Health services must take an active part in the fight against climate change, in becoming more resilient, more aware and leading by example.

1. "Climate change: a driver for
(faster) change also for
health services"
Dr. Jean-Jacques BERNATAS (jbernatas@adb.org)
Asian Development Bank
Trilateral Scientific Meeting: Climate Change, Big Data Management and Health
Bogor, Indonesia - 28 October 2015.

2. Climate Change and Health:
Why it is becoming a concern?
• Human beings are selfish …
 CC comes on top of the development
agenda because it represents theoretically
a direct threat to human lives.
• Human beings are naïve …
 Relation between CC and Health
might be confusing.

3. CC and public health
• Current impact of CC is not obvious at global level, except (?) spectacular
consequences of extreme weather events (typhoon, tsunami);
• “Climate-related hazards exacerbate other stressors, often with negative
outcomes for livelihoods, especially for people living in poverty” (IPCC, 5th
Assessment report, 2014)
• Clues at local level: Lyme disease, DF and CHIKV extension, heat waves
(France and Europe, 2003; China …..), but could be observation biases:
• Extreme complexity and uncertainty: interactions with other determinants
of health;
• There might be positive impact of CC on health (↓ morbidity/lethality by
cold; geographical shifts in food production, and reduced capacity of
vectors to transmit some diseases …), but negative impacts of CC should
overweigh the positive.
• CC is likely to exacerbate the impact of social determinants of health and to
widen the gap of health inequities, at least until mid-21st century (IPCC, 5th
Assessment Report, 2014).

4. Other Determinants of Health
and CC
Schematic diagram of pathways by which climate change affects health, and
concurrent direct-acting and modifying (conditioning) influences of environmental,
social and health-system factors. In: Human health. Climate Change 2007: Impacts, Adaptation
and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the
Intergovernmental Panel on Climate Change, Confalonieri, U., et Al.

5. Impact of CC on Health (1)
Climate change and health: on the latest IPCC report - Alistair Woodward et Al.
Main impacts of CC:
• Undernutrition
• VB Diseases
• Occupational
Health
• Mental
health/violence
• Extreme weather
events
• Air quality
(household air
pollution=3rd RF of
GBD in 2010)
• Food/water
borne infections
• Heat waves

6. Impact of CC on Health (2)

7. Health Services (HS): basic
ingredients
• “Making” health (preventive/curative)
requires:
– Health Care Workers: ratio to target
population, adequate training, migration,
repartition (rural vs. urban)
– Facilities: adequate repartition according to
level of care;
– Equipment: adequacy to the need, maintenance
– Procedures: efficiency, evidence-based, quality
of care, people-centred and integrated health
services
– Availability of treatment/Drugs: adequate
prescription/delivery; continuing supply; quality;

8. Health Services delivery
• Adequate and sustainable financing: out-of
pocket share vs. Universal Health Coverage;
private vs. public;
• Public Health policy: based on a vision of Health
as a universal public good Vs. good following
market law/ supply&demand; planning,
implementation, monitoring, enforcement,
supervision, control;
• Accessibility (geographical, financial, social,
cultural) to health services is crucial.
• Sustainable development in health services
delivery is key.

9. Impact of CC on HCS
• Disruption of HCS service delivery:
– Facilities affected (destruction, supply of energy);
– Procurement: disruption of supply chain (imported items); deficit of
maintenance;
– Lack of HR4H due to migration of HCW;
– Budget becoming insufficient for necessary equipment;
– Surge in medical care: immediate and collateral impacts on HCS.
• Inadequacy of HCS in regards with changing needs:
– Training
– Diagnosis tools
– Geographical distribution of providers
• Inaccessibility of HCS:
– Geographical: mobility of population and HCW on different scales of
time and place. Costal populations/long term; displaced population due
to extreme weather events/short term (and repeatedly).
– Financial /Social/cultural CC increase vulnerability of the poor by
lowering incomes, and limiting access to HCF (f.e.: displaced population
to different social or religious environment)

10. Contribution of Health Services to
CC management (1): leading by
example
• Mitigating its own carbon footprint, GHG emission,
production of water and air pollutants:
– Access to clean, high-efficiency and renewable source of energy;
– Sustainable management: sustainable and eco-responsible
supply chain management;
– Eco-construction; healthier and climate-resilient buildings;
– Sustainable management of effluents.
• Increasing resilience of Health system to CC-induced
constrains:
– Unforeseeable (?) natural disaster: preparedness.
– Progressive change in disease burden and patterns: knowledge
management, continuing education, adequacy of means
• Advocating for UHC, poverty reduction, multisectoral
approach.

11. Contribution of Health Services to
CC management (2): Health
promotion
• Promoting health while mitigating CC= co-benefits to Health
and Climate
– “health gains from strategies that are directed primarily at
climate change and mitigation of climate change from well-
chosen policies for health advancement”.
– reducing local emissions of health-damaging and climate-altering
air pollutants in shifting to cleaner energy sources;
– Transport changes favoring public transport, walking, and
cycling;
– Short-term strategy, at community level;
– Multiple direct impacts on health: respiratory diseases, traffic
accidents, cardiovascular diseases.
• Requires cross-sectoral approach (urbanism, transport,
agriculture, education, …) at local/national/global level.

12. Contribution of Health Services to
CC management (3): Health
education
• Supporting communities to adapt to climate
change impacts = resilience strengthening:
– Health education to emerging risks (ComDis, heat
waves, exposure to pollution);
– (Re-)Education to basic hygiene: hands hygiene,
access and use of safe water, waste
management at individual and community level;
– Diseases prevention: improve vaccination
coverage, prevention of NCD in promoting healthy
nutrition and physical activity;

13. Contribution of Health Services to CC
management (4): data management
• “Recording/reporting/analysis/utilization” of data
and “monitoring/evaluation” in the era of internet
and in a connected world:
– Geolocalization, data collection and transfer
capabilities at community level and in health care
facilities;
– Mobile technology (mobile health/e-Health) is
opening a new era in Health management;
– Generation of big data: by whom and what for?
– Useful real-time disease modelling at the right
scale of observation, where the right action is to be
taken urgently. Ex.: early warning system for health
surveillance extended to climate data collection.

14. Example of available climate
warning: ENSO
El Niño Southern Oscillation, drought/precipitations -> health consequences
(VBD, water supply and WBD).

15. Clinician
Reports
Public
Health Emergency
services
Data
from
Public
Health
Surveilla
nce
Non- Health
sector
response to
crisis
Laboratory
Reports
Medical
Care
Surge
Hospital
Reports
Pharmacy
Sales Data
First
Responder
Data
Risk
Assessment
Risk
Assessment
Lives
Saved
Bio-
Preparedness
(Resilience)
Epidemiologic
Control
Quarantine
Response Information
Coordination
& Control
Risk
Communication
Information
Coordination
& Control
Risk Communication
Surveillance
Outbreak
Investigation
Courtesy of Pr. Rodney Hoff

16. Wheel of Health
Resilience
Prevent Mitigate Respond Recover Transform
Adapted from Pr. Rodney Hoff

17. The global strategy: back to
Alma-Ata
• Primary Health Care – Alma Ata, September 1978:
“Primary health care: … includes at least:
– Health education on methods of preventing and
controlling diseases;
– promotion of food supply and proper nutrition;
– adequate supply of safe water and basic sanitation;
– maternal and child health care, including family planning;
– immunization against the major infectious diseases;
– prevention and control of locally endemic diseases;
– appropriate treatment of common diseases and injuries;
and provision of essential drugs.”
• All provision of services aiming at strengthening resilience
at community level.

18. Health services response to CC
in practice
• Health Care Workers:
– Aware, committed, resilient.
– Continuously informed and trained
• Facilities:
– resilient to CC-related catastrophic events;
– environmentally sustainable construction (material, power supply, GHG
emission control, …)
• Equipment: accessibility and adequacy to the need. Short chain
supply. Low environmental impact technologies. E-Health.
• Procedures: Revision and improvement to respond to the risks
posed by climate change. Assessment of negative secondary impact
on health;
• Availability of treatment/Drugs: adequate prescription/delivery;
adaptation to CC. Ex. Drug supply management in extreme heat.
• Adequate and sustainable financing: out-of pocket share vs.
Universal Health Coverage; private vs. public; PPP.
• From Public Health to Global Health policy:

19. ADB, Climate Change, and
Health
• ADB: a major player in fight against CC
in Asia-Pacific region.
• Assessment of the ADB on CC in Asia-
Pacific region.
• ADB, Nordic Development Fund Help
GMS Counter Climate Change Health
Threat
• ADB Operational Plan for Health 2015-
2020.

20. Conclusions
• CC is not everything for health, but is everywhere in the
future.
• The overall risks of climate change impacts can be reduced by
limiting the rate and magnitude of climate change:
– CC pushes Health Services to change/adapt at a faster pace
– Health Services: take the lead and “walk the talk”
– Health Services  Health sector  Other sectors
• Impact of the remaining unavoidable risk:
– resilience strengthening = vulnerability and poverty reduction
 narrow the health inequity gap.
– primary care service delivery improvement, quality and
accessibility.
• Particularly relevant in Asia-Pacific region;
• Hippocrates mentioned the relevancy of an environmental
approach of health in “On Airs, Waters and Places”, basis of
CC impact on health as a chapter of Global health.

21. “On Airs, Waters and Places”,
Part 1
“Whoever wishes to investigate medicine properly, should proceed
thus: in the first place to consider the seasons of the year, and
what effects each of them produces for they are not at all alike,
but differ much from themselves in regard to their changes. Then
the winds, the hot and the cold, especially such as are common
to all countries, and then such as are peculiar to each locality.
We must also consider the qualities of the waters, (…) whether
they be marshy and soft, or hard, and running from elevated and
rocky situations, and then if saltish and unfit for cooking …
and the ground, whether it be naked and deficient in water, or
wooded and well watered, and whether it lies in a hollow, confined
situation, or is elevated and cold; and the mode in which the
inhabitants live …”
Hippocrates, 460 B.C.-370 B.C. (?)

22. References
• IPCC, 2014: Summary for policymakers. In: Climate Change 2014: Impacts, Adaptation, and
Vulnerability.Part A: Global and Sectoral Aspects. Contribution of Working Group II to the
Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Field, C.B., V.R.
Barros, D.J. Dokken, K.J. Mach, M.D. Mastrandrea, T.E. Bilir, M. Chatterjee, K.L. Ebi, Y.O. Estrada, R.C.
Genova, B. Girma, E.S. Kissel, A.N. Levy, S. MacCracken, P.R. Mastrandrea, and L.L. White (eds.)].
Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 1-32.
• Climate change and health: on the latest IPCC report - Alistair Woodward, Kirk R Smith, Diarmid
Campbell-Lendrum, Dave D Chadee, Yasushi Honda, Qiyong Liu, Jane Olwoch, Boris Revich, Rainer
Sauerborn, Zoë Chafe, Ulisses Confalonieri, Andy Haines - The Lancet Volume 383, Issue 9924, pages
1185-1189 (April 2014) DOI: 10.1016/S0140-6736(14)60576-6
• A comparative risk assessment of burden of disease and injury attributable to 67 risk factors
and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global
Burden of Disease Study 2010 Lim, Stephen S et al. The Lancet , Volume 380 , Issue 9859 , 2224 -
2260
• Human health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of
Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on
Climate Change, Confalonieri, U., B. Menne, R. Akhtar, K.L. Ebi, M. Hauengue, R.S. Kovats, B. Revich
and A. Woodward, 2007: M.L. Parry, O.F. Canziani, J.P. Palutikof, P.J. van der Linden and C.E. Hanson,
Eds., Cambridge University Press, Cambridge, UK, 391-431.
• Conference on Health and Climate Change 27 – 29 August 2014, Geneva, Switzerland. Conference
Report
• Spatial analysis of the effect of the 2010 heat wave on stroke mortality in Nanjing, China. Chen, Kai et
Al. Nature. Scientific Reports. 2015/06/02/online. 5;10816. Macmillan Publishers Limited.
http://dx.doi.org/10.1038/srep10816 (accessed at
http://www.nature.com/articles/srep10816#supplementary-information on 10 October 2015)