these deaths in China and
107 000 of these deaths in India. In the EU, the number
of premature deaths from ambient air pollution was
about 310 000 in 2015; 53 506 of these premature deaths
were from coal and 42 028 from the transport sector.
Household fuel combustion is also a substantial
contributor, accounting for a total of 678 000 premature
deaths from ambient air pollution (136 000 from coal)
globally in 2015, and many more from indoor air
pollution, and hence even larger reductions in premature
mortality could be achieved through a transition to clean
household fuels.
Indicator 3.6: clean fuel use for transport
Headline finding: global road transport fuel use (terajoule fuel
consumption) increased 2% from 2013 to 2015 on a
per-capita basis. Although fossil fuels continue to dominate,
the growth in use of non-fossil fuels outpaced fossil fuels in
recent history, rising by 10% over the same period
Fuels used for transport produce more than half the
nitrogen oxides emitted globally, and a substantial
proportion of particulate matter, posing a great threat to
human health.82 These pollutants are predominantly
urban in their nature, and persist as a substantial
contributor to urban ambient-air pollution and pollutant-
related deaths (indicator 3.5), of which two thirds are
related to air pollution. This indicator monitors global
trends in fuel eciency and the transition away from the
most polluting and carbon-intensive transport fuels; the
indicator follows the metric of fuel use for road
transportation on a per-capita basis (terajoule per person)
by type of fuel.83,84
Globally, despite notable gains for electricity and
biofuels, road transport continues to be powered almost
exclusively by fossil fuels (figure 19). Since the previous
publication,2 the use of non-fossil fuels (electricity and
biofuels) has continued to outpace fossil fuel energy,
rising more than 10% on a per-capita basis compared
with an overall growth of 2% for fossil fuels from 2013 to
2015. This trend had a small, but notable, eect on the
overall share of non-fossil fuel energy for road transport,
which rose from 3·9% to 4·2% over these two years.
The take up of electric vehicles across the global motor
vehicle stock has increased by a further 1 million vehicles,
or 50%, from 2016.85,86 More than 2 million electric ve-
hicles are on the road, and global per-capita electricity
con sumption for road transport grew by 13% from
2013 to 2015.87 In Organisation for Economic Co-operation
and Development (OECD) countries, per-capita electricity
consumption for transport more than doubled compared
2010 2011 2012 2013 2014 2015 2016
0
50
100
150
200
250
300
Mean annual average PM
2·5 (µg/m3)
Year
Southeast Asia
2010 2011 2012 2013 2014 2015 2016
Year
Western Pacific
0
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300
Mean annual average PM2·5 (µg/m3)
Eastern Mediterranean Europe
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Mean annual average PM2·5 (µg/m3)
Africa Americas
Yaoundé, Cameroon
Harare, Zimbawe
WHO region
Cairo, Egypt
Baghdad, Iraq
WHO region
Ankara, Turkey
Moscow, Russia
WHO region
Dhaka, Bangladesh
Meerut, India
WHO region
Harbin, China
Chengdu, China
WHO region
Corcoran, CA, USA
Cochabamba, Bolivia
WHO region
Figure 17: Mean of annual average PM2·5 concentrations over the period 2010–16 for Sustainable Healthy
Urban Environments cities by WHO region, estimated using digital marketing qualification
WHO regions are represented by blue lines. Also shown are the range for all cities (light blue shaded area) and cities
with the largest decrease (green lines) and increase (red dotted lines) over the period based on linear trends.
PM2·5=atmospheric particulate matter with a diameter of less than 2·5 µm.
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23
with a 10% increase in non-OECD countries. In China,
per-capita electricity use was five times the global average
because of the country’s high market share of electric
vehicles. In 2016, China accounted for more than 40% of
the electric cars sold globally (appendix).87
Indicator 3.7: sustainable travel infrastructure and
uptake
Headline finding: cycling comprised less than 7% of total modal
share for a fifth of global cities sampled from the SHUE
database, stratified by income, population size, and geography
Although the shift to clean fuels is imperative, green-
house-gas emissions and those of air pollutants can also
be reduced by moving from private motorised transport to
more sustainable modes of urban travel (such as public
transport, walking, and cycling). These sustainable modes
of travel reduce emissions from vehicles, which is crucial
for addressing urban air pollution (indicator 3.5.1) and has
several health co-benefits. Focusing on sus tainable travel
infrastructure and uptake in urban areas, this section
focuses on cycling modal share, presenting the data
collected over the past decade from 48 of all the randomly
sampled cities across the world (stratified by national
wealth, population size, and Bailey’s Ecoregion) in the
SHUE database.88 Mode share data come from travel
surveys of individual cities, national census data, and
governmental and non-governmental reports (appendix).
Within the sample, the prevalence of cycling is low in
most cities, with less than 10% of trips being made by
cycling. However, the prevalence of cycling is high in
some Western Pacific cities, notably those in Cambodia
and China, and European cities, such as Copenhagen.
Nonetheless, relatively low prevalence of cycling persists
in the Americas, eastern Mediterranean, and many
European cities (appendix).
Increasing the prevalence of cycling in some settings is
challenging, but cycling mode shares can be im proved in
many cities. Evidence suggests that good cycling infra-
structure, integration with public transport, training of
both cyclists and motorists, and making driving in-
convenient and expensive can help make cycling more
attractive.89,90 A full description of the data and methods
for this indicator are available in the appendix.
Indicator 3.8: ruminant meat for human consumption
Headline finding: the amount of ruminant meat available for
human consumption worldwide has decreased slightly from
12·09 kg per capita per year in 1990, to 11·23 kg per capita
per year in 2013. The proportion of energy (kcal per capita per
day) available for human consumption from ruminant meat
decreased marginally from 1·86% in 1990 to 1·65% in 2013
Defining and tracking meaningful changes in sus-
tainable, healthy food production presents multiple
challenges. The 2017 report2 presented ruminant meat
for human con sumption (which decreased slightly from
12·09 kg per capita per year in 1990 to 11·23 kg per capita
per year in 2013) because the production of ruminant
meat, from cattle in particular, dominates greenhouse-gas
emissions from the livestock sector (estimated at
5·6–7·5 gigatons of CO2 emission per year). Although
meat is a highly nutri tious food, consumption of red
meat, particularly proces sed red meats, has known
associations with adverse health outcomes.91,92 The major
limitation of this indicator is that it reflects only one
aspect of sustainable diets, which is unlikely to have
equal health implications for high-income countries with
excessive ruminant-meat consum ption and low-income
countries with low ruminant-meat consumption. Track-
ing progress towards more sustainable diets requires
standardised and continuous data on food consumption
and related greenhouse-gas emissions throughout food
product life cycles. This process would require annual
nationally representative detailed dietary survey data on
food consumption. Eorts to compile data and ensure
comparability are underway, but their format is not
suitable for global monitoring of progress towards
optimal dietary patterns. The collaboration will continue
to work on developing a standardised indicator on
sustainable diets.
Indicator 3.9: health-care sector emissions
Headline finding: no systematic global standard for measuring
the greenhouse-gas emissions of the health-care sector exists,
but several health-care systems in the UK, the USA, Australia,
and around the world are working to measure and reduce their
greenhouse-gas emissions
Comprehensive national greenhouse-gas emission repor-
ting by the health-care system is only routinely done in the
UK, where NHS emissions decreased by 11% from 2007 to
2015, despite an 18% increase in activity.93 In Australia, CO2
emissions of the health-care sector were estimated to be
35 772 kilotons in 2014–15, which is 7% of Australia’s total
emissions.94 In the USA, a study estimated the greenhouse-
gas emissions of the health-care sector to be 655 million
metric tons, nearly 10% of US emissions.95 Elsewhere,
selected health-care organisations, facilities, and com-
panies provide self-reported estimates of emissions;
however, these estimates are rarely standardised across
Western Pacific
Southeast Asia
Europe
Eastern Mediterranean
Americas
Africa Waste
Ships
Agriculture
Other
Coal
Power plants
Industry
Land-based transport
Households
0 10 20 30 40 50 60 70
Annual premature deaths from ambient PM2·5 per 100
000 inhabitants
Figure 18: Health impacts of exposure to ambient fine particulate matter (PM2.5) in 2015, by key sources of
pollution by WHO region
Coal as a fuel is highlighted by hatching. Country aggregations correspond largely to WHO regions, except for small
exceptions (appendix). PM2·5=atmospheric particulate matter with a diameter of less than 2·5 µm.
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sites. The Lancet Countdown will continue to work on
developing a standardised indicator on health sector
emissions.
Conclusion
The indicators presented in this section provide an
overview of activities that are relevant to public health
and climate change mitigation in the energy, transport,
food, and health-care sectors. The indicators present a
mixed picture. Positive trends include ongoing com-
mitments to the phase-out of coal in many countries, the
fact that renewable energy continues to account for most
added capacity annually, and the increasingly rapid
uptake of electric vehicles. However, the scale of the
challenge in reversing past trends and rapidly reducing
greenhouse-gas emissions is immense. Mitigation action
to date is still far lower than the action required to meet
the aspirations of the Paris Agreement to keep warming
well below 2°C. Not only is this fact a concern for limiting
the future harms of climate change, but this also means
that many near-term benefits for health, such as those
from improved air quality, are not being realised. Rapid
acceleration of action in almost all sectors and across all
regions is still needed.
Section 4: finance and economics
Introduction
So far, indicators in the first section of the Lancet
Countdown’s 2018 report have highlighted the health
impacts of climate change, whereas those in sections 2 and
3 detail the adaptation and mitigation interventions
deployed to respond to this public health challenge.
Section 4 focuses on the financial and economic enablers
of a transition to a low-carbon economy, and the impli-
cations of inaction. Although on the face of it, some of the
indicators presented do not have an immediately obvious
link to human wellbeing (for ex ample, indicator 4.3), these
indicators are often important upstream determinants and
drivers of the processes described in sections 1–3.
The consequences of climate change come with clear
costs, both to human health and the economy, including
increased health-care costs and decreased workforce
productivity. However, health and economic benefits,
beyond avoiding the potential costs of inaction, are also
to be gained from tackling climate change. Markandya
and co-workers96 estimate that the global cost of reducing
greenhouse-gas emissions in line with the aims of the
Paris Agreement could be oset by the economic value of
improved health associated with the co-benefit of reduced
air pollution alone, by a ratio of 2:1.
The eight indicators in this section fall into four broad
themes: the economic costs of climate change, investing
in a low carbon economy, economic benefits of tackling
climate change, and pricing greenhouse-gas emissions
from fossil fuels. The methods and datasets used closely
mirror those from the 2017 Lancet Countdown report,2
with no substantial changes to the indicators being made
in this year’s report. The nature of economic and
financial data allows for important updates despite the
regular annual update cycle of the Lancet Countdown.
The appendix provides a more detailed discussion of the
data and methods used, as initially described in the 2017
Lancet Countdown report.2
Indicator 4.1: economic losses due to climate-related
extreme events
Headline finding: in 2017, a total of 712 events resulted in
$326 billion in overall economic losses, with 99% of losses in
low-income countries remaining uninsured. This is almost
triple the total economic losses of 2016
The economic costs of extreme climate-related events,
borne by individuals, communities, and countries, often
compounds the direct health eects described in in-
dicators 1.2–1.6. These economic costs often result in
insidious, indirect eects on health and wellbeing in the
subsequent months to years. With projections suggesting
the frequency and intensity of these events will increase
substantially, this indicator tracks the present day total
Natural gas
Electricity
Other liquid biofuels
Biodiesels
Biogasoline
Biogases
Fuel oil
Other kerosene
Liquefied petroleum gases
Gas and diesel oil excluding biofuels
Motor gasoline excluding biofuels
1971
1975
1979
1983
1987
1991
1995
1999
2003
2007
2011
2015
0
0·002
0·004
0·006
0·008
0·010
0·012
1971
1975
1979
1983
1987
1991
1995
1999
2003
2007
2011
2015
0·014
Per
-capita fuel consumption (
TJ/person)
Year
0
0·0001
0·0002
0·0003
0·0004
0·0005
0·0006
Year
AGlobal per capita fuel consumption
for road transport (all fuels)
BGlobal per capita fuel consumption
for road transport (non-fossil fuels)
Figure 19: Per-capita fuel use by type (TJ per person) for road transport with all fuels and non-fossil fuels only
(A) Global per-capita fuel consumption for road transport using all types of fuels. (B) Global per-capita fuel consumption for road transport using only non-fossil fuels.
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25
annual economic losses (insured and uninsured) across
country income groups relative to GDP, resulting from
climate-related extreme events (figure 20).
The data for this indicator are sourced from Munich
Re’s NatCatSERVICE,97 with climate-related events
categorised as meteorological, climatological, and hydro-
logical events (geophysical events are excluded). The
methods used have not changed since 2017, and are
described in full in the 2017 report,2 and in the appendix,
along with data for 1990–2017.
Global economic losses due to extreme climate-related
events in 2017 totalled at $327 billion, around triple the
value for 2016. The clear majority of this increase in
economic losses occurred in high-income countries,
where losses relative to GDP increased from $1·44 per
$1000 GDP to $5·58 per $1000 GDP. Economic losses in
low-income countries decreased slightly between 2016,
and 2017, both in absolute terms and per unit GDP.
However, whereas nearly half of the losses in high-
income countries were insured, just 1% of low-income
country losses were insured.
Indicator 4.2: investments in zero-carbon energy and
energy efficiency
Headline finding: in 2017, proportional investment in
zero-carbon energy and energy efficiency decreased as a
proportion of total energy-system investment, whereas the
proportion of fossil fuels increased. However, this decrease is in
part due to the declining costs of renewables
Indicator 4.2 monitors global investment in zero-carbon
energy, and in energy eciency (both as a proportion of
the total energy system, and in absolute terms; figure 21).
All values reported are based on the value of the US dollar
in 2017 (US$2017), with data sourced from the IEA.98–100
The methods and data sources for this indicator have
not changed since the 2017 Lancet Countdown report,2
and are outlined in detail there, and in the appendix. The
IEA estimated that to maintain a 50% chance of limiting
global average temperature rise to 2°C, cumulative
investment in the energy system from 2014 to 2035, must
reach $53 trillion, with 50% of this being invested in
zero-carbon energy and energy eciency.101
Total investment in the global energy system reduced
by 2% in real terms between 2016, and 2017. Investment
in fossil fuels reduced slightly, because of lower
investment in coal electricity generation capacity than
previously (see indicator 4.3), but this reduction was
oset to a large degree by increased investment in
upstream oil and gas. Investment in zero-carbon energy
also decreased because of a substantial reduction in new
nuclear investment, but also because of a continuation of
declining unit costs for renewables (eg, solar photovoltaics
decreased in cost by 15% between 2016, and 2017).
Investment in energy eciency continued to increase.
However, overall, between 2016, and 2017, fossil fuels
increased slightly as a proportion of total energy-system
investment, whereas zero-carbon energy and energy
eciency decreased (from 33% to 32%).102
Indicator 4.3: investment in new coal capacity
Headline finding: investment in new coal capacity reduced
substantially in 2017, reaching its lowest level in at least
10 years, from a possible all-time peak in 2015
Indicator 4.3 tracks global annual investment in the
most CO2-intensive method of generating electricity—the
combustion of coal in coal-fired power plants. We used
data from the IEA to present an index of annual investment
in new coal capacity from 2006 to 2017 (figure 22).
The methods and data sources (the IEA) for this
indicator have not changed since the 2017 Lancet
Countdown report,2 and are outlined in detail there and
in the appendix.99
Low income
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Upper-middle
High income
Low income
Lower-middle
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High income
Low income
Lower-middle
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High income
Low income
Lower-middle
Upper-middle
High income
Low income
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High income
Low income
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Low income
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Low income
Lower-middle
Upper-middle
High income
0
1·00
2·00
3·00
4·00
5·00
6·00
Economic losses (US$1 per $1000
GDP, US$ 2017)
2010 2011 2012 2013
Year
2014 2015 2016 2017
Insured loss
Uninsured loss
Figure 20: Economic losses from climate-related events relative to GDP
GDP=gross domestic product. US$2017=based on the value of the US dollar in 2017.
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Investment in new coal-fired electricity-generating
capacity reduced substantially in 2017, continuing the
trend in 2016 (figure 22). This decrease is largely the
result of fewer new plants being commissioned in China
and India. Investment in new coal capacity is at its
lowest in more than 10 years, with the IEA suggesting
that investment in coal-fired capacity reached an all-time
peak in 2015.103 In addition, the retirement of existing
coal-fired capacity oset nearly half of new capacity
additions in 2017.102
Indicator 4.4: employment in renewable and fossil-fuel
energy industries
Headline finding: in 2017, renewable energy provided
10·3 million jobs, an increase of 5·7% from 2016. Employment
in fossil-fuel extraction industries also increased to 11 million,
an 8% increase from 2016
As the low-carbon transition gathers pace, fossil fuel-
energy industries and associated jobs will decline. Employ-
ment in some key fossil fuel industries, such as coal
mining, have well documented eects on human health.2
However, in the place of these industries new low-carbon
industries and employment opportunities, such as those
in the renewable energy sector, will be stimulated. With
appropriate planning and enabling policy, the transition of
employment opportunities between high-carbon and low-
carbon industries could yield positive consequences for
both the economy and human health.
This indicator tracks global direct employment in fossil-
fuel extraction industries (coal mining and oil and gas
exploration and production) and direct and indirect (supply
chain) employment in renewable energy (figure 23). The
data for this indicator are sourced from the International
Renewable Energy Agency (renewables) and IBIS World
(fossil fuel extraction).102,104,105
The number of direct and indirect jobs in the global
renewable energy industry continues to increase, reaching
10·3 million in 2017 (a 5·7% increase from 2016). The solar
photovoltaic sector overtook the bioenergy sector to
become the largest employer in 2016, and saw a further
9% growth in 2017 (driven by China and India).
Employment in biofuels increased for the first time since
2014 (a 12% increase in 2017 from 2016), because of
increased production of ethanol and biodiesel (particularly
in Brazil and the USA).105
By contrast to the trend of decreasing employment in the
global fossil-fuel extractive industries (particularly in coal
mining) established in 2011, employment in this industry
rose by around 8% between 2016, and 2017, driven by
reducing prices, industry consolidation, and the rise in
automation.2 This rise is also driven by the coal mining
sector, reflecting expansion due to a double-digit price
increase. However, the decreasing trend will be likely to
return as the low-carbon transition progresses.102
The data for fossil-fuel extraction employment for
2012–16 dier substantially from those presented in the
2017 Lancet Countdown report9 because of improved data
collection methods and improved estimation of global
coal-mining employment by IBISWorld. Further details on
this indicator can be found in the appendix.
Indicator 4.5: funds divested from fossil fuels
Headline finding: in 2017, the global value of funds committed to
fossil fuel divestment was $428 billion, of which funds from
health institutions accounted for $3·28 billion; these funds
represent a cumulative sum of $5·88 trillion, with health
institutions accounting for $33·6 billion
Indicator 4.5 tracks the total global value of funds com-
mitted to divestment from fossil fuels, and the value of
funds committed to divestment by health institutions.
This evolving movement seeks to both remove the social
licence of the fossil fuel industry and guard against the
risk of losses due to stranded assets, by encouraging
institutions and investors to commit to divest their assets
invested in the industry. This approach is often contrasted
with an approach that sees investors actively engage with
the fossil fuel industry, for example, by looking to
mandate a reduction in high-carbon activities through
shareholder resolutions. These two approaches might not
360 373 335
227 228 235
271 300 303
1002 937 927
2015 2016 2017
0
200
400
600
800
1000
1200
1400
1600
1800
2000
US$ 2017 billion
Year
Renewables and nuclear
Energy efficiency
Electricity networks
Fossil fuels
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 20172016
60
70
80
90
100
110
120
130
140
Index
of global investment in coal-fired
power capacity (100 represent 2006)
Year
Figure 21: Annual investment in the global energy system
US$2017=based on the value of the US dollar in 2017.
Figure 22: Annual investment in coal-fired capacity from 2006 to 2017
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27
be mutually exclusive, and might be most eective when
employed in tandem.106
By the end of 2017, 826 organisations with cumulative
assets worth at least $5·88 trillion, including 17 health
organisations with assets of around $33·6 billion, had
committed to divest, including the World Medical
Association, Royal Australasian College of Physicians, and
the Canadian Medical Association. Between 2016, and
2017, the annual value of new funds that were committed
to divestment decreased from $1·24 trillion in 2016 to
$428 billion in 2017. However, health institutions have
divested at an increased rate, from $2·4 billion in 2016 to
$3·28 billion in 2017, with the American Public Health
Association, the Hospital Contributions Fund, and
Medibank Australia as notable contributors.
In the context of this indicator, divestment is broadly
defined, and includes organisations that have committed
to divest from one form of coal to those that have actively
divested from all fossil fuel industries. Ultimately, the
Lancet Countdown aims to analyse the amount of divest-
ment from dierent sectors. The methods and data for
this indicator have not changed since the 2017 Lancet
Countdown report;2 further details are available in the
appendix.
Indicator 4.6: fossil fuel subsidies
Headline finding: in 2016, fossil fuel consumption subsidies
continued to follow the trend established in 2013, and decreased
to $267 billion (a 15% reduction from 2015)
Section 3 of this report makes clear some of the cardio-
pulmonary consequences of fossil fuel combust ion. Fossil
fuel subsidies (both for consumption and production)
artificially lower prices, promoting over consumption and
further exacerbating air pollution and its consequences for
human health.
This indicator tracks the global value of fossil-fuel
consumption subsidies. Although these subsidies are
intended to moderate energy costs for low-income
consumers, in practice, 65% of such subsidies in LMICs
benefit the wealthiest 40% of the population.107 We note the
continuation of the downward trend that began in 2013,
with global fossil-fuel consumption subsidies reaching
$267 billion in 2016 (figure 24).58
Increasing fossil fuel prices tend to increase subsidies as
the dierence between the market and regulated consumer
price increases. For example, the doubling in oil price
between 2009, and 2012, was the principal driver behind
the increase in subsidies in these years. However, when
fossil fuel prices decrease, the gap between market and
regulated prices also narrows, allowing governments to
review the use of such subsidies while keeping overall
prices largely constant.58
Both factors were responsible for the declining trend
between 2012, and 2015, which continued into 2016 with a
further decrease in oil prices (to prices that had not been
seen since 2002), and continuing subsidy reforms in the
Middle East in particular.2,108 Although the Middle East
continues to provide around 30% of total subsidies, their
value decreased from around $120 billion in 2015 to
$80 billion in 2016. As a result, subsidies for electricity
consumption in 2016 were, for the first time since such
data was collected, larger than those provided for oil
consumption.58
The methods and data source (the IEA) for this indicator
have not changed since the 2017 Lancet Countdown report,2
and are described in the report and in the appendix.58
However, the breakdown of subsidies by type of fuel for
2009–13, which was previously not available, is now
included.
Indicator 4.7: coverage and strength of carbon pricing
Headline finding: carbon pricing instruments in early 2018
continue to cover 13·1% of global anthropogenic greenhouse-
gas emissions reached in 2017, but with average prices being
around 20% higher than those of 2017
Adequately pricing carbon (both in terms of strength,
coverage, and integration of varying mechanisms)
could potentially be the single most important intervention
in responding to climate change. This indicator tracks the
Fossil fuel extraction
0
2
4
6
8
10
12
14
Number of jobs (millions)
Year
2012 2013 2014 2015 2016 2017
Solar photovoltaic
Other technologies
Large hydropower
Bioenergy
Solar heating and cooling
Wind energy
Figure 23: Employment in renewable energy and fossil-fuel extraction
sectors
2009 2010 2011 2012 2013 2014 2015 2016
0
100
200
300
400
500
600
US$ 2017 (billion)
Year
Oil
Gas
Coal
Electricity
Figure 24: Global fossil-fuel and electricity consumption subsidies in
2009–16
US$2017=based on the value of the US dollar in 2017.
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extent to which carbon pricing instruments are applied
around the world as a proportion of total greenhouse-gas
emissions, and the weighted average carbon price
instruments provided (table). The same methods and data
source (the World Bank Carbon Pricing Dashboard)109 were
used for this indicator as in the 2017 Lancet Countdown
report,2 and are further detailed in the appendix.
The coverage of carbon pricing instruments re-
mained at 13·1% of global anthropogenic greenhouse
gas emissions between 2017, and 2018, implemented
through 42 national and 25 subnational instruments
(appendix).
The range of carbon prices across instruments remains
vast (from <$1 per tonnes of CO2 equivalent in Poland
and Ukraine to $139 per tCO2e in Sweden), although
weighted-average prices in early 2018 were 20% higher
than those of 2017 (both across instruments and total
global anthropogenic greenhouse-gas emis sions). For
example, the price under the EU Emissions Trading
Scheme (ETS; the largest carbon pricing instrument in
the world) rose by $10 per tCO2e between Dec 1, 2017, and
April 1, 2018.
With the addition of instruments scheduled for
implementation, including the Chinese national ETS
(replacing the existing subnational pilots), around
20% of global anthropogenic greenhouse gas emissions
will be subject to a carbon price.110 Further carbon pricing
instruments are under consideration in several other
national and subnational jurisdictions.
Indicator 4.8: use of carbon pricing revenues
Headline finding: revenues from carbon pricing instruments
increased 50% between 2016, and 2017, reaching $33 billion,
with $14·5 billion allocated to further climate change
mitigation activities
Indicator 4.8 tracks the total government revenue from
carbon pricing instruments and how this income is
subsequently allocated. Government revenue from carbon
pricing instruments can be put to a range of uses. Revenue
can be invested in climate change mitigation or adaptation
activities, be explicitly recycled for other purposes
(eg, enabling the reduction of other taxes or levies), or
simply contribute towards general government funds.
Government revenue generated from carbon pricing
instruments in 2017, totalled at nearly $33 billion,
a 50% increase from the $22 billion generated in 2016.
This increase is driven by a combination of increasing
carbon pricing coverage in 2017 (with the introduction of
the Ontario, Canada, ETS and carbon taxes in Alberta,
Canada, in Chile, and in Colombia), an increase in
average prices, and an increasing share of ETS permits
bought at auction (rather than distributed for free).110
The absolute value of allocated funds has increased in
all four categories, with the proportional share remaining
largely stable between 2016, and 2017. The most marked
change is a shift of approximately 4% of total revenue
from revenue recycling to mitigation (appendix). This is
in part driven by Colombia and particularly Ontario,
which have committed to allocate all revenues from their
newly-introduced instruments to further mitigation
action.
Data on revenue generated are provided on the World
Bank’s Carbon Pricing Dashboard, with revenue allo-
cation information obtained from various sources. Only
instruments with revenue estimates and with revenue
received by the administering authority before redis-
tribution are considered. The methods and principle data
source (the World Bank)109,110 for this indicator have not
changed since the 2017 Lancet Countdown report,2 and
are described there and in the appendix, along with
further detail on the various sources used to obtain this
global picture of carbon pricing revenues and data for
individual instruments.
Conclusion
Section 4 has presented indicators on the costs of the
broader impacts of climate change and the economics
and finance that underpin climate mitigation. The
results of these indicators suggest that the beginning of
an economic transition towards a low-carbon economy
is underway, with many of the trends identified in the
2017 report2 continuing. These trends can be interpreted
as early signs of a broader transformation, with
important health benefits to follow, as a result of
growing investment in low-carbon technology and
employment, a transition away from fossil fuels, and
strengthened and expanded pricing of greenhouse-gas
emissions.
However, the indicators presented here also make
clear that meeting the Paris Agreement commitments
will require substantial further engagement from
govern ments, private sector, and general public to
increase the pace and scale of action.
Section 5: Public and political engagement
Introduction
As earlier sections make clear, climate change is still
moving much faster than we are, and its negative eects
on human health continue to multiply.111 The impact
(section 1) and response (sections 2–4) sections of this
2016 2017 2018
Global emissions coverage* 12·1% 13·1% 13·1%
Weighted average carbon price
of instruments (current prices
in US$)
7·79 9·28 11·58
Global weighted average
carbon price (current prices in
US$)
0·94 1·22 1·51
*Global emissions coverage is based on 2012 total anthropogenic greenhouse-gas
emissions.
Table: Carbon pricing: global coverage and weighted average prices per
tonnes of CO₂ equivalent
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29
report highlight the fact that action to date remains
insucient to achieve the ambitions of the Paris
Agreement.112 Public and political engagement is central
to increasing the speed and scale of action.
Four domains of engagement are the focus of this final
section: media, science, government, and corporate
sector. Indicators have been identified for which annual
and global data are available. Trends are largely reported
from 2007, the year before the 2008 World Health
Assembly in which member states of the UN resolved to
protect human health from climate change.113
The media have a central role in public understanding
and perceptions of climate change.114 The public rely on the
news media to communicate and interpret climate change
science, and to make sense of extreme weather events and
assess actions by businesses and govern ments.115,116 The
first indicator enriches the methods deployed in 2017,
providing a global overview of media coverage of health
and climate change from 62 newspapers, which is
then complemented with expanded in-depth analysis of
three national newspapers—the New York Times (NYT) in
the USA, Le Monde in France, and Frankfurter Allgemeine
Zeitung (FAZ) in Germany.
The second indicator focuses on science journals, the
major source of evidence on health and climate change
for the public, policy makers, and the business sector.
The third indicator focuses on government engagement
in health and climate change. Surveys point to wide-
spread public concern about climate change and its
health related risks, with most people believing that
their country has a responsibility to take action on
climate change and that their government is not doing
enough.117–119 This indicator captures high-level govern-
ment engagement by tracking references to health and
climate change in the statements made by national
governments at the annual UNGD of the UN General
Assembly (UNGA). The UNGD is a unique international
forum that provides all UN member states with the
opportunity to address the UNGA on issues they
consider important.120
The corporate sector is integral to the transition to a
low-carbon economy, both through their business
practices and by influencing political responses to
climate change.121,122 Data for this new indicator come
from the UN Global Compact (UNGC), in which com-
panies report annually on their progress on embed ding
environmental sustainability and SDGs into their
business plans and activities.123,124
Indicator 5.1: media coverage of health and climate
change
Headline finding: coverage of health and climate change in
the media increased substantially between 2007, and 2017,
a trend evident in both the global indicator and in-depth
analysis of leading global newspapers
This indicator tracks coverage on health and climate
change in the global media, and provides insight into
the content of media coverage through analysis of
selected leading newspapers.
Global media coverage of health and climate change
increased by 42% between 2007, and 2017 (figure 25).
This increase contrasts with global newspaper coverage
of climate change alone. Although climate change
coverage declined at an average rate of 1·25% per year,
coverage of health and climate change increased by an
average of 4% per year.
Marked regional dierences can be observed, with
more extensive media coverage in southeast Asia driving
the global trend (figure 25). Southeast Asian coverage
accounts for a large proportion (42–64%) of global
coverage across the same period. Moreover, the overall
increase in global coverage is driven by increased
coverage in this WHO region, with the Times of India,
India’s largest English-language newspaper, contributing
disproportionately to the global total.125 English-language
newspapers occupy a particularly central place in the
Indian media by communicating the perspectives and
priorities of political and business elites.126,127
Methods and data sources for this indicator are
described in full in the Lancet Countdown’s 2017 report2
and in the appendix. Analysis has been expanded greatly,
from 24 newspapers in 2017, to 62 newspapers in 2018.
The second component of indicator 5.1 focuses on
three major national newspapers that form part of the
elite news media, which is seen to have a pivotal role in
shaping public and political responses to climate
change.128 Coverage of health and climate change
increased in all three newspapers (figure 26). Between
2009 and 2017, the number of articles increased by
200% in FAZ, 133% in the NYT, and 18% in Le Monde.
However, health remains marginal to wider climate
change coverage (figure 26). Of the climate change
articles published in 2017 in the NYT and in FAZ, only
2% referred to health and climate change; in Le Monde,
the proportion was slightly higher, at 8%. Media
attention has been characterised by peaks linked to
climate change action at the global level, and to the
UNFCCC COPs in particular.2
Content analysis of the three newspapers points to
marked national dierences in coverage. In European
newspapers, the proportion of articles explaining and
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
0
200
400
600
800
1000
Articles per source
Year
Africa
Eastern MediterraneanEurope
Western PacificSoutheast AsiaAmericas
Figure 25: Newspaper reporting on health and climate change (for 62 newspapers) in 2007–17, by WHO region
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justifying why climate change is a public health issue
declined over the period from 2007 to 2017, with a
parallel increase in those highlighting the health
dimensions of national climate change interventions. By
contrast, in the NYT, most (92%) articles referring to
both health and climate did so without linking the
two topics. For example, the NYT referred separately to
US health-care reforms (Obamacare) and US disengage-
ment from the Paris Agreement. Such articles are
therefore not included among those linking health and
climate change (figure 26). In European newspapers,
health and climate change are most frequently covered
in news sections—for example, as an environmental
issue (Le Monde) and an economic issue (FAZ).
However, in the NYT, health and climate change appear
less frequently as news items and more frequently
within the opinions section. The distinctive patterns of
US media coverage of climate change have also been
noted elsewhere.129
Methods and data sources are described in full in the
2017 Lancet Countdown report2 and in the appendix. The
analysis has been enhanced both by the addition of a
third national newspaper (the NYT) and by examining
media engagement in health and climate change in the
context of the wider coverage of climate change; further
analyses are also presented in the appendix.
Indicator 5.2: coverage of health and climate change in
scientific journals
Headline finding: coverage of health and climate change
increased by 182% in scientific journals between 2007, and 2017
Between 2007, and 2017, more than 2500 scientific
articles examined the links between climate change and
health. Just under half (47%) presented new research.
The remainder comprised research-related articles (eg,
research reviews, editorials, comments, and viewpoints),
with research reviews making up the majority (55%) of
these articles. The slight decline in scientific output on
health and climate change between 2016, and 2017, is the
result of fewer research-related publications than
previously (appendix).
As in previous years, scientific interest in health and
climate change in 2017 was focused on America and
Europe. More than a third (35%) of the papers
concentrated on climate change and health in America,
with just under 30% of all papers concerned with
North America only. A further 25% focused on countries
in Europe. Of the 20% of articles relating to the Western
Pacific region, half focused solely on China. Less than
10% of papers related to health and climate change
related to Africa (n=23) and southeast Asia (n=18), a
region that includes India and Bangladesh. With respect
to health outcomes, infectious diseases (particularly
dengue fever and other mosquito-borne diseases) were
the most common health focus (24%).
Although this analysis points to increasing scientific
engagement in health and climate change over the past
decade, the area is marginal to climate change science.
Of the 43 000 articles published in 2017 in the general
area of climate change, only 4% made any link to health,
and less than 1% (n=265) had a specific focus on health
and climate change.
Methods and data sources are explained in full in the
Lancet Countdown’s 2017 report2 and in the appendix.
In addition to updating the analysis to include the date
of 2017, this year’s report also explores the type of
scientific output (research or research-related) and the
volume of outputs relating to climate change more
broadly.
Indicator 5.3: engagement in health and climate change
in the UN General Assembly
Headline finding: from 2007 to 2017, national statements in
the UNGD have increasingly linked climate change and health
In this subsection we present trends from 1970 to 2017,
looking separately at references to health, climate change,
and health and climate change (figure 27). Although both
health and climate change have been central focuses of
the UNGD for an extended period, joint references to
health and climate change did not truly begin to rise until
2000. Since 2007, trends in engagement in health and
climate change have broadly matched the separate trends
for climate change and health.
Two spikes in engagement are apparent; in 2009–10,
20% of countries referenced health and climate change
as linked issues, a sharp increase associated with the
build-up to the UNFCCC’s COP15. The second, larger,
spike in 2014, coincided with the transition from the
Millennium Development Goals to the SDGs and the
lead-up to the UNFCCC’s COP21. In that year, almost a
NYT (climate change coverage)
NYT (health and climate change coverage)
Le Monde (climate change coverage)
Le Monde (health and climate change coverage)
FAZ (climate change coverage)
FAZ (health and climate change coverage)
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
0
500
1000
1500
2000
2500
3000
3500
0
50
100
150
200
250
300
Number
of all articles for climate change coverage
only (solid lines)
Number of articles for health and climate change coverage (dashed lines)
Year
Figure 26: Newspaper reporting of climate change and health and climate change in the NYT, Le Monde, and
FAZ in 2007–17
FAZ=Frankfurter Allgemeine Zeitung. NYT=New York Times.
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31
quarter of all governments referenced the health impacts
of climate change. Since 2014, a decline in engagement
with health and climate change in the UNGD has been
observed, with only 12% of the 196 UN member states
referring to the two issues together in 2017. By contrast, a
substantial majority of states referred to climate change
(>75%) in their 2017 UNGD statement.
Marked global and national dierences in the
attention given to health and climate change exist.
Countries in the Western Pacific region are the most
likely to refer to climate change and health links in
their UNGD state ments, with around 40% doing so in
2017. For example, Tuvalu’s statement notes that “the
impacts of climate change pose the most immediate,
fundamental and far-reaching threat […] to the right to
the highest attainable standard of physical and mental
health”. The Australian statement discusses how SDGs,
the Paris Agreement, and the Sendai Framework
provide a blueprint for global action in areas such as
climate change, diseases (including malaria), and
resource management. The Cambodian Government
also stated that “the 2030 Agenda is inextricably linked
to many of the issues that perturb the world today,
the most pressing being climate change, which is not
only a direct threat in itself but is also a multiplier of
many other threats—from poverty, diseases and food
insecurity, to mass migrations and regional conflicts”.
The text for individual GD statements is available as
part of the UN General Debate Corpus.130
Western Pacific regional engagement is driven by the
Pacific Island states. In 2017, as in previous years,
the Small Island Developing States (SIDS) were pro-
minent among the countries referring to health and
climate change in their UNGD addresses. Nauru, the
Maldives, the Marshall Islands, Tuvalu, St Kitts and Nevis,
and Vanuatu all discussed climate change and health
links. By contrast, engagement was lowest in Europe and
North America.
Methods and data sources are explained in full in the
Lancet Countdown’s 2017 report2 and in the appendix.
This year’s analysis reports on the proportion of countries
referring to health and climate change rather than the
number of references; for continuity with the 2017 report,
trends relating to the number of references are provided
in the appendix, together with additional analyses.
Indicator 5.4: engagement in health and climate change
in the corporate sector
Headline finding: engagement with health and climate change
has remained low among companies within the UNGC
This new indicator tracks engagement with health and
climate change among the 12 000 companies signed
up to the UNGC, the world’s largest corporate sus-
tainability initiative.131 Established to address gaps in the
global governance of corporations, the UNGC seeks a
more sustainable and inclusive global economy.132 The
ten principles of the UNGC relate to human rights,
working conditions, and environmental responsibility.
Companies report annually on their implementation in
Communication of Progress reports (CPs) that are made
publicly available. Our analysis focuses on 2011–17,
because very few CPs are publicly available before 2011
(appendix).
The proportion of companies referring separately and
jointly to health and climate change in their annual CPs
indicates relatively high engagement in health and in
climate change as separate issues; across the period
2011–17, 55–60% of the reports engage with health and
around 45% with climate change. By contrast, less than
one in seven reports refer conjointly to health and climate
change (appendix).
There are no spikes in engagement related to other UN
initiatives, including the launch of the SDGs, COP21,
or the 2015 Paris Agreement. There are, however,
marked dierences in engagement by corporate sector.
Engagement is highest among telecommunication
companies, in which more than 40% of CPs made
reference to the intersection of climate change and health
(appendix).
The UNGC has been subject to critique, including of
its voluntary status, limited participant base, and inability
to control the environmental externalities generated by
the corporate sector.133–135 Nonetheless, as a platform for
developing and promoting sustainable policies and
practices, the UNGC represents the largest corporate
citizenship programme to date.132
The new indicator is based on the application of a
keyword search in the text corpus of CPs submitted
in English; in total, 48% (n=15 220) of CPs from
129 countries were analysed. Climate change-related
terms were searched for the 25 words before and after a
reference to a public health-related term. Methods and
data sources are explained in full in the appendix.
Because companies are listed in one country, but often
operate across multiple countries both directly and via
subsidiaries, analyses by WHO region are not given here,
however, they can be found in the appendix.
1970 1988 2000 2009 2014 2017
0
25
50
75
100
Proportion of countries (%)
Year
Health
Climate change
Health and climate change
Figure 27: Proportion of countries referring to climate change, health, and
health and climate change in UN General Debates in 1970–2017
Review
32
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
Conclusion
Section 5 of this report has presented indicators of public
and political engagement, which are crucial to trans-
formational action on climate change. The barriers to
action on health and climate change are predominantly
societal and not technical, with public and political
engagement therefore holding the key to accelerating the
pace and scale of action.1 Three conclusions can be drawn
from this analysis of engagement in the media, science,
UN, and corporate sector.
First, engagement in health and climate change has
increased in the media, science, and the UNGD over the
past decade. The upward trend underlines the role of the
UN, particularly through the UNFCCC and its COPs,
in mobilising engagement. For example, spikes in the
indicators around COP15 (2009) and COP21 (2015) were
observed. The years that follow tend to see a decline in
engagement. The exception to this broad pattern is the
corporate sector, in which evidence for companies within
the UNGC points to little change in engagement in
health and climate change.
Second, although overall engagement has increased
over the past decade, engagement remains partial and
uneven. Rather than reflecting a process of global
mobilisation, the upward trend is being driven by
individual regions and countries. The increase in global
media attention is the result of increased coverage by
newspapers in southeast Asia and by the Indian press in
particular. With respect to political engagement, SIDS
are using the global platform of the UNGD to draw
attention to the health impacts of climate change. Within
the scientific domain, overall trends again reflect uneven
engagement. In this domain, however, increased
engagement has been driven by research focusing on
health and climate change in high-income and high-
emitting countries. By contrast, very few studies focus on
Africa and southeast Asia, regions bearing the brunt of
the health impacts of climate change.
Third, although engagement in health and climate
change has increased over the past year, this engagement
represents a very small part of public and political
engagement in climate change. Across the media,
science, government, and the corporate sector, climate
change is being framed in ways that largely ignore its
health dimensions. Thus, analyses of national news-
papers and scientific journals indicate that less than
5% of climate change coverage relates to health. Analysis
of the intergovernmental forum of the UNGD suggests
that climate change and health are largely represented as
separate issues, with much less attention given to them
as interconnected phenomena. Similarly, a high pro-
portion of companies within the UNGC refer separately
to health and climate change in their annual reports;
however, only a small minority make links between
health and climate change.
Taken together, these conclusions point to increasing
engagement in the health impacts of climate change,
and to the challenge of making health central to climate
change action.
Conclusion: the Lancet Countdown in 2018
The Lancet Countdown: tracking progress on health and
climate change monitors progress on health and climate
change across five domains: climate change impacts,
exposures, and vulnerabilities; adaptation, planning, and
resilience for health; mitigation actions and health
co-benefits; finance and economics; and public and
political engagement. The collaboration is committed to
an iterative and open process, and will continue to
develop the methods and data sources its indicators draw
on, publishing annually in The Lancet through to 2030.
In 2018, many of the global trends previously identified
accelerated, both in terms of the health impacts of climate
change, and the mitigation and adaptation interventions
being implemented around the world. The first section of
the report made clear that vulnerable populations are
continually exposed to more severe climate hazards, with
indicators reporting 157 million heatwave exposure events
for such groups in 2017, more than 153 billion hours of
labour lost due to rising temperatures, and that climatic
conditions are at their most suitable for the transmission
of dengue fever virus since 1950. Section 2 explored the
various ways in which ministries of health, cities, and
health systems are planning to enhance resilience and
adaptation, providing more detailed insight into the
quality and compre hensiveness of these strategies, and
highlighted the fact that only 3·8% of adaptation funds
available for development were allocated specifically for
public health. Although more than 2·9 million premature
deaths were caused by ambient pollution from PM2·5
globally in 2015, promising trends reported in sections 3
and 4 showed a continued phase-out of coal-fired power,
accelerated deployment of renewable energy, and
continued divestment from fossil fuels, which should
help to reduce premature mortality from air pollution.
Indicators in the final section pointed to the same
conclusions—that engagement in health and climate
change is increasing, enabling this engagement to be an
important driver of policy change globally.
Four key messages emerge from the 41 indicators of
the Lancet Countdown’s 2018 report. First, present day
changes in labour capacity, vector-borne disease, and
food security provide early warning of compounded and
overwhelming impacts expected if temperature continues
to rise. Trends in climate change impacts, exposures, and
vulnerabilities show an unacceptably high risk for the
current and future health of populations across the
world. Second, slow progress in reducing emissions and
building adaptive capacity threatens both human lives
and the viability of the national health systems they
depend on, with the potential to disrupt core public-
health infrastructure and overwhelm health services.
Third, despite these delays, trends in a number of sectors
are helping to generate the beginning of a low-carbon
Review
www.thelancet.com Published online November 28, 2018 http://dx.doi.org/10.1016/S0140-6736(18)32594-7
33
transition, and clearly the nature and scale of the
response to climate change will be the determining factor
in shaping the health of nations for centuries to come.
And fourth, ensuring a widespread understanding of
climate change as a central public-health issue will be
vital in delivering an accelerated response, with the
health profession beginning to rise to this challenge.
Taken as a whole, the indicators and data presented in
the Lancet Countdown’s 2018 report provide great cause
for concern, with the pace of climate change outweighing
the urgency of the response. Despite this concerning
trend, exciting trends in key areas for health, including
the phase-out of coal, the deployment of healthier,
cleaner modes of transport, and health system adaptation,
give justification for cautious optimism.
Regardless, the way in which these indicators of impact
and response progress up until 2030 will clearly shape
the health of nations for centuries to come.
Contributors
The Lancet Countdown: tracking progress on health and climate change is
an international academic collaboration that builds o the work of the 2015
Lancet Commission on health and climate change, convened by The
Lancet. The Lancet Countdown’s work for this report was conducted by its
five working groups, each of which were responsible for the design,
drafting, and review of their individual indicators and sections. All authors
contributed to the overall structure and concepts of the report and provided
input and expertise to the relevant sections. Authors contributing to
Working Group 1 included Nigel Arnell, Helen Berry, Jonathan Chambers,
Ilan Kelman, Tord Kjellstrom, Bruno Lemke, Lu Liang, Rachel Lowe,
Jaime Martinez-Urtaza, Maziar Moradi-Lakeh, Kris Murray,
Fereidoon Owfi, Mahnaz Rabbaniha, Elizabeth Robinson, Jan C Semenza,
Meisam Tabatabaei, and Joaquin Trinanes. Authors contributing to
Working Group 2 included Sonja Ayeb-Karlsson, Peter Byass,
Diarmid Campbell-Lendrum, Paula Dominguez-Salas, Kristie L Ebi,
Lucia Fernandez Montoya, Lucien Georgeson, Delia Grace, Jeremy Hess,
Dominic Kniveton, Maquins Odhiambo Sewe, Mark Maslin,
Maria Nilsson, Tara Neville, Karyn Morrissey, Joacim Rocklöv, and
Joy Shumake-Guillemot. Authors contributing to Working Group 3
included Markus Amann, Kristine Belesova, Michael Davies,
Ian Hamilton, Stella Hartinger, Gregor Kiesewetter, Melissa Lott,
James Milner, Tadj Oreszczyn, David Pencheon, Steve Pye,
Rebecca Steinbach, Julia Tomei, and Paul Wilkinson. Authors contributing
to Working Group 4 included Paul Drummond and Paul Ekins. Authors
Contributing to Working Group 5 included Maxwell Boyko,
Meaghan Daly, Niheer Dasandi, Anneliese Depoux, Helen Fischer,
Hilary Graham, Rébecca Grojsman, Lucy McAllister, Slava Mikhaylov,
Olivia Pearman, Olivia Saxer, and Stefanie Schütte. Additional technical
input and support was provided by Timothy Bouley and Wenjia Cai.
The coordination, strategic direction, and editorial support for this Review
was provided by Anthony Costello (Co-Chair), Hugh Montgomery
(Co-Chair), Peng Gong (Co-Chair), Nick Watts (Executive Director), and
Nicola Wheeler. The findings and conclusions in this Review are those of
the authors and do not necessarily represent the ocial position of WHO,
the World Bank, or the World Meteorological Organization.
Declarations of interest
The Lancet Countdown’s work is supported by an unrestricted grant from
the Wellcome Trust (200890/Z/16/Z). The Lancet Countdown covered
travel costs for meetings related to the development of the paper. Six of
the authors (NWa, NWh, ML, PD, JC, and KB) were compensated for their
time while working on the drafting and development of the Lancet
Countdown’s report. HM is a board member of the UK Climate and
Health Council and has a patent particulate pollution mask pending
(no competing interest). NA, MD, HF, JT, and PW respectively received
separate grants from: the UK Foreign and Commonwealth Government;
the Wellcome Trust; the Heidelberg University Excellence Initiative,
Institutional Strategy ZUK 5.4; the National Oceanic and Atmospheric
Administration’s OceanWatch and Atlantic Oceanographic and
Meteorological Laboratory; and the Wellcome Trust and National
Environment Research Council. All other authors declare no competing
interests.
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