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Health, healthcare, health care, health services, sustainability, climate change, peak oil, energy vulnerability, mitigation, adaptation.

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Citations were filtered independently by two members of the research team (JR and VM). Where there were discrepancies, the full article was retrieved.

Waterborne disease

The increase in ambient temperature and flooding associated with climate change is likely to result in an increase in the spread of vectors such as mosquitoes, with a resultant increase in incidence of water-borne diseases such as malaria,^2,25,26 particularly in developing countries;^27,28 it is unlikely however, that in those countries that have adequate public health and medical infrastructures there would be a significant spread of malaria.²⁷ Nevertheless, Campbell²⁵ highlights the need for vigilance throughout Europe with the possibility of the arrival of new species of mosquito that could act as more effective vectors. Similarly, the increased risk of infection due to flooding is most likely to affect poorer countries and not the UK or the West unless water sources themselves are breached.²⁷ The effect of rising temperatures on the development of toxic blooms that are detrimental to health have also been highlighted by Hunter,²⁷ along with an increased incidence of cholera associated with such blooms.

Vector borne disease

Campbell²⁵ reports that changes in human behaviour associated with alterations in land usage and leisure activity due to warmer temperatures in the UK are likely to have the greatest impact on the transmission of vector-borne diseases such as that spread by insects (e.g. flies, ticks and mosquitoes).²⁵ In addition, there have been reports of vector species responding to climate change in Europe, with latitudinal shifts in the population of ticks due to rising temperatures, resulting in changes in the incidence, distribution and transmission of tick-borne encephalitis.²⁶ However, the likelihood that tick-borne encephalitis would become a major problem in the UK is probably very limited.²⁶ Factors such as temperature, humidity, levels of precipitation, soil moisture and sea level rise can all have an impact on the transmission of vector-borne infectious diseases, so determining how these factors may affect the risk to populations is not straightforward. Added to these environmental factors, there are also a number of plausible alternative explanations for changes to vector species, such as changes to land usage and socio-economic and demographic factors as outlined by Haines et al.²⁹

Food borne disease

A number of authors report an increase in death and disease from food poisoning associated with climate change and the effects of flooding^25,30 as well as the effects of higher temperatures on food storage and food hygiene.² Rising temperatures and increased risk of flooding are also likely to affect the distribution and incidence of diarrhoeal disease, with associated increased risk of food contamination.^2,26–2728 It is expected that the greatest risk of diarrhoea will occur in populations in developing countries, with Western countries suffering little or no additional risk.²⁶ Food contamination may also result from flooding with the remobilisation of chemicals and pesticides on the land, particularly in areas where industrial or agricultural land directly abuts residential land. However there has been little research in this area to determine the causal effect of chemical contamination on health of neighbouring communities.²⁶

Incidence of temperature related deaths

Death due to increases in temperature and humidity associated with climate change and more frequent heat waves are predicted with many of the actual causes of death being due to cardiovascular, cerebrovascular and respiratory events which will predominately affect the most vulnerable populations such as the elderly.^26,28,29 Urban areas are more likely to be affected than rural or sub-urban areas due to the ‘heat island effect’ and the increase in air pollution resulting in respiratory deaths.²⁹

There is some suggestion that warmer temperatures associated with climate change will bring about a reduction in cold-related deaths, particularly in the elderly (e.g.^26,28,31 though it is expected that these benefits are likely to be very small.

Skin cancer and cataracts

It is reported that modifications to health behaviours as a result of rising temperatures associated with climate change will lead to an increase in human UV exposure as individuals spend more time in the sun. This increased exposure to UV light, along with the ozone depletion also associated with climate change, is likely to result in an increase in incidence of skin cancer and cataracts.^32,33

Increase in malnutrition/starvation

The effect of climate change and weather extremes on agricultural productivity will have a direct impact on the health and nutrition of the population.^25,26 Such effects will have greatest impact on agriculture and crop yields in areas such as Africa and other developing countries already affected by drought and conflict.²⁵ Droughts will have wide ranging effects on health including nutrition and famine²⁶ with crop failures having worldwide impact resulting in food insecurity and food shortages.²⁵ Rising sea levels and flooding in coastal areas may impact on local agricultural infrastructure²⁵ and will affect local biodiversity and ecosystems with a knock on effect on goods and services.²⁶ Reduction in yields from agriculture result in reduced availability of food and increase in malnutrition and consequent disorders with implications for child growth and development.²⁸ There is also likely to be an increase in armed conflict over water, land and food supplies, resulting in population migration and displacement.²⁵

Increase in respiratory disease and deaths due to pollution/particulate matter

A predicted increase in cardio-respiratory and respiratory diseases is expected due to an increase in ground level ozone,²⁸ an increase in general air pollution caused by more frequent forest fires,²⁶ and an increase in particulate matter as a result of rising use of diesel fuel in the UK.²⁶ However, one health benefit associated with rising temperatures that has been identified is the shortening of the respiratory syncytial virus (RSV) season.³⁴

Injury/death due to flooding/storms

The direct and immediate effects of flooding and/or storms on health and well-being have been well documented, and include an increased risk of drowning and other injuries as well as potentially longer lasting effects on mental health.²⁶ Contamination due to mobilisation of dangerous chemicals and increased risk of diarrhoeal and respiratory diseases have also been identified as a direct result of flooding.²⁶

Psychological effects

The impact of flooding and the stress of population displacement on the psychological health of individuals is also well documented.^26,30 For example, due to climate change and more frequent natural disasters, communities are displaced as result of flooding, drought and environmental degradation and this creates pressures in neighbouring areas as they struggle for survival or compete for employment. This population displacement and the creation of environmental refugees creates psychological and mental health problems for those concerned.^25,26

Food and health

Fairchild and Morgan³⁵ describe a comprehensive food policy developed for Cardiff that encompasses sustainability, education, training, nutrition, food provision and food supply. The policy objectives included rapid appraisal of food initiatives, establishment of a food health strategy working group, and a preparation of food and health strategy. Their approach reinforces recommendations that policies should be guided by health and broader ecological sustainability.³⁵ The impacts of poor food policy decisions on public health are outlined by Caraher and Coveney.³⁶ They argue for the need for food policy to take into account the wider elements of the food system, such as the control of food supply, and the effects of globalisation on health. Haines et al²⁹ consider the implications of climate change on food production, processing and distribution and outline the need for policies that increase food crop production and prioritise food security. With the possibility of some food crops being diverted to produce biofuels for transportation, there is a need to ensure food security in those areas and to support sustainable land-use policies that maintain and enhance food crop production.

Contraction and convergence

Contraction and convergence has been proposed as the most practical and equitable strategy for reducing CO₂ emissions and tackling climate change.^{18,37–383940} This approach has also been proposed by the Global Common Institute³⁷ and would require the establishment of a global carbon budget with allocation of entitlement of carbon to each region, country or individual¹⁸ and major changes in all sections of the economy including: electricity production, transport, housing, agriculture, industry and commerce.⁴¹ Stott¹⁸ outlines the injury control benefits that would result from carbon rationing.

Waste and water management

Brayford⁴² examines sustainability in the UK NHS and considers actions and co-benefits around the five key themes of energy, water, waste, transport and procurement. In relation to waste management in the NHS, Brayford⁴² outlines the requirements placed upon NHS Estates who have been tasked with producing a strategy for ‘Total Healthcare Waste Management’ in order to enhance sustainability, to reduce waste disposal costs and reduce the environmental impact of the NHS whilst at the same time bringing about benefits to patient care and health services. There is also reference to further plans that have been proposed, such as Waste Not, Want Not–-A Strategy for Tackling Waste Production in England⁴³ that have been developed to reduce dependence on landfill. Mohan et al⁴⁴ outlines the involvement of public health professionals in regulation of waste management as part of the Integrated Pollution Prevention and Control (IPPC) process which is designed to ensure that all waste management installations are operating so as to minimise risk to human health. Recommendations are made for the use of health impact assessments (HIA) to determine the impact that a waste management site could have on the health of a local community and for consideration of possible mitigation measures, such as the use of Life Cycle Assessments (LCA) to ensure a sustainable approach.⁴⁴ The LCA approach takes into account the environmental impact of a product or service over its entire life cycle and provides an evidence based approach to waste management and planning for sustainability.

Sustainability

Brayford⁴² describes the latest strategy from NHS Estates: New Environmental Strategy for the NHS which encompasses buildings, energy, waste, water, transport and procurement and tasks the NHS with both reducing waste and enhancing efficiency in these areas, whilst at the same time bringing about patient benefit. A document produced to guide the NHS in its development of sustainability policies in these areas is Sustainable Development in the NHS.⁴² The need for sustainability policies covering such areas as energy, transport, town planning and structure of economy have been highlighted by Hanlon and McCartney⁴⁵ as essential to address shortfalls in energy supply, rising energy prices and energy vulnerability associated with ‘peak oil’. Hanlon and McCartney⁴⁵ emphasise that there is scope through economic planning and sustainable development to reduce the adverse effects of such changes on public health and that this should be tackled at both the national and international level through structures such as the European Union. Haines et al²⁹ considers policies to promote access to clean and sustainable energy sources in order to improve public health and mitigate climate change. They report on a number of technology and policy options and economic instruments for the mitigation of greenhouse gas emissions and use of energy in different sectors, such as power generation, transport, agriculture, and the built environment, with policies to reduce human population growth and livestock production also potentially playing an important role in tackling climate change. Coote⁴⁶ outlines the need for NHS policies that promote sustainable development to include all aspects of its business including: food for patients, cleaning equipment, pharmaceuticals, vehicles, childcare services, new buildings, energy, water and waste, and how it involves patients and public in decision making; and a sustainable health policy that gives priority to maintaining and improving health for all and reducing health inequalities.

Transport

Brayford⁴² outlines transport policies that are aimed at limiting environmental impact, reducing congestion and improving health. NHS philosophy is supported by the Government's White Paper New Deal for Transport: Better for Everyone which emphasises the role that the NHS and its hospitals can play in encouraging a more sustainable approach to travel.⁴² The health benefits of transition to a low-carbon, low-energy transport system have also been highlighted by Roberts and Arnold.⁴⁷ These benefits include a reduction in the volume and speed of traffic that could mitigate climate impacts, reduce injury rates and improved air quality whilst simultaneously improving health. Roberts and Arnold⁴⁷emphasise that increases in levels of active transport (such as walking and cycling) are key to limiting environmental pollution whilst at the same time bringing considerable health co-benefits. Co-benefits outlined include reductions in traffic pollution, noise, congestion and energy security and associated health benefits as a consequence of increased physical activity and personal energy consumption on rates of obesity, diabetes and cardiovascular disease.

Mazzi and Dowlatabadi⁴⁸ have highlighted that climate mitigation policies are a means of reducing fuel consumption and CO₂ emissions, though caution that these may not necessarily lead to associated health benefits. A switch from petrol to diesel fuelled vehicles may impact on green house gas reduction, but could impact negatively on air pollution and health due to an increase in health-damaging emissions e.g. black carbon emissions from diesel engines.⁴⁸ In addition to the above, Haines et al²⁹ highlight the need for policies and incentives that make walking and cycling a more attractive option; these include issues such as legal priority and reallocation of street space and time, making trips more pleasant and attractive.

Energy use

Haines⁴⁹ outlines the potential health benefits of renewable energy sources and policies that promote sustainability and use of renewable energy sources, describing how emissions of greenhouse gases can be reduced by increased use of renewable sources, such as wind power in the UK, greater energy efficiency and other measures to promote sustainability. Haines also highlights the considerable health benefits in the short term resulting from policies to reduce the combustion of fossil fuels, particularly those associated with high levels of pollution, such as oil and coal, with estimates from the Working Group on Fossil Fuels and Public Health of some 700,000 lives saved as a result of reductions in greenhouse gas emissions. Haines⁴⁹ refers to a report from the UN Intergovernmental Panel on Climate Change (IPCC) which has reviewed a range of technical options in relation to renewable energy use and its potential for health benefits. Haines et al²⁹ consider the importance of policies in promoting access to clean and sustainable energy sources and their potential to both improve public health whilst at the same time mitigating the effects of climate change.²⁹ They identify the need for policies that will transform patterns of power generation and energy use in order to address climate change and to improve public health, and to help reduce the vulnerability of poorer populations to the effects of climate change. A number of technology and policy options for the mitigation of greenhouse gas emissions and use of energy in different sectors are considered, for example: energy efficiency and conservation; fuel shift; carbon dioxide capture and storage; nuclear fission; renewable electricity and fuels; forests and agricultural soils. Brayford⁴² outlines the Climate Change Programme devised by the Government to tackle climate change and the recent Energy White Paper, Our Energy Future–-Creating a Low Carbon Economy⁵⁰ which sets out the UK's energy policy which aims to encourage the use of renewable energy and improving energy efficiency in buildings and procurement.

Buildings and settlements

Hales et al³⁰ emphasises the need for planners of housing and human settlements to consider energy efficiency alongside other criteria for sustainability such as the local impacts of housing design on human health and biodiversity. They use heat waves as an example of the effects and response measures in terms of buildings and health and of the need for land use planning to restrict building on flood plains, coastal areas and heat wave and drought-prone areas. Brayford⁴² refers to environment and building policies/windows such as the NHS Estates’ New Environmental Strategy for the NHS⁵¹ which aims to address sustainability in an holistic way by ensuring that healthcare buildings are waste reducing and energy efficient, whilst at the same time patient focused. The emphasis is on ensuring a healthcare environment that is not only sustainable but one that also maximises social and health benefits. The need for sustainability policies covering such areas as town planning have been highlighted by Hanlon and McCartney⁴⁵ as essential to address shortfalls in energy supply, rising energy prices and energy vulnerability associated with ‘peak oil’ (see sustainability theme). Haines et al²⁹ considers housing and the built environment and indicates that many of the policies that mitigate the effects of climate change will inevitably involve changes that will also serve to enhance the built environment. For example, reducing traffic congestion and pollution and increasing the number of trees in urban environments will make areas more attractive for safe and healthy active transport.

Behaviour modification strategies

Coote^46,52 and Mohan et al⁴⁴ describe the good corporate citizen model as a means by which NHS organisations can embrace sustainable development and tackle health inequalities. Griffiths et al⁵³ describe the use of doctors and other health professionals as advisors or role models in tackling climate change and for championing associated health benefits. McCartney et al⁴⁰ outlines the need for changes in mindset (including values, attitudes, norms and behaviours) which are required along with clear definitions of the problems faced in terms of economics, society and culture in order to respond to climate change.

Methods that support sustainable development

In considering the potential for the use of Health Impact Assessment to test for and promote health and sustainability, Barton and Grant⁵⁴ highlight some of the problems with planning processes for new developments and the lack of emphasis on the interplay between individual health, lifestyle, social networks and environment. They advocate the use of an integrated appraisal approach that embraces economic, social and environmental aspects of sustainable development (the Spectrum Approach). They provide an example of this approach as it has been used in practice and illustrate the stages of the appraisal process, stating that ‘Spectrum is expressly designed to recognize both the integrated agendas of health and sustainable development and the need for an inclusive communicative process’ (p134). Few⁵⁵ uses Health Impact Pathways as an approach to assessing event occurrence (physical risk), social vulnerability and coping capacity, and links this approach with population health and disaster management, stressing the importance of contextual and societal factors that constrain or promote coping efforts. This method focuses on risk reduction at pre-event, event, and post event stages, thus considering both mitigation and adaptation. The Department of Health Health Action Zones initiative provides an opportunity to link sustainability with health, environment and social justice, and to address inequalities in health.⁵⁶ Drawing on the work carried out in Sandwell, in the West Midlands of the UK, Middleton provides an example of regeneration projects, environmentally sustainable buildings, and community food co-operatives; initiatives aimed at promoting local enterprise and building resilience.

Governance and attitude/behaviour change

Jeffrey⁵⁷ highlights the World Humanity Action Trust (WHAT) report emphasis on governance ‘in terms of inter-relationships between systems and structures of governance, emphasising the need to take into account all relevant aspects of problems in an integrated way rather than as a series of single-issues’ (p606). This requires organisations to change behaviour and implement action to promote multidisciplinary working. Jeffrey provides an example of an attempt to address water quality through this approach. Tudor et al⁵⁸ found that NHS employees who reported recycling behaviour at home were also more likely to report recycling at work, and that such reports were influenced by underlying attitudes and beliefs about the environment. However, these self-reports of behaviour did not necessarily translate into actual behaviour when measured through observations and waste-bin analysis.⁵⁹ Suggestions for behaviour change at an organisational level included training managers, with an emphasis on cost-savings, increased communication about recycling and environmental issues through staff training and development.⁵⁹

Gardening and food

Efforts to reduce food miles and provide healthy local food have been implemented, reducing food miles by two thirds in one NHS Trust.^25,60 Health Action Zone initiatives have promoted food co-operatives and enhanced the local supply of healthy food.⁵⁶ Holland⁶¹ examined the community garden movement in the UK. ‘Health Issues’ was an important feature of the original purpose of the 96 community gardens surveyed. Connecting purposes were apparent from the data, in particular: education, health, food provision and leisure were linked. Thirty five of the garden projects linked health with skills, suggesting the application of food growing to skills and health promotion.⁶¹

Energy saving/waste management

Efforts to reduce carbon emissions and improve energy efficiency, through, for example, the installation of combined heath and power plants can also bring savings to NHS Trusts;^60,62 wind turbines and solar panels can provide energy and save costs.²⁵ Sustainable building programmes can encourage environmentally sound housing, as well as engagement of the local community (for example those with learning difficulties) and provide healthier domestic environments.⁵⁶ More effective management of clinical waste has been achieved by changing from disposable to reusable nappies.²⁵

Transport

Green travel plans encourage cycling and public transport use,^25,60 with the associated benefits of increasing physical activity.