Climate Change Public Health Impacts

1. Climate Change Public Health Impacts Helene G. Margolis, PhD Source: NASA California Public Health Association – North 2008 Annual Meeting UC Davis, Davis, California March 14, 2008 Environmental Health Investigations Branch Division of Environmental & Occupational Disease Control University of California, Davis Department of Internal Medicine

2. Overview • Changing Planet: Net Results • Public Health Impacts: Opening Thoughts • Comment on the current ‘big picture’ • Taking a broad perspective on “Vulnerability” • Direct Effects • Effects Arising from Ecological Shifts & Environmental Degradation • Public Health Impacts: Closing Thoughts

3. Our Changing Planet: Net Results Predicted Weather-related Consequences • “Virtually certain” Over most land areas • Warmer and fewer cold days and nights • Warmer and more frequent hot days and nights • “Very Likely” Over most areas • Warm spells / heat waves. Frequency increases • Heavy precipitation events. Frequency (or proportion of total rainfall from heavy falls) increases • → increased risk of floods and/or damage to buildings hgm • “Likely” • Area affected by droughts increases • Intense tropical cyclone activity increases • Increased incidence of extreme high sea level (excludes tsunamis) Source: IPCC Climate Change 2007: The Physical Science Basis: Summary for Policymakers

4. Public Health Impacts: Opening Thoughts • Climate change will lead to amplification of: • Most existent public health challenges.... • Serious consequences in developed nations, • catastrophic consequences in struggling nations. • Including health risks known to be associated with outdoor and indoor environments…. Currently no great surprises. However, amplification will highlight and/or reveal weaknesses in public health and societal infrastructures. Those weaknesses reflect vulnerabilities – at level of nations, regions, State, local (County, community, neighborhood), populations & individuals Identification of those vulnerabilities in advance of crisis will serve us well in mitigation of climate change impacts.

5. Vulnerability: Conceptual Framework As for most public health issues… There are disparities in how climate change will impact different sub-populations, .e.g., lower socioeconomic groups, elderly, people of color. The relative impacts are a function of individual & population Vulnerability The impact of environmental factors on populations… begins with impacts on individuals.

6. Environmental Impacts of Global Warming & Sequelae “Exposures” Extreme Weather Events Heat Waves Floods Droughts Wildfires Air Pollution (O3, PM, GHG) Nuisance Plants Allergens Pesticides Ecological Shifts => Distribution & abundance of : hosts, vectors, pathogens of Vector-Borne Diseases Water-Borne Pathogens Water-Food Supply & Quality Malnutrition, diarrhea, harmful algal blooms “Public Health Impacts” Acute Morbidity/Mortality Injury Heat-related illness Chronic dz. acute events Toxin-related illnesses Chronic Disease Respiratory (Asthma, COPD, Allergy) Cardiovascular (Atherosclerosis, ... Communicable Disease V-B: West-Nile, malaria, dengue, encephalitis, hantavirus, Rift Valley fever W-B: Cholera, cryptosporidiosis, campylobacter, leptospirosis Population Displacement Psychosocial Greenhouse Gases => ◊ Changing Climate ↑ Long-term Ave. Temp. ↑ Freq. Hot Days/Nights (& Heat Waves) ↓ Freq. Cold Days/Nights ↑ Heavy Rainfall Events (without ↑ in total annual precipitation) ↓ Snowfall & Snow pack ↓ Mountain Glaciers ↑ Drought (Areas, Freq. & Duration) ↑ Tropical Cyclones & Hurricanes (Freq. & Intensity) ↑ Extreme High Sea Level ◊ Plant Growth (CO2) ◊ Ozone & photochemicals Source: IPCC Climate Change 2007: The Physical Science Basis: Summary for Policymakers

7. Public Health Impacts: Direct Effects • Extreme weather events (Heat waves, storms, floods, droughts, hurricanes, tornadoes) • Short-time course events present immediate risk of • Death • Injury & complications of injuries (e.g., wound infections) • Infectious disease outbreaks • Hurricane Katrina: ~1000 cases of diarrheal diseases (e.g., norovirus) among evacuees in Texas & Mississippi. • Increased risk of exposures to toxic agents • Psychosocial stress • Disruption & Displacement • Longer-time course events (e.g., droughts) • Greater adaptive capacity; Still pose risks to public health

8. Public Health Impacts: Direct Effects • Temperature-related Illness and Mortality • Fewer cold- and heat-related deaths in past 30 yrs (US) • Attributed to higher % of homes with central heat & AC • Heat Wave: National Weather Service definition (e.g.) ≥ 3 consecutive days with temperatures ≥ 90°F (32.2°C) Heat stress & exhaustion Cramping Heavy perspiration Weakness Heat Stroke Core body temperature >104°F Multi-organ system dysfunction Often fatal despite treatment Risk Factors Exertion Dehydration Children ≤ 5 years or Age >60 years Lack of air conditioning Social isolation Chronic diseases (CVD, COPD) Cognitive and mobility impairments Low socio-economic status Housing characteristics

9. Public Health Impacts: Direct Effects • Prevention requires knowledge not assumptions • Heat-related morbidity/mortality risk is greater in cooler climates than in warmer climates • More northern latitudes and higher elevations • Attributed to less capacity to acclimatize through physiological, behavioral, technological means. • Built environment • Access/Use of AC • Example: Weather-related influence on hospitalizations for cardiovascular diseases & stroke greater in San Francisco than in Los Angeles (Ebi KL et al. Int J Biometeorol 2004;49(1):48-58) • Fans may contribute to heat stress & illness when high humidity (> ~33%) and high temperatures (≥ 90°F (32.2°C)) or temperatures ≥ 100°F (37.8°C).

10. Public Health Impacts: Simultaneous Risks Built Environment & Co-Exposures: Heat Islands, Topography & Ozone El Dorado County Built-up rural area

11. Public Health Impacts: Direct Effects2006 Heat Wave in California Heat-Related Deaths in Counties with ≥10 DeathsJuly 15 – August 1, 2006 99% of cases lived in zip codes where > 50% of residents live below Poverty Guide Line Source: R. Trent, T. Kim. 2007. CDPH

12. Public Health Impacts: Indirect Impacts of Direct Effects • Economic impacts of heat wave on dairy industry ~ $1 Billion. 2006 California heat wave kills 16,500 dairy cows statewide. (Other estimates – 25,000 in Central Valley or 1% of State’s Dairy Herd succumbed plus 70,000 poultry (Source: http://news.bbc.co.uk/1/hi/world/americas/5223172.stm) Central Valley saw disruption of animal breeding and >10% reduction in milk-production. Source: Fresno Bee: Mark Crosse • Wide array of potential “downstream” public health risks e.g., water quality, communicable disease, psychosocial stress Misters give cows some relief at Pacheco Dairy in Kerman, Fresno County. Source: Fresno Bee/Mark Crosse Source: Modesto Bee/Marty Bicek

13. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • Insect- & Animal-Borne Diseases Temp, humidity, rainfall & sea level influence geographic distributions & population growth of infectious disease-causing pathogens (e.g., viruses, bacteria) & reservoir hosts (e.g., rodents, deer, birds) & vectors (e.g., mosquitoes, ticks, fleas) which exist in complex ecologic relationships Examples: • 1992/1993 Hanta Virus outbreak (HV pulmonary syndrome) (New Mexico, Arizona, Colorado, Utah) drought followed by El-Nino related heavy rainfall; ↑ mouse population & movement indoors • 1999 West Nile Virus (WNV) – Arbovirus (mosquito-borne virus) associated with drought conditions First US cases in NY during hottest summer on record to that date CA -- by 2004 – 830 human cases across 58 counties

14. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • Emergent & Re-emerging Infectious Diseases • Potentially: • Malaria • Dengue • Viral encephalitides • Cholera • etc, etc., etc. http://www3.niaid.nih.gov/research/topics/emerging/default.htm

15. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • Water- & Food-Borne Diseases (Longer-term changes & extreme weather events) Naturally occurring toxins (e.g., phytoplankton – red tides) Infectious disease pathogens • Relatively rare in U.S. Adequate food safety systems Good drinking water supply systems • One failure can be costly 1993 Cryptosporidiosis outbreak in Milwaukee 400,000 people infected $96 million ($32M direct medical; $65M lost productivity) Attributed to drinking water contamination Coincided with Mississippi River flooding • Reduced snow pack, altered rainfall…. ↓ water supply (surface & groundwater) ↓ water quality

16. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • ↑ Temperature + ↑ UV radiation + primary emissions = ↑ secondary air pollutants (ground-level ozone, particulates) • Predicted ↑ extreme heat episodes = ↑ electric power use (= ↑ emissions & pollutant formation) • Particulate Matter (PM) ≤ 10 (PM2.5, PM10-2.5) associated with premature deaths Annual CA:8800 (3000, 15,000 probable range) hospitalizations Annual CA:9500 (4600, 14,000 probable range) California Air Resources Board • Ozone associated with 3-fold increased risk of new onset asthma among children who participate in ≥ 3 team sports McConnell et al., Lancet 359: 386-391, 2002. • Nitrogen dioxide & other combustion-related pollutants associated with permanent deficits in children’s lung function growth. Gauderman et al. New Engl. J. Med. 351(11):1057-67, 2004.

17. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • Increases in Aeroallergens & Plant Biomass • CO2 is essential to photosynthetic processes promotes plant growth • ↑ CO2 = ↑ Invasive plant species • ↑ Temperatures + ↑ CO2 = ↑ Ragweed in urban locations (grew faster, flowered earlier, greater above-ground biomass & pollen) Ziska LH et al. J Allergy Clin Immunol 2003;111(2):290-5. • ? Increase in asthma & allergy in urban communities? (↑ exposures to allergens or allergen+ diesel emissions) Diaz-Sanchez, D. et al. Current Allergy and Asthma Reports 2003;3(2):146-52. • ↑ Biomass + more arid conditions = ↑ risk of wildfires (↑ risk of injury & ↑ air pollution)

18. Public Health Impacts: Effects Arising from Ecological Shifts & Environmental Degradation • Increased Risk of Exposure to Pesticides & Herbicides • Response to shifts in distributions of vector species, agricultural pests and nuisance or invasive plants will likely lead to increased use of pesticides & herbicides • ↑ Use in urban areas (e.g., West Nile Virus eradication programs short-term use may have + cost-benefits long-term/frequent use cost-benefits unknown.) • Residential developments near agricultural areas

19. Public Health Impacts: Closing ThoughtsVulnerability, Disparities & Social Responsibility To reduce vulnerability at individual, population or community levels: Promote good health (reduces risk, increases resilience) Ensure access to health care, medical management Improve standard of care for all groups (Increase physician awareness) Reduce potential exposure (individual, community) Prevention & Response Ensure response is adequate & does no harm (e.g., cooling centers & transportation; not fans) In developing/applying solutions think about unintended consequences. Investment of resources to mitigate climate-change health impacts can also contribute significantly to improvement of overall health of the public.

20. Public Health Impacts: Closing Thoughts • Actions • Public health networks • Develop a comprehensive and coordinated strategy to prevent or mitigate the hazards posed. • Strategies can capitalize on existing surveillance systems and databases to detect, track, evaluate, prepare for and respond to those hazards with optimum adaptive strategies. • Capitalize on existing public health, clinical and societal infrastructure to apply adaptive strategies. • Identify weaknesses in infrastructure/strategies & fix.

21. Public Health Impacts: Closing ThoughtsActions • Public health and environmental protection strategies need to be integrated, complementary... • For example – Community actions to increase air conditioning in residences, need to be accompanied by actions that promote more green-energy production strategies. • Public health and environmental protection strategies need to be Equitable. • Public health community needs to be a partner in promotion of ‘climate change solutions.’ • Education & Outreach • Get the messages right & get them coordinated.

22. Public Health Impacts: Closing Thoughts Global Responsibility Source: Patz, J. Nature: 438 (November 2005)

23. “Climate Change Public Health Impacts Assessment and Response Work Group” Scripps Institution of Oceanography Alexander Gershunov, Ph.D. UC Berkeley/LBNL Thomas McKone, Ph.D. Richard Jackson, M.D. NRDC Gina Solomon, M.D., M.P.H. Miriam Rotkin-Ellman, Ph.D. Zev Ross Spatial Analysis Ithaca, NY CDPH: EHIB Helene Margolis, Ph.D., M.A. Paul English, Ph.D., M.P.H. Thomas Kim, M.D. Kathleen Fitzsimmons, M.P.H. CDPH: EPIC Roger Trent, Ph.D. CDPH: DCDC Anne Kjemtrup, D.V.M., Ph.D. Jonathan Kwan, Ph.D. CDPH: EHLB – IAQS Jed Waldman, Ph.D. OEHHA Bart Ostro, Ph.D.

24. Contact Information: Helene G. Margolis, Ph.D., M.A. hmargoli@cdph.ca.gov helene.margolis@ucdmc.ucdavis.edu 916-552-9837 Thank You!