"Climate change: a driver for change also in healthcare services"

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

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 nave Relation between CC and Health might be confusing.

CC and public healthCurrent 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).

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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.

Impact of CC on Health (1)

Climate change and health: on the latest IPCC report - Alistair Woodward et Al. Main impacts of CC:UndernutritionVB DiseasesOccupational HealthMental health/violenceExtreme weather eventsAir quality (household air pollution=3rd RF of GBD in 2010)Food/water borne infectionsHeat waves

Until mid-century, projected climate change will impact human health mainly by exacerbating health problems that already exist (very high confidence). Throughout the 21st century, climate change is expected to lead to increases in ill-health in many regions and especially in developing countries with low income, as compared to a baseline without climate change (high confidence). Examples include greater likelihood of injury, disease, and death due to more intense heat waves and fires (very high confidence); increased likelihood of under-nutrition resulting from diminished food production in poor regions (high confidence); risks from lost work capacity and reduced labor productivity in vulnerable populations; and increased risks from food- and water-borne diseases (very high confidence) and vector-borne diseases (medium confidence). Positive effects are expected to include modest reductions in cold-related mortality and morbidity in some areas due to fewer cold extremes (low confidence), geographical shifts in food production (medium confidence), and reduced capacity of vectors to transmit some diseases. But globally over the 21st century, the magnitude and severity of negative impacts are projected to increasingly outweigh positive impacts (high confidence). The most effective vulnerability reduction measures for health in the near term are programs that implement and improve basic public health measures such as provision of clean water and sanitation, secure essential health care including vaccination and child health services, increase capacity for disaster preparedness and response, and alleviate poverty (very high confidence). By 2100 for the high-emission scenario RCP8.5, the combination of high temperature and humidity in some areas for parts of the year is projected to compromise normal human activities, including growing food or working outdoors (high confidence)5

Impact of CC on Health (2)

Health Services (HS): basic ingredientsMaking 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, maintenanceProcedures: efficiency, evidence-based, quality of care, people-centred and integrated health servicesAvailability of treatment/Drugs: adequate prescription/delivery; continuing supply; quality;

Health Services deliveryAdequate 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.

Impact of CC on HCSDisruption 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:TrainingDiagnosis toolsGeographical distribution of providersInaccessibility 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)

Contribution of Health Services to CC management (1): leading by exampleMitigating 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 meansAdvocating for UHC, poverty reduction, multisectoral approach.

Contribution of Health Services to CC management (2): Health promotionPromoting health while mitigating CC= co-benefits to Health and Climatehealth 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.

Contribution of Health Services to CC management (3): Health educationSupporting 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;

Contribution of Health Services to CC management (4): data managementRecording/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.

Example of available climate warning: ENSO

El Nio Southern Oscillation, drought/precipitations -> health consequences (VBD, water supply and WBD).

Clinician ReportsPublic Health Emergency services

Data fromPublic Health SurveillanceNon- Health sector response to crisisLaboratory ReportsMedical Care Surge HospitalReportsPharmacy Sales DataFirst Responder DataRisk AssessmentRisk AssessmentLives Saved Bio-Preparedness (Resilience) Epidemiologic ControlQuarantine ResponseInformationCoordination & ControlRisk Communication InformationCoordination & ControlRisk Communication SurveillanceOutbreak InvestigationCourtesy of Pr. Rodney Hoff

Vet reportsFoodborne investigationsCoronerAbsenteeismdetector15

Wheel of Health Resilience

Prevent Mitigate Respond RecoverTransform

Adapted from Pr. Rodney Hoff

The global strategy: back to Alma-AtaPrimary 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.

Health services response to CC in practiceHealth Care Workers: Aware, committed, resilient.Continuously informed and trainedFacilities: 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:

ADB, Climate Change, and HealthADB: 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 ThreatADB Operational Plan for Health 2015-2020.

ConclusionsCC 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 paceHealth Services: take the lead and walk the talkHealth Services Health sector Other sectorsImpact 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.

On Airs, Waters and Places, Part 1Whoever 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. (?)

ReferencesIPCC, 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.

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