Human Health

environment
Human health
& Global c l i m a t e c h a n g e
A Rev ie w o f Po te nt ia l I mpa c ts in th e U ni t ed St ate s

+
John M . Bal bus

T H E G E OR G E WA S H I N G T O N
UN IVE R S I T Y
Mark L. Wil son

T H E U N IV E R S I T Y OF M I C H I GAN
+
Contents
Foreword ii
Executive Summary iii
I. Introduction 1
II. Status and Determinants of Health 4
A. Current Status of Health in the United States 4
B. Global Health 6
C. Main Determinants of Human Health 7
D. Environmental Trends in the United States 8
III. Discussion of Health Impacts of Climate Change in the United States 10

A. Direct Health Effects 12
B. Indirect Health Effects 15
IV. Strengths and Limitations of the Current State of Knowledge 26

26
A. Issues Related to the Quality of the Scientific Literature
B. Lack of Baseline Data on Human Disease Incidence 27
C. Few Studies of Climate and Disease Interactions 28
D. Future Climate Change and Variability 28
E. Validity of Comparing Different Regions to Approximate Future Climate Changes 28 +
F. Future Steps 29
V. Gaps in Current Assessments 31
A. Consideration of Cross-Sectoral Political and Economic Impacts 31
B. Psychological Effects 32
C. International and Intranational Conflict and War 32
VI. Research Needs in Climate Change and Health 33
A. Enhanced, Systematic, Long-Term Monitoring and Surveillance 33
B. Ecologically Based Research and Evaluation 34 +
C. Multidisciplinary Perspectives and New Analytic Techniques 34
D. Planning that Integrates Health Concerns into Economic Development 35
VII. Conclusions 36
Endnotes 39
References 40
i
Human health and global climate change +
Foreword Eileen Claussen, President, Pew Center on Global Climate Change
At the dawn of the twenty-first century, the population of the United States as a whole is one of the
healthiest in the world. The socioeconomic development of the last century and a half both allowed for a
vast improvement in sanitation and nutrition, and provided resources for the development and
maintenance of a generally effective public health system. While current health concerns in this country
revolve largely around lifestyle factors such as diet, alcohol use, and physical inactivity, climate change
raises the possibility that environmental factors — including higher temperatures and increased occur-
rence of infectious diseases — could become a growing problem.
“Human Health and Global Climate Change” is the sixth in a series of Pew Center reports evalu-
ating the potential impacts of climate change on the U.S. environment and society. The report finds that,
in general, the United States should have sufficient resources to limit climate change impacts on human
health over this century. At the same time, because the linkages between climate and human health are
often complex and not well defined, it is difficult to predict exactly how climate change will impact human
health in the United States. Nevertheless, there are some important findings worthy of our attention:
• Higher temperatures are likely to negatively affect health by exacerbating air pollution and
increasing the occurrence of heat waves. The elderly, infirm, and poor are most at risk because
+ these conditions can exacerbate pre-existing disease. Lack of access to air conditioning
increases the risk of heat-related illness.
• While there is some indication that changing climatic conditions may increase the risk of
vector- and water-borne diseases, sanitation and public health system infrastructures in the
United States should prevent these diseases from becoming widespread. To prevent such out-
breaks, it is vital that we take steps to maintain and strengthen these infrastructures, including
increased surveillance and vector control. At the same time, global health impacts from infec-
tious diseases will almost certainly be greater, as many countries lack either the resources
and/or infrastructures to protect their populations.
+ • Uncertainty about adverse health effects should not be interpreted as certainty of no adverse
health effects. Moreover, the potential for unexpected events — e.g., sudden changes in cli-
mate or the emergence of new diseases — cannot be ruled out.
The authors and the Pew Center gratefully acknowledge Drs. Kris Ebi, Duane Gubler, and
Jonathan Patz for their review of previous drafts of this report. This report also benefited from
comments received at the Pew Center’s July 2000 Workshop on the Environmental Impacts of Climate
Change. The Pew Center would also like to thank Joel Smith and Brian Hurd of Stratus Consulting for
ii their management of this Environmental Impacts Series.
+ Human health and global climate change

Executive Summary
The population of the United States is among the healthiest in the world, although there are dis-
parities in life expectancy, infant mortality, and other indices of health among different groups within the
U.S. population. The main determinants of disease-related mortality in the United States today are
lifestyle factors — tobacco use, alcohol use, dietary intake of calories and fats, sexual behavior, and phys-
ical inactivity. The national level of economic and social development in this country has generally provid-
ed resources to address critical health determinants such as nutrition, sanitation, and housing quality. In
addition, the United States devotes a large amount of resources to health care and maintains a relatively
effective public health infrastructure.
This report on the effects of climate change on human health in the United States finds that the
complexity of the pathways by which climate affects health represents a major obstacle to predicting how,
when, where, and to what extent global climate change may influence human well-being. Some linkages
are strong and clearly defined, whereas other important connections are made difficult to define by being
variable, region-specific, or mediated through multiple intervening steps. +

Mortality from heat waves has been predicted to increase under most scenarios of climate
change. The degree to which heat-related mortality rates increase will be determined by the ability to
implement early warning systems and other interventions that focus on at-risk populations, as well as by
the frequency of extreme heat waves and the changes in daytime temperature variation under future cli-
mate regimes. It is less clear whether warmer winter temperatures will result in a significant decline in
wintertime mortality from cardiovascular disease.
If extreme precipitation events become more frequent, and sanitation and water-treatment infra-
+
structure is not maintained or improved, an increase in water-borne infections may result. People are also
at risk of injury or death from exposure to extreme climate events such as floods, hurricanes, and torna-
does. The public health burden of such events, however, partly depends on the ability to anticipate them,
and the education and emergency response planning that may reduce impacts. In addition, current cli-
mate models are not able to confidently predict the future frequency of such events, although there has
been a trend toward heavier precipitation events during the twentieth century. iii
Global climate change may affect human respiratory health by changing levels of air pollutants
and pollens. For the United States, impacts of climate change on tropospheric, i.e., ground-level, ozone
are both more certain and likely to be more important than impacts on other air pollutants. This is due to
the importance of temperature in the formation of ozone as well as the large areas of the country currently
affected by ozone levels exceeding national standards. Nonetheless, to date, no published studies have
modeled the health impacts in the United States due to climate change effects on air pollutants.
In the United States, improved housing, sanitation, and public health interventions have controlled
most of the infectious disease risks that are felt to be most climate sensitive (e.g., dengue, malaria,
cholera). Of greatest concern are insect vector-borne infections that may increase as the result of changing
climate. However, the multiple determinants of vector-borne disease risk and the complexity of transmission
dynamics make estimating future patterns of disease difficult. In addition to climate, the risk of many
vector-borne diseases is linked to lifestyle, hygiene, housing construction, trash removal, and a host of
other socially- and economically-based factors. Thus, infectious disease risk may increase or decrease
with climate change, depending upon the interplay of the above factors within a specific region.
For the United States, the success of public health interventions in eradicating malaria and other
vector-borne diseases early in the twentieth century underscores the importance of continued public
+ health surveillance and prevention in protecting the U.S. population from any climate-induced enhance-
ment in vector-borne disease transmission. Maintenance and strengthening of public health infrastructure,
especially surveillance and vector control, will be critical to preventing significant outbreaks in the future.
Inclusion of public health and climate change experts in planning regarding land-use and utility
infrastructure will also help assure maximal protection of public health during this upcoming period of
climate change.
It is critical to keep in mind that uncertainty regarding adverse health outcomes is not the same
+ as the certainty of no adverse outcomes. Given the potential scope and irreversibility of ecosystem
changes and consequent effects on human health and society, traditional public health values would urge
prudent action to prevent such changes. The possibility of relatively sudden but unpredictable conse-
quences further raises the value of climate change mitigation for health concerns.
iv
I. Introduction
The World Health Organization (WHO) defines health as “… a state of
complete physical, mental, and social well-being and not merely the absence
of disease or infirmity.” The WHO also recognizes that an ensemble of factors contribute to
human health, including biophysical, social, economic, political, and cultural factors. These factors oper-
ate through a diversity of determinants, ranging from individual lifestyles and consumption behaviors,
sexual practices, and psychosocial stressors, to workplace and environmental toxic exposures, population
movements, and health care and public health interventions.
Both the WHO and the U.S. Centers for Disease Control and Prevention (CDC) have recently
expressed concern that global climate change may have major impacts on human health, either by directly
influencing disease patterns, or through indirect pathways involving food production, water distribution, or
international economies. A number of reviews have summarized the evidence for health impacts of climate
change, both globally (Watson et al., 1996; McMichael et al., 1996) and specifically for the United States
(Patz et al., 2000; Smith and Tirpak, 1989). +

Human health may be affected by both the regional climate and the ambient weather. Climate, or
the long-term (decades or longer) average weather conditions in a region, may influence diseases by
determining suitable habitats for disease agents. Weather, or the short-term (minutes to days) condition of
the lower atmosphere, generally affects human health through extremes of temperature, precipitation, or
winds. The term “climate variability” refers to deviations from the average climate for a region over a
period of weeks to years, and includes such phenomena as droughts and the El Niño Southern Oscillation
(ENSO). Scientists frequently use associations of climate variability and human health to infer how cli- +
mate change will affect human health.
The complexity of the pathways by which climate and weather affect health represents a major
obstacle to predicting how, when, where, and to what extent global climate change may influence human
well-being. Health is affected by the availability of adequate and nutritious food, ample potable water,
1
good quality housing, and other conditions of hygiene that also are strongly influenced by forces in the
environment, including the climate. Thus, exposure to infectious agents, immune responses, and extent
of contagiousness may be altered under conditions of global climate change. In addition, people are at
risk of injury or death from exposure to extreme climate events such as floods, hurricanes, tornadoes, and
heat waves. For such exposures, increased frequency or severity of these events under climate change
scenarios could produce direct and measurable impairment of physical and mental health. The magnitude
of such effects, however, depends partly on the ability to anticipate them, and on the education and
emergency response planning that may reduce impacts. In general, the ultimate public health burden
from climate change will be determined by the balance between changes in health stressors due to
climate change and adaptive measures designed to protect populations from those health stressors.
Although climate change is a global issue, this paper primarily addresses the current state of
knowledge of the potential effects of climate change on human health in the United States. These effects
are explained in the context of current trends in health in the United States, as well as non-climate
environmental stressors that may interact with any changes brought about by a changing climate. While
the focus of this paper is on health in the United States, some discussion of climate impacts on health
in other countries is necessary for several reasons. First, the world is increasingly interconnected —
accelerating international travel is a main factor behind the re-emergence of many infectious diseases.
+
Many climate-sensitive diseases (Figure 1) are not wide-
spread in the United States today, nor are they likely to Figure 1
Which Diseases are

become endemic in the near future. For these diseases,
Climate Sensitive?
however, imported cases may become a more significant
threat to U.S. health if climate change increases their High heat stress
effects of storms
air pollution effects
incidence abroad. Second, global interconnections are
asthma
vector-borne diseases
Sensitivity
more than conduits of diseases. Increasing economic and water-borne diseases

food-borne diseases
+ political links to other countries will lead to a sharing of violence
myocardial infarction
tuberculosis
the burdens imposed by health changes around the world.
atherosclerosis
most cancers
Lastly, although climate-sensitive diseases, such as sexually transmitted diseases
Low
malaria and cholera, are not currently prevalent in the
2
United States, they were domestic health concerns as recently as the first half of the twentieth century.
The ability to study and understand how these diseases respond to climate variability, which is crucial to
assessing possible domestic resurgence in a setting of climate change, depends on an understanding of
these diseases in other countries. Thus, the goal of this report is to highlight the potential public health
burden for various kinds of health impacts, and identify which populations would be most at risk. This
report also reviews the quality and quantity of scientific literature supporting inferences about specific
health impacts, noting the relative importance of climate change for each health impact compared to
other factors. While this paper focuses on potential impacts on human health, rather than possible adap-
tations to lessen those impacts, the authors acknowledge that the ultimate effects of climate change on
the health status of the nation will be determined by future changes in society and technology.
3
II. Status and Determinants of Health
A. Current Status of Health in the United States
The population of the United States is among the healthiest in the

world, with a life expectancy that increased from 47 years a century ago to
76.5 years in 1997 (Hoyert et al., 1999). The main causes of death in the United States vary
among the different age groups, with deaths among those over 55 dominating overall mortality (Table 1).
With the exception of unintentional injuries, the five leading causes of death for the population as a
whole are chronic diseases with multiple causes, and are primarily determined by genetic predisposition
and lifestyle factors such as diet and
cigarette smoking. Climate or climate- Table 1
sensitive factors may be linked to Leading Cause of Death

in the United States by Age Group (1996)
exacerbations of these chronic diseases,
Age Group Cause of Death Number of Deaths
as when heat stress or increased air 1-14 Unintentional Injuries 5,580
+ pollutants exacerbate underlying chronic

Malignant Neoplasms
Congenital Anomalies
2,561
1,095
Homicide 934
pulmonary disease, but the impact of Heart Disease 551
15-34 Unintentional Injuries 26,634
climate relative to other factors is likely Homicide 11,976
Suicide 10,219
to be small. Nonetheless, even a small HIV 8,461
Malignant Neoplasms 6,477
influence, if consistent and widespread, 35-54 Malignant Neoplasms 61,676
Heart Disease 48,251
may have a substantial public health Unintentional Injuries 24,113
HIV 19,896
impact given the large burden of the Suicide 11,578
55 and over Heart Disease 679,534
chronic diseases.
Cerebrovascular Disease 150,164
+ Chronic Lung Diseases
Pneumonia and Influenza
101,516
78,592
Current mortality in the United
Whole Population Heart Disease 733,361
States from the diseases most commonly
Cerebrovascular Disease 159,642
Chronic Lung Diseases 106,027
associated with climate change (see Unintentional Injuries 94,948
Box 1) is comparatively small and

Source: Adapted from CDC - National Center for Injury Prevention and Control,
Leading Causes of Death Reports (http://www.cdc.gov/ncipc/osp/data.htm), accessed
includes heat-related deaths and deaths on May 25, 2000.
4
Box 1
What Makes a Human Disease Climate Sensitive?
Most human diseases have numerous causes and determinants of the activity of vector-borne diseases.
determinants (see Section II.C). The effect of changes in Alternatively, climate may exacerbate or influence
climate on any given disease depends on whether climate mortality from a chronic, multifactorial disease, such
is itself an important determinant of the disease, or as chronic obstructive lung disease or coronary artery
whether climate has a strong influence on any of the disease, without having much of an effect on the original
important determinants of the disease. Two examples of causes of the disease. In this case, the stress of
diseases for which climate itself is an important determi- extreme temperatures can lead to exacerbation of the
nant are heat stress and heat stroke. Heat stress and heat diseases, but the original causes of the diseases involve
stroke have relatively few non-climate determinants (see lifestyle factors and genetics, which are not significantly
discussion below), so changes in climate are likely to have influenced by climate.
a significant effect on the occurrence and severity of these Thus, for complex, multifactorial diseases such as
diseases. At the opposite extreme would be a disease such vector-borne infectious diseases and respiratory diseases,
as colon cancer. Colon cancer has a number of determinants, the ultimate impact of climate change will depend not only
including genetics and diet, that are not strongly affected on the extent of regional changes in climate and climate
by changes in climate. Thus, colon cancer would be a variability, but also on changes in the many other factors
disease that would not be considered climate sensitive. involved in the disease. For example, climate-induced
In between heat stress and colon cancer are a number increases in mosquito populations will be much more likely
of diseases caused or influenced by many factors, some of to have an effect on vector-borne diseases if there is a
which are related to climate. In the case of vector-borne coincident increase in pesticide resistance, making vector
infectious diseases, climate factors have a strong impact control more difficult. In general, the more factors
on vector and disease agent reproduction and survival, but involved in the causation of a disease, and the more
less of an impact on vector control measures, vaccines, complex the interrelationships, the more difficult it is to
medical treatments, travel, pesticide resistance, and other predict how sensitive that disease will be to climate change.
+
from vector-borne and water-borne diseases. There were an average of 175 deaths annually from weather-
related heat stress between the years 1979 and 1995 (CDC, 1997b). Reported cases of climate-sensitive
vector-borne and other infectious diseases

Table 2
in the United States are summarized in
Table 2.
Reported Cases of Potentially Climate-
sensitive Diseases in the United States (1997)
While the United States as a whole Vector-borne Diseases Number of reported cases
Malaria 2,001
enjoys excellent health, there are disparities Dengue
Lyme Disease
56 imported; 3 acquired in U.S.
12,801 +
in life expectancy, infant mortality, and Arboviral Encephalitis
La Crosse 127
other indices of health among different St. Louis 13
Eastern Equine 14
groups within the population. Life
Other infectious diseases
expectancy in 1997 ranged from 67.2 Hantavirus 21
Cryptosporidiosis (45 states) 2,566
Cholera 6
years for black males to 79.9 years for
Source: Adapted from CDC (1997a).
5
white females (Hoyert et al., 1999).

Death rates from cardiovascular disease among those 25 to 64 years old were about 2.4 to 2.9 times high-
er in persons earning less than $10,000 annually than in those earning more than $15,000 annually
(National Center for Health Statistics, 1998). It is likely that multiple risk factors for climate-related
health effects will occur together in specific populations. For example, advanced age, underlying pul-
monary disease, and lack of air conditioning at home — all risk factors for heat-related mortality — may
all be present in high frequencies among the urban poor population.
B. Global Health
To more fully understand the current status of health in the United

States, especially with respect to climate-sensitive diseases, it is instructive
to compare the United States to other parts of the world. The current story of global
health is one of contrasts. Whereas chronic, Table 3
noninfectious diseases account for the Leading Causes of Death

vast majority of deaths in the developed in the Developed vs. the Developing World
world, climate-sensitive infectious diseases Developed World Developing World

1. Ischemic heart disease 1. Lower respiratory infections
2. Cerebrovascular disease 2. Ischemic heart disease
are among the leading causes of death in
3. Lower respiratory cancer 3. Cerebrovascular disease
4. Lower respiratory infections 4. Diarrheal diseases
the developing world (Table 3). Worldwide,
5. Chronic obstructive pulmonary disease 5. Conditions arising during
+ life expectancy varies widely, ranging from 6. Colorectal cancer
the perinatal period
6. Tuberculosis
7. Stomach cancer 7. Chronic obstructive
79.7 years in Japan to 40 years in Sierra pulmonary disease
8. Road traffic accidents 8. Measles
Leone in 1995 (WHO, 1996). When the 9. Self-inflicted injuries 9. Malaria
10. Diabetes mellitus 10. Road traffic accidents
burden of disease is measured by disability-
Source: Adapted from Murray and Lopez (1996a), p. 179.
adjusted life years (DALYs) lost (i.e., years
of life lost due to premature death and/or spent living with a disability of specified severity and duration)
instead of absolute mortality, the contrast between causes becomes more apparent. Of the seven leading
causes of DALYs lost in the developing world, five are infectious diseases; conversely, none of the top ten
+ causes of DALYs lost in the developed world are infectious diseases (Murray and Lopez, 1996b). This
difference in disease burden reflects a number of socioeconomic factors relevant to vulnerability to climate
change, as discussed briefly in the next section.
6
C. Main Determinants of Human Health
To understand in a comprehensive fashion how global climate change

may impact human health, one must consider climate change impacts on the
wide range of health determinants. The determinants of human health are traditionally divid-
ed into host (i.e., specific to the individual) and environmental (i.e., external to the individual) factors.
Important host factors include nutrition, age, underlying disease, genetic factors, and immune status.
Environmental factors are many, and include quality of housing, access to sanitary facilities and clean
water, and air and food that are free from chemical contamination. Additional determinants, representing
an interaction of environment and host, could include psychological stress, access to preventive and
curative health services, and behavioral or “lifestyle” choices. Historically, the greatest improvement in
human health in the Western world was seen during the marked period of socioeconomic development
that occurred between the mid-nineteenth and mid-twentieth centuries. This change has been attributed
to improvements in host and environmental factors related to greater wealth, including better nutrition,
improved shelter and decreased urban crowding, improved working conditions, and improvements in sani-
tation (Tyler and Warren, 1998). During this time, premature mortality from infectious diseases such as
tuberculosis, cholera, typhoid fever, and malaria dropped dramatically in the United States. The link
between economic growth and health is evidenced by the fact that changes in per capita national income
+
have accounted for up to 25 percent of improvements in life expectancy (Tyler and Warren, 1998).
The division between environmental and host factors has been helpful in thinking about non-
communicable diseases that do not involve infectious microbes. For infectious diseases, however, a third
category termed “agent” factors is usually considered to represent the added characteristics of the infec-
tious agent (Webber, 1996). These characteristics may include differences in transmissibility, ability to
cause clinical disease, ability to invade specific tissues, and host specificity of various parasite strains.
The main determinants of disease-related mortality in the United States today are lifestyle
+
factors — tobacco use, alcohol use, dietary intake of calories and fats, sexual behavior, and physical
inactivity (National Center for Health Statistics, 1998). The national level of economic and social devel-
opment in this country has generally provided resources to effectively address critical health determinants
such as nutrition, sanitation, and housing quality. In addition, the United States devotes a large amount
of resources to health care and maintains an effective, if not optimal, public health infrastructure.
7
In contrast, the two greatest risk factors for disease in the developing world are malnutrition and
unsafe water (Murray and Lopez, 1996a). Their estimated combined contribution to overall global mortali-
ty in 1990 was 17 percent of all deaths, and for some regions of the world, they account for a far greater
health burden. For example, while malnutrition was insignificant as a cause of death in the Established
Market Economies,1 it caused 32 percent of the deaths in sub-Saharan Africa and more than 18 percent
of all deaths in India. Similarly, poor water quality accounted for far less than 1 percent of the deaths in
the Established Market Economies, but nearly 11 percent of deaths in sub-Saharan Africa and 9 percent
of deaths in India (Murray and Lopez, 1996b). In general, climate change is more likely to have an
impact on areas that currently have difficulty controlling diseases that are felt to be more climate
sensitive, such as vector- and water-borne infectious diseases. Similarly, any possible declines in food
production will have a far greater effect if they occur in parts of the world currently experiencing hunger
and malnutrition. Thus, this contrast in disease determinants suggests that the United States should
be less vulnerable to the health impacts of climate change than much of the developing world.
D. Environmental Trends in the United States
Climate is only one of many factors influenced by humans that affect

the environment and ultimately human health. Contaminants released to air, water,
+ and soil, and alteration of vegetation and other land surfaces have had and continue to have profound
influences on local ecosystems and human health in the United States and worldwide.
Emissions of air pollutants, particularly the six criteria air pollutants,2 have had direct negative
impacts on human health. U.S. outdoor air quality, as measured by monitoring stations, has
generally improved since the late 1960s and early 1970s. Since the Clean Air Act of 1970, the levels of
these six criteria air pollutants have tended to decrease (U.S. EPA, 1996a). Levels of some pollutants,
however, such as the ozone precursor nitrogen dioxide, have not decreased significantly. Forecasts for
emissions of the six criteria air pollutants through 2010 show stabilization at current amounts, except for
+
a 5 to 10 percent increase in particulate matter measuring less than 10 microns (PM10) (U.S. EPA, 1996a).
In contrast to air quality, trends in water quality are harder to ascertain. The most recent U.S.
Environmental Protection Agency (EPA) report on national water quality noted that 36 percent of the
surveyed miles of streams and rivers and 38 percent of the estuarine area surveyed were considered
impaired (U.S. EPA, 1998). The main causes of this impairment were nutrients and bacteria for both
8
types of surface water. Rivers were also impaired by siltation, and estuaries were also impaired by toxic
organic chemicals. Groundwater supplies have not been as thoroughly monitored as surface waters. Most
measurements have focused on chemical pollutants such as nitrates and pesticides, and only three states
reported to the EPA in 1996 about levels of bacteria in groundwater (U.S. EPA, 1998). Nonetheless,
recent studies suggest moderately frequent contamination of groundwater supplies with a variety of
intestinal viruses (Abbaszadegan et al., 1999). The extent of microbial contamination of U.S. water
supplies is a critical factor for determining the impacts of climate change on water-borne infectious
diseases. In addition to quality, though, the quantity of available, clean water for both irrigation and
direct consumption is also essential for maintaining health in the United States.
9
III. Discussion of Health Impacts of Climate Change in the United States
Weather and climate variability (see Box 2) can affect human health
through direct and indirect mechanisms. Direct effects involve mostly physical impacts that
act to cause physiologic stress (e.g., temperature) or bodily injury (e.g., storms, floods). Direct effects
tend to be observed soon after the causative weather event, and are generally more easily modeled and
understood than indirect effects. On the other hand, indirect effects, such as climate impacts on food
supplies and the outbreak of vector-borne diseases, may operate through diverse pathways involving multi-
ple variables. These more complex mechanisms may demonstrate a threshold or nonlinear response to
increasing levels of a climate factor.
The complexity of these health effects leads health impact assessments to focus on partial mech-
anisms — or pieces of the full causal chain — in discussing how climate change may affect human
health. Moving from analyzing these partial mechanisms to being able to predict incidence of human dis-
ease for a specific location is a huge step. One critical question, often unanswerable for a complex sys-
+ tem that links climate to health outcomes, is whether the most significant factors in the causal chain
have been identified, measured, and evaluated. This section attempts to identify the extent to which the
critical factors for a given disease are identified and measurable, the level of confidence regarding how
climate change will affect that disease, and who will most likely be affected. In addition, consideration of
all relevant factors, including actions taken to adapt to climate change impacts, is required to assess cli-
mate vulnerability as opposed to climate sensitivity. A health problem may be climate sensitive if its
severity responds in some way to changes or variation in climate. Whether or not those changes translate
into measurable effects on a population, however, depends on the ability of that population to adapt or oth-
+ erwise protect itself against the increased threat. As an example, heat-associated mortality in New York
City is sensitive to changes in climate. The vulnerability of two separate populations, one in a wealthy
area of Manhattan, for example, and the other in a poor area of the Bronx, will be very different. The
wealthy population is likely to have better access to air conditioning and more of an indoor lifestyle, while
10
Box 2
Climate Variability versus Climate Change
Most observations of the relation between health and Examples of health impacts that are primarily associated
climate are based on climate variability (i.e., short-term with climate variability include respiratory effects from air
variations in patterns of weather and climate). On a day- pollutants and health impacts related to extreme weather
to-day, month-to-month, and even year-to-year basis, cli- events. Heat-related mortality is another example of a
matic conditions change a great deal more than they do health impact that is primarily related to climate variability.
on a decade-to-decade basis, and even more than is Studies of future heat-related mortality in a setting of climate
predicted with greenhouse-gas-induced climate change. change have generally applied predicted mean temperature
Aspects of this short-term variability (such as periods of increases to current patterns of variability. Heat-related
unusual nighttime minimum or daytime maximum temper- mortality is partly related to daytime maximum temperatures
atures, unusually warm summers or snowy winters, or exceeding a physiologic threshold. Thus, applying a fixed
droughts spanning several seasons) are most noticeable to temperature increase to cur rent patterns of variability
the general population, and have most commonly been leads to a higher frequency of days exceeding a given
associated with effects on human health. Longer-term threshold, and therefore greater estimates of heat related
climate change can only be detected by reviewing long- mortality. To the extent that future climate variability on
term data records. In assessing the health impacts of a scale of days to months changes, these estimates will
long-term climate change, a distinction must be made be incorrect. Should climate variability decrease, days
between health effects that are influenced by short-term exceeding a given threshold would also decrease, leading
climate variability and health effects that may be influenced to less of a change in heat-related mortality. On the other
by long-term changes in climate regimes. For example, the hand, should climate variability increase, this increase in
understanding of interactions between temperature and variability combined with an increase in average tempera-
rainfall and specific diseases, such as dengue or Lyme disease, tures would lead to a marked increase in days exceeding
is based on studies done on effects of variable short-term a given threshold. This effect becomes more complicated,
climate in a setting of stable long-term climate. For these though, when one considers the effects of daily variation
vector-borne diseases, the important question is whether, in temperature. Specifically, climate change is expected
in addition to any effects of shorter-term climate variability,
prolonged climate change will alter the abundance and
to warm nighttime temperatures more than daytime tem-
peratures, thus decreasing the daily temperature variation.
+
behaviors of the various animal species that sustain these Since heat-related mortality is also associated with
diseases. Such changes, which may be hard to predict elevated nighttime minimum temperatures, a decrease
due to the unprecedented nature of climate change, may in the daily variability of temperatures could also increase
lead to increases or decreases in disease activity. the risk of heat-related mortality.
the poorer population, particularly the elderly poor, is likely to have less access to air conditioning, and is
therefore more vulnerable to the changes in heat stress. While this section discusses the factors that
account for population vulnerability, a full consideration of all adaptive measures is beyond the scope of
this work. The role of adaptation in responding to climate change will be explored more fully in future
+
Pew Center reports.
11
A. Direct Health Effects
Temperature Extremes, Heat-related Deaths, and Winter Mortality
Well-publicized death tolls from heat waves in 1995, 1998, and 1999 have focused public
attention on the effects of warmer temperatures on human health. During hot weather, perspiration evapo-
rates from the skin, which cools the body and maintains an acceptable body temperature for physiologic
functions. Beyond certain heat extremes, however, the body is unable to cool itself, and the normal bio-
chemical processes that allow life shut down. The precise weather conditions under which the body fails
to maintain normal function, however, vary depending on age, presence of heart or lung disease, ability to
maintain hydration, and other health conditions. In addition, continued exposure to warm temperatures
leads to acclimatization, a physiologic change in the body that allows it to adapt to the increased warmth.
The lethality of a heat wave is enhanced by its occurrence early in the summer (before popula-
tions have had a chance to acclimate), by long duration, and by higher nighttime minimum temperatures
(Ramlow and Kuller, 1990). This last factor is important because increased greenhouse-gas-induced
climate change is expected to have a greater effect on nighttime temperatures, as the heat trapping effect
of the greenhouse gases (GHGs) prevents radiative nighttime cooling of the earth. This climate change
effect will also be exacerbated in cities by the “urban heat island effect,” which involves the nighttime
+ release of heat stored during the day in cement and metal urban materials. Heat-wave-related mortality
is greatest among infants and the very old, especially those with underlying diseases. The highest risk
among these groups is associated with urban isolation and lack of access to air conditioning (Semenza et
al., 1996; Kilbourne et al., 1982).
Kalkstein and Greene (1997) made predictions of heat wave-related mortality for 44 U.S.
cities based on climate scenarios for 2020. Changes in mortality range from an increase of 347 deaths
(181 percent) in Chicago to a decrease of 30 deaths (23 percent) in Philadelphia, depending on the
+ general circulation model (GCM) used. These estimates assume full acclimatization, constant populations,
and no change in availability of air conditioning or housing stock. They also rely on GCMs for their esti-
mates of climate and weather variability. The ability to extrapolate from observations and the directness
of the relation between temperature and human physiology lend a high degree of confidence to estimates
of heat-wave-related mortality. Nonetheless, uncertainty in future climate variability and future trends in
social and technological mitigating factors may render those estimates inaccurate.
12
At the other extreme, overexposure to cold temperatures leads to frostbite and death, as the body
is unable to generate enough heat to maintain normal physiologic functions. Climate change is expected
to increase average winter temperatures in the United States by at least as much as the increase in
average summer temperatures (Wigley, 1999). This raises several critical questions: (1) Does an increase
in average winter temperatures mean a decrease in the severity and/or frequency of episodes of extreme
cold?; (2) Does overall wintertime mortality increase significantly with colder temperatures?; and
(3) Would warmer winter temperatures result in lower overall mortality?
Overall mortality has a clear seasonal pattern, in both temperate and sub-tropical states, with
highest mortality occurring during the winter. Of note, mortality among those under 45 years of age has
the opposite pattern, with a summertime peak of mortality, but this pattern is obscured by the greater
number of deaths among those over 45 years old (Kilbourne, 1998). The peak in wintertime mortality is
due to deaths from a number of causes, including pneumonia, influenza, cardiovascular disease, stroke,
and chronic obstructive pulmonary disease (Kilbourne, 1998). The issue of how climate change will affect
winter mortality is not settled. Some authors have concluded that change in climate is unlikely to affect
the infectious diseases that peak in the winter (e.g., influenza), therefore little improvement in wintertime
mortality is likely with a warming climate (Kalkstein, 1993). One study based on British data concluded
that a substantial decrease in wintertime mortality could occur in a setting of climate change (Langford
+
and Bentham, 1995). Conflicting results have been obtained for studies of the United States.
Martens (1997) focused on the relation between monthly average temperatures and overall mor-
tality, with emphasis on respiratory and cardiovascular disease. His combined analysis of a number of
studies on this issue revealed a consistent decrease, primarily in cardiovascular mortality, with warmer
winter temperatures, and a sharper increase in mostly respiratory mortality with increasing summer tem-
peratures. His modeling of overall changes in mortality under climate change scenarios for the United
States indicated a 5.6 percent decrease in overall mortality in the over-65 population. This overall
decrease was due to the decrease in the rate of cardiovascular mortality with less severe winter tempera-
+
tures. Using a synoptic approach that characterized and grouped entire air masses rather than analyzing
the effects of individual climate variables, Kalkstein and Greene (1997) analyzed the relation between
anticipated changes in climate and wintertime mortality. Their findings suggested a more modest decrease
or even an increase in wintertime mortality by 2020, depending on the GCM model, and showed an
13
overall increase in mortality when summer and winter data were combined. It remains debatable to what
extent warmer winter temperatures may decrease mortality among those with cardiovascular disease even
as mortality from summertime heat waves rises among the very young and the very old.
The ultimate public health burden of changes in temperature extremes, both warm and cold, will
be moderated by a number of factors. The true burden of heat-related mortality could decrease over time
in a setting of climate change should social factors relieve isolation of the urban poor and provide greater
access to cooled environments and should the decrease in cardiovascular mortality with warmer winters prove
to be significant. Alternatively, the burden from heat waves could be greater than predicted if availability
of cooled environments should decrease for any reason. It should be noted that with current air conditioning
technology, creating cooled environments will have high economic and environmental costs, as air condi-
tioners require significant consumption of energy that, in turn, results in more global warming. The true
burden of temperature extremes will also be affected by future climate variability. Sustained warmth will
tend to acclimate a given population to heat stress and lessen cold-induced cardiovascular stress, where-
as more variable and intense temperatures will increase physiologic stress and associated mortality.
Extreme Events
Extreme weather events — severe storms, floods, and hurricanes — have well-documented short-
+ and long-term effects on human health (Noji, 1997). Extensive precipitation producing floods,
avalanches, or mudslides, and intense wind from hurricanes can cause immediate injury and death. Wind,
flooding, or drought can also produce longer lasting and further reaching impacts on housing, food pro-
duction, drinking water, and social infrastructure, which can result in infectious diseases and economic
disruption. For the United States, the health impacts of extreme weather events have been more moder-
ate than for most other parts of the world. Trends in direct mortality from floods, hurricanes, and severe
storms have been sharply downward in the twentieth century, probably due to early warning, evacuations,
+ and improved housing construction standards (Noji, 1997). Most deaths related to recent storms have
been the result of either drownings in motor vehicles or accidental electrocutions.
Populations at risk from extreme weather events include those living in coastal and other vulnera-
ble zones (e.g., flood zones). No published studies have modeled health consequences of extreme events
related to climate change. Studies and surveillance following the severe flooding of North Carolina result-
ing from Hurricane Floyd in September 1999 will give greater insight into this country's vulnerability to
14 extreme events.

Whether climate change will increase the frequency of extreme events in the United States is
quite uncertain. Several authors have suggested an increase in the intensity of Atlantic hurricanes. Such
an increase would be difficult to detect, however, because the changes in hurricanes from year-to-year are
far greater than the expected increase in intensity due to increased GHGs (Wigley, 1999). While midlatitude
storms are capable of affecting large parts of the United States, it is not yet possible to make useful
predictions of their frequency or intensity in a setting of global climate change (Wigley, 1999). On the
other hand, the observation of a trend toward increasing intensity of rainfall during the twentieth century
(Karl et al., 1995) is consistent with predictions of a more active hydrologic cycle in a setting of
increased GHGs. While specific regional impacts are not clear, flooding could become more common and
extreme (Frederick and Gleick, 1999).
B. Indirect Health Effects
Respiratory Health
Global climate change may affect human health by changing levels of air pollutants and pollens.
Climate conditions interact with air pollutants in a variety of ways. For example, air inversions in stagnant
high pressure systems are associated with the highest levels of particulates, ozone, nitrogen oxides (NOX),
and sulfur oxides (SOX), and heat waves are usually marked by high humidity and elevated levels of these
same air pollutants. Warmer weather may enhance dispersion of fungal spores and pollen, which may
+
increase allergic reactions and asthma. At the same time, increased winds and precipitation generally
reduce airborne pollutants, including pollens, through dispersion or adsorption to water droplets.
The ultimate impact of climate on pollen-induced disease is difficult to predict, but will depend
in part on whether local allergenic species increase or decline in response to climate changes. Since the
start of the twentieth century, the length of the growing season has increased in much of the world, and
further increases are likely with continued warming. A longer growing season would lead to greater cumu-
lative exposures to pollens from weeds and grasses that tend to pollinate until the first annual frost. +
Longer-term changes in climate may lead to altered plant distribution and increases or declines in the
numbers of allergen producing species (Emberlin, 1994). Additional factors, including ultraviolet radia-
tion and air pollutant concentration, may change levels of pollen produced by plants or alter the aller-
genicity of pollen grains (e.g., Behrendt et al., 1997).
15
A substantial body of literature documents the health impacts of outdoor air pollutants
(Committee of the Environmental and Occupational Health Assembly of the American Thoracic Society,
1996a and b). For the United States, impacts of climate change on tropospheric (i.e., ground-level)
ozone (commonly referred to as “smog”) are both more certain and likely to be more important than
impacts on other air pollutants given the importance of temperature in the formation of ozone (Walcek
and Yuan, 1997). In addition, greater health significance is imparted by the fact that ozone is the criteria
air pollutant to which the highest numbers of U.S. residents are currently exposed at levels above EPA
standards (U.S. EPA, 1996b). It should be noted that despite a relatively direct impact of temperature on
ozone levels, concurrent changes in wind, precipitation, and cloud cover may moderate the effect
of temperature.
Models have estimated an increase in ground-level ozone for eight U.S. cities of around 2 to
4 percent if temperatures increase 2ºC and stratospheric (i.e., atmospheric) ozone depletion leads to
increased ultraviolet radiation hitting the lower atmosphere (Grey et al., 1987). Thus, to the extent that
higher ambient temperatures lead to a marginal increase in ground-level ozone concentration, a large pro-
portion of the population would be at greater risk. Most affected would be those with underlying respirato-
ry diseases, including asthma. People living in an area susceptible to high ozone levels, such as southern
California or the northeastern and Mid-Atlantic states, would also be most affected. Although the litera-
+
ture on ozone effects in asthmatics is not wholly consistent, substantial data link higher ambient ozone
concentrations to asthma exacerbation. Members of the general population experience mild lung inflam-
mation due to high ozone levels; whether this inflammation leads to permanent lung damage is unclear.
Thus, high temperatures may affect health through mechanisms besides heat alone as susceptibility to
increased ozone concentrations will also affect the morbidity and mortality associated with a heat wave.
Aside from ozone, no published studies to date have modeled the effects of climate change on
air pollution concentrations or the health impacts in the United States due to climate change effects on
+ air pollutants. Lack of knowledge regarding climate impacts on other pollutants makes a comprehensive
assessment of these impacts on human respiratory health highly uncertain.
Lastly, an important question is whether ambient temperatures or other climate factors alter the
toxicity of air pollutants. As an example, might a given concentration of particulates cause more serious
or more frequent adverse health effects at higher temperatures? There is some evidence of an impact of
16
warmer temperatures on the effect of particulates on asthma exacerbation (de Diego et al., 1999) and on
the effect of sulfur dioxides on overall mortality (Katsouyanni et al., 1993). On the other hand, using
data from Philadelphia, Samet et al. (1998) did not find that weather altered the impact of exposure to
particulates or sulfur dioxides on health. Unfortunately, most studies have aimed to prove independent
effects of either weather or air pollution on respiratory health. The authors have analyzed data in such a
way as to control for the effects of weather on respiratory health when studying air pollution, and vice
versa, but not to be able to explicitly report on possible interactive effects. The answer to this question
must therefore await further analysis of the interaction between air quality and climate factors in the
study of respiratory health.
Climate Change and Sea-level Rise
Rising seas accelerated by global warming may adversely affect human health. Sea level is pre-
dicted to rise 0.2 to 0.9 meters by 2100 (Wigley, 1999). This rise in sea level will be experienced both
as a gradual shift in the shoreline and as increasingly severe storm surges and damage from coastal
storms (Neumann et al., 2000). These changes will threaten low-lying regions of the coastal United
States to varying degrees. Because different regions of the United States are already rising or falling
because of movement of the earth’s crust, the actual relative change in sea level will vary in these differ-
ent regions. For example, the Chesapeake Bay area, which is subsiding, is predicted to experience twice +
the average amount of sea-level rise, while the West Coast, which is rising, will experience a smaller than
average sea-level rise (Neumann et al., 2000).
Sea-level rise may affect human health through saltwater intrusion into freshwater drinking sup-
plies, damage to estuarine ecosystems that are essential for filtering wastes and/or providing breeding
grounds for marine animals, and displacement of coastal communities. Higher sea levels may also lead to
greater storm surges and destructive impacts of coastal storms (Neumann et al., 2000).
While sea-level rise may affect health via a wide variety of mechanisms, health impacts of sea- +
level rise in the United States may well be related to economic consequences. It is likely that the United
States will have the economic resources necessary to protect critical coastal sanitary and drinking water
infrastructure. Damage to critical coastal ecosystems, such as wetlands and coral reefs, and erosion of
beaches, will be more difficult to avoid. Estimates for the costs of protecting coastal property have ranged
17
from $20 billion to $150 billion (Neumann et al., 2000). These costs, however, do not fully account for
loss of tourism revenue, loss of income from degraded fishing or shellfishing resources, loss of wetlands,
or investments in drinking water and sanitary infrastructure. Communities in areas experiencing more
severe sea-level rise, such as the Gulf Coast, Mid-Atlantic, and Chesapeake Bay, would also be affected
more than those in areas where sea-level rise is not predicted to be as great. Potential community
impacts such as decreases in income and unemployment are well-associated with poorer health status
(Syme and Balfour, 1998; Sorlie et al., 1995). These indirect impacts have the potential to be greater
than any primary impacts of sea-level rise on human health in this country.
Climate Impacts on Food Supplies
Climate changes associated with increased GHGs will alter agricultural productivity. Decreases in
production may be related to alterations in rainfall patterns and decreased soil moisture, while increases
have been predicted for certain crops because of increases in carbon dioxide and longer growing seasons
(Adams et al., 1999). Significant decreases in agricultural productivity would threaten health should
higher local food costs or unavailability make adequate nutritional intake difficult for any segment of the
population. In the United States, there will be some variability in productivity among the different regions
but overall little change or possibly increased production potential is anticipated in scenarios up to dou-
+ bled carbon dioxide concentrations (Adams et al., 1999). The combined protection of a large land area in
a temperate climate zone, well-developed transportation infrastructure, a strong economic and technologi-
cal base, and access to international trade should minimize any impact of potential regional changes in
food production on nutrition for the United States (Adams et al., 1999).
In addition to concerns about food quantity, climate change has raised concerns about bacterial
contamination of food (Bentham and Langford, 1995). Food-borne infections generally are more common
in the warm summer months, probably due in part to the fact that summertime is when most outdoor eating
+ events take place in the United States, with associated storage of food outside of refrigerators. Higher
ambient temperatures are likely to increase risk of bacterial growth sufficient to cause human infection.
Contamination is not simply a concern for individual outdoor events, however. The growth of a highly
centralized food processing and distributing industry over the past two decades in the United States has
increased the importance of factors that can lead to the contamination of foodstuffs. Once again,
contamination of food is a problem with multiple causal determinants, of which climate is only one.
18
No published studies projecting changes in food-borne illness under climate change scenarios have yet
been published.
Vector-borne Diseases
Because insects and other invertebrates are cold-blooded and heavily dependent on the environ-
ment, climate plays a major role in their behavior, development, and reproduction. In addition, pathogen
development is regulated by temperature. Thus, human diseases that are spread by these invertebrates
may also be more affected by climate change than some other diseases. Vector-borne diseases result from
transmission of infectious agents by arthropod vectors as they feed on human blood. Some vector-borne
diseases such as malaria and dengue fever, termed anthroponoses, may be uniquely human infections in
which an arthropod is able to transmit the microbe to another human only after first acquiring it from a
human. Alternatively, many other vector-borne diseases of humans, termed zoonoses, involve infectious
agents that normally are found primarily in animals, with occasional and accidental transmission to peo-
ple. The animals act as reservoirs for the disease, serving as hosts for the reproduction of disease agents
in between human outbreaks. Should climate change improve longevity, increase reproduction, enhance
biting, or increase the ranges of these vectors, an increase in the number of people infected could result.
Likewise, similar effects on the vertebrate animals that serve as reservoirs for agents associated with han-
taviral diseases (infectious viral pulmonary diseases), leptospirosis (a bacteria disease characterized by +
jaundice and fever), rabies, or vector-borne diseases could also result in greater human risk.
The complex and multiple impacts of climate on the various factors that determine transmission
of vector-borne diseases, however, make it extremely difficult to generalize about the mechanisms, much
less predict in what direction changes may take place. Moreover, predicting climate impacts for zoonoses
generally is more difficult than predictions for anthroponoses because of the involvement of these animal
reservoirs in their transmission dynamics. Forecasts must be based on extrapolations derived from existing
distributions, contemporary environmental tolerances, and current transmission frequencies. The fact that
+
other important variables also are likely to change under various climate-change scenarios further
complicates prediction.
The principal vector-borne diseases currently afflicting people living in the United States are
transmitted either by mosquitoes (e.g., St. Louis encephalitis, equine encephalitis, and La Crosse
19
encephalitis — all viral diseases associated with inflammation of the brain), ticks (e.g., Lyme disease,
Rocky Mountain spotted fever, ehrlichiosis — a bacterial disease characterized by fever and fatigue), or
fleas (plague). Studies have shown that aspects of these vectors’ life cycles, survival, and behavior that
are important to pathogen development or transmission are affected by climate variables, such as higher
temperature, altered precipitation, or changes in wind and solar radiation (Reiter, 1988). Generally, it
appears that mosquitoes are more sensitive than ticks and fleas to such climate variability (Kettle, 1995).
Thus, previous assessments have suggested that climate change may result in certain mosquito-borne
diseases such as St. Louis encephalitis becoming more frequent in areas where they currently are rare
(Reeves et al., 1994). Similarly, it has been proposed that western equine encephalitis may appear after
future heavy precipitation events (Nasci and Moore, 1998). Other studies have characterized how wind
trajectories and flooding can either increase or decrease vector densities or distribution (e.g., Patz and
Lindsay, 1999). Interestingly, the outbreak in New York City during the late summer of 1999 of West
Nile-like viral encephalitis, which is similar to St. Louis encephalitis, was attributable to the summer
drought conditions. Specifically, while it is believed that the West Nile virus was recently introduced into
the United States (Lanciotti et al., 1999), the likely vectors in that setting (certain Culex or Aedes mos-
quitoes) were common to the New York area (Anderson et al., 1999). Because some Culex larvae develop
primarily in stagnant water, summer drought conditions may have allowed water in sewers and unused
+ swimming pools to stagnate, producing ideal conditions for this mosquito, thus increasing transmission of
West Nile virus (Wilgoren, 1999).
Most concern over climate change effects on infectious diseases has focused on the unfamiliar
“foreign” mosquito-borne diseases, such as malaria (caused by Plasmodium parasites), dengue fever, and,
more recently, West Nile virus along the northeastern coast. Dengue fever and malaria may occasionally
be introduced into the United States, but neither is regularly transmitted there. The vast majority of cases
of dengue and malaria among U.S. residents are acquired by tourists visiting countries where these dis-
+ eases are indigenous, and generally do not present a threat to people living within the United States.
West Nile virus, however, appears to have become established after overwintering and reappearing during
the summer and fall of 2000 throughout an increasingly large area of the northeastern United States.
While climate change is predicted to gradually increase the regions of the world where conditions are
suitable to the mosquito vectors, there are already many such suitable regions where these mosquitoes
are present but transmission does not occur. The reasons for this vary depending on conditions, but either
20
the mosquito species that are efficient vectors are not abundant, they rarely are in contact with people, or
the infectious agent is not often present in people. In regions where such diseases are already endemic,
these conditions exist. In the United States, there is reduced mosquito abundance, limited contact with
people, and low infection levels such that mosquitoes’ mere presence is inadequate to allow persistent
transmission. Even the occasional introduction of an infected person is inadequate to provoke a local
epidemic. Thus, even if climatic conditions were to change such that efficient vectors became more
abundant or widespread in the United States, other conditions needed for transmission of these infectious
agents would be required for the disease to appear or become important.
For example, in climatically similar border regions of southern Texas and northern Mexico, locally
acquired dengue occasionally occurs in Texas whereas transmission is usually much more intense in
adjacent areas of Mexico. Despite suitable environmental conditions in Texas for Aedes aegypti, the
mosquito vector, mosquito control and other protective efforts have kept dengue to extremely low levels
there. Similarly, locally-acquired malaria is very rare in the United States because the Anopheles mosquito-
vectors that are present have been kept to low numbers. Furthermore, the Plasmodium parasite is rarely
identified within mosquitoes, and then only when an infected person unintentionally introduces the parasite.
Because of the presence of mosquitoes that are able to act as disease vectors, vector-control
efforts in the United States and public health surveillance will continue to be an important deterrent to +
these diseases, regardless of changes in climate. As long as these control measures remain intact, cli-
mate change is not likely to significantly increase the domestic risk from malaria and dengue. Reduction
of mosquito abundance (e.g., removing breeding sites, spraying, etc.), limitation of feeding on people
(e.g., housing conditions, repellants, etc.), and the regional absence of infected people (i.e., travelers are
vaccinated or given preventative medication) all contribute to reduced risk of introduction. The greater
risk for these diseases among U.S. residents will remain related to travel to areas where Anopheles and
Aedes aegypti mosquitoes are abundant, and disease transmission already occurs.
+
Studies of tick-borne zoonotic diseases such as Lyme disease (see Box 3) or human ehrlichiosis
have demonstrated that incidence and distribution are strongly linked to environmental variables, but the
role that climate change may play in the future epidemiology of transmission is not well understood. Lyme
disease may be linked to differences in tick abundance associated with precipitation and elevation
(Amerasinghe et al., 1992), and is associated with habitat characteristics in a complex manner (Wilson,
1998). However, the role that climate change may play in altering the range and local abundance of Lyme
21
Box 3
Lyme Disease
Lyme disease is a tick vector-borne disease that is scapularis might expand. Curiously, seemingly appropriate
widespread throughout much of the northeastern United elements exist in many areas of the United States where
States, parts of the northern Midwest (especially this tick has not yet become established or widespread.
Wisconsin and Minnesota), and California. In most areas Thus, even where a suitable microclimate is present, large
infested with the vector tick (Ixodes scapularis), the Lyme vertebrates such as white-tailed deer are abundant (per-
disease-causing bacteria (Borrelia burgdorferi) are present mitting adult female ticks to feed and reproduce), and
and, thus, the potential for human infection exists. diverse small mammals are frequently encountered (these
However, transmission depends on many factors, most species serve as hosts to immature ticks), the tick vector
importantly the abundance of ticks, the percentage of may not be present. While it may be just a matter of time,
ticks infected, their survival, the activities of people in at present there is no adequate explanation for this obser-
relation to habitats of ticks, and people’s knowledge and vation. At the same time, this tick currently tolerates cold
awareness concerning tick bites and Lyme disease preven- and generally moist conditions in Minnesota, Maine, and
tion. The range of the vector tick and of Lyme disease parts of southern Canada, suggesting that low winter tem-
cases has been expanding over the past few decades, and peratures are not currently limiting. In fact, tick abun-
the current distributions of the deer tick and of Lyme dance does not correlate with increasing temperatures.
disease in the United States span a wide range of climatic Lastly, while increased precipitation might permit longer
conditions. While the factors that currently limit the distri - survival of unfed ticks, which are highly susceptible to
bution of this vector tick remain poorly understood, desiccation, deer ticks are cur rently found in some regions
research suggests that microclimate, abundant hosts, and with average precipitation that is less than that forecasted
suitable vegetation and soil habitat are important. under climate change scenarios.
One concern is that since present climate patterns Thus, while some have speculated that climate
influence the distribution of deer ticks, climate change change might increase the rate of spread of this disease or
might permit wider or more rapid expansion of this tick’s shift the areas that are susceptible, various factors other
range. Most climate change scenarios indicate that some than climate appear to be primarily responsible for risk of
+ regions of the United States may become warmer and this vector-borne disease.
moister, leading to speculation that the range of Ixodes
disease vector ticks (principally Ixodes scapularis) is speculative. The same holds for other tick species
that serve as vectors of certain Ehrlichia parasites that cause febrile disease in humans (Vail and Smith,
1998; Lindsay, et al., 1999). Again, climate assessments generally have interpreted these observations
cautiously, suggesting that climate change may alter the distribution or local incidence of human ehrli-
chiosis if tick abundance, survival, or feeding behavior were to be modified. Rocky Mountain spotted
+ fever, caused by a bacterium that is transmitted by particular species of Dermacentor ticks, is yet another
tick-borne disease that might be altered if changes in tick abundance result. Nevertheless, studies of this
possibility are not able to go beyond suggestion and speculation.
Of flea-borne zoonotic diseases, plague (the “Black Death” of history) is still a concern in regions
of the United States where flea-infested mammals are abundant (Campbell and Dennis, 1998). During
the past few decades, most human cases have occurred in northern New Mexico, northern Arizona, and
22
southern Colorado, in addition to other cases in California, southern Oregon, and far western Nevada
(Gage, 1998). Because vertebrate reservoir abundance and survival is a major determinant of flea move-
ment to humans and other hosts, the role of climate in the spread of plague beyond its normal reservoir
hosts is unclear. While climate change may alter the abundance and interactions of host and vector, little
concrete evidence is available to indicate that human health risks will be significantly changed.
Overall, most assessments examining studies of climate impacts on vector-borne diseases cur-
rently found in the United States have not been able to make strong, definitive statements about how pro-
jected climate change may impact health (e.g., Patz et al., 2000). Not only are the observations few and
the links sometimes weak, but just as other intervening variables are typically not considered, neither is
pathogen evolution or adaptation to new and existing environments (e.g., Reiter, 1996).
Water-borne Diseases
Several mechanisms have been proposed to link climate and climate variability to water-borne
infectious diseases, generally in association with specific infectious agents. Climate factors (ambient tem-
perature and rainfall) are among various factors affecting survival and replication of bacteria and viruses
in the general environment. Warmer temperatures tend to improve survival of bacteria and may facilitate
the transmission of certain water-borne illnesses, while many viruses persist for longer times in colder
temperatures. A growing body of evidence shows that the cholera bacterium, Vibrio cholerae, survives
+
between outbreaks of human disease in a dormant form attached to small zooplankton in coastal waters
(Colwell, 1996). Cholera outbreaks in Bangladesh have been associated with water surface temperatures
(Colwell, 1996). Likewise, it has been hypothesized that the anomalous warm sea temperatures associat-
ed with the El Niño phenomenon contributed to the simultaneous outbreak of cholera in South America in
1991-1992, the first such outbreak in the twentieth century.
Cholera is not a major health threat in the United States because virtually all surface waters
consumed as drinking water are chlorinated, which effectively kills the cholera bacteria. Nevertheless, +
cholera outbreaks occurred in the United States throughout the nineteenth century, and the Vibrio
cholerae bacterium is still present in U.S. coastal waters, particularly the Gulf of Mexico (Weber et al.,
1994). The few sporadic cases in the United States occur generally as a result of ingestion of the bacteria
by consuming contaminated, uncooked seafood (Weber et al., 1994). Because sanitary facilities and
water treatment are widespread, sporadic cholera outbreaks in the United States have not resulted in
widespread epidemics like those in South America or southern Asia (see Box 4). While warming coastal
23
water temperatures and other climate-associated factors may increase the numbers of viable cholera
bacteria in the water and in seafood, large epidemics in the United States are highly unlikely so long
as the water and sewage treatment infrastructure remains functional.
Another water-borne disease, cryptosporidiosis, an intestinal disease caused by species of
Cryptosporidium protozoa, is likely to be responsive to high rainfall events. Cryptosporidium oocysts are
resistant to chlorination and are very small, making them more difficult to kill or filter out than most bac-
teria in the water supply. Cryptosporidium species are also widespread in livestock feces on farms. Thus,
large amounts of rainfall may bring Cryptosporidia into surface waters through runoff. Large amounts of
rainfall also place greater stress on sewage treatment plants, particularly those that do not separate sani-
tary sewers from storm drainage. Under these stress conditions, sewage treatment plants may release
Box 4
International Health Impacts
Because most health impacts that are associated with climate change scenarios indicate significant regional
climate currently exact a greater toll on underdeveloped variability (Watson et al., 1996). Unfortunately, many
countries than on developed countries, it is anticipated regions that currently have serious malnutrition and star-
+ that climate change will disproportionately impact these

poor nations relative to more developed countries. Today,
vation, such as sub-Saharan Africa and India, are project-
ed to experience even less favorable conditions for agricul-
for example, 95 percent of the mortality related to extreme ture under climate change scenarios (Parry and
weather events around the world is suffered by the poorest Rosenzweig, 1993). Most underdeveloped countries have
66 percent of the world’s nations (Anderson, 1991). The inadequate facilities for water treatment and storage, mak-
difficulty poorer nations have in creating the necessary ing shifts in precipitation in either direction likely to dis-
infrastructure to address extreme events and natural proportionately increase water-borne and water-associated
disasters such as floods and hurricanes is likely to render diseases. Areas that currently experience vector-borne dis-
them even more vulnerable should climate change increase eases, especially those where cool seasonal temperatures
the frequency or severity of such extreme events. limit current transmission, are more likely to experience
In addition to health effects from extreme events, climate-related increases in transmission. These impacts
population displacement from sea-level rise, disruption of will be greater in those underdeveloped countries charac-
food supplies leading to malnutrition, and increased inci- terized by poor housing quality and social disorganization
that prohibits effective vector control programs. Overall,
+ dence of vector- or water-borne diseases also are more
likely to be exacerbated in the developing world as a result the burden of climate change-related impacts on health is
of climate change. Projections of food production under likely to be greatest in countries that currently are least
capable of responding to such changes.
24
greater amounts of Cryptosporidia into surface waters. Ultimately, large outbreaks of cryptosporidiosis,
such as the one that occurred in Milwaukee in 1993, are due to failures of drinking water treatment,
particularly filtration.
Because of population pressures and growing opportunities for cross contamination of sewage
and potable water systems, improved survival of organisms could lead to higher rates of disease, particu-
larly among populations drinking unfiltered spring or groundwater. To date, however, no systematic studies
have been done to assess risks of water-borne disease increases from climate change. As appears to be
the case with recent cholera and cryptosporidiosis cases in the United States, climate factors may
increase concentrations of the organism in source waters; the ultimate health impact depends on the suc-
cess of water treatment technology to remove or inactivate the organisms.
25
IV. Strengths and Limitations of the Current State of Knowledge
A. Issues Related to the Quality of the Scientific Literature
The reliability of analyses of health impacts of climate change depends

on the quality of data sources. In general, the assessment of health impacts of climate change
has used the following types of information:
• comparisons of disease patterns among different places with different average climates;
• contrasts of disease patterns in one location in association with short-term climate variability;
• analysis of long-term historical trends in climate and disease;
• experimental or perturbation studies of biophysical mechanisms;
• statistical extrapolations based on past patterns and trends; and
• model simulations based on partial knowledge of interactions and processes.

+
Confidence in each of the inferences regarding health and climate change depends upon the
complexity of the health impact in question and the type of information used to make the inference.
There should be more confidence in projected health impacts of climate change when:
• the effect is direct and does not involve multiple steps;
• the mechanism of climate impact is well understood;
• the relation between change in the climate factor and change in the health outcome is well-
+
characterized (analogous to “dose-response”);
• there is a substantial body of literature documenting the relation between climate and health
outcome in a variety of geographic settings;
• there are few non-climate determinants of the health outcome; or
26
• non-climate determinants of the health outcome are likely to remain constant over the time
interval considered. This situation is most likely in health outcomes related to short-term
climate variability.
Rarely do studies of projected health impacts from climate change meet these criteria. How these factors
influence current knowledge and confidence in forecasted impacts is briefly summarized below.
The greatest confidence can be given to forecasts of climate change impacts on health when the
pathways of effect are rapid, simple, and direct. This is most applicable to health impacts of unusual
weather events involving extreme temperatures and severe storms. If climate change projections that indi-
cate more extreme weather events are correct, then an increased incidence of heat- and storm-related
deaths is likely to result. Even though the weather forecasting capacity and civil preparedness in the
United States are already well-organized, further improvements in these defenses would lessen the health
impact of an increase in heat or storm events. Thus, both current knowledge and the ability to use this
knowledge are greatest in the area of impacts from extreme events.
Other health impacts result from indirect pathways with many variables in the causal chain. In
general, understanding and predictive capacity decrease rapidly as more and more intermediate variables
are added. This is the situation with many infectious diseases — not only do the impacts of climate vari-
ability on intermediate factors differ, but also the factors themselves interact in various kinds of feed-
+
back. For this reason, the ability to forecast long-term patterns of many diseases with more complex
ecosystem links is very rudimentary.
B. Lack of Baseline Data on Human Disease Incidence
For most health impacts, the baseline data needed to carefully analyze
possible health impacts are inadequ at e, thus severely limiting understanding
of these impacts. Empirical research on changes in disease requires long-term surveillance records to
be able to compare similar long-term data on climate variability. Lacking this information for most
+
diseases, the process of inference and forecasting must rely on other, more speculative approaches. Even
where comparable data for a few decades exist, it is unclear whether the short-term fluctuations and
extremes they contain can be used as a surrogate for longer-term climate trends (see Box 2). Nevertheless,
such surveillance data are critical for many analyses and will serve as the basis of any “early warning”
efforts based on short-term climate variability.
27
C. Few Studies of Climate and Disease Interactions
Overall, knowledge of potential health impacts is based on a very small

body of appropriate research. A review of the literature suggests that, despite many published
reports that address the possible impact of climate change on health, only a small minority present rigor-
ous scientific research involving data collection, statistical analysis, or simulation modeling. The majority
of published reports, including those in major scientific journals, represent summaries, reviews, or efforts
to speculate on possible impacts. Except for heat-related mortality and extreme event impacts, the extent
of solid scientific research on which most discussions of health impacts rest is less than what most scien-
tists would require to have confidence in the conclusions.
D. Future Climate Change and Variability
As with all sectors, assessing the potential health impacts of climate

change first requires understanding how climate change will manifest itself
over the time period to be assessed. GCM models have provided fairly consistent estimates of
temperature changes related to increased GHG concentrations. They have been less consistent in their
predictions of precipitation trends, and much uncertainty remains in predictions of how climate variabili-
ty, as well as the frequency of extreme events, will be affected by increasing concentrations of GHGs
+ (Wigley, 1999). Studies to date have often dealt with this problem by superimposing current variability on
projected increases in average temperature. In addition, the current low resolution of GCMs makes it very
difficult to predict climate change on a smaller, regional to local scale. Accurate assessment of future
health impacts will require an enhanced ability to predict climate change at a finer geographic resolution
and at the full range of time scales needed to assess climate variability.
E. Validity of Comparing Different Regions to Approximate Future Climate Changes
Results of studies from specific geographic areas may not be valid in

+ predicting changes for other parts of the world. Thus, simulation models that project
increased risk of malaria epidemics in areas where vector mosquitoes might expand may be more appro-
priate in Africa, where transmission is already widespread and prevention difficult, than in the United
States, where many means of combating transmission exist. Similarly, studies suggesting the appearance
of similar diseases in regions where future climate may become like that of the present climate in another
28
part of the world ignore many other important ecological, social, behavioral, and economic determinants.
In general, extreme caution must be exercised in interpreting studies that use space as a substitute for
time. Enormous changes in the distribution and incidence of many diseases have occurred in the absence
of major changes in climate. Within the past decade or two, dozens of emerging and re-emerging diseases
have appeared and reappeared throughout the world, primarily as the result of increased air travel, antibi-
otic drug resistance, civil strife, urbanization, crowding, and deforestation. These and other non-climate
factors, which may be difficult to predict, are likely to remain major determinants of changes in the spa-
tial pattern of diseases in the future.
F. Future Steps
While it is relatively easy to point out insufficiencies and uncertainties

in current assessments, it is more difficult to su gg est the steps that might be
taken in the face of such uncertainty to protect public health most fully and
efficiently. It should be remembered that uncertainty regarding adverse health outcomes is not the
same as the certainty of no adverse outcomes. Given the potential scope and irreversibility of ecosystem
changes and consequent effects on human health and society, traditional public health values would urge
prudent action to prevent such changes. The great challenge is to select actions that provide benefits
over a wide range of future climate change possibilities, and that minimize economic costs that would +
bring their own negative impacts on public health. A summary of the health impacts discussed in this
paper (including information on which populations are most affected and the non-climate determinants of
each impact) and potential adaptation options appears in Table 4.
29
+
30
V. Gaps in Current Assessments
A. Consideration of Cross-Sectoral Political and Economic Impacts
To date, most human health impact assessments have assembled

published investigations and analyses from a wide variety of disciplines,
and catalogued the evidence for changes in the rates of specific diseases and
health outcomes. Such a “synthesis” is a difficult undertaking, not only because of the unevenness
in quality and type of investigations, but also because overall impacts on human health will undoubtedly
be more than the simple sum of projections of individual diseases. Previous sections highlighted the
important interrelations between socioeconomic conditions and human health. The disruption of natural
systems predicted under global climate change is likely to have economic impacts around the world,
and, to some extent, in the United States as well. Climate change assessments have predicted changes
on a sectoral basis, separating possible impacts on coastal zones, forests, agriculture, water resources,
etc. Adaptive and other responses to climate change in these other sectors will most certainly require
diversion of societal resources. These economic changes due to impacts on other sectors have not been +
analyzed in most health impact assessments in a comprehensive fashion, due in part to the significant
increase in complexity such an inclusion would entail, and in part to the fact that the relations between
economic determinants and human health have not been adequately characterized. Thus, health impact
predictions have been developed under the assumption that most non-climate health determinants will
not change significantly. And yet these very determinants may not only be more powerful than climate
change, they may also be significantly altered as a result of climate change. While this gap is not easily
filled at present, it is one that needs to be considered as a source of considerable potential adverse
impact on human health; the whole may indeed be greater than the sum of the analyzable parts.
+
31
B. Psychological Effects
Consideration of the psychological effects of global climate change has

been absent or insubstantial in most rep or ts to date. There are several
reasons for this, including the difficulty in associating mental heath effects
with environmental changes, and the unprecedented nature of climate change.
Nonetheless, studies suggest that adverse mental health consequences may result if climate change
results in either clearly perceivable ecological disruption, frequent severe storms, or severe disease out-
breaks. Baum and Fleming (1993) have suggested that human-caused stressors contribute more than
naturally occurring stressors to chronic stress and other persistent health problems. Specific stressors
related to acute traumatic events have included suffering intentional injury and/or harm, causing harm to
another, and learning of exposure to a factor that may cause harm over a long period of time (Green,
1993). Whether these stressors, identified from observations of acute trauma, will also be important in
the setting of chronic environmental disruption remains to be determined.
C. International and Intranational Conflict and War
While international conflict has been listed as a possible consequence

of climate change with he al th impacts, it has generally attracted much less
+ attention than human diseases. For the United States, however, international political conse-
quences may ultimately affect health more than changes in local disease rates. A study commissioned by
the Carnegie Foundation noted that stressors related to environmental deterioration interact with historical
tensions and other political conflicts (Kennedy et al., 1998). The report concluded that climate impacts
on agricultural production, water resources, human diseases, and inundation of coastal zones may exacer-
bate existing instability and tension in areas such as the Middle East, southern Africa, and southern Asia.
While perhaps speculative in the case of climate change, the concept that international health crises con-
stitute a U.S. security threat has recently emerged in connection with the AIDS epidemic (Gellman, 2000).
+
32
VI. Research Needs in Climate Change and Health
Major research efforts are needed to understand and eventually protect
against possible health impacts of climate change. However, the complexity of these
problems, involving many different diseases and health consequences that vary among social groups and
regions of the United States, is daunting. Most changes in disease patterns or health determinants will
involve diverse biological and physical systems spread over a large area, and these changes will play out
over a relatively long period of time. Given current analytic tools and methods, this level of complexity
introduces so much uncertainty into any prediction of future health that the usefulness of such a forecast
is very limited. First and foremost, the development of a useful research program will require more
robust, systematic, and long-term disease surveillance. Many current studies and modeling efforts are
limited by a regrettable lack of such surveillance data. With such data, the further development of new
integrative methods for studying climate-health interactions will be facilitated. This section addresses
some of these needs and recommends where opportunities should be exploited.
A. Enhanced, Systematic, Long-Term Monitoring and Surveillance +

As has been recognized by many recent panels addressing the problem
of emerging diseases, disease surveillance in the United States, as well as
surveillance assistance to other countries, is woefully inadequate. Without
systematically gathered epidemiological records, there is not enough basic information to track and
retrospectively analyze changes in disease patterns. Not only does disease information differ among cities
and states, but also the variable extent of voluntary reporting makes some surveillance data difficult to
interpret. These data are critical to studies aimed at understanding disease trends, analyzing changes
+
associated with the environment, and eventually anticipating future outbreaks and situations of high risk.
Historically, such data have been vital to developing hypotheses of causal links, and may be the only way
to test these predictions prospectively. In addition to the important role that surveillance plays in recognizing
new and re-emerging diseases, high quality disease data are critical to studies of climate impacts on health.
33
B. Ecologically Based Research and Evaluation
The vast majority of health research in the United States today

involves treating disease rather than preventing it in the first place. A new
research emphasis is needed that focuses on identifying and understanding disease-specific environmen-
tal factors that can be used to prevent many cases of disease before they occur. Climate variables are
only a few of many such environmental factors. Based on the limited understanding of individual ecologi-
cal and physiologic mechanisms that underlie exposure and human response, focused experiments are
needed to explore how multiple variables interact and what different impacts they have on health out-
comes. Classical laboratory experiments aimed at demonstrating dose-response or transmission of infec-
tious agents cannot fully replicate the diverse conditions that occur under natural climate variation.
Unfortunately, the nature of the current research funding system has lead to an increasing focus on sim-
ple experiments that produce rapid results, at the expense of studies producing long-term prospective
observations. In addition, new experiments that evaluate how changing environments may lead to rapid
evolution will increase understanding of how adaptation may occur in the face of climate change during
the twenty-first century.
C. Multidisciplinary Perspectives and New Analytic Techniques

+ As information needs change, not only must the design of observations
be improved, but also new methods for gathering or analyzing data and inter-
preting patterns become important. The recognition that complex interactions among physi-
cal, biological, and socioeconomic variables determine disease risk argues that multidisciplinary studies
of multiple variables are needed. The major determinants of health outcomes involve not only traditional
disciplines such as climatology, immunology, or physiology, but also sociology, psychology, and econom-
ics, among others. In particular, methods for the analysis of interactions among qualitatively different
kinds of variables are needed to address the complex processes that occur as climate change affects
+
health. Simulation modeling and system dynamics of complex interactions that include socioeconomic
and behavioral adaptation need additional development. Implied in this is an increasing need for scholars
with a breadth of knowledge and integrative perspective who will be able to work with specialists.
Academic programs will need to be developed to train scientists in developing methods of studying
climate change and health issues.
34
D. Planning that Integrates Health Concerns into Economic Development
Ultimately, a new approach to planning for economic development is

needed that incorporates knowledge gained from such novel multidisciplinary
research initiatives. Indeed, development planners could work more closely with health and
environment researchers to define the direction of development and the knowledge needs that will inform
policy decisions about that development. In a complementary manner, health goals could be incorporated
into the planning process rather than added on after plans have been completed. Such a restructuring
and coordination of intentional environmental change, impacts assessment, and health and environment
input will be facilitated by collaborative research among business management, public administration,
and environmental health experts.
35
VII. Conclusions
1. The complexity of the pathways by which climate affects health
makes it extremely difficult to predict exactly how, when, where, and to what
extent global climate change will influence human well-being. Nonetheless, our
understanding of the linkages between climate and health makes it reasonable to anticipate changes in
the risks of illness and injury as a consequence of climate change. Some risks may decrease, such as
wintertime mortality from cardiovascular disease. Other risks may increase, including those from heat stress,
ozone air pollution, water-borne illnesses, and certain vector-borne diseases. In general, the United States
should have sufficient resources to address increased health risks and limit the actual occurrence of climate-
related illness and injury. It will require, however, advance planning and commitment of resources to achieve
this protection.
2. Uncertainty regarding adverse health outcomes is not the same as

the certainty of no adverse outcomes. Given the complexities of the various factors involved
+ with disease persistence and transmission, society must also be prepared to “expect the unexpected.”
This may involve unpredicted sudden severe shifts in climate, the emergence of new diseases, or an unex-
pected synergy among various social, economic, and natural systems. The possibility of relatively sudden
but unpredictable consequences raises the value of climate change mitigation for health concerns.
3. The linkage bet we en warmer temperatures and increased heat stress

is well-defined, and the relative certainty that summertime temperatures will
increase in the near future makes worsened heat-related mortality the most
+ certain of potential health impacts. The linkage between extreme weather events and injuries
and illness is similarly well-defined, but there is less certainty regarding the frequency of extreme events
in the near future. The ultimate effect of climate change on these health problems will depend on the
balance between changes in local weather and emergency preparedness and other protective measures.
Changes in climate are also predicted to affect air pollutant concentrations, with the association between
36
warmer temperatures and increased ozone production being the strongest. Since changes in weather may
either increase or decrease air pollutant concentrations, the ultimate impact of climate change on respira-
tory health is unclear.
4. D et ermining who in the population is most vulnerable to the health

impacts of climate change dep en ds strongly on the health impact being con-
sidered. The elderly, the very young, and those with underlying heart or lung disease will be most
affected by heat stress and increased air pollutants. Vector-borne diseases tend to be more severe in the
very young, but this varies by specific disease. Since many of the potential health impacts of climate
change will not be realized for decades, today’s children and future generations could be considered the
population most affected by current decisions on climate change. In addition, health impacts of climate
change are likely to be far more severe in developing countries where climate-sensitive diseases are cur-
rently major health problems, and where additional resources to protect the population’s health are often
not available.
5. Diseases with the greatest potential public health impact are typical-
ly multifactorial and among the most difficult to model and forecast. Modeling
the complex pathways of vector-borne infectious diseases, for example, often requires information specific
to the local region and species for greatest accuracy. Observations of infectious disease responses to +
climate variability suggest that climate can be an important factor in disease incidence, but applying
these observations of short-term variability to longer-term climate changes increases the uncertainty of
the prediction, and may not be appropriate. The complexity of these interactions, the variable time frames
over which change may occur, and the multiple factors that are important all suggest a need for enhanced
research efforts aimed at analysis of mechanisms and improved understanding.
6. Focus should be maintained not only on potential changes in disease

pathways, but also on societal vulnerability to health impacts of climate +
change and what is needed to maintain the systems that decrease that vulner-
ability. These systems include water and utility infrastructure, housing and urban planning, and a
strong U.S. economy in general. Integrating public health and climate change experts into land-use and
utility infrastructure planning will help assure maximal protection of public health during this upcoming
period of climate change.
37
7. In the United States, public health infrastructure has controlled most
of the infectious disease risks that are felt to be most climate sensitive (e.g.,
dengue, malaria, cholera); climate change may increase the current very low
chance that these diseases could re-establish themselves through ecosystem
changes, changes in vector and disease agent survival, and possibly increased
migration of infected individuals. It may also increase the frequency of sporadic disease out-
breaks that currently occur extremely rarely. Maintenance and strengthening of public health systems,
especially surveillance and vector control, will be critical to preventing significant outbreaks in the future.
Public health systems also will be critical in implementing early warning systems and other interventions
for heat-related mortality and air pollution exceedances. Since most of these health problems may be
exacerbated by a multitude of factors unrelated to climate, such an investment in public health infra-
structure is likely to have benefits with or without significant climate change.
38
Endnotes
1. The Established Market Economies are: Australia, Austria, Belgium, Canada, Denmark, Finland, France,
Germany, Greece, Iceland, Ireland, Italy, Japan, Luxembourg, Malta, Monaco, the Netherlands, New Zealand, Norway,
Portugal, Spain, Sweden, Switzerland, the United Kingdom, and the United States.
2. The Clean Air Act of 1970 identified carbon monoxide, lead, nitrogen oxides, ozone, particulates, and sul-
fur oxides as the six air pollutants most in need of standards, or “criteria.”
39
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environment

A Rev ie w o f Po te nt ia l I mpa c ts in th e U ni t ed St ate s

John M . Bal bus

Mark L. Wil son

III. Discussion of Health Impacts of Climate Change in the United States 10

IV. Strengths and Limitations of the Current State of Knowledge 26

ii their management of this Environmental Impacts Series.

+ Human health and global climate change

effective public health infrastructure.

variable, region-specific, or mediated through multiple intervening steps. +

wintertime mortality from cardiovascular disease.

movements, and health care and public health interventions.

(Patz et al., 2000; Smith and Tirpak, 1989). +

Which Diseases are

more than conduits of diseases. Increasing economic and water-borne diseases

malaria and cholera, are not currently prevalent in the

assessing possible domestic resurgence in a setting of climate change, depends on an understanding of

The population of the United States is among the healthiest in the

and lifestyle factors such as diet and

cigarette smoking. Climate or climate- Table 1

sensitive factors may be linked to Leading Cause of Death

+ pollutants exacerbate underlying chronic

Box 1) is comparatively small and

What Makes a Human Disease Climate Sensitive?

vector-borne and other infectious diseases

Human health and global climate change +

all be present in high frequencies among the urban poor population.

To more fully understand the current status of health in the United

noninfectious diseases account for the Leading Causes of Death

world, climate-sensitive infectious diseases Developed World Developing World

adjusted life years (DALYs) lost (i.e., years

change, as discussed briefly in the next section.

To understand in a comprehensive fashion how global climate change

D. Environmental Trends in the United States

Climate is only one of many factors influenced by humans that affect

increasing levels of a climate factor.

Climate Variability versus Climate Change

Temperature Extremes, Heat-related Deaths, and Winter Mortality

al., 1996; Kilbourne et al., 1982).

(3) Would warmer winter temperatures result in lower overall mortality?

been the result of either drownings in motor vehicles or accidental electrocutions.

+ Human health and global climate change

extreme (Frederick and Gleick, 1999).

B. Indirect Health Effects

genicity of pollen grains (e.g., Behrendt et al., 1997).

assessment of these impacts on human respiratory health highly uncertain.

study of respiratory health.

Climate Change and Sea-level Rise

average sea-level rise (Neumann et al., 2000).

Climate Impacts on Food Supplies

West Nile virus (Wilgoren, 1999).

agents would be required for the disease to appear or become important.

possibility are not able to go beyond suggestion and speculation.

1991-1992, the first such outbreak in the twentieth century.

as the water and sewage treatment infrastructure remains functional.

Another water-borne disease, cryptosporidiosis, an intestinal disease caused by species of

International Health Impacts

+ that climate change will disproportionately impact these

cess of water treatment technology to remove or inactivate the organisms.

The reliability of analyses of health impacts of climate change depends