Public health benefits of strategies to reduce greenhouse-gas emissions: household energy

Data mashups: potential contribution to decision support on climate change and health

Linking environmental, socioeconomic and health datasets provides new insights into the potential associations between climate change and human health and wellbeing, and underpins the development of decision support tools that will promote resilience to climate change, and thus enable more effective adaptation. This paper outlines the challenges and opportunities presented by advances in data collection, storage, analysis, and access, particularly focusing on “data mashups”. These data mashups are integrations of different types and sources of data, frequently using open application programming interfaces and data sources, to produce enriched results that were not necessarily the original reason for assembling the raw source data. As an illustration of this potential, this paper describes a recently funded initiative to create such a facility in the UK for use in decision support around climate change and health, and provides examples of suitable sources of data and the purposes to which they can be directed, particularly for policy makers and public health decision makers.

Home energy efficiency and radon related risk of lung cancer: modelling study

OBJECTIVE

To investigate the effect of reducing home ventilation as part of household energy efficiency measures on deaths from radon related lung cancer.

DESIGN

Modelling study.

SETTING

England.

INTERVENTION

Home energy efficiency interventions, motivated in part by targets for reducing greenhouse gases, which entail reduction in uncontrolled ventilation in keeping with good practice guidance.

MAIN OUTCOME MEASURES

Modelled current and future distributions of indoor radon levels for the English housing stock and associated changes in life years due to lung cancer mortality, estimated using life tables.

RESULTS

Increasing the air tightness of dwellings (without compensatory purpose-provided ventilation) increased mean indoor radon concentrations by an estimated 56.6%, from 21.2 becquerels per cubic metre (Bq/m(3)) to 33.2 Bq/m(3). After the lag in lung cancer onset, this would result in an additional annual burden of 4700 life years lost and (at peak) 278 deaths. The increases in radon levels for the millions of homes that would contribute most of the additional burden are below the threshold at which radon remediation measures are cost effective. Fitting extraction fans and trickle ventilators to restore ventilation will help offset the additional burden but only if the ventilation related energy efficiency gains are lost. Mechanical ventilation systems with heat recovery may lower radon levels and the risk of cancer while maintaining the advantage of energy efficiency for the most airtight dwellings but there is potential for a major adverse impact on health if such systems fail.

CONCLUSION

Unless specific remediation is used, reducing the ventilation of dwellings will improve energy efficiency only at the expense of population wide adverse impact on indoor exposure to radon and risk of lung cancer. The implications of this and other consequences of changes to ventilation need to be carefully evaluated to ensure that the desirable health and environmental benefits of home energy efficiency are not compromised by avoidable negative impacts on indoor air quality.

Climate Change and Nutrition: Creating a Climate for Nutrition Security

Background

Climate change further exacerbates the enormous existing burden of undernutrition. It affects food and nutrition security and undermines current efforts to reduce hunger and promote nutrition. Undernutrition in turn undermines climate resilience and the coping strategies of vulnerable populations.

Objectives

The objectives of this paper are to identify and undertake a cross-sectoral analysis of the impacts of climate change on nutrition security and the existing mechanisms, strategies, and policies to address them.

Methods

A cross-sectoral analysis of the impacts of climate change on nutrition security and the mechanisms and policies to address them was guided by an analytical framework focused on the three ‘underlying causes’ of undernutrition: 1) household food access, 2) maternal and child care and feeding practices, 3) environmental health and health access. The analytical framework includes the interactions of the three underlying causes of undernutrition with climate change, vulnerability, adaptation and mitigation.

Results

Within broad efforts on climate change mitigation and adaptation and climate-resilient development, a combination of nutrition-sensitive adaptation and mitigation measures, climate-resilient and nutrition-sensitive agricultural development, social protection, improved maternal and child care and health, nutrition-sensitive risk reduction and management, community development measures, nutrition-smart investments, increased policy coherence, and institutional and cross-sectoral collaboration are proposed as a means to address the impacts of climate change to food and nutrition security. This paper proposes policy directions to address nutrition in the climate change agenda and recommendations for consideration by the UN Framework Convention on Climate Change (UNFCCC).

Conclusions

Nutrition and health stakeholders need to be engaged in key climate change adaptation and mitigation initiatives, including science-based assessment by the Intergovernmental Panel on Climate Change (IPCC), and policies and actions formulated by the UN Framework Convention on Climate Change (UNFCCC). Improved multi-sectoral coordination and political will is required to integrate nutrition-sensitive actions into climate-resilient sustainable development efforts in the UNFCCC work and in the post 2015 development agenda. Placing human rights at the center of strategies to mitigate and adapt to the impacts of climate change and international solidarity is essential to advance sustainable development and to create a climate for nutrition security.

Co-benefits of Global Greenhouse Gas Mitigation for Future Air Quality and Human Health

Actions to reduce greenhouse gas (GHG) emissions often reduce co-emitted air pollutants, bringing co-benefits for air quality and human health. Past studies^1-6 typically evaluated near-term and local co-benefits, neglecting the long-range transport of air pollutants^7-9, long-term demographic changes, and the influence of climate change on air quality^10-12. Here we simulate the co-benefits of global GHG reductions on air quality and human health using a global atmospheric model and consistent future scenarios, via two mechanisms: a) reducing co-emitted air pollutants, and b) slowing climate change and its effect on air quality. We use new relationships between chronic mortality and exposure to fine particulate matter¹³ and ozone¹⁴, global modeling methods¹⁵, and new future scenarios¹⁶. Relative to a reference scenario, global GHG mitigation avoids 0.5±0.2, 1.3±0.5, and 2.2±0.8 million premature deaths in 2030, 2050, and 2100. Global average marginal co-benefits of avoided mortality are $50-380 (ton CO₂)^-1, which exceed previous estimates, exceed marginal abatement costs in 2030 and 2050, and are within the low range of costs in 2100. East Asian co-benefits are 10-70 times the marginal cost in 2030. Air quality and health co-benefits, especially as they are mainly local and near-term, provide strong additional motivation for transitioning to a low-carbon future.

Quantitative metrics of stove adoption using Stove Use Monitors (SUMs)

The sustained use of cookstoves that are introduced to reduce fuel use or air pollution needs to be objectively monitored to verify the sustainability of these benefits. Quantifying stove adoption requires affordable tools, scalable methods and validated metrics of usage. We quantified the longitudinal patterns of chimney-stove use of 80 households in rural Guatemala, monitored with Stove Use Monitors (SUMs) during 32 months. We counted daily meals and days in use at each monitoring period and defined metrics like the percent stove-days in use (the fraction of days in use from all stoves and days monitored). Using robust Poisson regressions we detected small seasonal variations in stove usage, with peaks in the warm-dry season at 92% stove-days (95%CI: 87%,97%) and 2.56 average daily meals (95%CI: 2.40,2.74). With respect to these values, the percent stove-days in use decreased by 3% and 4% during the warm-rainy and cold-dry periods respectively, and the daily meals by 5% and 12% respectively. Cookstove age and household size at baseline did not affect usage. Qualitative indicators of use from recall questionnaires were consistent with SUMs measurements, indicating stable sustained use and questionnaire accuracy. These results reflect optimum conditions for cookstove adoption and for monitoring in this project, which may not occur in disseminations undertaken elsewhere. The SUMs measurements suggests that 90% stove-days is a more realistic best-case for sustained use than the 100% often assumed. Half of sample reported continued use of open-cookfires, highlighting the critical need to verify reduction of open-fire practices in stove disseminations.

Assessing framing assumptions in quantitative health impact assessments: a housing intervention example

Health impact assessment (HIA) is often used to determine ex ante the health impact of an environmental policy or an environmental intervention. Underpinning any HIA is the framing assumption, which defines the causal pathways mapping environmental exposures to health outcomes. The sensitivity of the HIA to the framing assumptions is often ignored. A novel method based on fuzzy cognitive map (FCM) is developed to quantify the framing assumptions in the assessment stage of a HIA, and is then applied to a housing intervention (tightening insulation) as a case-study. Framing assumptions of the case-study were identified through a literature search of Ovid Medline (1948-2011). The FCM approach was used to identify the key variables that have the most influence in a HIA. Changes in air-tightness, ventilation, indoor air quality and mould/humidity have been identified as having the most influence on health. The FCM approach is widely applicable and can be used to inform the formulation of the framing assumptions in any quantitative HIA of environmental interventions. We argue that it is necessary to explore and quantify framing assumptions prior to conducting a detailed quantitative HIA during the assessment stage.

A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: limited evidence from India and Pakistan

Cardiovascular diseases (CVD) are major contributors to mortality and morbidity in South Asia. Chronic exposure to air pollution is an important risk factor for cardiovascular diseases, although the majority of studies to date have been conducted in developed countries. Both indoor and outdoor air pollution are growing problems in developing countries in South Asia yet the impact on rising rates of CVD in these regions has largely been ignored. We aimed to assess the evidence available regarding air pollution effects on CVD and CVD risk factors in lower income countries in South Asia. A literature search was conducted in PubMed and Web of Science. Our inclusion criteria included peer-reviewed, original, empirical articles published in English between the years 1990 and 2012, conducted in the World Bank South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka). This resulted in 30 articles. Nine articles met our inclusion criteria and were assessed for this systematic review. Most of the studies were cross-sectional and examined measured particulate matter effects on CVD outcomes and indicators. We observed a bias as nearly all of the studies were from India. Hypertension and CVD deaths were positively associated with higher particulate matter levels. Biomarkers of oxidative stress such as increased levels of P-selection expressing platelets, depleted superoxide dismutase and reactive oxygen species generation as well as elevated levels of inflammatory-related C-reactive protein, interleukin-6 and interleukin-8 were also positively associated with biomass use or elevated particulate matter levels. An important outcome of this investigation was the evidence suggesting important air pollution effects regarding CVD risk in South Asia. However, too few studies have been conducted. There is as an urgent need for longer term investigations using robust measures of air pollution with different population groups that include a wider range of air pollutants and outcomes, including early indicators of CVD. These regions are facing burdens from increasing urbanization, air pollution and populations, generally weaker health infrastructure, aging populations and increased incidence of non-communicable diseases, included CVD. The extent to which the problem of air pollution and CVD will impact these countries will depend largely on the information available to inform policy and programs, which are still lacking, political will as well as social and economic development.

Climate change air toxic co-reduction in the context of macroeconomic modelling

This paper examines the health implications of global PM reduction accompanying greenhouse gas emissions reductions in the 180 national economies of the global macroeconomy. A human health effects module based on empirical data on GHG emissions, PM emissions, background PM concentrations, source apportionment and human health risk coefficients is used to estimate reductions in morbidity and mortality from PM exposures globally as co-reduction of GHG reductions. These results are compared against the "fuzzy bright line" that often underlies regulatory decisions for environmental toxics, and demonstrate that the risk reduction through PM reduction would usually be considered justified in traditional risk-based decisions for environmental toxics. It is shown that this risk reduction can be on the order of more than 4 × 10(-3) excess lifetime mortality risk, with global annual cost savings of slightly more than $10B, when uniform GHG reduction measures across all sectors of the economy form the basis for climate policy ($2.2B if only Annex I nations reduce). Consideration of co-reduction of PM-10 within a climate policy framework harmonized with other environmental policies can therefore be an effective driver of climate policy. An error analysis comparing results of the current model against those of significantly more spatially resolved models at city and national scales indicates errors caused by the low spatial resolution of the global model used here may be on the order of a factor of 2.

Cobenefits of replacing car trips with alternative transportation: a review of evidence and methodological issues

It has been reported that motor vehicle emissions contribute nearly a quarter of world energy-related greenhouse gases and cause nonnegligible air pollution primarily in urban areas. Reducing car use and increasing ecofriendly alternative transport, such as public and active transport, are efficient approaches to mitigate harmful environmental impacts caused by a large amount of vehicle use. Besides the environmental benefits of promoting alternative transport, it can also induce other health and economic benefits. At present, a number of studies have been conducted to evaluate cobenefits from greenhouse gas mitigation policies. However, relatively few have focused specifically on the transport sector. A comprehensive understanding of the multiple benefits of alternative transport could assist with policy making in the areas of transport, health, and environment. However, there is no straightforward method which could estimate cobenefits effect at one time. In this paper, the links between vehicle emissions and air quality, as well as the health and economic benefits from alternative transport use, are considered, and methodological issues relating to the modelling of these cobenefits are discussed.

Climate change threats to population health and well-being: the imperative of protective solutions that will last

BACKGROUND

The observational evidence of the impacts of climate conditions on human health is accumulating. A variety of direct, indirect, and systemically mediated health effects have been identified. Excessive daily heat exposures create direct effects, such as heat stroke (and possibly death), reduce work productivity, and interfere with daily household activities. Extreme weather events, including storms, floods, and droughts, create direct injury risks and follow-on outbreaks of infectious diseases, lack of nutrition, and mental stress. Climate change will increase these direct health effects. Indirect effects include malnutrition and under-nutrition due to failing local agriculture, spread of vector-borne diseases and other infectious diseases, and mental health and other problems caused by forced migration from affected homes and workplaces. Examples of systemically mediated impacts on population health include famine, conflicts, and the consequences of large-scale adverse economic effects due to reduced human and environmental productivity. This article highlights links between climate change and non-communicable health problems, a major concern for global health beyond 2015.

DISCUSSION

Detailed regional analysis of climate conditions clearly shows increasing temperatures in many parts of the world. Climate modelling indicates that by the year 2100 the global average temperature may have increased by 34°C unless fundamental reductions in current global trends for greenhouse gas emissions are achieved. Given other unforeseeable environmental, social, demographic, and geopolitical changes that may occur in a plus-4-degree world, that scenario may comprise a largely uninhabitable world for millions of people and great social and military tensions.

CONCLUSION

It is imperative that we identify actions and strategies that are effective in reducing these increasingly likely threats to health and well-being. The fundamental preventive strategy is, of course, climate change mitigation by significantly reducing global greenhouse gas emissions, especially long-acting carbon dioxide (CO(2)), and by increasing the uptake of CO(2) at the earth's surface. This involves urgent shifts in energy production from fossil fuels to renewable energy sources, energy conservation in building design and urban planning, and reduced waste of energy for transport, building heating/cooling, and agriculture. It would also involve shifts in agricultural production and food systems to reduce energy and water use particularly in meat production. There is also potential for prevention via mitigation, adaptation, or resilience building actions, but for the large populations in tropical countries, mitigation of climate change is required to achieve health protection solutions that will last.

Management of chronic obstructive pulmonary disease in India: a systematic review

OBJECTIVES

Chronic diseases are fast becoming the largest health burden in India. Despite this, their management in India has not been well studied. We aimed to systematically review the nature and efficacy of current management strategies for chronic obstructive pulmonary disease (COPD) in India.

METHODS

We used database searches (MEDLINE, EMBASE, IndMED, CENTRAL and CINAHL), journal hand-searches, scanning of reference lists and contact with experts to identify studies for systematic review. We did not review management strategies aimed at chronic diseases more generally, nor management of acute exacerbations. Due to the heterogeneity of reviewed studies, meta-analysis was not appropriate. Thus, narrative methods were used.

SETTING

India.

PARTICIPANTS

All adult populations resident in India.

MAIN OUTCOME MEASURES

1. Trialled interventions and outcomes 2. Extent and efficacy of current management strategies 3. Above outcomes by subgroup.

RESULTS

We found information regarding current management - particularly regarding the implementation of national guidelines and primary prevention - to be minimal. This led to difficulty in interpreting studies of management strategies, which were varied and generally of positive effect. Data regarding current management outcomes were very few.

CONCLUSIONS

The current understanding of management strategies for COPD in India is limited due to a lack of published data. Determination of the extent of current use of management guidelines, availability and use of treatment, and current primary prevention strategies would be useful. This would also provide evidence on which to interpret existing and future studies of management outcomes and novel interventions.

Embedding non-communicable diseases in the post-2015 development agenda

The post-2015 development agenda will build on the Millennium Development Goals (MDGs), in which health is a core component. This agenda will focus on human development, incorporate the components of the Millennium Declaration, and will be made sustainable by support from the social, economic, and environmental domains of activity, represented graphically as the strands of a triple helix. The approaches to prevention and control of non-communicable diseases (NCDs) have been elaborated in the political declaration of the UN high-level meeting on NCDs and governments have adopted a goal of 25% reduction in relative mortality from NCDs by 2025 (the 25 by 25 goal), but a strong movement is needed based on the evidence already available, enhanced by effective partnerships, and with political support to ensure that NCDs are embedded in the post-2015 human development agenda. NCDs should be embedded in the post-2015 development agenda, since they are leading causes of death and disability, have a negative effect on health, and, through their effect on the societal, economic, and the environmental domains, impair the sustainability of development. Some drivers of unsustainable development, such as the transport, food and agriculture, and energy sectors, also increase the risk of NCDs.

Are rocket mud stoves associated with lower indoor carbon monoxide and personal exposure in rural Kenya?

Household use of biomass fuels is a major source of indoor air pollution and poor health in developing countries. We conducted a cross-sectional investigation in rural Kenya to assess household air pollution in homes with traditional three-stone stove and rocket mud stove (RMS), a low-cost unvented wood stove. We conducted continuous measurements of kitchen carbon monoxide (CO) concentrations and personal exposures in 102 households. Median 48-h kitchen and personal CO concentrations were 7.3 and 6.5 ppm, respectively, for three-stone stoves, while the corresponding concentrations for RMS were 5.8 and 4.4 ppm. After adjusting for kitchen location, ventilation, socio-economic status, and fuel moisture content, the use of RMS was associated with 33% lower levels of kitchen CO [95% Confidence Interval (CI), 64.4-25.1%] and 42% lower levels of personal CO (95% CI, 66.0-1.1%) as compared to three-stone stoves. Differences in CO concentrations by stove type were more pronounced when averaged over the cooking periods, although they were attenuated after adjusting for confounding. In conclusion, RMS appear to lower kitchen and personal CO concentrations compared to the traditional three-stone stoves but overall, the CO concentrations remain high.

PRACTICAL IMPLICATIONS

The rocket mud stoves (RMS) were associated with lower CO concentrations compared to three-stone stoves. However, the difference in concentrations was modest and concentrations in both stove groups exceeded the WHO guideline of 7 μg/m(3) , suggesting the unvented RMSs on their own are unlikely to appreciably benefit health in this population. Greater air quality benefit could be realized if the stoves were complemented with behavior change, including education on extinguishing fire when not in use as well as fuel drying, and cooking in locations that are separate from the main house.

The importance of health co-benefits in macroeconomic assessments of UK Greenhouse Gas emission reduction strategies

We employ a single-country dynamically-recursive Computable General Equilibrium model to make health-focussed macroeconomic assessments of three contingent UK Greenhouse Gas (GHG) mitigation strategies, designed to achieve 2030 emission targets as suggested by the UK Committee on Climate Change. In contrast to previous assessment studies, our main focus is on health co-benefits additional to those from reduced local air pollution. We employ a conservative cost-effectiveness methodology with a zero net cost threshold. Our urban transport strategy (with cleaner vehicles and increased active travel) brings important health co-benefits and is likely to be strongly cost-effective; our food and agriculture strategy (based on abatement technologies and reduction in livestock production) brings worthwhile health co-benefits, but is unlikely to eliminate net costs unless new technological measures are included; our household energy efficiency strategy is likely to breakeven only over the long term after the investment programme has ceased (beyond our 20 year time horizon). We conclude that UK policy makers will, most likely, have to adopt elements which involve initial net societal costs in order to achieve future emission targets and longer-term benefits from GHG reduction. Cost-effectiveness of GHG strategies is likely to require technological mitigation interventions and/or demand-constraining interventions with important health co-benefits and other efficiency-enhancing policies that promote internalization of externalities. Health co-benefits can play a crucial role in bringing down net costs, but our results also suggest the need for adopting holistic assessment methodologies which give proper consideration to welfare-improving health co-benefits with potentially negative economic repercussions (such as increased longevity).

Implications of global climate change for the assessment and management of human health risks of chemicals in the natural environment

Global climate change (GCC) is likely to alter the degree of human exposure to pollutants and the response of human populations to these exposures, meaning that risks of pollutants could change in the future. The present study, therefore, explores how GCC might affect the different steps in the pathway from a chemical source in the environment through to impacts on human health and evaluates the implications for existing risk-assessment and management practices. In certain parts of the world, GCC is predicted to increase the level of exposure of many environmental pollutants due to direct and indirect effects on the use patterns and transport and fate of chemicals. Changes in human behavior will also affect how humans come into contact with contaminated air, water, and food. Dietary changes, psychosocial stress, and coexposure to stressors such as high temperatures are likely to increase the vulnerability of humans to chemicals. These changes are likely to have significant implications for current practices for chemical assessment. Assumptions used in current exposure-assessment models may no longer apply, and existing monitoring methods may not be robust enough to detect adverse episodic changes in exposures. Organizations responsible for the assessment and management of health risks of chemicals therefore need to be more proactive and consider the implications of GCC for their procedures and processes.

Health co-benefits and risks of public health adaptation strategies to climate change: a review of current literature

Objectives

Many public health adaptation strategies have been identified in response to climate change. This report reviews current literature on health co-benefits and risks of these strategies to gain a better understanding of how they may affect health.

Methods

A literature review was conducted electronically using English language literature from January 2000 to March 2012. Of 812 articles identified, 22 peer-reviewed articles that directly addressed health co-benefits or risks of adaptation were included in the review.

Results

The co-benefits and risks identified in the literature most commonly relate to improvements in health associated with adaptation actions that affect social capital and urban design. Health co-benefits of improvements in social capital have positive influences on mental health, independently of other determinants. Risks included reinforcing existing misconceptions regarding health. Health co-benefits of urban design strategies included reduced obesity, cardiovascular disease and improved mental health through increased physical activity, cooling spaces (e.g., shaded areas), and social connectivity. Risks included pollen allergies with increased urban green space, and adverse health effects from heat events through the use of air conditioning.

Conclusions

Due to the current limited understanding of the full impacts of the wide range of existing climate change adaptation strategies, further research should focus on both unintended positive and negative consequences of public health adaptation.

Social, economic, and resource predictors of variability in household air pollution from cookstove emissions

We examine if social and economic factors, fuelwood availability, market and media access are associated with owning a modified stove and variation in household emissions from biomass combustion, a significant environmental and health concern in rural India. We analyze cross-sectional household socio-economic data, and PM(2.5) and particulate surface area concentration in household emissions from cookstoves (n=100). This data set combines household social and economic variables with particle emissions indexes associated with the household stove. The data are from the Foundation for Ecological Society, India, from a field study of household emissions. In our analysis, we find that less access to ready and free fuelwood and higher wealth are associated with owning a replacement/modified stove. We also find that additional kitchen ventilation is associated with a 12% reduction in particulate emissions concentration (p<0.05), after we account for the type of stove used. We did not find a significant association between replacement/modified stove on household emissions when controlling for additional ventilation. Higher wealth and education are associated with having additional ventilation. Social caste, market and media access did not have any effect on the presence of replacement or modified stoves or additional ventilation. While the data available to us does not allow an examination of direct health outcomes from emissions variations, adverse environmental and health impacts of toxic household emissions are well established elsewhere in the literature. The value of this study is in its further examination of the role of social and economic factors and available fuelwood from commons in type of stove use, and additional ventilation, and their effect on household emissions. These associations are important since the two direct routes to improving household air quality among the poor are stove type and better ventilation.

How well does climate change and human health research match the demands of policymakers? A scoping review

BACKGROUND

In 2008, the World Health Organization (WHO) Member States passed a World Health Assembly resolution that identified the following five priority areas for research and pilot projects on climate change and human health: health vulnerability, health protection, health impacts of mitigation and adaptation policies, decision-support and other tools, and costs of health protection from climate change.

OBJECTIVES

To assess the extent to which recently published research corresponds to these priorities, we undertook a scoping review of original research on climate change and human health. Scoping reviews address topics that are too broad for a systematic review and commonly aim to identify research gaps in existing literature. We also assessed recent publication trends for climate change and health research.

METHODS

We searched for original quantitative research published from 2008 onward. We included disease burden studies that were specific to climate change and health and included intervention studies that focused on climate change and measured health outcomes. We used MEDLINE, Embase, and Web of Science databases and extracted data on research priority areas, geographic regions, health fields, and equity (systematic differences between advantaged and disadvantaged social groups).

DISCUSSION

We identified 40 eligible studies. Compared with other health topics, the number of climate change publications has grown rapidly, with a larger proportion of reviews or editorials. Recent original research addressed four of the five priority areas identified by the WHO Member States, but we found no eligible studies of health adaptation interventions, and most of the studies focused on high-income countries.

CONCLUSIONS

Climate change and health is a rapidly growing area of research, but quantitative studies remain rare. Among recently published studies, we found gaps in adaptation research and a deficit of studies in most developing regions. Funders and researchers should monitor and respond to research gaps to help ensure that the needs of policymakers are met.

Health benefits of a low carbon economy

This article summarizes a presentation given at 'Health and Well-being: the 21st Century Agenda', which focused on the potential to make progress by making appropriate connections between activity to promote health and respond to the threat of climate change. It argues that a transition to a low carbon economy would bring together two of our greatest public health challenges, supporting action to improve public health within resource constraints and action to avert climate change as far as possible. Deep cuts in emissions are needed to prevent dangerous consequences arising from climate change. In addition, many of the policies to reduce greenhouse gas emissions will, in themselves, have beneficial effects on public health. This article provides an overview of several modelling studies which demonstrate that well-designed initiatives that curb greenhouse gas emissions in energy, residential construction, urban transport and agricultural systems can enhance global public health, including improving health among poor populations. Some of these health co-benefits can be achieved in a relatively short time frame, and they can help offset the costs of climate change mitigation policies.

From the Earth Summit to Rio+20: integration of health and sustainable development

In 2012, world leaders will meet at the Rio+20 conference to advance sustainable development--20 years after the Earth Summit that resulted in agreement on important principles but insufficient action. Many of the development goals have not been achieved partly because social (including health), economic, and environmental priorities have not been addressed in an integrated manner. Adverse trends have been reported in many key environmental indicators that have worsened since the Earth Summit. Substantial economic growth has occurred in many regions but nevertheless has not benefited many populations of low income and those that have been marginalised, and has resulted in growing inequities. Variable progress in health has been made, and inequities are persistent. Improved health contributes to development and is underpinned by ecosystem stability and equitable economic progress. Implementation of policies that both improve health and promote sustainable development is urgently needed.

Global environmental health and sustainable development: the role at Rio+20

The Rio+20 United Nations Conference on Sustainable Development represents a crucial opportunity to place environmental health at the forefront of the sustainable development agenda. Billions of people living in low- and middle-income countries continue to be afflicted by preventable diseases due to modifiable environmental exposures, causing needless suffering and perpetuating a cycle of poverty. Current processes of economic development, while alleviating many social and health problems, are increasingly linked to environmental health threats, ranging from air pollution and physical inactivity to global climate change. Sustainable development practices attempt to reduce environmental impacts and should, in theory, reduce adverse environmental health consequences compared to traditional development. Yet these efforts could also result in unintended harm and impaired economic development if the new "Green Economy" is not carefully assessed for adverse environmental and occupational health impacts. The environmental health community has an essential role to play in underscoring these relationships as international leaders gather to craft sustainable development policies.

Intervention to lower household wood smoke exposure in Guatemala reduces ST-segment depression on electrocardiograms

BACKGROUND

A large body of evidence suggests that fine particulate matter (PM) air pollution is a cause of cardiovascular disease, but little is known in particular about the cardiovascular effects of indoor air pollution from household use of solid fuels in developing countries. RESPIRE (Randomized Exposure Study of Pollution Indoors and Respiratory Effects) was a randomized trial of a chimney woodstove that reduces wood smoke exposure.

OBJECTIVES

We tested the hypotheses that the stove intervention, compared with open fire use, would reduce ST-segment depression and increase heart rate variability (HRV).

METHODS

We used two complementary study designs: a) between-groups comparisons based on randomized stove assignment, and b) before-and-after comparisons within control subjects who used open fires during the trial and received chimney stoves after the trial. Electrocardiogram sessions that lasted 20 hr were repeated up to three times among 49 intervention and 70 control women 38-84 years of age, and 55 control subjects were also assessed after receiving stoves. HRV and ST-segment values were assessed for each 30-min period. ST-segment depression was defined as an average value below -1.00 mm. Personal fine PM [aerodynamic diameter ≤ 2.5 μm (PM₂.₅] exposures were measured for 24 hr before each electrocardiogram.

RESULTS

PM₂.₅ exposure means were 266 and 102 μg/m³ during the trial period in the control and intervention groups, respectively. During the trial, the stove intervention was associated with an odds ratio of 0.26 (95% confidence interval, 0.08-0.90) for ST-segment depression. We found similar associations with the before-and-after comparison. The intervention was not significantly associated with HRV.

CONCLUSIONS

The stove intervention was associated with reduced occurrence of nonspecific ST-segment depression, suggesting that household wood smoke exposures affect ventricular repolarization and potentially cardiovascular health.

Incentives for health

This article discusses incentives to help make healthy choices the easy choices for individuals, operating at the levels of the individual, producers and service providers, and governments. Whereas paying individuals directly to be healthier seems to have a limited effect, offering financial incentives through health insurance improves health. Changing the environment to make healthier choices more accessible acts as an incentive to improve health. Employers can provide incentives to improve the health of their employees. Producers and service providers can take voluntary action to make their products less harmful, and they can be nudged into marketing healthier products within a regulatory environment. International agreements and monitoring systems can incentivize governments to do more for health. Lessons from climate change adaptation suggest that multilevel governance and policy integration are greater obstacles to policy change and implementation than knowing what has to be done. Policy change and implementation are triggered by many drivers, many of which are side effects of other policy pressures rather than of the direct policy goal itself. Effective action to reduce noncommunicable diseases will require leveraging social networks into a new ways of thinking about health; making better health prestigious and aspirational, and giving health and wellness a brand that encourages positive behavior change.

Climate change and climate variability: personal motivation for adaptation and mitigation

BACKGROUND

Global climate change impacts on human and natural systems are predicted to be severe, far reaching, and to affect the most physically and economically vulnerable disproportionately. Society can respond to these threats through two strategies: mitigation and adaptation. Industry, commerce, and government play indispensable roles in these actions but so do individuals, if they are receptive to behavior change. We explored whether the health frame can be used as a context to motivate behavioral reductions of greenhouse gas emissions and adaptation measures.

METHODS

In 2008, we conducted a cross-sectional survey in the United States using random digit dialing. Personal relevance of climate change from health threats was explored with the Health Belief Model (HBM) as a conceptual frame and analyzed through logistic regressions and path analysis.

RESULTS

Of 771 individuals surveyed, 81% (n = 622) acknowledged that climate change was occurring, and were aware of the associated ecologic and human health risks. Respondents reported reduced energy consumption if they believed climate change could affect their way of life (perceived susceptibility), Odds Ratio (OR) = 2.4 (95% Confidence Interval (CI): 1.4-4.0), endanger their life (perceived severity), OR = 1.9 (95% CI: 1.1-3.1), or saw serious barriers to protecting themselves from climate change, OR = 2.1 (95% CI: 1.2-3.5). Perceived susceptibility had the strongest effect on reduced energy consumption, either directly or indirectly via perceived severity. Those that reported having the necessary information to prepare for climate change impacts were more likely to have an emergency kit OR = 2.1 (95% CI: 1.4-3.1) or plan, OR = 2.2 (95% CI: 1.5-3.2) for their household, but also saw serious barriers to protecting themselves from climate change or climate variability, either by having an emergency kit OR = 1.6 (95% CI: 1.1-2.4) or an emergency plan OR = 1.5 (95%CI: 1.0-2.2).

CONCLUSIONS

Motivation for voluntary mitigation is mostly dependent on perceived susceptibility to threats and severity of climate change or climate variability impacts, whereas adaptation is largely dependent on the availability of information relevant to climate change. Thus, the climate change discourse could be framed from a health perspective to motivate behaviour change.

Preventing cold-related morbidity and mortality in a changing climate

Winter weather patterns are anticipated to become more variable with increasing average global temperatures. Research shows that excess morbidity and mortality occurs during cold weather periods. We critically reviewed evidence relating temperature variability, health outcomes, and adaptation strategies to cold weather. Health outcomes included cardiovascular-, respiratory-, cerebrovascular-, and all-cause morbidity and mortality. Individual and contextual risk factors were assessed to highlight associations between individual- and neighborhood-level characteristics that contribute to a person's vulnerability to variability in cold weather events. Epidemiologic studies indicate that the populations most vulnerable to variations in cold winter weather are the elderly, rural and, generally, populations living in moderate winter climates. Fortunately, cold-related morbidity and mortality are preventable and strategies exist for protecting populations from these adverse health outcomes. We present a range of adaptation strategies that can be implemented at the individual, building, and neighborhood level to protect vulnerable populations from cold-related morbidity and mortality. The existing research justifies the need for increased outreach to individuals and communities for education on protective adaptations in cold weather. We propose that future climate change adaptation research couple building energy and thermal comfort models with epidemiological data to evaluate and quantify the impacts of adaptation strategies.

Global health and climate change: moving from denial and catastrophic fatalism to positive action

The health effects of climate change have had relatively little attention from climate scientists and governments. Climate change will be a major threat to population health in the current century through its potential effects on communicable disease, heat stress, food and water security, extreme weather events, vulnerable shelter and population migration. This paper addresses three health-sector strategies to manage the health effects of climate change-promotion of mitigation, tackling the pathways that lead to ill-health and strengthening health systems. Mitigation of greenhouse gas (GHG) emissions is affordable, and low-carbon technologies are available now or will be in the near future. Pathways to ill-health can be managed through better information, poverty reduction, technological innovation, social and cultural change and greater coordination of national and international institutions. Strengthening health systems requires increased investment in order to provide effective public health responses to climate-induced threats to health, equitable treatment of illness, promotion of low-carbon lifestyles and renewable energy solutions within health facilities. Mitigation and adaptation strategies will produce substantial benefits for health, such as reductions in obesity and heart disease, diabetes, stress and depression, pneumonia and asthma, as well as potential cost savings within the health sector. The case for mitigating climate change by reducing GHGs is overwhelming. The need to build population resilience to the global health threat from already unavoidable climate change is real and urgent. Action must not be delayed by contrarians, nor by catastrophic fatalists who say it is all too late.

Readying health services for climate change: a policy framework for regional development

Climate change presents the biggest threat to human health in the 21st century. However, many public health leaders feel ill equipped to face the challenges of climate change and have been unable to make climate change a priority in service development. I explore how to achieve a regionally responsive whole-of-systems approach to climate change in the key operational areas of a health service: service governance and culture, service delivery, workforce development, asset management, and financing. The relative neglect of implementation science means that policymakers need to be proactive about sourcing and developing models and processes to make health services ready for climate change. Health research funding agencies should urgently prioritize applied, regionally responsive health services research for a future of climate change.

Increased traffic exposure and negative birth outcomes: a prospective cohort in Australia

BACKGROUND

Pregnant women exposed to traffic pollution have an increased risk of negative birth outcomes. We aimed to investigate the size of this risk using a prospective cohort of 970 mothers and newborns in Logan, Queensland.

METHODS

We examined two measures of traffic: distance to nearest road and number of roads around the home. To examine the effect of distance we used the number of roads around the home in radii from 50 to 500 metres. We examined three road types: freeways, highways and main roads.

RESULTS

There were no associations with distance to road. A greater number of freeways and main roads around the home were associated with a shorter gestation time. There were no negative impacts on birth weight, birth length or head circumference after adjusting for gestation. The negative effects on gestation were largely due to main roads within 400 metres of the home. For every 10 extra main roads within 400 metres of the home, gestation time was reduced by 1.1% (95% CI: -1.7, -0.5; p-value = 0.001).

CONCLUSIONS

Our results add weight to the association between exposure to traffic and reduced gestation time. This effect may be due to the chemical toxins in traffic pollutants, or because of disturbed sleep due to traffic noise.

Global burden of disease as a result of indoor air pollution in Shaanxi, Hubei and Zhejiang, China

Indoor air pollution in developing countries is a major global health problem, yet estimates of the global burden of disease vary widely and are associated with large uncertainty. The World Health Organization uses the fuel based approach to estimate 1.6 million premature deaths globally each year associated with exposure to indoor air pollution, of which 420000 are in China. The fuel based approach uses a ventilation factor to account for differences in indoor air concentrations and exposures in different parts of the world based on regional differences in stove technology. In China this approach assumes that flues eliminate the majority of indoor air pollution, with a ventilation factor of 0.25. To account for historic exposure leading to current disease patterns the ventilation factor was adjusted to 0.5 for adult health endpoints. Measurements in three Chinese provinces, Shaanxi, Hubei and Zhejiang, however, show that high PM(4) concentrations are present in kitchens and living rooms even with stoves with flues as a result of multiple stove and flue use. Comparison of Indian and Chinese indoor air concentrations suggests more appropriate ventilation factors in the range 0.76-1.0 for women and children, and 1.0 for men. Premature mortality in the three provinces using these estimates would be closer to 60600, rather than current estimates of 46000. With the addition of cardiovascular diseases these estimates would increase by 92000. Pollutant based estimates using measured indoor air concentrations and combined with dose-response estimates would imply a burden of disease of 157800 premature deaths including cardiovascular diseases, a tripling of current estimates.

Greenhouse gas emission reductions from domestic anaerobic digesters linked with sustainable sanitation in rural China

Anaerobic digesters provide clean, renewable energy (biogas) by converting organic waste to methane, and are a key part of China's comprehensive rural energy plan. Here, experimental and modeling results are used to quantify the net greenhouse gas (GHG) reduction from substituting a household anaerobic digester for traditional energy sources in Sichuan, China. Tunable diode laser absorption spectroscopy and radial plume mapping were used to estimate the mass flux of fugitive methane emissions from active digesters. Using household energy budgets, the net improvement in GHG emissions associated with biogas installation was estimated using global warming commitment (GWC) as a consolidated measure of the warming effects of GHG emissions from cooking. In all scenarios biogas households had lower GWC than nonbiogas households, by as much as 54%. Even biogas households with methane leakage exhibited lower GWC than nonbiogas households, by as much as 48%. Based only on the averted GHG emissions over 10 years, the monetary value of a biogas installation was conservatively estimated at US$28.30 ($16.07 ton(-1) CO(2)-eq), which is available to partly offset construction costs. The interaction of biogas installation programs with policies supporting improved stoves, renewable harvesting of biomass, and energy interventions with substantial health cobenefits are discussed.

Constraints and barriers to public health adaptation to climate change: a review of the literature

Public health adaptation to climate change is an important issue and inevitably is needed to address the adverse health impacts of climate change over the next few decades. This paper provides an overview of the constraints and barriers to public health adaptation and explores future research directions in this emerging field. An extensive literature review was conducted in 2010 and published literature from 2000 to 2010 was retrieved. This review shows that public health adaptation essentially can operate at two levels, namely, adaptive-capacity building and implementation of adaptation actions. However, there are constraints and barriers to public health adaptation arising from uncertainties of future climate and socioeconomic conditions, as well as financial, technologic, institutional, social capital, and individual cognitive limits. The opportunities for planning and implementing public health adaptation are reliant on effective strategies to overcome these constraints and barriers. It is proposed here that high research priority should be given to multidisciplinary research on the assessment of potential health impacts of climate change, projections of health impacts under different climate and socioeconomic scenarios, identification of health co-benefits of mitigation strategies, and evaluation of cost-effective public health adaptation options.

Modelling inhalation exposure to combustion-related air pollutants in residential buildings: Application to health impact assessment

Buildings in developed countries are becoming increasingly airtight as a response to stricter energy efficiency requirements. At the same time, changes are occurring to the ways in which household energy is supplied, distributed and used. These changes are having important impacts on exposure to indoor air pollutants in residential buildings and present new challenges for professionals interested in assessing the effects of housing on public health. In many circumstances, models are the most appropriate way with which to examine the potential outcomes of future environmental and/or building interventions and policies. As such, there is a need to consider the current state of indoor air pollution exposure modelling. Various indoor exposure modelling techniques are available, ranging from simple statistical regression and mass-balance approaches, to more complex multizone and computational fluid dynamics tools that have correspondingly large input data requirements. This review demonstrates that there remain challenges which limit the applicability of current models to health impact assessment. However, these issues also present opportunities for better integration of indoor exposure modelling and epidemiology in the future. The final part of the review describes the application of indoor exposure models to health impact assessments, given current knowledge and data, and makes recommendations aimed at improving model predictions in the future.

Reducing asthma disparities by addressing environmental inequities: a case study of regional asthma management and prevention's advocacy efforts

Regional Asthma Management and Prevention describes its collaborative approach to address a social determinant of health--air quality--and the associated inequities that have led to asthma disparities impacting African American and Latino communities in the San Francisco Bay Area. The strategies, aimed at decreasing diesel pollution in disproportionately impacted communities, span the levels of the socioecological model, with an emphasis on policy outcomes. Regional Asthma Management and Prevention describes how this work fits within a larger comprehensive approach to address asthma disparities encompassing several components, ranging from clinical management to environmental protection.

Mind the gap

BACKGROUND

Recent analysis has demonstrated a remarkably consistent, nonlinear relationship between estimated inhaled dose of combustion particles measured as PM(2.5) (particulate matter with aerodynamic diameter ≤ 2.5 µm) and cardiovascular disease mortality over several orders of magnitude of dose--from cigarette smoking, environmental tobacco smoke (ETS) exposure, and ambient air pollution exposure.

OBJECTIVES

Here we discuss the implications of this relationship and point out the gaps in our knowledge that it reveals.

DISCUSSION

The nonlinear exposure-response relationship that is revealed-much steeper at lower than at higher doses-explains the seemingly inconsistent risks observed from ambient air pollution and cigarette smoking but also raises important questions about the relative benefits of control at different points along the curve. This analysis also reveals a gap in the evidence base along the dose-response curve between ETS and active smoking, which is the dose range experienced by half the world's population from indoor biomass and coal burning for cooking and heating.

CONCLUSIONS

The shape of the exposure-response relationship implies much larger public health benefits of reductions at the lower end of the dose spectrum (e.g., from reductions in outdoor air pollution) than from reducing the rate of active smoking, which seems counterintuitive and deserving of further study because of its importance for control policies. In addition, given the potential risks and consequent global disease burden, epidemiologic studies are urgently needed to quantify the cardiovascular risks of particulate matter exposures from indoor biomass burning in developing countries, which lie in the dose gap of current evidence.

Public perceptions of climate change as a human health risk: surveys of the United States, Canada and Malta

We used data from nationally representative surveys conducted in the United States, Canada and Malta between 2008 and 2009 to answer three questions: Does the public believe that climate change poses human health risks, and if so, are they seen as current or future risks? Whose health does the public think will be harmed? In what specific ways does the public believe climate change will harm human health? When asked directly about the potential impacts of climate change on health and well-being, a majority of people in all three nations said that it poses significant risks; moreover, about one third of Americans, one half of Canadians, and two-thirds of Maltese said that people are already being harmed. About a third or more of people in the United States and Canada saw themselves (United States, 32%; Canada, 67%), their family (United States, 35%; Canada, 46%), and people in their community (United States, 39%; Canada, 76%) as being vulnerable to at least moderate harm from climate change. About one third of Maltese (31%) said they were most concerned about the risk to themselves and their families. Many Canadians said that the elderly (45%) and children (33%) are at heightened risk of harm, while Americans were more likely to see people in developing countries as being at risk than people in their own nation. When prompted, large numbers of Canadians and Maltese said that climate change can cause respiratory problems (78–91%), heat-related problems (75–84%), cancer (61–90%), and infectious diseases (49–62%). Canadians also named sunburn (79%) and injuries from extreme weather events (73%), and Maltese cited allergies (84%). However, climate change appears to lack salience as a health issue in all three countries: relatively few people answered open-ended questions in a manner that indicated clear top-of-mind associations between climate change and human health risks. We recommend mounting public health communication initiatives that increase the salience of the human health consequences associated with climate change.