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Climate change & health: the case for sustainable development

Paul Wilkinson a
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London School of Hygiene & Tropical Medicine, London

To cite this Article Wilkinson, Paul(2008) 'Climate change & health: the case for sustainable development', Medicine,
Conflict and Survival, 24: 1, S26 — S35
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 Medicine, Conflict and Survival
Vol. 24, No. S1, April–June 2008, S26–S35

Climate change & health: the case for sustainable development

Paul Wilkinson*

London School of Hygiene & Tropical Medicine, London WC1E 7HT

(Accepted 14 January 2008)

The Earth’s climate has been stable for around 10,000 years, though it
has been very variable in earlier periods and has occasionally changed
abruptly through natural processes. Industrialization and population
growth have brought an exponential rise in the use of carbonaceous
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fuels, which is now having an observable impact on the composition of

the atmosphere. Carbon dioxide levels are already substantially above
pre-industrial levels, and rising appreciably year on year. Climate
models suggest that the anthropogenic rise in carbon dioxide and other
greenhouse gases will lead to rapid climate change over the twenty-first
century, with an increase in global average temperatures in the region of
two to five degrees Celsius. This will present problems of adaptation for
many natural systems and have largely negative effects on human health
through both direct and indirect mechanisms. There is also a possibility
of unpredicted catastrophic impacts arising from non-linear effects of
climate change, which may have more damaging effects on human and
other populations. Policy responses have to be directed towards both
adaptation needs and mitigation. Mitigation in particular presents
formidable social, political and technological challenges, but it may
bring net health benefits in the short as well as the longer term.
Keywords: climate change; health; epidemiology; sustainable development;
policy

Climate change in context

Although short of complete consensus, the position is now broadly accepted
by the majority of climatologists and other scientists that significant climate
change, driven in large part by anthropogenic emissions of greenhouse
gases, is almost certain over the course of this century. The Fourth
Assessment Report (FAR) of the Intergovernmental Panel on Climate
Change (IPCC), published in 2007, provided the clearest assessment yet1.
The magnitude of future change in global temperatures is uncertain, for
models are imperfect, and many assumptions are needed about how the

*Email: paul.wilkinson@lshtm.ac.uk

ISSN 1362-3699 print/ISSN 1743-9396 online

Ó 2008 Taylor & Francis
DOI: 10.1080/13623690801957331
http://www.informaworld.com
 Medicine, Conflict and Survival S27
world will develop and respond to the climate change challenge. But a rise of
between two and five degrees Celsius seems probable, with a smaller
probability of change outside this range.
The drivers of concern are the greenhouse gases, primarily carbon
dioxide (CO2), whose emissions have risen in parallel with socio-economic
development over the last 200 years or more. The effect on atmospheric
concentrations has been directly observed since the mid twentieth century by
measurements at the Mauna Loa monitoring station on Hawaii. There the
annual cycle of fluctuation in CO2 levels and, more importantly, the steady
year on year increase in concentrations, have been clearly documented.
Atmospheric concentrations of carbon dioxide are now over 383 parts per
million (ppm) by volume compared with around 280 ppm in the pre-
industrial era. They are at their highest level for 650,000 years, possibly
much longer, and are continuing to rise by around two ppm by volume per
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year2. If the effect of other greenhouse gases is taken into account, the
concentration in CO2 equivalents is more than 420 ppm. Stabilization below
550 ppm CO2 equivalent is necessary to avoid more damaging climate
change associated with increases in temperature above two degrees Celsius
by the end of the century.
Climate change is nothing new, however: it has been a constant feature
throughout the history of the Earth. Over different timescales, variations in
global temperatures have been driven by many natural processes, including
variations in the orbit of the Earth and in its obliquity and precession of
spin, which have been the main cause of the glacial cycles of the last
million years or so. Life itself has played a crucial role through its
acceleration of rock weathering and in the capture of carbon in plant
biomass and marine sediments which are central to the crucial long-term
carbon cycle.
In the past the Earth has been both much warmer and much cooler than
today, and there is every reason to believe that profound climate change will
continue in future and will sometimes be abrupt. Palaeo-climatological
records suggest that at the end of the Younger Dryas stadial around 11,500
years ago, for example, a regional increase in temperature of seven degrees
Celsius occurred within just a few decades3, possibly as a result of changes to
the ocean circulation in the North Atlantic. However, over the last 10,000
years, the period known to geologists as the Holocene, the climate has been
unusually stable. This stability may have been an important factor in the
development of agriculture and the flourishing of human civilization.
Current global temperatures are not necessarily optimal for life, but they
are the ones to which organisms and ecosystems have had centuries to
adapt. What is potentially so destabilizing about the anthropogenic climate
change now in prospect is its rapidity—a faster rate of change than at any
point since the inception of agriculture. Despite impressive technological
advance, human populations remain vulnerable, and indeed this
 S28 P. Wilkinson
vulnerability is in large measure a function of the density of human
settlements and our dependence on intensive utilization of land and natural
resources.

Effects on health
The effects of climate change are likely to be complex and far-reaching, and
their likely impact on health, diverse4,5,6,7. Most obvious, perhaps, are the
direct effects of temperature extremes, particularly periods of unusually high
temperature, which are set to increase in frequency and magnitude. The heat
wave in France and western Europe in August 20038,9, and in Chicago in July
199510, are among the more visible events that have demonstrated
susceptibility to such temperature extremes even in high-income populations.
It has been estimated that more than 35,000 people died during the 2003
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European heat wave. Climate projections suggest that the temperature

extremes seen in Paris that year are likely to become the norm for northern
Europe by the middle of this century. Less well documented, but potentially
of greater concern, is the vulnerability of populations in lower income
countries who have fewer resources to help protect themselves against the
effects of temperature extremes. In such settings, younger populations
appear to be affected to larger degree, in part because of the importance of
infectious disease11.
Temperature-related mortality and morbidity has been observed in most
populations that have been studied, but their patterns appear to vary
appreciably for reasons that are only partly understood. Some of the
modifying factors are known, however: population age, prevalence of
‘climate sensitive’ disease, degree of socio-economic development, and
adaptive responses. In the US, there is evidence that air conditioning may
offer fairly effective protection12,13. It is less clear how great vulnerability
will be in low- and middle-income countries, particularly if temperatures rise
well above the upper limits of their current distributions.
Low-income populations are also likely to be especially vulnerable to
other forms of extreme weather, including floods and storms. In 2005
Hurricane Katrina demonstrated that even the most developed countries
can be very vulnerable to the effects of severe storms14, but the loss of life
and livelihoods is generally much greater in lower income settings15. For
example, severe flooding has resulted in major loss of life in such countries
as China, Guatemala, Venezuela and Mozambique16. Bangladesh, long
ravaged by frequent floods, will become increasingly vulnerable because of
the combination of more frequent periods of heavy precipitation and rising
sea levels, coupled with increasing population density and the effects of land
use change. Although health impacts have been comparatively small in high-
income countries, the absolute financial impact is typically very high. Similar
arguments apply with respect to droughts, where the human costs have been
 Medicine, Conflict and Survival S29
especially great in the Horn of Africa, India, Bangladesh and other low-
income populations, while the financial cost (mainly to agricultural
production) has tended to be high in the most developed and productive
countries, including Australia, the USA and parts of Europe16.
Debates also continue about the possible effect of climate change on
food- and water-borne disease, especially where the pathogen itself
replicates outside the stable environment of the human host. Environmental
temperature and humidity may affect the survival and replication rates of
bacteria and other enteric pathogens in water or on food, as well as the
survival of enteroviruses in the environment. The relative importance of
different pathogens and modes of transmission (e.g. via water, food, insects
or human–human contact) varies between areas, and is influenced by levels
of sanitation.
Data necessary to quantify the influence of temperature are sparse, but
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several studies have demonstrated temperature links in low-income settings.

For example, Checkley et al.17 reported a substantial impact of temperature
on daily hospital admissions in Lima, Peru, and interestingly observed an
additional increase during the 1997–1998 El Niño period, when there was an
increase in admissions above that expected on the basis of the pre-El Niño
temperature relationships. Similarly, Singh et al. used time-series methods to
demonstrate a strong quantitative relationship between variations in both
temperature and rainfall and diarrhoeal illness in Fiji18, and Hasizume et al.
have demonstrated relationships between temperature and rainfall on
diarrhoeal disease in Bangaldesh19. Relationships between food-borne
disease and temperature have also been reported in European populations20,
but in developed countries it seems probable that substantial temperature-
related increase in food- and water-borne disease should largely be
preventable by effective refrigeration and appropriate hygiene measures.
Evidence about the effect of climate change on vector-borne disease
remains limited. In the case of malaria, the basis for concern is laboratory
evidence about the biological dependence of both the vector (the
mosquito) and the disease-causing organism (the parasite) on temperature.
Such evidence suggests that temperature changes and, potentially, changes
in precipitation patterns that affect mosquito-breeding sites, will alter
transmission potential. In broad terms, as temperatures rise, so too does
the potential for disease spread, raising concerns especially in areas on
the edge of the current geographical distribution of disease. However, the
relative importance of meteorological against other environmental,
social and health care determinants, remains unclear. Early modelling
exercises, for example by Martens et al.21, Rogers and Randolf22,
and Tanser et al.23 provide varying but limited evidence about future
changes in malaria risk. There have also been reports of observed
association between altitudinal shifts in malaria as temperatures rise,
though the interpretation of such evidence remains controversial24.
 S30 P. Wilkinson
Attempts to examine the shift in risk of dengue consequent on global
warming23 have also provided evidence to suggest at least the potential for
significant alterations in the distribution of disease over this century.
However the true potential for spread remains unclear because of the
important but largely unquantified modifying influences of non-climatic
factors which, for example, have been responsible for the disappearance of
malaria from most of Europe over the last 100 years or so. At present, it is
possible to conclude only that there is a theoretical risk of greater spread of a
number of vector-borne diseases under climate change, but that more
research is needed before reliable predictions can be made.
Beyond these direct connections between climate change and health,
there are concerns about indirect effects, arising, for example, from adverse
effects on sustainability of water resources and agricultural production. In
poorer countries, adverse effects on water resources and agriculture may
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lead to increases in malnutrition and in food- and water-borne disease,

especially in children. Another consequence may also be an increase in
environmental refugees, and even heightened international tension and
conflict. Once again, such risks are difficult to quantify with any precision,
but as with so many climate change related impacts, areas of particular
vulnerability are those where water resources and agriculture are already
stressed and socio-economic development low25.
Taken as a whole, the known risks to health of climate change add up
to a substantial concern25,26. For the most part they represent a significant
worsening of many current public health burdens, but by themselves they
do not present a compelling case that the risks to health from climate
change are unique in magnitude and demand extraordinary global action.
The case for action is compelling when the health consequences are viewed
alongside the many other consequences of climate change, and when
consideration is given to the small but finite risk of non-linear (and largely
unpredictable) changes to global or regional environments which may have
much more serious consequences. Rees summarized the situation thus: ‘If
we could be absolutely sure that nothing more drastic than ‘‘linear’’
changes in the climate could occur, it would be reassuring. The small
chance of something really catastrophic is more worrying than the greater
chance of less extreme events . . . [and such change] could negate decades
of economic and social advance’27. What those catastrophic changes might
be remains a matter of conjecture. Candidates include threats arising from
disruption of critical ocean circulations and of accelerated climate change
resulting from the release of methane, a powerful if short-lived greenhouse
gas, from the massive gas hydrate deposits in the oceans and tundra. These
uncertain possibilities are a reminder that in contributing to climate
change mankind has embarked upon an unprecedented and effectively
irreversible global experiment whose consequences are not readily
predictable. Leaving aside moral arguments about our responsibility for
 Medicine, Conflict and Survival S31
stewardship of the environment and other species, self-interest should be
motivation enough to consider strong action to address the climate change
challenge.

Policy responses
Responses are needed both to help limit the degree of climate change
(‘mitigation’ in the terminology of the IPCC) and to protect against its
adverse effects (‘adaptation’).
Because of the long half-life of carbon dioxide as a greenhouse gas, the
enormous inertia in atmosphere and ocean systems, and the practical
barriers to achieving rapid reduction in fossil fuel use, some degree of global
warming is inescapable. Two degrees Celsius increase over the course of this
century is conservative. If such a contained level of warming is achieved, it
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will probably keep the risk of dangerous climate change to an acceptably

low level, but there will still be disruptive and damaging consequences in all
major regions. Development decisions therefore need to take account of
local risks and to adapt to them, bearing in mind the varying timescales
involved and the inherent lag in infrastructure development and response
planning.
Fortunately, the greatest risks are still some way off, which gives time for
the planning of adaptation measures. But what cannot be long delayed to
avoid more severe climate change is the process of beginning major
reduction in greenhouse gas emissions1. Such reduction will require a
combination of international and local actions, and regard for health is one
of many reasons for basing action on principles of equity, such as those
proposed by the Global Commons Institute in Contraction and Conver-
gence28. These principles are: (1) that global emissions of carbon dioxide
should be reduced to an internationally agreed level (contraction); and (2)
that global governance must be based on justice and fairness with
convergence to equal per capita carbon emission shares. There is currently
enormous inequity in such emissions, with close to twenty-fold variation
between the richest and poorest countries. The level of emissions is also
broadly in inverse relation to vulnerability to climate change impacts, both
of which are largely determined by wealth: those who contribute least to
climate change are likely to be among those who suffer most from it. There
is little doubt that, from a health perspective, many in the lower income
countries do not have enough access to energy services and would benefit
from having more6,29.
The goals of emissions reduction are challenging, requiring as much as
an 80–90% reduction by 2050 in the high-income countries such as the UK.
This will require major change in all sectors of the economy: in electricity
production, transport, housing, agriculture, industry and commerce. There
will be costs. One of the often cited disadvantages of mitigation is that it
 S32 P. Wilkinson
may adversely effect economic growth, and so too in consequence the
capacity to adapt. However, the influential Stern Review30 provided an
alternative position: failure to mitigate could itself have significant
detrimental impact on economic prosperity.
It is difficult to be precise about the balance of costs and benefits of
mitigation policies, in part because technology and other factors are likely to
change rapidly and in unforeseen ways over the course of the next few
decades. At present, most renewable energy technology appears uncompe-
titive, yet it will doubtless become cheaper and more accessible as time goes
by; given sufficient investment, eventually it is likely to become competitive
with more traditional fossil fuel-based generation. There are also issues
about the fact that at present the full environmental costs of fossil fuel use
are not borne by the producer or user.
Arguably, the crucial task is to set broad policy direction, but there are
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nonetheless many difficult questions about specific policies – the role of

nuclear power (currently 16% of global electricity generation); whether and
how to limit air travel; the role of renewable technology in low-income
countries given arguments about its affordability even in richer countries;
and where and how to limit population growth. Populations and their
governments around the world face major challenges. Yet the means to
achieve adequate emissions reductions exist, and in spite of all the
difficulties, a switch towards cleaner, renewable technology and a reduction
in dependence on fossil fuels will carry a significant health dividend29. This is
not only because of its contribution to limiting future climate change, with
all that that entails, but also because of the immediate benefits that arise
from lower air pollution levels, improved urban environments, and the
positive effects of active transport. There are major social, political and
technological barriers to meeting the challenges that climate change
presents, but there is also an important opportunity for improving
population health worldwide.
International cooperation and agreement are essential. The United
Nations Framework Convention on Climate Change (UNFCC), parent
treaty of the 1997 Kyoto Protocol on greenhouse gas emissions reduction, is
the central vehicle for such agreement. At its Climate Change Conference in
Bali, in December 2007, after protracted and sometimes fraught negotia-
tions, 187 countries agreed to launch negotiations towards ‘a crucial and
sustained international climate change deal’31. In one sense the agreement
was a major breakthrough, with wide recognition of the urgency for action,
and agreement among delegations that are almost ideologically opposed on
the mechanisms of action. But in the end the agreement was only a
‘roadmap’ for further negotiations, and no one can be in any doubt of the
scale of the task ahead and of the short timescale (by 2009) for agreeing
practical steps. The obvious difficulties that the negotiations entailed and the
limited progress achieved are indications of the varying perspectives on how
 Medicine, Conflict and Survival S33
to tackle climate change and the immense political complexities involved.
The jury is still out on the prospects for a final settlement that will bring
about emissions reductions with the required speed. Perhaps the real hope is
that needed changes are achieved by a myriad of more local solutions,
following the dictum of ‘think globally, act locally’.

Conclusions
Climate change has been a constant feature of the Earth’s history.
Anthropogenic emissions of greenhouse gases will however bring about a
change in the global climate of greater magnitude and more rapidly than at
any point during the last 10,000 years. This will cause problems for many
natural systems and the human population. Health impacts are likely to
arise through many pathways, including through direct effects of more
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extreme temperatures, an increase in severe floods and storms, influence on

food- and water-borne disease and potential impact on vector-borne disease.
Substantial impacts are likely to arise from indirect effects on water
resources and the sustainability of agriculture. The small but finite
possibility of unpredicted catastrophic change arising from non-linear
effects of climate change remains and is one of the more compelling reasons
for precautionary action. The challenges to policy-makers of mitigation are
however considerable, but there may be major net benefits to health in both
the short as well as the longer term.

Notes on Contributor
Paul Wilkinson is Reader in Environmental Epidemiology and a public health
physician at the London School of Hygiene and Tropical Medicine. He trained in
clinical medicine in Oxford and London, and began epidemiological research at the
National Heart & Lung Institute before moving to the London School in 1994. His
principal research interests are climate and health, the heath consequences of
environmental change, and methods for assessing environmental hazards to health.
Address for correspondence: Dr Paul Wilkinson, London School of Hygiene &
Tropical Medicine, Keppel Street, London WC1E 7HT.

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