Health topics for the COP28 agenda

Introduction

Climate change is defined by the United Nations as long-term weather alterations, including temperature, wind, and precipitation patterns. The United Nations Conference of Parties (COP) summit gathers experts and political leaders from around the world to discuss pressing environmental challenges and formulate climate adaptation strategies. On my way to attend COP27, which took place in Sharm Elsheikh in Egypt last year, I was among a delegation of health researchers facing the question of “What will health researchers be doing at COP?”. Their query may seem oblivious at first, but there is a valid reason why people wonder about the presence of health professionals in COP. Historically, health has not been a focus in climate discussions. Although the presence of the World Health Organization (WHO) and its participation in COP conferences has increased in recent years, the prioritization of relevant health topics remains inadequately addressed, despite the substantial health costs of climate change.

Moreover, a common misconception is that climate change poses a risk to “future” health and well-being, but the reality is that millions of people around the world have been and continue to suffer from health consequences that are directly attributable to climate change, including chronic morbidity and premature mortality. The WHO estimated that environmental conditions are responsible for 13 million deaths each year, which is predicted to increase to a quarter million annual deaths by 2050.1 

In an unprecedented move, Dr. Sultan Al Jaber, the President-Designate of COP28, has affirmed that health will form an integral part of the COP28 agenda this year. A Conference Day will be dedicated to discussing the impacts of climate change on health at the highest level, sending an ambitious and courageous message that recognizes the need to address the critical connection between climate change and health. Additionally, a notable aspect of the COP28 announced agenda is the presentation of a thematic program that highlights the interconnectedness of health and other sectors concerning climate change. The agenda also emphasizes “cross-cutting themes” such as technology, innovation, finance, inclusion, and frontline communities, which form key action areas, offering potential impactful opportunities towards improved climate adaptation.2-5

Health in the era of climate change

The direct and indirect health impacts of climate change are mediated through intense extreme weather events such as heatwaves, flooding, droughts, and heavy rainfall. The consequences of these events threaten social and economic ecosystems, challenging the overall health and well-being of nations worldwide. While current and future generations of children lack the power and agency to influence the drivers of climate change, they bear the highest disease burden attributable to the climate crisis. In this insight piece, the observed and projected health effects of climate change are outlined, with an emphasis on climate change-associated morbidity and mortality in children.

Air pollution

The incidence and extent of wildfires have been consistently increasing over the last decade. 

Climate change implications of extended droughts and heatwaves have been identified as key drivers of the increasing trends of fire weather. Future projections estimate an increase in fire risk by 600% for every 1 Celsius annual increase in average temperatures.6 Global predictions indicate an increase of 30% by 2050.7 Additionally, the warmer temperatures not only mean more fires but also longer episodes of fire weather.6,7 The prolonged durations of wildfires result in more smoke that is currently responsible for up to 50% of atmospheric pollution particles,8 drastically compromising air quality. Exposure to air pollution, often defined as exposure to particular matter (PM2.5), Ozone, and nitrogen dioxide (NO2), has detrimental effects on human health outcomes. According to the World Health Organization, over 40% of the world population is exposed to high levels of air pollution, which is responsible for 7 million deaths each year.9

The changing exposure patterns and intensity of aeroallergens, which are air-borne substances that trigger allergies, constitute another source of air pollution concerns. Climatic variations trigger changes in aeroallergens’ concentrations and seasonality. Exposure to aeroallergens can exacerbate respiratory complications through mild and severe allergic responses and conditions. Similarly, other air pollutants such as Ozone also compromise individuals’ capacities to manage their respiratory disorders, whether it is asthma, conjunctivitis, or atopic dermatitis.10

By compromising the respiratory system, air pollution can impact people of all ages. However, children bear an unacceptably high disease burden due to air pollution, which is responsible for one in ten deaths in children under five years of age.1,11 It is not exactly clear how air pollutants impact children’s organs; recent publications proposed various mechanisms, including genetic and epigenetic factors.12 The effects of air pollution impact a child before they are born. Through maternal exposure, air pollution can compromise fetal development, leading to adverse birth outcomes, including preterm birth and low birth weight. Adverse birth outcomes have been well-established as markers of later morbidity and mortality. Recent estimates indicate that air pollution causes 20% of all neonatal mortality.13

Morbidity from air pollution continues to take place across the life stages of a growing child. In their early years, children grow rapidly, and their heights and weights increase to meet their genetic potential and have optimal growth. Accordingly, children breathe, eat and sleep more for their size to fulfill the needs of their growing brains and bodies. By breathing at a faster rate, children’s exposure to air pollutants is heightened.13 Today, more than 90% of the world’s children breathe toxic air every day.11 The disease burden from air pollution in children is most commonly characterized by higher rates of respiratory diseases, including asthma and pneumonia.10,11,14 Research has linked increased exposure to smoke from wildfires to asthma and asthma attacks.14,15 Additionally, changes in temperatures have been linked to an increased incidence of pneumonia, which is the third-top killer among children under five years of age.14,16,17

Besides physical health, air pollution has been associated with adverse neurological development. Research findings reported an increased risk of autism and attention deficit hyperactivity disorder (ADHD) among exposed children.10,18,19 Accordingly, these health conditions compromise the child’s ability to focus and lead an active life, resulting in various negative social, emotional, and academic impacts. Similarly, asthma has been identified as the most common cause of absence from school among children, disrupting children’s learning process.15,20 Moreover, according to a study, 61% of parents of asthmatic children identified asthma as a barrier for their children to be involved in sports activities.20 A qualitative analysis that interviewed primary school children with asthma indicated that asthmatic children experienced negative social experiences and bullying. Accordingly, impacted children experience higher rates of depression and social isolation. These adverse social effects are compounded by children’s inability to freely engage in social and leisure pursuits, further compromising their self-esteem.15,21

Emission sources responsible for greenhouses, such as transportation, industries, and energy use, are also key contributors to air pollution. Accordingly, decarbonization actions leading to better air quality will aid in reversing the health challenges facing children. A modeling study that estimated the impact of removing all combustion-related emissions on child health outcomes in 16 cities indicated a substantial reduction in asthma rates and adverse birth outcomes by 22% and 10%, respectively.22

Heatwaves

Heatwaves are defined by a prolonged period of abnormally high temperatures, which are often accompanied by high levels of humidity. The incidence, intensity, and duration of heatwaves have been on the rise. Future projections of global average temperature indicate an increase of at least 2 degrees Celsius,10,23 and these temperature changes are recognized as a direct effect of climate change. The number of individuals exposed to heatwaves has been estimated to be around 125 million over the past two decades.23 Heatwaves affect all age groups and are considered to be one of the most dangerous weather changes. Exposure to heatwaves can result in serious illness and death; morbidity from heatwaves is often characterized by kidney illness, heat strokes, dehydration, and infectious diseases.10,23,24 The consequences of heatwaves on human health are observed all over the world, even in regions with naturally cooler climates, as seen in the 2003 heatwave in Europe, where 70,000 people died.23 However, areas with high levels of poverty experience a higher burden of heatwaves due to various reasons, including the built environment, where homes are often made with cheaper materials that are conductors of heat, such as corrugated iron sheets. Also, to further minimize building costs, most buildings in these environments have no windows, which leads to poor airflow.24 The effects of heatwaves in poor-resource settings are also exacerbated by the prevalent water crisis.26

Among the key risk groups for heatwaves are mothers and children. The younger the child, the more susceptible they are to morbidity and mortality due to heatwaves.10,24-30 Among children, heatwaves pose greater morbidity and mortality risks for infants (0-2 years of age), compared to other age groups. Exposure to extreme heat during pregnancy compromises the health of both mother and baby. The mother’s body, during pregnancy, undergoes metabolic and cardiovascular adaptations to best support the growth of the fetus. Although the specific physiological mechanisms remain unclear, heat exhaustion increases the risk of premature delivery, low birth weight, and congenital anomalies, among other complications in newborns.10,24-30

Furthermore, dehydration is a common challenge facing women living in hot climates, negatively impacting pregnancy and breastfeeding experiences.24 Breastfeeding has been associated with positive physical, cognitive, and immunological effects in children, providing optimal levels of essential nutrients to promote growth and well-being.31 As breast milk is mainly composed of water, maternal dehydration can significantly hinder milk production. The decreased milk supply challenges the infant’s ability to receive adequate intake to have sufficient nourishment. Additionally, mothers suffering from dehydration are also at risk of experiencing fatigue and headaches, which can challenge a mother’s overall ability to attend to her child’s needs.31-34

The effects of heatwaves on mothers and children are exacerbated by limited availability and access to water. Furthermore, in areas most affected by climate change, water intake is affected not only by water scarcity but also by water safety concerns.24-25 Findings from African nations indicated that while pregnant women often need to commute for hours to access the nearest water source, they may abstain from drinking water due to water contamination concerns.24-25 Low water intake during pregnancy results in fatigue and dehydration, which are associated with an increased need for cesarean delivery and a higher risk of adverse birth outcomes, including stillbirth and low birth weight. Additionally, water contamination poses serious threats to newly born and growing children. As children grow, their bodies rely on nutritional sources to support growth processes, including brain development, physical growth, and overall well-being. Water consumption is key for children’s well-being and survival, as dehydration in children has been recognized as a risk factor for infant and child mortality.10,16,25

Altered rainfall

Altered rainfall is a direct climate change consequence that can either result in floods or droughts. The environmental changes attributable to altered rainfall have been associated with an increased risk for infectious diseases.10 The distribution of disease-carrying insects such as malaria, ticks, and dengue has been shown to change. Due to weather changes, insects can expand their geographical range, increasing their presence in areas where they are already prevalent as well as in new areas. Evidence from various countries in Africa indicates an increased transition rate of malaria in areas affected by temperature and rainfall changes. According to the Centers for Disease Control and Prevention (CDC), Malaria is currently among the top ten causes of mortality in children, responsible for 7% of child deaths worldwide.16 Recent projections indicate that without the necessary climate adaptation strategies, malaria under-five mortality is expected to rise by 15%. In addition, weather changes have also been shown to favor the spread and transmission of viruses and parasites that are responsible for an array of infectious diseases 10.

Also, flooding poses great health challenges by increasing the risk of infectious water and food-borne diseases. When exposed to such diseases, children experience prolonged diarrheal episodes causing loss of body water and nutrient content that is substantial for their size. Such episodes are life-threatening.10,16,24 According to the CDC, one in nine children die of diarrheal diseases, making it the second global killer in children below five years of age. Moreover, water contamination alone accounts for 88% of diarrhea-attributable deaths, with dehydration being a key risk factor for death from diarrhea.16

Children surviving diarrheal diseases are often left with undernutrition. Without timely medical care and adequate nutritional support, malnourished children can become wasted and stunted, which are markers of compromised growth that can lead to irreversible adverse growth.10,16,24 Additionally, a recent publication from the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks indicated that wasted and stunted children are put at greater risk of death from diarrheal diseases, highlighting the vicious cycle of malnutrition and diarrhea facing children in impacted communities.35

Furthermore, changes in rainfall patterns have increased the rate and duration of droughts, a widely prevalent consequence of climate change. Droughts are characterized by prolonged periods of dry weather and no or minimal precipitation. In periods of drought, there is an imbalance between water evaporation and precipitation. This imbalance introduces a range of adverse effects on human activities due to a shortage in water supply and significantly reduced agricultural productivity.36,37 Through restricting households’ access to water resources for basic needs, droughts act as a risk factor for dehydration, undernutrition, and infectious diseases. Previous findings from the African region indicated that changes in rainfall patterns are directly reflected in child mortality rates, whereby an increased incidence of droughts is found to be correlated with a higher mortality risk in children. Additionally, droughts put a serious strain on individuals’ mental well-being.10,16,24

One of the most critical effects of droughts on human health is their influence on human nutritional status through compromising agricultural productivity. Agricultural droughts significantly reduce soil quality by depleting its moisture content, which is influenced by the availability of water for irrigation. Droughts also make crops more susceptible to insect and fungal infestations, resulting in crop failure and, thus, reduced yields for human and animal consumption. Livestock farming is also heavily impacted by agricultural droughts. Water scarcity influences farmers’ ability to feed their livestock, which in turn impacts the animals’ weight and milk production.36,37 These challenges may force farmers to slaughter or sell their animals, causing a significant loss of financial security.

The reduced crops and livestock productivity directly impact the livelihoods of farmers and their communities by introducing food shortages. A decrease in agricultural supply impacts the availability and accessibility of safe and nutritious food sources, which act as key determinants of food insecurity that can lead to hunger. A recent United Nations (UN) report indicated an alarmingly increasing trend in world hunger, with 828 million individuals experiencing hunger in 2021, showing an increase of 46 million people since 2020.38,39 Future projections indicate that 8% of the world’s population will be experiencing hunger in 2030. The disparity in the distribution of climate change effects is reflected in the variations of food insecurity and hunger levels across regions. In 2021, 20% of the African population experienced hunger, compared to 9% in Asia, with the lowest levels observed in Europe and North America at less than 3%.38,39 This highlights that regions around the world have been unequally burdened by weather changes that are affecting agricultural productivity and hence food availability and accessibility. Individuals experiencing hunger or food insecurity are more likely to experience a range of physical and mental health complications, as outlined in the next section of this insights piece.40,41

The obesity epidemic and the climate crisis

Climate change within the context of the obesity epidemic adds an additional layer of complexity to the current health status of the world’s population. The multifactorial etiology of obesity has made it difficult to directly attribute obesity cases to climate change. However, recent obesity trends have emphasized the need to identify the mechanisms by which weather effects impact human diets and physical activity levels to guide public health action.

Due to climatic effects on temperature and rainfall patterns, individuals relying on subsistence farming experience fluctuations in their food production.10,37 With an increased incidence and longer periods of droughts, reliance on rain-fed agriculture comes with unpredictable risks of food shortage, leaving impacted communities with food insecurity threats. Food insecurity is defined by the Food and Agriculture Organization of the United Nations as lacking “regular access to enough safe and nutritious food for normal growth and development and an active and healthy life”.38 Thus, the unpredictable food supply experienced by communities heavily affected by climate change increases the risk of food insecurity for everyone.

Adequate and consistent intake of nutritious foods helps individuals maintain healthy eating habits, which is a key determinant for overall physical and mental health. On the other hand, food insecurity has been established as a risk factor for an array of non-communicable diseases (NCDs), including obesity, cardiovascular diseases, and diabetes. Non-communicable diseases are responsible for 74% of global deaths each year.42 When individuals are unable to access healthy food options, they consume a diet that is characterized by a low-nutrient and high-energy content.43,44 While such a diet is low in essential micronutrients, it can significantly increase individuals’ intake of saturated fats, sugars, and salt. This puts consumers at risk of becoming overweight and obese. In 2022, more than 1 billion people were obese, and this number is predicted to continue to increase. 42 By leading to obesity and high blood pressure, an unhealthy diet acts as the leading risk factor for the top causes of mortality globally. According to the World Health Organization, 19% of worldwide deaths are attributed to high blood pressure, followed by increased blood glucose and obesity. 42

Food insecurity in childhood leads to adverse growth and developmental outcomes that result in life-long morbidity and mortality.37,43-46 Food insecurity is a risk factor for undernutrition. Today, 149 million children under five years of age are stunted due to undernutrition, and 45 million suffer from wasting, which is described by the World Health Organization as “the deadliest form of malnutrition” that increases the child’s risk of death by 12 times.39,47 Moreover, current generations of children also experience high rates of excess weight, with 39 million children being overweight.48 This well-known double burden of malnutrition, which is characterized by the simultaneous occurrence of undernutrition and overnutrition (obesity),49,50 has drastic health implications for children by compromising children’s ability to grow to reach their genetic potential and have optimal physical and neurological development.

Besides the issue of unhealthy diets, sedentary lifestyles have been associated with an increased risk of metabolic complications, including obesity, diabetes, and cardiovascular diseases. Almost 1 million individuals die due to lack of physical activity every year.42 With increased urbanization, families are generally less active. In addition, climatic effects such as heatwaves, wildfires, and heavy rains all influence people’s ability to engage in outdoor activities. This is especially concerning for children, given the restrictions imposed by weather changes on playing outside with their age counterparts, resulting in overall sedentary behavior. Lack of physical activity is a key risk factor for overweight and obesity in both children and adults. Sedentary lifestyles also amplify mental health concerns.15,51,52

The changing climate and mental health

Climate change-related weather changes and natural disasters are associated with various implications for mental health. Exposure to natural disasters can affect individuals’ livelihoods, causing major challenges, including loss of life and destruction of built environments (e.g., homes and hospitals). These events often result in displacement and forced migration, imposing an array of mental challenges such as stress, depression, and anxiety. Additionally, research findings have indicated that individuals who have been exposed to natural disasters can suffer from post-traumatic stress disorder (PTSD).10,53 Although knowledge of the long-term mental health implications of climate change is lacking, some evidence suggests a link between long-term exposure to natural disasters and suicide.53,54

Poor air quality has also been directly associated with compromised mental well-being. As individuals are forced to stay indoors in order to avoid smoke from wildfires, they are more likely to experience isolation and depression.18,19 Altered rainfall patterns and heatwaves also disrupt essential services and daily routines, which in turn impact mental health outcomes.53,54

Furthermore, the financial and emotional loss due to natural disasters and the unequal distribution of climate change burden may introduce and fuel social conflicts, which can negatively impact the social cohesion of communities and reduce their sense of security, further amplifying the development of mental health complications among impacted individuals.53

There are additional indirect effects of weather changes on mental health due to an array of climate-associated consequences, including, but not limited to, hunger, unfavorable working conditions, food insecurity, lack of access to clean water, migration, and increased spread of infectious diseases. These events cause financial uncertainties, deterioration of physical health, and food and water safety concerns that can result in anxiety, fear, and trauma. The implications of climate change for mental health are especially critical considering the already high global burden of morbidity due to mental illnesses. It is estimated that one billion people suffer from mental health challenges, with only one in every four affected individuals in low- and middle-income settings having access to adequate support.55

Climate-health inequalities

The health, social, and financial implications of climate change are unequally distributed, with certain groups being disproportionally affected.56-64 This is due to certain areas being geographically disadvantaged. For example, regions closer to the equator are more vulnerable to intense weather changes, while coastal areas are impacted by the rise in sea levels and its repercussions. Sandstorms and wildfires impact some regions more than others due to variations in proximity to deserts and forests. Besides geographical location, social and economic development are also key factors in defining climate change risks and consequences in certain regions.

Climate change disparities heavily intersect with already existing health inequalities that are characterized by an unequal distribution of health and disease due to social and economic gaps.59-61 Communities in poor-resource settings are faced with numerous challenges in accessing basic resources, including healthcare services. Individuals with existing health conditions due to lower socioeconomic status are more likely to bear a disproportionally high disease burden due to being in climate-impacted areas. Marginalized communities are more vulnerable to environmental risks and natural disasters as their climate adaptation capacities, and resilience are largely compromised due to restricted resources. Accordingly, these communities are more likely to experience climate-related social and health consequences such as heat-related illnesses, food insecurity, and food- and water-borne diseases.10,56-59 They are also more susceptible to moving into poverty and experiencing hunger due to forced migration, displacement, water scarcity, and loss of livelihoods. These events directly increase and compound morbidity and mortality risks among impacted populations.

Climate change also discriminates against population sub-groups that are naturally more vulnerable to adverse health outcomes, including children, pregnant women, and the elderly. While there has been a steady increase in publications measuring climate change impacts on vulnerable groups such as children, most country-specific research (41% of all publications between 2000 and 2019) was conducted in high-income countries. Hence, even though low- and middle-income countries suffer great challenges from climate change, only 12% of published studies were specifically focused on examining climate change effects in low-income countries. Reported findings also indicate that the majority of studies disregarded any variation due to sex, with only 30% of all publications considering sex-specific implications. This is especially concerning as “the climate crisis is not gender neutral.”59

Women are disproportionally impacted by weather changes as they are more dependent on natural resources for survival. In many cultures, women are expected to secure food and water for household consumption. Accordingly, they are often heavily involved in agricultural work, making the agriculture sector the main employment sector for women. With climatic changes negatively impacting agricultural productivity, most women are threatened with losing their primary source of income. This acts as a major stressor for women who need to find alternative ways to secure income, food, and other basic needs. The growing pressure and uncertain working conditions impact women’s risk of physical and mental issues due to poor nutrition, heavy labor, and stress. 59 Climate-induced health risks are greater for pregnant women. Research findings indicate that varying climate change effects increase the risk of adverse pregnancy and birth outcomes among impacted women.59,65

The role of the healthcare system

In recent years, numerous voices from around the world have called for making COP a health COP, recognizing the importance of growing the influence of health sectors in climate conversations. International health organizations consider climate change to be the biggest health threat humans have ever faced. The inclusion of health professionals in the development of climate adaptation strategies ensures that health priorities are well-defined within the context of the climate crisis and that climate action serves the most vulnerable populations.66,67 Accordingly, various opportunities can be realized through the inclusion of healthcare leaders and professionals in climate discussions, including:

1.         to identify the mechanisms by which climate change impacts human health

2.         to make climate change part of health discussion with impacted populations

3.         to gain and provide insights from other fields to better anticipate collaboration venues

4.         to promote climate action and educate the general public

5.         to help formulate health-centered policies

6.         to better prepare the healthcare systems and their response capacities

7.         to reconsider the sector’s emission contributions and harness improvement opportunities

8.         to better identify research priorities

9.         to improve the system’s preparedness to deal with emerging climate-related disorders

Conclusion

The climate crisis is a health crisis. Climate change threatens physical, mental health and psychosocial well-being. So far, the consequences of climate change have taken a disproportionally high toll on human health. However, individuals, including political leaders and policymakers, often fail to recognize the vital link between climate change and health and its immense impacts on individuals’ survival and well-being. While all ages bear an unacceptably high morbidity and mortality burden due to climate change, children experience far worse outcomes. In their response to the climate crisis, governments around the world should integrate climate considerations with public health programs for physical and mental health outcomes while also keeping human health at the core of climate action strategies.

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