The

n e w e ng l a n d j o u r na l

of

m e dic i n e

review article
global health

Globalization, Climate Change,

and Human Health
Anthony J. McMichael, M.B., B.S., Ph.D.

he global scale, interconnectedness, and economic intensity

of contemporary human activity are historically unprecedented,1 as are many
of the consequent environmental and social changes. These global changes
fundamentally influence patterns of human health, international health care, and
public health activities.2 They constitute a syndrome, not a set of separate changes,
that reflects the interrelated pressures, stresses, and tensions arising from an overly large world population, the pervasive and increasingly systemic environmental
impact of many economic activities, urbanization, the spread of consumerism, and
the widening gap between rich and poor both within and between countries.
In recent decades, international connectivity has increased on many fronts, including the flow of information, movements of people, trading patterns, the flow
of capital, regulatory systems, and cultural diffusion. These exponential increases
in demographic, economic, commercial, and environmental indexes have been
labeled the Great Acceleration.3 Remarkably, the resultant environmental effects
are now altering major components of the Earth system.4,5 The current geologic
epoch is being called the Anthropocene (successor to the Holocene epoch)5,6 in
recognition of the global force that Homo sapiens has become, pushing or distorting
Earths great natural global systems beyond boundaries considered to be safe for
continued human social and biologic well-being.4,7 The loss of biodiversity, the
greatly amplified global circulation of bioactive nitrogen compounds, and humaninduced climate change have already reached levels that are apparently unsafe.4
These changes pose fundamental threats to human well-being and health.4,7
For example, a positive relationship has been observed between regional trends
in climate (rising temperatures and declining rainfall) and childhood stunting in
Kenya since 1975, indicating that as projected warming and drying continue
tooccur along with population growth, food yields and nutritional health will be
impaired.8 These human-induced climatic changes often act in concert with environmental, demographic, and social stressors that variously influence regional food
yields, nutrition, and health. Furthermore, at the current level of global connectedness and interdependence, the environmental impact of human activity has a wider
geographic range, although its influence may be offset somewhat by more effective
global alerts and more rapid distribution of food aid. The extreme heat and wildfires in western Russia in the summer of 2010 destroyed one third of that countrys wheat yield, and the subsequent ban on exported grain contributed to a rise
in the price of wheat worldwide, exacerbating hunger in Russia (where flour prices
increased by 20%) and in low-income urban populations in countries such as
Pakistan and Egypt.9,10 On the economic front, the recent global financial crisis
has underscored the domino-like interdependence of national economies.

From the National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia.
Address reprint requests to Dr. McMichael
at the National Centre for Epidemiology
and Population Health, Australian National
University, Canberra, ACT 0200, Australia,
or at [email protected].
N Engl J Med 2013;368:1335-43.
DOI: 10.1056/NEJMra1109341
Copyright 2013 Massachusetts Medical Society.

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Increases in interpopulation connectivity and increases in scale

and intensity of action and impact

Demographic
Changes
Economic Activity
Trade and capital mobility
Labor conditions
Wealth creation and distribution
International aid: financial
and health care

Social Changes
Institutions, governance,
international codes
Cultural diffusion

Impacts on
Population
Health

Large-Scale and Systemic

Environmental Impacts
Degradation of land and water
Depletion of resources
Ecosystem disturbances
Disruption of biogeophysical
systems (e.g., climate
system)

Figure 1. Influence on Human Health of Changes Related to Globalization.

The figure is a schematic representation of the three major domains social,
economic, and environmental within which globalizing processes and
changes are occurring. Shown are their main components, the two-way interactions between them, and the central fact that all three domains influence
the conditions for and levels of population health. In particular, changes in
population size, distribution, mobility, levels and types of economic activity,
and global flows of capital and labor all have consequences for the environment, including the recent rapid increase in greenhouse-gas emissions as
the primary cause of current climate change. Those great contemporary
environmental changes have diverse and far-reaching consequences for
human health.

Effec t s of Gl ob a l i z at ion
on P opul at ion He a lth
Global influences on population health such as
those described above transcend the more specific, focused frame within which international
health issues are addressed.2 The processes of
global change are more systemic, involving disruption or depletion (not merely local pollution).
Remediating or adapting to these changes requires an understanding of dynamic systems,
their complexity and associated uncertainties,
and coordinated policy responses across relevant
sectors. The relationships between these perva1336

m e dic i n e

sive processes of change and human health are

shown in Figure 1.

Globalization and Global Changes

Population growth
Urbanization, increased density
Aging
Increased mobility
Family structures

of

Demographic Changes

Population growth is often overlooked in the discourse on global change, including its relation
to the mitigation (abatement) of climate change,
to which the contribution of global emissions is
obvious.11 The projections by the United Nations
that todays population of 7 billion will increase
to 9.3 billion by 205012 should reactivate the debate about whether we can succeed in pursuing
realistic objectives for a healthy climate without
curtailing the actual number of humans pressing
on the environment. Furthermore, the negativefeedback loop of excessive population pressure
on regional environments (involving soil exhaustion, water depletion, and the loss of various wild
animal and plant food species) not only exacerbates various ongoing worldwide environmental
and ecologic changes but also entrenches conditions of poverty and disadvantage. In these latter
circumstances, fertility rates tend to remain high.
Some additional increase in the world population is inevitable in countries with high fertility rates, given the demographic flywheel momentum of populations weighted toward the young.
Meanwhile, moderate gains have been made in
facilitating education for girls, although progress
in this, as well as in the provision of adequate
education about reproduction and reproductive
choice, remains slow in many low-income countries.13 Where unplanned pregnancy rates remain
high (e.g., Timor-Leste and Nigeria), so do risks
to maternal and child health.
Social Changes and Economic Activity

Many other aspects of globalization influence

population health,2 including the accelerated
emergence of new infectious diseases,14,15 the
near-ubiquitous rise in the rates of obesity and
associated noncommunicable diseases as daily
bodily energy budgets (food energy input vs.
physical energy output) shift into surplus,16 the
spread of cigarette marketing, the effects of climate change,17,18 increases in resistance to antimicrobial agents, and health risks in the workplace due to the deregulation of international
labor markets.2 Looming large in the background
as additional determinants of health are the persistent, even increasing, disparities in wealth,
education, autonomy, and social inclusion.19 There
are, of course, certain aspects of globalization

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Global Health

that are beneficial to health, such as the enhanced flow of information, improvements in
internationally coordinated vaccination programs
and systems to respond to infectious diseases,
and a greater capacity for long-distance responses
to disasters.
Adverse global influences on health, such as
rising food prices and extended ranges of some
infectious diseases, have also impeded attainment of the United Nations Millennium Development Goals.20 Future global health goals must
be better integrated with the fundamental influences of poverty, inequity, illiteracy, climate
change, land-use patterns, and food insecurity
on health. After the Rio+20 Conference (2012),
the Millennium Development Goals are to be
replaced by Sustainable Development Goals in
2016, reflecting the principle set forth at the
original Rio Declaration on Environment and
Development (1992) that concern for humans
must be at the center of sustainable development. Nevertheless, concern for human health is
not yet near that center. This reflects the continuing misperception of what health means and
the dominance of a narrow, clinically based view
that seemingly does not take into account the
fundamental need, in improving population
health, to address the poor fit between environmental and sociocultural conditions and basic
human biologic and psychological needs.
Environmental and Ecologic Changes

The deep-seated, essentially ecologic risks to population health cannot be countered effectively at
the local level alone. Climate change induced by
human activities, for example, is due to the globally aggregated excess of greenhouse emissions.
Primary prevention of health problems arising
from such global environmental and sociodemographic changes therefore requires coordinated
international policy, supplemented by more local
policy-making and action. For example, the World
Trade Organization should give greater priority
to averting the adverse health and environmental
effects of international free trade.21 There is also
a need for instruments similar to the WHO
Framework Convention on Tobacco Control1,22
and the WHO Global Outbreak Alert and Response Network, in relation to the emergence of
infectious diseases,23 as well as the United Nations Environmental Programme Montreal Protocol to protect the ozone layer.24
The following four examples describe other

environmental and ecologic changes on a global

scale that will increasingly influence the worlds
health. First, the probability that new strains of
influenza virus will emerge is increasing, particularly in the rural villages of Southeast Asia and
East Asia.14,25 The risk increases with population
growth; the juxtaposition of traditional backyard
pig, chicken, and duck farming with intensified
commercial poultry production; and environmental changes that affect the flight paths of migrating wild birds.
Second, the decline in available seafood protein (which is important for many low-income
coastal populations) is a threat to health and
reflects the unprecedented combination of ocean
warming, acidification (due to increased uptake
of carbon dioxide), deoxygenation,26 destruction
of coastal fish nurseries, and overfishing.27
Third, diverse health risks are posed by the
deprivation, displacement, and conflict that result from shortages of fresh water.8,28 Many
populations, such as those in Bangladesh, Vietnam, Egypt, and Iraq, live downstream on great
rivers that traverse several countries. In many
cases, river flows are threatened by the loss of
glacier mass and snowpack due to global warming and by the increased diversion of flow by
neighbors upstream.
Finally, the need to maintain food supplies
and adequate nutrition for the increasing world
population presents a major challenge.29 Global
food production also faces pressures as a result
of reduced yield due to land degradation, water
shortages, and climate change and the rising
demand for animal foods among middle-income
populations. Furthermore, agriculture (especially
livestock production) accounts for around one
fourth of global greenhouse-gas emissions.30
Thus, there are growing pressures to transform
food production (e.g., more mixed cropping and
inclusion of acceptable genetically modified
crops), distribution, and consumption. Since the
environmental, particularly climatic, effects of
producing red meat from methane-producing
ruminants (e.g., cattle, sheep, and goats) are so
great, thought needs to be given to the question
of whether production of this protein source will
need to be curtailed while allowing a sufficient increase to ensure safe childhood nutrition
in the many poorer populations, which currently
consume levels of red meat that are lower than
those in the overconsuming rich populations by
a factor of 10.30 The global food security issue is

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further complicated by the ongoing land grab in

eastern Africa and elsewhere by richer countries
seeking investment opportunities and self-insurance against future land, food, and biofuel shortages (e.g., Middle Eastern oil-producing states,
China, and South Korea).31
These four examples also confirm that, in a
world of global and systemic changes, these individual changes for the most part do not impinge
on population health in isolation; instead, they
typically act jointly and often interact. Specific
examples are discussed in the next section, which
reviews the health risks posed by climate change.

Gl ob a l Cl im ate Ch a nge

An interactive
graphic showing
global temperature
trends is available
at NEJM.org

Global climate change is part of the larger Anthropocene syndrome of human-induced global environmental changes. These include land degradation, ocean acidification, and disruptions and
depletions of the stratospheric ozone concentration, soil fertility, fresh-water resources, biodiversity stocks and ecosystem functioning, and global
nitrogen and phosphorus cycles.4 Greenhouse
emissions from fossil fuelbased power generation and transport and from the agriculture and
mining sectors increase the heat-retaining capacity of the lower atmosphere, resulting in global
warming (see the interactive graphic at NEJM
.org). In addition, deforestation and ocean saturation have added to greenhouse warming by reducing the capacity of terrestrial and marine environments to absorb extra carbon dioxide (the
main greenhouse gas) from the atmosphere. Also
contributing to such warming are any ongoing
natural variations in climate caused by cosmologic and geologic influences.32

Table 1. Categories of Climate-Change Risks to Health, According to Causal

Pathway.
Risk Category

Causal Pathway

Primary

Direct biologic consequences of heat waves, extreme weather

events, and temperature-enhanced levels of urban air
pollutants

Secondary

Risks mediated by changes in biophysically and ecologically

based processes and systems, particularly food yields, water
flows, infectious-disease vectors, and (for zoonotic diseases)
intermediate-host ecology

Tertiary

More diffuse effects (e.g., mental health problems in failing

farm communities, displaced groups, disadvantaged
indigenous and minority ethnic groups)
Consequences of tension and conflict owing to climate change
related declines in basic resources (water, food, timber, living
space)

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Most of the global warming since 1950 (an

increase of 0.7C) has been the result of human
activity.32 Annual global emissions of carbon dioxide have increased over the past decade, as have
the rates of sea-level rise, the loss of Arctic sea ice,
and the number of extreme weather events.33
Without substantial and prompt international action to abate these emissions, average global temperatures (relative to the year 2000) are likely to
rise by 1 to 2C by 2050 and by 3 to 4C by 2100,
including increases of up to 6 to 7C at high
northern latitudes.33,34 Additional warming of another 0.7C is locked in from the extra radiative
energy already absorbed by the lower atmosphere
and, in turn, by the oceans, though not yet manifested as surface warming. An average rise of 4C
would return Earths temperature to a level not
experienced for 10 million to 20 million years.35
Rainfall patterns will also change, with rainfall increasing in some regions and seasons and
decreasing in others. Modeling consistently pro
jects an increase in regional aridity, and in the
geographic range and severity of droughts, during this century.36 The frequency, and perhaps
intensity, of extreme weather events is also expected to increase in most regions and may
well have already begun to do so.37

Effec t s of Cl im ate Ch a nge

on Hum a n He a lth
The complex nature of climate change and its
environmental and social manifestations results
in diverse risks to human health.17,18,38 A threeway classification of these risks and causal pathways is shown in Table 1.39
Our current, rather skewed knowledge of
climatehealth relationships has come from epidemiologic studies of health risks in relation to
differences and extremes in temperature and
from quasicyclical climatic events such as the
El NioSouthern Oscillation phenomenon. However, most of the health risks will arise from
climatic influences on environmental systems
and social conditions that affect food yields,
water supplies, the stability of infectious disease
patterns, and the integrity of natural and humanbuilt protection against natural disasters (including forest cover, windbreaks, mangroves,
vulnerable constructed seawalls, and urban waterdrainage systems) and from the adverse health
consequences of social disruption, displacement
of communities, and conflict situations.18,38

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Global Health

Key examples of these types of causal paths

are shown in Figure 2. Many of the indirect effects of climate change will be simultaneously
influenced by other global changes and socio
demographic pressures that act in conjunction
with climate change. Food yields and, hence,
nutritional status reflect changes not only in

climate40 but also in water supplies, soil fertility,

nitrogen levels, biodiversity (e.g., pollinators and
pest predators), and the health and vitality of
farm workers.
It is not surprising that the health effects of
climate change will be predominantly adverse.38
After all, human biology, domesticated food

Climate Change
Changes in mean climatic conditions
Increased variability, including extreme weather events
and heat waves

Other systemic environmental

changes acting and interacting
with climate change

Primary Environmental and Social Impacts

Direct Health Impacts

Loss of Jobs,
Livelihoods
Glacier
loss, sealevel rise

Shortages,
Price
Changes

Altered
surface
water

Reduced
food
yields

Fresh
water
availability

Food
prices and
availability

Ecosystem
damage

Tourism
and
recreation

Property
loss

Microbial
ecology
(host
animals,
vectors,
pathogen
multiplication)

Infrastructure
damage

Injury, death,
postevent
traumatic
stress and
disease risk

Physical
hazards, risk
of death

Indirect Health Impacts

Hygiene,
homegrown
food

Conflicts,
displacement

Nutrition;
child development
(and lifecourse adult
health)

Community
and family
morale;
mental
health
problems

Infectiousdisease
risks

Depression
after event

Relocation
of people

Figure 2. Processes and Pathways through Which Climate Change Influences Human Health.
The direct health impacts of climate change are shown in the upper right part of the figure, most of them due to amplified extreme
weather events. All the other, less direct health impacts, shown in the lower part of the figure, are mediated by the primary environmental and social impacts of climate change. These include the five categories of indirect health impacts and the tertiary effects on health
and survival that arise from more diffuse disruptions, dislocations, and conflicts, which are likely to increase in future decades and are
indicated by upward-pointing arrows.

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sources, and culture in general have evolved over

many millennia within the usual prevailing climate. Furthermore, populations everywhere will
be vulnerable to increasingly severe extreme
weather events.
Some beneficial health effects are expected to
occur, at least in the earlier stages of climate
change.38 In some temperate zones, milder winters may lead to fewer wintertime deaths from
myocardial infarction and stroke, and in some
low-latitude regions, hotter and drier conditions
may reduce mosquito survival and, hence, mosquito-borne infection.
Populations living in diverse social, economic,
and physical conditions will be affected differently by climate changes.18,38 Low-income and
remote populations are more vulnerable to physical hazards, undernutrition, diarrheal and other
infectious diseases, and the health consequences
of displacement. Populations on low-lying islands
and in coastal areas, such as Bangladesh, are
vulnerable to increased storm surges and flooding as the sea level rises. In Arctic circumpolar
regions, communities may undergo enforced
changes in diet as land and marine animal
populations migrate or decline and as access to
traditional food sources becomes physically more
difficult.41
The likely future effects of climate change on
various health outcomes have been modeled with
the use of plausible scenarios of future climate
change that have been agreed on internationally.
For example, in temperate countries, as summers
become hotter and heat waves more severe,
modeling indicates that, from around mid-century, additional heat-related deaths will progresTable 2. Indicators of Early Health Effects of Climate Change.
Increases in annual numbers of deaths and hospitalizations due to extreme heat, observed in a range of
high-income and low-income countries
Increases in rates of injuries and deaths due to the rising
frequency of weather disasters in many regions
Extensions in the geographic range of several vector-borne
infectious diseases or their vectors, including tickborne encephalitis in Sweden, the tick vector of Lyme
disease in eastern Canada, and malaria in the western
Kenyan highlands
Although less certain, increases in the tempo of coastal
outbreaks of cholera relative to the warming of
coastal waters and El Nio events
Increases in the price of some staple foods, especially in
vulnerable, food-insecure regions, leading to nutritional deprivation in low-income households

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sively overwhelm the number of deaths averted

as a result of milder winters.42,43 Such estimates
of the extreme effects of weather will improve as
the modeling of changes in climatic variability
under climate-change conditions improves and
as researchers take better account of physiological, behavioral, and technological adaptation by
populations over time.
In China, the modeling of medium-scenario
warming indicates that the transmission zone of
freshwater snailmediated schistosomiasis will
extend northward, putting another 20 million
people at risk by 2050.44 Such model-based estimation of the direction and approximate extent of
likely change in health risks is an important resource for decision-making about both climatechange abatement and localized adaptation.
Meanwhile, an important research task is to
identify ongoing changes in health risks and
outcomes that can be reasonably attributed to
recent climate change. Given the multivariate
causation of most human health outcomes, attribution is rarely simple.45 Nevertheless, over the
past decade, observed changes in some health
outcomes, viewed collectively, suggest a climate
signal (Table 2).18,38,46

He a lth R isk s a nd Benefi t s

of Cl im ate- Ch a nge Mi t ig at ion
a nd A da p tat ion
The mitigation of climate change is a crucial
first-order task for the world. However, while
governments continue to wrestle with this unprecedented, complex political and ethical task,
the more immediate challenge for the health sector is to identify the main regional health threats
posed by climate change and ensure the development of risk-lessening adaptations.
Adaptation Strategies

Adaptation capacities and strategies will differ

greatly among populations. They will be particularly important where the rates of preexisting
disease (e.g., childhood diarrhea and malnutrition) are already high and therefore, in absolute
terms, would become considerably higher because of the multiplier effects of climate change.
Effective adaptive strategies will mostly require
collaboration among diverse government sectors,
research disciplines, and communities.
During heat waves, deaths and hospitalizations predominate among the elderly, patients

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Global Health

with chronic cardiorespiratory disease, and persons living in low-grade housing. Early heat
wavewarning systems, community caregiver
schemes for vulnerable persons, well-insulated
housing, and educational advice from primary
health care providers would lower this risk. Meanwhile, longer-term planning is needed to climateproof urban residential areas.47
Health Benefits of Climate-Change Mitigation

environment-related technologies will help to

replace indoor-polluting cooking fuels with lowcarbon fuels, and improvements in reproductive
literacy will lead to fewer, better-spaced pregnancies; both types of improvement reduce pressures on the climate system.11 All these actions
will directly reduce well-known risk factors for
disease and premature death (e.g., air pollution,
sedentary living, and dietary excesses).48 Innovative urban design can have wide-ranging positive
effects with regard to energy use, greenhousegas emissions, the effects of urban heat islands,
patterns of physical activity, social relations, and
community cohesion.

One favorable aspect of efforts to mitigate climate

change is that local health gains will quickly accrue to populations that undertake such efforts.48
Awareness of this potential health dividend in
addition to the longer-term global health benefits
should strengthen support for such actions.
Ch a l l enge s for the He a lth
Health benefits will result from mitigating acSec t or
tions that address modes of transport, housingdesign standards, energy generation, and agri- The health sector has important roles to play in
cultural systems (including livestock production). relation to climate-change abatement and adapIn many poor populations, improvements in tation strategies for lessening unavoidable risks
Table 3. Role of the Health Sector in Climate-Change Mitigation (Primary Prevention) and Adaptation (Preparedness,
or Secondary Prevention).*
Goal and Generic Action

Suggested Strategies

Mitigation of climate change

Carry out health impact assessment of mitigation strategies

Conduct epidemiologic research to estimate and document changes

in health outcomes that result directly from mitigation actions

Limit the carbon (and other environmental)

footprint related to the health care system

Design buildings, transport services, and facilities to achieve energy

efficiency, in terms of energy sources and use, and to minimize
waste

Enlist health professional organizations and

government health departments

Educate the public about risks to health from climate change and
explain that mitigating actions can confer additional, local health
benefits

Include physicians and other health care

workers as citizens

Participate in wider public discussion and moderate personal behaviors

Adaptation to lessen health risks

Provide adequate health care facilities and
services

Improve facilities for handling increased patient volume resulting from

extreme weather events and ensure adequate stocks of vaccine

Anticipate necessary surge capacity (e.g., for

major heat waves, fires, epidemics)

Coordinate with emergency-services agencies and ambulance facilities

and consider morgue capacity

Reinforce and extend public health programs

to provide a foundation for dealing with
most types of climate-related health effects

Develop early-warning systems (e.g., for heat waves, floods, and

possible epidemics); programs for infectious-disease surveillance
and analysis, vaccination, and vector control (e.g., mosquitoes,
ticks); support for vulnerable communities; and mental health
services (e.g., for postevent trauma and depression)

Educate and train the health workforce

Develop programs that prepare health care workers to contribute to

public education and to be on the alert for unexpected diagnoses

Engage in broader collaboration with other

sectors

Institute policies for creating green spaces in cities (to promote

physical and mental health); develop housing design and insulation to optimize health protection; consider livestock and wild
animals as possible risks for infection

* The listed adaptation activities are intended to reduce health risks on the local and regional levels.

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to health (Table 3).49,50 Such strategies would include the greening of health care institutions
and participation in national health impact assessments and in intersectoral planning of sustainable energy systems, transportation, and urban design. National delegations to international
policymaking meetings that address global
trends and threats (e.g., the annual conferences
convened under the United Nations Framework
Convention on Climate Change) should include
representatives from, or at least substantive briefing by, the formal health sector.

C onclusions
Rapid globalization has brought new, large-scale
influences to bear on patterns of human health.
Various global-scale changes economic, social,
demographic, and environmental (particularly
climatic) are linked, for example, to the increased prevalence of obesity, changes in regional

of

m e dic i n e

food yields, the emergence of infectious diseases,

the spread of cigarette smoking, and the persistence of health disparities.
Undertaking primary prevention at the source
to reduce health risks resulting from these
global influences is a formidable challenge. It
requires conceptual insights beyond the conventional understanding of causation and prevention,
as well as political will, trust, and resources. The
complexities of policies to mitigate human-
induced climate change are clear. Meanwhile,
additional resources and strategies will be needed to reduce the health risks related to global
change that have already arisen or are now unavoidable. For populations to live sustainably
and with good long-term health, the health sector must work with other sectors in reshaping
how human societies plan, build, move, produce,
consume, share, and generate energy.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.

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