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Climate change and Health Across Africa: Issues and Options

Working Paper 20

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United Nations Economic Commission for Africa

African Climate Policy Centre

Working Paper 20

CLIMATE CHANGE AND HEALTH ACROSS AFRICA:

ISSUES AND OPTIONS

November 2011

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Acknowledgment

This paper is the product of African Climate Policy Center (ACPC) of United Nations Economic Commission for Africa (UNECA) under the Climate for Development in Africa (ClimDev Africa) Programme. The paper is produced with guidance, coordination and contribution of ACPC and contributing authors from various institutions. Contributions to this paper are made by Owen C. Owens and Chuks Okereke from the University of Oxford, Smith School of Enterprise and the Environment; Jeremy Webb from the UNECA-ACPC, and Miriam Musa, York University, Ontario, Canada. This working paper is prepared as an input to foster dialogue and discussion in African climate change debate. The findings, interpretations and conclusions presented in this working paper are the sole responsibility of the contributing authors and do not in any way reflect the official position of ECA or the management team. As this is also a working paper, the ECA does not guarantee the accuracy of the information contained in this publication and will not be held responsible for any consequences arising from their use. Copyright © 2011, by UNECA. UNECA encourages the use of its material provided that the organization is acknowledged and kept informed in all such instances. Please direct inquiries and comments to: acpc@uneca.org

A free copy of this publication can be downloaded at http://www.uneca.org/acpc/publications

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TABE OF CONTENTS LIST OF FIGURES ......................................................................................................... iv LIST OF TABLES ........................................................................................................... iv LIST OF ACRONYMS .................................................................................................... v Abstract ............................................................................................................................. 1 Introduction ...................................................................................................................... 2 ClimatechangeandhealthacrossAfrica:criticalissues............................................................3 ClimatechangetrendsacrossAfrica...................................................................................................4 ImpactsonHealth.......................................................................................................................................5 

Indirect impacts ................................................................................................................. 5 Malnutrition...................................................................................................................................................6 Communicablediseases............................................................................................................................7 NeglectedTropicalDiseases...................................................................................................................8 Waterborndiseases................................................................................................................................11 Diarrhoea................................................................................................................................................11 

Vectorborndiseases...............................................................................................................................12 Malaria......................................................................................................................................................13 

Meningitis–anairbornedisease.......................................................................................................16 HIV/AIDS......................................................................................................................................................18 Socialstatus.................................................................................................................................................18 

Direct impacts ................................................................................................................. 21 Extremeweathereventsandtheirdirecteffects........................................................................21 UVrelatedcancersanddiseases........................................................................................................22 Temperatureandprecipitationeffects...........................................................................................23 Airquality....................................................................................................................................................25 

Gaps in knowledge and research ..................................................................................... 25 Africa’s response to climate change and health ............................................................... 27 Options for consideration ................................................................................................ 28 References ....................................................................................................................... 31 

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LIST OF FIGURES

Figure1:Potentialhealtheffectsofclimatechangeandhealth.AdaptedfromPatzetal.(2000).....................................................................................................................................................................2 Figure2:DistributionoftheprevalenceofNTDsinAfrica.Source:ImperialCollegeLondon,SchistosomiasisInitiative(availableat:http://www3.imperial.ac.uk/schisto/whatwedo/ntdsinafrica).................................................9 Figure3:Malariaendemicity:thespatialdistributionofP.falciparum(Hayetal.,2009)..................................................................................................................................................................................14 Figure4:Africanmeningitisbelt(Palmgren,2009;WHO/EMC/BAC/98.3)........................16 Figure5:AssociationbetweenGDP/personadjustedfor$USPurchasingPowerParityandlifeexpectancyfor155countriescirca1993(Lynchetal.,2000)....................................19 Figure6:AfricanCO2emissionscomparedwiththeworld(UNEP,2002)............................20 Figure7:TemperaturechangesinAfricacomparedwiththeworld(UNEP,2002)..........24 

LIST OF TABLES

Table1:Healthrelatedimpactsofclimatechange(TheSmithSchoolofEnterpriseandtheEnvironment,2010).................................................................................................................................5 Table2:ExamplesofNTDsaffectedbyclimatechange.(Hotez&Kamath,2009[http://goo.gl/qgFIA&http://goo.gl/XJdpT])...................................................................................10 Table3:Examplesofvectorbornediseasesaffectedbyclimatechangeindecreasingorderofaffliction.............................................................................................................................................12 Table4:NumberofpeoplekilledinEWEsinthe1980’sand1990’sbyglobalregion(McMichaeletal.,2003)...............................................................................................................................22 

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LIST OF ACRONYMS ACPC AfricanClimatePolicyCentreAIDS AcquiredImmuneDeficiencySyndromeCHWGClimateandHealthWorkingGroupDALYs DisabilityAdjustedLifeYearsEWE ExtremeWeatherEventHESA HealthandEnvironmentStrategicAlliancefortheImplementationofthe

LibrevilleDeclarationHIV HumanImmunodeficiencyVirusIPCC IntergovernmentalPanelonClimateChangeIRI InternationalResearchInstituteforClimateandSocietyNPJAs NationalPlansofJointActionsNTDs NeglectedTropicalDiseasesSANA SituationAnalysesandNeedsAssessmentSSA Sub‐SaharanAfricaUNFCCC UnitedNationsFrameworkConventiononClimateChangeUNDP UnitedNationsDevelopmentProgrammeUV Ultra‐VioletWHO WorldHealthOrganization

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Abstract

Climatechangeisexpectedtoaltertemperature,airmovement,andprecipitationinvariouswaysandtovaryingdegreesacrossAfricawithconsequencesforhumanhealth.Withthestrongconnectionbetweenapopulation’shealthandeconomicandenvironmentalhealth,theimpactofclimatechangeoneachisoneofthemajorwaysinwhichclimatechangemayimpedethedevelopmentoftheAfricancontinent.

AfricancountrieswillsufferhealthconsequencesduetoimpactsofclimatechangeasmanyAfricancountrieshavepopulationsthatareamongthemostvulnerabletoclimaticchangesintheworld.Thisvulnerabilityisdueinparttoexistingproblemsofpoverty,weakinstitutionsandarmedconflict,whichlimitapopulation’scapacitytodealwiththeadditionalhealthchallengesposedbyclimatechange.Therelativeimpactofclimaticandsocioeconomicfactorsisgenerallydifficulttoquantify.ThiscomplexityinturnaffectsthecertaintyofstudiesandpoliciesonthehealthimpactofclimatechangeonAfrica.

Themajorityofhumanhealthproblemsthatcanbelinkedtoclimatechangearenotstrictlyspeakingcreatedbychangesinclimatebutareproblemsexacerbatedbychangingweatherpatternsandclimaticconditionsleavingpopulationsillpreparedfornewhealthimpacts.Forexample,climatechangemayaffecthealththroughincreasedfrequencyandintensityofextremeweathereventswhicharedriversofmalnutritionandcandirectlyimpacthealthforexampleduringheatwaves.Risingtemperatureswillaffectpathogenlifecycleandrangeaffectingrateofinfections,especiallyvector‐bornediseases.TheoverallbalanceofeffectsfromclimatechangeonhealthgloballyislikelytobenegativeanditispredictedtobemuchgreaterinAfricanpopulationsthaninEuropeanpopulationsforexample.

WithinAfricathetypeandmagnitudeofthehealthimpactsofclimatechangewillvarysignificantlyamongcommunitiesandregions.Variationswillbeduetomanyfactorssuchasgeographicandmicroclimatedifferences,socio‐economicconditions,thequalityofexistinghealthinfrastructure,communicationcapacityandunderlyingepidemiology.

ThisworkingpaperlaysoutthecurrentstateofknowledgeregardingdirectandindirectimpactsofenvironmentalfactorsonhealthacrossAfrica.Whiletherearemanyuncertaintiesinmagnitudesofclimatechange,particularlywithtiming,theexistingliteraturemakesinterestingobservationsaboutpotentialhealthimpactsandthepopulationsthatcouldbemostatrisk.TheworkingpaperpresentsthepotentialimpactsclimatechangemayhaveonhumanhealthandanalysesthevariousdirectandindirectimpactsthatclimatechangewillhaveonAfricanpopulations.Duetotheemergingnatureoftheissueandliterature,therearemanygapsinknowledgeontheimpactsclimatechangewillhaveonhumanhealth.

ImportantlyAfricaisalreadyaddressingclimateandhealth,andexamplesinclude"TheLibrevilleDeclarationonHealthandEnvironmentinAfrica"byAfricanMinistersofHealthandMinistersofEnvironment,alongwithgrassrootsactionssuchthosebeingtakenbytheClimateandHealthWorkingGroupinEthiopiaandelsewhere.Intermsofpolicyanimportantquestionis:whatshouldbedonedifferentlytoaddresshealthconcernsacrossAfricagivenwhatweexpectintermsofclimatechange?Insomecasesitmaybemoreofthesame(e.g.theuseofmosquitonetsandothermeasurestopreventmalaria).Inothercaseseffectivepreparationorresponsemayrequirecompletelydifferentapproachestohealthcareacrossthecontinent.

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Introduction

Itiswellknownthatthehealthofapopulation,ifitistobesustained,requirescleanair,safewater,adequatefood,tolerabletemperature,stableclimate,andhighlevelsofbiodiversity(WHO,1995;IPCC,2007).Globally,climatechangeisexpectedtoaltertemperature,airmovement,andprecipitationinvariouswaysandtovaryingdegreesacrossAfricawithconsequencesonhumanhealth.Withthestrongconnectionbetweenapopulation’shealthandeconomicandenvironmentalhealth,theimpactofclimatechangeoneachisoneofthemajorwaysinwhichclimatechangemayimpedethedevelopmentoftheAfricancontinent(IPCC,2001;Sperling,2003;Stern,2006).

Africancountrieswillsufferserioushealthconsequencesduetoimpactsofclimatechange.ManyAfricancountrieshavepopulationsthatareamongthemostvulnerabletoclimaticchangesintheworld.Thisvulnerabilityisdueinparttoexistingproblemsofpoverty,weakinstitutionsandarmedconflict,whichlimittheircapacitytodealwiththeadditionalhealthchallengesposedbyclimatechange.Therelativeimpactofclimaticandsocioeconomicfactorsisgenerallydifficulttoquantify.ThiscomplexityinturnaffectsstudiesandpoliciesonthehealthimpactofclimatechangeonAfrica.Ingeneral,itisrarelypossibletoseparateclimaticandsocio‐economiceffectswhenassessingthehealthimpactsofclimatechangeonanyspecificpopulation(Figure1).

Figure1:Potentialhealtheffectsofclimatechangeandhealth.AdaptedfromPatzetal.(2000).

Health Effects

Temperature-related illness and death

Extreme weather related health effects

Effects of food and water shortages

Air pollution related health effects

Water and food-borne diseases

Vector-borne diseases

Regional Weather Changes Temperature

Heat waves

Precipitation

Extreme weather events

Modulating Influences Population growth

Standards of living

Health care facilities

Demographic change

DiseasePathways Air pollution levels

Contamination pathways

Transmission dynamics

Climate Change

Adaptation Measures

Themajorityofhumanhealthproblemsthatcouldbelinkedtoclimatechangearenotstrictlyspeakingcreatedbychangesinclimate.Rather,theyareproblemsexacerbatedorintensifiedbychangingweatherpatternsandotherclimaticconditionsleavingpopulationun‐or‐ill‐preparedfornewhealthimpacts.Forexample,climatechangemayaffecthealththroughincreasedfrequencyandintensityofextremeweatherevents(EWEs)(suchashurricanes,heat‐waves,floods,anddroughts)eachofwhicharedriversofmalnutritionandchangesinthedistributionofdiseases.Risingtemperatureswillaffectpathogenlifecycleandrangeaffectingrateofinfections,especiallyvector‐bornediseases(Costelloetal.,2009).Anincreaseinglobalmeantemperaturewillalso

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alterheatandcold‐relateddeathratesaroundtheglobe(Costelloetal.,2009).Whiletheremightbesomepositivebenefitsassociatedwithweatherchangessuchasareductionincold‐relateddeathsinsometemperateregions,theoverallbalanceofeffectsonhealthgloballyislikelytobenegative(IPCC,2007).Theseeffectswillnotbeevenlydistributedacrosstheworld’spopulationsaslossofhealthylifeyearsasaresultofclimatechangeispredictedtobe500timesgreaterinpoorerAfricanpopulationsthaninricherEuropeanpopulations(Ebi,2006;McMichaeletal.,2008).

EvenwithinAfrica,thetypeandmagnitudeofthehealthimpactsofclimatechangewillvarysignificantlyamongcommunitiesandregions.Variationswillbeduetomanyfactorssuchasgeographicdifferencesintemperatureandprecipitation,socio‐economicconditions,thequalityofexistinghealthinfrastructure,communicationcapacityandunderlyingepidemiology.Therefore,inthisreportwelayoutthecurrentstateofdirectandindirectimpactsofenvironmentalfactorsonhealthinAfrica.Whiletherearemanyuncertaintiesinmagnitudesofclimatechange,particularlywithtiming,theexistingliteraturemakesinterestingobservationsaboutpotentialhealthimpactsandthepopulationsthatcouldbemostatrisk.

Thesectionsbelowwill: identifycurrenthealthissuesacrossAfrica; introducethecurrentunderstandingofchangesintemperature,precipitation,

andextremeweathereventsexpectedaspartofclimatechangeacrossAfrica; presentthepotentialimpactsclimatehasonhumanhealth; analysethevariousdirectandindirectimpactsthatclimatechangewillhaveon

Africanpopulations; acknowledgeanddiscussgapsinknowledgeoftheimpactsclimatechangewill

haveonhumanhealth,and; assessoptionsandthewayforwardtoaddressclimatechangeandhealthacross

Africa.

Climate change and health across Africa: critical issues

Inouranalysis,carefulattentionispaidtodistinguishingclimateandhealthissuesfromclimatechangeandhealth.Theformerreferstotheexistingstatusquoandthehistoriclinksbetweenclimateandhealth.Thelatterrelatesmorespecificallytotherelationshipbetweencurrentandfutureanthropogenicclimatechangeandconditionsofhealth.Forexample,itisevidentthattheprevalenceofmalariainthecontinentisrelatedtotropicalclimateacrossAfrica.Infuture,however,thenatureandspreadofmalariaacrossthecontinentmaywellbeaffectedbythechangesintemperatureandprecipitationexpectedwithinthecontinent.

Ingeneral,climatechangewillacttoincreaseordecreasetheprevalenceofdisease,injuryorotherhealthissues.However,itisdifficulttogauge,intermsofnumbers,howmanymoreorlesspeoplewillbeaffectedindifferentpartsofAfrica,whatchangesinmortalitytheremaybeorthechangesinDisabilityAdjustedLifeYears(DALYs).Thisuncertaintyisduemainlytothescarcityofmodelsthatcanrobustlypredictpatternsofclimatechangeatnationalandlocalscales.Inadditiontothis,manyAfricancountriescurrentlyexperiencealotofsocio‐economicchallenges,whilecompoundingtheeffectsofclimatechangeonhealth,aredifficulttoseparateoutfromthosecausedbyclimatechange.

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Accordingly,acriticalissueforAfricancountriesandgovernmentsisnotjusttheinfluenceclimatechangemayhaveonhealth,butwhatneedstobedonetoimprovehealthservicesandconditionsgenerallyandespeciallytakingintoaccountclimatechange.ThiscanbereferredtoasthepolicydimensionofclimatechangeandhealthaimedatdrivingmitigationandadaptationmeasurestoimproveAfricanhumanhealth.Perhapsthemostimportantquestionis:whatshouldbedonedifferentlytoaddresshealthconcernsacrossAfricagivenwhatweexpectintermsofclimatechange?Insomecasesitmaybemoreofthesame(e.g.theuseofmosquitonetsandothermeasurestopreventmalaria).Inothercaseseffectivepreparationorresponsemayrequirecompletelydifferentapproachestohealthcareacrossthecontinent.

Climate change trends across Africa

TheIPCCreport(2007)andtheAfricanClimateTrendsandProjectionsreport(2007)provideagoodsummaryofkeytrendsandoutlinesbasedonthebestavailableprojectionsforclimatechangeinAfrica.Thesearesummarisedbelow:

Withrespecttotemperature:o LandareasoftheSaharaandsemi‐aridpartsofsouthernAfricamaywarmbyasmuchas1.6°C(Hernesetal.,1995;Ringiusetal.,1996).

o Inthattime,equatorialcountries(eg:Cameroon,Uganda,andKenya)mightwarmabout1.4°C.

o Sea‐surfacetemperaturesintheopentropicaloceanssurroundingAfricaareexpectedtoincreaselessthantheglobalaverage,onlyabout0.6‐0.8°C,thereforethecoastalregionsofthecontinentareexpectedtowarmmoreslowlythanthecontinentalinterior.

PrecipitationchangesexpectedbymostGCMsindicaterelativelymodestmoistureincreasesovermostofthecontinent.

o AlthoughsouthernAfricaandpartsoftheHornofAfricashouldexpectadeclinebyabout10%.

o Seasonalchangesinrainfallarenotexpectedtobelarge(Joubert&Tyson,1996;Hewitson&Crane,1996).

o PartsoftheSahelcouldexperiencethegreatestincreasesinrainfallbyasmuchas15%overrecentaverages.Itisimportanttonotehere,however,thatthisriseinrainfallwouldfollowadroughtthathaslasted30yearsintheregion.

o EquatorialAfricacouldexperienceasmall(5%)increaseinrainfall. Extremeweatherevents(EWEs)arestillpoorlyunderstoodandconclusive

evidenceastochangesintheirfrequencyisnotagreeduponintheliterature.o CurrentlyoccurringEWEsthattheAfricanpopulationneedtocontendwithareheatwaves,droughts,andheavyprecipitation).

o Althoughtheirprevalenceisnotexpectedtochangemuch(IPCC,2007),theircompoundingeffectsonotherclimatechangesareacauseforconcern.

Thelikelyandpotentialimpactsthesechangesinclimatemayhaveonhealtharediscussedbelow.

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Impacts on Health

Whenaddressingclimatechangeandhealthitisimportanttobeawarethatclimatechangecandirectlyandindirectlyimpacthealth.Directhealthimpactsaffecthumanbiologydirectlyandincludeinjury,morbidityandmortalitycausedbyclimate‐inducedEWEs(suchascyclones,floods,anddroughts),thermalstress(heatwavesandcoldperiods),skinandeyedamage(viaUVradiation),andcardio‐respiratorydiseasesdirectlyrelatedtochangesintemperatureandairquality(Table1).Howevermostofthehealthimpactsofclimatechangeareindirect.Indirectimpactsaffectnon‐humanbiogeochemicalsystemsandincludemalnutrition(duetodecreasecropsuccess),waterinsecurityandqualitychanges,lifecycleandrangeofpathogensviawaterandvectors.TheclassificationofdirectandindirectheathimpactsofclimateisabitcomplexbutTable1belowprovidesasummaryofthebreakdownusedforthepurposesofthispaper.

Table1:Healthrelatedimpactsofclimatechange(TheSmithSchoolofEnterpriseandtheEnvironment,2010).

ClimateChanges HealthImpacts

Direct

EWEs Highlevelsofmortalityandmorbidity,changeindiseaseprevalenceandpatterns

Temperature Thermalstress,skincancer,eyediseases

Airquality Cardio‐respiratorydiseases,allergicdisorders

Indirect

Temperature Foodavailability,malnutrition,famine,infectiousdiseasesofmigrants,droughts

PrecipitationWater‐bornediseases,vector‐bornediseases,droughts,foodandwateravailability

EWEs(+rainfall+temperature+ecosystem)

Diseasesofmigrants,conflicts,foodandwateravailability,malnutrition,famine

Ecosystemcompositionandfunction

Foodyieldsandquality,aeroallergens,vector‐bornediseases,water‐bornediseases

Itisimportanttostressthatclimateandclimatechangeareonlysomeoftheimpactshumanhealthisinfluencedby.Asstated,healthoutcomesareusuallytheresultofcomplexinteractionsbetweensocial,cultural,andeconomiccharacteristics,geographicsettings,andpre‐existinghealthstatus.GiventhatmuchofthehealthimpactofclimatechangeinAfricawillbeviatheindirectroute,wediscussthesefirstbeforeturningtothedirectheatheffects.

Indirect impacts

Thepotentialindirecthealtheffectsofclimatechangeonacommunities’healthwilloccurpredominantlythroughchangestonon‐humanbiologicalorbiogeochemicalsystems.Thisincludeschangesincropyield,geographicalrangeanddistributionofinfectiousdiseasesandtheirmethodsoftransportandresultsofadditionalsocial

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pressuresthatresultfromchangesinrainfallandtemperature.Ultimatelytheseclimaticchangesplacepressureonill‐preparedhumansupportsystemsbeyondfoodandwatersecurityandthecapacitytomanagealreadystressedhealthcaresystems.

Malnutrition

Goodnutritionisessentialforgoodhealth.Deficienciesinenergy,fat,protein,nutrientorvitaminintakeleadtomalnutritionwithmajorconsequencesforpeoples’physicalandmentalhealth.Malnutritionhasdetrimentalandlastinghealthconsequencesoftenlimitingaperson’sphysicalandintellectualdevelopment,particularlythosewhoareaffectedasinfantsorasyoungchildren.Additionally,malnutritionvastlyincreasespeoples’susceptibilitytoacquiring,anddyingfrominfectiousdiseases(Baro&Duebel,2006;Schaible&Kaufmann,2007;Confalonierietal.,2007).Itaffectsgroupsofpeoplewhoaremostvulnerabletochangingenvironmentalpatterns,suchasfarmersandcoastalcommunities,andthosewhoareleastabletopurchasefoodsuchasthepoorandlandlesswagelabourers.

Malnutritionisconsideredthemostimportanthealthriskgloballyasitaccountsforanestimated15%oftotaldiseaseburdeninDALYs.Atpresent,under‐nutritioncauses1.7milliondeathsperyearinAfricaandiscurrentlyestimatedtobethelargestcontributortoclimatechangerelatedmortalityaroundtheworld(Patzetal.,2005).Moreoverleadingscientistsindevelopmentandhumanitarianresearchagreethatclimatechangewilllikelyworsenexistingproductionandconsumptionstressesinfood‐insecurecountries(Bloemetal.,2010,p.133S;Schmidhuber&Tubiello,2007,p.19704).Bloemetal.(2010)explainthataccesstofoodreliesontwokeyfactors:availability(throughthemarketorsubsistentproduction)andaffordability(throughmonetaryincome).AvailableevidencestronglyindicatesthatclimatechangewillnegativelyaffectfoodavailabilityandaffordabilityacrossAfricancountries.

Intermsofavailability,changingtemperatures,humidity,andprecipitationareexpectedtodisruptagriculturalproductionsystemsindifferentpartsofAfricarequiringtheneedforadaptation.Examplesofclimateimpactsaffectingfoodsecurityincludesalinisationofagriculturalregions,changesincroprange,andmigratingcroppests(Confalonierietal.2007;Schmidhuber&Tubiello,2007,p.19704).InEthiopia,forexample,significantrainfallreductionshavealreadybeenobservedwithincriticalcrop‐growingareas(Funketal.,2007,p.11086)andthishasbeenattributedtoanthropogenicallyinfluencedwarmingoftheIndianOcean(Funketal.,2007).Effectsofthisarebeingobservednowasseveredrought,resultinginfamine,intheeasternAfricannationsofDjibouti,Somalia,EthiopiaandKenya.

ThereareanumberofothergrimpredictionsregardingclimatechangeandfoodproductioninAfrica.Forinstance:increasedtemperaturescanbeexpectedanddryareasareexpectedtoexperienceincreasedevaporationresultinginlowersoilmoisture;tropicalgrasslandsmaybecomemorearid.Therefore,semi‐aridandaridregionsshouldexpect:decreasedlivestockproductivity;wintersurvivalofpestspeciesshouldincreaseputtingmorespringcropsatrisk;and,humanpathogensurvivalisexpectedtoincreasealongwiththeprobabilityoffoodpoisoning.ThelatterhasbeenobservedasfoodbacteriasuchasSalmonellaproliferatemorerapidlyinwarmertemperatures(Schmidhuber&Tubiello,2007,p.19704;McMichaeletal.,2006.p,860).Whileclimatechangemayhavetheeffectofimprovingfoodproductioninsometemperateregionsof

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theworld‐duetoelevatedCO2concentrationsintheatmosphereandextendedgrowingseasons‐itislargelyexpectedtohavenegativeeffectsacrossAfricaandotherrelativelyfood‐insecureregions(Schmidhuber&Tubiello,2007,p.19704).

Withregardstoaffordability,decadesofdatashowcorrelationsbetweenfoodpricesandthenutritionalstatusofthepoor(Bloemetal.,2010,p.133S).WorldfoodpricesareparticularlyimportantforfoodaccessacrossAfricaanddevelopingcountriesingeneral,becausethesesocietiesaremorereliantonpurchasedfoodthandomesticallyproducedfood(Bloemetal.,2010,p.133S).Although,itisrecognisedthatevenforcountriesthatarenetfoodexporters,theremaystillbeinsecurityofaccesstofoodattheindividuallevel(SchmidhuberandTubiello2007).Withoutsignificantimprovementsinagriculturalyieldsthroughimprovedpractices,acrossAfrica,relianceonfoodimportswillmakeAfricancountriesvulnerabletotheglobalfoodprices.

Grainisasignificantindicatoroffoodproductionasitaccountsfor70%ofglobalfoodenergy(McMichael,etal.,2003).SomeoftheeffectsofincreasedfoodpriceshavealreadymanifestedinmanyAfricancountries.Theupsurgeinfoodpricesprecedingthefinancial,andglobaleconomiccrisisof2008,resultedinadeclineinfoodaccessandoverallmicro‐nutrientmalnutritionforthedevelopingworld,asindividualssimultaneouslylostpurchasingpowerasaresultofreducedincomeinfailingeconomies(Bloemetal.,2010,p.133S).

Generally,expectationsarethatfoodpriceswillrisemoderatelyinlinewithincreasesintemperatureuntil2050.After2050,however,foodpricesareexpectedtoincreasesubstantiallyastemperaturesfurtherincrease,withthevalueofsugarandrice,forexample,expectedtoriseby80%(Schmidhuber&Tubiello,2007,p.19706).Somestudiesindicatethefirstcoupleofdegreesofclimatewarmingmayleadtoanoverallincreaseinsomegrainoutputsbutthatanyprofitinthismaybecancelledoutbyincreasesinweedinfestations.Onestudypredictsthata1.1°Cincreaseintemperaturewouldreduceglobalgrainoutputby10%(Brown,2003).GiventhattheIPCCestimatesa2°Ctemperatureincreaseinthe21stcenturyonecan,onthebasisofBrown’sstudypredict20%reductioningrainoutputworldwidebytheendofthiscentury.Meanwhile,othersindicatethatgrainyieldmayincreasemarginallywithinanarrowrangeoftemperaturechange.Theseconflictingconclusionsarebasedonlackofcertaintyandunderstandingofchangingprecipitation.

AcrossAfrica,climatechangeisexpectedtohavetheeffectofcompoundingreducedaccesstofoodwhichasstatedisalreadyamajorprobleminmanyAfricancountries(Schmidhuber&Tubiello,2007,p.19703).AWHOreportindicatesthatmultiplesocialandpoliticalfactorswillgoverntheoveralleffectthatclimatechangewillhaveonfoodsecurity(McMichaeletal.,2003).Moreunderstandingofthecontributionofclimatechangetomalnutritionisanimportantsteptowardseffectiveadaptationthroughgoodgovernance.Similarly,furtherunderstandingoflocaleffectsofclimatechangeonfoodyields,nutritionalqualityandpricewillcontributetodevelopingstrategiestoprotectfuturepopulationsfromthepotentialdangerofchangingweatherpatterns.

Communicable diseases

Communicablediseasesresultfrominfectionbypathogenssuchasviruses,bacteria,fungi,protozoa,andparasites.Communicablediseasesaretransmittedbyphysical

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contactwithinfectedhumans,vectororganismsorwithcontaminatedsubstances(water,food,objects,andair).Climatechangesareexpectedtoaffectthelifecycleandmodesoftransmissionofmanyinfectiousdiseases.Theabilityofapathogentospreadisaffectedbyitsabilitytomatureandreplicate.Temperatureandmoistureavailabilityaretwoenvironmentalfactorsinfluencedbyclimatechangethataffectpathogenproliferation.Temperaturehasaparticularlystrongaffectontherateofpathogenreplicationandmaturation.Further,thesetwoclimatefactorsalsoaffectthesurvivabilityanddensityofvectorsinaparticularareathereforeincreasingthelikelihoodofinfectionuptocertainthresholds(WHO,2004).

Althoughtheenvironmenthasadominantinfluenceonthediversityofpathogensinaregion,thisdiversityisalsoinfluencedbyhumanpopulationsizeanddensity,theageofasettlementandthepopulation’sdiseasecontrolefforts(Shuster‐Wallaceetal.,2008;Dunnetal.,2010).Dependingontheregion,carrier(waterorvector),disease,andmitigationstrategies,thechangeinclimatewillimpactdiseasedistribution,rateofcontagionandtransmissionseasonswithdifferentlevelsofintensity.Thisreportfocusesonselectedwater‐borneandvector‐bornediseasesbasedontheircurrentandexpectedtollonpeopleacrossAfrica.

Transmissionofpathogensbetweenhumanscanoccurinvariouswaysthatincludephysicalcontact,contaminatedwaterorobjects,airborneinhalation,vectororganisms,orbodyfluids.Inourreport,wedivideourfocuscommunicablediseasesintoadiscussionofneglectedtropicaldiseases(NTDs);waterborndiseases,withemphasisondiarrhoea;thenontovectorborndiseases,withemphasisonMalaria;weintroducemeningitisseparatelyasanairbornedisease;followedbyHIVandsocialstatusfortheircompoundingeffectsoncommunityhealth.

Neglected Tropical Diseases

TheNeglectedTropicalDiseases1(NTDs)arethemostcommonconditionsaffectingthepoorest500millionpeoplelivinginSub‐SaharanAfrica(SSA).TheNTDsareagroupof13majordisablingconditions1thataredistributedthroughoutAfricatovaryingdegrees.InfactmanycountriesinAfricasufferundertheburdenofbeinghosttoabouthalfofallthepathogensdefinedasNTDsbytheWHO1(Figure2).Together,NTDsproduceaburdenofdiseasethatmaybeequivalenttouptoone‐halfofSSA'smalariadiseaseburdenandmorethandoublethatcausedbytuberculosis,twomuchmorecommonlyknowncausesofdeathinAfrica.HotezandKamath(2009)indicatesoil‐transmittedhelminthsinfections(seefootnote1)accountforupto85%ofthediseaseburdencausedbyNTDsandoccurinmorethanhalfofSSA’spoorestpeople(Table2;Hotez,2003&2009).Theysuggestthattheprevalenceofthisdiseaseisconnectedtoanumberoffactorsincludingflooding,irrigationprojectconstructionandclimatechange(Mangaletal.,2008).Otherfactorscitedincludedisplacementofpopulations,urbanization,otherEWEs,andairpollution(Campbell‐Lendrum&C.Corvalan,2007).Duetotheirconnectionwithwaterandotherorganisms,theeffectthatclimatechange

1 The WHO listed NTDs include soil transmitted helminths (roundworms such as Ascaris lumbricoides which causes ascariasis, whipworm which causes trichuriasis, hookworms which cause necatoriasis and ancylostomiasis), snail fever (schistosomiasis), lymphatic filariasis, Trachoma, leishmaniasis, Chagas disease (American trypanosomiasis), leprosy, Human African Trypanosomiasis, Guinea-worm (dracunculiasis), buruli ulcer, Cysticercosis, Dengue/dengue haemorrhagic fever, Echinococcosis, Fascioliasis, Onchocerciasis, Rabies, and Yaws.

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hasonthespreadingofcommunicablediseasesisinincreasingtherangeandseasonaldurationofsuitableconditionsforcommunicablepathogenstosurvive.Alsonotethatinthesurvivablerangeoftemperaturesapathogencansurvive,thereisamaximum.

Figure2:DistributionoftheprevalenceofNTDsinAfrica.Source:ImperialCollegeLondon,SchistosomiasisInitiative(availableat:http://www3.imperial.ac.uk/schisto/whatwedo/ntdsinafrica).

Note:Theboundaries,thenamesshown,andthedesignationsusedonthismapdonotimplyofficialendorsement

oracceptancebytheUnitedNations.

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Table2:ExamplesofNTDsaffectedbyclimatechange.(Hotez&Kamath,2009[http://goo.gl/qgFIA&http://goo.gl/XJdpT]).

NTDs Trans‐missionvia

Estimated%ofSSA*populationinfected

Africancountry

withhighestprevalence

SSAdiseaseburdenofGlobaltotal

Source

Hookworms H2O 29% Nigeria 34%Molyneuxetal.,2005;deSilvaetal.,2003

Ascariasis Vector 25% Nigeria 21%Molyneuxetal.,2005;deSilvaetetal.,2003

Schistosomiasis H2O 25% Nigeria 93% Steinmannetal.,2006

Trichuriasis H2O 24% Nigeria 27%Molyneuxetal.,2005;deSilvaetal.,2003

LymphaticfilariasisVector 6‐9% Nigeria 37‐44%

Michael&Bundy,1997;GAELF,2005&2008;Zagaria&Savioli,2002

Onchocerciasis Vector 5% Yemen >99% WHO,2008Trachoma H2O 3% Ethiopia 48% WHO,2008Drancunculiasis H2O <0.01% Sudan 100% WHO,2008

Leishmaniasis Vector <0.01% Sudan NoData

Alvaretal.,2008;Reithingeretal.,2007;Bernetal.,2008;Collinetal.,2004

HumanAfricanTrypanosomiasis Vector <0.01% DRCongo 100% WHO,2006;WHO,

2006Buruliulcer H2O <0.01% Coted’Ivoire57% WHO,2008,2008Leprosy H2O <0.01% DRCongo 14% WHO,2008*SSA–sub‐SaharanAfrica.

Untilrecently,veryfewstudieshavebeencarriedoutregardingtheconnectionofNTDswithclimatechange,althoughsomereviewershavediscussedthesituationwithafocusonvector‐borneNTDs(Campbell‐Lendrun,2003).Table2ranksNTDs(andtheirprimarycarrier)accordingtheproportionofSSA’spopulationaffected,fromthehighestpercentagetothelowest.

Thisisalargediseasecategorythat,basedonregionsofhighestprevalence(Table2),appearstobeprimarilytheresultofpoverty(Manderson,2009).Duetolackofattentionoutsidetheseareas,littleiscurrentlyknownaboutthepatternofthespreadofthesediseasesandtheirpotentiallinkstoclimatechangeormorebroadly,the“environmentalconstraintskeepingaspecieswithinitscharacteristicrange”(RogersandPacker,1993).Belowwelookatthediseasesintwocategoriesbasedonprimarymodesofpathogentransmission:waterbornandvectorborndiseases.

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Water born diseases

Water‐bornediseasesarecausedbyprotozoa,virusesorbacteriawhichtypicallypopulatetheintestinesofhumans.Waterisoftenconnectedtodiseasespreadduetoitsroleinthelifecycleofvectorsoritsdirecteffectonthehealthofpeople.Climatechangealterationstothehydrologiccyclewillaffectwaterdistributionsworldwide(IPCC,2007).TheIPCCexpectswateravailabilityandqualitytobeaffectedinvariouspartsofAfricaposingathreattohumanpopulations.

Currentlyalmosttwomilliondeathsayear,mostlyinyoungchildren,arecausedbyconditionsthatareattributabletounsafewaterandlackofbasicsanitation(Confalonierietal.,2007).Water‐bornediseaseisextremelyprevalentinAfrica(Figure2andTable2)where334water‐borneepidemicsoccurredbetween1980and2006(PWRI,2008;Leroy,2009).Thespreadofwater‐bornediseaseafterextremeclimate‐change‐relatedweatherevents,suchasfloodsorheavyrainfallorunseasonablywarmseasons(suchaslongerwarmperiods,extendinggrowingseasons)areexpectedtobeparticularlyhighinAfricaduetolimitedinfrastructureandcontrolprogramsatthesourcesofthesediseases(Schmidhuber&Tubiello,2007,p.19705).

Perhapssurprisingly,droughtsmayalsocauseincreasesincommunicablediseases,asreducedriverflowmayresultinincreasedpathogenloadingasseenintheAmazon,wherecholeraoutbreaksareassociatedwiththedryseason(Confalonierietal.,2007).Epidemicmeningitis,althoughadiseasespreadviaairborneparticlesanddroplets,alsoappearstobelinkedwiththeoccurrenceofdroughtsasreflectedbytherecentspreadofthediseaseintoWestAfrica.

ThewaterborneNTDsaremostlypreventablebywaterfiltration,casecontainment,andaccesstosafewater.ThistechniquealonehasbeensuccessinbringingthetransmissionandannualcasesofDrancunculiasis(guineaworm)downtoonly4countriesworldwidesinceaneradicationprogrambeganin1989.Infacttherehasbeenareductionincasesinthe20yearperiodfrom1986to2009of99.91%(from~3,500,000in1986to3,190in2009;WHO,2010).Asidefromsafewatersupplies,treatmentcampaignshavealsoincreasedinprevalence,withsomediseasetreatmentsprovingtoberelativelyinexpensive.

Diarrhoea

InSSA,diarrhoealdiseasesaresecondonlytoacuterespiratoryinfectionsasacauseofmortalityofchildrenunder5,withanestimated4.3episodesperchildperyearandanattributedmortalityrateof4.2/1000representing27%ofalldeathsinthisagegroup(ZimbabwePublicHealthReview,1987).Themajorityofpathogensthatinducediarrhoeainhumansarewaterborn,makingthissusceptibletoclimatechangeastemperatureandprecipitationchangesareexpected.Deathiscausedbyinfection,malnutrition,and/ordehydration.Inadditiontothewell‐documentednutritionaleffectsofdrought,causedbyreduceddietaryrangeandconsumption(Confalonierietal.,2007;Campbell‐Lendrum&Bertollini,2009).

In1998,diarrhoeawasthe10thbiggestcauseofdeathsforallagesinSouthAfrica(SA).By2005diarrhoeawasthethirdbiggestkillerinSA.Whenthisdatawascomparedwiththefactorscontributingtodiarrhoealdiseaseitindicatedaninterestingcorrelation

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betweenthenumberofpeoplewithHIV/AIDSandpeoplenothavingaccesstoprivatewatersupply.Essentially,itisexposuretonewdiseases,onesthatapersonmaynotalreadyhaveimmunitytothatputpeopleatthemostrisk.Thisexposuretonewdiseasesistheresultofshiftingpathogenhabitatsorhumanmovement(directlyorindirectlyinducedbyclimatechange).

EnvironmentallyinducedconditionsthatareexpectedtochangeunderanticipatedclimatechangeinAfrica,suchasprecipitationandtemperaturechangesaretheveryenvironmentalfactorsthatsupportdiarrhoea‐causingpathogensinwater.ConditionsthatmakeapopulationpronetodiarrhoeaoccurredinthemonthsfollowingMozambique’sfloodingin2000:8000additionalcasesofdiarrhoeaand447resultantdeathswererecorded(IPCC,humanhealthchapter,2007,p.399).Ahealthysupportsystemcoupledwithsufficientinfrastructurethatcanhandletheconditionswillincreasetheresilienceofanunsuspectingpopulationtothis,andotherhealthimpactsaffectedbywateravailability(cleanliness,access,regulatedavailability,etc.).

Vector born diseases

Therehasbeenaworldwideresurgencein,andaredistributionofmanyoldinfectiousdiseases(Table3).TheWHO(1996)estimates30newinfectiousdiseasesemergedfrom1975to1995withsomeexpertssuggestingthatsomeofthesearepossiblyconnectedtoclimatechange(Costelloetal.,2009;McMichael,2004).Globalclimatechangemayhaveamajorinfluenceonvector‐bornediseaseepidemiology(Dobson&Carper,1992;Epstein,2000;Epstein,2007;Githekoetal.,2000;Sutherst,2004).Vector‐borneinfectiousdiseasesmaybetransmittedtohumansbycontaminatedarthropods(i.e.fleas,mosquitoes,ticks,sandflies,andlice)andanimals(typicallymammalssuchasratsandlessoftenbirds).Morethan1,400speciesofhumanpathogenhavebeenidentified.Ofthese,58%aretransmittedfromanimalstohumansandaretwiceaslikelytobeemergingorre‐emergingasothervector‐borneandwater‐bornepathogens.Thetablebelowshowsthegeographicdistributionofvectorbornediseasesandtheprinciplevectorresponsibleforeach.Notethatthetop6vectorbornediseasesallexistinAfrica.Table2liststheprevalenceofvectorborndiseases,inrelationtowaterborndiseases.

Table3:Examplesofvectorbornediseasesaffectedbyclimatechangeindecreasingorderofaffliction.

Disease Vector Currentgeographicaldistribution

1.Malaria

Mosquitoes

Tropics

2.DengueFever Africa,Caribbean,Pacific,FarEast

3.WestNile Worldwide

4.YellowFever Africa,SouthAmerica

5.Leishmaniasis Sandflies Africa,Central&SouthAmerica

6.Trypanosomiasis Tsetseflies Africa,Central&SouthAmerica

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Mosquitospecies,suchasthegenusAnopheles(approximately40specieswhichspreadmalaria),Culex(C.quinquefasciatus;WestNileVirus)andAedes(A.aegypti;dengueandyellowfever)areresponsibleforthetransmissionofmostvector‐bornediseasesgloballyandacrossAfrica(Githekoetal.,2000).Mosquitoescarryingdiseasessuchasmalariaanddenguefever,twoofthemostprominentmosquito‐bornediseasesinAfrica,areamongthoseundergoingresurgenceandredistribution(Gubler&Kuno,1997;Gubler,2005;Coelho,2008).

Threeofthekeycomponentsthatdeterminetheoccurrenceofvector‐bornediseasesarepresentedintheWorldHealthOrganizationTaskGroup's(1990)reportPotentialHealthEffectsofClimaticChange.Theyare:

Occurrence:theabundanceofvectorsandreservoirhosts; Environment:theprevalenceofdisease‐causingparasitesandpathogenssuitably

adaptedtothevectors,thehumanoranimalhostandthelocalenvironmentalconditions,especiallytemperatureandhumidity,and;

Resilience:theresilienceandbehaviourofthehumanpopulation,whichmustbeindynamicequilibriumwiththevector‐borneparasitesandpathogens.

Thecombinedeffectsofchangingtemperatures,precipitationmayleadtoamoresuitableenvironmentforthespreadofvector‐bornediseasesandtheemergenceofnewonesindifferentpartsofAfrica.Forexample,temperaturechangesaffectvector‐bornediseasesbyinfluencingreproductivecyclesandbehaviours.BitefrequencygenerallyriseswithtemperatureandatmosphericCO2content(deLucia,2008).Ingeneral,higherambienttemperatures(toamaximum)shortentheviralincubationperiodandbreedingcycleinvectors(Campbell‐Lendrum&Bertollini,2009).Forinstance,reproductionofP.vivax(aprotozoalparasite)inmosquitoestakes55daysat16°C;29daysat18°Candonlysevendaysat28°C.ForP.falciparum,whichcausesthemajorityofseveremalaria,16.5–18°Cistherequiredminimumtemperaturefordevelopment.Thereishighmortalityinmosquitoesfrom32‐39°C,andat40°Ctheirdailysurvivalbecomeszero(Craigetal.,1999).

Someepidemiologicalmodelsillustratethepotentialofthesevector‐bornediseasestorapidlyspread.allieddatafromweatherstationswithsatellitedatatodeterminewhichcombinationofpredictorvariablesismostusefulfordescribingvectordistributionsofanumberofNTDs,andperhapsforforetellingalterationsindistributionwithclimatechange.Theresultsfoundonlyveryslightdifferencesbetweenthemeantemperaturesofplaceswheretsetsedoanddonotoccurnaturally(Rogers,1993;Rogers&Randolph,1993;Rogers&Packer,1993).Thisfinding,theysay,indicatesthatasmallchangeintemperaturemightconsiderablyaffecttheirdistribution.

Malaria

Outofthe700,000to2.7millionpeoplethatdieofmalariaannuallyaroundtheworld,94%occurredinAfricawith90%inSSA,and75%ofthesearechildren(Thompson,2004;Patzetal.,2005;Ramin&McMichael,2009;WHO,2008;Figure3).Asof2010,the41countrieswiththehighestdeathratefrommalariaper100,000populationareinAfrica,startingwithCoted'Ivoire(86.2),Angola(56.9)andBurkinaFaso(50.7;WHO,2010).ThesefiguressuggestthatperhapsoneofthegreatesthealththreatstoAfrica,aftermalnutrition,ismalaria.Themajorityofclimate‐malariaresearchinAfrica,suggeststhatmalariatransmission,especiallyepidemicoutbreaks,isassociatedwith

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increasedrainfallintypicallydryregionsandincreasedtemperaturesinhigh‐altitude,typicallycoolregions(Connoretal.,2006,p.22).Thereasonforthisisthatrainfallproducesthemoistureconditionsandsurfacewaterthatfacilitatesbreedingformalariatransmittingmosquitoesandwarmertemperaturesfacilitatefasterdevelopmentformosquitolarvaeandsurvivalforadultmosquitoes;moreimportantlythough,warmtemperaturesallowsthemalariaparasite,plasmodium,tomultiplymorequicklyinmosquitohosts(Grover‐Kopecetal.,2006,p.2).

Figure3:Malariaendemicity:thespatialdistributionofP.falciparum(Hayetal.,2009).

Note:Theboundaries,thenamesshown,andthedesignationsusedonthismapdonotimplyofficialendorsement

oracceptancebytheUnitedNations.

Therelationshipbetweenmalariaandclimatesystemshasbeenthemostextensivelystudiedclimate‐relatedillnessinAfrica(Connoretal.,2006).Thisispartlyduetothefactthatclimateinformationcanbeusedtoproducemalariariskmapsintheabsenceofhigh‐qualityepidemiologicalinformation(Connoretal.,2006)aswellasthefactthemalariaisamajorhealthissueinAfrica.Theresultingresearchhasshedlighton‘associations’,‘correlations,and‘links’betweenmalariatransmissionratesandclimateconditions(Grover‐Kopecetal.,2006,p.2).

AnumberofstudieshavelinkedwarmertemperaturestoincreasedmalariacasesinthehighlandsofeastAfricaanddecreasedmalariacasestothedroughtintheSahelregion(McMichaeletal.,2003,p.51).InEthiopia,analysisofmalariamorbiditydataindicatesthathigherminimumtemperaturescorrelatewithincreasedinstancesofmalariaoutbreaks(Confalonierietal.,2007).Furtherincreasingcaseloadoccurswhencouplingincreasedtemperaturewithasimultaneousincreaseinprecipitation(Confalonierietal.,2007).ForinstancefollowingtheElNinoeventin1997,Kenyaexperiencedasix‐foldincreaseinthenumberofmalariacasescomparedwiththepreviousyear(McMichael,etal.,2003).ResearchhasalsofoundastatisticallysignificantrelationshipbetweenElNinoeventsandmalariaepidemicsinColombia,Guyana,Peru,andVenezuela(Ibid.).Controversiesremainamongmalariologistsabouttheextentofthecontributionofclimatechangetomalaria‐changingpatterns.Somethinkitisrelativelyminor,withagreaterriskfordengueandotherviruses,eg,arboandhantaviruses.

Socialandpoliticalconditions,increasingresistancetoinsecticidesandanti‐malarialdrugs,andthedeteriorationofvectorcontroloperationsexplainmuchoftherecentresurgenceanddeathsduetomalaria(James,1929;Dobson,1980;Martens&Hall;

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Wingate,1997;Hutchinson&Lindsay,2006;Pascualetal.2006;Chavesetal.2008).ScientistsalsosaythereareanincreasingnumberofdeathsandmorbidityacrossAfricathatareduetomalaria(Snalletal.2009)anddenguefever(Cazellesetal.2005).

Asignificantbodyofresearchhassuggestedthatoverallglobalwarmingisexpectedtoincreasetheseasonalityandrangeofmalaria,bothacrossAfricaandonaglobalscale(McMichaeletal.,2003,).Malariainfectionrateisexpectedtoincreaseby16‐28%inperson‐monthsbytheyear2100inAfrica(Patzetal.,2005).TheMappingMalariaRiskinAfrica(MARA/ARMA)projectreportsthatbetween2050and2080,malariaisexpectedtodeclineinwesternSahelandsoutherncentralAfricaastheseareasarelikelytobecomeunsuitableforMalariatransmission(Thomasetal.,2004).TheIPCCreportsthatby2050previouslymalariafreeareasinBurundi,Ethiopia,KenyaandRwandamaysuffer“modestincursions”ofMalaria.Further,thechangedrangeofmalariacarryingmosquitosisexpectedtoincreasethelikelihoodofepidemicsinhighlandareassuchasEastAfricaduetoalackofgeneticresistanceinthepopulationtomalaria(IPCCWGII2007,Chapter9).Elsewhere,inDebreZeit,Ethiopia,withcontrolonchangesindrugresistance,mosquitocontrolprograms,andhumanmigration,warmingtemperatureshavebeenidentifiedasthemostlikelycauseforincreasedmalariatransmissionobservedbetween1968to1993(Patz,2005,p.311).Thisexamplereferstoan‘association’betweenmalariatransmissionandwarmingtemperaturesbecausetheremaybeotherfactors,perhapsunidentifiedthatcouldhaveplayedamajorrole(Patz,2005,p.311).

Whileamajorityofresearchsupportstheideathatmalariatransmissionratesareaffectedbyclimate,therearesomestudiesthatasserttheopposite.Confirminglinkswithclimatechangeastheprimarycauseforchangesinmalariatransmissionratesrequiresaseriesofotherfactorsthatcontributetotransmissionratestobeconsidered,suchas:theuseofdrugresistanceandmosquitocontrolprograms,humanmigrationandimmunestatus,andchangesinland‐usepatterns(Patzetal.,2005,p.311).Forexample,despiteseveralstudieslinkingmalariaprevalenceandclimatechangeinthehighlandsofEastAfrica(e.g.Pascualetal.,2006),Hayetal.(2002),studiedfoursitesinthatregionwhichexperiencedincreasedmalariatransmissionandfoundthatclimaticfactorsthatwouldhaveenhancedsuitabilityformalariatransmission,didnotchangeverymuch;thusmakingclimateunaccountableforincreasedmalariaprevalence.Similarly,Jacksonetal.(2010)foundverylittlecorrelationbetweenratesofmalariaprevalenceandclimateconditionsinamalaria‐endemicregionofWestAfrica.Veryfewstudieshavelinkedincreasedmalariatransmissiontochangesinclimatewhilecontrollingforotherconfoundingfactors.

Malariatransmissionrateshavenotrisensimplybecausehumansareencounteringmoremalaria‐carryingmosquitosandbeingbittenmorefrequently.Manyfactorsplayaroleinmalariatransmissionratesinapopulation.Socialandpoliticalconditions,increasingresistancetoinsecticidesandanti‐malarialdrugs,andthedeteriorationofvectorcontroloperationsexplainmuchoftherecentresurgenceanddeathsduetomalaria(James,1929;Dobson,1980;Martens&Hall;Wingate,1997;Hutchinson&Lindsay,2006;Pascualetal.2006;Chavesetal.2008).

Inspiteoftheconflictingfindingsregardingthecorrelationbetweenmalariaprevalenceandchangesinclimate,itremainsafactthatMalariaisaserioushealthproblemacross

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SSAandcontrolprogramsagainstthisdiseaseneedtobeamplifiedwhetherornotclimatechangewillexpanditsspread.

Meningitis – an airborne disease

MeningococcalmeningitisiscausedbythebacteriaN.meningitidisthatexistsallovertheworld.However,innoregionoftheworldisitasgreataproblemasintheSahelregionofAfrica(Figure4).ForAfricaasawhole,meningitisisoneofthecontinent’stopthreeclimatesensitivediseases,withroughly350millionpeoplelivinginendemiczonesforthisdisease(McMichaeletal.,2003;Palmgren,2009).Humansaretheonlynaturalreservoirforthisdiseaseanditisoftenspreadbetweenhumansviarespiratorydropletsorsaliva(i.e:throughcoughing,sneezing,kissingorotherformsofcloseanddirectcontact),withthesymptomsapparentonsomeindividualsandnon‐apparentonothers.Thedisease,asitischaracterizedbytheinfectionofthemeninges,canhavelifelongdamagingeffectstothecentralnervoussysteminsomesurvivorsandittendstokillfrom4‐17%ofitsvictims.Themostsusceptiblevictimsofthisdiseasearetypicallychildren,adolescentsandyoungadults(Menactra,2011).

Figure4:Africanmeningitisbelt(Palmgren,2009;WHO/EMC/BAC/98.3).

Note:Theboundaries,thenamesshown,andthedesignationsusedonthismapdonotimplyofficialendorsement

oracceptancebytheUnitedNations.

17

Meningococcalmeningitisisanairbornedisease,forwhichepidemicsaremostoftenreportedinyearsofseveredrynessanddrought,industladenenvironmentsandrarelyinareasofdenseforestandhighhumidity.Theassociationbetweenthisdiseaseandduststemsoutofsuggestionsfromanumberofstudies,thatdustislikelythekeyelementthatconvertstheN.meningitidisbacteriafromitsbenignformtoitspathogenicone.Themechanismsforhowthisconversionmightoccur,however,areunclear.Althoughaclearcausallinkbetweenincreasedmeningitisincidenceandclimatefactorsismissing,thedistributionandseasonalityofmeningitisiswidelybelievedtobeassociatedwithdustyconditionsthatariseoutofdrynessanddrought(IPCC,2007,p.400).Forexample,SouthAfricahasbeensubjectedtoseasonalincreasesduringthewinterandspringmonths(May–October)ofendemicmeningococcaldiseaseoutbreaks(Küstner,1979).Thereforeareaspronetoincreasingdroughtconditionsasaresultofclimatechangecanexpecttobesubjecttoanincreaseinmeningitisoccurrences.

Meningitisisconcentratedinthesemi‐aridSahelregionofAfrica.InfactthestripoflandalongtheSahelwithhighestconcentrationsofmeningitisisoftenreferredtoasthe‘meningitis‐belt.’ThisspansfromEthiopiaandSudanintheEasttoSenegal,MaliandGuineainthewest(Figure4;Palmgren,2009).Epidemicsofmeningococcalmeningitisbreakoutin5to‐10yearsintervalsinthemeningitisbelt.Inrecentyears,thewidthofthismeningitisbeltappearstobeexpandingsouthwardasaresultofregionalclimatechangeandchangesinlanduse(IPCC,2007,p.400).CountriessuchasKenya,Uganda,Tanzania,Togo,Coted’Ivoire,CameroonandBenin,whicharetypicallynotaccustomedtoexperiencingsevereepidemicsofmeningitis,andwhichdonottechnicallybelongtothemeningitisbelt,havebeguntoexperiencelargescaleepidemicsofthedisease.Thissouthwardexpansionofthemeningitis‐beltintothesecountriesisalsoassociatedwiththeexpansionofincreasinglyhotanddryconditionsintotheseareas(McMichaeletal.,2003).

TheclimatechangeprojectionsfortheSahelregionincludemorefrequentandlongerdroughtasaresultofexpectedincreasesintemperatureanddecreasesinrainfall.Ithasbeensuggestedthatthiswillcauselongerdurationsoftheepidemicsandperhapsevenhigherratesofincidenceofthedisease.However,becauseepidemiologicalresearchhasnotbeenabletoconfirmthecorrelationbetweenthediseaseandclimate,thiscannotbedeclaredcertainly.

Furtherstill,thedisease’suniqueregionalcharacteristicsanditsprevalencedrivenbyenvironmentalconditionshasshownclearpatternsofoutbreaksofthediseaseinSouthAfrica.Thoughnotinthemeningitisbelt,inrecentdecades,SouthAfricahasbeensubjecttoincreasingnumberofepidemicoutbreaksofmeningitis(Küstner,1979).Here,theburdenofdiseaseoccursinacyclicalpatternatintervalsof8–10years(Bikitsha,1998).

Successhasbeenobserved,theincidenceofclinicalnotificationtothenationalDepartmentofHealth(Pretoria,SouthAfrica)hasdecreasedsincethelate1980s:fortheperiod1992–1997,therewere1–2casesper100,000persons(Bikitsha,1998).ByJuly2002(overthethreepreviousyears),854casesoflaboratory‐confirmeddiseasecaseswerereportedinSA.Thisisanannualdiseaseincidencerateof0.64/100,000population(Incidencewashighestininfants<1yearofage;Coulson,2007).Furthermore,withtherecentavailabilityofthegroupAconjugatevaccine,whichismeanttotargetthemostsignificantstrainoftheN.meningitidisbacteria,

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epidemiologistsarehopefulthattheproblemofmeningitis,acrossAfrica‐andnotjustthemeningitisbelt‐willbegintobecontrolled.ThedevelopmentofthisvaccineisnotthebeallandendallforcurbingmeningitisinAfrica,however.EpidemiologistsconferthatepidemiologicalandenvironmentaldatasetsofthedryseasoninAfrica,needtobeimprovedinordertoenhancemeningitisearlywarningsystems,andtherebyefficientlytargetanddispersethisvaccine.

HIV/AIDS

HIVisnotlikelytobedirectlyaffectedbyclimatechange.However,HIVinfectedindividualsareatincreasedriskofcommunicablediseasesandthosewhoaremalnourishedorunhealthymaybeatgreaterriskofHIV.Giventheselinksitislikelythatclimatechangewillhaveaneffectondiseasepatterns(BlaserandCohn,1986).By2007,anestimated33.2millionpeoplecontractedthediseaseworldwidekillinganestimated2.1millionpeople,withgreaterthan75%ofthesedeathsinSSA.

Theoccurrencesofopportunisticdiseases,whichdefinetheAcquiredImmuneDeficiencySyndrome(AIDS),includeprotozoans(Cryptosporidium,Microsporidium),bacteria(Mycobacteriumaviumcomplex)andviruses(Astroviridae,Adenoviridae,RotavirusandCytomegalovirus).Eachofthesecanbewaterandvectorbornpathogens,highlightingtheneedforeradicationprograms.Theseappeartobemoreheavily‐dependentongeographythanotherfactorssuchasdemographicsandsoitseemslikelythatasgeographicaldistributionofcommunicablediseasesevolves,infectionsinHIV‐affectedpopulationswillchangeaccordingly.

Theexpectationisthatclimatechangemaygeneratemoremigrantsaspeoplesearchforsecurity,whetheritisforfood,water,safety,orhealthcare.Aspopulationsareforcedtomigrateasaresultofclimatechange,HIVinfectionrateswouldincreaseincertainregions,aspeoplefromdifferentareasmixorifsexworkbecomesameansofsustenanceforrural/farmermigrantswhoareforcedtomakealifeforthemselvesinthecity(McMichael,2008).

Social status

Geopolitical,socioeconomic,demographicandtechnologicalevolutioncompoundsocialandeconomicunpredictability.Culturaladjustmentsintimethatprotectusfromsocialandeconomicuncertaintiesaretheretolessentheimpactontherelationshipbetweenenvironmentalstressandmortalityrates,forexample,improvementsinhousingconditionsandbetterclothing.Thereisstrongevidencethatdisadvantagedgroupshavepoorersurvivalchances,anddieatayoungeragethanmorefavouredgroups(Figure5).Thescaleofthedifferencesinmortalityisimmense(Marmotetal.,2008).Whileachildborninsomedevelopedcountriestoday,suchasJapanorSweden,canbeexpectedtoliveto80years,childrenborninacountryinSSAarenotexpectedtolivepast50years.Furthermore,whilethecarbonfootprintoftheworld’spoorest1billionpeopleaccountsforroughly4%oftheworld’stotalcarbonfootprint,itisthesevulnerablepopulationsthatwillbearthehighestcostsofclimatechange(Costelloetal.,2009).Infact,somehaveassertedthatthenegativeimpactsofclimatechangewillbesufferedmoreseverelyinSSA‐inspiteofthecontinentsrelativelylowemissions(seeFigure6)‐thaninotherregions(RaminandMcMichael,2009).Thisislargelyattributabletothecontinent’soveralllimitedadaptivecapacity.Manyofthehumanhealthissues

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discussedarenotjustcommonlyassociatedwithpovertybutarealsoacauseofpovertyandamajorhindrancetoeconomicdevelopment.Thesediseasesareassociatedwithmajornegativeeconomiceffectsinregionswheretheyarewidespread.Countrieswithpoororweakhealthservicesandwaterdistributioninfrastructurefindtheyareamajorfactorintheirsloweconomicdevelopment(forexample,MalariainSSA;Sachs&Malaney,2002).Incountrieswheremalariaiscommon,averagepercapitaGDPhasrisen(between1965and1990)only0.4%peryear,comparedto2.4%peryearinothercountries(Ettlingetal.,1994).TheestimatedeconomicimpactofmalariaonAfricais$12billionUSDeveryyear(Greenwoodetal.,2005;includescostsofhealthcare,workingdayslostduetosickness,dayslostineducation,decreasedproductivityduetobraindamagefromcerebralmalaria,andlossofinvestmentandtourism).

Figure5:AssociationbetweenGDP/personadjustedfor$USPurchasingPowerParityandlifeexpectancyfor155countriescirca1993(Lynchetal.,2000).

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Figure6:AfricanCO2emissionscomparedwiththeworld(UNEP,2002).

Note:Theboundaries,thenamesshown,andthedesignationsusedonthismapdonotimplyofficialendorsement

oracceptancebytheUnitedNations.

Asaresultofpoverty,conflict,andchangingenvironments,forcedmigrationanddisplacementisoccurringinvariousregionsoftheworld.SomecausesformigrationrelatedtoclimatechangeandhealthincludeincreasedEWEs,droughts,desertification,sealevelrise,anddisruptionofseasonalweatherpatternswhichcausediseaseoutbreaksandmalnutrition.Also,migrantsmaycarrytheinfectiousdiseasesoftheirplaceoforigintotheirdestinationsand,oncethere,theymaybesusceptibletodiseasestheyhadnotbeenpreviouslyexposedto.Oftentheyliveoutsidetheestablishedsocial

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systemandmaynothaveaccesstoadequatehealthcareservices.TheWorldDisastersReport2001publishedbytheInternationalFederationofRedCrossandRedCrescentSocietiesestimatesapproximately25millionpeoplearecurrentlyonthemoveasforcedmigrantsduetoclimatechangerelatedissues.

Direct impacts

Potentialdirecthealtheffectsofglobalclimatechangeuponanindividual’sorpopulation’shealthwilloccurpredominantlythroughtheimpactsofclimatevariablesuponhumanbiology.Themainclimatic‐environmentalvariablesconcernedherearetemperature,precipitationandairquality.Itisimportanttopointoutwhilstthemaindriversareclimaticvariables,impactsaremodulatedbyhumanpopulationdensity,thevulnerabilityoflocalsettlements,regionaleconomicwealthandthestrengthofinfrastructure.Asaresult,theseimpactsarefeltmorestronglyacrossAfricathaninricherregionswheretheyareoftenneglectedasissues.Theseissuesaretheresultofspecificevents,suchasheatwaves,floods,airqualitychanges,oftenleadingtoindirecteffects.Betterunderstandingoftheseconnectionscanleadtothedevelopmentofappropriateadaptationandmitigationtechniquesforthebenefitofapopulation’shealth.

Extreme weather events and their direct effects

Thedirecthealtheffectsofclimatechangewiththepotentialforgreatestimpactsaretheforcesthatcreatedroughtsandfloods.Unfortunatelythisisanareaforwhichthereisinsufficientdata(IPCCWGII2007,Chapter9).WorkingGroupIIoftheIPCC,initsdiscussionofclimatechangesinAfrica,isinconclusivewithregardstoanychangesinthefrequencyorsizeofEWEsbutsuggeststheremightbeaslightincreaseindroughtsforexampleinthesecondhalfofthe21stcenturyandthattheremaybemorefrequentandstrongertropicalstormsoffthesouthernIndianOcean.SinceEWEsarerelativelylocationspecific,regionswithahistoryofaspecificEWEwilltendtocontinuetoexperiencesuchevents.InlandandcoastalfloodshavebeenthemostfrequentEWE(EpsteinandMills,2005).

Evenwithoutclimatechange,theimpactofEWEscanbe,andhavebeen,devastating.TheimpactofEWEsistypicallythegreatestinthemostvulnerableregions,wherepopulationsareleastabletodefendthemselves,resultingindisproportionatedeathtolls,typicallyamongstthepoor.Extremeweatherevents,suchas,cyclones,droughtsandhurricaneshaveanextraordinaryimpactonhumanmortality.Table4outlinesthenumberofpeoplekilledbyEWEsbyregion.OfnoteisthatwhilethefrequencyofEWEsisincreasingthenumberkilledwassignificantlysmallerinthe1990sthaninthe1980s.

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Table4:NumberofpeoplekilledinEWEsinthe1980’sand1990’sbyglobalregion(McMichaeletal.,2003).

Region

Deathsin1980s Deathsin1990s

(‘000s) (%oftotal) (‘000s) (%oftotal)

1.Africa 416.9 60.3 10.4 1.72.EasternEurope 2.0 0.3 5.1 0.83.EasternMediterranean 161.6 23.4 14.4 2.44.LatinAmericaandtheCaribbean 11.8 1.7 59.3 9.9

5.SouthEastAsia 53.9 7.8 458.0 76.26.WesternPacific 35.5 5.1 48.3 8.07.Developed 102.1 14.8 5.6 0.9Total 691.9 100.0 601.2 100.0

TheeffectsonindividualsofEWEsarecompoundedbydamagetoinfrastructureandhealthsystems,forexampleitwasdifficultforHIVretroviraldrugstobedeliveredtoNorthernNamibiaduetothefloodsthereearlierthisyear.Oncetheinitialdisasterhaspassed,secondaryissuesmayemerge,suchasalackoffoodandadequatecleanwater(Shultzetal.,2005)andincreasesincommunicableandnon‐communicablediseases.Survivorshaveanincreasedriskofcontractingrespiratory,diarrhoealandcommunicablediseasesintheaftermathofanextremeeventduetopopulationovercrowding,limitedornoaccesstopotablewaterandfood,andexposuretochemicals,pathogensandwaste(Kovatsetal.,2003).Poordrainageandstorm‐watermanagementinlow‐incomeurbancommunitiesincreasesratesofinfectiousdiseasetransmission(Confalonierietal.,2007).Extremeweathereventscancausevariationinthepatternsofvector‐bornediseaseseitherbycreatingfavourableenvironmentsforvectorsorthroughthedestructionofavector’senvironment.Forexample,floodingcanintensifythetransmissionofhydrophilicvectorsanddiseases(Connor,1999).Long‐termimpactsincludeincreasesininfectiousdiseaseandmentalstresses,lossesofinfrastructureandterritoryandenvironmentally‐inducedmigrationwhichcanleadtofurtherincreasesininfectiousdiseases,conflictsoverwater,energyandotherincreasinglyscarceresources,resultinginpoliticaltension.

UV related cancers and diseases

Thisisarangeofhealtheffectsthatwillincreaseinimportanceaspopulation’slifespanbegintolengthen.ClimatechangemayalterhumanexposuretoUVRinseveralways,withlimitedpredictabilityandvariationamongregions(McMichaeletal.,2003).TheIPCCconcludedthatexcessiveUVRexposurewasresponsiblefor1.5milliondisability‐adjustedlifeyearsand60,000prematuredeathsworldwidein2000fromskin,eye,andcardio‐respiratorydiseases(Confalonierietal.,2007).SmallamountsofUVRarebeneficialtohealth,andplayanessentialroleintheproductionofvitaminD.However,excessiveexposuretoUVRisassociatedwithdifferenttypesofskincancer,sunburn,acceleratedskinageing,solarkeratoses,cataractandothereyediseasesthatreducetheeffectivenessoftheimmunesystem.

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Worldwide,approximately18millionpeopleareblindasaresultofcataracts,withtherateofcataractssurgerythelowestinAfrica(Yorstonetal.,2001).Asaresult,indevelopingcountriescataractscauses50–90%ofallblindness(Murray&Lopez,1996).Ofthese,5%ofallcataract‐relateddiseasesaredirectlyattributabletoUVRexposure.

Intheyear2000,UVRexposurehadledtomorethan200,000casesofmelanomaand65,000melanoma‐associateddeathsglobally.AprogramtoeliminatecataractblindnessinAfricaby2020hasbeenproposed,andtherearegroundsforthisoptimismthatthisispossible.Firstly,thenumberofcataractoperationsisincreasingrapidlyinsomecountries.InKenya,therewerealittleover5000cataractoperationsin1996(asreportedtotheNationalPreventionofBlindnessCommittee).By1999,thishadincreasedtoover12000,withthequalityofsurgeryalsoimproving(Yorstonetal.,2001).Secondly,humanresourcesdevelopmentandaccesstolowcostmaterialsismakingcataractsurgerymorewidelyavailable(Brian&Taylor,2001).ManysurgeonshavebeensuccessfullytrainedorretrainedinvarioustypesofcataractsurgerywitheducationclinicssetupinsuchcountriesasGhana,Nigeria,SouthAfricaandTanzania.IthasbeennotedthatFrancophoneandPortuguese‐speakingAfricahasfewertrainingprogrammesatthemoment(Alhassanetal.,2000).

TheWHOconfirmsthatinstancesofskincancerhavebeenincreasingsteadilyinthetwodecades,especiallyinregionswithhighUVRexposure,withSouthAfricahighlighted(McMichael,etal.,2003).Therelationshipbetweenozonedepletionandpoorskinandeyehealthisunclear.Scientistspointoutthedifficultiesofdistinguishingozonedepletionbetweenpollutionandclimate.Researchisneededonattitudestowardsunbathingandtheuseofprotectivemeasures.Protectivemeasures,suchassunscreenointmentsandcreams,andprotectiveeyewear,requireevaluation.Toomuchrelianceonsunscreenshasbeenidentifiedasapotentialcauseofincreasingskinandeyedisease(Garlandetal.,2002).

TheeffectUVRhasonthehumanimmunesystemappearstobeareductionineffectivenessbychangingtheactivityanddistributionofthecellsresponsiblefortriggeringimmuneresponses(DeFabo&Noonan,1983).Fortheeyesandtheimmunesystem,thisisindependentofskinpigmentation,soallpeopleeverywhereareatriskfrompotentialadverseeffectsincludingincreasedincidenceandseverityofinfectiousdisease,andenhancedriskofmalignantchanges(Last,1993).Theabilitytorespondtoincreasesofskinandeyediseaseswillbelowerinlowerandmiddleincomecountries.Populationsrequiredtoworkoutdoorswillbemostaffected,aswellasthosethatspendtheiryouthinthesun.

Temperature and precipitation effects

Increasesinaveragetemperaturerepresentaverysignificantsourceofpotentialdirectclimatechangeimpactsonhumanhealth.Amajorconcernisthatsuchincreasesmayleadtotemperaturesbeyondthosecomfortable(calledheatstress)foraregionaffectingmortalitythroughthermalstress(Figure7).Heatstressaffectsindividualsduringextremes(inintensityand/orfrequency)oflocalweather‐inthecoldestorwarmestseasonsforexample.Theseenvironmentalconditionscanbefurtherexacerbatedbyhumanactivitiessuchasdeforestationandurbanisationbyaffectinglocalclimatesbyincreasinglocaltemperaturesby3+°C(Hamilton,1989).

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Figure7:TemperaturechangesinAfricacomparedwiththeworld(UNEP,2002).

Seasonalvariationinmortalityhasbeendescribedinmanycountriesthroughouttheages.InancientGreece,Hippocrates(HippocratesVol.1.,McKEE,1989)describedtheoccurrenceofsuddendeathsandstrokeswhenacoldspringfollowedamildwinter.Researchsuggeststhatinwarmerclimatespatientsmayhaveoptimumcardiovascularhealthathighertemperatures(Panetal.1995).ForexampleinTaiwan,elderlypatientshaveoptimumcardiovascularhealthandthefewestdeathsfromcoronaryarterydiseaseatatemperaturerangecorrespondingto26‐29°C(Ibid).

Thoughrarelydiscussedintheliterature,mortalityduetoheatwaveshavebeenextensivelystudiedinEuropeandNorthAmerica,howeverdataisvirtuallyabsentforSouthAmericaandAfrica(McMichaeletal.,2006).Risingtemperatureswillbemostdangerousforpoorpeopleindevelopingcountriesandamongthemostvulnerable(youngandelderly,sickandpoor).AswiththeotherhealthaffectsafflictingAfrica,thisisexacerbatedduetolimitedresourcesavailabletopoorerpopulations.Thereisdifficultyinpredictingtheeffectsofchangesinfrequencyandintensityofheatwaveson

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mortalityratesinhightemperatureregionslikeinAfricaduetothelackofdataaboutmortalityintheseregions.

Air quality

Climatechangeisexpectedtoreduceairqualityinsomeareas(IPCC,2007)contributingtorespiratorydisorders(Kinney,2008;McMichael,etal.,2003).Therelationshipbetweenclimatechangeandairqualityiscomplexwithmanyinteractingmechanisms.Forexample,airqualityinfluencescanbeofclimatic/meteorologic(temperature,humidity,windspeed,winddirectionandmixingheight),natural(ground‐levelozoneandlight‐catalysedairchemistryreactions,aeroallergens,forestfires,anddustfromdrysoils),oranthropogenic(usingcarbonbasedfuelsforlocalenergyuse,transportation,andagriculture)origin,resultingineventualdepositionofairpollutants(Sapkota,2005;Confalonieri,etal.,2007;Kovats,Ebi,&Menne,2003).Particulatematterisapollutantofconcernasitisacomplexmixtureofextremelysmallparticlesandliquiddroplets.Wheninhaled,theseparticlescanreachthedeepestregionsofthelungs.Exposuretoparticlepollutionislinkedtoavarietyofsignificanthealthproblems.Vulnerabilityisdeterminedbythequalityofhousing,theavailabilityofairconditioningandtheurbanheatislandeffect,resultinginincreaseddeathsamongtheelderlyandurbanpoor(McMichealetal.,1996;Piver,1999aandb;Epstein&Mills,2005).

Sunlightandhightemperatures,combinedwithotherpollutantssuchasnitrogenoxidesandvolatileorganiccompoundscancauseground‐levelozonetoincrease.Ozoneformsinthetropospherebytheactionofsunlightonozoneprecursors(throughphotochemistry)fromtheby‐productsofburningcarbon‐basedfuels.Atthesurface,anincreaseintemperatureacceleratesphotochemicalreactionrates(strongcorrelationbetweenhigherozonelevelsandwarmerdays–butnotalways).Ground‐levelozonecandamagelungtissueandisespeciallyharmfulforthosewithasthmaandotherchroniclungdiseases.Eventhosewithmoderatediseasemaybeatriskfromtemperaturerisesabove16.5°C(Levy,2005).

Theincreasesofairpollutantsduetoclimatechangediscussedabovemayinfluencecardio‐respiratorydisease(McMichaeletal.,2003)aswellasbyexposingpatientswithpre‐existingconditionstodangeroustemperatureextremes,whichstressthecardiovascularsystem.TheWHO(2002)hasestimatedthatpoorairqualitycausedbyclimatechangewasresponsibleforover2.4millionprematuredeathsin2000alone(1/3byoutdoorand2/3byindoorpoorairquality)andaccountsforapproximately2%oftheglobalcardiopulmonarydiseaseburden(Prüss‐Üstün&Corvalán,2006;Watts,2009).Exposuretooutdoorairpollutionaccountedforapproximately2%oftheglobalcardiopulmonarydiseaseburden(WHO,2002;Cohenetal.,2004).Thearrayofhealthimpactsincludesheadaches,nausea,cardio‐respiratorydiseasesandcancer.

Gaps in knowledge and research

Climateandhealthresearchisstillinaratherprimitivestageandmanyofthedirectandindirecthealtheffectsofclimatechangeinbothregionalandglobalcontexthavenotbeenfullyidentifiedorunderstood.Hence,althoughalotisknownaboutthescienceofclimatechange,thereremainmanyuncertaintiesofitspotentialimpactonhealth(IPCC,2007).Theseuncertaintiesrelatemostlytothreemainareas:

1. Climatechangeuncertainties;

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2. Linksbetweenclimatechangeandhealthandtheirmechanisms,and;3. Humanmitigationandadaptationcapabilities.

Climatechangeuncertaintiesareduetoinsufficientdataanduncertainclimatedata.Theglobalclimatesystemiscomplex:simulationsinvolvemanyvariablesthatdescribeandrelatetonature'schemical,physical,andbiologicalprocesses.Theseleadtodifficultiesinpredictingfutureclimatetrendsintemperature,precipitation,cloudcover,windsandthetimingandscaleofweathereventsatregionalandlocallevelswithaccuracy.ThedifficultyinpredictingthesenaturalphenomenaarecompoundedbyuncertaintyinfutureratesofGHGemissionsandgovernments’willingnessandabilitytomitigateandadapttochangingconditions.Ultimately,newtechniquesandapproachestoclimatechangescienceareneededtodealwiththeuncertaintiesthatinevitablysurroundtheseestimates.Improvedmodellingofclimatechange,includingregionalmodelswillallowformorereliablepredictionsofthepotentialimpactsonhumanhealth,andimprovedregionalunderstanding.

Sofar,themajorityofwidescopingclimate‐healthresearchhasbeencarriedoutinthedevelopedworld,wherethetools,technologyandcapacityforcarryingoutthisresearchareavailable.Thisleadstoverytentativeresultsnottheleastbecausethegreatesthealthrisksduetoclimatechangeareexpectedtobeborneamongstthoseleastcapabletoresponding,inthedevelopingworld(RaminandMcMichael,2009).LimitedtoolsandtechnologyacrossAfricahasproducedinaccuratefindingsinclimate‐healthrelationships(Connoretal.,2006).Forexample,climatologydata,usedforsurveyingmalariahavenotgivenconsistentinformationonthelinksbetweenmalariaandclimate(e.g.Tulu,1996vs.Hayetal.,2002).Furthermore,thenumberofmeteorologicalstationsacrossAfricaisinsufficientformanyanalyticalpurposes,thusprovidinganobstacletotrackingclimatetrends(Connoretal.,2006).Also,climatologydatawidelyusedinAfricahasoftenbeenbasedonout‐datedandinconsistentobservations(Connoretal.,2006).

Thesecondsetofchallengesareuncertaintiesregardingmechanismswhichlinkhealthimpactstoclimatechange.Forinstance,accuracyinpredictingtheeffectofclimatechangeonimportanthealth‐relatedfactorssuchascropyieldandpests(weeds,insects,plantdiseases,etc)canbeimproved.Improvementscanalsobemadeinepidemiologicresearchmethodstopredicthealthimpactsthroughmodelaccuracyoftheprocessesthroughwhichimpactswilloccur.Partofthechallengeinachievingtheseimprovementsisthatclimateexpertsandhealthexperts(suchasepidemiologists)tendtooperateseparately,andarenotfullyinformedonhowtoeffectivelyemployinformationfrombothsectorstogenerateinsightfuldataontheinterrelationofclimateandhealth(Connoretal.,2006).Overall,ithasbeendifficulttobuildandmaintaincross‐sectoralrelationshipsbetweentheresearchersofclimate‐basedearlywarningsystemsandthesubsequentresponsesneededfromthepublicsector(Connoretal.,2006).

Thirdly,itisdifficulttopredicthowhumanswillmitigateandadapttoclimatechange,confoundingmodellingattempts.Mostoftheeffectsofclimatechangeonhealthdiscussedabovecanbeminimisedthroughappropriatemitigationandadaptivemeasures.Geopolitical,socio‐economic,demographicandtechnologicaladvanceswilldeterminetheultimateimpactofclimatechangeonhumanpopulations.Forinstance,developmentofnewvaccinesmayattenuatetherelationshipbetweentemperature

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increaseandmalariaspread.AgoodexamplecanbefoundinthecaseofmeningitiswheretherecentavailabilityofthegroupAconjugatevaccine,whichismeanttotargetthemostsignificantstrainofthemeningococcusbacteria,offerhopethattheproblemofmeningitisacrossAfricamightultimatelytobecontrolled.

Africa’s response to climate change and health

Theprecedingsectionsindicatethatdespiteabidinguncertaintiesandcomplexities,therearearangeofindirectanddirecthealthimpactsassociatedwithclimatechange.MinistersofHealthandMinistersofEnvironmentfromacrossAfricaareawareofthepotentialimpactofclimatechangeonhealthandassuchhaverespondedwith:

TheLibrevilleDeclarationonHealthandEnvironmentinAfrica(Libreville,2008);

TheAfricanMinistersofHealthandEnvironmentJointStatementonClimateChangeandHealth(Luanda,2010a),and;

TheHealthandEnvironmentStrategicAlliancefortheImplementationoftheLibrevilleDeclaration(Luanda,2010b).

TheseresponsesreflectaproactiveintentamongstAfricanleaderstoprotecttheirpeoplefromtheanticipatednegativehealthconsequencesofclimatechange.TheabovementioneddocumentscontainanumberofrecommendationsandactionsaimedatimprovingAfrica’sunderstandingofclimateandhealthandatthesametimeaddressingthehealthimpactsofclimatechangeacrossAfrica.

AnimportantelementcontainedintheLibrevilleDeclarationisthecommitmenttoestablishaHealthandEnvironmentStrategicAllianceasaplatformforplanningandcoordinatingjointcontinent‐wideaction.Similarly,theAfricanMinistersofHealthandEnvironmentJointStatementonClimateChangeandHealth(Luanda,2010a),whichrecalledtheLibrevilleDeclarationcontainsacommitmentbyAfricangovernmentstointeralia:

Undertakeacomprehensivehealth‐andenvironment‐climatechangevulnerabilityassessmentsbytheendof2012;

CompletetheSituationAnalysesandNeedsAssessment(SANA)processaswellastheyprepareNationalPlansofJointActions(NPJAs)

Developanessentialpublichealthpackagetoenhancetheclimatechangeresiliencestatusofallcountriesby2014,and;

Reducevulnerabilityanduseecosystemsservicestobuildnaturaladaptiveresilienceagainsttheimpactofclimatechange.

Already,followingthemeetinginLibrevilletheHealthandEnvironmentStrategicAlliancefortheImplementationoftheLibrevilleDeclaration(HESA)hasbeenestablishedtoserveastheprimarymechanismforcoordinatingeffortsataddressingclimatechangeandhealthacrossAfrica.ThecoremandateofHESAistosupportcountryeffortsinaddressinghealthandenvironmentissues(includingclimatechangeandhealth)throughadvocacy,collaboration,resourcemobilization,capacitybuilding,technicalsupportandprogressmonitoring.

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ItishopedthatthefullimplementationoftheLibrevilleDeclarationandtheJointStatementwouldhelpensureevidencebased,andproperlycoordinatedpolicies,plansandactions.

Atgrassrootsleveltherearealreadyclimateandhealthactivitiesunderway,notablyinEthiopiawheretheClimateandHealthWorkingGroup(CHWG)hasbeenoperatingforover10years,andhasbeenaddressingtheissueofclimateandmalaria.SimilargroupshavebeenestablishedinKenyaandMadagascar.

InAprilof2011,a“ClimateandHealth:10YearOn”washeldinAddisAbabaandco‐organisedbytheInternationalResearchInstituteforClimateandSociety(IRI),theAfricanClimatePolicyCentre(ACPC),CHWG,theWorldHealthOrganisation,UNDP,TheUKMetOffice,andtheUniversityofExeter.TheworkshopreflectedonnearlyadecadeofpracticeandexperienceinAfricasincetheBamakoWorkshop(1999)onClimatePredictionandDiseases/HealthinAfrica.FromtheClimateandHealth:10YearsOnWorkshop(2011)aseriesof23recommendations2tosupporttheeffectiveimplementationoftheJointStatementonClimateChangeandHealthinAfrica(Luanda,2010)wereagreedregardingpolicy,practice,servicesanddata,andresearchandeducation.Theseincluded,forexample:

Bridgingthegapbetweenpoliciesandpracticesthroughlegislationandguidelines,appropriateplanning,includingrelevantvulnerabilityassessments,programmaticsupportandmulti‐sectoralandparticipatoryprocessesthataregendersensitive.

Supportingcountriestoestablishintegratedhealthsurveillanceandclimateobservationandprocessingsystems;

Integratingclimatehealthriskmanagementintocross‐sectorplanningandpracticeforadaptationtoclimatevariabilityandchangebydevelopingclimateservicesandproductsthataddressdiseasepreventionatend‐userlevel.

Ensuringthatclimatechangemitigationandadaptationstrategiesareinformedbymultidisciplinaryresearch.

Options for consideration

Baseduponareviewoftheliterature,thereareaseriesofoptionsthatmaybeconsideredbyAfricangovernments,coordinatingbodiessuchasHESA,andbyotherorganizationstoaddressclimatechangeandhealth.Theseoptionsneedadeeperinvestigationandmuchfurtherresearch,dialogueanddiscussion,butforthepurposesofstimulatingsuchaprocess,optionsthatmightbeconsideredinclude:

Giventhattheabilitytoaddressthehealthimpactofclimatechangedependsinpartonthequalityofpre‐existinghealthcareandfacilities,animportantstepistoinvestresourcesintheoverallhealthandrelatedinfrastructuredevelopmentinAfricancountries.

2 The complete set of recommendations are available online (http://portal.iri.columbia.edu/portal/server.pt/gateway/PTARGS_0_2_7668_0_0_18/Final%2010%20Years%20On%20Recommendations_April%206.11.pdf) and the report of the meeting is also available on-line with an elaboration of related presentations and discussions (http://portal.iri.columbia.edu/portal/server.pt/gateway/PTARGS_0_4972_7730_0_0_18/TR11-01_10YearsOn_WorkshopReport.pdf).

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ManyofAfrica’scurrenthealthproblemsarearesultoffrequentcontactwithcontaminatedwaterandopensewerage(UNFCCC,2007,p.18;IPCC,2007,p.399,416;Labonte,2004).ImprovedinfrastructurecouldreducethedamageandhealthdangersassociatedwithEWEs.

ComprehensivedrugtherapyandothermitigativeorpreventativemeasuresareusefulsothatthehealthsectorinAfricacancombatthemostprominent,andoftenclimate‐sensitive,infectiousdiseases,forexamplemalariaandmeningitis,plustheNTDs,etc.Medicationandotherparaphernalia(i.e.mosquitonets,condoms,sterilizationtabletsandsanitizers)forcuringorpreventingAfrica’scommoninfectiousdiseasesarerequiredinordertobuildtheoverallhealthstatusofAfrica’spopulation.Thesemeasuresalone,however,wouldnotsuffice.

Anincreasedpresenceofclinicsandhealthprofessionals,providingsupport,explainingoptionsandgivingdirectionsontheuseofdrugsandpreventativeparaphernaliaarealsorequiredtoimprovetheeffectivenessofthesemeasures.Ahealthierpopulaceiscriticaltodevelopmentandinturnadequatelevelsofdevelopmentareneededtoimprovetheoverallhealthstatusofthepopulace.TheGlobalStrategicPlanforRollBackMalaria,2005–2015,agrees,havingasserted"sixoutofeightMillenniumDevelopmentGoalscanonlybereachedwitheffectivemalariacontrolinplace"(Kopec‐Groverwtal.,2006,p.1;Connoretal.,2006,p.21).

Thereisaneedtotackletheproblemoffoodsecurityandmalnutritioninthecontextofclimatechange.Therearemanywaysofdoingthis,aswellasmanycomplications.Healthoutcomesmightbenefitfrominvestmentinagriculturalproductionsystems,improvedlandpolicyandinvestmentinirrigationsystemsforexample.Thereareanumberoforganizationsresearchingsuchissuesinthefieldandatthepolicylevel.Itisimportantthattheoutcomesofsuchresearchcontinuetobeusedtoinformgovernmentpoliciesandinterventions,coupledwithbuildingclimateresilienceintheagriculturesector.

AcrossAfricathereissignificantdevelopmentpotential,andassuchthereistheopportunitytoensureakeyelementofdevelopment,infrastructure,isclimateresilientbytakingclimatechangeintoaccountwhenplanninganddesigninginfrastructure.AchievingthisrequiressignificantincreaseintheawarenessofclimatechangeamongdevelopmentplannersandministriesinAfricancountries.Infrastructureisimportantbothforthedeliveryof,andaccessto,healthservices.

Africangovernmentscanincreasetheeffectivenessofaddressingthehealthimpactsofclimatechangethroughthecreationofknowledgemanagementplatformsforsharinginformation,skills,andtechnologybetweenandwithingovernments,privateinvestors,localandinternationalagencies,andacademicgroupsworking.Akeyissueforconsiderationistheneedforincreasedresearch.Itisimportanttoensurethatresponses,actionsandpoliciesarebasedonthebestavailableresearch.Itisalsoimportant,asstatedbytheWHO(2009)toimproveunderstandingofcurrentclimate‐relatedhealthrisksbeforetryingtounderstandfutureorlong‐termhealthrisks.Robustresearchisalsoneededtoidentifyrelativelyhiddenorunclearclimate‐healthlinks,ensureproperprioritizationofresponsemeasuresandidentifythemostcost‐effectiveinterventionsmeasures.

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Asclimatechangeisnotacompletelynewphenomenon,itwouldbeveryinsightfultolearnhowindigenouscommunitieshavedealtwithchangesoverpreviousgenerationsandhowthesecouldbeadaptedforscaled‐upeffectiveresponsestoclimatechange.

Thereisneedforimprovedregionalandlocalmodellingofclimatechangetoallowformorereliablepredictionsofthepotentialimpactsonhumanhealth.Improveddataandresearchcapacityisimportant.TherearealreadycollaborativeprogrammesinvolvingresearchorganisationswithtechnicalandcomputingcapacityworkinginpartnershipwithNationalHydrologicalandMeteorologicalOrganisationstoimprovingnationalcapacitiesandimprovemodellinganddownscalingoftheeffectsofclimatechangeonallsectorsincludinghealth.Suchinitiativescanbescaledupandwhencoupledwithhealthandothersocialandeconomicinformation,canbeutilisedintheformulationofpolicy.

Duetotheirlifesavingpotential,governmentsshouldworkhardtomakehydrometeorologicaldatasetseasilyaccessibleandusethemtoinformplanninganddevelopment.Further,thisinformationcanbeimprovedandtheapplicationanddevelopmentofearlywarningsystemspromoted.ExamplesofsuchtechnologyappliedacrossAfrica,butnotaspervasivelyasneeded,includemalariaandfamineearlywarningsystems.

ManyofthecurrentlimitationsonadaptationandmitigationresponsestoclimatechangerelatedhealthconcernsforAfricaareduetolimitedaccesstofinanceandbudgetarylimitations.Strategicallocationofclimatefinancewiththeaimofmitigatingclimate‐relatedhealthrisks,includingthosethatarealreadyveryprevalent,couldbecrucialtoimprovingAfrica’soverallhealthstatusinawarmingworld.

Ashighlightedinthisworkingpaper,climatechangeandhealthisacomplexissue,andaddressingclimatechangeandhealthrequiresintegratedanalysisofsocial,economicaswellasenvironmentalandclimaticdimensionsofdevelopmentandhealth.Thelistofoptionsaboveisnotexhaustiveandeachrequiressuchanintegratedanalysesandfurtherinvestigation.AssuchanyfeedbackonthecontentofthisworkingpaperandtheoptionspresentedwillbegreatlyappreciatedandwarmlyreceivedbytheACPC(acpc@uneca.org).

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