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Article
Tackling AMR: A Call for a(N Even) More Integrated and
Transdisciplinary Approach between Planetary Health and
Earth Scientists
Jennifer Cole 1*, Adam Eskdale 2 and Jonathan D. Paul 3
1 Department of Health Science, Royal Holloway University of London, Egham Hill, Egham, Surrey TW20
0ES; jennifer.cole@rhul.ac.uk
2 Department of Earth Sciences, Royal Holloway University of London, Egham Hill, Egham, Surrey TW20
0ES; adam.eskdale.2019@rhul.ac.uk
3 Department of Earth Sciences, Royal Holloway University of London, Egham Hill, Egham, Surrey TW20
0ES; Jonathan.paul@rhul.ac.uk
* Correspondence: jennifer.cole@rhul.ac.uk
Abstract: Antibiotic resistance is a pressing global and planetary health challenge. Links between
climate change, antibiotic use and the emergence of antibiotic resistance have been well docu-
mented, but less attention has been given to the impact(s) of earth systems on specific bacterial live-
stock diseases at a more granular level. Understanding the precise impacts of climate change on
livestock health – and in turn the use of antibiotics to address that ill-health – is important in provid-
ing an evidence base to tackle such impacts and to develop practical, implementable and locally
acceptable solutions within and beyond current antibiotic stewardship programmes. In this paper,
we set out the case for better integration of earth scientists and their specific disciplinary skill set
(specifically, problem-solving with incomplete/fragmentary data; the ability to work across four di-
mensions and at the interface between the present and deep/geological time) into planetary health
research. We then discuss a methodology that makes use of risk mapping, a common methodology
in earth science but less frequently used in health science, to map disease risk against changing
climatic conditions at a granular level. This will enable predictions of future disease risk and risk
impacts based on predicted future climate conditions, and thus provide an evidence base for plan-
etary health activists to influence policy and develop mitigations. Our case study – of climate con-
ditions’ impact on livestock health in Karnataka, India – clearly evidences the benefit of integrating
earth scientists into planetary health research.
Keywords: Climate change; antimicrobial resistance; earth science; risk mapping; transdiscipli-
narity
1. Introduction
In this paper we highlight the need for more flexible and iterative research agendas
to address the climate-change related root drivers of antimicrobial resistance (AMR). The
recent addition of the United Nations Environment Programme (UNEP) to the Quadri-
partite Joint Secretariat on Antimicrobial Resistance between WOAH, FOA, WHO, and
now UNEP is welcomed [1], but we argue that there needs to be further bridging between
the work of this group and the United Nations Framework Convention on Climate
Change (UNFCCC). Climate change and disease risks, including AMR, are two of the
most pressing challenges of the Anthropocene and cannot be considered in isolation [2].
Planetary Health is already deeply invested in identifying the complex links between cli-
mate change and zoonotic disease [3], to raising awareness of the intersection of Anthro-
pocene risks in general [4, 5, 6] and argues for addressing global and intergenerational
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© 2022 by the author(s). Distributed under a Creative Commons CC BY license.
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risks from AMR through a lens of planetary health ethics [7]. Other fields have also made
such links explicit [8, 9, 10]. However, fewer commentators focus on specific ways in
which earth scientists, environmental scientists and infectious disease researchers can
work together to evidence the exact conditions that drive emergence and transmission so
that this knowledge can more readily inform both climate change and AMR policy and
identify implementable solutions.
Thus far, for example, neither Challenges nor The Lancet Planetary Health, the planetary
health field’s two most prominent journals, have published a single original research pa-
per evidencing links between antibiotic resistance and climate change explicitly. Only two
short commentary papers [11, 12], the latter of which is by one of the authors of this paper,
touch on the specifics of the issue. Whilst we appreciate and are well aware that the field
of planetary health has already greatly expanded the range of disciplines whose scholars
see their work as part of the future of human flourishing [5], we feel there is a need to
reach out still further to additional disciplines that could be more fully engaged into re-
search programmes and to further foster transdisciplinary collaboration, knowledge
transfer and the utilisation of discipline-specific skills: in our case study, with earth scien-
tists.
Earth scientists’ work has deeply influenced the field of planetary health – not least
the work of those involved in determining the earth systems trends of the Great Acceler-
ation [13] and the planetary boundaries of a safe and just operating space for humanity
[14] but it is less common to see earth scientists and health scientists working side-by-side
on AMR within a single project team.
To begin to address this, in the second part of this paper we will present a case study
based on our own research [15, 16] which we believe shows the value in allowing space
for transdisciplinary research that more holistically and iteratively integrates earth scien-
tists’ discipline-specific skills into planetary health’s conceptual framework. These skills
include problem-solving with incomplete/fragmentary data [17–19], the ability to think
across four dimensions [20] and at the interface between the present and deep/geological
time [21]. This, we argue, enables the development of more compelling evidence on
changing climate conditions’ direct harms to the prevalence and spread of animal bacte-
rial disease, the use of antibiotics to treat it, and thus the emergency of antibiotic re-
sistance.
2. Transdisciplinary research: iterative, agile and adaptive
At this point, it is valuable to tell the story of how we ourselves came to see the value
in working together. In the process of conducting research into the drivers of antibiotic use
and poor antibiotic stewardship in the Indian livestock sector in a cross-disciplinary team
containing microbiologists, veterinarians, anthropologists and economists [12, 22, 23], we
listened to farmers and veterinarians in regions of India as far apart as Karnataka in the
south and Assam in North-East India who spoke, openly and implicitly during ethno-
graphic observations, of the pressures that climate change places on their livelihoods. The
changing climate has already pushed these farmers from crop farming to livestock raising
and now stresses the health of their animals [12]. These observations pushed us to consider
a closer examination of the environmental drivers of ill-health in order to understand the
root causes of antibiotic use intended to treat that ill-health; to consider not only which
bacteria were present in the environment but why and how they are there. Whilst a focus
on climate change was technically outside of the original remit of our funding and of the
project intentions, COVID-19 travel restrictions pushed us into desk-based research using
secondary data, and then enabled the replacement of ethnographic researchers, who left
the project when they were unable to undertake further fieldwork, with earth scientists
who were able to explore climate impacts more deeply.
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The evidence produced by the work of the earth scientists [15, 16], highlights not
only the value of their discipline to the immediate challenge at hand, but also the benefit
of enabling research projects to break out of their original silos when there is clear value
in doing so. The recent addition of UNEP to the (now) Quadripartite Secretariat on AMR
will hopefully act as a rallying call to other human, animal and planetary health research-
ers to take an even wider, even more transdisciplinary approach to AMR (and to other
health challenges of the Anthropocene) and to other earth and environmental scientists to
consider how they too might work together.
There are already frameworks into which such more complex collaboration can fit.
For example, the UNICEF-led Integrated Outbreak Analytics programme [15, 25] acts as
not only a platform for researchers from diverse fields working with disease outbreak data
but also a network through which collaborative researchers can connect, disseminate their
work, share methodologies, and seek out future collaborators. We urge more planetary
health researchers to connect and collaborate with them.
3. The value of more granular integration of earth science with planetary health
Understanding the impact of climate change on human and livestock health is critical
to safeguarding global food supplies and economies and to plan global recovery from the
COVID-19 pandemic [2] as well as to maintaining the efficacy of antibiotics. This raises a
unique challenge for planetary and one health researchers and practitioners who will need
to explore new (and perhaps even yet-to-be-developed) methodologies, knowledge, skills
and networks in order to enhance environmental awareness. At least in the short term,
such researchers are likely to be working with incomplete and fragmented data, as the
regions of the world most affected by climate change are also those where surveillance is
less robust [16]. Earth scientists, however, are more than familiar with the challenges of
such data [17, 19]. Furthermore, AMR and other wicked problems of the Anthropocene are
not only made visible by the earth system trends of the Great Acceleration graphs [13] but
are likely to need additional international policies and treaties to solve them, which will
need to be underpinned by robust evidence from outside of health science. For example,
tempering the spread of antibiotic resistant bacteria and their genes across borders may
require approaches similar to those used to address the transborder spread of pollution
through air, water and soil, or through travel and trade networks. Providing the evidence
to underpin international policy development is likely to require large and transdiscipli-
nary programmes consisting of hydrologists, geologists, atmospheric and climate scien-
tists, geochemists, civil engineers and others, well beyond the microbiologists who under-
stand the emergence and transmission of resistant bacteria and their genetic material; this
has been true in the past of, for example, of the development of the Stockholm Convention
on Persistent Organic Pollutants [25]; and the development of the Montreal Protocol that
protects the ozone layer [26]. Both of these treaties limit the use of chemicals detrimental
to the environment, but in each case the impact on (human) health was a driver for the
policy adoption and implementation. Future policies may be even more successful if they
foreground the risks to health, evidenced by the well-understood risks imposed by earth
system changes.
Current policies that govern such movements, such as the ‘PICs and POPs’ (Rotter-
dam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chem-
ical and Pesticides in International Trade, and the aforementioned Stockholm Convention)
should be considered key planetary health documents, but are less familiar to health sys-
tems researchers than to earth scientists. Their history, development, adoption and imple-
mentation rarely feature in medical or healthcare curricula, even though human health
can be a strong lever for international agreement [27]. Earth science could be better used
to understand risk and thus integrate this knowledge into the development of future
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health policy. Working together, earth scientists and health scientists can speak with a
collective voice that will be harder for policymakers to ignore.
Recognising that the root drivers of antibiotic use lie outside the (traditional) power
of health systems to address is a first step in achieving this end. For example, while mi-
crobiologists are able to quantify the levels of bacteria in the environment and their sus-
ceptibility (or not) to antibiotics [28] and genomics can map which genes they carry, how
closely they are related to other strains and where else those strains are found [29], those
same microbiologists will need to reach out to earth scientists to understand, map and
predict the meteorological conditions that are most conducive to disease emergence and
spread; and to soil and water chemists to understand which pollutants may help to drive
antibiotic resistance [30]. The ground set by these collaborative relationships will be even
more critical in the later stages of such work: after the mapping processes and meteoro-
logical relationships have been founded, the expertise of the microbiologists and veteri-
narians will be needed to divulge the true impact of the spatial-temporal mapping by car-
rying out disease surveillance and diagnosis that proves the model as the predicted cli-
matic conditions unfold and disease incidence increases. Experts from both fields will
then need to communicate the results of their observations to relevant stakeholders, in-
cluding commercial farms, governmental bodies, local research institutes etc for true
transdisciplinarity to be realised [31].
4. Mapping the spatial distribution of the conditions that drive ill-health
Earth scientists may in turn need to work with modelling specialists to build and
automate the production of climate-related risk maps [16] to ensure such models can be
utilised as widely as possible, whilst working with veterinarians and farmers to under-
stand not only where these conditions will have impact but also whether those regions
are the ones in which livestock production and farming livelihoods are currently located
or where industries are planning to expand. In addition, this will require input from ani-
mal health observatories to share epidemiological data from regions at risk (including
where and when the prevalence of cases and outbreaks changes). Neither epidemiologists
nor animal health observatories are strangers to mapping skills and methodologies but
earth science brings to the table different ways of interpreting risk and of working with
fragmentary and incomplete data [18, 21] over longer timescales, into both the deep past
and longer-term future [32]. Geographers are needed too, to map the topography and to-
pology of regions in which those cases occur, and to consider how farmer’s livelihoods,
access to veterinary services and patterns of sector transformation are intersecting with
climate changes and local development agendas; for example, whilst environmentally
controlled chicken sheds might on the surface appear to be a sufficient mitigation to the
risks of heat-stress induced disbiosysis and thus reduced immune response that drives
higher use of antibiotics in Indian poultry farms, the current failings of rural energy infra-
structure prevent this being a practical solution [12]. Looking instead for regions which at
present may be cooler than the ideal conditions for livestock rearing, but which may be
warming and likely to reach such thresholds in future, so that expansion into such regions
can be planned, or which currently favour poultry rearing but are becoming more suited
to aquaculture, are alternative options. Such integrated methodologies and ways of work-
ing have value beyond livestock farming to human health, and also encourage working
with public health officers to look at how else data can be combined, e.g. on the intersec-
tion of the spatial distribution of cases of human disease with distributions of social dep-
rivation [33], location of healthcare infrastructure [34] and access to blue and green space
[35]. There is growing interest in human health fields in ensuring the integration of air
quality and health [36], soil pollution and health [37] etc, on increasingly granular spatial
scales. The UK’s National Health Service [38] is a world-leader in setting a Green Agenda
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for health [39], aiming towards net-zero carbon operations by 2040, and this has, at least
in part, been achieved by showing that improving public health cannot be considered
without the integrated reform of transport systems, renewable energy and consideration
of reduced plastic use [39]. This approach has been as dependent on earth science as it has
on approaches that have come from inside health systems and medical science. Figure 1
demonstrates the sizable shared space between health and climate science, seen through
the skillset of an earth scientist, as well as the way in which this overlap is manifest across
different stakeholders and geographical scales.
Figure 1. Conceptualisation of the shared space between health and climate/earth science, together
with benefits to different stakeholders across different scales.
Practitioners of OneHealth (defined by the OneHealth Commission [40] as “an inte-
grated, unifying approach that aims to sustainably balance and optimize the health of
people, animals and ecosystems [that] recognizes the health of humans, domestic and
wild animals, plants, and the wider environment including ecosystems are closely linked
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and interdependent”) are quick to point out that animal health and human health cannot
and should not be considered independently [41]. Furthermore, true transdisciplinarity
must include practitioners and communities: farmers, like patients, can report symptoms
of ill-health, bringing in value from citizen science, another methodology earth science
has long embraced [42]. To understand what is making animals ill, however, a systematic
and systemwide approach is needed to look at the holistic environment and the conditions
within it that create disease ‘situations’ (where conditions such overcrowding and poor
welfare stress animals’ immune responses and causes otherwise commensal bacteria to
become pathogenic: [43]), and to map the ‘exposome’, the ecosystem of external risk ex-
posures [44].
How these risk exposures combine (with or without antibiotic exposure) to influence,
support or challenge equally complex animal and human microbiomes is still poorly un-
derstood, despite the considerable work of the decade-long Human Microbiome Project
[45]. Tellingly, this has included neither earth science nor a consideration of how climate
drivers such as recent and rapid increases in the magnitude and severity of geohazards
(e.g. heatwaves and monsoon rainfall) may impact microbiomes. Because of the complex-
ity that is now developing, systems thinkers [46] and modellers will be needed, who will
need to be able to combine multiple insights to model not only the risks that have already
been identified, and help predict where they may increase (or decrease) in future, but also
how the system-of-systems those risks inhabit are configured. Even then, ethnographers
and economists will need to work with communities to determine what can be done to
mitigate the predicted risks in a manner that is practical, acceptable and affordable; chang-
ing people’s behaviour towards making more rational choices regarding the use of anti-
biotics, let alone for the overall health of themselves or the planet, is far from being a trivial
exercise [47].
6. A new methodology for mapping the climate/disease risk interface
Having set the scene for why closer integration of earth scientists into planetary
health research teams has scientific value, we showcase our recent work in southern India
[16] to demonstrate how a methodology we have developed offers a first step towards the
future integration of researchers from interrelated and overlapping fields, so that each can
link their data with others through a causal chain of (in our case, animal) ill-health. This,
we hope, will help to drive interest in the need to better understand the factors that govern
environmental change (e.g. monsoon dynamics) in the present and future, and their im-
plications on human and animal health.
Our research emerged from two Newton-Bhabha Fund projects that aimed to address
drivers of Antimicrobial Resistance (AMR) in India, through quantifying and qualifying
the presence of antibiotic resistant bacteria in food animals, the farms on which they are
raised and the environments in which they are sold [28, 29, 48, 49] as well as understand-
ing the behavioural drivers influencing the use of antibiotics by farmers [12, 23] and vets
[22].
Farmers’ insights and lived experiences [12, 22, 23], observed during a rapid ethno-
graphic assessment of livestock systems and recorded in semi-structured interviews, fo-
cus groups and transect walks through peri-urban farming communities, led us to con-
sider the role of climate change on animal ill-health as a trigger for antibiotic use. This in
turn led us to develop a risk classification tool that assesses how disease risk varies in
Karnataka in the present and in possible future scenarios. Despite a relatively limited ep-
idemiological dataset (from the NADRES-v2 database [50]), clear relationships between
bacterial disease and high-risk zones were defined using time-series data over a period of
33 years (1987–2020). By constructing risk maps, which are common across geoscientific
(e.g. for volcanic hazard and flood risk) and epidemiological research, we used a physics-
based statistical approach to define risk thresholds based on the inferred relationships
between climate and disease data. The maps were constructed using open-source climate
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data (Climate Research Unit (CRU) TS 4.5 dataset). Thresholds for risk were defined by
using the inferred relationships between the climate data and disease data after statisti-
cally investigating the spatio-temporal relations between the two, first with correlative
statistical analysis (Spearman's rank) followed by principal component analysis (PCA).
Through this methodology it is possible to interpret the individual climate variable con-
tribution to risk in each grid box, providing insight into the varying climatic controls for
higher and lower risk across the areas. Although there are far more socio-economic factors
that also play a role in predicting disease outbreak risk (farm locations, population den-
sity, sanitation standards, food standards, veterinary access, vaccination campaigns etc.),
these are typically more granular controls whilst climate-associated risk is useful for a
‘bigger picture’ perspective – identifying complete regions of higher and lower risk, which
can then be investigated in more detail using the aforementioned socio-economic factors.
Our transdisciplinary approach led us to identify that hitherto unconsidered changes
in the key climate variables of precipitation and vapour pressure (i.e. humidity) are the
most important factor governing outbreaks of haemorrhagic septicaemia (HS), anthrax
(AX), and black quarter (BQ) in livestock across the Indian state of Karnataka. Un-
addressed, such outbreaks risk economic damage to the farming community, food secu-
rity and, in turn, poorer livelihoods for those dependent on both the farming economy
and the food it produces, but addressing them needs more granular data on precisely
which climate conditions are likely to impact which specific diseases, in which species, in
which regions and over what timescales, ensuring that those informed by the data will
have sufficient time to act.
We intend to continue working with this methodology, improving the robustness of
the risk maps by defining more quantitative thresholds upon which disease outbreaks
may relate to specific climate variable change i.e. at what average rainfall, at what average
temperatures, and at what average vapour pressure does risk increase; we will need to
work across more disciplines, for example with computational modellers, livestock and
human disease experts, ethnographers and local data collectors, to achieve these aims. We
hope to provide a new platform through which planetary health researchers and earth
scientists can come together in new transdisciplinary spaces. In order to achieve this, we
seek more robust, long-term disease data across a variety of global case studies (currently
Nepal, Egypt, Kenya, South America), preferably with diverse meteorological conditions
to provide the best range of test scenarios – data that other planetary health researchers
may hold or be encouraged to gather. Ideal outputs from this modelling work are cap-
tured in Figure 2, where each case study will have the raw data presented in time-series
graphs, followed by the statistical correlative results, then finally the risk maps them-
selves. While our research in India was primarily interested in drivers of AMR, and thus
bacterial diseases, this methodology can be replicated to investigate other diseases and
other regions, or even climatic conditions that impact crop yields, as long as the climate
and epidemiological/harvesting data cover similar time periods.
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Figure 2. Generalised output for risk-mapping model, using state of Karnataka as an example: (A)
Location map for Karnataka; (B) time-series graphs for both climate variable data and disease out-
break data; (C) PCA results for combined data; (D) Spearman's rank correlation statistics between
climate and disease data; (E) final risk map output with seasonal contribution to risk, and individual
variable contribution to risk also mapped in grid-box format. Data presented is modified from
Eskdale et al. 2022.
7. Towards climate models for social justice
Beyond animal health, once earth scientists’ skill sets are embedded into research
investigating the underlying drivers of bacterial disease, antibiotic use and thus the emer-
gence of resistance to antibiotics, they can be cascaded out to human health research more
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widely. Increasing unpredictability and magnitudes of annual hydrological budgets (in-
flows, outflows and storage of water), greater temperature and wet-bulb humidity ex-
tremes, as well as the effects of this on the environmental realm (such as exacerbating the
magnitude of air and water pollution) increases the risks associated with human health
conditions such as obesity, diabetes and hypertension, which in turn increases suscepti-
bility to more severe symptoms of respiratory diseases, including COVID-19 [51], partic-
ularly during heatwaves [52]. On 7 October 2022, a joint report published by the Office for
National Statistics and UK Health Security Agency indicated there had been 3,000 more
deaths in England and Wales than would usually be expected during the year’s unusually
hot summer [53].
The impact of climate factors is known to intersect strongly with socioeconomic dep-
rivation [54]: evidencing this impact may help to drive policy to tackle underlying socio-
economic drivers at source and thus help to deliver justice to the most vulnerable pockets
of society, speaking to planetary health’s strong ethical focus on championing equity and
social justice [55]. Short of relocating agricultural operations to regions of the world less
impacted by climate stress, and human populations to regions where their livelihoods will
be made less precarious by climate change, developing a methodology for identifying, at
very precise granular resolutions, where the areas of highest risk are found – today and
in the short-mid-term future – so that limited resources for intervention can be prioritised
to where they are needed most acutely provides a practical mid-term intervention strat-
egy.
Thus, only by taking a system-of-systems approach to health, working simultane-
ously across all the societal systems and earth systems implicated in the Great Accelera-
tion [13], will we be able to address the real underlying drivers that place pressure on
those systems. For all planetary health’s lauding of the conceptual framework of the Great
Acceleration and planetary boundaries [13, 14], truly integrated, evidence-producing pro-
jects between earth scientists, health systems scientists and social scientists remain scarce.
This is in spite of strong evidence that earth systems change profoundly challenges hu-
man, animal and plant health directly e.g. through ill-health caused by heat-stress [56, 57]
and crop failure [58, 59], and indirectly e.g. through increased incidence of biological dis-
ease caused by pathogens that proliferate more in warmer conditions [60]; or food short-
ages [61] that cause malnutrition and reduce the immune response. In short, we argue that
research on the drivers of antibiotic resistance can no longer afford not to embrace earth
scientists, wider environmental considerations and earth systems science more fully.
Health researchers need to go further than just referring to the current climate science
literature by meaningfully integrating earth systems scientists into their ongoing research
across the entire lifecycle of a research project, from problem conception/definition, to co-
development of data collection and analysis methods, to the dissemination of data/infor-
mation to relevant stakeholders. This in turn leads on to other considerations: once en-
gaged, earth scientists might look to develop enhanced process understanding of e.g. the
monsoon; health scientists might want to determine under what specific climate condi-
tions disease transmission or severity of cases increases, and if the relationship is linear,
logarithmic or if it reaches a tipping point aligned to regime change [62]. Local communi-
ties will be able to use the evidence earth scientists provide to invest in or implement new
ways to de-risk their livestock falling ill and thus safeguard their future livelihoods; gov-
ernment stakeholders will be able to use the same data to protect their population and
economies. True earth/health collaboration would satisfy all of these stakeholder needs,
and would involve an equitable and fair balance of resources and time, which goes far
beyond just having a token health scientist on a largely earth science programme or vice
versa.
8. Conclusions
Successful transdisciplinary research projects such as the one we have described in
this paper have the potential to tackle larger, international and complex issues that affect
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global communities and speak directly to planetary health’s willingness to face up to even
the most complex and challenging ‘wicked problems’ of the Anthropocene [63, 64] The
evidence our research provides, of granular links between specific diseases and specific
climate conditions, highlights the need for greater synergies between earth scientists, cli-
mate change science, planetary and OneHealth research and policy formation. In the
short-term, we argue this puts forward a(n even) strong(er) case for greater alignment
between the Quadripartite Agreement (between WOAH, FOA, WHO, and UNEP) on an-
timicrobial resistance and the United Nations Framework Convention on Climate Change
(UNFCCC) as these two pressing challenges of the Anthropocene cannot be considered in
isolation.
Author Contributions: Conceptualization, J.C. A.E and J.D.P.; methodology, A.E. and J.P.; software,
A.E; validation, A.E.; formal analysis, J.C., A.E. and J.D.P.; investigation, J.C., A.E. and J.D.P; re-
sources, J.C., A.E. and J.D.P; data curation, A.E.; writing—original draft preparation, J.C., A.E. and
J.D.P; writing—review and editing, J.C., A.E. and J.D.P; visualization, A.E.; supervision, J.C.; project
administration, J.C.; funding acquisition, J.C., J.D.P. All authors have read and agreed to the pub-
lished version of the manuscript.
Funding: J.C. and A.E. were funded by a Newton-Bhabha awards co-funded by the UK Economic
and Social Research Council grant number ES/S000216/1 and the India Department of Biotechnology
grant number BT/IN/Indo-UK/AMR/05/NH/2018-19. JP received no funding.
Data Availability Statement: Data used in this study was obtained from the publicly available Cli-
mate Research Unit (CRU) TS 4.5 dataset and NADRES-2 dataset. Cleaned and formatted data is
available from the authors on request.
Acknowledgments: The authors acknowledge the contribution of farmers and veterinarians in Ben-
galaru, Karnataka, and Guwahati, Assam, who gave us their time during the original project.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the
design of the study; in the collection, analyses, or interpretation of data; in the writing of the manu-
script; or in the decision to publish the results.
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