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ICCG Think Tank Map: a worldwide observatory on climate think tanks Climate Change, Influencing the Health of Urban Populations Sabrina Dekker, ICCG Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 Climate Change, Influencing the Health of Urban Populations Sabrina Dekker (ICCG) Abstract Cities are facing the impacts of climate change and consequently faced with the demand to address it. However, policy has typically focused on the economic and social impacts of climate change. Recently, there has been a call for healthy cities as means to address climate change in urban environments. Thus this paper looks at the impacts of climate change on human health in urban environment. Then discusses how cities can address human health and climate change through the social determinants of health and the WHO’s Healthy Cities Guidelines. 1 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 Introduction Planning for healthy environments is not a novel concept. Throughout the history of urban planning there have been movements to make urban environments healthy and improve the quality of life experienced by citizens. From the sanitation/hygiene movement to the city beautiful movement, the garden city and now the healthy city, city planning has gone full circle1. A key shift in this transition has been the movement from planning as a means to mitigating public health issue, to a focus on the physical environment and the economic growth of the city, and now back to public health. The healthy cities movement began in the 1980s however, recently the movement experienced a resurgence, and cities are creating health city plans2. The driver of this has been climate change with its adverse impacts on urban environments in the forms of: extreme weather events, flooding, extreme temperatures, air pollution and poor air quality; all of which impact human health and well-being. Thus, what are the impacts of climate change on the health of urban populations and how can cities address them? To answer these questions it is important to firstly understand what health challenges are prevalent in urban environments, then how climate change impacts them. Then analyse how cities can approach the challenges with existing tools, namely the social determinants and the WHO Healthy City Guidelines, to develop effective policies and plans. Urban Health and Climate Change “Cities face health challenges from climate change that are similar in some respects to their hinterlands but in other respects are unique because of greater population density and diversity, complexity of the built environment and dependence on technological systems for survival. Urban residents are more insulated from the natural environment, which leads to a lack of understanding about human effects of environmental systems and negative feedbacks from degraded environments to human health” - Harlan and Ruddell, 2011 Urban environments by their nature present unique health challenges. A city’s physical structure plays a role in the health outcomes of residents by influencing and shaping the way they work, live and play3. Cities provide services to their residents in the forms of housing, water and sanitation, food, energy, transportation, social services and employment, all of which play a role in their livelihoods and health4. Notably the provision of health services is not listed or rather classified under social services; yet historically, public health was a key driver in planning, until economic development built on the physical and technical achievements of cities became central to a city’s competitiveness5. Health plays a vital role in the growth and success of a city. Cities are dependent upon its citizens, who need good health to maintain the economic and social competitiveness of a city and vice versa, and climate change is threatening health6. Climate change research has primarily focused on the economic costs to cities, and to some extent the social costs, but not the health costs to cities stemming from climate change7. This could be for several reasons namely the research linking health to climate change is scientific, and little has been done in relation to health economics8. Regardless, it is necessary to understand how climate change impacts health in cities. Hall, 1996; Botkin and Beveridge, 2008; Berger 2013; Fleischman and Barondess, 2004; Kenzer, 1999 WHO, 2000; Barton, Mitcham and Tsourou, 2003; Ritsatakis, 2012 3 Stephenson, et al., 2013; Blas, et al, 2008; Marmot, 2005; AIA, 2013; Barton, 2009 4 Marmot, 2005; Blas, et al., 2008 5 Kenzer, 1999 6 WHO, 2013; Berger, 2013; Barton, 2009; Younger, et al. 2008 7 Tol, 2009; Forde and Raine, 2008; 8 Hallegatte and Corfee-Morlot, 2011; Campbell-Lendrum and Corvalan, 2007; WHO, 2012 1 2 2 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 What are the health threats for urban populations and what factors of the urban environment that lend themselves to the perpetuation of ill health? There are broadly three categories of health challenges that face cities: communicable diseases, non-communicable diseases and medical conditions9. Communicable diseases are those which are transferred from human-to-human, and non-communicable diseases are those that are vector borne. Medical conditions include diseases that are neither vector borne or transferred by human-to-human contact, such as respiratory and cardiovascular diseases, cancer, injury and mental health. Below is a table derived from research conducted by the WHO on health and climate change, highlighted are the diseases likely to be found in cities and who’s prevalence may increase due to climate change. The research conducted by the WHO runs the risk of stating that all diseases related to climate change. It is important to emphasize the work of the WHO is global. Not all cities will experience a rise in these diseases in relation to climate change, geographical location of cities will determine what diseases will affect populations. Further, more research needs to be done to understand the causal pathways linking health and climate change10. The objective is to educate cities on how climate change will impact the health of citizens; such that they can plan to mitigate negative health outcomes. Table 1. Health Challenges and their climate factors11. Allergies Normal Geographical Range Global Vectors/Mode of Transfer N/A Asthma Global N/A Cancer (need to identify types) Global N/A Radiation, pollutants Cardiovascular disease Global N/A Various mechanisms, air quality, air pollution Global N/A Air quality, air pollution Global Global Global Global N/A N/A N/A N/A Various mechanisms, food shortages Extreme heat and heat waves Extreme cold, snow storms, ice storms. various mechanisms Global N/A Various mechanisms Global Global Global Global N/A N/A N/A N/A Malaria Tropical and semitropical world (106 countries approx.) Mosquitoes Dengue Cities in tropical and sub-tropical areas, because of abundant breeding sites and high density of human populations for transmission Mosquitoes HIV Global STD Leishmaniasis Four continents and considered to be endemic in 88 countries, 72 of which are developing countries: Female sandflies Drought, water shortages, Various mechanisms Various mechanisms Various mechanisms Rainfall (breeding sites for mosquitoes), humidity (survival), and temperature (development of parasite); cyclones and the breaking of a drought in a region Climate coupled with high density populations perpetuate its spread; heavy rainfall can lead to standing water; drought encourages people to store water around the home. Warm temperatures optimize mosquito and virus development. Complex, increased population, sexual violence, sanitation of health facilities Environmental changes, such as deforestation, building of dams, new irrigation schemes and urbanization, and the accompanying migration of nonimmune people to endemic areas. Disease/Health Outcome Chronic Obstructive Pulmonary Diseases (COPD) Diabetes Heat Exhaustion/stroke Hypothermia Injury Mental Health/Illness (depression, anxiety, etc) Malnutrition Morbidity/Mortality Obesity Physical disability Climate Change Factors/Influences Air pollution, air quality Air pollution, air quality, related to wild fires, heat, humidity, volcanic eruptions, emissions Campbell-Lendrum and Corvalan, 2007; WHO, 2010; WHO, 2012; McMichael et al, 2010 Hosking and Campbell-Lendrum, 2012 11 WHO, 2010; WHO, 2012 9 10 3 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 Chagas Disease Japanese Encephalitis West Nile Virus and other encephalitides Guanarito, Junin, and Machupo Viruses (Arenaviruses) Hantavirus Rabies Latin America. Increasingly detected in the United States of America, Canada, many European and some Western Pacific countries. Asia, from the islands of the Western Pacific to the Pakistani border, and from Korea to Papua New Guinea. Presence in Muslim countries is negligible. Africa, Europe, the Middle East, North America and West Asia South America Blood-sucking triatomine bug Population migration, consequently migration stemming from climate change can contribute to spread of disease Mosquitoes belonging to the Culex tritaeniorhynchus and Culex vishnui groups, Rainfall, stagnant water for breeding sites, Mosquitoes Rainfall, population movement, rising temperatures Transferred to humans via rodents Various factors Rodents Animals Poor sanitation, various other modes Poor sanitation, various other modes Fresh water snails Rising temperature and increased rainfall Animal waste Poor sanitation, various other modes Extreme weather events (hurricanes, earthquakes, typhoons), increased precipitation and flooding Extreme weather events (hurricanes, earthquakes, typhoons), increased precipitation and flooding Correlation to transmission with an increase in dust levels, and reduced humidity; working hypothesis is that dry, hot and dusty air irritates respiratory mucosa encouraging an invasion of the bacteria. Extreme heat Leptospirosis Global Global Tropical and sub-tropical areas Global Cholera Global Contaminated water and food Cryptosporidiosis Global Contaminated water Meningitis Global with burden on sub-saharan Africa, Dry air Schistosomiasis Coccidioidomycosis Onchocerciasis Southwestern United States, and parts of Mexico and Central and South America West and Central Africa, but it is also prevalent in Yemen and six countries in Latin America Rift Valley Fever Africa, Saudi Arabia, and Yemen Nipah/Hendra Viruses Australia, Bangladesh, Cambodia, China, India, Indonesia, Madagascar, Malaysia, Papua New Guinea, Thailand and Timor-Leste, and Africa Air borne, fungal spores transmitted through the bites of infected blackflies of Simulium species, Infects human when they consume the blood or organs of infected animals, Transmitted to animals via mosquitoes Fruit bats of the Pteropodidae family Dry air, drought, contributing to increases in dust, Rising temperatures, especially in bodies of water Above average rainfall, allowing for the breeding of mosquitoes Poor sanitation, reduced water quality Given the above information it would appear that cities do not have the means to address the human health impacts of climate change. However, research on the health impacts of extreme temperatures12, extreme weather events13 and air pollution14 have focused on the health Baccini et al, 2008; Dear et al 2005; Corburn, 2009; Harlan and Ruddell, 2011; Kim et al, 2012; Basagna, et al. 2011; Hajat et al 2010; Madrigano, et al (2013) 12 4 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 consequences in urban centers; thus, the recommendations stemming from the research state that cities are in the best position to respond15. Moreover, cites are responding by implementing policies focused on greening the city via green infrastructure and transportation policies centered on public transit and cycling, to mitigate climate change. Changing the nature of the built environment is not the only means by which cities can mitigate the health impacts of climate change. The social determinants of health (SDH) have gained prevalence in the dialogue on human health and climate change, primarily as a point from which to develop policy16. The SDH highlight how health is a result of the environments that people inhabit, and their interactions with it. Climate change impacts the human environment, therefore, the SDH can also provide insights into the means by which cities can address the health impacts of climate change17. Cities and the Social Determinants of Health “Health is associated with social determinants—nowhere more so than in cities” – Rydin et al, 2012 It is evident from research that living conditions play a significant role in human health outcomes. For example, poor housing, overcrowding, and poor sanitation contribute to the spread of diseases, risk of physical injury and death. The previous ICCG Reflection looked at the SDH and their relationship to climate change and human health, the discussion was broad. Here the focus is on cities and the potential for the SDH to serve as a link between climate change policy and public health policy in cities. In cities, the SDHs exert an incredible amount of influence on the health of human beings18. The SDH that contribute to human health and well-being, in urban environments are19: economic opportunity, wealth/poverty, housing, violence and crime, green space, and physical infrastructure20. As, economic opportunity and wealth/poverty were discussed in the previous reflection, this paper looks at the remaining SDH. Briefly, the challenge with both is that they hinder access to opportunities to improve quality of life via purchasing power; forcing the prioritization of income expenditure. Thereby compounding the ability of families and individuals to access an essential SDH, such as housing. Access to stable housing plays a role in health outcomes by reducing vulnerability to numerous health risks associated with living outside or precarious housing. The solution to this is often high density affordable social housing. However, overcrowded conditions in social housing (and slums) have adverse effects on human health such as contributing to the quick spread of disease21. Overcrowded conditions are also associated with poor facilities in terms of clean water, adequate sanitation and energy supply, which contribute to negative health outcomes22. Even, when housing is not overcrowded, but there is no access to clean water, and/or a reliable energy supply there are health challenges23. Studies related to extreme temperatures have highlighted the vulnerability of the elderly living in poor housing conditions where pipes are frozen during the winter, or electricity is cut off during heat waves; these factors have contributed to high mortality rates in this population24. Another factor related to housing, is safety, this refers not just to the physical structure and the maintenance of housing, but the location and social cohesion. Location Zanobetti et al, 2013; Epstein, 2002 Anlitias, et al, 2014; Harlan and Ruddell, 2011 15 Anlitais, et al, 2014; Campbell-Lendrum and Corvalan, 2007; Barton 2009 16 Galvao, et al, 2009; Blas, et al, 2008; Ritasatkis, 2012; Berger 2013 17 Galvao, et al, 2009; Forde and Raine, 2008; Marmot, 2008 18 Rydin, 2009; WHO 2013; Rydin, 2012; Rydin et al 2012 19 Rydin, 2009; WHO 2013; Rydin, 2012; Rydin et al 2012 20 Mikkonen and Raphael, 2010; WHO 2013; Blas et al., 2008 21 Barton, 2009; Younger, et al., 2008; Berger, 2013 22 Stephenson, et al., 2013; Grady and Goldblatt, 2012 23McMichael, et al., 2010; Corvalan et al, 2006; Stephenson, et al., 2013 24 Younger, et al, 2008; Kovats and Akhtar, 2008 13 14 5 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 contributes to perceptions of safety which is related to social cohesion. A lack of social cohesion in poor communities is often attributed to perceptions of safety and the fear of violence and crime25. Social housing is often found in neighbourhoods of high crime, which perpetuates fear and forces people to stay inside26. Collectively and separately, all of the afore mentioned determinants have negative consequences for health, mentally and physically. In turn, impacting the ability of individuals to access basic necessities to improve their livelihoods, such as stable employment27. By contrast, scientific evidence shows that green spaces and parks, are associated with: improvements in physical and mental health, maintenance of good health and prevention of ill health in urban environments28. Central to green spaces improving health are access and use, which are related to physical planning and safety. In order for health to be improved or be maintained individuals must have access to green spaces29. Parks need to be planned such that people can easily access them. Many cities incorporate the goal of “access to a park or green spaces within a 5 to 10 minute walk”, an important an attribute but it does not stand alone30. The desire to use green spaces must also be present. “Use” is complicated by individual behavior and attitudes towards physical activity, and perceptions of safety31. People will not use parks if they hold the belief that they could be victimized in a park. How parks and green spaces are planned determine their use and value to human health, which is linked to the overall physical planning of a city32. The physical layout of a city plays a role in shaping the health of its citizens, especially infrastructure which includes: transportation, sanitation and water, and energy33. Transportation is vital in creating healthy urban environments; planners are tasked with balancing the need to transport goods in and out of the city, with the movement of people within, and in and out of the city34. Roads are the primary means of doing this. However, as motorized vehicles are the primary contributor of greenhouse gases, there is a need to reduce the demand for motorized transport. The response has been transportation plans focused on increasing public transportation use, promoting cycling, and improving walkability35. Inadvertently improving the physical health of residents by encouraging active transport and mitigating the risk of injury and death from traffic accidents36. Improving the ability of people and goods to move has benefits for health. Yet, there are issues of access and use. The primary users of public transportation, and other alternative modes of transportation (walking and cycling), prior to the call for increasing their use, has been the urban poor37. Income and employment play heavily in this outcome, the need to have a job sees the urban poor willing to take employment that is far from their homes and at varying hours38. Consequently they are forced to take multiple modes of transportation, which may involve using a significant portion of their income. This is a simple causal relationship between transportation, income, and the health of the urban poor. In reality the relationship can be far more complex. The primary challenge is access in the form of affordability. Secondary to this is safety (as with parks) people need to know that public transportation, and cycle paths are safe39. Sanitation and water systems are essential services provided by cities or regional government depending on location. In urban areas, the assumption is often made that everyone has access to reliable sanitation and water systems and there are no health risks40. This is a false assumption as Barnett, 2001; Grady and Goldblatt, 2012; Berger 2013 Stephenson, et al., 2013; Grady and Goldblatt, 2012; Berger, 2013 27 WHO, 2013; Rydin et al, 2012; Stephenson, et al, 2013 28 Wolf, 2003; Kovats and Akthar, 2008; Corvalan, et al.2006; Charron, 2012 29 Wolf, 2003 30 Corburn, 2009; Tzoulas, et al., 2007 31 WHO, 2012; Rydin, 2012, Barton, 2009 32 Tzoulas, et al., 2007; Rydin, et al., 2012 33 Berger, 2013 34 Rydin, et al, 2012; Berger, 2013 35 Barton, 2009; Tzoulas, et al 2007 36 Barton, 2009; Berger, 2013; Younger, et al, 2008 37 Rydin, et al, 2012 38 Rydin et al, 2012; Stephenson, et al., 2013; Grady and Goldblatt, 2012; Berger, 2013 39 Berger, 2013 40 Younger et al, 2008; Barton, 2009; WHO 2013; Berger, 2013 25 26 6 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 the urban poor often experience living conditions where access to proper sanitation and safe drinking water is not possible. Consequently the health of the urban poor is compromised and increasing their risk of contracting water borne diseases, which in turn impede on their ability to work, and so forth. Energy is another service provided by cities that plays a role in health; as it is essential for daily activities41. Without energy individuals and families are at risk of dying from exposure to cold or heat, injury from attempting to use alternative means of heating, and numerous other health risks. Overall, the physical infrastructure provided by cities and urban regions is a significant determinant of health. Moreover, each of the SDH are connected to each other via diverse causal pathways. Adding the impacts of climate change into this equation only amplifies the challenge of maintaining and improving human health in urban environments. Thus the question becomes how can cities integrate health into their existing plans (or in some cases use health as a starting point for developing a plan), such that cities become resilient to climate change and prevent poor health outcomes? WHO Guidelines for Healthy Cities The WHO’s guidelines for healthy cities are built as a generic approach based on the experience gleaned from the implementation of healthy city programmes across the WHO’s various regions. The key reasons for this are the recognition of variations in: health, political structure, level of urbanization, leadership, and capacity. Given this the guidelines begin with a three phase approach, acknowledging the broad spectrum of development that cities fall within. The phases are as follows42: 1. Awareness raising and establishment of an intersectoral initial task force for a Healthy Cities project and ends with gaining strong commitment and support of the local government. 2. Works to develop organizational structure, working mechanisms, city health profile, plan of action and capacity for the project. 3. Implementation of the established plan of action and continued development of sustainable mechanisms to ensure promotion of health in the city. Phases 2 and 3 revolve around the development of an action plan, the puts into motion the city’s efforts to improve its population’s health. The recommendation for the contents of an action plan by the WHO are: • • • • • • • • 41 42 Characteristics of the city: topography and climate, history, culture and heritage, administration, and demographics Vision of the city Health and environmental situation of the city: population health, lifestyles and preventive activities, health care services, welfare services, environmental health services, living environment, environmental quality, urban infrastructure, natural environment, land-use and urban planning, local economy, education, income and family living expenses, community activities, legislation and regulations. Priority health problems Planning goals and targets Actions and activities to resolve priority health problems, including elemental healthy settings activities: schools, work places, market places. Roles of Individual groups in implementing above actions/activities Resources required and available for implementing the actions/activities Campbell-Lendrum & Corvalan, 2007; Corvalan, et al. 2006; Rydin, et al, 2012 WHO, 2000; Berger 2013; Barton 2009; Kenzer, 1999 7 Climate Change, Influencing the Health of Urban Populations ICCG Reflection No. 20/March 2014 • Implementation and monitoring/evaluation mechanisms: coordination and communication mechanisms for implementation, indicators for monitoring and evaluation of progress, mechanisms for evaluation and reporting systems. The WHO guidelines are not a panacea, as there are limitations. Not every city has the capacity to conduct and finance research into the health status of their populations, much less conduct comprehensive environmental assessments. However, it is a starting point that provides direction and guidance for cities as they plan for the impacts of climate change on human health. As the WHO highlights, intergovernmental, intersectoral and engagement with a range of stakeholders will be vital in enabling cities to develop plans that incorporate the scientific evidence and connect it to the economic and social policies that have dominated urban planning. As such, research needs to be conducted into the health economics of climate change; this will not be without challenges, particularly related to the valuation of human life43. In general, more research is necessary to fully understand how climate change will impact human health, especially beyond heat related mortality, and air pollution. Increased knowledge on the causal pathways that link climate change and human health will only serve to strengthen policy in the future. Regardless, cities should not wait, action needs to build on and innovate current climate change policies to incorporate health Conclusion: Action and Research Cities are not stagnant environments, they are in constant flux, they do not pause; nor does climate change. While it will be challenging for many cities to incorporate health into plans on the mitigation of climate change, especially under the guidelines of the WHO44. The unknown costs of not developing policies far outweighs costs of incorporating health now. More importantly the scientific evidence, as it currently stands, suggests that impacts of climate change are undeniable. Thus, focusing on the physical environment and climate change is not enough, human health needs to be placed at the core of climate change plans45. This paper has shown how the physical environment plays a role in health, but there are other compounding factors highlighted by the SDH, that shape health. As such, policy can use the SDH as a tool, and the WHO Health City Guidelines, as guides for policy development. They can also highlight where more research is needed, namely the economic costs, such that the case for health focused climate policy is strengthened The health of endangered species in natural environments have long be toted as a reason for climate change mitigation; it is only logical that human health be at the fore climate change mitigation in urban environments. References Anlitias, A., et al. (2014). “Effects of Heat Waves on Mortality: Effect Modification and Confounding by Air Pollutants”. Epidemiology 25(1):15-22. Baccini, M. et al (2008). “Heat Effects on Mortality in 15 European Cities”. Epidemiology 19(5):711719. Barton, H. (2009). “Land use planning and health and well-being”. Land Use Policy 265: S115-S123. 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