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CONTEMPO UPDATES CLINICIAN’S CORNER LINKING EVIDENCE AND EXPERIENCE Health Effects of Climate Change Andy Haines, MD, MBBS Jonathan A. Patz, MD, MPHH

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Health Effects of Climate Change - CA Clean Cars

CONTEMPO UPDATES CLINICIAN’S CORNER LINKING EVIDENCE AND EXPERIENCE Health Effects of Climate Change Andy Haines, MD, MBBS Jonathan A. Patz, MD, MPHH

CONTEMPO UPDATES CLINICIAN’S CORNER

LINKING EVIDENCE AND EXPERIENCE

Health Effects of Climate Change

Andy Haines, MD, MBBS celerated global warming because of the through a range of mechanisms, physi-
positive feedbacks of the carbon cycle ological, behavioral, technological, but
Jonathan A. Patz, MD, MPH (eg, methane released from thawing arc- it is not yet clear how much such pro-
tic tundra). The probability of these cesses will diminish the adverse effects
HUMANS ARE NOW MAKING UN- events may be very low but is likely to of climate change. The extent to which
precedented changes to the be affected by the speed and duration increases in heat-related mortality will be
global environment. Eco- of climate change. The potential path- offset by reductions in cold-related mor-
nomic development has been ways by which climate change may tality is likely to vary by location.
fostered by the use of fossil fuels but the affect health are shown in the FIGURE.2
accompanying accumulation of green- Floods and Droughts
house gases, particularly carbon diox- Thermal Stress
ide and methane, has implications for the Populations in developing countries are
world’s climate (BOX).1 Since the 1850s Major increases in the frequency of heat likely to be particularly vulnerable to
when temperature records began, the waves with climate change may occur. floods because of the habitation of high-
world has warmed by approximately For example in England, the heat wave risk areas, such as flood plains and coastal
0.6°C, largely in the last 3 decades. The of 1976 was a very rare event (occur- zones, weak public health infrastruc-
United Nations Intergovernmental Panel ring once every 310 years) that will ture, and proportionally higher eco-
on Climate Change (IPCC) projects an probably occur every 5 to 6 years by nomic damage. The health impacts in-
increase of between 1.8°C and 5.8°C and 2050.3 The urban heat island effect re- clude physical injury and increases in
an increase in sea levels between 9 and sults in the temperatures being some- diarrheal diseases, particularly in devel-
88 cm during the next century.1 Warm- what higher in cities than in suburban oping countries where malnutrition may
ing is likely to be greater at the poles than and rural areas, primarily because of the also increase. Increased incidence of res-
at the equator. The residence time in the abundance of heat-retaining surfaces piratory infections may be caused by
atmosphere of carbon dioxide exceeds such as concrete and black asphalt. In crowding of populations. Overgrowth of
100 years; therefore, our actions affect 1995, the week-long heat wave in Chi- molds may also cause respiratory symp-
the prospects of future generations. cago, Ill, caused more than 700 heat- toms. Increases in psychiatric disor-
related deaths.4 Much of the excess mor- ders, such as anxiety and depression, of-
The IPCC concluded, “There is now tality from heat waves is related to ten occur, probably related to damage to
good evidence that regional changes in cardiovascular, cerebrovascular, and the home environment and economic
climate, particularly increases in tem- respiratory disease and is concen- losses. Increases in suicide have been re-
perature, have already affected a di- trated in elderly persons and individu- ported and behavioral disorders may in-
verse set of physical and biological sys- als with preexisting illness. A propor- crease in children.8 An increase in sea lev-
tems in many parts of the world.”1 tion of these deaths occur in susceptible els would pose even added risks to coastal
Earlier break-up of ice on rivers and people who are likely to have died in communities.
lakes and movements of plant and ani- the near future but there also may be
mal ranges to higher altitudes are some substantial numbers of potentially pre- Drought may have an impact on
examples. There is also potential for ventable deaths. The thousands who health in developing countries be-
large-scale and potentially irreversible died in the recent European heat wave
changes in Earth systems, such as slow- show current failings in dealing with Author Affiliations: London School of Hygiene and
ing of the ocean circulation that trans- this threat.5 Tropical Medicine, London, England (Dr Haines); De-
ports warm water to the North Atlan- partment of Environmental Health Sciences, Johns Hop-
tic, large-scale melting of the Greenland In the United States, cities with cooler kins Bloomberg School of Public Health, Baltimore, Md
and west Antarctic ice sheets, and ac- climates tend to experience more heat- (Dr Patz).
related deaths than those with warmer Corresponding Author and Reprints: Jonathan A. Patz,
CME available online at climates6,7 because populations can ac- MD, MPH, Department of Environmental Health Sci-
www.jama.com climatize to some extent to different lev- ences, Johns Hopkins School of Hygiene and Public
els of temperature. Acclimatization is Health, 615 N Wolfe St, Baltimore, MD 21205 (e-mail:
[email protected]).
Contempo Updates Section Editor: Sarah Pressman
Lovinger, MD, Fishbein Fellow.

©2004 American Medical Association. All rights reserved. (Reprinted) JAMA, January 7, 2004—Vol 291, No. 1 99

HEALTH EFFECTS OF GLOBAL WARMING

Box. Projected Changes During the 21st Century in Extreme Air Pollution
Climate Phenomena and Their Likelihood*
The impact of some air pollutants on
Simple Extremes health appears to be stronger during
summer months or during high tem-
Higher maximum temperatures; more hot days and heat waves† over nearly all peratures,11 but this is not a universal
land areas (very likely‡) finding. Ozone levels tend to be higher
at higher temperatures and some stud-
Higher (increasing) minimum temperatures; fewer cold days, frost days, and cold ies have suggested that ozone contrib-
waves† over nearly all land areas (very likely‡) utes to the excess mortality observed.12

More intense precipitation events (very likely‡ over many areas) Climate change is likely to affect the
risk of forest fires, which in some lo-
Complex Extremes cations (eg, Malaysia and Brazil) have
been associated with the increased risk
Increased summer drying over most mid-latitude continental interiors and asso- of outpatient visits for respiratory dis-
ciated risk of drought (likely‡) ease. An increase in emergency depart-
ment visits for asthma, bronchitis, and
Increase in tropical cyclone peak wind intensities, mean and peak precipitation chest pain occurred after the 1998 wild-
intensities (likely‡ over some areas)§ fires in Florida.13

Intensified droughts and floods associated with El Nin˜ o events in many different Allergens
regions (likely‡)
Warmer winters may result in an earlier
Increased Asian summer monsoon precipitation variability (likely‡) start of the grass pollen season, and birch
Increased intensity of mid-latitude storms (little agreement between current mod- pollen concentrations may also increase.
Also, rising carbon dioxide has been
els)† shown to increase the timing and release
of biogenic allergens (eg, ragweed) in
*Adapted with permission from Houghton et al.1 Likelihood refers to judgmental estimates both indoor and in situ studies.14 Cli-
of confidence used by the Intergovernmental Panel on Climate Change (IPCC) Working Group mate change may thus increase the inci-
1 in its Third Assessment Report. dence of allergic rhinitis, the intensity and
†Information from the IPCC Working Group 1, Technical Summary.1 duration of symptoms, or both.11
‡Summary for policy makers: very likely (90%-99% chance); likely (66%-89% chance).
§Changes in regional distribution of tropical cyclones are possible but have not been estab- Infectious Diseases
lished.
Changes in temperature, humidity,
cause of its adverse effects on food pro- east Asia, Indonesia, and southern rainfall, and sea level rise could all affect
duction and in hygiene because of use Africa, whereas flooding may occur in the incidence of infectious diseases.
of water primarily for cooking rather the southwest United States, Argen- Mosquitoes, ticks, and fleas are sensi-
than cleaning. Outbreaks of malaria can tina, and Kenya. tive to subtle temperature and humid-
also occur during droughts as a result ity changes. But vector-borne diseases
of changes in vector breeding sites. There have been a number of time se- are also dependent on many other in-
ries analyses during more than 1 event teracting factors. Although there has
El Nin˜ o and Health that suggest a range of impacts of the El been a resurgence of infectious dis-
Nin˜ o cycle on health.9 The most consis- eases in recent years, it is unclear that
El Nin˜ o events have probably oc- tent relationships are with malaria epi- climate change has played a signifi-
curred for millennia. The name arises demics in parts of Latin America and cant role. Other factors such as the
from the observation that warm water South Asia. The effects may be medi- movement of human and animal popu-
appears off the coast of Peru and Ec- ated by short-term atypical climatic con- lations, the breakdown in public health
uador, most noticeably around Christ- ditions (eg, rainfall in arid regions and infrastructure, changes in land use, and
mas (El Nin˜ o thus refers to the infant drought in more humid climates). The the emergence of drug resistance have
Jesus). On an irregular basis between incidence of many other diseases, such been contributory.15
every 2 and 7 years, the warming is as dengue, hantavirus infections, chol-
anomalous and persists for 12 to 18 era, and Murray Valley encephalitis, may The TABLE illustrates the potential im-
months. It may be followed by a cold be influenced by El Nin˜ o, although the pacts of climate change on vector-
phase called La Nin˜ a. El Nin˜ o events quality of the evidence is variable.9 borne and rodent-borne disease trans-
are consistently associated with heavy mission, focusing on malaria and
rainfall and flooding on the west coast There is a relationship between the dengue.11 Malaria is currently present in
of Latin America but in addition have El Nin˜ o phenomenon and the popula- 101 countries, and 40% of the world’s
important distant linkages with cli- tion affected by natural disasters, par-
mate in other parts of the world; this ticularly droughts, on a global scale.10
occurs because altered convection loops It is not fully known how the El Nin˜ o
at the equator change weather pat- phenomenon will be affected by cli-
terns. For example, during El Nin˜ o mate change, but the IPCC has sug-
years, drought usually occurs in South- gested that associated droughts and
floods will be intensified (Box).

100 JAMA, January 7, 2004—Vol 291, No. 1 (Reprinted) ©2004 American Medical Association. All rights reserved.

HEALTH EFFECTS OF GLOBAL WARMING

population lives in areas with malaria.16 This represents a 2% to 4% increase in veys and represents findings follow-
Malaria claims 1 to 2 million lives an- the number of people at risk of malaria. ing extensive analysis.20
nually, most of which are those of chil-
dren. In Africa, distribution of the dis- Use of a statistical empirical ap- Climate change may contribute to the
ease is largely limited by climate, except proach suggested no significant net resurgence of malaria in areas where the
at the southern limit.17 In many parts of change by 2080 in the proportion of the public health infrastructure has bro-
the world, effective public health sys- world’s population living in actual ma- ken down (eg, in central Asia and
tems ensure that malaria transmission re- laria transmission zones.19 But this ap- southern parts of the former Soviet
mains well within the climatic limits of proach may not capture potential cli- Union). In regions where malaria has
its distribution.17 mate change effects on the seasonality been locally eliminated but the vec-
of malaria in areas where transmis- tors persist, there is a theoretical but
There are different approaches to mod- sion already occurs. small risk of localized outbreaks that
eling malaria risk with climate change, could increase under climate change.
including biological models building Using the latest climate change sce-
from known disease transmission dy- narios, recent modeling experiments This is a topic of intense controversy
namics and statistical empirical ap- suggest a 5% to 7% potential increase and our understanding will continue to
proaches based on malaria’s current epi- in malaria distribution in Africa by evolve as new research is conducted.
demiology. A study using a biological 2100, primarily expanding malaria’s al-
model suggested, based on specific cli- titudinal reach rather than latitudinal. Dengue Fever and
mate scenarios, that there might be a An overall increase in person-months Other Arboviruses
global increase of 260 to 320 million of exposure risk to malaria was 16% to
people in 2080 living in a potential trans- 28%, largely because of a prolonged The rate of dengue virus replication in
mission zone, against a baseline popu- transmission season. This most recent Aedes aegypti mosquitoes increases di-
lation expectation of about 8 billion.18 study used data that were spatiotem- rectly with temperature in the labora-
porally validated against parasite sur- tory. Biologically based models have been
developed to explore the influence of

Figure. Potential Health Effects of Climate Variability and Change

Natural and Climate Variability Regional and Local Changes in Intermediate Factors Adverse Health Effects
Human Influences and Change Weather Change Air Pollution Concentration Heat-Related Illnesses
Extreme Weather and Distribution and Deaths
on Climate Temperature Pollen Production
Precipitation Extreme Weather–
Mitigation Policies Microbial Contamination Related Health Effects
Change in and Transmission
Sea Level Air Pollution–
Crop Yield Related Health Effects

Coastal Flooding Allergic Diseases
Coastal Aquifer Salinity
Infectious Diseases
Water- and
Food-Borne Diseases
Vector- and
Rodent-Borne Diseases

Malnutrition

Storm Surge-Related
Drowning and Injuries

Health Problems of
Displaced Populations

Moderating Influences and
Adaptation Measures

Mitigation Policies for Reduction Moderating Influences Adaptation Measures
of Greenhouse Gas Emissions Population Density and Growth Vaccination Programs
Level of Technological Development Disease Surveillance
Energy Efficiency Standard of Living and Local Environmental Condition Protective Technologies
Use of Renewable Energy Sources Preexisting Health Status Weather Forecasting and Warning Systems
Forest Preservation Quality and Access to Health Care Emergency Management and Disaster Preparedness
Public Health Infrastructure Public Health Education and Prevention
Legislation and Administration

Adapted from Patz et al.2 Schematic of pathways through which climate change can affect multiple health outcomes. Examples are also given of moderating factors
and adaptive measures determining extent of adverse outcomes, as well as mitigating measures to prevent global warming.

©2004 American Medical Association. All rights reserved. (Reprinted) JAMA, January 7, 2004—Vol 291, No. 1 101

HEALTH EFFECTS OF GLOBAL WARMING

projected temperature change on the in- vector but decrease the range of an- Rodent-Borne Diseases
cidence of dengue fever. When linked to other.11 Climate change could in-
future climate change projections, such crease the geographical distribution of The emergence of hantavirus pulmo-
models suggest that relatively small in- vectors in parts of Latin America and nary syndrome in the southwest United
creases in temperature in temperate re- in southwest Asia. States in 1993 may be linked to drought
gions, given viral introduction into a sus- followed by El Nin˜ o–driven heavy rain-
ceptible human population, should Tick-Borne Diseases fall resulting in growth in rodent popu-
increase the potential for epidemics.21 lations and subsequent disease transmis-
There has been considerable interest in sion.26 Extreme flooding or hurricanes
Epidemics of certain arboviral (mos- the potential impact of climate change can lead to outbreaks of leptospirosis. An
quito-borne) encephalitides, such as on a number of tick-borne diseases, par- epidemic of leptospirosis in Nicaragua
Saint Louis encephalitis virus, and West ticularly Lyme disease, Rocky Moun- followed heavy flooding in 1995. In a
Nile virus may be influenced by cli- tain spotted fever, and tick-borne en- case-control study, a 15-fold risk of dis-
matic factors. Both have been associ- cephalitis. Temperature and humidity ease was associated with walking through
ated with drought conditions22 and are important determinants of tick dis- flood waters.27
when West Nile virus appeared in the tribution. In Sweden, the extension of
United States in the summer of 1999, the northern limit of the distribution Water-Related Diseases
the July temperatures in New York were of the local tick vector23 and increased
the hottest on record. Outbreaks have cases have been attributed to milder Worldwide more than 1 billion people
also occurred in the Middle East and winters. A statistical model of tick- lack access to safe drinking water.28 Mod-
in eastern Europe following droughts. borne encephalitis in Europe sug- eling of impacts of climate change on wa-
gested that although disease foci could ter stress shows considerable variability
Leishmaniasis spread to higher latitudes and alti- between climate scenarios. Increased wa-
tudes, the disease could largely disap- ter stress is likely to occur in countries
Leishmaniasis has become an impor- pear from central Europe because cli- of southern and west Africa and in the
tant coinfection with human immuno- mate change would disrupt the complex Middle East. It is difficult however to re-
deficiency virus in southern Europe and life cycle of the tick.24 However, land late this directly to the attributable risk
parts of Asia. There may be differ- use change, in addition to the burgeon- of water-related diseases, although wa-
ences between vectors in susceptibil- ing deer population in the eastern ter scarcity may result in the use of more
ity to climate change. For example, a United States, may be responsible for contaminated sources of fresh water be-
study in Italy suggested that climate the increased risk of Lyme disease.25 cause of combined use (same source for
change could expand a range of one drinking, bathing, and irrigation). If in-

Table. Potential Range of Effects of Climate on Vector-Borne and Rodent-Borne Disease Transmission*

Climate Factor Vector Pathogen Vertebrate Host and Rodents
Warmer winters favor rodent survival
Increases in temperature Decreased survival (eg, Culex tarsalis) Increased rates of extrinsic
Change in susceptibility to some pathogens; incubation in vector Decreased food availability can
reduce populations
seasonal effects Extended transmission season
Increased population growth Expanded distribution Rodents may be more likely to move
Increased feeding rate to combat dehydration, into housing areas, increasing
human contact
therefore increased vector-human contact
Expanded distribution seasonally and spatially Increased food availability and
population size
Decreases in precipitation Increase in container-breeding mosquitoes No effect
because of increased water storage Risk of contamination of flood
waters or runoff with pathogens
Increased abundance for vectors that breed in from rodents or their excrement
dried-up river beds (eg, Leptospira from rat urine)

Prolonged droughts could reduce or eliminate No effect
snail populations

Increases in precipitation Increased rain increases quality and quantity Little evidence of direct effects
of larval habitat and vector population size Some data on humidity effect on

Excess rain can eliminate habitat by flooding malarial parasite development
Increased humidity increases vector survival in Anopheline mosquito host
Persistent flooding may increase potential

snail habitats downstream

Increase in precipitation Heavy rainfall events can synchronize vector No effect
extremes host-seeking and virus transmission

Sea-level rise Coastal flooding affects vector abundance for No effect
mosquitoes that breed in brackish water
(eg, Anopheles subpictus and Anopheles
sundaicus malaria vectors in Asia)

*Adapted with permission from McMichael et al.11

102 JAMA, January 7, 2004—Vol 291, No. 1 (Reprinted) ©2004 American Medical Association. All rights reserved.

HEALTH EFFECTS OF GLOBAL WARMING

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©2004 American Medical Association. All rights reserved. (Reprinted) JAMA, January 7, 2004—Vol 291, No. 1 103


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