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Skeptics Step Aside Climate Change Refugees 18 Reproductive Health and Climate Change 06 10

Issue 07

SUMMER 2010 $4.95 U.S.


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contents IN THIS ISSUE:
















Annmarie Christensen MANAGING EDITOR

Tina Flores


Winnie Mutch Liza Nanni GRAPHIC DESIGN

Shawn Braley E-MAIL:

HOT TOPIC, HEALTH HAZARD It is easy to imagine the effects of global warming – glaciers melting, changing weather patterns – as the thermometer passes the 100° F mark this summer. After a year of incongruous weather, it is safe to say that few doubt the existence of climate change. Anthony Costello, director of the University College of London’s Institute of Global Health, references a Stanford University study that shows skeptics of global warming comprise at most 3 percent of the community. That said, we are only beginning to discover the lasting impact of our changing climate. If we reach the high end of climate model predictions, the earth could warm by 7 degrees by 2100, way beyond the heat endurance of humans and mammalians. But even before that, and taking the middle of model predictions, the effects would be profoundly felt: food and water insecurity, heat stress, communicable diseases, population migration, and deaths from extreme climatic events. But even with this dour look into the future, there is a dearth of hard, measurable evidence to show the health effects of this change. As Onome Akpogheneta notes in her piece, evidence to reflect climate change effects on mosquitoborne diseases has not kept pace. So, too, is the case with climate migration. And Kathleen Mogelgaard of Population Action International talks about how women are disproportionately vulnerable to climate change, and how we need to address population growth. Come with us through this summer issue, as we turn the prism on climate change and look at its effects on health. Also, remember, the discussion continues through blogs in the online edition of the magazine at

The Editors


Joel Lamstein, SM, chair William Foege, MD, MPH, chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Christopher Elias, MD, MPH Elizabeth Furst Frank, MBA Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Patricia McGrath Reeta Roy Jeffrey L. Sturchio, PhD, President and CEO GLOBAL HEALTH is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in GLOBAL HEALTH do not necessarily reflect the views of the Global Health Council, its funders or members. Learn more about the Council at

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&THE BLOG What’s Climate Justice Got to Do with It? Lauren Gifford of the Climate Justice Research Project at Dartmouth College draws links between climate change and public health in this blog series.



A collection of book reviews, music picks, and other cultural forays.

Project HOPE finds community support to be the key to its TB program in Malawi.

Q India: Severe Weather = Severe Droughts Q Palau: Will Rising Tides Result in IDPs? Q Choosing between Fuel, Food and Health Care The Unbreakable Link: Environmental Sustainability and Human Health Jade S. Sasser of the Public Health Institute’s Center for Public Health & Climate Change explores the connection.

Grace Under Fire, a documentary exploring the effect of conflict on women and childbirth.

Toilets Allow Girls to Go to School A sanitation project in Nepal facilitates more than health and hygiene.

&GOING VIRAL Links to great resources online.

A Fierce Radiance, is a fictitious account of the mass production of penicillin during WWII. Go online for more Dim Sum.

&HOT ESCAPES Morgan Roth explores relaxing and altruistic adventures in Sayulita, Mexico. WWW.GLOBALHEALTHMAGAZINE.COM



screenshots CARS PER 1,000 PEOPLE






US 482.4 ISSUE 07 SUMMER 2010





CHILE 88.9




RUSSIA 139.8




CANADA 561.3 Source: Population Action International, Population and Climate Change Data Sheet, April 2010

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LAOS 69.9%




RWANDA 19.5%

CAMEROON 45.6% CHINA 21.2% POLAND 30% INDIA 22.8% Source: Population Action International, Population and Climate Change Data Sheet, April 2010









INDIA 10.9


10.1 9.7 9.4





8.6 6.6


6.2 4.1




Source: Population Action International, Population and Climate Change Data Sheet, April 2010























Climate Change Skeptics Step Aside Many of us have prior experience of scientific skepticism and denial about the health consequences of HIV infection and tobacco use. When scientists doubted the link between HIV and AIDS, and influenced policymakers in South Africa to delay treatment rollout, there were at least 300,000 unnecessary deaths. The link between tobacco and lung cancer was denied for nearly 50 years by tobacco companies and apologists, despite huge loss of life.

Jon Hrusa/EPA

Climate skeptics had a brief respite this winter. The media had a bonanza with the e-mails leaked from the UK University of East Anglia climate research group hinting at some kind of conspiracy to withhold climate data, followed by the admission by Dr. Rajendra Pachauri, director of the Intergovernmental Panel on Climate Change (IPCC) that there had been an error


about the rate of Himalayan glacier melting in their last report. But the summer is here and climate issues have not gone away. Skeptics and contrarians in the scientific community are a tiny minority – a recent Stanford University study shows they comprise at most 3 percent of the field. So we should spend little time debating climate change denial. The science, in truth, is fairly simple. Global warming, whereby net heat gain exceeds heat losses, can only occur through three mechanisms: increased solar radiation (no evidence for major recent change), decreased albedo (reflection of radiation from the planet) and changes in atmospheric composition.

Anthony Costello is professor of international child health and director of the University College London (UCL) Institute of Global Health, chaired the UCL Lancet Commission on Managing the Health Effects of Climate Change, and directs research on maternal and child survival in Malawi, India, Nepal and Bangladesh.

Photo by Gurdas Dua

Jon Hrusa/EPA


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The hard evidence comes from increases in surface temperature (about 0.8 degrees since 1900), increasing differentials between surface and deep ocean temperatures, ocean acidity, sea level rise, and melting rates of the Greenland and Antarctic ice sheets. Coupled with the steady and relentless increase in atmospheric carbon dioxide levels from human burning of fossil fuels, this scientific evidence is why many members of the U.S. National Academy of Sciences signed a letter to Science in May 2010 stating, “There is compelling, comprehensive, and consistent objective evidence that humans are changing the climate in ways that threaten our societies and the ecosystems on which we depend.” Every doubling of CO2 levels is expected to raise temperature by 1.9 to 4.5 degrees. With business as usual, current midline estimates are for 3-4 degrees warming by 2100. If nothing is done to arrest greenhouse gas emissions, tipping points may kick in and accelerate the warming process.

If temperature rises are at the upper end of current climate model projections, there is a risk that we could warm by 7 degrees or more, which would exceed the limit of heat endurance for many human and mammalian populations, according to a recent paper by Sherwood and Huber in Nature. Effects on health will be expressed much earlier: changes in the distribution and transmission of communicable diseases, heat stress, the consequences of food and water insecurity, deaths from extreme climatic events, and population migration. The effects of climate change will exacerbate an already profoundly worrying deterioration in our ecosystem services as a result of the increase in human consumption, pollution and population footprint. So what can be done? Last year the UCL Lancet Commission published a report on ‘Managing the Health Effects of Climate Change’ and made clear that global warming was the biggest threat to health in the current century. There were three broad actions needed by the health community to address the problem: to help reduce emissions, to address the pathways linking climate change to health outcomes, and to strengthen health systems.

Photo by Abutaher Khokon

Two major threats are from sudden displacement or increases in melting from ice sheets, and from release of methane hydrate gases, 23 times as powerful as CO2 in their greenhouse effects, because of melting of the Siberian and north Canadian permafrost, a process that has already started.

The health sector has a crucial role in helping to reduce greenhouse gas emissions and to bring about ‘contraction and convergence’ across the world. Highemitting countries—the U.S., in Europe and elsewhere must drastically reduce emissions by up to 90 percent by 2050 with an individual annual limit eventually capped at about 2 tons per head of CO2 equivalent (industrialized countries currently emit 10-20 tons per head). Low-emitting developing countries, who have contributed almost nothing to the problem, should be able to increase emissions up to the same level. Until recently, I was deeply pessimistic about the ability of our global leaders to bring about such an enormous change in our industrial processes, and to police and effect such challenging policy changes. But two things have made me more optimistic.



COSTELLO - CONTINUED FROM PAGE 7 and companies such as WalMart, Nike, O2, Unilever and Marks and Spencer have implemented ambitious eco-efficiency drives which reduce waste, use of fuel and packaging, thereby improving their profitability. Non-fossil fuel options are vying for the interest of major investors, from countries like China, from our pension funds, and from high net-worth individuals like Bill Gates and Warren Buffett.

Photo by Maurice Adams

The International Energy Agency says that $10,000bn of investment will be needed globally over the next 20 years, but estimates that $8600bn will be recouped in fuel savings and other benefits. Governments are devoting a large proportion of stimulus spending to environmental projects and emerging markets are recognizing the economic potential. The World Bank is financing a project called Lighting Africa using lightemitting diodes (LED) to provide an alternative to polluting kerosene lamps which is a surprisingly large market. In Brazil, the government has set deforestation reduction targets and, in India, government subsidies have supported the growth of a wind power industry. The second strategy from the UCL Lancet Commission was to manage the complex pathways linking individual effects of warming on health. Each country must develop plans to reduce vulnerability to communicable diseases, heat stress, food and water insecurity, extreme climatic events, poor shelter and population migration. First, we can afford it. The high costs for the U.S. economy of reducing emissions were a major reason for rejecting U.S. ratification of the Kyoto Protocol. Recent reviews by Barker and Ekins of the costs needed to bring about required reductions in greenhouse gases suggests that if policies are expected, gradual, and well designed, they should cost no more than 1-4 percent of world GDP. The amount, several trillion dollars, sounds like a lot, but actually represents no more than 6-12 months of world economic growth. This is equivalent to the recent bank bailouts, and the sooner such policies are planned and coordinated, the lower the bill.

Governments and international agencies must provide additional resources to poorer countries. The poorest billion people contribute just 3 percent of the global carbon footprint but may, according to climate epidemiologist Anthony McMichael, suffer up to 500 times the loss of life compared to the richer world. In addressing these pathways, the science and health communities face a great challenge. We need much more information about local climate risks and how to build resilience. Poverty and inequalities in all countries will increase vulnerability, and our efforts to bring populations out of poverty must be redoubled.

Second, there are reasons to be optimistic about the development of renewable energy technology. The technology we need is either available or not too far from development. Solutions are needed to develop renewable energy sources. Protecting ideas through intellectual property rights is a key issue if ecotechnology is to succeed.

Technological advances and research are needed to improve crop varieties, irrigation techniques, pest control, cheaper ways of desalinating and conserving water, improvements in building materials and heat insulation, improvements in communications technology to obviate the need for so much aviation and travel, and the development of early warning systems for climate events and their local consequences. Social and cultural change to move toward a low-carbon lifestyle presents the biggest challenge. Incentives and legislation to change behavior will need to be effective

Private companies are recognizing the economic potential of a green second industrial revolution. There is significant commercial gain through going green,



Photo by Upendra Upadhyay

and on a large scale, but must not alienate electorates. Advocacy about the health consequences is a high priority. The United Nations Convention on Climate Change was set up in 1992 to ensure nations worked together to minimize the adverse effects. But McMichael and Neira noted that in preparation for the Copenhagen conference in December 2009, only four of 47 nations mentioned human health as a consideration. The third major strategy is to strengthen health systems. In many countries health systems are fragmented, with little in the way of coherent, population-based, and bottom-up health planning. They must not only deliver clinical services but also effective public health responses to climate-induced threats to health. Weak health governance and management structures require long-term investment in human capacity. As a colleague wryly observed, many countries have an airline but not a coherent research or health policy. This needs to change. There is also much to be done in harnessing existing resources in the private sector to better serve the public interest. In brief, health systems need three specific climate actions. First, each country needs its own detailed risk assessment which is reviewed and updated at intervals. Second, they need to plan a program of specific interventions to reduce risks in key areas of vulnerability, for which many will need extra financial support from climate change aid funds. And third, countries need to promote the health benefits of reducing greenhouse gas emissions. A Lancet series in December 2009 reviewed mitigation strategies for household energy, transport, food and

agriculture, and electricity generation and showed that actions to reduce greenhouse-gas emissions often produce substantial benefits for health. Specific policies that reduce emissions and result in health benefits include increased active transport (walking and cycling) and reduced private-car use in urban settings, increased use of improved cook stoves in low-income countries, reduced consumption of animal products in high-consumption settings, and generation of electricity from renewable or other low-carbon sources rather than from fossil fuels. The health benefits include reductions in obesity and heart disease, in deaths from pneumonia and asthma, and in diabetes, stress and depression. Apart from the human benefits, there will be major costsavings within the health sector. Climate change remains an enormous challenge for national and international government. But the economic crisis has taught us that our global well-being is highly interconnected and that nations must work together to bring financial, trade and climate stability. Wealthier countries must be prepared to maintain aid support to the poorest, because achieving the Millennium Development Goals will assist countries to reduce poverty, mortality and fertility rates, which will stabilize population growth and increase the resilience of populations to cope with climate change adaptation. High-consumption countries must also recognize the central part they have played in creating the threat of climate change, but with strong leadership and informed electorates, there is still no reason why we should not create a second industrial revolution and bequeath a sustainable world to our children and grandchildren. GH —




People on the Move As the World Warms Natural climate change and natural disasters have been disrupting and displacing humans for millennia. But now man-made climate change is challenging the way we understand and forecast these phenomena. Among the many questions stumping climate researchers is how to measure the ways the warming planet is uprooting people, and perhaps even driving them into conflict.

The numbers, though, are hard to pinpoint and constantly changing: the International Office of Migration, an intergovernmental organization established in 1951, estimates that 200 million people will be forced to move because of the changing climate by 2050, while other groups have said it could be as high as 700 million. Of particular concern is the mounting frequency and intensity of climate-related events like heat waves, floods, droughts and storms. In 2008 alone, more than 20 million people were displaced by climate-related sudden-onset disasters such as floods and storms, according to a 2009 study by the Norwegian Refugee Council. Of the 20 disasters in 2008 with the highest levels of displacement, 17 were in Asia. Scientists expect climate-related disasters to continue to increase as the climate warms and meteorological, hydrological and climatological systems adjust to new conditions. Bangladesh, a densely packed coastal country, most of which is less than 40 feet above sea level and streaked with rivers, is especially vulnerable. Sea level rise together with storm surges linked to cyclones could inundate up to 25 percent of the country, according to a study by the United Nations Environment Program. And evacuations of some of the tiniest, low-lying atolls and islands in the world have already begun: in 2009, some 2,600 people from the Carteret Islands, part of Papua


New Guinea in the South Pacific, were instructed to move to the nearby Solomon Island of Bougainville. Drought is another devastating outcome of the fragile interplay between precipitation and evaporation, whether sudden or protracted. As precipitation over regions like the Sahel in Africa declines and evaporation increases from higher temperatures, drought has become more commonplace, threatening the security of food and people, according to the Intergovernmental Panel on Climate Change. Much of the discussion to date on the new climate patterns that have or will kindle migration has focused on the most conspicuous risks like sea level rise and flooding. But according to Charles Ehrhart, climate change coordinator for CARE International, another equally important and hastening factor has been overlooked: changing rainfall patterns, which are difficult for scientists to monitor and measure. “Science is poor at capturing the nature of rainfall,” says Ehrhart. “We measure annual averages but we don’t know when it comes and how it comes. If you are a farmer depending on rain-fed agriculture, when it falls is at least as important as how much falls.” Around 90 percent of Africans depend on agriculture for their livelihoods – many are subsistence farmers who only grow enough food to feed themselves and their families. Many parts of Africa are already considered “water stressed,” a condition that will be exacerbated by unpredictable and unreliable rainfall from climate change. Recently, Ehrhart visited the Ivory Coast where he met several young men in an Abidjan slum who said they’d migrated there from Niger. “What they explained was

Eliza Barclay is a freelance journalist based in Washington, D.C., whose work has appeared in The Atlantic and The New York Times.

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that stresses on pasture and lack of water for livestock meant that being a traditional pastoralist was no longer a viable livelihood,” Ehrhart said. “They felt their culture’s traditional [way of life] was a dead end.” CARE and other organizations working with migrants in urban slums around the world say they are noticing climate as a reason why people leave their homes, but the phenomenon remains hard to measure. Within the humanitarian community, there is some disagreement about what to call these new migrants. Some people who study displacement from climate change, like Ehrhart, aren’t comfortable with the term “climate refugee” because “refugee” implies an escape from persecution and crossing a border. Climate, or environmental, migrants are not moving for ethnic or political reasons, and to date are not eligible for any kind of refugee status or benefit, he said. Yet others are more open to extending refugee status to them. “This is a highly complex issue, with global organizations already overwhelmed by the demands of conventionallyrecognized refugees… We should prepare now, however, to define, accept and accommodate this new breed of ‘refugee’,” United Nations Under Secretary-General Hans van Ginkel said recently on the UN Day for Disaster Reduction. Other scientists, exploring the human impact of climate change, are looking at whether conflict over resources stressed by climate change may be spurring displacement or even war. In a startling paper published in November 2009 in the Proceedings of the National Academy of Sciences, researchers argued that climate change could increase the risk of African civil war by nearly 60 percent in 2030 relative to 1990, with huge potential costs to human livelihoods. Looking at data from 1980 to 2002, they found that civil wars were significantly more likely in warmer-than-average years. The researchers concluded that when temperatures rise, African farmers suffer and become more susceptible to participating in armed conflict. “The results were really surprising especially in their magnitude,” said Marshall Burke, a doctoral student in agricultural and resource economics at the University of California-Berkeley and lead author of the study. “You would expect to see some relationship between agricultural productivity and changes in civil conflict, and everyone’s picture of failed harvest is drought. But if you look statistically, you see just as strong a signal from temperature as precipitation.”

Families in the drought-stricken Somali region of Ethiopia banding together and pooling their assets—their goat livestock—to migrate in search of rain. Photo by Chris Bessenecker

There are two ways higher temperatures can affect crops, Burke says. For one, heat will evaporate more water out of the soil, effectively creating drought conditions without a change in rainfall. Temperature also changes how quickly plants develop, accelerating growth and reducing overall yield. Burke and his colleagues ultimately suggest that governments should aid farmers in adapting to extreme conditions and avoiding conflict by developing drought-tolerant crop varieties, training and incentives to use them, or improving irrigation. Burke’s pioneering study has broad implications for the potential risk of displacement from climate-related conflict. But according to Nils Petter Gleditsch, a professor at the Peace Research Institute Oslo, its results rely only on national-level data and a short time CONTINUED ON PAGE 17


A Photographer’s Encounter in Kroo Bay



Recently while working in Freetown, the capital of Sierra Leone to document maternal and infant mortality issues, the ministry of health was launching a free health-care program for pregnant women and children under five. I had planned to stay after my contract was over, in hopes of sharing more time with Sierra Leone mothers and their families and to make known the difficulties they live every day.

typhoid fever and malaria, not to forget a high incidence of child malnutrition.

My plans quickly changed after meeting a wonderful family who lived underneath a small bridge in Freetown. I was surprised by the amount of raw sewage and the lack of clean water. After visiting this family a couple more times they told me there were communities in Freetown much worse.

Within minutes of entering the community, I stood shoulder to shoulder, making pictures of children digging in heaps of trash and pools of blackened water. I walked slowly introducing myself with a soft voice and sometimes placing my hand over my heart to show my respect. As I walked deeper into the neighborhood and slowly made pictures, I was feeling overwhelmed, almost frozen.

This was when I first heard of Kroo Bay, a difficult slum filled with good families and shanty structures overrun with garbage, extreme sanitation issues, and a long list of health conditions due to the lack of clean water. Some of the biggest issues they are facing are polio, ringworm,


For little over a week, I spent as much time as possible documenting the community. These families lived in some of the worst conditions I have seen, yet they opened their makeshift homes and offered what little they had. Many homes had hard packed dirt floors, no windows, no doors and with poor roofing materials to shelter them from the heat and rain.

At that moment I heard a man screaming from maybe 25 feet away; I lowered my camera slowly and saw no one moving except one, he was marching towards me. Dominic Chavez is a freelance photographer, who had worked in more than 40 countries, covered the wars in Iraq and Afghanistan, and currently focuses on global health issues. He has published six books and won numerous awards, including the Global Health Council’s Excellence in Media Award in 2004. To learn more about Chavez and view his portfolio, please go to

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He was enraged. He had open sores all along his arms and was built like a malnourished body builder. At this point I was reminded I had broken my first rule of always creating a simple exit (just in case), there was nothing I could do except to face him. He unloaded and was venting his frustrations. After a few minutes, I interrupted him and told him, your anger is why I’m here! It silenced him for a second and then he burst loudly with laughter – he laughed with his mouth wide open pointing towards the sky. He then asked me: you want to know the truth? We’re all

suffering here in Kroo Bay. He began talking about the water issues again and showing me his arms with open sores, “you see these, they move at night” – he was talking about the worms in his body. I continued listening humbly as he talked, after a few more minutes he was aware we could help one another and began introducing me to his family and friends. My hope is never to take pictures or shoot pictures, but to share the experience and the moment with the people I’m photographing. It’s important to me that they feel I am not there to take something from them. GH —




Will Bugs Creep North as Climate Heats?

A mother waits for assistance as her son suffers from “dengi” in Kolkata, India. Due to the poor sanitation system, most of this portion of Kolkata City sinks after heavy rains, causing different types of malaria. © 2008 Sandipan Majumdar, courtesy Photoshare

With predictions of temperatures rising by the end of this century, what will happen to the bugs that carry disease when the world warms? Will diseases of the Southern Hemisphere become more prevalent in these countries? Will the insects carry their disease burdens to the North? For many statistical models, the effect of climate change on vector-borne diseases are real causes for concern. But perhaps predictions about climate change and disease migration support actions to limit climate change rather than highlight the most likely of diseasespread scenarios. It has been widely hypothesized that global warming will bring new permissive environments for biting insects that can carry viral, bacterial, helminth and protozoal diseases. These insects include mosquitoes, ticks, sandflies, snails and blackflies; all are sensitive to climatic changes. Mosquito-borne diseases, including ISSUE 07 SUMMER 2010

malaria, dengue, viral encephalitides, West Nile fever, filariasis and yellow fever, are some which have caused climate change associated concerns and investigations in recent years. Fears persist that newly resident infected mosquitoes could harbor and import diseases to regions and countries from which they have been absent or eradicated. The result could be greater disease prevalence and more disease outbreaks within countries of the Global South, as well as northern migration of disease epidemics. Fears have grown that climate change disease migration could become a global health threat in the 21st century. While fears have grown, reliable evidence to reflect long-term climate change effects on mosquito-borne diseases has not kept pace. “Detailed scientific evidence remains scanty,” says Peter Byass in an 2009 article in Global Health Action magazine; he considers that Onome Akpogheneta has a PhD from the London School of Hygiene and Tropical Medicine. Her work has been published in Infection & Immunity, Parasite Immunology, The Faster Times, MalariaWorld, The Periscope Post and Livestrong.

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“entomological studies [are] expensive [and] not seen as high priority for disease surveillance.” It is precisely because of “scanty” historical and longitudinal data on vector habitats and associated disease outbreaks that climate change predictions will likely be unreliable for vector-borne diseases. Predictions for simplistic longterm correlations should be made with disclaimers; there’s simply not enough data to prove cause and effect. “We still need evidence of the [long-term] effect of climate change,” says Tarekegn Abeku, senior technical specialist in disease prevention at the Malaria Consortium and a contributor to the 2007 report of the International Panel on Climate Change. Abeku says “several studies have shown malaria in highlands might be caused by changes in weather” but these were shortterm changes. Short-term studies can inform long-term predictions, but in order to reach conclusions, Abeku says, “you have to have data for decades” and even then the picture is still “very complex.” So what contributes to this complexity? Surely associations could be simply made between climate change factors and disease vectors. Wouldn’t more rainfall, higher humidity and higher temperatures simply mean more hospitable areas for mosquitoes? It has long been known that seasonal rains, with hot, humid conditions are frequent correlates with mosquito-borne disease epidemics and outbreaks. Short-term climatic anomalies, such as the El Nino Southern Oscillation, are also known to lead to epidemic spikes and have been associated with malaria and dengue outbreaks in Africa, Asia and South America. In addition, higher temperatures can mean shorter maturation periods for mosquito larvae, and faster blood digestion with more frequent feeding for adult females. But there is a downside for the bugs, too; warming above 34oC could have a deleterious effect on their habitats and lifespan. Higher temperatures are predicted to make arid and semi-arid areas drier, while making mid-to-high latitude areas wetter. As ecosystems change, so too will the distribution of mosquitoes; both increased and reduced rainfall could mean shifting habitats, but these generalized effects will not move in a uniform direction for all mosquitoes. “It’s almost a routine tool to model distribution of [mosquitoes] by determining their climate envelope,” says Steve Lindsay, professor of public health entomology at the London School of Hygiene and Tropical Medicine, but it’s “important not to overinterpret conclusions.” Statistical models and exploratory analyses can provide “insight,” “scenarios”

and a “foundation for understanding vector-borne diseases [and disease] transmission” but for Lindsay it’s crucial to “go to the field” and collect real-life data. Hypotheses of disease importation with vector migration are unsubstantiated and often overlook evidence that mosquitoes capable of carrying disease are resident and living comfortably in many locations where particular diseases are not endemic. Within 5 years after West Nile Virus was introduced to the U.S. in 1999, the disease spread rapidly from the northeastern corner across the country. “There is little evidence that the entry and establishment of West Nile Virus in the U.S.A. was influenced by climate change,” says Walter Tabachnick in the Journal of Experimental Biology this year. Tabachnick describes that the “vectors were present in the U.S.A., and entry of West Nile Virus was not contingent on climate change in North America.” Until the mid 20th century, malaria was endemic in parts of the Northern Hemisphere; in Europe, as far north as Finland, and in North America, as far as Canada. Malaria caused illness and death in these areas at rates comparable to those in some malaria-endemic parts of sub-Saharan Africa today. In England today, there are currently six species able to transmit malaria. Although these malaria-capable vectors persist, Lindsay et al comment in the Malaria Journal that “one is much more likely to be struck by lightning than to get malaria from an English mosquito.” Climate was not a factor associated with malaria eradication from the developed world. It was due to ecological changes in insect habitats, in particular effective mosquito control measures, improvements in human living conditions, and greater access to medical care that malaria was eradicated prior to the advent of man-made global warming. While malaria began to wane as a worldwide public health problem by the mid 20th century, dengue and yellow fever, which belong to the same virus family and share the same mosquito vectors, began to emerge. According to WHO surveillance data, prior to 1960, dengue cases were reported in fewer than five countries; after 1960, the disease began to emerge in all continents, with cases reported in nearly 60 countries by 2007. The migration of mosquito vectors (and the viruses themselves) had already occurred centuries earlier with transnational shipping and commerce in the 17th and 18th centuries. By the 20th century vectors were already permanent residents in today’s disease endemic and non-endemic countries. According to WHO, the reemergence of dengue after 1960 was associated with



Photo by Maggie Hallahan

BUGS—CONTINUED FROM PAGE 15 “rapid population growth, rural-urban migration.” In addition, an increase in water containers and discarded items provided urban larval habitats. It was independent of climate change that mosquito vectors for dengue and yellow fever viruses adapted efficiently to new habitats, maintained close proximity with humans, and became especially well domesticated disease vectors.

movement away from largely rural endemic diseases, such as malaria, and toward urban epidemics with diseases like dengue. For filariasis, however, urbanrural human migration patterns may not suggest a clear epidemic outcome; some filariasis vectors have adapted to rural habitats, while others are urban or semi-urban residents.

Vector-borne diseases rely on the availability of human populations as much as their vectors for disease transmission. As such, it’s important to consider more widely how climate change will likely affect a host of other socio-economic and human migration factors. The effect of climate change on human migration patterns could mean movement away from or movement toward disease carrying vectors, decreasing risk for one disease while increasing risk for another, depending on which diseases are endemic where. If global warming drives human migration toward urban areas, it could mean a

To make robust associations between climate change and vector-borne disease means ignoring the absence of evidence. Climate change won’t cause uniform changes for all vectors and all disease. It will have direct impacts not only on vectors, but also on pathogens and human hosts. Disentangling these multiple climate change effects and proving direct, causal relationships between specific diseases and climate change will likely continue to prove problematic and complex for many decades to come. GH

&Challenges in predicting climate and environmental effects on vectorborne disease episystems in a changing world content/abstract/213/6/946 Tabachnick, (2010); Journal of Experimental Biology 213, 946-954

&World Health Organization: Impact of Dengue

&Assessing the future threat from vivax malaria in the UK using 2 markedly different modeling approaches cgi?accid=PMC2845590 Lindsay et al. (2010); Malaria Journal, 9: 70

& Climate change and population health in Africa: where are the scientists? Byass (2009); Global Health Action, v. 2

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Warmer/fewer cold days/nights; warmer/more hot days/nights over most land areas

Increased yields in colder environments; decreased yields in warmer environments

Effects on water resources relying on snow melt

Reduced human mortality from decreased cold exposure

Warm spells/heat waves: frequency increases over most land areas

Reduced yields in warmer regions due to heat stress at key devel. stages; fire danger increase

Increased water demand; water quality problems, e.g., algal blooms

Increased risk of heatrelated mortality

Reduction in quality of life for people in warm areas without air conditioning; impacts on elderly and very young; reduced thermoelectric power production efficiency

Heavy precipitation events: frequency increases over most land areas

Damage to crops; soil erosion, inability to cultivate land, water logging of soils

Adverse effects on quality of surface and groundwater; contamination of water supply

Deaths, injuries, infectious diseases, allergies and dermatitis from floods and landslides

Disruption of settlements, commerce, transport and societies due to flooding; pressures on urban and rural infrastructures

Area affected by drought: increases

Land degradation, lower yields/crop damage and failure; livestock deaths; land degradation

More widespread water stress

Increased risk of food and water shortages and wild fires; increased risk of water and food-borne diseases

Water shortages for settlements, industry and societies; reduced hydropower generation potentials; potentials for population migration

Number of intense tropical cyclones: increases

Damage to crops; windthrow of trees

Power outages cause disruption of public water supply

Increased risk of deaths, injuries, water and foodborne diseases

Disruption by flood and high winds; withdrawal of risk coverage in vulnerable areas by private insurers

Incidence of extreme high sea level: increases

Salinization of irrigation and well water

Decreased freshwater availability due to saltwater intrusion

Increase in deaths by drowning in floods; increase in stressrelated disease

Cost of coastal protection versus costs of land-use relocation; also see tropical cyclones above

Reduced energy demand for heating; increased demand for cooling; declining air quality in cities; reduced effects of snow, ice etc.

Source: U.S. Environmental Protection Agency

period. One of the challenges of studying climate patterns and conflict (or migration) is a lack of good local level data that can correlate specific conflicts to specific rainfall or temperature patterns. And, Gleditsch says, the fear of climate change leading to increased conflict is questionable in light of the larger global trend of decreasing armed conflict since the end of the Cold War. “I see it as relatively unlikely that the conflict-generating effect of climate change will outweigh trends towards fewer and less severe wars,” Gleditsch said. “If I were to venture a hypothesis, the kind of conflict most likely generated by climate would be local and relatively small-scale conflicts.” Even if the link between conflict and climate may not cause widespread displacement, humanitarian agencies are already concerned about extreme weather events and natural disasters that affect health. Droughts and tropical cyclones can up the risk of food and water shortages and food and water-borne diseases. Heavy precipitation events, meanwhile, like storms and flooding, can cause death by drowning and infectious diseases like cholera and diarrhea.

Humanitarian groups have begun to create climate divisions to prepare for both health risks and displacement. The Red Cross/Red Crescent Climate Centre, for example, has started to push Red Cross national chapters in Kenya and Tanzania to team up with meteorological services to use early warning information about rainfall patterns for preventive health care, according to Lina Nerlander, a health and climate specialist for the Climate Centre. Health workers can use early warning systems to promote awareness and education on how to avoid exposure and when to seek care for vector-borne diseases like malaria or dengue that may resurge from climatic conditions. But there is still a very long way to go in both understanding the potential human impacts of climate change and preparing for them. And, as Ehrhart says, the main focus for governments should still be mitigating climate change to avoid some of the worst possible impacts. “The single biggest thing countries can do to avert large-scale displacement is to make serious reductions in greenhouse gas emissions,” Ehrhart said. GH —




Reproductive Health and Solutions to Climate Change:

Connecting the Dots

Shortly before heading to Beijing for an international conference on reproductive health, I had dinner with a friend who works on climate and energy policy in the U.S. Senate. “Beijing – how exciting!” he said. “What will you be doing there?” I described the conference, and told him I was going to give a presentation on how access to voluntary family planning and reproductive health services can contribute


to solutions to climate change. Not surprisingly, he looked perplexed. “Give me your one-minute summary,” he said. People engaged in climate change decision-making are not accustomed, generally, to thinking about reproductive health – and most probably have never considered how reproductive health can affect women’s empowerment and population growth, and how those things can be meaningful in climate change responses. But connecting

Kathleen Mogelgaard is senior advisor for population, gender and climate at Population Action International.

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those dots reveals a story that is full of good news: investing in women’s reproductive health needs can yield big, tangible dividends for people and the planet. It will do this in two important ways: by empowering women, who are key stakeholders in adaptation to the negative impacts of climate change; and by ultimately slowing population growth, which will ease the challenge of reducing global emissions of the greenhouse gases that cause climate change.

WOMEN, REPRODUCTIVE HEALTH AND CLIMATE CHANGE ADAPTATION Because we’ve not yet been able to get global greenhouse gas emissions under control, communities around the world will have to figure out how to adapt to changes that are already “locked in” the climate system – more severe floods, droughts, extreme weather, declining agricultural production. We already know that universal access to family planning and reproductive health services – a goal embodied in the Millennium Development Goals – would greatly improve maternal and child health. What is less appreciated is that meeting this goal would also have the serendipitous effect of strengthening our abilities to adapt to these impacts of climate change. Women are disproportionately vulnerable to climate change. For example, shifting temperature and precipitation patterns are affecting water supplies and agricultural production in many parts of the world. When water is scarce, women spend more time each day collecting it for themselves and their families, adding to the burden of physical labor. Decreased crop yields mean that more women go hungry, as they feed their families first.

In their roles as providers of food, water and fuel, women are instrumental in determining a family’s ability to survive and effectively cope with the impacts of climate change. When women are empowered to manage the timing of their own child-bearing and the size of their families, they can be more powerful agents in negotiating the unpredictable impacts of climate change, and ensuring the survival of their families. A woman with access to reproductive health services is healthier and has healthier children, an important foundation for effectively coping with sudden and short-term stresses. She has greater opportunities to diversify income sources, which can be critical in areas where climate change will undermine primary economic activities like agriculture or fishing. And she is more likely to be able to safeguard herself and her family in the event of disaster. All of these things contribute to resilience in the face of the impacts of climate change. REPRODUCTIVE HEALTH, POPULATION AND GREENHOUSE GASES Access to reproductive health is an important part of strengthening women’s capacity as leaders in adaptation to the impacts of climate change. In addition, access to reproductive health can contribute to another critical aspect of addressing climate change: it can slow population growth, creating brighter prospects for reducing greenhouse gas emissions over the long-term. In a climate-challenged world, truly sustainable development – that is, the creation of a future we all can envision in which people are healthy and no one lives in poverty – requires bold strategies to reduce our dependence on fossil fuels by tapping into cleaner energy sources like wind, solar and geothermal. We need to develop and spread technologies that will help us meet our needs – and allow for continued economic development in the poorest countries of the world – while using less energy. We need to better protect and manage forests to store carbon dioxide, and find additional ways to lock up carbon dioxide. And we need to address population growth. Not because ending population growth alone can solve our climate challenges, but because addressing our climate challenges will be a lot harder if we continue to grow at our present pace. The most recent population projections from the United Nations indicate a wide range of possible outcomes for the size of the world’s population in 2050. We often hear that the world’s population will grow from today’s 6.8 billion to 9.2 billion in 2050, which is the medium fertility



variant. What we don’t often hear is that to reach 9.2 billion, average global fertility would need to fall below two children per woman, which would require expanded access to and use of family planning. A recent study by the Futures Group demonstrates that meeting women’s stated desires to limit or space births would have a significant effect on fertility, and would be likely to bring world population below the medium fertility variant by 2050. An estimated 215 million women around the world would like to avoid pregnancy, but don’t have meaningful access to contraceptives. Meeting the family planning and reproductive health needs of these 215 million women will yield positive outcomes that are almost too numerous to count. The benefits to women have ripple effects throughout society, including strengthening our resilience to the impacts of climate change and bolstering our efforts to restore the atmosphere.


My climate policy friend from the Senate has thought long and hard about fixes for the climate challenge – how to create incentives for renewable energy here in the U.S., and how to support low-carbon development in the developing world. But many of the policy-makers embroiled in climate change decision-making in the U.S. and around the world are only just beginning to consider how investments in the social sector relate to climate change solutions. The time is ripe to demonstrate how reproductive health goals can contribute to efforts to address climate change. Connecting these dots to reveal low-cost, win-win strategies requires persistence and a willingness to step out of the comfort of our sector-specific silos. But the potential rewards for doing so are immense: a healthier, more resilient population; a recovered climate system; and the hope for a truly sustainable future. GH —

PAGE 21 —


From the Front Lines of the Global AIDS Fight The picture of the current state of AIDS in South Africa is ambivalent. There are some notable successes in preventing mother-to-child transmission and access to antiretroviral treatment (ART), but a worrisome lack of progress in preventing new adult infections. Prospects for resourcing and financing over the next five years are equivocal at best.

Earlier this year a group of South Africa’s leading HIV experts, the authors among them, gathered to reflect on progress, identify challenges, and recommend strategies and tactics for surmounting obstacles in the fight against HIV and AIDS. A special report in the online edition of GLOBAL HEALTH magazine summarizes the analysis and recommendations that emerged from that meeting. One theme was transcendent – winning the AIDS fight requires a paradigm shift on the part of all South Africans. Two strategic objectives were mooted again and again as essential to galvanize this shift: 1) The South African department of health must change the way it does business; and 2) Reversing the trend of new infections requires a mass social movement. At a glance, these objectives appear as inchoate as they do intractable, though they reflect several fundamental truths about the current state of AIDS. With five infections for every two people started on ART, HIV incidence remains too high. Extant public sector health staff, including doctors, pharmacists and laboratory technicians, cannot cope with the 3 million plus people needing ART by 2015. Finally, there is not enough money in the AIDS budget to treat everyone needing ART.

Peter Navario is a fellow in global health at the Council on Foreign Relations and Alan Whiteside is a professor in the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal in Durban.

The success of prevention and treatment programs in South Africa hinges on leadership from the department of health at national and provincial levels. Management capacity within the health sector merits a great deal more attention than it currently receives. Far too few people in leadership and management positions have any management training; the drug stock outs in Free State Province and high rates of ART patients, who are lost to follow-up, are just two indicators of the current state of health system management. Fiscal management is also a major concern. The independent Budget and Expenditure Monitoring Forum reports that provincial health departments routinely incur large amounts of unplanned expenditures, fail to budget based on estimated service needs, and suffer widespread corruption. Doctors, nurses and other key leadership staff should be incentivized to receive management training. Better management should lead to more efficient use of resources, improved supply chain efficiency and reliability, greater levels of accountability, improved working conditions, and ultimately, better patient care at lower cost. For example, given the talk of clinic overcrowding and health worker burden, it is curious that clinics across the country are empty every day by three o’clock and closed after one o’clock on Fridays and on weekends. Moreover, the public health system does a notoriously poor job of holding non-performing and/or negligent health professionals accountable, jeopardizing patient health and program efficacy. The health department’s policy options to cut costs and reduce workload and patient burden include better



use of community health workers; modification of the current treatment guidelines to permit quarterly dosing for patients who are adherent and stable on treatment; and less intensive laboratory monitoring – recent research from Uganda and Zimbabwe found twice-yearly laboratory monitoring to be cost-ineffective. Finally, data management is a shambles. Public sector data are poor quality and not used to inform program management or even future budgets, which are just carried over from year to year with small annual increases. Worse still, some provincial health departments have undermined facility-based efforts to implement their own data management systems, citing fragmentation and quality concerns. The time has come to either expedite the database selection process or publish data standards and guidelines and let the facilities select the database that best suits their needs. Changing the course of the South African epidemic cannot be the sole responsibility of government, and a commensurate effort by individuals and communities across the country is essential. All South Africans should know their HIV status. The new testing campaign announced by President Zuma is a start, but HIV testing must become habitual for all sexually active adults and adolescents. The Botswana model of opt-out testing, where doctors and nurses automatically suggest an HIV test during consultations – and the patient may elect to decline – resulted in the highest treatment coverage in Africa. In the absence of a “game-changing” bio-medical intervention (e.g. vaccine), it is up to all South Africans to cut the infection rate. Even under the rosiest of scenarios, 5 million are expected to contract HIV over the next 10 years. But this need not be a fait accompli. New research estimates that incidence among young women aged 15 to 24 dropped by 60 percent between 2005 and 2008, driven in part by higher rates of condom use. Significant reductions in new infections are possible through behavior change. A national social movement for behavior change, rooted in a national dialogue led by national and local leaders, churches, traditional healers, chiefs, private sector companies and others should focus on prevention in the context of epidemic drivers: intergenerational sex, multiple concurrent sex partnerships, and discordant couples. Indigenous leadership and organic, context-specific prevention initiatives are crucial: all prevention is local.

THE DEMAND FOR HIV SERVICES IN SOUTH AFRICA IS BEGINNING TO EXHAUST THE FINANCIAL AND HUMAN CAPACITY TO PROVIDE THEM. allocations from the Treasury show a clear commitment to grow domestic investment in HIV. However, with the U.S. President’s Plan for AIDS Relief (PEFPAR) – South Africa’s biggest AIDS donor – budget essentially frozen, and the Global Fund for AIDS, TB and Malaria facing its own multi-billion dollar budget gap, the prospects for additional donor money are bleak. Cost cutting and improved efficiency is imperative, starting with HIV drugs, which typically comprise more than 50 percent of total treatment costs. Incomprehensibly, South Africa pays more for drugs than its neighbors despite having the largest ART drug market in the world. The next biggest cost driver is staff – training lower level staff to perform more of the routine aspects of HIV care should yield savings without compromising quality. The current PEPFAR law expires at the end of 2013. Increased domestic spending shows the U.S. Congress that South Africa is serious about addressing AIDS, and should put it in a favorable position as it requests an extension of PEPFAR funds through 2015 (at which point the number of patients starting treatment should level off). The government would do well to organize an “all donors” financing meeting to secure longer-term commitments, coordinate funding streams and harmonize domestic and donor-funded programs. The demand for HIV services in South Africa is beginning to exhaust the financial and human capacity to provide them. Tough choices need to be made to close the demand-resource gap, but it’s not clear just how willing leaders and citizens alike are to engage in HIV/AIDS realpolitik. What is the government willing to pay for HIV and AIDS care? What is required of communities and individuals? The role of the private sector? And civil society?

Government has two options to address the HIV program financing gap: increase investment and reduce costs. In reality, it needs to do both. The new budget

At the January meeting in Cape Town, there was consensus that South Africa is exceptional, not just for the scale of its epidemic, but also for its ability to lead the region and the world in responding to the global AIDS crisis. Its ability to succeed requires bold leadership and an engaged populace: the paradigm shift begins now. The success of the World Cup shows this is indeed possible. GH


&View the full report on

PAGE 23 —









How often do we think about the connection between our health and the health of the planet? A healthy earth, in balance with a stable climate, is a basic requirement for the thriving of human life – and disruptions to this system have direct implications on global health. The World Health Organization has stated that “climate change affects the fundamental requirements for health – clean air, safe drinking water, sufficient food, and secure shelter.” In fact, in 2008, the WHO selected climate change as the theme of World Health Day, in recognition of the growing threat climate change poses to global public health security.

“I enjoy staying in the classroom where I can concentrate on studying,” fifth-grader Lalit Khatri told me when I spoke to him at the Pashupati Primary School in Dashera village, which is located in the Jajarkot District of Nepal.

In 2009, the Lancet Commission produced a report describing climate change as “the biggest global health threat of the 21st century.” The Commission described the climate change threat to public health as a matter of “clear and present danger” affecting billions of people across the globe – not just in a distant future, but rather in “our lifetimes and those of our children.”

Through its local partner, Nepal Water for Health, Concern recently implemented a program to improve water and sanitation facilities at Lalit’s school in an effort to promote basic health for the students of this rural region. I was back to visit with the children and teachers and see how the project was impacting their lives.





The implications of the hidden epidemic is discussed by Elden Chamberlain of AIDSTAR Two/International HIV AIDS Alliance.

Marco Gomes, of the Centre for Health Policy and Innovation, IDRC, explores this topic.









AT THE HEART OF THE MDGs Progress on the health MDGs, particularly in maternal, newborn and child health, requires equitable access to quality, essential health services. Nowhere is this more evident than in fragile contexts, where levels of morbidity and mortality are highest and where progress on the MDGs is most off-track. This is a huge challenge, but one that must be met if we are to reach the millennium targets and realise the right to health for all. Globally, more than 2 million more doctors, nurses and midwives are needed – the number balloons to 4 million if managers and other public health workers are included. These figures, however, mask particular shortages, both between and within countries. Fifty-seven counties currently fall below the WHO target of 2.3 health workers (doctors, nurses and midwives) per 1,000 population – the minimum health worker density needed to deliver essential health care. For many sub-Saharan African countries and some parts of Asia, the distribution is far less than 1.15/1000.



Research and development (R&D) for neglected diseases can significantly change the public health equation for the world’s poorest countries. However, global research for diseases of the developing world is still too fragmented and we continue to need a much greater critical mass and more partnerships between the public and private sectors to take on crucial global public health challenges. Take malaria, for example. The disease takes a devastating toll on communities and economies across Africa. The battle against malaria must be fought on all fronts using a wide range of interventions, including insecticide-treated bed nets, indoor residual spraying, effective medicines and treatments, and eventually, a vaccine – a core component of the malaria R&D agenda. R&D can help address these challenges and industry must play its part in tackling these kinds of global health problems. Given the scale of the task we all face, particularly in malaria, we must find new ways for industry, academia, NGOs and governments to work together on global health R&D.



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Issue #7 - Climate & Change - Global Health Magazine  

Global Health Magazine Issue #7 Summer 2010

Issue #7 - Climate & Change - Global Health Magazine  

Global Health Magazine Issue #7 Summer 2010