2020 Book HealthOfPeopleHealthOfPlanetAn PDF

Wael K.
Al-Delaimy
Veerabhadran Ramanathan
Marcelo Sánchez Sorondo Editors
Health of People,
Health of Planet
and Our
Responsibility
Climate Change, Air Pollution
and Health
Health of People, Health of Planet and Our
Responsibility
Wael K. Al-Delaimy
Marcelo Sánchez Sorondo
Editors
Health of People, Health

of Planet and Our
Responsibility
Climate Change, Air Pollution and Health
Editors
Wael K. Al-Delaimy Veerabhadran Ramanathan
University of California San Diego Scripps Institution of Oceanography
La Jolla, CA, USA University of California at San Diego
La Jolla, CA, USA
Marcelo Sánchez Sorondo
Bishop-Chancellor of the Pontifical
Academy of Sciences
Vatican City, Holy See
ISBN 978-3-030-31124-7 ISBN 978-3-030-31125-4 (eBook)

https://doi.org/10.1007/978-3-030-31125-4
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Message from Pope Francis
Some forms of pollution are part of people’s daily

experience. Exposure to atmospheric pollutants
produces a broad spectrum of health hazards,
especially for the poor, and causes millions of
premature deaths. People become sick, for example,
from breathing high levels of smoke from fuels used in
cooking or heating. There is also pollution that affects
everyone, caused by transport, industrial fumes,
substances that contribute to the acidification of soil
and water, fertilizers, insecticides, fungicides,
herbicides, and agrotoxins in general. Technology—
which linked to business interests, is presented as the
only way of solving these problems—in fact proves
incapable of seeing the mysterious network of
relations between things and so sometimes solves one
problem only to create others.
vi
O God of the poor,

Help us to rescue the abandoned
and forgotten of this earth,
So precious in your eyes.
Bring healing to our lives,
That we may protect the world
and not prey on it,
That we may sow beauty, not
pollution and destruction.
—Pope Francis, Laudato Si’
Foreword
The notion of the Anthropocene—the age of humans—comes from the observation

that humanity is contesting nature in shaping our planet by profoundly changing the
atmosphere, biosphere, land surface, and oceans. In the Anthropocene, climate
change is tightly linked to many of the other grand challenges that we face—includ-
ing the improvement of air quality, public health, sustainable development, and
human well-being.
For example, the consumption of limited resources, as well as global warming
and shifting precipitation patterns, can affect agriculture and jeopardize food secu-
rity. Global warming and environmental pollution are also challenging issues of jus-
tice because the poor and future generations are the ones most affected. Global
environmental change and societal disparity can lead to migration, territorial con-
flicts, and pressure on resources like water and arable land, which in turn can endan-
ger international stability and peace. Thus, the well-being of humans and the integrity
of our environment are closely coupled, as expressed by the term “planetary health.”
Both the challenges and the opportunities of a safe and prosperous Anthropocene
are reflected in this book, including perspectives of sciences, engineering, medicine,
humanities, politics, and religions. I hope and wish that the integration of scientific
knowledge with societal considerations will help to solve the challenges and grasp
the opportunities of the Anthropocene for the well-being of humanity, now and for
future generations.
Paul Crutzen1
Nobel Laureate in Chemistry 1995 (shared with Mario J. Molina and F. Sherwood
Rowland).
Paul J. Crutzen
Max Planck Institute for Chemistry
Mainz, Germany
1
I thank Uli Pöschl, Mark Lawrence, Jos Lelieveld, and Veerabhadran Ramanathan for helpful
discussions.
vii
Preface
This book was almost 8 years in the making at the Pontifical Academy of Sciences
(PAS). It perhaps originated at a 2011 meeting that we organized on the topic of
mountain glaciers, which was held inside the Vatican at the headquarters of PAS. The
glacier meeting was followed by a historic meeting in 2014, again organized by PAS
at the Vatican, in which we joined hands with the Pontifical Academy of Social
Sciences (PASS). The joint PAS/PASS meeting was ambitious in scope and was
titled Sustainable Humanity, Sustainable Nature, Our Responsibility. On the last
day, we briefed Pope Francis on the primary findings of this meeting, including the
moral and ethical issue of climate change, by pointing out the following: more than
50% of climate pollution is being emitted by the wealthiest one billion people,
while the poorest three billion, who suffer the worst consequences of climate
change, contribute about 5% or less.
A year later, Pope Francis published his climate encyclical Laudato Siʼ, with the
best espousal to date of climate justice. Among other things, it clearly states that
“The climate is a common good. … A very solid scientific consensus indicates that
we are presently witnessing a disturbing warming of the climatic system. … A num-
ber of scientific studies indicate that most global warming in recent decades is due
to the great concentration of greenhouse gases (carbon dioxide, methane, nitrogen
oxides and others) released mainly as a result of human activity. As these gases
build up in the atmosphere, they hamper the escape of heat produced by sunlight at
the Earth’s surface. The problem is aggravated by a model of development based
on the intensive use of fossil fuels, which is at the heart of the worldwide energy
system. Another determining factor has been an increase in changed uses of the
soil, principally deforestation for agricultural purposes” (Laudato Si’).
Recent meetings at PAS on our responsibility vis-à-vis our “Common Home”
have included, in addition to PAS academicians, a number of natural scientists,
social scientists, philosophers, theologians, and faith leaders, including, at times,
the Pope himself. A fourth of the PAS’s 80 members are Nobel Laureates in physics,
chemistry, and medicine. At the 2014 meeting on Sustainable Humanity, Sustainable
Nature, Our Responsibility, the combination of thought leaders from around the
world concluded that solving the climate change problem would require a
ix
x Preface
transformational change in people’s attitudes toward nature and that an alliance

between science, policy, and religion could make such a transformational
change happen.
The Pope’s climate encyclical was published in 2015. A few months later at PAS,
we helped the Holy Father organize two summits on climate change: one that
consisted of mayors from around the world, and a second that comprised judges
from our global community.
During the historic December 2015 UN Climate Conference in Paris, which gave
birth to the Paris Agreement to limit warming to well below 2 °C, we both joined the
Vatican delegation as science advisors. We had the unique privilege of witnessing
firsthand the alliance between science, policy, and religion.
Around the time of the 2015 Paris Conference, there was another major
momentous development in the science of climate change. An international group
of climate and public health experts, called the Lancet Commission, released a
report that concluded that climate change would pose unacceptable and catastrophic
health risks.
In 2017, the American Meteorological Society (AMS) declared for the first time
that “We are experiencing new weather extremes because we have made a new
climate.” Most weather forecasters, meteorologists, and climate scientists in the
USA are members of AMS. The AMS statement is significant because this link
between climate warming and extreme weather is directly relevant to public health,
since weather extremes such as heat waves, droughts, and floods cause most of the
fatalities attributed to natural factors. Numerous studies by individual scientists and
institutions have suggested that by 2050, over two billion people could be exposed
to extreme heat waves, major droughts, and severe floods.
These studies, along with the Lancet Commission’s conclusion and the findings
of the American Meteorological Society, have elevated the health impacts of climate
change as a major emerging topic of climate change. In response, PAS organized a
meeting of scientific leaders, faith leaders, and political leaders from around the
world on November 2–4, 2017. The meeting was titled Health of People, Health of
Planet and Our Responsibility: Climate Change, Air Pollution and Health. It was
co-sponsored by the World Health Organization (through Dr. María Neira), the
Institute of Public Health at the University of California at San Diego (through its
then head, Dr. Bess Marcus; now at Brown University), and the Miraglo Foundation
based in San Diego (through its directors Dr. E. Guarneri and Rauni King).
The November 2017 meeting on health produced a declaration signed by several
Nobel Laureates, mayors, the governor of California, and faith leaders. This decla-
ration is reproduced in this book. The papers submitted at this meeting provided the
background materials for all of the chapters in this book. There are numerous reports
and books that are being published on the topic of climate change and health, but
this book is unique in one important aspect: the authors not only represent the natu-
ral and social sciences but also include faith leaders, political leaders, and practitio-
ners of medicine. As such, this book is a product of an alliance between leaders
in science, policy, medicine, and religion, and it is such alliances that can catalyze
the sort of transformational change we need to solve the climate change problem.
Preface xi
The funding for the open access of this book was provided by the Center for
Development Research, Bonn University (through Professor Joachim von Braun),
and the Max Planck Institute of Chemie, Mainz (through Dr. Jos Lelieveld).
La Jolla, CA, USA Veerabhadran Ramanathan

Vatican City, Holy See Marcelo Sánchez Sorondo
Declaration: Our Planet, Our Health,
Our Responsibility
Veerabhadran Ramanathan (PAS & UCSD), Monsignor Marcelo Sánchez

Sorondo (PAS Chancellor).
Partha Dasgupta (PASS & CU), Peter Raven (PAS & MBC), Joachim von
Braun (PAS President & UOB), Jeffrey Sachs (UN SDSN).
PAS: Pontifical Academy of Sciences; UCSD: University of California at San
Diego; CU: Cambridge University; MBC: Missouri Botanical Garden; UOB:
University of Bonn; UN SDSN: United Nations Sustainable Development Solutions
Network.
This declaration is based on the data and concepts presented at the workshop:
Health of People, Health of Planet and Our Responsibility: Climate Change, Air
Pollution and Health.
Organized by the Pontifical Academy of Sciences, Casina Pio IV, Vatican City,
2–4 November 2017.
Statement of the Problem
With unchecked climate change and air pollution, the very fabric of life on Earth,
including that of humans, is at grave risk. We propose scalable solutions to avoid
such catastrophic changes. There is less than a decade to put these solutions in
place to preserve our quality of life for generations to come. The time to act is now.
We human beings are creating a new and dangerous phase of Earth’s history that
has been termed the Anthropocene. The term refers to the immense effects of human
activity on all aspects of the Earth’s physical systems and on life on the planet. We
are dangerously warming the planet, leaving behind the climate in which civiliza-
tion developed. With accelerating climate change, we put ourselves at grave risk of
massive crop failures, new and re-emerging infectious diseases, heat extremes,
droughts, mega-storms, floods, and sharply rising sea levels. The economic activi-
ties that contribute to global warming are also wreaking other profound damage,
including air and water pollution, deforestation, and massive land degradation,
xiii
xiv Declaration: Our Planet, Our Health, Our Responsibility
causing a rate of species extinction unprecedented for the past 65 million years and
a dire threat to human health through increases in heart disease, stroke, pulmonary
disease, mental illness, infections, and cancer. Climate change threatens to exacer-
bate the current unprecedented flow of displacement of people and add to human
misery by stoking violence and conflict.
The poorest people of the planet, who are still relying on nineteenth-century
technologies to meet basic needs such as cooking and heating, are bearing a heavy
brunt of the damage caused by the economic activities of the rich. The rich too are
bearing heavy costs of increased flooding, mega-storms, heat extremes, droughts,
and major forest fires. Climate change and air pollution strike down the rich and
poor alike.
Principal Findings
• Burning of fossil fuels and solid biomass releases hazardous chemicals into
the air.
• Climate change caused by burning fossil fuels and other human activities
poses an existential threat to Homo sapiens and contributes to mass extinction
of species. In addition, air pollution caused by the same activities is a major
cause of premature death globally.
Supporting data are summarized in the attached background section. Climate
change and air pollution are closely interlinked because emissions of air pollutants
and climate-altering greenhouse gases and other pollutants arise largely from
humanity’s use of fossil fuels and biomass fuels, with additional contributions from
agriculture and land use change. This interlinkage multiplies the costs arising from
our current dangerous trajectory, yet it can also amplify the benefits of a rapid tran-
sition to sustainable energy and land use. An integrated plan to drastically reduce
climate change and air pollution is essential.
• Regions that have reduced air pollution have achieved marked improvements
in human health as a result.
We have already emitted enough pollutants to warm the climate to dangerous
levels (warming by 1.5 °C or more). The warming as well as the droughts caused by
climate change, combined with the unsustainable use of aquifers and surface water,
pose grave threats to the availability of fresh water and food security. By moving
rapidly to a zero-carbon energy system (replacing coal, oil, and gas with wind, solar,
geothermal, and other zero-carbon energy sources), by drastically reducing emis-
sions of all other climate-altering pollutants, and by adopting sustainable land-use
practices, humanity can prevent catastrophic climate change while tackling the huge
disease burden caused by air pollution and climate change.
• We advocate a mitigation approach that factors in the low-probability–high-
impact warming projections such as the one-in-twenty chance of 6 °C warming
by 2100.
Declaration: Our Planet, Our Health, Our Responsibility xv
Proposed Solutions
We declare that governments and other stakeholders should urgently undertake the
scalable and practical solutions listed below:
1. Health must be central to policies that stabilize climate change below danger-
ous levels, drive zero carbon as well as zero air pollution, and prevent ecosys-
tem disruptions.
2. All nations should implement with urgency the global commitments made in
Agenda 2030 (including the Sustainable Development Goals of the United
Nations) and the Paris Climate Agreement.
3. Decarbonize the energy system as early as possible and no later than midcen-
tury, shifting from coal, oil, and gas to wind, solar, geothermal, and other
zero-carbon energy sources.
4. The rich should not only expeditiously shift to safe energy and land-use prac-
tices but also provide financing to the poor for the costs of adapting to climate
change.
5. Rapidly reduce hazardous air pollutants, including the short-lived climate
pollutants methane, ozone, black carbon and hydrofluorocarbons.
6. End deforestation and land degradation, and restore degraded lands to pro-
tect biodiversity, reduce carbon emissions, and absorb atmospheric carbon
into natural sinks.
7. To accelerate decarbonization, there should be effective carbon pricing
informed by estimates of the social costs of carbon, including the health
effects of air pollution.
8. Promote research and development of technologies to remove carbon dioxide
directly from the atmosphere for deployment if necessary.
9. Forge collaborations between health and climate sciences to create a power-
ful alliance for sustainability.
10. Promote behavioral changes that are beneficial for human health and protec-
tive of the environment, such as increased consumption of plant-based diets.
11. Educate and empower the young to become the leaders of sustainable
development.
12. Promote an alliance with society that brings together scientists, policy mak-
ers, health care providers, faith/spiritual leaders, communities, and founda-
tions to foster the societal transformation necessary to achieve our goals in
the spirit of Pope Francis’s encyclical Laudato Si’.
To implement these 12 solutions, we call on health professionals to engage, edu-
cate, and advocate for climate mitigation and to undertake preventive public health
actions vis-à-vis air pollution and climate change; and to inform the public of the
high health risks of air pollution and climate change. The health sector should
assume its obligation in shaping a healthy future. We call for a substantial improve-
ment in energy efficiency and electrification of the global vehicle fleet and all other
downstream uses of fossil fuels. Ensure that clean energy benefits also protect soci-
xvi Declaration: Our Planet, Our Health, Our Responsibility
ety’s most vulnerable communities. There are numerous living laboratories—

including tens of cities, many universities, Chile, California, and Sweden—that
have embarked on a pathway to cut both air pollution and climate change. These
thriving models have already created eight million jobs in a low-carbon economy,
enhanced the well-being of their citizens, and shown that such measures can both
sustain economic growth and deliver tangible health benefits for their citizens.
End of Declaration
Signatories: This declaration was signed by members of the Pontifical Academy of

Sciences, including Professor Stephen Hawking (now deceased), all authors of this
book, eight Nobel Laureates, faith leaders from the Church of England and the US
Evangelical Association, 14 mayors from around the world, the Governor of
California, and the Governor of St Luis, Argentina. For a full list of signatories,
please see http://www.pas.va/content/accademia/en/events/2017/health/declara-
tion.html
Introduction
This book provides a unique perspective on the multidimensional aspects of the

health impacts of climate change and air pollution, which include the science,
impacts, solutions, and advocacy of the solutions. The book is intended to add a new
approach to climate change by focusing on its health impacts from a multidisci-
plinary understanding that can be used for academic, political, faith, community,
and activism purposes. The authors of the 33 chapters have expertise in an impres-
sive array of topics relevant to the book. We have attempted to make the text in the
scientific chapters less technical and more understandable by nonscientists, yet the
book has enough technical background and scientific rigor to make it relevant to
higher education and professional entities and individuals for use in teaching and
practice. More importantly, we have made it freely available online to reach every
individual across the globe, including traditionally less involved populations and
regions that are most affected by the consequences of climate change.
Even though the influence of humans on climate change has been established
through extensive published evidence and reports, the connection between climate
change, the health of the planet, and the impacts on human health has not received
the same level of attention. Therefore, the global focus on the public health impacts
of climate change is a recent area of interest triggered by two recent international
initiatives, one by the World Health Organization and the other by The Lancet,
known as the Lancet Commission on Climate Change and Health. The majority of
the previous work on the health impacts of climate change was limited to epidemio-
logical approaches and outcomes, and less focused on multidisciplinary, multifac-
eted collaboration between physical scientists, public health researchers, and policy
makers. Further, the context of faith and ethics as the underpinning of such multi-
disciplinary approaches was not previously explored.
The gravity of the environmental impacts of climate change on human health, the
planet’s ecosystem, and the intercorrelations between them—to the degree that it is
threatening our very existence and the natural systems that sustain the planet—is
real. We therefore need to act immediately and in a holistic approach to be able to
make a difference.
xvii
xviii Introduction
This book is not intended to recapture everything related to climate change and
health that is already covered by other books. Our intent is to capture just the high-
lights and summarize the areas we think will resonate most with the public, faith
leaders, scientists and students of science, and policy makers. All scientists, not just
health scientists, need to turn their attention to the health impacts of climate for the
benefit of the survival of mankind.
Part I of the book provides the big picture of the Anthropocene and nature–
human interactions. We start the book with a chapter authored by a biology Nobel
Laureate, who writes about the importance of protecting habitats and their living
organisms to preserve our planet and our well-being (Chap. 1). This leads to a dis-
cussion on species extinction rates, which are leading to rapid loss of organisms as
a result of climate change (Chap. 2). The impacts of such extinctions on human life
and the planet’s ecosystem are also addressed. The following chapter connects the
changes in the planet to human health (Chap. 3) by providing examples of the spread
of contaminating chemicals and discussing land use in addition to the direct health
impacts of excessive heat, flooding, and severe weather. The economics of climate
change and overuse of the Earth’s resources are described insightfully and speak to
the connection between the planet’s sustainability and human health (Chap. 4). The
author discusses the need for better and more accurate measures of wealth that take
into consideration the planet’s environment. The connection between air pollution
and climate change is then described to explain how pollutants can cause global
warming and what solutions are possible by making changes to our sources of
energy (Chap. 5).
Part II is focused on air pollution, addressed from multiple angles. The evidence
of the health impacts of each specific pollutant is well known and is extensively
documented in the first chapter in this part, along with the associated disease burden
(Chap. 6). The mechanism of these health impacts of air pollution through oxidative
stress is then explained scientifically (Chap. 7). The health impacts of air pollution
need to be a major component in the aim of policies and regulations related to
energy, transport, technology, water, and urban planning so as to lead to a system-
atic shift in dealing with air pollution (Chap. 8). Furthermore, the global burden of
mortality from air pollution can be substantially reduced, as demonstrated across
regions and countries, by reducing residential biomass energy use and agricultural
sources of ammonia, and by increasing use of new technology in transport and
energy (Chap. 9).
Part III addresses fundamental aspects of sustainability in water, agriculture, and
deforestation and their region-specific health impacts from climate change. This is
exemplified in the Middle East, which is the area most vulnerable to climate change
and its health impacts through heatwaves, water scarcity, desert storms, and their
impacts on refugees in the presence of political instability (Chap. 10). A globally
important topic with particular relevance to this region is water access and water
quality, and how we can become sustainable in using the available global water
resources (Chap. 11). Agricultural practices that are critical for food security and
quality will have a detrimental health effect and require a shift toward climate-smart
food systems (Chap. 12). The Amazon has been the region most central to the cli-
Introduction xix
mate change debate because of deforestation. However, what has been overlooked
is the health impacts of forest fires and air pollution on the health of the vulnerable
indigenous human populations within that region (Chap. 13). A focus on these
human impacts could be a more effective tool for developing environmental policy
against deforestation.
Part IV provides a perspective from a number of physicians who are in clinical
practice, and what they see is climate change impacts relevant to health. Important
and often neglected health impacts of the consequences of climate change and
extreme weather are mental illness and psychological trauma associated with such
events (Chap. 14). A focus on the specific impacts of air pollution on cardiovascular
diseases is missing from clinical practice and requires further attention as a cost-
effective approach to limit the health costs of this causal association (Chap. 15).
There is a need to explore new paradigms in health care that are holistic and incor-
porate well-being, the environment, and economic well-being as essential compo-
nents of health care practice (Chap. 16).
Part V is focused on societal aspects of climate change. Social peace and injus-
tice caused by environmental catastrophes are affecting the most vulnerable global
populations, and there is a need to recognize and support stateless populations
through specific action because we are all part of one community (Chap. 17). This
is also related to global migration and the acceptance of immigrants, whether they
are migrating for political reasons or reasons related to environmental and economic
privations (Chap. 18). Climate change should be approached in terms of climate
justice and the distribution of responsibility. Examples of actions by visionary lead-
ership, such as those in some Latin American cities, and how they have successfully
led to green urbanization despite limited resources, are described (Chap. 19).
Part VI is an important focus of this book, as it brings a perspective from Christian
faith leaders who participated in the workshop that was the basis of this book. These
views, like those of the physicians in Part V, are not inclusive of all communities and
faiths but provide perspective and insight into why climate and health matter. For
Evangelical Christians, climate change has been politically polarizing. In the first
chapter in this part (Chap. 20), the president of the US National Association of
Evangelicals provides action items to move beyond such polarization. He focuses
on the moral and religious expectations to care for and preserve God’s creation,
using the term “Christian environmentalism.” This view is echoed by the president
of the Evangelical Environmental Network, who considers climate change the
greatest moral challenge of our generation (Chap. 21). He links the prolife argument
and concept to living a healthy life in a healthy environment and to tending to
Earth’s needs in order to maintain a relationship with God. The role of faith leaders
in pointing to human responsibility in the protection of the environment as a divine
mandate is also discussed in view of the fact that faith leaders have the ability to
bring people together to work on significant issues (Chap. 22).
Part VII includes several chapters on solutions from the scientific perspective.
Health co-benefits of mitigation are an approach that will make climate change miti-
gation policies more acceptable (Chap. 23). Transformative policies in energy,
transportation, urban development, and food systems are required if we are to
xx Introduction
achieve the goals of slowing climate change and protecting human health (Chap.
24). It is not too late to bend the curve of global warming, and its overall impact on
health is a dominant driver to raise concerns and trigger action on ten clearly
described solutions, which form the topic of another book (Chap. 25). Energy pov-
erty is closely associated with climate change and the health impacts and injustice
borne by the poorest communities. However, there are viable solutions exemplified
by mini-grids in indigenous and rural communities in Asia (Chap. 26). These com-
munities can have access to renewable energy as an alternative to disruptive and
unnecessary dams that submerge lands and displace people. In line with mini-grids,
using sensor technology to monitor the use of clean energy cookstoves and reward-
ing users by payments using cell phones are practical solutions for the three billion
people who rely on solid fuels (Chap. 27). This part ends with a unique perspective
from the Wellcome Trust Foundation, which has embarked on a mission to fund
projects on climate and human and planetary health (Chap. 28). The solutions pro-
posed by this foundation focus on generating knowledge and impacting policy
through risk-taking projects and engagement with industry, scientists, and
governments.
The final section of the book, Part VIII, is focused on specific actions, with the
former California Governor Brown describing how California was able to set the
standards and lead the rest of the nation to address air pollution and now renewable
energy (Chap. 29). US Congressman Peters describes the US politics of climate
change and partisan differences, and why these differences exist (Chap. 30). He
offers solutions and hope on how to counter this partisanship on climate by calling
on scientists, local and state governments, the armed forces, businesses, church
communities, and others to have a say and move beyond partisan politics. A Nobel
Laureate in Chemistry then describes the solutions to our climate change problem—
decreasing consumption, decreasing population growth, and turning to renewable
solar energy—but all must be implemented at a global level rather than at a country
level (Chap. 31). The 17 Sustainable Development Goals of the United Nations
provide an opportunity to address climate change by making the common good and
human dignity the goal so that all stakeholders come together in making it happen
(Chap. 32). The final call in this part is appropriately addressed to health profession-
als, who have the moral authority and are trusted by society to lead the effort to
address climate change and its health impacts (Chap. 33). An example from Australia
is described, in which an alliance of health care professionals set up a national
framework and strategy that is going to be adopted after the election of the political
party that supported them.
With these eight parts in the book and its rich, wide-reaching, and diverse content
and authors, we have attempted—hopefully with success—to provide something for
everyone as a book that will help academics teach their courses, faith leaders preach
to their congregations, policy makers communicate with their constituents, health
care professionals talk to their patients, and all of the public understand what the
major issues of climate change are and how they are impacting our health.
La Jolla, CA, USA Wael K. Al-Delaimy

Contents
Part I The Anthropocene: Human–Nature Interactions

1 Complexity of Life and Its Dependence on the Environment�� 3
Werner Arber
2 Biological Extinction and Climate Change�� 11
Peter H. Raven
3 Sustaining Life: Human Health–Planetary Health Linkages�� 21
Howard Frumkin
4 How Do Our Actions Undermine Nature?�� 39
Partha Dasgupta
5 Climate Change, Air Pollution, and Health: Common
Sources, Similar Impacts, and Common Solutions�� 49
Part II Air Pollution, Climate Change, and Health:

The Underlying Science and Impacts
6 Air Pollution: Adverse Effects and Disease Burden �� 63
Jonathan M. Samet
7 Air Pollution, Oxidative Stress, and Public Health in the
Anthropocene �� 79
Ulrich Pöschl
8 Climate Change, Air Pollution, and the Environment:
The Health Argument�� 93
Maria Neira and Veerabhadran Ramanathan
9 Reducing Air Pollution: Avoidable Health Burden�� 105
Jos Lelieveld
xxi
xxii Contents
Part III Climate Change and Health: Sustainability and Vulnerable

Populations and Regions
10 Vulnerable Populations and Regions: Middle East
as a Case Study�� 121
Wael K. Al-Delaimy
11 Climate Change Risks for Agriculture, Health, and Nutrition�� 135
Joachim von Braun
12 Sustaining Water Resources�� 149
Paolo D’Odorico and Ignacio Rodriguez-Iturbe
13 Health Climate Justice and Deforestation in the Amazon�� 165
Virgilio Viana
Part IV Climate Change and Health: Perspectives from Physicians

14 Psychological Impacts of Climate Change
and Recommendations�� 177
Lise Van Susteren and Wael K. Al-Delaimy
15 Air Pollution and Cardiovascular Disease:
A Proven Causality�� 193
Conrado J. Estol
16 Healthy People, Healthy Planet: Holistic Thinking�� 205
Jamie Harvie and Erminia Guarneri
Part V Climate Change and Health: Social Impacts

17 Climate Change, Public Health, Social Peace�� 225
Hans Joachim Schellnhuber and Maria A. Martin
18 Climate Justice and Public Health: Practical Ethics
in Urgent Times�� 239
Fonna Forman
19 Health of People, Health of the Planet, Health
of Migrants �� 251
Marcelo Suárez-Orozco
Part VI Overarching Solutions: The Role of Religion

20 Faith in God and the Health of People�� 265
Leith Anderson
21 Caring for Creation: The Evangelical’s Guide�� 273
Mitchell C. Hescox
Contents xxiii
22 Call to Action from Faith Leaders�� 285

Alastair Redfern
Part VII Overarching Solutions: The Role of Science and Technology

23 Public Health Co-benefits of Reducing Greenhouse
Gas Emissions�� 295
Qiyong Liu and Jinghong Gao
24 Good Health in the Anthropocene Epoch: Potential
for Transformative Solutions�� 309
Andy Haines
25 Well Under 2 °C: Ten Solutions for Carbon Neutrality
and Climate Stability �� 321
V. Ramanathan, M. L. Molina, D. Zaelke, and N. Borgford-Parnell
26 Defeating Energy Poverty: Invest in Scalable Solutions
for the Poor �� 333
Daniel M. Kammen
27 Sensor-Enabled Climate Financing for Clean Cooking �� 349
Nithya Ramanathan, Erin Ross, Tara Ramanathan, Jesse Ross,
Martin Lukac, and Denisse Ruiz
28 Research Is Vital to Tackling Climate Change, But It
Cannot Succeed Alone �� 361
Jeremy Farrar
Part VIII Call to Action

29 Governor of California�� 371
Edmund G. Brown Jr.
30 United States Congressman�� 377
Scott Peters
31 Challenges and Opportunities for a Sustainable Planet�� 385
Yuan T. Lee
32 Sustainable Development Goals and Health: Toward
a Revolution in Values�� 391
Jeffrey D. Sachs
33 A Call to Action by Health Professionals �� 395
Edward Maibach, Mona Sarfaty, Rob Gould, Nitin Damle, and
Fiona Armstrong
Index�� 407
Part I
The Anthropocene: Human–Nature
Interactions
CHAPTER 1
Complexity of Life and Its Dependence
on the Environment
Werner Arber
Summary Because of the extensive scientific research carried out over the past
200 years, mainly in biology, astrophysics and geology, we have obtained increas-
ingly better insights into the ongoing evolution of living organisms and their habi-
tats. We have thereby acquired information on the complexity of life and its
dependence on the environment, which lead us to better appreciate the need to safe-
guard the high diversity of both living organisms and their environments. On the one
hand, all living organisms interdepend on their cohabitation with other kinds of
organisms. On the other hand, the slowly changing living conditions of habitats
require a living species to occasionally undergo appropriate genetic variation.
Ongoing research projects continue to provide insight into evolutionary processes,
which are carried out in nature by self-organization, taking care to safeguard a rela-
tively high genetic stability and also ensuring occasional variations of living condi-
tions and their inhabitants. The human population on our planet should avoid
intervening in these naturally ongoing evolutionary processes to ensure high biodi-
versity and its sustainable long-term development.
Introduction
In the 1940s, scientific research revealed that the phenotypes of living organisms
depend on the genetic information carried in their genomes. In subsequent decades,
it became more clear that life activities also depend on environmental conditions,
Nobel Laureate, Medicine/Physiology 1978.
W. Arber (*)
Molecular Microbiology, Biozentrum, University of Basel, Basel, Switzerland
e-mail: [email protected]
© The Author(s) 2020 3

W. K. Al-Delaimy, V. Ramanathan, M. Sánchez Sorondo (eds.), Health of People,
Health of Planet and Our Responsibility, https://doi.org/10.1007/978-3-030-31125-4_1
4 W. Arber
including the living and material compositions of the habitats and various temporal
impacts from the wider environment. We therefore realize that living organisms
depend on both their own genetic information and various environmental condi-
tions. The latter also exert their impact on biological evolution at the popula-
tion level.
Symbiosis and Nutritional Interdependencies
The cohabitation of various kinds of living organisms can greatly facilitate the life
of individual organisms. Human beings and many other eukaryotic organisms are
known to strongly depend on cohabiting microorganisms in so-called microbiomes
(Blaser, Bork, Fraser, Knight, & Wang, 2013). Thereby, various kinds of bacteria
live in symbiosis with humans, animals or plants. Their hosts provide nutrition to
the cohabiting bacteria, and the bacteria help their hosts in food digestion and other
essential functions. In contrast, several pathogenic microorganisms, both bacteria
and viruses, occasionally infect human beings and eukaryotic animals, making them
ill. However, we have to be aware that only a minority of bacteria are pathogenic,
whereas beneficial microbiomes permanently contain a large number of nonpatho-
genic bacteria.
Another obvious interdependency resides in the provision of nutrition to other
kinds of organisms. Wild animals generally gather and hunt their food in their habi-
tats. To improve their lives, about 10,000 years ago, human beings started to domes-
ticate food plants and animals, which is known as agriculture. Until relatively
recently, agriculture was mostly carried out manually on a small scale.
I mpacts of Nonliving Environmental Factors on Terrestrial

Life Conditions
Many living organisms depend, to some degree, on environmental factors such as

climate, temperature, solar radiation, air pollution and weather conditions. These
can vary over the course of time both intrinsically and due to the impacts of human
activities. Some of these interdependencies caused by human civilization strengthen
the negative impacts on the living conditions and thus also on the lives of individ-
ual beings. However, it can be quite difficult to ameliorate the situation on a
global level.
1 Complexity of Life and Its Dependence on the Environment 5
Value of High Biodiversity
As a result of the long history of biological evolution, our planet benefits from a
high diversity of species. As a consequence, any habitat usually contains a relatively
high number of different species, and this richness can be quite beneficial for the
cohabiting species. For this reason, as well as for other reasons (to be explained
below), our civilization should avoid causing any negative impact on this rich bio-
diversity, which would also affect human life, as shown by the following two
examples.
Occasionally, a segment of genetic information can be horizontally transferred
from one kind of organism to another, where it can become a part of the genome and
exert its activities. Horizontal gene transfer is one of the natural strategies of bio-
logical evolution (see below). It is obvious that the loss of rich biodiversity can
reduce the available genetic information and thus also affect the biological evolu-
tion of other kinds of organisms.
Advancements in scientific knowledge can reveal previously unknown biological
potentials of a member of the biodiversity. In order not to lose such a function upon
a future extinction of the species in question, one can try to save this genetic poten-
tial by transferring it in the laboratory into another kind of organism, which can be
expected to express the gene product under consideration. This can allow the inves-
tigators to isolate a product that might contribute to a technological advance for our
civilization. A striking example is the horizontal transfer of the genetic potential of
some spiders into appropriate bacteria to produce silk-like fibres (Rech &
Arber, 2013).
Insight into the Laws of Nature for Biological Evolution
Biological evolution is a very slow, continual process; it cannot be easily perceived.

As a result of the intensive research on bacterial populations, a number of molecular
mechanisms are known to occasionally produce genetic variants and thus contribute
to biological evolution after natural selection of mutants that demonstrate a func-
tional improvement for living in their habitat, or sometimes for adapting to an alter-
native habitat. One can assign the identified individual molecular mechanisms of
mutagenesis to just a few natural strategies of biological evolution (Arber, 2007).
According to our knowledge to date, one of these strategies is based on local muta-
genesis affecting one or a few adjacent nucleotides in the genome. The second strat-
egy of spontaneous mutagenesis involves a genomic segment, which can become
transposed, duplicated, deleted or inversed in the genome. Finally, the third strategy
is based on the previously mentioned horizontal gene transfer, which allows a recip-
ient organism to acquire a functional genome segment from a donor organism. This
acquisition of foreign genetic information is a very efficient process because of the
universal genetic code (i.e., the common language of different kinds of organisms).
6 W. Arber
For some of these mutagenesis events, the products of so-called evolution genes
carried in the genome are involved in intragenomic DNA rearrangements. Other
evolution genes limit the frequency of mutagenesis events. Some other mutagenesis
processes result from the impacts of nongenetic factors, such as environmental
mutagens, short-living isomeric forms of biologically active molecules or random
encounters. We are aware that Mother Nature only rarely causes a spontaneous
genetic variation, so the genetic potential of most individuals in a given population
remains preserved. The aforementioned mutagenesis processes occur mostly ran-
domly on the genome and randomly in time. Therefore, only a minority of novel
genetic variants reveal, upon natural selection, a functional improvement.
Improvement of Life Expectancy
The knowledge acquired from intensive biological and technological research over
the past 200 years has considerably improved human health and various human life
facilities, including communication, travelling and the procurement of food. In only
a few decades, biomedical knowledge and its applications have resulted in consider-
ably increased human life expectancy, particularly in developed countries. It is our
duty to help populations in developing countries, which often have high rates of
child mortality, to also benefit from this available biomedical knowledge.
To the best of our knowledge, all living organisms have a statistical average of
life expectancy. Genetic alterations or behavioural or environmental impacts can
occasionally increase the life expectancy of a given species to some extent. This has
recently led to discussions about the possibility of providing immortality to living
organisms (including Homo sapiens), i.e., an eternal life (Knell & Weber, 2009; Die
Frage nach der Zukunft, 2017). In my point of view, this goal is not compatible with
the wonderful natural process in which biological evolution helps a species adapt to
changing living conditions.
Improvement of Nutritional Diets for Better Health
It is well known that an appropriate diet provides our body with the energy required
for our daily activities. The lack of a nutritional source of energy is felt as hunger. It
has lately also become known that various biological activities may require so-
called micronutrients, such as vitamins or some chemical elements. The lack of an
essential micronutrient causes so-called hidden (unfelt) hunger and can lead to an
organic mis-development. An example is a deficiency in vitamin A, which is
required for the proper neuronal development of a child, both during its embryonic
development and during the first few years after birth (Potrykus & Ammann, 2010).
In this case, insufficient vitamin A leads to a neuronal mis-development that can
cause the death of the child in its first few years or blindness.
It is important for scientific researchers to explore other adverse health effects

due to a lack of sufficient micronutrients. Such knowledge may prevent mis-devel-
opments by providing the necessary specific micronutrients in due time. Ideally, this
goal can be reached by enriching commonly used food crops with the required
micronutrients, thus preventing hidden hunger in the people in question.
Intensive Agriculture or Protection of the Rich Biodiversity?
As mentioned previously, agriculture has been carried out manually for a long time.
In many countries, a shift has occurred in recent decades to use tractors with spe-
cialized machines for cultivation, maintenance, and harvesting of food crops. These
cultivations are often combined with the use of herbicides or insecticides to remove
other plants and insects from large monocultures of agricultural crops. This practice
can contribute to severe reductions in the rich biodiversity.
Reflection on Future Living Conditions on Our Planet Earth
As we have already discussed, a steadily, but very slowly, progressing biological

evolution has resulted in the current rich biodiversity. This permanent creation orig-
inated approximately 3500 million years ago with unicellular organisms. According
to astrophysical theories, the Sun is expected to continue to provide energy to its
planets for approximately 4000 million years. However, we do not know how long
our planet Earth will exist and contain habitats that host different kinds of living
organisms. Let us hope that human civilization in its rich biodiversity will have a
time horizon of about 1 million years; during this period of time, biological evolu-
tion can be expected to steadily continue slowly. As we have seen, the natural strat-
egy of horizontal gene transfer can provide qualitative improvements to evolving
organisms. For this reason, it is important to maintain the rich biodiversity on our
planet Earth. Future scientific investigations are expected to allow our civilization to
reach this goal by preventing activities that lead to the partial extinction of species
existing in the diversity of life. In addition, we should also take care not to entirely
use up essential raw materials by our life activities.
From Quantitative to Qualitative Growth
Our planet Earth has a constant size and therefore a limited capacity to host living
organisms. In view of the conceptual relevance of a rich biodiversity, a given species
of living organisms should not overgrow other kinds of organisms. The aforemen-
tioned interdependence of different kinds of organisms, both for their life activities
8 W. Arber
and for their biological evolution, is of high conceptual relevance to the living
world. A logical conclusion from this insight is that no species should quantitatively
overgrow the others. However, a qualitative growth would always be welcome.
Applying this concept to the human population is of primary importance for the
healthy long-term persistency of human civilization on our planet.
Conclusion
As members of the human species, we have the privilege of a high intellectual

capacity. Thus, we realize that our life interdepends on the presence and activities of
many other species of living organisms. Based on these long-term insights, the
Christian religions attribute to Homo sapiens the role of a good shepherd of cre-
ation, who should take care of other kinds of organisms and their habitats. Following
this conceptual task, we are expected to protect the presence of a rich diversity of
other kinds of living organisms. This essential conclusion is based both on a reli-
gious tradition and on more recently acquired scientific knowledge.
As shepherds, we have the responsibility to protect the long-term living condi-
tions of the planet, including the natural process of biological evolution. In addition,
it is our task to bring the world view described here to the attention of all human
beings on our planet. This requires a well-qualified education applied to human
societies worldwide.
References
Arber, W. (2007). Genetic variation and molecular evolution. In R. A. Meyers (Ed.), Genomics and
genetics (Vol. 1, pp. 385–406). Weinheim: Wiley-VCH.
Blaser, M., Bork, P., Fraser, C., Knight, R., & Wang, J. (2013). The microbiome explored: Recent
insights and future challenges. Nature Reviews Microbiology, 11, 213–217.
Die Frage nach der Zukunft. In: zur Debatte 4/2017. Themen und Tagungen der Katholischen
Akademie, Bayern.
Knell, S., & Weber, M. (2009). Menschliches Leben. Berlin, Germany: Walter de Gruyter.
Potrykus, I., & Ammann, K. (Eds.). (2010). Transgenic plants for food security in the context of
development. Special Issue of New Biotechnology, 27, 445–717.
Rech, E. L., & Arber, W. (2013). Biodiversity as a source for synthetic domestication of useful
specific traits. Annals of Applied Biology, 162, 141–144.
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the copyright holder.
CHAPTER 2
Biological Extinction and Climate Change
Peter H. Raven
Summary What are the current dimensions of biological diversity? Taxonomists

have described approximately two million species of eukaryotic organisms. Many
more remain unknown, and the global total may approximate 12 million species or
more. Generally, for the past 65 million years, the rate of extinction of these species
appears to have been ~0.1 extinctions per million species per year. Now, however,
as a result of human activities, it has increased by about 1000 times, to ~100 species
per million per year. We are losing species at about 1000 times the rate at which new
ones are evolving. Many species are local and particularly liable to extinction, with
climate change and increasing human-related pressures of all kinds pushing very
strongly on life as it exists. Most of the species cannot be saved by forming parks
and protected areas or away from their natural habitats unless human pressures are
lessened by general action among nations, a prospect that is not being well realized
at present. The strong call for the preservation of biodiversity in the encyclical
Laudato Si’ represents the kind of ethical responsibility that must be adopted if
there is to be any hope for the survival of our civilization.
Background
This chapter presents the most up-to-date information on biological extinction. Its
rate and intensity have made it increasingly urgent for us to create a sustainable
planet. Our individual and collective greed and seeming inability or unwillingness
to face reality are preventing our coming to grips with the problem, but there is no
other solution than common action for the common good.
We depend on the communities of living organisms that have formed over hun-
dreds of millions of years for our survival, and on the properties of individual kinds
P. H. Raven (*)
Missouri Botanical Garden, St. Louis, MO, USA

12 P. H. Raven
of organisms for almost every aspect of our lives. There is no reason to think that the
dimensions of the extinction crisis we are facing now will leave communities
functioning properly to hold steady the qualities of the atmosphere, soils, or water,
and no reason to think that we have already recognized all of the kinds of organisms
that would be useful to us if we understood them and their properties better. That is
why the following words expressed by Harvard biologist E.O. Wilson (1984, p. 121)
are so very important for us to ponder:
The worst thing that will probably happen—in fact is already well underway—is not energy
depletion, economic collapse, conventional war, or the expansion of totalitarian govern-
ments. As terrible as these catastrophes would be for us, they can be repaired in a few gen-
erations. The one process now going on that will take millions of years to correct is loss of
genetic and species diversity by the destruction of natural habitats. This is the folly our
descendants are least likely to forgive us.
Climate change is one of the major forces that will drive biological extinction in
our time and by doing so will have an extraordinary and lasting detrimental effect on
our collective health. In turn, any loss of species caused by other factors, including
those discussed in this chapter, will have further detrimental effects not only now but
permanently (Isbell et al., 2017). We depend on other species and the ecosystems
they comprise for the air we breathe, the soil in which we grow our crops, the ability
to absorb pollution, all of our food, many of our medicines, a major proportion of our
building materials, and the beauty that surrounds us when we appreciate and protect
it. In short, there is no factor that will harm human health and our ability to live sus-
tainably on this planet more than the loss of biological diversity. While climate
change and pollution are proving to be hugely damaging to human health directly, as
amply illustrated by the rich diversity of chapters presented in this book, the loss of
biological diversity and the natural systems it drives will prove much worse over the
longer run. Biological extinction will be the worst legacy of climate change and pol-
lution, as well as the most damaging to the continuation of our sustainable lives on
earth and to our ability to maintain our health and our civilization in the near term.
It is difficult to estimate the current rate of extinction because in fact we know so
little about the living world, even though our lives depend completely on its healthy
functioning. As we shall discuss in this chapter, we have recognized and given
names to a relatively small proportion of the total number of organisms on earth. We
cannot even begin to understand the harm we are doing to ourselves by ignoring the
loss of as many as half of them during the remainder of this century. Overall, the
account presented here is based on the reviews of extinction presented in our
February 2017 Study Week on Biological Extinction (Dasgupta & Ehrlich, 2019;
Pimm & Raven, 2019) and in the outstanding paper in the same session by Lenton
(2019). In the earth’s 4.54 billion year history, life originated early and invaded the
land about 400 million years ago. Our species, Homo sapiens, was first discovered
in African fossils that were 300,000 years old, migrated to Eurasia at least
60,000 years ago, and reached all habitable continents by at least 15,000 years ago.
Our spread and ultimate increase, discussed below, has had and is continuing to
have a massive negative effect on all other forms of life on earth except for those we
encourage for our own use.
2 Biological Extinction and Climate Change 13
How Many Species Exist Now?
Our summary paper (Pimm & Raven, 2019), with others presented at the PAS/PASS
meeting on biological extinction in February 2017, attempted to estimate the num-
ber of species that exist as well as to predict their rate of extinction. Most of the
references for conclusions offered by us in that symposium will not be repeated here.
Science has discovered and named approximately two million species or organ-
isms to date, and most of them remain poorly known. Judging from well-known
groups of eukaryotes and their overall patterns of distribution, we might assume that
at least 12 million species may actually exist. For marine eukaryotes, estimates vary
greatly (Appeltans et al., 2012; Mora, Tottensor, Adl, Simpson, & Worm, 2011),
with further investigations clearly necessary to arrive at realistic estimates. When it
comes to prokaryotes, we cannot even guess the numbers of species reasonably;
Locey and Lennon (2016) recently speculated that the total number of species of
Eubacteria and Archaea might even amount to an astonishing one trillion. It would
be well worth putting more effort into estimating their diversity and geographical
specificity because they, as much or even perhaps more than eukaryotes, are clearly
of fundamental importance for us both ecologically and economically (Montgomery
& Bicklé, 2015). Whatever we learn about them is very likely to serve us well.
Most species that exist now are likely to become extinct before they are discov-
ered, particularly in the tropics; thus, it will be important to choose our research and
conservation directions very carefully during the coming decades. The record we
shall be able to assemble is likely to be a limited representation of the richness of
life as we know it now.
Factors Driving Extinction
The key factors driving massive biological extinction in our time have resulted from
the continuing, rapid growth of the human population in the roughly 11,700 years
of the Holocene Epoch, a relatively warm time following the most recent glacial
maximum. Early in the Holocene, our ancestors mastered agriculture. Over the sub-
sequent 10,000 years or so, the total human population has grown from only about
one million people to more than 7.6 billion; our numbers are estimated to keep
growing to about 9.9 billion by mid-century (www.prb.org). In contrast, when peo-
ple began cultivating crops, there were fewer than 100,000 living in all of Europe!
With the development of agriculture, however, early farmers began to be able to live
together permanently in villages, towns, and ultimately cities. The inhabitants of
such settlements could store enough food to carry them through unfavorable times.
Living for the long term together in groups, individuals could for the first time spe-
cialize in various professions—the activities that together form the basis of our
modern civilization. Everywhere in the world, forests began to be cut rapidly, with
disastrous effects on biological diversity that have been greatly accelerated recently
(e.g., Betts et al., 2017).
14 P. H. Raven
Particularly since the acceleration of the Industrial Revolution some 250 years

ago, with its subsequent intensification of all our activities, the pollutants that we
have produced have poisoned soils, waters, and the air we breathe, damaging our
health and the natural systems that support us. Ultimately, the gasses our activities
generate have begun to alter the world’s atmosphere markedly and to drive major
climate change that became evident about 75 years ago. Agriculture, urban sprawl,
deforestation, and all of the activities associated with human population growth; the
spread of invasive plants and animals, pests and pathogens; and the hunting and
gathering of plants and animals from nature, have all damaged natural populations
and sometimes driven them to extinction.
As our numbers have grown, our desire for enhanced consumption has grown
even more rapidly. The Global Footprint Network (www.footprintnetwork.org) esti-
mates that we are using approximately 175% of the world’s sustainable productivity
now, up from an estimated 70% in 1970—a situation that clearly cannot be sus-
tained, and one in which the stronger nations will be led ever more forcefully to
drain the potentially renewable resources from the poorer and weaker ones.
Biological communities provide the basis of our lives, and the levels of species loss
from them that we are experiencing therefore pose dangers for the sustainable func-
tioning of life on earth (Duffy et al., 2017). Today, nearly 40% of Earth’s land sur-
face is devoted to farming and grazing, most of the latter unsustainable. One can
only imagine how many species must have disappeared while agriculture was
spreading over wide regions like the intensively cultivated, broadly defined
Mediterranean region of western Eurasia and North Africa. At the same time, inva-
sive species of animals and plants, pests and pathogens, are spreading around the
world in ever-increasing numbers, out-competing others in the new regions that they
have reached and often driving them to extinction.
Another significant driver of biological extinction, recognized from the 1950s
onward, is anthropogenic climate change; methane, enormous quantities of carbon
dioxide and other greenhouse gasses are being emitted into the atmosphere continu-
ously. Reviewed elsewhere, the changes that we are experiencing are extremely
dangerous, and our collective will to deal with them remains dangerously limited,
with greed always a more attractive alternative for many. There is a great deal of
urgency in coping strongly with this enormous threat, and Pope Francis’ powerful
encyclical Laudato Si’ warns all of humanity to attend to the problem for our com-
mon benefit.
Extinction Rates
With this review of the current factors driving extinction, we are enabled to return
to a calculation of extinction rates now and in the future. The calculations that we
presented in our earlier review were explicitly based on current records, the fossil
record, and comparisons with rates of the origin of new species as determined by
molecular phylogenies (Pimm & Raven, 2019). We express our estimates in terms
of extinctions per million species-years (E/MSY). With a historical extinction rate

of approximately 0.1 extinctions per million species per year, we have now reached
at least 1000 times that level, with the rates increasing rapidly.
Comparing International Union for Conservation of Nature (IUCN) Red List of
Threatened Species (www.iucnredlist.org/) estimates of the likelihood of extinction
for the species they include with other extinction probabilities leads to an estimate
that perhaps 20% of all species in these groups may be in danger of extinction over
the next several decades. At present observed extinction rates and a total of 12 mil-
lion species of eukaryotes, about 60,000 of them might become extinct over the next
40 years. In sharp contrast, if 20% of all species were actually to become extinct
during this period, 40 times that many, amounting to some 2.4 million, would have
to be lost. Such a rate would amount to losing 60,000 species per year (higher in the
future, lower now, of course). Considering that unknown species or poorly known
ones are more likely to be rare and therefore on the average more likely to be in
danger of extinction than those that have been rated, these huge numbers might
actually be attained, but that will depend to a great extent on the nature and scale of
human activities in the future. At any rate, the estimate is staggering!
Most species have relatively small ranges, and those that do are on the average in
greater danger of extinction than common, widespread ones. Even the widespread
ones are virtually never distributed uniformly and densely within the boundaries of
their ranges, although that is often an implicit assumption in calculations. In addi-
tion, local species are usually also scarce even where they occur (Pimm & Raven,
2019). In his definition of biological “hot spots”—areas of high concentrations of
endemic unusual species—Myers (1988) by definition included only those areas
that had already lost 70% or more of their original vegetation to human activities
and which had at least 2000 species of plants found nowhere else. Certainly such
areas are likely to become important centers for extinction as human activities
increase in intensity and in volume and conservations select and pursue the best
goals for conservation they can define—intrinsically limited. Hotspots, therefore,
are especially critical areas for future extinction, and ones where adequate conser-
vation plans would be especially helpful in lowering future rates of extinction
(Pimm & Raven, 2000). In comparing 25 hotspots using the data on original area,
endemic bird or mammal species, and the current remaining natural vegetation
(Crooks et al., 2017; Pimm & Raven, 2000), dismal futures are predicted for a high
proportion of the species now living in these hotspots.
Considering the increasing number of factors that are driving species to extinc-
tion, it indeed seems plausible that 20% of them may disappear during the next
several decades. If that is the case, and given the rates of extinction that would have
been attained during the next few decades, it seems possible that a proportion of
species amounting to roughly half of the total may vanish from nature by the end of
the century (Pimm & Raven, 2017). Detailed analyses are provided by Ceballos
et al. (2015, 2017) and Dasgupta and Ehrlich (2019), which support the idea that the
rate of population is proceeding much more rapidly than we have realized. In addi-
tion, the well-documented shrinking of many populations of birds (Gross, 2015;
Vorisek, Gregory, Van Strien, & Meyling, 2008; http://www.stateofthebirds.
16 P. H. Raven
org/2017/wp-content/uploads/2016/04/2017-state-of-the-birds-farm-bill.pdf;
http://www.stateofthebirds.org/2016/wp-content/uploads/2016/05/SotB_16-04-26-
ENGLISH-BEST.pdf) and insects (e.g., Hallmann et al., 2017; Vogel, 2017) appear
to speak to the same point—human beings are simply taking up so much of the
space that the numbers of other kinds of organisms must decrease and keep decreas-
ing unless we find and deploy the means we need to maintain a sustainable world.
Regardless of what I consider to be a largely semantic problem, which is whether
we have entered a major extinction event comparable with the earlier five the world
has experienced (e.g., Baranosky et al., 2011), we are clearly living in times that
have the potential to be catastrophic for our own future. In such a time, we must not
lose hope, but rather strengthen our efforts to the extent to deal with scientifically
demonstrated trends as effectively as we possibly can!
The least well understood factor that is driving future extinction is global climate
change, a problem with which we are just starting to come to grips intellectually.
Such rapid and catastrophic events would, of course, often be outside of the possi-
bility of adaptation for the species concerned. Although the mechanisms underlying
the relationship between climate change and extinction are complex (Pereira et al.,
2010), some detailed, regional modelling exercises have been carried out in Australia
(Williams, Jackson, & Kutzbach, 2007) and South Africa (Erasmus et al., 2002).
These have led to predictions of the extinction of many species with restricted
ranges during the coming decades in those areas. We do not understand yet how
much climate change will add to biological extinction, and that of course depends
in part on what actions we manage to take to slow down the change itself. Under any
scenario, however, the current habitats of those species restricted to the southern
edges of the southern continents will simply disappear, as will the habitats of those
species restricted to the higher elevations in mountains worldwide, although they
would have some opportunity for dispersal. Certainly, the rich arrays of endemic
plants and other organisms that occur along the southern borders of Australia and
Africa are in extreme danger of extinction from climate change.
Extinction rates during periods of rapid climate shift in the Pleistocene were not
especially high, except in areas where humans were actively hunting populations of
specific animals. As Lenton (2019) has pointed out, this observation would tend to
suggest climate-caused extinction rates when the changes have been relatively
extreme. A detailed review of estimates of extinction rates likely to occur in relation
to climate change (Bellard et al., 2012) has shown a large degree of uncertainty with
a number of factors still to be considered in detail. Thus, Lenton (2019) inquired to
what extent the projected high levels of species loss would compromise the function
of ecosystems and the biosphere, and found that massive changes are likely to occur.
Changes of this magnitude could well result in the loss of entire biomes by the tip-
ping of critical balance points. The massive changes in precipitation levels that are
projected as part of global climate change, as from the Green Sahara of 6000 years
ago to the sere desert of today, or from dense forests to deserts and savannas, could
result from the overall pattern of change.
For the seas, projections of extinction rates are being developed slowly, with a
relatively small proportion of marine organisms rated by the IUCN for degree of
threat. It is clear, however, that climate change with its accompanying acidification
have become key factors in marine extinction. Overfishing is the most important of
the obvious factors affecting extinction in the seas. Pollution from the land, histori-
cally chemical but now including the massive deposits of plastic, remains important
and must certainly also be controlled if we want to maintain the productive seas that
exist today. Our relatively poor knowledge of the extent of marine eukaryotic biodi-
versity makes estimates of extinction difficult, too, as Webb and Mindel (2015)
have stressed.
Fortunately, efforts to measure and to ameliorate the environmental damage we
are causing to the seas are growing (e.g., Sullivan et al., 2019). Certainly specific
communities, such as coral reefs, attuned to narrow temperature ranges, appear to
be in extreme danger of collapse (Hoegh-Guldberg et al., 2007; Hughes et al., 2017;
Lucht et al., 2006). Marine anoxia resulting from the runoff of nitrogen and phos-
phorus from agricultural systems on land is leading to increased ocean warming and
thus further reducing the capacity of the water to absorb oxygen. Summarizing,
overfishing, habitat destruction, climate change, pollution, and ocean acidification
(e.g., DeWeerdt, 2017) are all contributing to extinction in the seas.
The possibility of even higher rates of climate warming than are generally
assumed to be likely would of course have a much more damaging effect on biologi-
cal diversity than anything discussed thus far in this chapter. A continuing disregard
for our common welfare could lead to global temperate increases of 6 °C; if we reach
such levels, or even higher ones, the consequences would be staggering. For exam-
ple, Malin, Pinsky, and Jon Payne (personal communication) have pointed out that
10 °C warming at the time of the end Permian extinction drove more than 75% of the
genera then in existence to extinction. This amounted to the most extensive extinc-
tion event in the history of our planet, permanently changing the character of life on
earth. Regardless of whether we are wise enough to stop the process somewhere
short of those levels, we are clearly facing major losses of biological diversity. That
loss in turn will have an immediate and long-lasting effect on our civilization and our
collective health both directly and indirectly. We must find effective ways to address
the loss before it is too late (e.g., Lovejoy, 2017; Tilman et al., 2017).
Conclusions
Nothing we are doing to damage the functioning of the living world and the stability
of its ecosystems will do more harm than biological extinction. Curbing global climate
change will be indispensable, but it is only one of the steps that we will need to take
collectively if we wish to curb extinction and maintain a stable planet for our succes-
sors. Increasing human population and especially increased human greed for ever-
higher levels of consumption will greatly increase future rates of extinction through
the creation of a warmer world and in many other ways as well. We have estimated that
as many as 2.4 million species of organisms, 20% of the estimated total, could become
extinct during the next several decades as human pressures of all kinds intensify and
18 P. H. Raven
presently sustainable systems collapse, and that perhaps half of the estimated total
number of species could be gone by the end of the twenty-first century.
As Dasgupta and Ehrlich (2019) have concluded, seeking to limit the proximate
causes of extinction will not ultimately prevail unless the basic drivers are
addressed—“continued population growth, policies seeking economic growth at
any cost, overconsumption by the rich, and racial, gender, political, and economic
inequality (including failure to redistribute). Collectively addressing these are pos-
sibly the greatest challenges civilization has ever faced.”
Achievement of the goals just outlined clearly must be taken as our common
responsibility; without doing so, we simply have not got a chance. Learning about
how to achieve these goals and then working to achieve them ultimately will be
responsible for our survival. We must learn, teach, act, and vote in such a way as to
advance our common cause, the search for a sustainable world. Doing so will
require a degree of humility, compassion, and love that we have yet to exhibit, but
which is indicated very clearly in our topical encyclical Laudato Si’. We must fol-
low the example of Pope Francis in contemplating the beauty and importance of life
as it is and the urgency of working to preserve it for the future.
Acknowledgments I have received helpful comments and discussion of this chapter from
V. Ramanathan and Partha Dasgupta; Douglas H. Erwin, Smithsonian Institution; John
F. Fitzpatrick, Cornell Laboratory of Ornithology; Jane Lubchenco and Jenna Sullivan, Oregon
State University; Guy Midgley, Stellenbosch University; Camille Parmesan, University of Texas;
Stuart Pimm, Duke University; Melin Pinsky, Rutgers University; Hugh Possingham, Nature
Conservancy.
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CHAPTER 3
Sustaining Life: Human Health–Planetary
Health Linkages
Howard Frumkin
Summary Our planet is infinitely beautiful, complex, and precious. As each of us

is well aware, our species has begun to alter the planet, sometimes inadvertently,
sometimes negligently or even recklessly. Ecologists often ask, “How do our actions
undermine nature?” We need also to invert the question, asking “How do the plan-
etary changes to which we contribute undermine our own health and well-being?”
This query lies at the heart of the emerging field of Planetary Health. The prem-
ise of Planetary Health is this: the earth system changes we have wrought are now
so far-reaching that they drive a substantial, and increasing, proportion of the global
burden of disease. Because we depend on stable earth systems to survive and thrive,
environmental destruction amounts to self-destruction. We need to understand these
consequences. Based on that understanding, we need to reexamine many of our core
assumptions about our place on the earth. Finally, we need to deploy both scientific
insight and conceptual reorientation to inspire, and to guide, corrective action.
This chapter begins with several examples of the ways in which planetary
changes threaten human health and well-being—the human dimensions of plane-
tary boundaries, as described by Will Steffen and colleagues at the Stockholm
Resilience Centre (Steffen, Richardson, Rockstrom et al., 2015). The first is climate
change. While the consequences of climate change range broadly, from air pollution
to mental health to infectious disease, this chapter focuses on just one aspect: the
effects of heat—an apparently straightforward hazard that when explored reveals
great complexity. But even if there were no climate change, we would still need the
field of Planetary Health, because other global-scale changes are also affecting
health and well-being. Three examples discussed here are chemical contamination,
land use changes, and biodiversity loss. For each of these four e xamples, I submit,
H. Frumkin (*)
University of Washington, Seattle, WA, USA

22 H. Frumkin
the science paints a clear and sobering, if not yet complete, picture: global environ-
mental change threatens human health and well-being.
Reviewing the relevant science behind these four examples raises far-reaching
questions. What are the implications of Planetary Health for the conceptual para-
digms we use to apprehend the natural world and our place in it? To what extent
does conventional biomedical ethics provide a sufficient ethical framework for
considering these phenomena? The chapter ends with a consideration of these
questions.
Science
Of the planetary changes that affect human health, climate change is perhaps the
best recognized. Climate change threatens human health through many pathways,
as graphically depicted by the Lancet Commission on Health and Climate Change
(Watts, Adger, Agnolucci et al., 2015). Some are primary and direct, such as those
due to heat and severe weather events. Others are secondary, such as infectious dis-
ease risks that are mediated by earth system changes. Still others are tertiary, such
as armed conflict and population displacement, mediated by more diffuse and com-
plex social disruptions (McMichael, 2013). Of course, these categories overlap con-
siderably. Every important category of human health outcome is affected: infectious
diseases, noncommunicable diseases, traumatic injuries, mental distress and illness.
Consider the effects of heat. Excessive heat causes a well-known cascade of medical
consequences, from the relatively mild and self-limited heat rash and heat cramps,
to more severe heat exhaustion and potentially fatal heat stroke. People die during
heat waves, sometimes in frightful numbers. Those who are most vulnerable are the
very young and very old, the poor and socially marginalized, those who live alone,
and people with certain medical conditions (Kovats & Hajat, 2008). Most of the
deaths that occur with extreme heat are not recognized or certified as heat-related;
they occur from underlying illnesses such as cardiovascular disease. Heat waves can
have substantial population impacts—70,000 deaths during the 2003 European heat
wave (Robine, Cheung, Le Roy et al., 2008), 54,000 in Russia during the 2010 heat
wave (Revich, 2011), and thousands per year in India—not well quantified—during
the summers of 2010, 2013, 2015, and 2016 (Mazdiyasni, AghaKouchak, Davis
et al., 2017). People can adapt to heat, but only up to a point (Hanna & Tait, 2015)—
and with more frequent, more intense, and longer-lasting heat events coming, that
point will be increasingly exceeded (Im, Pal, & Eltahir, 2017; Jones et al., 2015;
Lelieveld et al., 2016; Mueller, Zhang, & Zwiers, 2016; Pal & Eltahir, 2015).
But heat threatens health and well-being in less obvious ways. Heat may predis-
pose people to violence and crime; crime rates rise on hotter days (Anderson, 2001;
Gamble & Hess, 2012; Schinasi & Hamra, 2017). Heat may predispose people to
self-harm as well; some data suggest an association between heat and suicide
(Dixon & Kalkstein, 2016; Dixon, Sinyor, Schaffer et al., 2014; Kim, Kim, Honda
et al., 2016; Williams, Hill, & Spicer, 2015). Heat seems to increase the risk of
3 Sustaining Life: Human Health–Planetary Health Linkages 23
k idney disease (Glaser, Lemery, Rajagopalan et al., 2016)—a problem that espe-
cially targets workers in low-income countries who toil in high temperatures with-
out adequate rehydration (Tawatsupa, Lim, Kjellstrom, Seubsman, & Sleigh, 2012;
Wesseling, Aragon, Gonzalez et al., 2016). In hot conditions, it is more difficult to
protect food and water from bacterial contamination; the incidence of diarrheal dis-
eases such as Shigella and Campylobacter rises during hot weather (Kovats et al.,
2004; Levy, Woster, Goldstein, & Carlton, 2016). Heat compromises the quality of
sleep (Obradovich, Migliorini, Mednick, & Fowler, 2017); sleep deprivation, in
turn, is a risk factor for inflammatory conditions, metabolic and neuroendocrine
abnormalities, and cardiovascular disease (Cappuccio, Cooper, D’Elia, Strazzullo,
& Miller, 2011; Irwin, Olmstead, & Carroll, 2016; Knutson, Spiegel, Penev, & Van
Cauter, 2007). People reduce their physical activity during hot weather (Obradovich
& Fowler, 2017); being more sedentary increases the risk for cardiovascular disease
(Biswas, Oh, Faulkner et al., 2015; Lee et al., 2012). Similarly, heat reduces work
capacity (Dunne, Stouffer, & John, 2013; Kjellstrom et al., 2016), to the point that
economic output may decline substantially in very hot places—compounding pov-
erty in such places. Workers are affected in another way: workplace injuries rise
during hot weather (McInnes et al., 2017; Otte Im Kampe, Kovats, & Hajat, 2016).
In these and other ways, both direct and indirect, through mechanisms that range
from sleep loss to food poisoning to deepening of poverty, heat threatens health and
well-being—and heat is just one of the pathways through which climate change
undermines public health.
A second planetary change is the widespread dissemination of synthetic chemi-
cals through the world’s ecosystems. Plastics, a family of polymers of ethylene,
propylene, styrene, vinyl chloride, and other simple molecules, are emblematic.
Large-scale production of plastics began in the years after World War II. Global
production of plastics has now reached 300 million metric tons per year, or about
40 kg for each man, woman, and child on earth, and accounts for about four percent
of the global petroleum supply (Thompson, Moore, vom Saal, & Swan, 2009). That
may not sound like much. But given the current average life expectancy of 71 years,
this means that, on average, each of us will account for over 2800 kg of plastic pro-
duction during the course of our lives, or 30 or 40 times our body weight.
Plastics are persistent. If Michelangelo had sipped water from plastic bottles
while painting the ceiling of the Sistine Chapel 500 years ago, those plastic bottles
would still exist. As one commentator put it, with just a bit of hyperbole, “every
piece of plastic ever made still exists today” (Every piece of plastic ever made still
exists today, 2015). That is not completely true; after four or five centuries, some
plastics do degrade, and of the roughly 8.3 billion metric tons of plastic that have
been produced to date, a bit over a tenth has been incinerated (Geyer, Jambeck, &
Law, 2017). But that still means that for every human being now alive, there is,
somewhere in the world, about one metric ton of plastic. Some of it is still in use,
but well over half of it is waste. Some of this is in large pieces, some is pellet-sized,
and some has broken down to microplastics.
Where is it? Some of the waste is in landfills. Some ends up in waterways—a
common and heartbreaking sight in many of the world’s major cities, especially in
24 H. Frumkin
low- and middle-income countries. Plastic generally floats, so it travels with cur-
rents and accumulates in eddies, forming patches that can be as large and imposing
as islands. From streams, rivers, and harbors, the waste winds its way to oceans,
where it continues to move under the influence of wind and currents. According to
one recent estimate, between 4.8 and 12.7 million metric tons of plastic waste
entered the oceans in 2010 (Jambeck, Geyer, Wilcox et al., 2015).
The plastic seems to go everywhere, making this a global problem (Barnes,
Galgani, Thompson, & Barlaz, 2009). It has been found in the deepest ocean
trenches, in arctic ice, on the shores of remote islands. According to the United
Nations Environment Programme, “Microplastics have been detected in environ-
ments as remote as a Mongolian mountain lake and deep sea sediments deposited
five kilometres below sea level” (UNEP, 2016, p. 32). The world’s ocean systems
tend to concentrate waste in the great ocean gyres of the North and South Pacific,
the North and South Atlantic, and the Indian Ocean. The highest concentration of
plastic debris ever measured on a beach was on remote Henderson Island, in the
South Pacific, 5000 km from the nearest significant human habitation—but on the
western edge of the South Pacific gyre (Lavers & Bond, 2017).
The plastics permeate ecosystems. We now know that some birds confuse plastic
bits with food, and ingest the plastic—but cannot digest it. An estimated 90% of
seabirds now have plastic in their bodies (Wilcox, Van Sebille, & Hardesty, 2015).
The albatross is one such bird. Traditionally a sign of good luck for sailors, later a
symbol of guilt in Samuel Taylor Coleridge’s Rime of the Ancient Mariner, it takes
on new metaphorical power in the Anthropocene, as a graphic warning of our envi-
ronmental recklessness—the seabird over the ocean as the Planetary Health equiva-
lent of the canary in the coal mine (Millow, Mackintosh, Lewison, Dodder, &
Hoh, 2015).
Nor are birds the only affected species. In one recent study, investigators pur-
chased fish and shellfish from markets in Indonesia and California, and assessed
them for plastic debris. They found it in 28% of the individual fish and 55% of spe-
cies sampled in Indonesia, and in 25% of individual fish and 67% of species sam-
pled in the USA (Rochman, Tahir, Williams et al., 2015). When we eat fish, we are
eating plastic.
When ecosystems are infused with plastics, human health can suffer (Efferth &
Paul, 2017). Importantly, about 7% of plastic, on average, consists not of the poly-
mers themselves, but of additives such as plasticizers, fillers, and flame retardants
(Geyer et al., 2017). Moreover, plastics and microplastics, especially polypropyl-
enes, polyethylenes, and polystyrenes, are efficient carriers of synthetic organic
chemicals such as polychlorinated biphenyls (PCBs) and other PAHs, which adsorb
to their surfaces (Lee, Shim, & Kwon, 2014; Rochman, Hoh, Hentschel, & Kaye,
2013; Rochman, Manzano, Hentschel, Simonich, & Hoh, 2013; Teuten, Saquing,
Knappe et al., 2009). Many of these chemicals are highly persistent in the environ-
ment, hence the term Persistent Organic Pollutants, or POPs. Indeed, environmental
loading with such chemicals is a defining feature of the Anthropocene (Diamond,
2017; Diamond, de Wit, Molander et al., 2015).
POPs are fat-soluble. They bioconcentrate within the fat of organisms such as
fish, cattle, and polar bears, and they are biomagnified as they move from lower to
higher trophic levels of food webs (Corsolini & Sara, 2017; Mackay & Fraser,
2000). POPs have become widely distributed across the globe, even in ecosystems
such as the Arctic, far from where they were ever produced or used (Hung,
Katsoyiannis, Brorstrom-Lunden et al., 2016; Rigét, Bignert, Braune, Stow, &
Wilson, 2010).
When POPs are widely distributed through ecosystems, human exposure is
unavoidable. Measurement of population tissue levels of POPs has revealed nearly
ubiquitous body burdens in human populations (Fisher, Arbuckle, Liang et al.,
2016; Fourth National Report on Human Exposure to Environmental Chemicals.
Updated Tables, 2017; Koch & Calafat, 2009; Porta, Puigdomenech, Ballester et al.,
2008; Pumarega, Gasull, Lee, López, & Porta, 2016). Many of these chemicals are
biologically active, affecting neurodevelopmental, endocrine, metabolic, and other
delicately balanced systems in humans and in animals. Consider the many chemi-
cals collectively known as endocrine disrupters, which either block or activate
receptors in sex hormone, thyroid, and other pathways. Synthetic organic chemicals
that act in this manner include PCBs, bisphenols (e.g., bisphenol A, or BPA),
organochlorine pesticides, brominated flame retardants, and perfluorinated sub-
stances (perfluorooctanoic acid, or PFOA, and perfluorooctane sulfonate, or PFOS).
Evidence suggests that these exposures play a role in several noncommunicable
diseases, through both epigenetic and non-epigenetic mechanisms (Barouki,
Gluckman, Grandjean, Hanson, & Heindel, 2012; Hou, Zhang, Wang, & Baccarelli,
2012; Meeker, Sathyanarayana, & Swan, 2009; Vandenberg, Colborn, Hayes et al.,
2012). POPs exposure has been associated with metabolic conditions such as adi-
posity, insulin resistance, and dyslipidemias (Cano-Sancho, Salmon, & La Merrill,
2017; Grandjean, Henriksen, Choi et al., 2011; Lee et al., 2011; Lee et al., 2011;
Lee, Lee, Song et al., 2006). One recent study of First Nation Inuit natives in the
Canadian Arctic found that those with the highest levels of blood PCBs were 1.9–3.5
times more likely to have diabetes than those with the lowest levels (Singh & Chan,
2017). The concept of chemical obesogens is well established (Cano-Sancho et al.,
2017; Darbre, 2017; Wassenaar & Legler, 2017). POPs exposure has also been asso-
ciated with increased risk of some cancers, especially non-Hodgkin’s lymphoma
(Freeman & Kohles, 2012) and hormone-responsive cancers such as those of the
breast, ovaries, and prostate; to date, the animal evidence is more extensive than the
human epidemiologic evidence (Gore, Chappell, Fenton et al., 2015; Soto &
Sonnenschein, 2010). POPs may increase the risk of thyroid disease, neurobehav-
ioral disorders, and reproductive dysfunction (Gore et al., 2015).
There are many features of global chemical contamination we do not fully under-
stand: its geographic extent, its pathways through ecosystems, its full impacts on
human health, to what extent these exposures account for rising trends in some
diseases, where are the boundaries we should not cross. But as the Lancet
Commission on Pollution and Health recently made clear (Landrigan, Fuller, Acosta
et al., 2017), this planetary change does no favors to ourselves or to ecosystems.
26 H. Frumkin
A third example of global environmental change that affects human health is

land use change. The pressures of a growing human population and its resource
demands have led to dramatic expropriation of land and water globally (Foley,
DeFries, Asner et al., 2005; Lambin, Turner, Geist et al., 2001; Turner, Lambin, &
Reenberg, 2007). As much as half the world’s ice-free land surface has been trans-
formed, much of it converted from natural grassland or forest to cropland and pas-
ture for grazing (Turner et al., 2007). These changes have far-reaching effects, on
such domains as biodiversity (Newbold, Hudson, Arnell et al., 2016; Newbold,
Hudson, Hill et al., 2015). They also have far-reaching effects on human health.
Consider two examples.
The effects of land use change and the resulting ecosystem alterations on infec-
tious disease risk have long been appreciated and described for diseases as diverse
as malaria, schistosomiasis, hantavirus pulmonary syndrome, Lyme disease, and
West Nile virus (Bauch, Birkenbach, Pattanayak, & Sills, 2015; Pongsiri, Roman,
Ezenwa et al., 2009). Many mechanisms contribute, from changes in microbial
ecology to increased contact between humans and vectors.
A recently published example is instructive. A team of investigators based at the
University of Vermont was interested in the effect of degraded watersheds on chil-
dren’s health. They studied nearly 300,000 children under 5 years of age in 35 coun-
tries (Herrera, Ellis, Fisher et al., 2017). Their primary exposure measures were of
watershed quality—the hydrologic influence of upstream livestock, people, and tree
cover on downstream water quality. Their primary outcome of interest was diar-
rhea—an important condition, as it is the second leading cause of death among
children in the under-5 age group (Pruss-Ustun, Bartram, Clasen et al., 2014),
responsible for about 448,000 deaths in 2016 (Global Burden of Disease, 2017).
The Demographic and Health Surveys program provided health and socioeconomic
data, and geolocated climate and watershed data came from the WaterWorld model.
After controlling for socioeconomic factors, the presence of improved water and
sanitation, and other potential confounders, the investigators found that more intact
tree cover in the upstream watershed reduced rural children’s probability of diar-
rhea. Thirty percent more tree cover offered roughly the same protection as improved
sanitation infrastructure (but not as much as wealth, education, or an improved
water supply). Healthy tree cover in a watershed is good for human health.
A second example of the impact of land use change on health comes from palm
oil production in South Asia. Production is increasing as a result of demand for
biofuels in Europe and food in India, Indonesia, and China. Oil palm plantations
affect local ecology; they are consistently less biodiverse than primary forests, with
only about 50% of the vertebrate species found in primary forests (Savilaakso,
Garcia, Garcia-Ulloa et al., 2014). To clear tropical forests in Indonesia for palm oil
production (as well as for other purposes, such as timber plantations), fire is com-
monly used; the resulting smoke blows in defined ways, affecting populations in
Indonesia and the Malay Peninsula. This smoke, containing fine particulate matter,
is an established risk factor for cardiovascular mortality; in fact, the smoke from
such fires accounts for over 250,000 global deaths annually (Johnston, Henderson,
Chen et al., 2012; Marlier, DeFries, Kim et al., 2015). A team of investigators based
at Harvard has studied this phenomenon over recent years, innovatively combining
data on land types, land use, fire occurrence, wind patterns, smoke composition, and
health outcomes (Kim, Jacob, Mickley et al., 2015; Koplitz, Mickley, Marlier et al.,
2016; Marlier et al., 2015; Marlier, DeFries, Voulgarakis et al., 2013; Spracklen,
Reddington, & Gaveau, 2015). The Indonesian fires were found to cause, on aver-
age, approximately 11,000 excess regional deaths each year, but in a pattern that
varies considerably with such factors as El Niño (Marlier et al., 2013). In an espe-
cially bad year, 2015, the toll was an order of magnitude higher, at just over 100,000
excess deaths (Koplitz et al., 2016). In addition, the smoke is not the only health
impact of palm oil production. The loss of forests and the combustion of peat con-
tribute to climate change. Furthermore, dietary palm oil contains highly saturated
fatty acids, which have been proposed as a risk factor for heart disease and other
noncommunicable diseases (Basu et al., 2013; Ismail, Maarof, Ali et al., 2018).
The final example of global environmental change I will mention is biodiversity
loss. Biodiversity loss has accelerated dramatically during the Anthropocene
(Cardinale, Duffy, Gonzalez et al., 2012; Newbold et al., 2016). While this has
numerous potential impacts on human health (Bernstein, 2014), two examples are
especially illustrative: pollinator loss and fisheries depletion.
Pollination by insects is an important form of reproduction for more than 35% of
the annual global food production by volume. At least 87 major food crops, and up
to 40% of the world’s supply of some micronutrients, such as vitamin A, depend on
pollination by insects (Klein, Vaissière, Cane et al., 2007). Pollinators are declining
in many parts of the world for a combination of reasons, including habitat loss,
pesticide use, and parasitic infestation. Pollinator loss can reduce the amount of
fruits, vegetables, nuts, and seeds in the diet, contributing to vitamin A and folate
deficiencies. A recent analysis projected that a 50% loss of pollination would cause
about 700,000 additional deaths worldwide, mostly as a result of increased ischemic
heart disease and stroke due to reduced fruit and vegetable consumption (Smith,
Singh, Mozaffarian, & Myers, 2015).
Fisheries depletion has emerged as a global problem, with about 90% of fisheries
now at or beyond maximum sustainable levels of exploitation (FAO, 2016). Climate
change will intensify this problem in the coming decades (Comte & Olden, 2017).
For many populations, fish are a leading dietary source of protein, micronutrients
(often in highly bioavailable form), and omega-3 fatty acids (mainly from oily fish).
Dietary omega-3 fatty acids may reduce ischaemic heart disease risk, although evi-
dence remains inconsistent (Balk & Lichtenstein, 2017; Rangel-Huerta & Gil,
2017). In addition, through gene regulation, anti-inflammatory effects, or other
mechanisms, omega-3 fatty acids may play a role in preventing and/or treating other
conditions such as cancer (Lee, Sim, Lee, & Na, 2017) and arthritis (Senftleber,
Nielsen, Andersen et al., 2017). However, reductions in fish stocks could limit these
potential benefits. For example, the UK is unable to meet healthy diet guidelines for
its population from its domestic catch, and fish intake fell to only 19% of the
recommended level in 2012 (Thurstan & Roberts, 2014). One study projected that
28 H. Frumkin
more than 10% of the global population could face micronutrient and fatty-acid
deficiencies due to fish declines over coming decades, especially in low-and mid-
dle-income nations near the equator (Golden, Allison, Cheung et al., 2016).
Fortunately, there is some indication that with aggressive management, collapsed
fisheries can recover, as may be happening with the North Atlantic cod fishery,
which abruptly collapsed in 1992. Aquaculture is to some extent replacing wild fish
catches, but most aquaculture (70% in 2012) depends on external feedstocks that
may be unsustainable (FAO, 2016). Challenges such as disease in farmed fish
(Stentiford, Neil, Peeler et al., 2012; Stentiford, Sritunyalucksana, Flegel et al.,
2017), chemical contamination of farmed fish (Hamilton et al., 2005; Jacobs,
Covaci, & Schepens, 2002), genetic contamination of wild fish stocks (Cognetti,
Maltagliati, & Saroglia, 2006), and pollution of waters near fish farms (Cao, Wang,
Yang et al., 2007) must be addressed if sustainable aquaculture is to be achieved.
These four sets of examples—climate change, chemical contamination, land use
changes, and biodiversity loss—together paint a compelling picture. Human disrup-
tions of planetary systems threaten human health and well-being. Those who are
most at risk from these disruptions are those who live each day with high levels of
risk, due to poverty and deprivation.
Ways of Thinking and Knowing
This has been a grim litany. Indeed, planetary changes are threatening human health
and well-being—even civilization as we know it—on a frightening scale. But the
news is not all bad. Some planetary changes may offer benefits, such as higher agri-
cultural yields, or more physical activity, in cold areas that are becoming warmer.
More importantly, the steps we need to take to address planetary challenges such as
climate change yield a range of co-benefits, such as stronger communities, cleaner
air and more wholesome food. In the meantime, the threats I have described call on
us to change our thinking, as scientists and as global citizens, in some fundamental
ways—addressing what the Rockefeller Foundation–Lancet Commission on
Planetary Health called imagination challenges (conceptual and empathy failures)
and research and information challenges (knowledge failures) (Whitmee, Haines,
Beyrer et al., 2015).
First, we need to learn to acknowledge, and live within, limits (Butler, 2017). We
have all lived our lives during the last half of the twentieth century and the first part
of the twenty-first century—a time of plenty unprecedented in human history. What
enabled this, of course, was our profligate consumption of energy and materials,
propelled by ever more powerful technologies. The years during and after World
War II were a time of widespread limits, even in wealthy countries, and of course,
those who are poor face limits every day. But for the most part, we are no more
conscious of our extravagance than fish are conscious of water. And as we have
learned from recent behavioral economics research, we humans are wired not to
confront limits (Lorenzoni, Nicholson-Cole, & Whitmarsh, 2007; Shu & Bazerman,
2011; Weber, 2017). We are biased toward short-term thinking and we discount
future consequences. We have a status-quo bias; we cling to what we have and are
averse to making what we see as risky change. We are lousy at probabilistic think-
ing. We need to work to replace profligacy with restraint, extravagance with mod-
esty, wastefulness with thrift.
Second, we need systems thinking. Every serious thinker about sustainability, or
climate change, or human affairs in general, knows that reductionist, linear thinking
misses the mark. Nowhere is this truer than in Planetary Health. But still, university
departments, government agencies, and foundations organize themselves in silos,
without enough cross-links. Too many donors remain infatuated with silver bullet
technical solutions, rather than aiming for patient, long-term adaptive management
of complex systems. In my own field, medicine, why do we still require prospective
students to have studied chemistry, physics and calculus, but not ecology and evolu-
tionary biology? We need thinking habits and institutional arrangements to be based
on systems.
Third, we need a sense of urgency. Our house is on fire, and we need to act
accordingly. Our scientific discourse is typically sober and dispassionate, but pas-
sion in this setting is no sin; rather, it is a necessity. Fifty years ago, discussing a
very different emergency, the Vietnam War, Martin Luther King wrote words that
are deeply appropriate today: “We are now faced with the fact, my friends, that
tomorrow is today. We are confronted with the fierce urgency of now. In this unfold-
ing conundrum of life and history, there is such a thing as being too late.
Procrastination is still the thief of time. Life often leaves us standing bare, naked,
and dejected with a lost opportunity. The tide in the affairs of men does not remain
at flood—it ebbs. We may cry out desperately for time to pause in her passage, but
time is adamant to every plea and rushes on. Over the bleached bones and jumbled
residues of numerous civilizations are written the pathetic words, ‘Too late’. There
is an invisible book of life that faithfully records our vigilance or our neglect. Omar
Khayyam is right: ‘The moving finger writes, and having writ moves on’” (Beyond
Vietnam, 1967). As it was then for Reverend King, so it is now for us. We must
confront the “fierce urgency of now.”
Fourth, we need intellectual humility. Modern science and technology, animated
by positivism for the last few centuries, have delivered untold benefits to human-
kind. But they have also brought wicked problems and profound dilemmas. Science
and technology do not offer all the answers. We scientists need to be open to other
intellectual traditions, to faith traditions (Bingham, 2016; Francis, 2015; Hayhoe &
Farley, 2009) (and I am so appreciative of Pope Francis and of the Pontifical
Academy of Sciences for engaging the challenges of climate change and health, and
for convening us) and to the traditional ecological knowledge of indigenous peoples
(Finn, Herne, & Castille, 2017; Gomez-Baggethun, Corbera, & Reyes-Garcia,
2013). This will take us beyond our comfort zones—the right place to be when we
need to be stretching toward solutions.
30 H. Frumkin
Ethics
Let me close with a word about ethics. As a medical student and young physician, I
learned and took seriously the principles of biomedical ethics: respect for auton-
omy, non-maleficence, beneficence, and justice. These principles guided some very
sound decisions: Do not treat a patient without his or her consent. Do not withhold
information from a patient. These are all well and good, but they are not nearly
enough. Biomedical ethics has been far too confined to clinics and hospitals
(Macpherson, 2013).
We need an ethics that recognizes everybody’s right to have access to the clinic
in the first place—and not only to the clinic, but to all of the precursors needed for
a fully expressed and healthy life: education, housing, political voice. This is an eth-
ics of social justice. It is essential in Planetary Health for both practical and moral
reasons; those who are most vulnerable to all the threats I discussed are the disen-
franchised, those without voice, those who must be at the center of any system of
ethical principles (Shue, 2014). We need an ethics that recognizes intergenerational
responsibility. Our obligations extend well beyond our own lifetimes (Weston, 2008).
Finally, we need an ethic that extends from humans to the more-than-human
world (Leopold, 1949; Rolston, 1989). As much as we bear responsibility for each
other, we bear responsibility for other species, and for ecosystems. At the very least,
this responsibility is derivative from conventional ethics; Planetary Health science
makes clear that care for people intrinsically includes care for the earth. But it may
go further, suggesting an ethical system grounded in our place as part of the larger
world we share.
Conclusion
We are living in a Golden Age. Prosperity has increased around the globe, poverty
has been reduced, and human health has never been better. But, in the words of the
Rockefeller Foundation–Lancet Commission on Planetary Health, “we have been
mortgaging the health of future generations to realize economic and development
gains in the present” (Whitmee et al., 2015). As scientists, we have increasingly
uncovered and quantified the human health impacts of disrupting earth systems and
crossing planetary boundaries. We need to continue this task, with ever-greater
sophistication and accuracy, creating and using scientific frameworks appropriate to
the complexity of the challenges, and with intellectual humility. Just as important,
we need to act on the science, with passion for sustaining life, with urgency, with a
drive for social and environmental justice, ever mindful of the great privilege we
have: to choose the legacy we leave.
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CHAPTER 4
How Do Our Actions Undermine Nature?
Partha Dasgupta
Summary The global growth experience since the end of the Second World War
has given us two conflicting messages. On the one hand, if we look at the state of
the biosphere (fresh water, ocean fisheries, the atmosphere as a carbon sink—more
generally, ecosystems), there is strong evidence that the rates at which we are utiliz-
ing them are unsustainable. For example, the rate of biological extinctions globally
today is 10–1000 times the average rate over the past several million years (the
“background rate”). The mid-twentieth century years are acknowledged to have
been the beginnings of an era that environmental scientists now call the Anthropocene
(Vosen, 2016), during which the processes that define the biosphere are being
altered enormously (see Waters et al. 2016).
On the other hand, it is argued by many that just as previous generations in the
West and (and more recently in the Far East) invested in science and technology,
education, and machines and equipment so as to bequeath to the present generation
the ability to achieve high living standards, we in turn can make investments that
would assure still higher living standards in the future. In 1950, global income per
capita was approximately 3500 international dollars (at 2011 prices) and world
population was about 2.5 billion. In 2015, the corresponding figures were 15,000
international dollars and 7.5 billion. A somewhat-greater-than 12-fold increase in
global income over a 65-year period is unprecedented, that too starting at a 3500
international dollars base. The years immediately following the Second World War
are routinely praised by commentators for being the start of the Golden Age of
Capitalism (Micklethwait and Wooldridge (2000), Ridley (2010), Norberg (2016),
and Pinker (2017) are a sample of books with that message).
P. Dasgupta (*)
Faculty of Economics and the Centre for the Study of Existential Risk, University
of Cambridge, Cambridge, UK

40 P. Dasgupta
We should not be surprised that the Anthropocene and the Golden Age of
Capitalism began at about the same time. We should also not be surprised that the
conflicting signals of the 65 years following 1950, particularly the potentially irre-
versible changes to the biosphere, do not receive much airing by economic com-
mentators. That is because contemporary models of economic growth and
development (e.g. Helpman, 2004) largely ignore their damaging impacts on the
workings of the biosphere.
Part I
The Idea of Sustainable Development
Recently, a group of economists have studied the tension inherent in the conflicting
intuitions by appealing to the idea of “sustainable development”, a term coined in
the famous Brundtland Report (World Commission on Environment and
Development, 1987). By sustainable development, the Commission meant “devel-
opment that meets the needs of the present without compromising the ability of
future generations to meet their own needs”. In this reading, sustainable develop-
ment requires that, relative to their respective demographic bases, each generation
should bequeath to its successor at least as large a productive base as it had inherited
from its predecessor. If a generation follows this prescription, then the economic
possibilities facing its successor would be no worse than those it faced when inherit-
ing productive assets from its predecessor.
The problem is that the rule leaves open the question of how the productive base
is to be measured. We are thus in need of an index whose movements over time track
the sustainability of development programmes. Prominent attempts at constructing
ways to assess sustainability have been less than satisfactory because they did not
arrive at their favoured indices from a well-articulated notion of sustainable devel-
opment (Fleurbaey & Blanchet, 2013; Stiglitz, Sen, & Fitoussie, 2009).
Wealth and Well-Being
In this chapter intergenerational well-being refers to not only the well-being of

those who are present today, but also the well-being of people in the future. The
term indicates an aggregate measure of the flow of personal well-beings across
time and the generations. Now, if sustainable development is meant to indicate that
intergenerational well-being should not decline over time, then the index that sig-
nals whether an economy is on a sustainable d evelopment path is an inclusive mea-
sure of wealth (see Arrow et al., 2004; Arrow et al., & Oleson, 2012, 2013; Dasgupta
& Mäler, 2000). Formally, if intergenerational well-being increases over time,
inclusive wealth also increases over time; and if intergenerational well-being
4 How Do Our Actions Undermine Nature? 41
decreases over time, inclusive wealth also decreases over time. We call this rela-
tionship the wealth/well-being equivalence theorem. Inclusive wealth and intergen-
erational well-being are not the same thing, but they move in the same way. The
wealth/well-being equivalence theorem tells us that neither GDP nor the United
Nations’ Human Development Index should be used as an index for determining
whether an economy is on a path of sustainable development.
Inclusive wealth is the dynamic version of income. It is the social worth of an
economy’s stock of produced capital (roads, buildings, machines), human capital
(health, education), and natural capital (ecosystems, sub-soil resources). Wealth is a
stock, whereas income (e.g., GDP) is a flow. In a stationary economy, the two
amount to the same thing; however, they can point in different directions when an
economy is not in a stationary state.
To better appreciate the notion of inclusive wealth, imagine someone is asked to
estimate their personal wealth. The individual would most likely turn first to finan-
cial assets (savings in the bank, stocks and bonds) and the properties he owns (house
and belongings, e.g.). He would use their market value to compute wealth. If
pressed, he would acknowledge that his future earnings at work should be included,
and he would estimate that part of his wealth by making a forecast of the flow of his
(post-tax) earned incomes and adding them over the working life that is ahead of
him, using perhaps a market interest rate to discount future earnings. If he were
pressed no further, he would probably stop there and agree that his earned incomes
represent returns on the human capital he has accumulated (sociality, education,
skills, health). He would also agree that wealth is important to him because it deter-
mines the opportunities he has to shape his life—the activities he can engage in, the
commodities he can purchase for pleasure, and so on. But he would probably over-
look that his taxes go to pay for the public infrastructure he uses, and he would
almost certainly not mention the natural environment he makes use of daily, free
of charge.
The notion of wealth in which a society should be interested is far wider. Inclusive
wealth is the social worth of the economy’s entire stock of assets. Assets are often
called by a more generic name, “capital goods”, so we may use the terms inter-
changeably. Assets offer potential streams of goods and services over time; the more
durable an asset, the more lasting is the potential stream. Time is built into an asset.
That explains why an economy’s inclusive wealth at a point in time is able to reflect
the flow of well-being across time and the generations.
Accounting Prices and the Social Environment
An asset’s accounting price is the social worth of the stream of goods and services
a society is able to obtain from a marginal unit of it. A mangrove forest is a habitat
for fish populations. It is also a recurrent source of timber for inhabitants, and it
protects people from storms and tsunamis. The forest’s accounting price measures
its worth to society. An economy’s institutions and politics are factors determining
42 P. Dasgupta
the social value of its assets because they influence what people are able to enjoy
from them. The value of the house a family inhabits is not independent of whether
society is at peace.
Accounting prices can be very different from market prices. The difference
between an asset’s accounting price and its market price reflects a distortion in the
economy and should be eliminated if possible. To give an example, as the market
price of fish in the open seas is zero, fishermen harvesting them ought to be charged
for doing so. The charge, or tax, in this case is the accounting price of fish in their
natural habitat. It may be even be judicious to impose a quota on fishing, but quotas
are only an extreme form of taxation (zero tax per unit up to the quota, a prohibitive
tax beyond it).
The assets whose accounting value adds up to inclusive wealth (i.e. produced
capital, human capital, and natural capital) should be distinguished from an econo-
my’s social environment and practices. The latter pair comprises the intangible
medium in which goods and services are produced and allocated across persons,
time, and the generations. The social environment consists of the laws and social
norms that provide people with incentives to choose one course of actions rather
than another; it includes the workings of social and economic institutions such as
families, firms, communities, charities, and government; it includes the play of poli-
tics; and it includes personal motivations and norms of conduct. The social environ-
ment is the seat of mutual trust. A strengthening of trust facilitates enterprise and
exchange, thus enhancing personal well-being and thereby inclusive wealth.
Sustainable Development Goals
The practical significance of the equivalence between intergenerational well-being

and inclusive wealth was lost on the framers of the Sustainable Development Goals
(SDGs), which were adopted by the United Nations General Assembly in September
2015. The UN has made a commitment to attain the goals by 2030. The SDGs are
noble goals; they are to be lauded. Seventeen in number, the goals range from pov-
erty eradication and improvements in education and health, to the protection of
global assets that include the oceans and a stable climate. Each is of compelling
importance. But neither the SDGs nor their background documents mention the
need to move to a system of national accounts that contains estimates of inclusive
wealth. Without that move, however, there would be no way for governments to
check that the economic measures they take to meet the international agreement
would not jeopardize the sustainability of those goals. If inclusive wealth (adjusted
for population and the distribution of wealth) increases as governments try to meet
the SDGs, the SDGs will be sustainable; if it declines, the SDGs will be unsustain-
able. It could be that the goals are reached in the stipulated time period but are not
sustainable because the development paths nations follow erode productive capaci-
ties beyond repair. The supporting documents of the United Nations’ Sustainable
Development Goals do not tell us how to check that the goals are being met in a
sustainable way. Managi and Kumar (2018), in their Inclusive Wealth Report 2018,
have found that 44 out of the 140 countries in their sample experienced a decline in
(inclusive) wealth per capita since 1998, even though GDP (read, “income”) per
capita increased in all but a handful of them. The tension I alluded to is expressed
quantitatively in that study.
Part II
What Is Investment?
Today, the most commonly used measure of people’s health is longevity. We rou-
tinely talk about investment in a country’s health and commend it when longevity
rises. But does an increase in longevity amount to investment?
The word “investment”, as customarily used, embodies a sense of robust activ-
ism. But that is only because national income statisticians have traditionally limited
the term’s use to the accumulation of produced capital. When a government invests
in roads, the picture that is drawn is one of bulldozers levelling the ground and tar-
mac being laid by men in hard hats. That is investment. In Part I, we found it neces-
sary to extend the notion of capital beyond produced capital to include human
capital and natural capital. So we were obliged to stretch the notion of “net invest-
ment” to mean any decision that raises future well-being. To leave a forest alone so
that it can grow is in our extended sense to invest in the forest. Net investment is
positive when trees grow. To allow a fishery to restock under natural conditions is to
invest in the fishery. Net investment in the fishery is positive when the stock
increases. And so on.
That could suggest that investment amounts to deferred consumption; however,
the matter is subtler. Providing additional food to undernourished people via, for
example, food guarantee schemes not only increases their current well-being, it
enables them also to be more productive in the future and to live longer. Because
their human capital increases, the additional food intake should count also as net
investment. Note, though, that food intake by the well-nourished does not alter their
nutritional status, which means the intake is consumption, not investment. By “net
investment” in an asset we mean the value of the change in the stock of that asset
over the past period.
To illustrate, consider a closed, egalitarian economy with constant population.
Suppose in a given year it invests 40 billion dollars in produced capital, spends 20
billion dollars on primary education and health care, and depletes and degrades its
natural capital by 70 billion dollars. The economy’s System of National Accounts
(SNA) would record the 40 billion dollars as investment (“gross capital formation”),
the 20 billion dollars as consumption, and would typically remain silent on the 70
billion dollars of loss in stocks of natural capital (e.g. wetlands, the atmosphere).
Proper accounting methods in contrast would reclassify the 20 billion dollars as
44 P. Dasgupta
expenditure in the formation of human capital (“investing in the young”, as the say-
ing goes) and the 70 billion dollars as depreciation of natural capital. Aggregating
them and assuming that expenditure on education is a reasonable approximation of
gross human-capital formation, we would conclude that, owing to the depreciation
of natural capital, the economy’s wealth will have declined over the year by 10 bil-
lion dollars—and that is before taking note of the depreciation of produced capital
and human capital. The moral we should draw is that development was unsustain-
able that year.
Wealth in India: Estimates
Arrow et al. (2012) put the wealth/well-being equivalence theorem to work by esti-
mating the change in wealth per capita over the period of 1995–2000 in Brazil,
China, India, United States, and Venezuela.1 The choice of countries was in part
designed to reflect different stages of economic development and in part to focus on
particular resource bases. Because of an absence of data, the authors did not study
wealth inequality within countries. Their publications are like reconnaissance exer-
cises. They explore the land mostly in the dark; you know they have got it wrong,
but you have reasons to believe they are in the right territory.
Table 4.1 reproduces their findings for India. The value of produced capital in
1995, amounting to $1530 per head, was calculated from government publications
on past capital investments. The implicit assumption was that prices used by the
government to record expenditures are reasonable approximations of shadow (true
price) prices. The value of education per person ($6420) was estimated on the basis
of a functional relationship between wage differences and differences in levels of
education.
No data were available for calculating the contribution of health to labour pro-
ductivity and current well-being. For that reason, the authors studied longevity only.
Its accounting price was estimated from the value of a statistical life (VSL), which
is commonly obtained from the willingness-to-pay for a marginal reduction in the
risk of death. Recent work suggests VSL in India is approximately $500,000. Arrow
et al. (2012) showed that under a set of simplifying assumptions VSL equals the
value of health per person [row (3), column (1)]. They then estimated the value of a
statistical life-year and used that to value the increase in life expectancy between
1995 and 2000 [row (3), column (2)].
Four categories of natural capital were included in the study: forests (valued for
their timber), oil and minerals, land, and carbon concentration in the atmosphere.
Like institutions and knowledge, atmospheric carbon was interpreted to be an
“enabling” asset, which is why it is excluded from columns (1) and (2) but included
in the estimate of the change in wealth over the 5-year period.
IHDP-UNU/UNEP (2012, 2014) used the same framework to measure wealth in 120 countries.
1
Table 4.1 Per capita wealth and its growth in India, 1995–2000 (2000 US$)
(1) (2) (3) (4)
1995 2000 Change Growth rate
stock stock (1995–2000) (% per year)
(1) Produced capital 1530 2180 650 7.30
(2) Human capital, 1 (education) 6420 7440 1020 3.00
(3) Human capital, 2 (health 500,000 503,750 3750 0.14
(4) Natural capital 2300 2280 −20 −0.15
(5) Oil (net capital gains) −140
(6) Carbon damage −90
(7) Total 510,250 515,650 5400 0.20
(8) TFP 1.84
(9) Wealth per capita 2.04
Source: Arrow et al. (2012), Table 5 (modified)
The value of land was taken from World Bank publications. Using market prices
for timber and oil and minerals, the shadow value of natural capital in 1995 was
estimated to be $2300 per person [row (4), column (1)]. Because of the lack of rel-
evant data, the figure did not include the value of all the many ecological services
that forests provide. Moreover, ecosystems such as fisheries, wetlands, mangroves,
and water bodies are missing from Table 4.1. That means $2300 is an underestimate,
in all probability seriously so. Adding the figures, wealth per capita in 1995 was
found to be $510,250 [row (5), column (1)].
The population in India grew at an average annual rate of 1.74%. Column (3)
records changes in per capita capital stocks over the period in question; and column
(4) presents the corresponding annual rates of change. The former is embellished by
two factors. First, India is a net importer of oil, whose real price rose during the
period. The capital losses owing to that increase amounted to a wealth reduction in
India, which was calculated to be $140 per person [row (5), column (3)]. Secondly,
during 1995–2000, global carbon emissions into the atmosphere exceeded 38 bil-
lion tons. At the levels of concentration prevailing in 1995 (380 parts per million),
carbon was a global “public bad”. The theory of public goods says that the loss to
India over the period would have been global emissions times the shadow price of
carbon specific to India. In their base case, Arrow et al. (2012) took the global
shadow price to be negative $50 per ton. The loss to India per ton of carbon emis-
sions was taken to be 5% of the global shadow price, which is negative $2.50. This
amounted to a loss per person of $90 [row (6), column (3)].
Row (7) records the change in wealth per capita in India over the period of
1995–2000. It translates to 0.20% a year, a figure so near to zero as to be alarming.
However, the estimate does not include improvements in knowledge and institu-
tions. Arrow et al. (2012) modelled the latter as “enabling assets” and interpreted
improvements in them as growth in total factor productivity (TFR), which in India
has been estimated to be 1.84% a year (row (8)). Based on a formula the authors
derived for including the residual in wealth calculations, row (9) records the annual
rate of growth of wealth per head in India during 1995–2000 as having been 2.04%.
46 P. Dasgupta
The composition of wealth in Table 4.1 does not have direct implications for
policy. A mere study of the relative magnitudes of the different forms of wealth
would not tell us their relative importance. Suppose, for example, that the value of
asset i swamps all other forms of capital, by a factor of 1000. That does not mean
investment ought to be directed at further increases in i, for we do not know the
costs involved in doing so. Only social cost–benefit analysis, using the same shadow
prices as are estimated for sustainability analysis, would tell the evaluator which
investment projects are socially desirable.
Taken at face value, Table 4.1 reveals a number of interesting characteristics of
India’s economic development during the final years of the twentieth century. It is
helpful to highlight the most striking:
1. Of the four types of capital comprising measured wealth, produced capital is the
smallest. Even though the value of natural capital in both years is in all likeli-
hood a serious underestimate, it was considerably greater in 1995 than reproduc-
ible capital.
2. The rapid growth of produced capital (7.30% a year), as against a 0.15% annual
rate of decline of natural capital, meant that by 2000 their stocks were nearly
identical.
3. In 1995, human capital in the form of education was more than four times that of
produced capital. However, the ratio declined over the 5-year period owing to a
slower growth in education.
4. Health swamps all other forms of wealth. It was some two orders of magnitude
larger than all other forms of wealth combined in 1995, in what was then a low-
income country; this is unquestionably the most striking result of the exercise.
That the finding is a cause for surprise is, however, no reason for dismissing it.
Health has been much discussed in the development literature but has not been
valued within the same normative theory as produced capital. There was no basis
for a prior expectation of what the finding would be once health was placed in
the same normative footing as other forms of wealth. Health dominates because
of the high figure for V reported in the empirical literature. Longevity matters to
people everywhere and matters greatly. In democratic societies, that should
count.
5. Growth in wealth per capita in India has been largely a consequence of TFP
growth (the “residual”). However, contemporary estimates of the residual should
be treated with the utmost suspicion because they are based on models that do
not include natural capital as factors of production. If the rate at which natural
capital is degraded were to increase over a period of time, TFP growth obtained
from regressions based on those models would be overestimated. The implica-
tion is more than just ironic. The regressions would misinterpret degradation of
the environment as increases in knowledge and improvements in institutions.
Worse still, the greater the under-coverage of natural capital, the greater the bias
in the estimate of TFP growth. By plundering Earth, TFP could be raised by as
much as the authorities like.
References
Arrow, K. J., Dasgupta, P., Goulder, L., Daily, G., Ehrlich, P. R., Heal, G. M., et al. (2004). Are we
consuming too much? Journal of Economic Perspectives, 18, 147–172.
Arrow, K. J., Dasgupta, P., Goulder, L. H., Mumford, K. J., & Oleson, K. (2012). Sustainability and
the measurement of wealth. Environment and Development Economics, 17, 317–355.
Arrow, K. J., Dasgupta, P., Goulder, L. H., Mumford, K. J., & Oleson, K. (2013). Sustainability and
the measurement of wealth: Further reflections. Environment and Development Economics, 18,
504–516.
Becker, G. S., Philipson, T. J., & Soares, R. S. (2005). The quantity and quality of life and the
evolution of world inequality. American Economic Review, 95, 227–291.
Dasgupta, P., & Mäler, K.-G. (2000). Net national product, wealth, and social well-being.
Environment and Development Economics, 5, 69–93.
Fleurbaey, M., & Blanchet, D. (2013). Beyond GDP: Measuring welfare and assessing sustain-
ability. New York: Oxford University Press.
Helpman, E. (2004). The mystery of economic growth. Cambridge, MA: Belknap Press.
IHDP-UNU/UNEP. (2012/2014). Inclusive wealth report. Cambridge: Cambridge University
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Klenow, P. J., & Rodriguez-Clare, A. (2005). Externalities and growth. In P. Aghion & S. Durlauf
(Eds.), Handbook of economic growth. Amsterdam: North Holland.
Landes, D. S. (1998). The wealth and poverty of nations. New York: W.W. Norton.
Managi, S., & Kumar, P. (2018). Inclusive wealth report 2018. London: Routledge.
Micklethwait, J., & Wooldridge, A. (2000). A future perfect: The challenge and promise of global-
ization. New York: Random House.
Mokyr, J. (2002). The gifts of Athena: Historical origins of the knowledge economy. Princeton, NJ:
Princeton University Press.
Mokyr, J. (2016). The culture of growth: The origins of the modern economy. Princeton, NJ:
Princeton University Press.
Norberg, J. (2016). Progress: Ten reasons to look forward to the future. London: One World.
Pinker, S. (2017). Enlightenment now: The case for reason, science, humanism, and progress
New York: Allen Lane.
Putnam, R. D., Leonardi, R., & Nanetti, R. Y. (1993). Making democracy work: Civic traditions in
modern Italy. Princeton, NJ: Princeton University Press.
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Stiglitz, J. E., Sen, A., Fitoussi, J.-P., & Commission on the Measurement of Economic Performance
and Social Progress. (2009). Mismeasuring our lives: Why GDP doesn’t add up. New York:
The New Press.
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Waters, C. N., Zalasiewicz, J., Summerhayes, C., Barnosky, A. D., Poirier, C., Galuszka, A., et al.
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common future. New York: Oxford University Press.
48 P. Dasgupta
CHAPTER 5
Climate Change, Air Pollution, and Health:
Common Sources, Similar Impacts,
and Common Solutions
Summary We are living in the Anthropocene. Human beings have become a major
force by massively polluting the air we breathe as well as the entire atmosphere, which
maintains the climate in a habitable zone. Close to one trillion tons of air and climate
pollutants are blanketing the earth, and trillions of additional tons will be added this
century. Millions of people are dying prematurely every year due to air pollution. If
climate pollutant emissions are allowed to continue well into the twenty-first century,
global warming and climate change can pose existential threats to Homo sapiens and
many other species. The dominant sources of air pollution and climate change are the
same: (1) combustion of fossil fuels and biomass for energy; and (2) agriculture,
including livestock. Both air pollution and climate change have catastrophic impacts
on human health, exposing billions of people to toxic pollution, deadly heat waves,
floods, droughts, and fires. Basically, fossil fuel has become an outdated fuel. There is
still time to mitigate and avoid the worst consequences. An integral strategy to mitigate
air pollution and climate pollution is required because drastic emission cuts in climate
pollutants, such as by switching from fossil fuels to abundantly available renewable
fuels, will also reduce air pollution. Less wasteful use of fertilizers and greater con-
sumption of a plant-based diet are also required. Technical solutions have to be bol-
stered by societal transformation solutions to solve the problem in time and transition
to a safer Anthropocene.
Science of Air Pollution and Climate Change
Air pollution and climate change have been the subjects of rigorous scientific
enquiry for more than a century. The focus of air pollution studies has been primar-
ily on the impacts on human and ecosystem health. Climate change studies have
V. Ramanathan (*)
Scripps Institution of Oceanography, University of California at San Diego,
La Jolla, CA, USA

50 V. Ramanathan
largely focused on impacts on the physical climate system, including temperature,

weather, glaciers, and sea level rise, among others. Only during the last two decades
has the integrated nature of the air pollution and climate change problems been
recognized; that is, both air pollution and climate change affect public health as well
as the health of the ecosystem. The dominant sources of air pollution and climate
change are the same: burning of fossil fuels; burning of solid biomass, including
forests; and agriculture emissions. Air pollutants also have a strong influence on
climate change. Likewise, weather extremes caused by climate change affect health
in major ways. These linkages between air pollution, climate change, and health of
the people and the ecosystem are explored in this chapter, as well as many other
chapters in this book.
The primary climate warming pollutant gases are carbon dioxide, methane,
ozone, nitrous oxide, and halocarbons. The primary air pollutants are particles and
ozone. The primary air pollution particles are sulfates, nitrates, black carbon (soot),
and organics. All particles intercept sunlight and cause a dimming of sunlight at the
surface. Black carbon absorbs sunlight and is one of the largest climate warming
pollutants. All other particles act like mirrors and reflect sunlight back to space,
which causes cooling.
Air Pollutants: Air pollution particles are very small in size, ranging from nano-
meters (billionth of a meter) to 10 μm (micrometers). A micrometer is a millionth of
a meter. For reference, a human hair ranges from 20 μm to larger sizes. Air pollution
particles sampled from the air typically consist of sulfates and nitrates from fossil
fuel burning; black carbon from diesel combustion and biomass burning; organic
carbon from fossil fuel combustion and biomass burning; and mineral dust and sea
salt particles from natural sources. These particles are too tiny to see with our eyes.
The particles scatter sunlight, which gives a hazy appearance to the sky; it is this
hazy sky that we perceive as air pollution. Some particles, such as black carbon, also
trap sunlight in blue and UV wavelengths, which gives a brownish appearance to the
hazy sky and is called brown clouds.
Ozone is also an air pollutant, but it is a gas. Human activities do not emit ozone,
but they emit pollutant gases such as carbon monoxide, nitrogen oxides (NOx),
nitrous oxide, and methane, which produce ozone in the air. Ozone is also a major
climate warming pollutant.
Air pollution is transported far and wide by atmospheric winds. For example, air
pollution from the east coast of China travels within 5–7 days to the west coast of
North America; air pollution from the east coast of the United States travels to
Europe in less than five days. The lifetime of an air pollution particle in the air
ranges from a few days to a few weeks depending on the location, the season, and
the altitude. The particles are removed from the air either by rain or by directly
depositing on the surface. These are important facts because solutions to the air pol-
lution problem often require local, regional, national, and even global actions.
Climate Pollutants: The major climate pollutants are gases that absorb and emit
infrared (heat) radiation. Because their lifetimes range from a decade to centuries,
greenhouse gases cover the planet like a blanket. A blanket on a cold winter night
5 Climate Change, Air Pollution, and Health: Common Sources, Similar Impacts… 51
keeps us warm by trapping body heat. Likewise, the greenhouse blanket in the air
traps the infrared heat emitted by the surface and the atmosphere and warms the
planet. The magnitude of the infrared heat trapping can be estimated from the quan-
tum mechanics of the gas molecules and verified by laboratory data. These infrared
heat-trapping gases are called greenhouse gases.
Greenhouse gases have multiple sources. The sources of carbon dioxide, which
is a major climate pollutant, are fossil fuel combustion and biomass burning (mainly
deforestation and cooking with firewood). For methane, the sources include fossil
fuel (natural gas) production and transport, agriculture (rice cultivation), cattle
breeding, farm manure, landfills, and sewage. Nitrous oxide is primarily from fertil-
izers, whereas the main sources of halocarbons are refrigerants. Greenhouse gases
stay in the air for months (ozone) to decades (methane and some halocarbons) to a
century (nitrous oxide and some halocarbons). Carbon dioxide is the most insidious
climate pollutant because it has multiple time scales, ranging from decades to cen-
turies to thousands of years. For example, we are likely still breathing carbon diox-
ide emitted in the nineteenth century by the improved steam engine invented by the
famous British engineer James Watt. In that sense, carbon dioxide is immortal when
judged by human time scales. Because of their long lifetimes (more than a decade),
greenhouse gases (except ozone) emitted on any corner of the planet can travel to
the rest of the planet, trap heat, and impact the climate globally. That is why the
phenomenon is called global warming.
Air Pollutants and Climate Pollutants: Similar Impacts
Both air pollution and climate change have large negative impacts on the health of
people and of the ecosystem.
Air Pollution Impacts
Health Impacts of Air Pollution: When inhaled, tiny nano- to micrometer sized
particles enter the lungs, the bloodstream, and even the brain (GBD 2013 Risk
Factors Collaborators 2015). Air pollution is the fourth largest risk factor to global
health, after high blood pressure, dietary risks, and smoking. It also is the biggest
environmental health risk factor.
Epidemiologists have classified air pollution particles under two categories:
ambient (outdoor) air pollution (AAP) and household air pollution (HAP). In prin-
ciple because of wind-driven mixing, AAP and HAP should be similar. However, in
rural households in Asia, Africa, and South America, cooking is mostly done by
burning solid fuels such as firewood, coal, dung, and crop residues in rudimentary
stoves. The incomplete combustion of solid fuels in such stoves gives rise to smoke
consisting of black carbon and organic carbon particles. Due to poor ventilation, the
52 V. Ramanathan
particles are concentrated inside homes, and this has a major impact on the health of
the poorest three billion who rely on such cooking. Every year, at least three million
succumb to indoor inhalation of HAP. Ultimately, however, the smoke particles
escape outdoors, become part of ambient air pollution, and kill even more.
The inhalation of outdoor air pollution causes millions (7–9.5 million) of prema-
ture deaths in addition to exposing more than six billion people to adverse health
effects. The health effects of air pollution are documented extensively in many
chapters of this book.
Ecosystem Impacts of Air Pollution: The impacts of air pollution on ecosystem
health include the following:
• Soil acidification due to the acidity of precipitation (acid rain) caused by sulfuric
and nitric acids, mostly from fossil fuel combustion;
• Eutrophication of lakes and rivers by NOx (from fertilizers and fossil fuels);
• More than one hundred million tons of damaged crops each year due to ozone
exposure (mainly fossil fuels).
Climate Impacts of Air Pollutants: Air pollution has major impacts on the cli-
mate, particularly on precipitation.
1. Global Dimming, Monsoon Weakening, and Drying: Air pollutant particles inter-
cept sunlight and reduce the amount of sunlight at the surface, which is com-
monly known as Global Dimming. The dimming leads to a decrease in
evaporation from the oceans, which results in a decrease in precipitation, thus
leading to droughts. The deadly multi-decadal Sahelian drought during the 1960s
to the 1980s was attributed in part to the dimming of the North Atlantic Ocean
by sulfate and nitrate aerosols from Europe. This asymmetric dimming of the
North Atlantic shifted the equatorial rain belt southwards, away from the Sahelian
latitude belt (Rotstayn & Lohmann, 2002). Numerous studies have attributed the
decrease in the Indian summer monsoon rains to dimming by widespread atmo-
spheric brown clouds (Ramanathan et al., 2005), which consist of black carbon
(soot), sulfates, nitrates, and organics particles that preferentially form over the
northern Indian Ocean compared with the southern Indian Ocean.
2. Warming Particles: In addition, black carbon (soot) aerosols from diesel and
wood burning are the strongest absorbers (per mass) of solar radiation and con-
tribute to warming (Ramanathan & Carmichael, 2008). For example, a ton of
black carbon from diesel vehicles has the same warming effect as that of 2000
tons of carbon dioxide. The deposition of black carbon has been shown to signifi-
cantly enhance the solar heating of snow-capped surfaces over Tibetan-Himalaya
glaciers, arctic sea ice, and glaciers (Xu et al., 2016).
3. Cooling Effects: Aerosols also have a large cooling effect on the climate.
Sulfates, nitrates, and some organics particles primarily scatter sunlight, some of
which is reflected back to space instead of being absorbed by the surface, thus
exerting a global cooling effect. This aerosol cooling effect has masked (offset)
as much as 40% of the warming effect of greenhouse gases.
4. Disruption of Global Weather Patterns: Because of their short lifetimes, the

cooling as well as the warming aerosols are more concentrated over land than
over oceans, as well as more concentrated over the northern hemisphere (because
it is more populated) than over the southern hemisphere. This asymmetric effect
disrupts the weather patterns because they are driven by temperature gradients
between the land and ocean and between the north and south. One such disrup-
tion is associated with a tropics-wide circulation called the Hadley circulation,
which originates in the tropical region and culminates in the sub-tropical regions
(20° latitude to 35° latitude) by bringing dry upper atmosphere air downwards.
This descending dry air is responsible for many of the major widespread desert
regions, such as the Sahara and other major arid regions in Middle East.
Climate Pollution Impacts
Since 1750, we have emitted 2.2 trillion tons of carbon dioxide, 45% of which is

still in the atmosphere. In addition, methane has been emitted from fossil fuels and
a number of other sources, halocarbons (CFCs, HFCs, etc.) from refrigerators and
air conditioners, ozone-producing pollutant gases from vehicle exhaust, and nitrous
oxide from fertilizers. In addition, the black carbon emitted by diesel vehicles and
biomass burning warms the planet. Among these non-CO2 climate warming pollut-
ants, methane, halocarbons, nitrous oxide, and black carbon are popularly known as
super pollutants; they are, per ton of emissions, 25 (methane) to 2000 times (halo-
carbons and black carbon from diesel) more potent than CO2. Among these super
pollutants, methane, HFCs (one form of halocarbon), and black carbon are known
as short-lived climate pollutants because their lifetimes are much shorter than that
of CO2, which ranges from a century to thousands of years. Methane’s lifetime is
approximately 11 years, the lifetimes of HFCs range from 10 to 20 years, whereas
the lifetime of black carbon ranges from days to weeks.
To date, the climate has warmed by approximately 1 °C. The magnitudes of
warming are always referred to in terms of the temperature of the planet before
1900. The contribution of CO2 to this warming is about 50%, with non-CO2 pollut-
ants accounting for the other 50%. However, future warming is expected to be dom-
inated by CO2 increases.
Present and Future Global Warming: Climate models are able to simulate the
observed surface warming of 1 °C. This by itself is not sufficient to validate the
simulations or verify the science of climate change. However, climate models are
also able to simulate the following observed climate changes: the penetration of this
warming to ocean depths of up to a kilometer, the warming of the atmosphere up to
about 15 km, increased humidity in the atmosphere, the retreat of the arctic sea ice,
and increases in sea level, among other changes. In addition, climate models pre-
dicted these observed changes decades ago, back in the 1970s and 1980s (e.g.,
54 V. Ramanathan
Madden & Ramanathan, 1980). The warming has been predicted (Ramanathan &
Xu, 2010) to pass 1.5 °C by 2030 and exceed 2 °C by 2050.
Global Warming to Climate Change: As the atmosphere warms, humidity

increases by about 7% near the surface and 10–20% aloft. Atmospheric thermody-
namic energy increases in proportion to the increase in humidity. The increase in
energy leads to stronger storms and more intense hurricanes, and these extreme
events alter the global wind patterns. When the storms get stronger in some loca-
tions, it leads to drying and less precipitation in other locations. This redistribution
happens in such a manner that wet regions get wetter and dry regions get drier. The
dry regions are typically in the sub-tropical regions between 25N and 40N. Because
of the intensification of the water cycle of the atmosphere, global warming leads to
a substantial increase in the severity of storms, floods, droughts, fires, and heat
waves, among other extreme events.
Predictions for the future show a range of probabilities, as illustrated in Fig. 5.1.
The red and brown curves are the projections for the baseline scenarios with
unchecked emissions. The green curve is the projected warming for 2100 with the
Fig. 5.1 Projected warming for four different scenarios from preindustrial to 2100 as adapted
from Xu and Ramanathan (2017). The warming is given in terms of the probability distribution
instead of a single value because of uncertainties in climate feedbacks, which could make the
warming larger or smaller than the central value shown by the peak probability density value. The
three curves on the right side indicated by BL (for baseline) denote the projected warming in the
absence of climate policies. BL (CI-80%) represents the scenario in which the energy intensity (the
ratio of energy use to economic output) of the economy decreases by 80% compared with its value
for 2010. In BL (CI-50%), the energy intensity decreases by only 50%. These scenarios bound the
energy growth scenarios proposed by IPCC-WGIII (2014). The right extreme curve is the BL (CI-
50%) case. The carbon cycle feedback uses IPCC recommended values for the reduction in CO2
uptake by the oceans as a result of the warming, the release of CO2 by melting permafrost, and the
release of methane by wetlands
mitigation measures described in a companion chapter in this book (Chap. 25). With

unchecked emissions, the end-of-century warming can be in the range of 2.5–8 °C.
Risk Categories of Climate Change: The warming has been categorized (follow-
ing Xu and Ramanathan 2017 and the climate risk assessment IPCC reports) under
three risk categories: dangerous risk (>1.5 °C), catastrophic risk (>3 °C), and exis-
tential risk (>5 °C).
Dangerous Risk (1.5–3 °C): Based on data presented in Xu and Ramanathan
(2017), the 1.5 °C threshold will be crossed by 2030 with a 50% probability.
• The 1 °C warming witnessed as of now has already led to the following impacts:
The likelihood of extreme events (defined as 3-sigma events), including heat
waves, has increased tenfold in recent decades (WMO, 2016). Human beings are
extremely sensitive to heat stress. For example, the 2003 European heat wave led
to about 70,000 premature mortalities (Mitchell et al., 2016). Hurricanes have
become about 25% more intense (Holland & Bruyère, 2013). Dry areas world-
wide have increased from about 15% during mid-twentieth century to about 30%
by the first decade of the twenty-first century. The number of disastrous floods
have increased from less than 50 per year during the mid-twentieth century to
more than 150 during the first decade of the twenty-first century.
• With an increase of another 0.5 °C above the 1 °C warming we have already
experienced, the underlying dynamic and thermodynamic forces that linked
the 1 °C warming with weather extremes described previously will intensify by
another 50%. Warming in the range of 1.5 °C will subject half of the world’s
population every other year to regional summer mean temperatures that exceed
those of the historically hottest summers (Mueller et al., 2016).
• During the last interglacial period about 130,000 years ago, called the Eemian,
the planet was warmer than the preindustrial climate by less than 1 °C. However,
this small warming was sufficient enough to raise the sea level by about 6 m.
• During the first decade of the twenty-first century, tropical forests have become
net sources of CO2 (Baccini, 2017). If this persists and expands to other forests,
forests can become a large source of carbon pollution.
• The last, but very important, issue concerns climate justice: Numerous island
nations, including the Maldives and low-lying nations like Bangladesh, will be
facing existential threats with a sea level rise of just 1–2 m.
Catastrophic Risks (3–5 °C): With unchecked emissions, there is a 10% proba-
bility of the warming reaching catastrophic levels by 2050 and a greater than 50%
probability of reaching catastrophic levels before 2100. Catastrophic risks have
been defined by some economists as follows: The magnitude of the change is too
large and the velocity of that change is too rapid for adaptation. The first major
concern with the 3–5 °C warming is the issue of tipping points. Several studies have
concluded that 3–5 °C global warming is likely to be the threshold for tipping points
such as the collapse of the western Antarctic ice sheet, disappearance of the sea ice,
disruption of the deep-water circulation in the North Atlantic, dieback of Amazon
rainforests and boreal forests, collapse of the West African monsoon, and world
56 V. Ramanathan
forests turning into net sources (instead of sinks) of carbon dioxide, among others.
The category of “Catastrophic Risk” is also justified by the burning embers diagram
from IPCC, in which it categorized climate risks under the following five reasons
for concern (RFCs): risks to natural systems, risks of extreme weather events, dis-
tribution of impacts between regions of the world, aggregate impacts, and risks of
large-scale discontinuities. For warming in the range of 3–5 °C, all RFCs were
ranked as a high-risk category, with two of them ranked as very high. The IPCC
burning embers diagram does not extend beyond 5 °C. Warming in the range of
3–5 °C can have the following health impacts on people and ecosystems:
• Extreme heat waves with effective (combination of temperature and humidity)
temperatures greater than 55 °C (131 °F) are projected (Russo, Sillmann, &
Sterl, 2017) to be routine phenomena when global warming exceeds 4 °C.
• Exposing more than 7 billion people to deadly heat stress (Mora et al., 2017).
• Exposing 2.5 billion people to vectorborne diseases (Proestos et al., 2015).
• Subjecting approximately 20% (Urban, 2015) to 37% (Thomas et al., 2004) of
species to extinction. Climate change interacting with other established drivers
of extinction, such as habitat destruction and commercial exploitation of valu-
able species, can lead to another mass extinction involving 75% of species
(Barnosky, 2015).
• About 30–44% of the planet’s land areas would be exposed to drying (Cook,
Smerdon, Seager, et al., 2014) with warming of 3–4 °C, accompanied by severe
drought conditions over Europe, the eastern United States, southeast Asia, and
most of the Amazon region. Food security will be severely threatened.
Existential Risks (>5 °C): With unchecked emissions of climate pollution, there
is at least a 10% probability for climate change to pose existential threats to Homo
sapiens and all other species.
IPCC risk discussions, as shown in the burning embers diagram, do not extend
beyond 5 °C. When all of the risks described under the dangerous and catastrophic
risk categories are summed, it is clear that the entire planet and all of the global
population will be severely impacted. The last time the planet was warmer by
5–8 °C (as shown in Fig. 5.1) was 35 million years ago, when the CO2 concentration
was around 1000 parts per million (Pagani et al., 2011). The planet was ice free,
including over the Antarctic, with an implied sea level rise of more than 50 m. It is
the combination of multiple catastrophic changes that compelled us (Ramanathan
et al., 2017; Xu & Ramanathan, 2017 ) to conclude that warming in excess of 5 °C
will pose existential threats.
Ethics and Justice Issues: The catastrophic and existential risks raise major ethi-
cal issues. More than 50% of climate pollution is caused by the wealthiest one bil-
lion people, while the poorest three billion people emit only 5% of the climate
pollution (Dasgupta & Ramanathan, 2014; Ramanathan, PAS-PASS workshop,
2014). As described in numerous IPCC reports and other reports, the poor will suf-
fer the worst consequences of climate change. Already today, more than 20 million
people are displaced each year from weather extreme events. In addition to this
intra-generational equity issue, there is huge inter-generational equity because cli-

mate change impacts, such as the melting of glaciers and sea level rise, are irrevers-
ible for centuries or longer, affecting generations unborn.
Concluding Remarks: Common Solutions
Both air pollution and anthropogenic climate change problems have been studied
for more than a century. However, air pollution science has enjoyed dramatic policy
successes. Air pollution emissions have been reduced dramatically, by as much as
70% for some pollutants (Samet, Burke, & Goldstein, 2017) in the USA and in other
industrialized nations, by deliberate policy actions. The policy actions in the USA
were mainly motivated by human health impacts. Climate change, however, is still
awaiting enforceable and mandatory laws to mitigate emissions of greenhouse gases
and other climate pollutants.
Miraculously, there is still time to avoid the sort of catastrophic outcomes
described in this chapter. What has been overlooked is the fact that integration of the
solutions to mitigate climate pollutant emissions will also mitigate air pollution
emissions. I will give two major examples:
1. Switching from fossil fuels to renewables, such as solar and wind, and banning
biomass burning will not only eliminate carbon dioxide emissions but will also
eliminate emissions of sulfates and black carbon, as well as decrease NOx emis-
sions by more than 80%.
2. Likewise, giving renewable energy access to the poorest three billion people can
phase out the burning of solid biomass fuels and pave the way for a carbon-
neutral pathway for the poorest three billion people (or more in the future).
In a companion chapter in this book (Chap. 25), I describe the solutions recom-
mended by a group of 50 researchers from the 10 campuses of the University of
California (Ramanathan et al., 2016) and a group of 33 international experts
(Ramanathan et al., 2017).
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Part II
Air Pollution, Climate Change, and
Health: The Underlying Science
and Impacts
CHAPTER 6
Air Pollution: Adverse Effects and Disease
Burden
Jonathan M. Samet
Introduction
Summary In 2017, the scientific evidence was certain: ambient air pollution (i.e.,
contamination of outdoor air consequent to man’s activities) is a major cause of mor-
bidity (ill health) and premature mortality (early death). While the rise of ambient air
pollution is relatively recent, air pollution has probably had adverse effects on human
health throughout history. In fact, the respiratory tract, which includes the nose,
throat and lungs, has a remarkable system of defense mechanisms to protect against
inhaled particles and gases. The use of fire for heating and cooking came with expo-
sure to smoke, an exposure that persists today for the billions who use biomass fuels
for cooking and heating. The rise of cities concentrated the emissions of pollutants
from dwellings and industry and led to air pollution, which was likely affecting
health centuries ago. Continued industrialization and also electric power generation
brought new point sources of pollution into areas adjacent to where people lived and
worked. During the twentieth century, cars, trucks, and other fossil fuel–powered
vehicles became a ubiquitous pollution source in higher-income countries and cre-
ated a new type of pollution—photochemical pollution, or “smog”—which was first
recognized in the Los Angeles air basin in the 1940s. The unprecedented growth of
some urban areas to form “megacities,” such as Mexico City, São Paulo, London, and
Shanghai, has led to unrelenting air pollution from massive vehicle fleets and snarled
traffic and from polluting industries and coal-burning power plants. With population
growth and urbanization, ever more megacities are anticipated; the current total of
cities with a population over 10 million has now reached 31.
This chapter provides an overview of the current state of knowledge concerning
the adverse health effects of ambient air pollution and the associated burden of
premature death. It draws on various authoritative reviews, particularly those car-
J. M. Samet (*)
Colorado School of Public Health, University of Colorado, Aurora, CO, USA

64 J. M. Samet
ried out by the US Environmental Protection Agency in support of revisions to the

National Ambient Air Quality Standards (NAAQS), which apply to the major out-
door pollutants. Emphasis is given to airborne particulate matter, a ubiquitous type
of ambient pollution that derives from multiple sources; the most widely used indi-
cators are PM10 and PM2.5 (particulate matter less than 10 and 2.5 μm in aerody-
namic diameter, respectively) and to ozone. The chapter also addresses the burden
of disease attributable to air pollution, documenting the target for air quality
improvement and the global gains in public health that can be made.
While the emphasis here is on ambient air pollution that has adverse effects at
local and regional levels, climate change also comes from air pollution with green-
house gases. The connections are direct; the same combustion processes that release
particles and toxic gases also generate carbon dioxide.
The Health Effects of Air Pollution
Overview Ambient air pollution comprises a complex and dynamic mixture of gas-
eous and particulate air pollutants. The array of health effects linked to ambient air
pollution is broad and includes increased risk for respiratory infections, exacerbation
of asthma, and chronic obstructive pulmonary disease (COPD—a disease involving
destruction of the lung structure) and cardiac (heart) events, contributions to develop-
ment of major chronic diseases (coronary heart disease, COPD, and cancer), and
impaired lung growth and respiratory symptoms during childhood. Additional
adverse health outcomes are under investigation: autism and other neurodevelop-
mental disorders, adverse reproductive outcomes, and more rapid “brain aging,” for
example. There are several general mechanisms underlying these health effects, par-
ticularly oxidant stress, an excess of reactive molecules, and a heightened inflamma-
tory state, given the oxidative nature of ambient air pollution. The increased risk for
cancer causally linked to air pollution likely comes primarily from the presence of
specific carcinogens (i.e., cancer-causing agents) in ambient air pollution (e.g., poly-
cyclic aromatic hydrocarbons, and inflammation); particles collected in outdoor air
are mutagenic, which means that they can damage DNA (IARC, 2015). Table 6.1
provides a listing of major pollutants and associated health effects, as well as some
of the current standards and guidelines for controlling their concentrations.
While the problem of air pollution was noted centuries ago, the contemporary era of
research on air pollution and health and evidence-driven air quality regulation and
management began in the mid-twentieth century following a series of episodes of
very high pollution with disastrous health consequences (Brimblecombe, 1987). The
most dramatic was the London Fog of 1952, which caused thousands of excess
deaths and prompted some of the first epidemiological studies of the health effects of
air pollution (Fig. 6.1) (Bell & Davis, 2001). In the United States, recognition of the
public health dimensions of air pollution also began in the mid-twentieth century,
driven by the rising problem of smog in southern California, episodes of visibly high
pollution in major cities, and the 1948 air pollution episode in Donora, Pennsylvania,
which caused 20 excess deaths and thousands of illnesses in one small town.
Table 6.1 Major ambient air pollutions: sources, health effects, and regulationsa
Source types and major sources Health effects Regulations and guidelines
Lead Primary Accumulates in organs and tissues. U.S. NAAQS:
Anthropogenic: leaded fuel (phased out in Learning disabilities, cancer, damage Quarterly average: 1.5 μg/m3
some locations such as the United States), to the nervous system WHO Guidelines:
lead batteries, metal processing Annual: 0.50 μg/m3
Sulfur dioxide Primary Lung impairment, respiratory U.S. NAAQS:
Anthropogenic: combustion of fossil fuel symptoms. Precursor to Annual arithmetic mean: 0.03 ppm (80 μg/m3)
(power plants), industrial boilers, PM. Contributes to acid precipitation
household coal use, oil refineries
Biogenic: decomposition of organic matter, 24-h average: 0.14 ppm (365 μg/m3)
sea spray, volcanic eruptions WHO Guidelines:
10-min average: 500 μg/m3
Annual: 20 μg/m3
Carbon Primary Interferes with delivery of oxygen. U.S. NAAQS:
monoxide Anthropogenic: combustion of fossil fuels Fatigue, headache, neurological 1-h average: 35 ppm (40 mg/m3)
6 Air Pollution: Adverse Effects and Disease Burden
(motor vehicles, boilers, furnaces) damage, dizziness 8-h average: 9 ppm (10 mg/m3)
WHO Guidelines:
15-min average: 100 mg/m3
30-min average: 60 mg/m3
1-h average: 30 mg/m3
(continued)
65
Table 6.1 (continued)
66
Source types and major sources Health effects Regulations and guidelines
Particulate Primary and secondary Respiratory symptoms, decline in lung U.S. NAAQS:
matterb Anthropogenic: burning of fossil fuel, function, exacerbation of respiratory PM10
wood burning, natural sources (e.g., and cardiovascular disease (e.g.,
pollen), conversion of precursors (NOx, asthma), mortality
SOx, VOCs)
Biogenic: dust storms, forest fires, dirt 24-h average 150 μg/m3
roads PM2.5
Annual arithmetic mean: 15 μg/m3
24-h average: 35 μg/m3
WHO Guidelines:
PM10
Annual: 20 μg/m3
PM2.5:
Annual: 10 μg/m3
Nitrogen oxides Primary and secondary Decreased lung function, increased U.S. NAAQS for NO2:
respiratory infection
Anthropogenic: fossil fuel combustion Precursor to ozone. Contributes to PM Annual arithmetic mean: 0.053 ppm (100 μg/m3)
(vehicles, electric utilities, industry), and acid precipitation
kerosene heaters
Biogenic: biological processes in soil, Related to compliance with NAAQS for ozone.
lightning WHO guidelines for NO2:
Annual: 40 μg/m3
J. M. Samet
Tropospheric Secondary Decreased lung function, increased U.S. NAAQS:
ozone Formed through chemical reactions of respiratory symptoms, eye irritation, 1-h average: 0.12 ppm (235 μg/m3). Applies in
anthropogenic and biogenic precursors bronchoconstriction limited areas.
(VOCs and NOx) in the presence of 8-h average: 0.075 ppm (147 μg/m3)
sunlight WHO guidelines:
“Toxic” Primary and secondary Cancer, reproductive effects, EPA rules on emissions for more than 80 industrial
pollutants neurological damage, respiratory source categories (e.g., dry cleaners, oil refineries,
(“Hazardous” effects chemical plants)
pollutants) (e.g., Anthropogenic: industrial processes, EPA and state rules on vehicle emissions
asbestos, solvents, paint thinners, fuel
mercury, dioxin,
some VOCs)
Volatile organic Primary and secondary Range of effects, depending on the EPA limits on emissions
compounds compound.
(e.g., benzene, Anthropogenic: solvents, glues, smoking, Irritation of respiratory tract, nausea, EPA toxic air pollutant rules
terpenes, fuel combustion cancer
6 Air Pollution: Adverse Effects and Disease Burden
toluene) Biogenic: vegetation, forest fires Precursor to ozone. Contributes to PM. Related to compliance with NAAQS for ozone.
Biological Primary Allergic reactions, respiratory
pollutants (e.g., Biogenic: trees, grasses, ragweed, animals, symptoms, fatigue, asthma
pollen, mold, debris
mildew) Anthropogenic systems, such as central air
conditioning, can create conditions that
encourage production of biological
pollutants.
Source: Bell ML, Samet JM. Air Pollution. In Frumkin H. (ed) Environmental health: From Global to Local. 2010;387-415. Figure 12.1
a
This table lists only a sample of the sources and health effects associated with each pollutant. Additionally, health effects may be the result of characteristics
of the pollutant mixture rather than the independent effects of a pollutant. Additional legal requirements often apply, such as state regulations
b
Sources and effects of PM can differ by size
67
68 J. M. Samet
Fig. 6.1 Approximate weekly mortality and SO2 concentrations for Greater London, 1952–1953
Multiple investigational approaches have been used to characterize the health

effects of ambient air pollution. Initially, the dramatic pollution episodes made clear
that high levels of air pollution caused excess mortality, particularly in elderly peo-
ple with chronic diseases and in infants and young children. As air pollution levels
declined with regulation, increasing emphasis was placed on understanding the
quantitative risks of air pollution so that air quality standards could be set that would
be protective of public health. In other words, researchers did studies to understand
by how much risk changes as air pollution increases or decreases. Epidemiological
studies (i.e., research based in populations) were critical for that purpose. Cohort or
longitudinal studies were most informative. Such studies involved following partici-
pants over time, estimating pollution exposures, and tracking health events; analy-
ses focused on quantifying the risks associated with air pollution exposure during
follow-up. For example, the Children’s Health Study in Southern California tracked
lung growth and respiratory health in school children from communities having a
range of pollution concentrations (Gauderman et al., 2015). Now in progress for two
decades, the study has shown that higher levels of air pollution slow lung growth
and that reduction of pollution enhances it.
These epidemiological approaches are complemented by toxicological studies
that provide insights into the mechanisms by which air pollution causes adverse
health effects. Such evidence is critical in reaching causal conclusions on the
adverse health effects of air pollution. In the past, toxicological studies often
involved exposure of animals to a single pollutant, such as ozone, to isolate the pol-
lutant’s effect from those of other pollutants present in the air pollution mixture. For
studying some pollutants, human volunteers have inhaled the pollutants in an expo-
sure chamber over a short interval and their responses closely monitored.
Additionally, pollutants are also studied in cell systems; these systems are likely to
gain increasing prominence as new, sophisticated systems probe gene expression of
different kinds of cells following exposure.
There are a number of national groups that periodically assess the evidence on
adverse effects of air pollution and provide guidance to the setting of standards and
guidelines. In the United States, the Environmental Protection Agency carries out
6 Air Pollution: Adverse Effects and Disease Burden 69
reviews of the evidence as the basis for renewal of major air quality standards (the
National Ambient Air Quality Standards or NAAQS) on a 5-year cycle. Reviews are
conducted by the United Kingdom, the European Commission and other nations.
The World Health Organization releases air quality guidelines, which are currently
being updated. In reviewing the evidence, a judgment that the findings are strong
enough to infer a causal relationship has great weight for regulation. The health
risks associated with major air pollutants are reviewed below.
While air pollution research and regulation generally focuses on specific pollut-
ants, air pollution outdoors is a complex mixture. Effects attributed to a single pol-
lutant, particularly when studied in the “real world” context, may reflect the toxicity
of the mixture as indexed by a particular pollutant. Ambient particulate matter (PM),
for example, comes from myriad sources and is emitted as a primary pollutant from
combustion and other sources; it is also formed through chemical transformations
of gaseous pollutants, such as the formation of particulate nitrates from gaseous
nitrogen oxides. The mixture of pollutants formed from vehicle emissions, gener-
ally referred to as traffic-related air pollution, may have specific toxicity beyond that
of well-studied individual components.
Particulate Matter The literature on the health effects of particles is enormous,
comprising many epidemiological and toxicological studies (U.S. Environmental
Protection Agency, 2009). With regard to ambient air pollution, the risks of particu-
late matter have assumed great prominence because particles are widely monitored
and used as the principal indicator for estimating the burden of morbidity and pre-
mature mortality attributable to air pollution. Particles are a robust indicator of
ambient air pollution because of their myriad sources and the contributions of sulfur
and nitrogen oxides and organic compounds to secondary particle formation.
Particles in outdoor air have numerous natural and man-made sources. The man-
made sources are diverse and include power plants, industry, and motor vehicles,
including diesel-powered vehicles that emit particles in the size range that pene-
trates into the lung. In areas where biomass fuels are used, the contributions of
indoor combustion to outdoor air pollution may be substantial.
Particles in outdoor air span a wide range of sizes (Fig. 6.2) and are highly
diverse in composition and physical characteristics, including size as indicated by
aerodynamic diameter. Thus, PM2.5 includes those particles less than 2.5 μm in aero-
dynamic diameter, a size band that contains most man-made particles in outdoor air
and also the particles of a size that can reach the smaller airways and air sacs of the
lungs. The very small ultrafine particles, which include freshly generated combus-
tion particles, are another set of particles of concern. Much research has been done
on characteristics of particles that determine toxicity. Hypotheses on determinants
of particle toxicity have focused on acidity, transition metals such as iron that can
cause damaging injury, organic compounds, bioaerosols, and size; as a further com-
plication, different characteristics could be relevant to different health outcomes.
However, in spite of extensive toxicological and epidemiological research, the evi-
dence is not yet sufficiently definitive to link particular characteristics to toxicity.
Making such linkages would be helpful for targeting control approaches.
70 J. M. Samet
Fig. 6.2 Changes in economic indicators, pollutant emissions, and concentrations of criteria pol-
lutants over time. Note: Shown are changes in criteria pollutant concentrations during 1990-2015
(Panel A) and changes in economic growth indicators and emissions during 1970-2015 (Panel B).
(Source: Drawn from EPA data at https://gispub.epa.gov/air/trendsreport/2016/)
There has been extensive epidemiological and toxicological investigation of the

effects of particles on health since the air pollution disasters of mid-century. The
toxicological studies have used approaches including exposing volunteers to gener-
ated particles or concentrated air particles, animal exposures, and diverse in vitro
assays. This extensive body of evidence shows that particles are injurious and indi-
cates mechanisms by which particles could cause adverse effects on the respiratory
and cardiovascular systems. The epidemiological studies have grown in size and in
the sophistication of their methodology. Recent studies involve large, national-level
populations, such as all people in the United States who are 65 years and older, and
estimation of exposures at all household addresses using models that incorporate
available monitoring data, satellite information, and land-use data, such as on road-
ways and manufacturing. Table 6.2 lists the findings of the most recent comprehen-
sive review of the evidence on airborne particles (the Integrated Science Assessment)
by the US Environmental Protection Agency. Both short-term and long-term adverse
effects were found to be caused by particulate matter. The most recent epidemio-
logical studies continue to find associations of PM2.5 with increased risk for mortal-
ity, even at contemporary concentrations in the United States. In a recent study
utilizing the Medicare data for persons 65 years of age and older, over 60 million
people, Di et al. showed increased mortality at annual averages below 12 μg/m, the
current annual standard in the United States3 (Di et al., 2017).
One analysis has suggested that reductions in particulate air pollution during the
1980s and 1990s have led to measurable improvements in life expectancy in the
United States. The researchers estimated that for each 10 μg/m3 reduction in air pol-
lution over this period, the average gain in life expectancy was 0.61 years (about
7.3 months). The authors concluded that as much as 15% of the total life expectancy
increase seen during this time in the United States was attributable to the air pollu-
tion reductions.
This strong evidence on the adverse health effects of particulate matter has led to
ever tighter ambient air quality standards (Table 6.1). Nonetheless, adverse health
effects are still observed and much of the world’s population is exposed to high
concentrations at which adverse effects are certain.
Ozone Ozone is a specific gas that has been studied for its toxicity using toxicologi-
cal approaches. It is also used as an indicator of photochemical pollution, or “smog,”
which is the complex oxidant mixture produced by the action of sunlight on hydro-
carbons and nitrogen oxides. Smog has become a worldwide problem as vehicle
fleets have grown. The problem of tropospheric (ground-level) ozone pollution is
distinct from the problem of depletion of the strato-pheric (high-level) ozone layer.
Ozone, a highly reactive molecule, has been extensively investigated using toxi-
cological approaches that have included exposures of human volunteers and short-
and long-term exposures of animals (U.S. EPA, 2013). The human studies have
involved exposures of volunteers, generally young and healthy, to concentrations of
ozone found in urban areas in the United States and elsewhere. Collectively, the
studies show that exposures of up to 6–8 h with intermittent exercise result in tem-
porary drops in lung function and that some individuals have greater susceptibility
72 J. M. Samet
Table 6.2 Summary of causal determinations for airborne particles by exposure duration and
health outcome
Size fraction Exposure Outcome Causality determination
PM2.5 Short-term Cardiovascular effects Causal
Respiratory effects Likely to be causal
Central nervous system Inadequate
Long-term Mortality Causal
Cardiovascular effects Causal
Respiratory effects Likely to be causal
Mortality Causal
Reproductive and developmental Suggestive
Cancer, mutagenicity, genotoxicity Suggestive
PM10-2.5 Short-term Cardiovascular effects Suggestive
Respiratory effects Suggestive
Mortality Suggestive
Long-term Cardiovascular effects Inadequate
Respiratory effects Inadequate
Mortality Inadequate
Reproductive and developmental Inadequate
Cancer, mutagenicity, genotoxicity Inadequate
Ultrafine Short-term Cardiovascular effects Suggestive
particles Respiratory effects Suggestive
Long-term Cardiovascular effects Inadequate
Respiratory effects Inadequate
Reproductive and developmental Inadequate
Cancer, mutagenicity, genotoxicity Inadequate
Source: U.S. EPA (2009). Table 2-6
to ozone. While the effects are transient, they are of sufficient magnitude in some
people (loss of around 10% of function) to be considered adverse. In some of the
studies, the lungs have been sampled and evidence of inflammation was found by
measuring concentrations of molecules that reflect the tissue’s response. In experi-
mental animals, sustained low-level exposure damages the small airways and leads
to early changes of COPD; thus, there is concern about permanent structural altera-
tion in ozone-exposed populations. In human studies, asthmatics have not been
shown to have increased susceptibility to ozone compared with non-asthmatics.
Epidemiological studies provide coherent evidence on the short-term effects of
ozone on respiratory health. There is also evidence from daily time-series studies
(studies examining day-to-day variations in death counts in relationship to varia-
tions in pollution levels) that ozone increases the risk for mortality. There is incon-
sistent evidence for cardiovascular effects and a just-completed exposure study of
older persons with cardiovascular disease did not find adverse effects.
Reflecting the evidence on short-term effects on lung function, standards for

ozone concentrations are directed at brief time spans (Table 6.1). Given the range of
susceptibility of the population, it is likely that feasibly achieved standards will not
protect the full population from adverse respiratory effects.
Nitrogen Oxides Gaseous nitrogen oxides are produced by combustion processes
and also contribute to the formation of aerosols. Nitrogen dioxide (NO2), an oxidant
gas, is the indicator that is generally monitored. The principal source of NO2 in
outdoor air is motor vehicle emissions, and NO2 is considered to be a useful indica-
tor of traffic-related air pollution in urban environments. Power plants and industrial
sources may also contribute. The health effects of NO2 emitted into outdoor air
probably come mainly from the formation of secondary pollutants, including ozone
and particles. NO2, along with hydrocarbons, is an essential precursor of ozone and
the nitrogen oxides also form acidic nitrate particles.
Nitrogen dioxide itself has been studied in animal models and in clinical studies.
It can reach the small airways and air sacs of the lung because of its low solubility.
The toxicological evidence at high exposures has raised concern that NO2 exposure
can impair lung defenses against infectious agents such as viruses and cause airway
inflammation, thereby increasing the risk for respiratory infections. Supporting epi-
demiological research is lacking and population studies directed at NOs are compli-
cated by its role in the formation of ozone and its presence in the complex mixture of
traffic-related pollutants. Human exposure studies have been performed to investigate
the immediate effects of NO2 on persons with asthma. Nitrogen dioxide could plau-
sibly increase airway responsiveness (the extent to which the airways constrict when
irritated) by causing airway inflammation. The findings of the exposure studies have
been inconsistent, but suggest that some people with asthma may be susceptible.
Carbon Monoxide Carbon monoxide (CO) is an invisible gas formed by incom-
plete combustion. It is a prominent indoor pollutant with sources including biomass
fuel combustion and space heating with fossil fuels. At high levels indoors, fatal CO
poisoning may result. Outdoors, vehicle exhaust is the major source and concentra-
tions are highly variable, reflecting vehicle density and traffic patterns. Urban loca-
tions with high traffic density (“hot spots”) tend to have the highest concentrations.
The toxicity of CO comes from its tight binding to hemoglobin, which carries oxy-
gen in the blood, and the resulting reduction of oxygen delivery to tissues. Exposures
to CO can be assessed by using the level of carboxyhemoglobin as a marker of
exposure or by measuring the concentration of CO in the breath.
Because of the reduction of oxygen delivery, persons with cardiovascular disease
are considered to be at greatest risk from CO exposure; research has focused on CO
and adverse effects in this susceptible group. The research has used an approach
referred to as a “clinical study”; volunteers with cardiovascular disease are exposed
to levels of CO of interest and clinical measurements made, such as by taking an
electrocardiogram. The evidence from such studies indicates that CO exposure
leads to earlier evidence of myocardial ischemia (inadequate oxygenation of the
heart) following exposure compared with unexposed controls. There are other
potential susceptible groups: fetuses and persons with COPD may also be harmed
74 J. M. Samet
by CO, and normal persons may have reduced oxygen uptake during exercise at low
levels of CO exposure.
The exposure studies have provided robust evidence for standards for CO, which
are based on brief time windows, reflective of the handling of CO in the body. In
higher-income countries, outdoor levels of CO have fallen greatly over recent
decades as controls have greatly reduced emissions (see Fig. 6.3). Nonetheless, CO
may be a concern in some high-traffic locations. Less is known about CO exposure
in middle- and low-income countries, where ambient CO may be added to indoor
exposure from biomass fuel combustion.
Sulfur Oxides Sulfur oxides are generated by combustion of fuels containing sul-
fur, such as coal, crude petroleum, and diesel, and by smelting operations. The
water-soluble gas, sulfur dioxide or SO2, is the indicator that is generally monitored.
However, other sulfur oxides are emitted and the sulfur oxides undergo transforma-
tion to form particulate sulphate compounds. Scientific research has been directed
primarily at SO2, although epidemiological studies provide information on sulfur
oxide exposure more generally. Sulfur dioxide is a reactive gas that is effectively
scrubbed or cleaned from inhaled air in the upper airway. With exercise and a switch
to oral breathing as ventilation increases, the inhaled dose of SO2 increases and
more reaches the lung.
Much of the evidence that has driven regulation comes from clinical studies that
involve exposure of people with asthma and that show adverse effects without expo-
sures to other pollutants. Asthmatics are particularly sensitive, with some asthmat-
ics having more severe health responses at a particular concentration than others
with asthma. With exercise and hyperventilation, some people with asthma respond
with increased resistance of the lung to airflow with an associated drop in lung func-
Frequency, % particles by mass
Ultrafine Fine Coarse Supercoarse

7
6
5
4
3
2
1
0.002 0.01 0.1 1.0 10 100 1000

Particle diameter (dpa), mm
Total Suspended
Particulate (TSP)
PM10
PM2.5
Fig. 6.3 Ambient particulate matter size distribution. (Source: Adapted from the EPA)
tion and with respiratory symptoms. Such effects have been demonstrated at con-
centrations that might be reached in the United States in high-exposure situations
and that may be common in some heavily industrialized countries. Epidemiological
studies from Hong Kong examined the consequences of a major and rapid reduction
in sulfur content in fuels. The investigators found an associated substantial reduc-
tion in health effects (childhood respiratory disease and all age mortality outcomes).
Lead Although lead in gasoline is now phased out in almost all nations, exposure
continues from industrial activities, such as smelting, and sometimes results in dan-
gerous exposures for children. Exposure to lead may occur through inhalation and
also ingestion in food and water, routes of exposure that have become the most
important in high-income countries. A substantial body of epidemiological evi-
dence links lead exposure of children to adverse neurodevelopmental effects, such
as lowering the level of intelligence; as a result of that evidence, recommendations
as to the acceptable level of lead for children have been lowered progressively. Lead
has also been linked to higher blood pressure and cardiovascular disease and to low
bone mineral density and osteoporosis.
The Disease Burden from Ambient Air Pollution
Given these adverse health effects and ubiquitous pollution of outdoor air, estimates
of the burden of disease caused by air pollution are needed as a basis for priority
setting and air quality management. Such estimates of disease burden can also prove
useful for motivating action, as they have done recently in China. The conceptual
basis for estimating disease burden draws on the conceptual framework of attribut-
able risk, originally proposed in the early 1950s for smoking and lung cancer by
Levin (Levin, 1953). He proposed a statistic, the population attributable risk (PAR),
which incorporates the prevalence of the exposure of concern (P) and the relative
risk (RR) for disease associated with that exposure, as follows: PAR = (Px[RR − 1])/
(1 + Px[RR − 1]). Thus, the PAR rises as either P or RR increases; in other words,
the burden rises as more people are exposed or the risk is increased. For lung cancer,
for example, in a population with 40% smokers and a lung cancer RR of 20, the
PAR is 0.88, interpreted as 88% of the cases resulting from smoking. The PAR is
interpreted based on comparison to a comparison group involving no or lower expo-
sure; for smoking, for example, the comparison is a hypothetical world in which
smoking never existed.
For air pollution, estimates of the burden of attributable disease have been made
by the World Health Organization and the Institute for Health Metrics and Evaluation
(IHME) in the United States, which carries out the Global Burden of Diseases,
Injuries, and Risk Factors Study (Cohen et al., 2017). A detailed analysis of the
global burden of disease attributable to ambient air pollution was recently reported
for the 25 years from 1990 to 2015. With regard to the exposure prevalence (P),
PM2.5 and ozone concentrations are estimated for smaller level spatial grids that
capture variation in urban areas and then aggregated to provide national mean expo-
76 J. M. Samet
sures. The IHME estimates for PM2.5 include ischemic heart disease (IHD), cerebro-
vascular disease, lung cancer, chronic obstructive pulmonary disease (COPD), and
lower respiratory infections (LRI), while only COPD is considered for ozone. The
RRs for these diseases come from complex analyses of epidemiological data. The
counterfactual values for burden estimation are derived from the lowest values con-
sidered in the epidemiological studies.
The latest estimates confirm that outdoor air pollution is a leading cause of pre-
mature mortality around the world, ranking at the fourth position in 1990 and the
fifth in 2015. The total of deaths attributed to PM2.5 globally in 2015 is 4.2 million
distributed by cause as follows: IHD—1.52 million, cerebrovascular dis-
ease—898,000, lung cancer—283,000, COPD—864,000, and LRI—675,000.
There is substantial geographic variation globally (Fig. 6.4) with China and India
together accounting for more than half of the attributable burden of premature mor-
tality. From 1990 to 2015, estimates have increased in some countries (e.g., India
and China), as the population has grown and aged, and air pollution levels have
risen. For ozone, the global mortality estimate is much smaller at 254,000.
From a policy perspective, these estimates offer a strong rationale for air quality
control and are cautionary in their implications. The estimates of exposure globally
describe a stratified target (Fig. 6.4): the high-income countries that have lowered
air pollution concentrations over the last half century and the numerous low- and
middle-income countries where air pollution has worsened with industrialization
and vehicle numbers have increased rapidly. Additionally, many of these countries
Fig. 6.4 Global and regional distributions of population as a function of annual average ambient
PM2.5 concentration for the 10 most populous countries in 2013. Note: Plotted data reflect local
smoothing of bin-width normalized distributions computed over 400 logarithmically spaced bins;
equally sized plotted areas would reflect equal populations. Dashed vertical lines indicate World
Health Organization Interim Targets (IT) and the Air Quality Guideline (AQG). (Source: Brauer,
M., et al. (2016). Ambient air pollution exposure estimation for the global burden of disease 2013.
Environmental Science & Technology, 50(1), 79–88. Figure 3)
still face the added challenge of household air pollution, also a leading cause of
premature mortality.
Research Needs
There is a robust body of evidence on the health effects of ambient air pollution,
which has both acute and chronic consequences. Given the underlying mechanisms
of injury and commonalities among pollution sources, the collective evidence
should have general applicability to people around the world. Nonetheless, many
nations still lack basic monitoring and air quality management, even as pollution
levels have risen in recent decades. In motivating action, locally generated data are
likely to be more powerful than the external evidence, particularly if from high-
income countries. At the least, monitoring data are needed for PM2.5 and other pol-
lutants if relevant to a particular place. Local research could use cross-sectional
epidemiological designs, for example, of the respiratory health of school children,
and time-series studies of morbidity (e.g., hospitalization counts) and mortality. The
Health Effects Institute in the United States has supported time-series studies of air
pollution in multiple Asian countries through its Public Health and Air Pollution in
Asia (PAPA) Project (Public Health and Air pollution in Asia (PAPA), 2010). The
Global Burden of Disease estimates provide a valuable starting point for priority
setting around ambient air pollution as a public health issue. The Health Effects
Institute has made this information available in a useful form through its State of
Global Air/2019 (https://www.stateofglobalair.org/).
Summary and Conclusions
Ambient air pollution is a well-documented threat to global health. Through man’s

expanding use of fossil fuels for manufacturing, vehicles, and power generation, the
numbers of people exposed to risky levels of air pollution has increased progres-
sively; some are exposed at levels historically associated with evident excess mor-
tality. Ambient air pollution now affects large swathes of the world, as contaminated
air crosses national boundaries and moves globally. Of course, greenhouse gases
represent another form of global pollution. The evidence is sufficiently certain and
the burden of disease sufficiently large to motivate action at national and global
levels. Evidence-driven regulations have had substantial impact on air quality in the
United States and elsewhere, driving down levels of the most prominent pollutants
(Fig. 6.3). Unfortunately, in many low- and middle-income countries, outdoor air
pollution is a rising problem consequent to population growth, industrialization, and
increasing numbers of vehicles—and, in too many countries, insufficient attention
to air quality management and regulation. Control of greenhouse gases has the co-
benefit of reducing ambient air pollution.
78 J. M. Samet
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ncea/isa/recordisplay.cfm?deid=247492
CHAPTER 7
Air Pollution, Oxidative Stress, and Public
Health in the Anthropocene
Ulrich Pöschl
Summary Air pollution severely affects air quality, climate, and public health in
the Anthropocene, which is the present era of globally pervasive anthropogenic
influence on planet Earth. Thus, we need to understand how humanity can best deal
with the sources and effects of air pollutants in relation to economic development,
human welfare, and environmental preservation. Recent advances in scientific
research provide deep insights into the underlying physical, chemical, and biologi-
cal processes that link air pollution with health effects and reveal the relative impor-
tance of different pollutants and sources, including natural and anthropogenic
contributions. This knowledge enables the development of efficient strategies and
policies to mitigate and counteract the adverse effects of air pollution on the Earth
system, climate, and human health (“planetary health”). Building on open access to
scholarly publications and data, a global commons of scholarly knowledge in the
sciences and humanities will help to augment, communicate, and utilize the scien-
tific understanding. Moreover, public peer review, interactive discussion, and docu-
mentation of the scientific discourse on the internet can serve as examples and
blueprints for rational and transparent approaches to resolving complex questions
and issues (“epistemic web”). With regard to the development, societal communica-
tion, and political implementation of appropriate policies for air quality manage-
ment, it seems worthwhile to emphasize that climate and health effects are two
facets of global environmental change that can be and need to be handled together.
The Anthropocene notion may help humanity to recognize both rationally and emo-
tionally: We are shaping our planet and environment, so let us get it right.
U. Pöschl (*)
Multiphase Chemistry Department, Max Planck Institute for Chemistry, Mainz, Germany

80 U. Pöschl
Background
Anthropogenic air pollution leads to a massive increase of atmospheric aerosol and

oxidant concentrations on local, regional, and global scales. For example, the aver-
age mixing ratios of ozone in continental background air have increased by factors
of ~2−4 from around 10−20 ppb at the beginning of the nineteenth century to
30−40 ppb in the twenty-first century, and the concentrations of fine particulate
matter in polluted urban air are typically a factor of ~10 higher than in pristine air
of remote continental and marine regions (∼10−100 μg m−3 vs. ~1−10 μg m−3). The
strong increase of these and other air pollutants is a characteristic feature of global
environmental change in the Anthropocene, which is the present era of globally
pervasive anthropogenic influence on planet Earth, including the atmosphere, bio-
sphere, land, and oceans (Crutzen, 2002; Foley, Gronenborn, Andreae, et al., 2013;
Pöschl & Shiraiwa, 2015; Seinfeld & Pandis, 2016; Waters et al., 2016 and refer-
ences therein).
Figure 7.1a illustrates the cycling and effects of gas molecules and aerosol par-
ticles exchanged between the atmosphere and the Earth’s surface, including the bio-
sphere, hydrosphere, and pedosphere/lithosphere (Pöschl, 2005; Pöschl & Shiraiwa,
2015). It involves primary emission from natural and anthropogenic sources as well
as secondary formation via oxidation of precursors in the atmosphere. In the atmo-
sphere, gases and aerosols undergo chemical and physical transformation (“aging”),
which includes the interaction with solar radiation and atmospheric oxidants as well
as cloud droplets and ice crystals (cloud processing). Besides mineral dust, sea
spray, and combustion- and traffic-related particles, atmospheric aerosol also con-
tains biological particles such as pollen, fungal spores, bacteria, and viruses, which
are important for the functioning of ecosystems as well as the spread of animal,
plant, and human diseases (Fröhlich-Nowoisky et al., 2016; Rodriguez-Caballero
et al., 2018). The atmospheric cycling of gases, aerosols, clouds, and precipitation
is essential for the evolution, current state, and future development of the atmo-
sphere and climate as well as the biosphere and public health or “planetary health.”
Multiphase chemical reactions, transport, and transformations between gaseous,
liquid, and solid matter are key to understanding the Earth system and climate as
well as life and health on molecular and global levels, bridging a wide range of
spatial and temporal scales from below nanometers to thousands of kilometers and
from less than nanoseconds to years and millennia (Fig. 7.1b). From a chemical
perspective, life and the metabolism of most living organisms can be regarded as
multiphase processes involving gases such as oxygen and carbon dioxide; liquids
such as water, blood, lymph, and plant sap; and solid or semisolid substances such
as bone, tissue, skin, wood, and cellular membranes. On global scales, the biogeo-
chemical cycling of chemical compounds and elements, which can be regarded as
the metabolism of planet Earth, also involves chemical reactions, mass transport,
and phase transitions within and across the atmosphere, biosphere, hydrosphere,
and pedosphere/lithosphere (Pöschl & Shiraiwa, 2015).
7 Air Pollution, Oxidative Stress, and Public Health in the Anthropocene 81
Earth & Climate Life & Health
kilometers ↔ nanometers
Atmosphere Gas
× 1012
Hydro- Bio- Semi-

sphere sphere Liquid
Solid
Geo/Litho- Solid
sphere
× 1018
years ↔ nanoseconds
regional & global fluxes molecular & cellular interactions
air pollution, climate change, oxidative stress, inflammation,

global warming … fever …
Fig. 7.1 (a) Atmospheric cycling of gases and particles, including natural constituents and anthro-
pogenic air pollutants that undergo physical, chemical, and biological interactions. (b) Multiphase
processes between gaseous, liquid, and solid substances influence the Earth system and climate as
well as life and public health from molecular and cellular to regional and global scales (adapted
from Pöschl & Shiraiwa, 2015)
82 U. Pöschl
Through biogeochemical and metabolic processes, air pollutants such as particu-

late matter, ozone, and nitrogen oxides can severely affect air quality, climate, and
public health. They influence the regional and global distribution of solar radiation,
energy, and water; and they enhance mortality, promote cardiovascular, respiratory
and allergic diseases, and decrease agricultural crop yields (Pöschl & Shiraiwa,
2015; Shiraiwa, Li, & Tsimpidi, et al., 2017; West et al., 2016; and references
therein). Globally, the annual number of premature deaths attributable to ambient
air pollution are estimated to exceed 4 million per year, corresponding to over 100
million of disability-adjusted life-years (DALYs) lost every year (Cohen et al.,
2017; Landrigan, Fuller, Acosta, et al., 2017; Lelieveld & Pöschl, 2017; Lelieveld,
Evans, Fnais, Giannadaki, & Pozzer, 2015; Lelieveld, Haynes, & Pozzer, 2018;
Stanaway et al. 2018; and references therein). Recent studies suggest that the mor-
tality rates attributable to air pollution are even higher (up to ~9 million per year;
Burnett et al., 2018; Lelieveld et al., 2019). Thus, we need to understand how human
activities can create a hazardous atmosphere affecting the health of people and
planet Earth, and how humanity can best deal with the sources and effects of air
pollution in relation to economic development, human welfare, and environmental
preservation in the Anthropocene.
Reactive Oxygen and Nitrogen Species
Reactive oxygen and nitrogen species (ROS/RNS) are central to both atmospheric
and physiological chemistry, and their coupling through human airways and epithe-
lia is illustrated in Fig. 7.2a. These chemical species include highly reactive free
radicals such as hydroxyl radicals (OH) and nitrate radicals (NO3) as well as more
stable compounds such as hydrogen peroxide (H2O2) and nitrous acid (HONO).
They play a central role in the adverse health effects of air pollution and are pro-
duced in a wide range of atmospheric and physiological processes (Halliwell &
Gutteridge, 2015; Pöschl & Shiraiwa, 2015; Shiraiwa, Li, Tsimpidi, et al., 2017;
Shiraiwa, Ueda, Pozzer, et al., 2017; Sies et al., 2017; Su et al., 2011; Tong et al.,
2017). In the atmosphere, ROS/RNS are generated via photochemical and multi-
phase reactions involving atmospheric oxidants, aerosols, and clouds. Ozone and
related ROS/RNS are among the most noxious components of summer smog, and
they are also involved in the secondary formation of air particulate matter by oxida-
tion and condensation of gaseous precursors in the atmosphere (e.g., secondary
organic aerosols and sulfate; Cheng et al., 2016; Hallquist et al., 2009). On the other
hand, ROS/RNS are crucial for the oxidative self-cleaning of the atmosphere by
increasing the water solubility of air pollutants and their removal by precipitation
(“washout” or wet deposition). For example, hydroxyl radicals convert nitrogen
dioxide into highly soluble nitric acid, which is efficiently absorbed by rain and
snow. In fact, hydroxyl radicals are such strong oxidants that they react with and
facilitate the removal of most air pollutants and are thus called the “detergent” of the
atmosphere (Pöschl & Shiraiwa, 2015; Seinfeld & Pandis, 2016).
Fig. 7.2 (a) Sources, interactions, and effects of reactive oxygen and nitrogen species (ROS/RNS)
at the interface of atmospheric and physiological chemistry with feedback loops involving the
Earth system, climate, life, and health. (b) Interactions of atmospheric and physiological ROS/
RNS with antioxidants (ascorbate, uric acid, reduced glutathione, α-tocopherol) in the epithelial
lining fluid (ELF) of the human respiratory tract. Reactive pollutants such as ozone (O3), hydrogen
peroxide (H2O2), nitrogen oxides (NOx), reactive oxygen intermediates (ROI), environmentally
persistent free radicals (EPFR), secondary organic aerosol (SOA), soot, quinones, and transition
metals can induce ROS/RNS formation in vivo, leading to oxidative stress and biological aging
(Pöschl & Shiraiwa, 2015; Reinmuth-Selzle et al., 2017)
84 U. Pöschl
Physiological sources of ROS/RNS include metabolic, signaling, and inflamma-

tory processes. In the human immune system, ROS/RNS are used in defense against
pathogens by oxidizing relevant biomolecules (DNA, proteins, lipids) and rendering
the pathogens biologically less active or inactive. For example, H2O2, OH radicals
and related ROS are involved in the elimination of pathogenic microbes (Halliwell
& Gutteridge, 2015). Under homeostatic conditions, the production of ROS/RNS is
balanced by antioxidants. Air pollution, however, can cause excessive production or
uptake of ROS/RNS and an imbalance between oxidants and antioxidants (oxida-
tive stress), leading to cell death, biological aging, inflammation, and various dis-
eases (Pöschl & Shiraiwa, 2015; Reinmuth-Selzle et al., 2017; Sies et al., 2017;
West et al., 2016). In other words, adequate levels of ROS/RNS are essential for the
functioning and self-cleaning of both the atmosphere and the human organism, but
excess concentrations of ROS/RNS are detrimental to human health.
Fine particulate matter suspended in the air contains reactive components such as
transition metals (TM), polycyclic aromatic hydrocarbons (PAH), semiquinones,
nanoparticles, and related substances. In the atmosphere, aerosols undergo transport
and transformation, which may lead to a change in their chemical composition and
toxicity as well as their optical properties and climate effects depending on tempera-
ture, humidity, and particle phase state (Ditas et al., 2018; Mu et al., 2018; Shiraiwa,
Ammann, Koop, & Pöschl, 2011; Shiraiwa, Li, Tsimpidi, et al., 2017; Shiraiwa,
Ueda, Pozzer, et al., 2017; Socorro et al., 2017; Tong et al., 2017). Upon inhalation
and deposition in the human respiratory tract, air pollutants can induce and sustain
chemical reactions that produce ROS in the epithelial lining fluid (ELF) covering
the airways. As illustrated in Fig. 7.2b, the reactive pollutants and ROS undergo a
multitude of chemical reactions in the ELF. A quantitative analysis and assessment
of these processes was recently achieved in investigations using a kinetic multilayer
model of surface and bulk chemistry in the ELF (KM-SUB-ELF) to obtain chemical
exposure–response relations between ambient concentrations of air pollutants and
the production rates and concentrations of ROS in the ELF of the human respiratory
tract (Lakey et al., 2016).
As illustrated in Fig. 7.3, the total concentration of ROS generated by redox-
active substances contained in fine particulate matter (PM2.5) deposited in the ELF
can increase by more than a factor of 20 from ∼10 nmol L−1 under clean conditions
up to almost ∼250 nmol L−1 under highly polluted conditions. The green-striped
horizontal bar indicates ROS concentration levels characteristic of the ELF or bron-
choalveolar lavage of healthy humans, respectively, which are around ~100 nmol L−1.
Compared to this reference level, the ROS concentrations generated by redox-active
particulate matter inhaled from pristine marine or rainforest air (PM2.5 < 10 μg m−3)
are much lower and appear negligible with regard to airway oxidative stress. In
moderately polluted air (PM2.5 ≈ 10–50 μg m−3), the particle-generated ROS con-
centrations can be of similar magnitude or higher than the physiological background
level and may thus significantly contribute to oxidative stress depending on aerosol
Fig. 7.3 Chemical exposure–response relationships between ambient concentrations of fine par-
ticulate matter (PM2.5) and the concentration of reactive oxygen species (ROS) in the epithelial
lining fluid (ELF) of the human respiratory tract. The green-striped horizontal bar indicates the
ROS level characteristic for healthy humans (∼100 nmol L−1). The gray envelope represents the
range of aerosol-induced ROS concentrations obtained with approximate upper and lower limit
mass fractions of redox-active components observed in ambient PM2.5. The data points represent
various geographic locations for which measured or estimated mass fractions are available, includ-
ing (1) Amazon, Brazil (pristine rainforest air); (2) Edinburgh, UK; (3) Toronto, Canada; (4)
Tokyo, Japan; (5) Budapest, Hungary; (6) Hong Kong, China; (7) Milan, Italy; (8) Guangzhou,
China; (9) Pune, India; (10) Beijing, China; (11) New Delhi, India; (12) Sumatra, Indonesia (bio-
mass burning/peat fire smoke) (Lakey et al., 2016)
concentration and chemical composition (see error bars and grey-shaded area). In
heavily polluted air (PM2.5 > 50 μg m−3), the particle-generated ROS concentra-
tions are as high as the ROS concentrations observed in the bronchoalveolar lavage
of patients with acute inflammatory diseases in respiratory tract (100–250 nmol L−1).
The pathologically high ROS levels calculated for ELF in airways exposed to high
ambient aerosol concentrations are consistent with epidemiology-based air quality
standards and regulations of the World Health Organization (WHO), aiming at
PM2.5 concentrations less than 10 μg m−3 averaged over a year (Lakey et al., 2016;
WHO, 2013; 2017). Further investigations building on the scientific approach and
exposure–response relations outlined above will help to identify key species and
processes to be targeted in efficient strategies and policies for air quality control
and improvement. For example, they may help to resolve the relative importance
and nonlinear interactions of different types and sources of air pollutants such as
combustion engine exhaust, brake-wear, and dust emitted or suspended by road or
railway traffic.
86 U. Pöschl
Allergic Diseases
Allergies constitute a major health issue in most modern societies, and related dis-
eases such as allergic rhinitis and atopic asthma have strongly increased during the
past decades. Among the environmental risk factors for allergic diseases are reduced
childhood exposure to pathogens and parasites (hygiene hypothesis), nutritional
factors, psychological or social stress, and environmental pollutants (diesel exhaust
particles, ozone, nitrogen oxides, etc.), which can effectively lead to an over- or
under-stimulation of the immune system (Reinmuth-Selzle et al., 2017). As outlined
in Fig. 7.4, air pollution and climate change can influence the bioavailability and
potency of allergens and adjuvants in multiple ways, including changes in vegeta-
tion cover, pollination and sporulation periods, and chemical modification or aggre-
gation. Moreover, air pollutants can act as adjuvants and skew physiological
Fig. 7.4 Pathways through which climate parameters and air pollutants can influence the release,
potency, and effects of allergens and adjuvants: temperature (T), relative humidity (RH), ultravio-
let (UV) radiation, particulate matter (PM), ozone and nitrogen oxides (O3, NOx), reduced nicotin-
amide adenine dinucleotide phosphate (NADPH) oxidase, pollen-associated lipid mediators
(PALMs), damage-associated molecular patterns (DAMPs), pattern recognition receptors (PRR),
type 2 T helper (Th2) cells, immunoglobulin E (IgE), allergenic proteins (green dots), and chemi-
cal modifications (red dots) (Reinmuth-Selzle et al., 2017)
processes and the immune system towards the development of allergies, for exam-
ple, by oxidative stress, inflammation, and disruption of protective epithelial barri-
ers. Environmental allergens are mostly proteins derived from plants, animals, and
fungi that can trigger chemical and biological reaction cascades in the immune sys-
tem leading to allergic sensitization and formation of IgE antibodies. Prominent
examples are major allergens of birch pollen (Bet v 1), timothy grass pollen (Phl
p 1), ragweed (Ambrosia, Amb a 1), molds (Alternaria alternata, Alt a 1;
Cladosporium herbarum, Cla h 1; Aspergillus fumigatus, Asp f 1), and dust mites
(Der p 1).
Figure 7.5 provides a simplified overview of cellular and molecular interactions
that are central to the processes of sensitization and response in IgE-mediated aller-
gies (type I hypersensitivities). Normally, IgE antibodies and related immune reac-
tions are involved in the defense against parasitic infections, and allergic reactions
can thus be regarded as a “false alarm” of the immune system. Interactions between
protein macromolecules acting as allergens, antibodies, cytokines, or receptors play
a key role in the innate and adaptive immune responses involved in the development
of allergies. Chemical modification by air pollutants can lead to changes in the
molecular structure and interactions of protein macromolecules that trigger such
false alarms (Reinmuth-Selzle et al., 2017 and references therein).
Fig. 7.5 Cellular and molecular interactions involved in allergic sensitization and response of IgE-
mediated allergies (type I hypersensitivities): blue color indicates protein macromolecules acting
as allergens, antibodies, cytokines, or receptors; red color indicates pro-inflammatory mediators
and reactive oxygen or nitrogen species (ROS/RNS) (Reinmuth-Selzle et al., 2017)
88 U. Pöschl
Rising concentrations of atmospheric aerosols and oxidants are likely to promote

the chemical modification of proteins in the atmosphere as well as in the human
body due to elevated ROS/RNS levels and oxidative stress, especially in the airways
(ELF) as outlined above. For example, elevated O3 and NO2 concentrations can
enhance the allergenic potential of proteins through nitration and cross-linking of
allergenic proteins through the aromatic amino acid tyrosine as illustrated in Fig. 7.6
(Franze, Weller, Niessner, & Pöschl, 2005; Liu et al., 2017; Reinmuth-Selzle,
Ackaert, & Kampf, 2014; Reinmuth-Selzle et al., 2017). Ongoing experimental and
theoretical studies provide new insights into the mechanism of these and related
processes, which will help to elucidate and counteract the influence of air pollutants
on the development and aggravation of allergic diseases.
Fig. 7.6 Posttranslational modification of proteins exposed to ozone (O3) and nitrogen dioxide
(NO2). The initial reaction with O3 leads to the formation of reactive oxygen intermediates (ROI,
tyrosyl radicals), which can further react with each other to form cross-linked proteins (dityrosine)
or with NO2 to form nitrated proteins (nitrotyrosine). The shown protein is Bet v 1.0101, for which
nitration and cross-linking were found to influence the immunogenicity and allergenic potential.
Red dot indicates a tyrosyl radical; red bar indicates dityrosine cross-link (Reinmuth-Selzle et al.,
2017)
Conclusions
In air quality, climate, and health studies, it is often challenging to separate natural
and anthropogenic effects and variations. Unperturbed natural conditions are diffi-
cult to find or reconstruct from current and recent observations of the environment,
which has already undergone massive anthropogenic change on global scales. All
the more, it is important to fully unravel and quantify the processes and interactions
influencing the current state as well as the history and future development of the
Earth system, climate, air quality, and public health. This requires interdisciplinary
exchange and collaboration across the Earth, environmental, and life sciences.
Recent advances in field observations, laboratory experiments, and mathematical
model simulations provide deep insights into the underlying physical, chemical, and
biological processes. They enable the development and refinement of target-oriented
ways and efficient approaches of effectively mitigating and counteracting the
adverse effects of air pollutants. Building on open access to scholarly publications
and data, a global commons of scholarly knowledge in the sciences and humanities
will help to augment, communicate, and utilize the scientific understanding (Berlin
Declaration, 2003; oa2020.org). Moreover, public peer review, interactive discus-
sion, and documentation of the scientific discourse on the internet can serve as
examples and blueprints for rational and transparent approaches to resolving com-
plex questions and issues (Pöschl, 2012). Combining the internet with open science
will ultimately reflect both what we know and how we know it (“epistemic web”;
Hyman & Renn, 2012). In any case, scholars and practitioners in the natural, social,
and medical sciences as well as humanities and politics should closely collaborate
to transfer the scientific knowledge of air pollutant sources and effects into effective
strategies and policies of air quality management and control. This should be pur-
sued in analogy to the successful example of protecting the ozone layer from
destruction by chlorofluorocarbons in the late twentieth century rather than the grid-
locked struggle for climate protection in the early twenty-first century. In this con-
text, it may be worthwhile to emphasize not only the need to mitigate negative side
effects of human activities but also the opportunities for actively using scientific
knowledge and technology to protect planet Earth for a sustainable development
and healthy future of humanity and its planetary home (“planetary health”). Thus,
the Anthropocene notion may help humanity to recognize both rationally and emo-
tionally: We are shaping our planet and environment, so let us get it right.
Acknowledgements This chapter provides an overview and synthesis of recent scientific

exchange, studies, and publications of the author with numerous colleagues who are gratefully
acknowledged—in particular, P. J. Crutzen, Y. Cheng, H. Su, M. Shiraiwa, P. Lakey, K. Reinmuth-
Selzle, C. Kampf, K. Lucas, J. Fröhlich, T. Berkemeier, H. Tong, C. Pöhlker, M. Pöhlker, M. Weller,
A. Duschl, I. Bellinghausen, J. Saloga, D. Schuppan, M. O. Andreae, and J. Lelieveld. The chapter
is dedicated to Paul J. Crutzen, whose curiosity, ingenuity, and wisdom have helped to prevent
ozone layer destruction and nuclear winter, and will help to avoid the perils and grasp the opportu-
nities of the Anthropocene.
90 U. Pöschl
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CHAPTER 8
Climate Change, Air Pollution,
and the Environment: The Health
Argument
Maria Neira and Veerabhadran Ramanathan
Summary There are no aspects of climate and environmental change that are more
critical than those that affect health and well-being, and none are more urgent than
those that affect the most vulnerable. Air pollution and climate change fit both these
categories, and now rank among our greatest contemporary threats to human health.
This is what we know: 92% of the global population breathes air pollution levels
that are unsafe. More than seven million lives are lost to indoor and ambient air pol-
lution every year. The major sources of air pollution are the combustion of fossil
fuels, the burning of biomass, and agriculture. Global health and welfare losses
from air pollution in 2013 were valued at about US $5110 billion, or almost 7% of
gross domestic product. However, there is no policy realm in the world that regu-
larly takes into consideration the potential costs and benefits to public health of all
decisions, even those that directly produce health-influencing externalities.
Health should be central to discussions around drivers of environmental degrada-
tion, such as production methods that pollute, deleterious consumption, distribution
patterns and disruption of ecosystems. Moreover, the attainment of health should be
promoted as an explicit aim, rather than an afterthought, of decisions in key sectors
such as energy, transport, technology, water and sanitation, and urban planning. The
health sector must show leadership and work with other sectors to assume its obli-
gations in shaping a healthy and sustainable future. The effects of human actions on
the environment are an ethical and human rights issue; they will be felt by future
generations and have the most severe impact on the most economically, demograph-
ically, and geographically vulnerable populations.
M. Neira (*)
The World Health Organization, Geneva, Switzerland
V. Ramanathan
Scripps Institution of Oceanography, University of California at San Diego, La Jolla, CA, USA

94 M. Neira and V. Ramanathan
At this point in history, no decision-maker can claim to be ignorant of the adverse

health consequences of environmental degradation. Together, we have a major
responsibility to drive the transformation needed to make radical changes in policies
and behaviors—while there is still time.
Air Pollution: A Major Killer
Known, avoidable environmental risk factors cause at least 13 million deaths every
year, which amounts to one quarter of the global burden of disease (Fig. 8.1) Air
pollution alone causes about seven million premature deaths a year, or one in eight
Fig. 8.1 (a) The big picture: 23% of global deaths are attributable to the environment (Source:
WHO Infographics, Preventing disease through health environments; http://www.who.int/quanti-
fying_ehimpacts/publications/PHE-prevention-diseases-infographic-EN.pdf?ua=1)
8 Climate Change, Air Pollution, and the Environment: The Health Argument 95
Fig. 8.2 (a) Air pollution: 92% of the global population breathes air pollution levels that are not
safe. Source: Global interactive map of ambient air pollution (http://maps.who.int/airpollution/)
of all deaths, placing it among the top global risks to health. The poorest three bil-
lion people are exposed to indoor air pollution due to cooking and heating homes
with solid fuels (coal, firewood, and dung and crop residues). Close to four million
people die prematurely from illnesses attributable to household air pollution from
inefficient cooking practices using polluting stoves paired with these fuels and kero-
sene. This is an unbearable cost in lives, health, and human development, particu-
larly for the poor (Fig. 8.2).
There is more evidence than ever before about the direct and indirect paths
through which a stable and protected environment maintains human health—and,
conversely, how failure to manage climate and environmental risk factors are con-
tributing to both communicable and noncommunicable diseases among all popula-
tions, from the poorest to the richest. We also have a wealth of evidence on effective
interventions to address many of the root drivers of the environmental determinants
of health, including action at the local level.
Countries are facing a combination of longstanding, unresolved environmental
and health challenges, as well as new ones. These include a lack of universal access
to clean household energy; limited access to safe water and sanitation; and conse-
quences from unsustainable development, such as air, water and soil pollution;
exposure to hazardous chemicals; more complex, chronic and combined exposure
in working and residential settings; ageing infrastructure; stagnating environmental
health progress; and increasing inequalities, in all countries.
These challenges result in a triple burden of environmental risks, which include
the direct impacts of emergencies, persistent and—in some cases—expanding
infectious disease risks, as well as noncommunicable diseases. For noncommuni-
cable diseases, environmental risk factors are now of a comparable magnitude to
other well-established risks (such as tobacco consumption, diet, alcohol consump-
tion, and physical inactivity).
Human influences on the global environment continue to grow, and they contrib-
ute to climate change, which is considered to be potentially the greatest threat to
global health in the twenty-first century. Many countries already suffer significant
loss of life and damage to crucial health infrastructure from extreme weather events.
These conditions threaten to undermine gains in health and development, and may
exacerbate migration and increase social and political tensions within and between
countries. In the absence of strong measures to cut carbon emissions and protect
populations from the effects of climate change, rising sea levels will submerge
extensive and densely populated coastal areas, including some entire small island
nations, by the end of this century.
Although the paramount concern is to protect human lives and ensure well-being,
environmental degradation also exacts large economic costs from the health sector.
Global health and welfare losses from air pollution in 2013 were valued at about
US$5110 billion, or almost 7% of gross domestic product. Approximately 10% of
global gross domestic product is now spent on health care, driven increasingly by the
costs of treating noncommunicable diseases. Failure to manage environmental risks
therefore increases the strain on health services and national and household budgets.
he Public Health Response to Climate and Environmental

T
Change
The responsibility and tools to tackle many environmental determinants of health lie
beyond those of individuals or the health sector alone. Therefore, we need a wider
societal, intersectoral, and population-based public health approach.
A wealth of evidence demonstrates the health impacts of individual exposure to
hazards in the environment, for example, to specific chemical or biological contami-
nants in water. At the same time, there is also strong evidence for the cost-
effectiveness of many interventions, from small-scale (e.g., point-of-use water
treatment) to large-scale investments (e.g., in sanitation infrastructure).
There have been notable successes in applying such evidence to intersectoral
policy. Examples range from removing lead from petrol in many countries to con-
trolling the depletion of the ozone layer and the associated health risks of ultraviolet
radiation through the application of measures set out in the Montreal Protocol on
Substances that Deplete the Ozone Layer (1987).
In dealing with environmental, climate and other determinants of health, the
World Health Organization (WHO) promotes a Health in All Policies approach,
including coverage of health in environmental and labor regulations and safeguards,
assessment of the health impact of development projects, and tackling several envi-
ronmental health issues in a single setting, community, or system.
Numerous examples of good practice are available, but such integrated
approaches are quite rare and are seldom directed to “upstream” environmental and
social determinants, such as more sustainable and equitable resource consumption,
climate stabilization, and protection of biodiversity and ecosystem services. This
patchy application of integrated approaches drives exposure to hazardous health

conditions.
Additionally, many environmental risks to health are interdependent and trans-
boundary in nature. These include the transfer of polluting industries, dangerous
work processes, and hazardous waste to poorer and less regulated countries; trans-
boundary air pollution and radiation risks; and the burning of fossil fuels that drives
global climate change. This transfer and extension of risk is occurring against a
background of decreased direct investment and a trend of environmental deregula-
tion for some national governments, and an increasing influence of diverse, often
politically and economically powerful, multinational, private-sector actors.
At the same time, there is continuous demand for more commonly recognized
“downstream” environmental health interventions to deal with the direct and local
effects of environmental risks to health—most obviously in the case of responding
to emergencies, which can in turn result in or be caused by environmental
degradation.
The persistent burden of environmental disease and the evolving range of risks
clearly call for a strengthening of primary prevention. A massively scaled-up pri-
mary prevention strategy will enormously benefit the health sector and make signifi-
cant, vital contributions to sustainable development. In fact, it would be a challenge
to achieve the 2030 Sustainable Development Agenda without rebalancing the
emphases on prevention and healthcare.
Currently, the average engagement of the health sector decreases rapidly. The
97% of global health resources spent on treatment are applied only to the health
effects at the end of the causal chain. Most of the remaining 3% spent on prevention
is applied to addressing specific exposures at the individual level.
In order to address the root causes of disease, the health sector needs to engage
more effectively to influence decisions that have impacts on the upstream determi-
nants of health. Rather than attempting only to deal with the fallout of having not
taken environmental health risks into consideration after the fact, the health sector
should aim to reclaim its role at the heart of environment and development policies.
We need to ensure that interventions that drive climate and environmental change
take account of health considerations.
Bolstering this approach is a growing recognition of opportunities for “co-
benefits” of measures that simultaneously protect health and the environment. For
example, it is estimated that doubling the share of renewable energy by 2030 would
not only reduce air pollution-related disease but also create 24 million jobs and
bring a global GDP increase of 1.1%. In another example, improving water and
sanitation services benefits public health, increases labor productivity, and reaps an
estimated return of between US$5 and 28 per dollar invested. Well-designed poli-
cies can maximize synergies and co-benefits: tackling local air pollution to cut
greenhouse gas emissions will reduce the economic burden of health problems.
We need to promote more efficient, equitable, and sustainable delivery of
Universal Health Coverage, with the reduction of environmental impact of health-
care as a co-benefit, and as an example of the leadership of the health sector.
The health sector should take the opportunity to “lead by example” by promoting
environmental sustainability within its own operations, ensuring environmentally
sustainable healthcare facilities.
Healthy Opportunities
If implemented and built on, the Paris Agreement on climate change is likely to be
remembered as one of the most important public health treaties in history. The pub-
lic health community should now join forces with the environment community to
take the lead in ensuring the Agreement is implemented and increasingly ambitious,
and open the door to a green health revolution.
The Paris Agreement should also inspire new and improved agreements to
address other threats to global health and well-being, including threats from air and
water pollution, waste mismanagement, soil degradation, and diminished biodiver-
sity. In the absence of such agreements, environmental threats to health and well-
being are unlikely to be contained.
The 2030 Agenda for Sustainable Development and its associated Sustainable
Development Goals provide the integrated framework for the ambitious changes
needed to fulfill the commitments made. The Goals and their targets provide the
structure to identify and implement actions to safeguard and enhance the upstream
determinants of health, and to follow a sustainable pathway to improved, and more
equitably distributed, health and well-being.
Health is relevant to all the Goals, not just Goal 3 (Ensure healthy lives and pro-
mote well-being for all at all ages). Within the scope of environmental and climate
change, there are specific and important opportunities for health gains through shap-
ing the agenda of nutrition (Goal 2, End hunger, achieve food security and improved
nutrition and promote sustainable agriculture); water and sanitation (Goal 6, Ensure
availability and sustainable management of water and sanitation for all); clean
energy (Goal 7, Ensure access to affordable, reliable, sustainable and modern energy
for all); decent work (Goal 8, Promote sustained, inclusive and sustainable eco-
nomic growth, full and productive employment, and decent work for all); sustain-
able cities (Goal 11, Make cities and human settlements inclusive, safe, resilient,
and sustainable); responsible production and consumption (Goal 12, Ensure sus-
tainable consumption and production patterns); and climate change (Goal 13, Take
urgent action to combat climate change and its impacts).
The Goals therefore provide an opportunity for the health sector to engage in
broad, inclusive and massively expanded primary prevention, effectively bringing
together Principle 1 of the Rio Declaration on Environment and Development
(1992) (“Human beings are at the centre of concerns for sustainable development.
They are entitled to a healthy and productive life in harmony with nature”) and
Article 1 of the Declaration of Alma-Ata (1978) (“… the attainment of the highest
possible level of health … requires the action of many other social and economic
sectors in addition to the health sector”).
Increasingly, much of this action and many of these decisions will occur in urban
settings. Over 50% of the global population now lives in cities, and that number is
growing. More than 3.5 billion people living in cities today—half of humanity—
suffer from inadequate housing and transport, poor sanitation and waste manage-
ment, and air quality failing WHO’s guidelines. World energy demand is expected
to increase by 80% by 2050 (compared to 2010 levels), most of which would be met
with fossil fuels if no new energy policies are put in place.
Cities embody the most acute health and environment challenges, from air pollu-
tion to sanitation, heat-island effect, chemical contamination, and solid waste man-
agement—but the concentration of people, wealth, connectivity, and local leadership
through city mayors also provide the greatest opportunities for integrated health,
climate and environment programs.
As most future urban growth will take place in cities, urban expansion needs to
be planned to make cities a centre of health and well-being. Promoting sustainable
transport, access to clean water and energy, waste management, sustainable food
production, and healthy urban planning will critically improve health, as well as
contribute to the Sustainable Development Goals for Health (3), Energy (7) Water
(6) Cities (11) and Climate Change (13).
We need a new framework of health policy leadership positioned to assess and
advocate for development that leads to healthier, greener and cleaner cities, and we
need a new generation of mayors to lead this healthy development.
Concluding Remarks: The Transformation Needed
In the twenty-first century, health needs to be central to discussions around drivers

of environmental degradation, such as production methods that pollute, deleterious
consumption, and distribution patterns and disruption of ecosystems. Moreover,
attainment of health should be promoted as an explicit aim, rather than an after-
thought, of decisions in key sectors such as energy, transport, technology, water and
sanitation, and urban planning.
Investment in the capacity of the health sector to engage in policy and to assess
and monitor investments that are made in other areas of the economy would support
promotion of mutually beneficial measures that simultaneously protect health and
the environment. This approach would, in turn, avoid current and future economic
costs, allowing for reinvestment in health and sustainable development.
For example, more sustainable urban transport systems that promote public
transport, cycling and walking would reduce air pollution, noise and risk of road
traffic injuries, and enhance physical activity levels. More generally, it is estimated
that placing a price on polluting fuels in line with their health impacts through air
pollution would result in a reduction of more than 50% of premature global air pol-
lution deaths, a 20% reduction in greenhouse gas emissions, and the generation of
some US$3000 billion in tax revenues every year—more than 50% of current global
health spending by governments.
The health sector has the specific responsibility to inform policy-makers and the
public of the health impacts of climate and environmental change, because of the
importance that populations give to health issues and the generally high quality of,
and public trust in, health evidence.
There is a continuous need for evidence on the effectiveness of measures to
tackle the environmental root causes of disease burden and on the health impacts of
sectoral policies. As such decisions often have wide-ranging effects, there is an
associated need for capacity to assimilate, interpret and communicate data and evi-
dence from sources not traditionally used by health policy-makers—evidence that
indicates that health-harmful (e.g., fossil) fuels should not be subsidized, for exam-
ple. Evidence of the impacts on human rights and equity, public acceptance of mea-
sures, and information on the socioeconomic and financial costs to individuals and
health systems are particularly important.
Implementation must occur not only through influencing other sectors but also
within the core functions of the health sector. For example, climate change should
be incorporated into risk assessments and preparedness and response plans for
health emergencies; climate resilience should be integrated into the building blocks
of health systems; and investments should be supported in the provision of energy,
water and sanitation for health facilities, as a crucial contribution to universal health
coverage.
However, for this approach to work, there needs to be a recognition of its merits
that drive institutional change. Major policy and implementation decisions in all
sectors are taken at the national and subnational levels. Health actors need to be
informed by evidence, connected through institutional mechanisms that allow them
to work with other stakeholders (for example, from urban planners to city mayors)
and empowered through regulatory frameworks that include health in intersectoral
policy-making. Effective regulations and standards should be used to promote
energy efficiency and safeguard human health, among other things.
Opportunities for action on health, climate and the environment are rapidly
opening up.
Health should be central to the framing of discussions around drivers of environ-
mental degradation and promoted as an explicit aim of decisions in key sectors such
as energy, transport, water, sanitation, waste, and urban planning (Figs. 8.3 and 8.4).
Fig. 8.3 Top ten causes of death from the environment (Source: WHO Infographics, Preventing
disease through health environments; http://www.who.int/quantifying_ehimpacts/publications/
PHE-prevention-diseases-infographic-EN.pdf?ua=1)
Fig. 8.4 Breathe Life campaign (Source: http://breathelife2030.org)
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30, 2017, from https://openknowledge.worldbank.org/handle/10986/25013
CHAPTER 9
Reducing Air Pollution: Avoidable Health
Burden
Jos Lelieveld
Summary Anthropogenic emissions have transformed atmospheric composition

to the extent that biogeochemical cycles, air quality, and climate have changed glob-
ally and profoundly. It is estimated that ambient (outdoor) air pollution causes an
excess mortality rate of about 4.5 million per year, associated with 122 million years
of life lost annually, mostly due to the detrimental health effects of fine particulate
matter (PM2.5). Globally, the largest source of this pollution is residential energy use
for heating and cooking, notably because of its importance in Asia. Agriculture,
power production, and road traffic also contribute significantly. If residential energy
emissions could be eliminated, up to 1.4 million deaths per year would be avoided.
Agriculture, through the release of ammonia, contributes strongly to PM2.5. A study
of health benefits achieved through European legislation since 1970 indicates that
emission controls in the transport and energy sectors have prevented approximately
61,000 deaths per year in Europe and 163,000 per year worldwide, the latter through
new technology that penetrated global markets. However, much stronger measures
are needed to substantially lower the health burden from air pollution. Clean air is a
human right, being fundamental to many sustainable development goals of the
United Nations, such as good health, climate action, sustainable cities, clean energy,
and protecting life on land and in the sea.
Introduction
Although air pollution episodes have been documented since antiquity by the Greeks
and Romans, public health concerns with smog emerged with urbanization and
industrialization, such as in London after World War II. The burning of wood and
J. Lelieveld (*)
Max Planck Institute for Chemistry, Mainz, Germany
Cyprus Institute, Nicosia, Cyprus

106 J. Lelieveld
coal for power generation, heating, and cooking releases sulfur dioxide (SO2), nitro-
gen oxides (NOx = NO + NO2), and carbon-containing compounds from which fine
aerosol particles are formed through atmospheric chemistry. London’s smog is typi-
cally dominated by sulfur compounds, whereas photochemical smog in Los Angeles,
for example, is characterized by high levels of ozone (O3), formed from hydrocar-
bons and NOx under the influence of sunlight. During the “great acceleration” of the
Anthropocene in the middle of the twentieth century (Crutzen, 2002; Steffen,
Grinevald, Crutzen, & McNeill, 2011), transboundary air pollution reached regional
dimensions, accompanied by the degradation of ecosystems through the deposition
of atmospheric sulfur and nitrogen compounds. In recent decades, widespread pollu-
tion emissions from traffic, industry, energy production, agriculture, and biomass
burning across all continents have emerged into a global challenge.
The chief pollutant that has been related to health outcomes is fine particulate
matter, which are aerosols with diameters less than 2.5 μm (PM2.5), followed by O3,
which is a strong oxidant. Depending on size, fine particles can penetrate deeply
into the lungs, and the smallest ones even reach the bloodstream and affect other
organs. Based on emission inventories, satellite observations, measurement data
from monitoring networks, and model calculations, it has been unambiguously doc-
umented that air quality has degraded on regional and global scales (Akimoto, 2003;
Anenberg, Horowitz, Tong, & West, 2010; Lelieveld & Dentener, 2000; Van
Donkelaar et al., 2010; Wang & Mauzerall, 2006) (Fig. 9.1). In parallel, evidence
that air pollutants adversely impact human health, based on epidemiological stud-
ies, has mounted (Burnett et al., 2014; Cohen et al., 2017; Dockery et al., 1993; Lim
et al., 2012; Pope et al., 2002). The diseases incited by the long-term exposure to air
Fig. 9.1 Global mean PM2.5 in the period 2010–2012 derived from satellite observations (NASA).
The World Health Organization (WHO) estimates that 90% of people on Earth are exposed to
PM2.5 concentrations higher than the air quality guideline of 10 μg/m3 (see also Brauer et al., 2016)
9 Reducing Air Pollution: Avoidable Health Burden 107
pollution include acute lower respiratory infections, chronic obstructive pulmonary

disease, cerebrovascular disease, ischemic heart disease, and lung cancer. This
chapter uses a global model to estimate the health burden from air pollution, and
especially how it can be avoided by reducing emissions.
Methods: Earth System Chemistry Model
We used the ECHAM/MESSy Atmospheric Chemistry (EMAC) computer model

that comprehensively simulates meteorological and atmospheric chemical pro-
cesses worldwide. It has been developed at the Max Planck Institute for Chemistry
in Mainz, building on the climate model of the Max Planck Institute for Meteorology
in Hamburg (Roeckner et al., 2006). EMAC couples atmosphere, ocean, and land
processes to simulate biogeochemical cycles of reactive compounds. Therefore, it
can be seen as an Earth system chemistry model, which can cover a wide range of
space and time scales, typically up to decades or centuries (Pozzer, Jöckel, Kern, &
Haak, 2011). Currently, the EMAC development is pursued by an international con-
sortium (see http://www.messy-interface.org for details and references). The model
can be applied at various horizontal resolutions (between about 50 and 250 km grid
spacing), and covers the lower and middle atmosphere (Jöckel et al., 2006, 2010).
Here, we use EMAC to investigate the global impact of growing air pollution emis-
sions in recent years and also to determine possible chemical states of the atmo-
sphere up to the middle of the twenty-first century, applying a grid spacing of
~100 km latitude/longitude. Air pollution emissions have been adopted from the
Emission Database for Global Atmospheric Research (EDGAR) (http://edgar.jrc.
ec.europa.eu/).
Model calculations have been extensively tested against measurement data of
gases and particles from ground-based air quality networks and global observations
from satellites (e.g., Karydis, Tsimpidi, Pozzer, Astitha, & Lelieveld, 2016; Karydis
et al., 2017; Lelieveld, Gromov, Pozzer, & Taraborrelli, 2016; Pozzer et al., 2012a,
2012b; Tsimpidi, Karydis, Pandis, & Lelieveld, 2016). To compute the public health
impacts attributable to air pollution, the model simulations have been combined
with integrated exposure–response (IER) functions that use annual mean pollution
concentrations to assess long-term health outcomes, following Anenberg et al.
(2010), Lim et al. (2012), Burnett et al. (2014), and Lelieveld, Evans, Fnais,
Giannadaki, and Pozzer (2015). We applied the updated IER coefficients according
to the Global Burden of Disease (GBD, 2017) and Cohen et al. (2017) to compute
the relative risk of mortality by cardiovascular and respiratory diseases and lung
cancer (Lelieveld, 2017). Data sets used as inputs, such as country-level baseline
mortality rates for the different disease categories and population data, have been
adopted from the WHO Global Health Observatory (www.who.int/gho/database/
en/), being representative of the year 2015.
108 J. Lelieveld
Multi-pollutant Index (MPI)
Considering that human health is affected by multiple gas and aerosol species, it is
helpful to combine them into an air quality metric, accounting for the so-called
criteria pollutants SO2, NO2, carbon monoxide (CO), O3 and PM2.5, for which many
countries have implemented control measures based on health standards. To assess
air quality changes globally, regionally and nationally, and also account for the
number of people subjected to poor air conditions, we adopted a Multi-pollutant
Index, MPI (Pozzer et al., 2012b). The index is population weighted to represent the
impact on public health. The scale extends from −1 to infinity, whereby levels above
zero indicate poor air quality according to the pollution thresholds of the WHO for
the criteria pollutants. Figure 9.2 compares the air quality development in seven
regions since preindustrial times.
Figure 9.2 illustrates the differences between regions and the time development
in the Anthropocene, that is, since the preindustrial period. For example, in the
Middle East, air quality has been relatively low even without human-induced emis-
sions, related to the high concentration of airborne desert dust, which has a signifi-
cant impact on human health (Giannadaki, Pozzer, & Lelieveld, 2014). Figure 9.2
also includes results from future projections with the EMAC model according to a
Fig. 9.2 Population-weighted multi-pollutant index for seven regions and five periods: preindus-
trial times (PI), 2005, 2010, 2025, and 2050. An MPI of −0.8 indicates good, whereas +0.8 indi-
cates poor air quality
business-as-usual (BaU) emission scenario for the years 2025 and 2050 (Pozzer
et al., 2012b). BaU means that only current legislation is being considered in the
modeled emission scenario. Therefore, the projections represent the present trajec-
tory into the future.
The largest changes in the population-weighted MPI occurred during industrial-
ization in the twentieth century, that is, between the preindustrial period and 2005.
This is related to the rapidly growing pollution emissions, especially since the mid-
dle of the twentieth century (the great acceleration), which strongly impacted air
quality for a large fraction of the world population. Although the changes between
2005 and 2050 are smaller, they partly occur rather abruptly. In Europe, the Americas
and Africa, the anticipated MPI differences are incremental; however, in economi-
cally emerging regions, such as East Asia, very rapid increases have taken place,
and may continue in the near future, especially in South Asia (Fig. 9.3). On a global
scale, the population-weighted MPI has increased from −0.63 (PI) to −0.13 in
2005, and an additional strong increase up to +0.18 is projected until 2050. This
implies that the BaU scenario will lead to worldwide violation of WHO air quality
standards.
Figure 9.3 presents the projected population-weighted MPI increase per country.
Under the BaU scenario, India may experience the strongest air quality degradation,
followed by Bangladesh and China. Figure 9.3 also includes countries in the Middle
East where both air pollution and population growth are rapid; hence, many more
Fig. 9.3 Increasing population-weighted MPI between 2005 and 2050 under a business-as-usual
scenario. The red dashed line shows the global mean MPI increase in this period
110 J. Lelieveld
people may become exposed to poor air quality. The large, densely populated coun-
tries with high levels of air pollution, notably in Asia, relatively strongly affect the
global mean decline of air quality, and thus adversely influence the health condi-
tions of the “average citizen.” Note that Asia is projected to continually dominate
the world population (about four of globally seven billion in 2010, and about five of
globally nine billion in 2050). Further, it is expected that the urban population will
grow relatively rapidly from 3.6 billion in 2010 to 5.2 billion in 2050.
Health Impacts of Air Pollution
The model results have been combined with integrated exposure–response (IER)
functions. We computed the relative risk of mortality by acute lower respiratory
infections (ALRI) in childhood, chronic obstructive pulmonary disease (COPD),
cerebrovascular disease (CEV) leading to mortality by ischemic and hemorrhagic
strokes (CEVI and CEVH, respectively), ischemic heart disease (IHD) leading to
mortality by heart attacks, and lung cancer (LC). These diseases are related to PM2.5,
while COPD is additionally related to O3 (Fig. 9.4). Our methodology follows that
of the Global Burden of Disease for 2010 (Lim et al., 2012), being updated for the
year 2015 (GBD, 2017).
The minimum risk exposure level distribution for annual mean PM2.5, applied in
the IER functions, is 2.4–5.9 μg/m3, which is lower than the previously assumed
range of 5.8–8.8 μg/m3 for the Global burden of Disease 2010, and that of O3 is
33.3–41.9 ppbv (unchanged). The recent downward adjustment of the “safe thresh-
old” for PM2.5 is the main reason for the higher mortality rates presented here com-
pared to previous estimates for 2010, since a larger fraction of the population is
exposed to hazardous levels of air pollution. In particular, the mortality rates for
COPD are significantly higher than reported previously. Thus, the state-of-the-
science is that only very low mean PM2.5 concentrations under 4.2 ± 1.8 μg/m3 do
not significantly contribute to morbidity and mortality. The global results presented
here agree with the GBD for the year 2015, on average within a few percent.
Fig. 9.4 Global excess

mortality rates attributed to
air pollution due to
different disease categories
The updated calculations indicate a total excess mortality rate attributable to

ambient (outdoor) air pollution of 4.5 million persons per year, which is about a
third higher than estimated previously by Lelieveld et al. (2015) and the GBD for
the year 2010 (Lim et al., 2012). The statistical uncertainty range is estimated at
3.4–5.6 million per year (95% confidence interval), hence approximately ±25%,
being dominated by uncertainties in the IER functions and to a lesser extent to esti-
mates of annual mean pollution concentrations (Kushta, Pozzer, & Lelieveld, 2018).
Note that the IER functions for very high levels of PM2.5 are associated with rela-
tively large uncertainty, as epidemiological data for such conditions are scarce.
The estimated mortality attributable to air pollution is about 265,000 per year in
the EU-28, 373,000 per year for Europe as a whole (not including Russia), and
120,000 per year for the United States. The global total number of years of life lost
(YLL) is about 122 million per year (92–148 million per year), which implies that
each individual who dies from diseases incited by air pollution loses about
28 ± 7 years of his or her life. The life expectancy reduction is greatest for ALRI as
it also affects children, especially in countries where nutrition and medical care are
inadequate, being on average 54 years, and 20–25 years for the other disease catego-
ries. Among the leading GBD risk factors, ambient particulate matter pollution
ranks fifth, after high blood pressure, tobacco smoking, diabetes, and being over-
weight (GBD, 2017). Poor air quality is the largest environmental risk factor
worldwide.
To put the problem in perspective, the WHO estimates that the number of people
who die annually from malaria and HIV/AIDS together is about 1.5 million, which
is roughly one third compared to outdoor air pollution. The additional mortality
attributable to household (indoor) air pollution is about 2.9 million per year (GBD,
2017). Even though the global implementation of the WHO air quality guideline for
PM2.5 of 10 μg/m3 would significantly reduce mortality attributable to air pollution
by more than 50% (Giannadaki, Pozzer, & Lelieveld, 2016), this threshold is still
too high, especially because the minimum risk exposure level has decreased to
4.2 ± 1.8 μg/m3 (Lelieveld & Pöschl, 2017). While the control of emissions in pol-
luted regions such as South and East Asia and Eastern Europe has a high potential
to reduce mortality, air quality improvements at relatively low concentrations still
have major health benefits because of the nonlinear response to exposure (Cohen
et al., 2017).
Table 9.1 ranks the countries where mortality exceeds 30,000 individuals per
year. China and India lead, partly related to their large population size because com-
paratively large numbers of people are exposed to poor air quality. The attribution
to source sectors in Table 9.1 has been adopted from Lelieveld et al. (2015), calcu-
lated by omitting the respective emissions in the EMAC model. These results repre-
sent the elimination of source categories one at a time, which to a large extent
represents the efficiency of PM2.5 reductions by controlling these sources, as mortal-
ity attributable to O3 represents only 6% of the total. On a global scale, residential
energy use for heating and cooking is the largest source category (31%), notably
because it is the major one in Asia. In eastern Asia and Europe, agricultural emis-
sions are important, such as ammonia (NH3) from animal husbandry and fertilizer
112 J. Lelieveld
Table 9.1 Top 20 ranked countries of mortality attributable to outdoor air pollution in 2015 (the
95% confidence interval is about ±25%), and contributions of seven main source categories (in %),
the leading ones in bold
Deaths Residential Power Biomass Road
Country (×103) energy Agriculture Natural generation Industry burning traffic
China 1,44 32 29 9 18 8 1 3
India 967 50 6 11 14 7 7 5
Russia 203 7 43 1 22 8 8 11
Nigeria 158 14 1 77 0 0 8 0
Pakistan 133 31 2 57 2 2 2 3
USA 120 6 29 2 31 6 5 21
Indonesia 90 60 2 0 5 4 27 2
Japan 84 12 38 0 17 18 5 10
Bangladesh 77 55 10 0 15 7 7 6
Ukraine 70 6 52 0 18 9 5 10
Sudana 58 1 0 92 1 0 6 0
Germany 49 8 45 0 13 13 1 20
Egypt 47 1 3 92 2 1 0 1
Brazil 41 9 4 1 2 6 71 7
Vietnam 34 51 12 0 13 8 12 4
Iran 32 1 6 81 4 3 1 4
Italy 32 7 39 6 15 14 2 17
Turkey 31 9 29 15 19 11 6 11
N-Korea 31 21 38 0 20 12 4 5
Poland 30 15 43 0 16 10 3 13
World 4,55 31 20 18 14 7 5 5
Including South Sudan
a
use, because this gas is an effective precursor of PM2.5 (Pozzer, Tsimpidi, Karydis,
de Meij, & Lelieveld, 2017).
World Avoided by Improving Technology in the EU
To illustrate the effectiveness of air pollution legislation and the consequent public
health improvement in the past, an emission scenario was adopted, which accounts
for trends in gaseous and particulate pollution sources in the period 1970–2010
(Crippa et al., 2016). The scenario focuses on the EU where the EURO norms for
light- and heavy-duty vehicles have been introduced. The EU additionally imposed
standards on fuel quality and flue gas desulfurization in the power production sec-
tor. The measures taken in the EU not only impacted European air pollution but also
worldwide, because the EURO standards penetrated global markets through
European and Japanese manufacturers, thus effectively exporting EU regulations.
The scenario assesses end-of-pipe reduction measures in the EU by comparing
actual emissions to historical fuel consumption along with a stagnation of technol-

ogy, by applying constant emission factors since 1970, that is, without abatement
measures imposed by European emission standards. It includes three regulated sec-
tors—power generation, manufacturing industry and road traffic—which together
account for 28% of mortality attributable to air pollution (Table 9.1).
The scenario calculations indicate that, without emission regulation, the European
sources of SO2 and NOx would have been about 70% and PM2.5 would have been a
factor of 2.3 higher in 2010 compared to 1970, mainly due to end-of-pipe controls
(Crippa et al., 2016). The model calculations suggest that regulation of the road
transport sector has made a relatively large contribution to emission control of SO2,
NOx, non-methane hydrocarbons (NMHC), and PM2.5 (including black and organic
carbon, BC and OC), while power production also contributed strongly, particularly
to the reduction of SO2 and PM2.5. In Europe, the 2010 emissions by industry were
higher than from power production, as abatement strategies for this sector have been
less stringent. Globally, European emission controls in power production have
played a significant role in reducing SO2 and BC, and road traffic in the reduction of
NMHC, NOx, and BC emissions. Power production was still the largest contributor
to SO2 emissions, both in 1970 and 2010. Nevertheless, without EU emission con-
trols, global SO2 emissions would have been 30% higher in 2010.
Emissions that have been avoided as a consequence of EU legislation have led to
a reduction of annual mean European concentrations of PM2.5 by about 5 μg/m3 and
of O3 by about 2.5 ppbv, and in Asia 1–2 μg/m3 and ppbv, respectively. Comparing
the scenario with uncontrolled EU emissions to the reference calculations suggests
that the mortality rate attributable to air pollution in the EU has been reduced by
about 61,000 persons per year, which means that 18–19% have been avoided.
Globally, the reduction has been about 163,000 persons per year, that is, 3–4% were
avoided; in China and Japan, approximately 2% and 7% were avoided, respectively.
Within the EU, relatively large reductions have been achieved in Western Europe,
such as in Germany (21%), France (23%), and the Netherlands (27%).
Discussion and Conclusions
Based on recently updated data on air pollution, disease and population statistics,
the excess mortality rate attributable to outdoor air pollution is estimated at 4.5 mil-
lion individuals per year, associated with about 122 million years of life lost in the
year 2015. This represents mortality through cardiovascular and respiratory ail-
ments that could have been avoided when annual average PM2.5 would be below
4.2 ± 1.8 μg/m3 and O3 below 37.6 ± 4.3 ppbv. The fractional contribution of PM2.5
to mortality is about 94%, and of O3 about 6%; hence, fine particulates constitute the
main health risk. Recent downward adjustment of the minimum risk exposure level
for PM2.5 to ~4.2 μg/m3 (from ~7.3 μg/m3) is a main reason for the 30% higher mor-
tality presented here for 2015 compared to previous estimates that referred to the
114 J. Lelieveld
year 2010 (Lelieveld et al., 2015; Lim et al., 2012), since a much larger fraction of
the population is exposed to hazardous levels of air pollution.
In view of the revised minimum risk exposure level of ~4.2 μg/m3, air quality
standards should be adjusted accordingly, currently being 12 μg/m3 in the USA and
25 μg/m3 in the EU, and higher or absent in Asian and African countries. The air
quality guideline by the WHO of 10 μg/m3 for PM2.5 should also be reevaluated.
While the global implementation of this WHO guideline would reduce mortality
attributable to air pollution by more than 50% (Giannadaki et al., 2016), further
reduction will be necessary. About 75% of the global mortality occurs in Asia, and
more than 50% in China and India (together 2.4 million per year). While the latter
countries lead the ranking of total mortality, the per capita mortality rate is highest
in Eastern Europe (e.g., Russia) with 1.6 deaths per 1000 inhabitants annually,
being more than twice that in India and four times compared to North America.
The most rapid increase in mortality attributable to air pollution worldwide
occurs in South Asia, particularly in India. Although the leading source category is
residential energy use, the recent increase is largely related to fossil fuel consump-
tion, notably of coal, which doubled in the past decade (IEA, 2016). Worldwide,
approximately 31% of mortality is due to residential energy use, amounting to about
1.4 million per year. This source category is also a main cause of household (indoor)
air pollution-related mortality, which adds about 2.9 million per year (GBD, 2017).
In South and Southeast Asia, residential energy use contributes >50% to mortality
attributable to outdoor air pollution. Globally, approximately 18% (~800,000 deaths
per year) is related to natural processes and is difficult to avoid, mostly due to eolian
desert dust in Africa and Asia.
Pozzer et al. (2017) found that strong reductions of PM2.5 can be achieved by
controlling agricultural ammonia (NH3) emissions from animal husbandry and fer-
tilizer use. The absolute impact of NH3 on PM2.5 is largest in East Asia, even for
relatively small emission decreases. In Europe and North America, the formation of
PM2.5 is not directly limited by NH3, but strong emission controls could nevertheless
substantially decrease PM2.5 and associated mortality, especially when the NH3 lim-
ited regime is reached at about 50% emission reduction. In other regions, including
South Asia, the influence of NH3 emissions on public health is relatively minor.
Based on the fractional contribution of agricultural emissions to PM2.5, it is esti-
mated that a 50% reduction of global NH3 emissions could avoid about 350,000
deaths per year. A theoretical reduction of 100% could avoid about 900,000 deaths
per year.
A study of European technology development illustrates the public health benefit
achieved by emission controls (Crippa et al., 2016). An emission scenario shows the
actual world avoided by EU legislation since 1970 through the EURO norms for
light- and heavy-duty vehicles, and standards on fuel quality and flue gas desulfur-
ization in the power production sector. The EU measures have influenced pollution
emissions in Europe and worldwide because the EURO standards penetrated global
markets. The scenario calculations suggest that mortality attributable to air pollu-
tion in the EU has decreased by about 61,000 persons per year, which means that
about 18–19% mortality have been avoided. Globally, the reduction has been about
163,000 persons per year, which means 3–4% were avoided. It should be noted that
these calculations do not account for illegitimate diesel-related NOx emissions.
Anenberg et al. (2017) estimated that about a third of heavy-duty and more than half
of light-duty diesel vehicle emissions have been in excess of certification limits,
associated with about 38,000 deaths globally in 2015.
Zhang et al. (2017) investigated the relationship between exports of goods and
services and the exposure to poor air quality. In effect, by exporting goods and ser-
vices, countries with emerging economies in Asia and eastern Europe “import” air
pollution-related mortality. These countries trade monetary revenue against health
expenditures through emissions embodied in exports. It is likely that some polluting
industries have been transferred internationally, such as from the EU and the USA
to regions with more permissive environmental regulations. To prevent such prac-
tices, international norms and agreements are needed. It would be an important
signal if the UN adopts a sustainable development goal on “clean air.” It can be
argued that actions to mitigate climate change and improve air quality have co-
benefits. Furthermore, clean air contributes to other sustainable development goals
that aim at good health, sustainable cities, clean energy, taking climate action, and
protecting life on land and in the water.
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Part III
Climate Change and Health: Sustainability
and Vulnerable Populations and Regions
CHAPTER 10
Vulnerable Populations and Regions:
Middle East as a Case Study
Wael K. Al-Delaimy
Summary There are published analyses predicting that the Middle East and North
Africa (MENA) region will be the most affected by climate change and global
warming. This region has a multitude of factors that makes it more vulnerable to
climate change. It is the first region in the world expected to run out of fresh water.
It has diversity in income levels between one country and another, but most low-
income countries rely on farming and agriculture that is rain-dependent, and there is
poor governance and lack of resources to address the impact of climate change
through adaptation. There is genuine interest by the MENA countries to address
climate change through submission of Intended Nationally Determined Contributions
by many countries in the region, but there is a lack of implementation with regard
to climate change action plans and no public awareness within countries in the
region. The heat waves, sand storms, declines in agriculture and food security,
declines in water access, and associated health outcomes in this region are going to
drive more migration within and outside the specific countries. The health impact
from these climate change scenarios will be overwhelming in many regions in
MENA, even if the target 2 °C global minimum temperature increase is achieved.
There is a dearth of data from the MENA region regarding climate change and its
impact on health.
Historical and Religious Relevance
The MENA region is identified differently by different entities, but for the purpose of
this chapter it is represented by the predominately Arab countries (Morocco, Algeria,
Tunisia, Libya, Egypt and Sudan in North Africa, and Syria, Lebanon, Palestine,
Jordan, Iraq, Saudi Arabia, Yemen, Oman, Kuwait, Qatar, United Arab Emirates-
W. K. Al-Delaimy (*)
University of California San Diego, La Jolla, CA, USA

122 W. K. Al-Delaimy
UAE, and Bahrain in the Middle East) as well as Iran, based on the World Bank
criteria. This area is inhabited by predominantly Arab ethnic groups, of whom the
majority (91.2%) are Muslims (Pew Research Center, 2011). The origin of the Arabs
in the region goes back to nomadic tribes roaming the region in search of pasture and
water for their livestock through regular seasonal migration in search of these
resources. The Arabs have been in the desert in the Arabian Peninsula or in farming
rural communities in Iraq, Syria, Palestine, Egypt, and coastal Mediterranean coun-
tries. With increasing affluence in the past century, most of the migration has been
internal from rural areas to cities, which offer more secure and higher paying jobs.
This trend has changed recently with increasing migration out of the region because
of conflicts and political instability, and is likely exacerbated by global warming
impacts.
The Quran, Islam’s Holy Scripture, documents a clearly identifiable historical
severe drought in great detail, which is corroborated by other Biblical and Judaic
Scripture. Prophet Joseph, son of Prophet Jacob who is revered by Muslims,
Christians, and Jews, lived around 600 B.C. and relayed his experiences of a 7-year
drought that affected all of today’s Egypt, Palestine, Israel, Lebanon, Syria, and
Jordan in the MENA region. Many lessons are provided by the story of Joseph and
the drought that apply to the region today, which includes good governance, adapta-
tion, and conservation. This concept is typically overlooked by the public, who read
the verses of the Quran about the story of Joseph but do not relate it to today’s cli-
mate change, drought, and needed adaptation measures. Other teachings of Islam
through the Holy text in the Quran that clearly point to the role of mankind in
destroying the planet include Chapter 30 verse 41: Corruption has appeared in the
land and the sea on account of what the hands of men have wrought, that He may
make them taste a part of that which they have done, so that they may return. The
teaching of Prophet Mohamed has many examples relevant to protecting the planet
as a duty (He said, Don’t waste water even if you are on the bank of a flowing river;
He also said, if the end of the world happened while you are planting a tree, con-
tinue planting it—to overemphasize the importance of planting trees). This teaching
in Islam is supportive of an anthropogenic origin of climate change, as well as the
means to mitigate it and to protect the resources of the planet.
Extreme Heat Wave Events
The occurrence of frequent heat waves is a direct manifestation of climate change

and has impacted many countries in recent years. Extreme heat waves are events
with record temperatures beyond the usual average heat wave event. Extreme heat
waves are expected to cause several countries in the Arabian/Persian Gulf area to
exceed the capacity of humans to be outdoors during summer periods (Lelieveld,
et al., 2016; Pal & Eltahir, 2016; World Bank, 2014a). The Warm Spell Duration
Index (WSDI) is defined as the annual or seasonal count of days with at least 6
consecutive days of a warm spell. During this warm spell, the maximum tempera-
10 Vulnerable Populations and Regions: Middle East as a Case Study 123
ture each day is above the 90th percentile of past daily temperatures that occurred
at the same time of the year during 1979–2009. In a 4 °C scenario, 80% of summer
months are projected to be hotter than 5-standard deviations above the average
(unprecedented heat extremes) by 2100, and about 65% are projected to be hotter
than 5-standard deviations above the average during the 2071–2099 period (see
Fig. 10.1). In a 2 °C scenario, the annual number of hot days with exceptionally
high temperatures and high thermal discomfort is expected to increase in several
capital cities, from 4 to 62 days in Amman (Jordan), from 8 to 90 days in Baghdad
(Iraq), and from 1 to 71 days in Damascus (Syria). The greatest increase is expected
in Riyadh (Saudi Arabia), where the number of these extremely hot days is pro-
40°N 40°N 8
6
30°N 30°N
4
20°N 20°N 2
0
10°N 10°N
10°W 10°E 30°E 50°E 10°W 10°E 30°E 50°E
Fig. 10.1 Multi-model mean temperature anomaly for RCP2.6 (2 °C world, left) and RCP8.5
(4 °C world, right) for the months of June–July–August for the Middle East and North African
region (temperature anomalies in degrees Celsius are averaged over the time period 2071–2099
relative to 1951–1980) (From World Bank, 2014a)
Table 10.1 Mean WSDI (Warm Spell Duration Index) for capital cities in the MENA region for
different levels of global warming based on regional climate model projections (World Bank,
2014a)
Period of observation Observed 1.5 2.0 3.0 4.0
Abadan 1951–2000 6 43 82 99 134
Amman 1959–2004 4 31 62 84 115
Ankara 1926–2003 7 44 67 111 128
Athens 1951–2001 1 40 61 121 166
Baghdad 1950–2000 8 47 90 113 162
Beirut – – 47 93 126 187
Belgrade 1951–2010 9 39 39 76 113
Cairo – – 32 53 80 94
Damascus 1965–1993 1 36 71 98 129
Istanbul 1960–2010 0 26 41 78 113
Jerusalem 1964–2004 7 26 46 73 102
Kuwait – – 45 87 123 167
Nicosia 1975–2001 6 25 58 81 162
Riyadh 1970–2004 3 81 132 157 202
Sofia 1960–2010 1 40 49 88 136
Tehran 1956–1999 5 48 92 122 159
Tirana 1951–2000 6 49 71 125 168
Tripoli 1956–1999 3 13 22 33 59
a TWmax HIST.
b TWmax RCP4.5
c TWmax RCP8.5
DOM = 27.0 DOM = 28.3 DOM = 29.8

LND = 26.4 LND = 27.7 LND = 29.1
AP = 26.7 AP = 28.0 AP = 29.3
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
°C
d Tmax HIST. e Tmax RCP4.5 f Tmax RCP8.5
DOM = 45.9 DOM = 48.0 DOM = 50.8

LND = 48.9 LND = 51.1 LND = 54.2
AP = 50.3 AP = 52.5 AP = 55.4
30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60
°C
Fig. 10.2 Spatial distributions of extreme wet bulb temperature and extreme temperature. (a–f)
Ensemble average of the 30-year maximum TWmax (a–c) and Tmax (d-f) temperatures for each
GHG scenario: historical (a, d), RCP4.5 (b, e) and RCP8.5 (c, f). Averages for the domain exclud-
ing the buffer zone (DOM), land excluding the buffer zone (LND) and the Arabian Peninsula (AP)
are indicated in each plot. TWmax and Tmax are the maximum daily values averaged over a 6-h
window (From Pal & Eltahir, 2016 reprinted with permission)
jected to rise from 3 to 132 days per year. In a 4 °C world, the average number of
such days is projected to exceed 115 days per year in all of these cities (see
Table 10.1 and Fig. 10.2) (Pal & Eltahir, 2016).
Heat waves have been shown to be related to increased mortality across many
countries (Guo, et al., 2017) and with some recent heat waves receiving wide media
attention coverage for their high death tolls, such as the 2003 European heat wave that
caused an estimated 70,000 deaths (Robine, Cheung, Le Roy et al., 2008) and the
2010 Russian heat wave that caused an estimated 11,000 deaths (Shaposhnikov et al.,
2014). Heat stroke, exhaustion, and hyperthermia are the most common causes of
mortality, but other causes of mortality from respiratory, cardiovascular and diabetic
complications have also been demonstrated (Ye et al., 2012). However, there is lim-
ited data describing the impact of heat waves on health in the MENA region. Given
the extreme temperatures expected from the business-as-usual scenario leading to a
4 °C increase in temperature, the resulting mortality from high temperatures in the
MENA is going to be the highest in history because 80% of summer is going to have
temperatures that are 5-standard deviations above the average temperature. The fact
that temperatures have never reached 60 °C, but are expected to reach such levels by
the end of this century in the Gulf Region, means the health impact will be devastat-
ing. While the European heat wave claimed so many lives when reaching 37–41 °C
for 9 consecutive days, the number of deaths will be much higher if reaching
60 °C. Unfortunately, there are no health-related studies regarding heat wave-related
mortality from the MENA region to better quantify the risk. There are also no clear
action plans to proactively deal with such heat waves within capital cities in the MENA.
Therefore, the consequences of climate change, even with a 2 °C scenario, are
rather serious for the MENA region and will be felt well before the end of this cen-
tury. Record temperatures are already being recorded in several countries.
Desert Sand and Dust Storms
The MENA region is a major source of desert dust storms travelling to Europe and
Asia (Fig. 10.3). The higher temperatures affecting the region are leading to lower
soil moisture and more arid conditions, which are exacerbated by lower precipita-
tion and longer drought periods. Aridity is expected to increase by 50% throughout
the entire coastal region if the business-as-usual model is followed (World Bank,
2014a). These conditions support more desert dust storms in the region. However,
local conflicts played an important role in desertification and dust storms from the
desert. The 1991 Gulf War and use of tanks and heavy equipment disrupted the
desert ecology in Iraq, Kuwait, and Saudi Arabia (in areas which are now major
sources of desert dust storms) with the topsoil becoming suspended as fine particles
at higher levels in the air. There have been more frequent desert dust storms affect-
ing the region in the last two decades. In Iraq, 122 dust storms were recorded in a
single year in 2010 and are expected to more than double in incidence to around 300
dust storms a year in 2020 (UNEP, 2016). The size and type of dust particles also
Fig. 10.3 The National Geospatial Program of the US Geological Survey map of origins of dust
storms from the Middle East and North Africa region
Fig. 10.4 Types of particles from the dust storms in the Middle East and the specific places with
most frequent dust storms (From the Comet Program by NOAA National Weather Service)
have an impact on human health, where finer particles that are more common in the
Arabian Peninsula (Fig. 10.4) reach deeper in the lung and cause more damage.
Frequent desert dust storms cause increased emergency visits for those with
respiratory illnesses. We have demonstrated in a study from Japan that desert dust
storms from the Taklamakan Desert in China led to a significant increase in asthma
admission among children in Japan (Kanatani et al., 2010). The best-fit model
adjusting for climate and other variables demonstrated an odds ratio (OR) of 1.71
(95% CI 1.18–2.48; p = 0.005). OR was higher for boys at 2.32 (95% CI 1.10–4.87;
p = 0.005) and for 6- to 12-year-olds at 3.33 (95% CI 1.02–10.92). The impact of
these desert dust storms will continue to inflict damage on these countries, but the
level of health impact from these frequent dust storms is unknown for the
MENA region.
There are other important health impacts of dust storms, including poor visibility,
leading to more road traffic accidents. Dust storms have also been shown to carry
bacteria and viruses for thousands of miles across the globe, with the bacteria types
varying by region. Studies have documented microorganisms in dust from Tunisia
(Hezbri et al., 2016), Lebanon (Itani & Smith, 2016), Kuwait (Leski, Malanoski,
Gregory, Lin, & Stenger, 2011), and Iraq (Al-Dabbas, Ayad Abbas, & Al-Khafaji,
2012). This has new implications and understandings for what might trigger certain
medical conditions. Toxins and allergens are also carried on dust particles in dust
storms (Abuduwailil, Zhaoyong, & Fengqing, 2015; Kameda et al., 2016).
Climate change will specifically impact the health of populations in the MENA
region through an increase in dust storms that are of higher frequency and wider
geographical spread, affecting millions of people every year. There is a need for
active adaptation approaches based on scientific evidence of who is at risk and what
is the magnitude of that risk.
Water Scarcity
All countries in the MENA region suffer from water shortage. The increase in
drought and high temperatures with lower precipitation and increased demand will
lead to scarcity in access to water. The MENA region will be the first region in the
world to run out of fresh water. It is expected that water availability will decrease
in most parts of the MENA region by 15% in a 2 °C scenario and up to 45% in parts
of the region in a 4 °C scenario (World Bank, 2014a). Water access is mostly
dependent on underground water or rain. The Gulf Countries have developed desal-
ination projects to cover the supply of water, although this is at high
financial and environmental costs.
Some of the countries with the poorest water supplies in the world are in the
MENA region, namely Jordan and the Palestinian Territories under occupation of
Israel. According to the Israeli Information Center for Human Rights in the Occupied
Territories, Palestinians get as little as 20–50 L/day per capita compared to 287 L/
day per capita for Israelis, while the WHO recommendation is to have a minimum
of 100 L per capita per day (B’Tselem, 2016). The lack of water access is going to
be exacerbated in that area because of overuse of underground water, lower precipi-
tation, longer droughts and higher temperatures. Dwindling resources can trigger
further conflict in an area already suffering from ongoing violence. It is estimated
that the withdrawal-to-availability ratio for underground water in Jordan, Yemen,
Libya, and most of the Gulf countries is more than 100%, meaning that withdrawal
is not being replenished and the water is going to be completely depleted (World
Bank, 2014a). This is going to lead to lower local agricultural production and food
insecurity.
Yemen is another country that is at the forefront of the water scarcity situation in
the MENA region. It is the least able to adapt; has a growing population; lacks
government control of water sources, which are dominated by local tribes; and has
an ongoing conflict, which is preventing any policies or approaches to ration water
or address the shortage (World Bank, 2014b). There is a 1.4 billion cubic meter
shortfall in water supply per year, which is being met by water pumped up with
modern tube wells or boreholes, depleting reserves of underground water. In rural
areas, when wells run dry, social tensions escalate into local conflicts. Mass dis-
placement from water scarcity causes migration and fuels the risk of wider conflicts
(World Bank, 2014b). With Yemen being mostly an agricultural country, crops in
Yemen are dying out because of water shortage leading to food insecurity, lower
incomes, higher unemployment and more displacement. Although southern parts of
Yemen are expected to have an increase in precipitation, this increase will be
through extreme rain events that are likely to cause considerable damage to crop-
land and will not be enough to replenish underground water (World Bank, 2014a).
The above examples within the region give an indication of the volatility of the
water situation in MENA and by no means cover all countries and challenges
related to water scarcity. Water scarcity will bring with it a multitude of negative
impacts in terms of agriculture and income, but also sanitation, violence and mass
migration. Droughts will be most severe in the coastal areas of North Africa, lead-
ing to decreases in precipitation and a decline in rain-dependent agriculture and
farming activities.
limate Change and Political Instability in Relation

C
to Refugees
Mass migration from flooding is expected to reach two billion at the global level by
the end of this century. More people will move inland as a result of coastal flooding,
becoming environmental refugees (Geisler & Currens, 2017). In the MENA region,
mass migration has largely been the result of violence and economic reasons.
There are attempts to link the refugee crises in Syria to global warming, citing
the drought that preceded the Syrian war in 2009. This is championed by notable
reporters such as Thomas Friedman and several other researchers (Kelley, Mohtadi,
Cane, Seager, & Kushnir, 2015); however, it might be an oversimplification of com-
plex geopolitical interests by regional and worldwide powers to control the region.
The evidence for climate change being responsible for the Arab Spring or the Syrian
war is only correlational in nature, and there is no evidence it was responsible for
this uprising. Such oversimplification ignores the history and political situation of
Syria and these countries. This connection between environment and war is not new
and originated from Malthus in the eighteenth century (Malthus, 1798). This con-
cept has been applied elsewhere in the MENA region such as Darfur, but there are
strong arguments against such an association (Verhoeven, 2011). Could the drought
in Syria and rapid urbanization by its rural populations have exacerbated the upris-
ing? It might have, but this cannot be said with certainty. There is anecdotal evi-
dence that frustration over lack of water and drought by farmers made it easier to
join a rebellion (Wendle, 2016). A more balanced explanation for the association
between climate change and the Syrian war and other conflicts would be to label it
as an eco-social or risk-multiplier (Butler, 2017), but the conflict would have hap-
pened regardless. The nature of this conflict goes back to decades of oppression; the
rebellion against dictatorships and oppression started in one place and then spread
elsewhere.
However, the risk is real regarding climate change leading to exacerbation or
triggering mass movements and future conflicts that result from such crises.
According to Brigadier General Stephen Cheney, a member of the US Department
of State’s Foreign Affairs Policy Board and CEO of the American Security
Project, “Climate change could lead to a humanitarian crisis of epic proportions.
We are already seeing migration of large numbers of people around the world
because of food scarcity, water insecurity and extreme weather, and this is set to
become the new normal. Climate change is acting as an accelerant of instability
in parts of the world on Europe’s footsteps, including the Middle East and Africa”
(Carrington, 2017).
Health of Refugees
Even though the initial trigger of the conflicts that led to the current refugee crises
are not necessarily related to the environment, the environment does exacerbate the
suffering of refugees. Challenges of extreme heat and cold, limited water access,
unemployment, rising food prices because of agricultural land degradation and
other factors relevant to climate change increase the suffering of refugees in their
host transitional countries such as Jordan, Lebanon, Egypt and Turkey. It is worth
noting that Jordan and Lebanon have the highest number of refugees per capita of
their respective populations. Therefore, the burden from migration is to a large
extent kept within the region. There was a massive refugee influx from transition
countries to Europe, mainly through Turkey. This in turn encouraged other refugees
coming from Afghanistan, Iraq, and sub-Saharan Africa to join the exodus and mass
migration by foot and boats, as smugglers established routes of illegal migration to
Europe. The Mediterranean Sea has become the graveyard for thousands who have
drowned on their path to reach Italy or other European countries. Others who sur-
vived the journey suffer the trauma of losing loved ones in the war or during their
dangerous path to Europe.
The health of refugees has been undermined by the lack of access to health care
for basic medical needs and the limited resources available in transitional countries
where they settle, such as Jordan, Lebanon, and Egypt. In Turkey, refugees gener-
ally have better access to health care. Refugees can also spread infectious diseases
through their mass movement across countries and because of living in unsanitary
conditions with no treatment, and limited or no access to health care (Vittecoq
et al., 2014).
One of the most important and highly neglected health needs of refugees is rec-
ognition and treatment of mental illnesses among both adults and children.
Historically, the region has had a stigma against mental illnesses and has a very
limited number of psychiatrists, estimated to be in the order of one psychiatrist per
100,000–200,000 people. Trauma from the conflicts and displacement is a long-
term cause of mental illnesses such as depression, anxiety, PTSD and suicide. While
the focus of NGOs and countries that care for refugees is on food and shelter, mental
illnesses are neglected and generations of children from Syria and other countries
suffer silently from loss and displacement.
We have shown through our own research among Somali refugees in San Diego
that mothers who have a history of severe trauma from before being resettled in the
USA continue to suffer mental illnesses and are more likely to have children who
suffer from depression or poor adjustment (East, Gahagan, & Al-Delaimy, 2017).
The trauma continues and might not heal like a physical illness. Therefore, poor
mental health is going to be a major health impact of climate change in the MENA
region among displaced populations, whether resulting from climate impacts on the
environment and livelihood of populations in the region or from ongoing civil unrest
and violence.
Solutions and Level of Preparedness
There is, to some extent, an understanding of the consequences of climate change on

the welfare of the countries in the MENA region by the governments of 11 countries
that have submitted Intended Nationally Determined Contributions (INDC) as of
September 2017 (Algeria, Bahrain, Egypt, Jordan, Saudi Arabia, Sudan, Qatar, UAE,
Palestine, Tunisia, and Morocco). Submissions vary in details of actions and poli-
cies; the most comprehensive was Jordan’s, which took a holistic approach and
developed a climate action plan. These countries plan mitigation and adaptation
strategies to a variable degree of detail. This is a positive indication, although there
is an equal number of countries from the region that still have not submitted
any INDC.
Some countries are generating specific data to support adaptation policies. One
such example is a recent study from Morocco, which demonstrated a tripling in
water deficit by 2050 due to increased demand, 30% less precipitation, and decreased
surface and underground water reserves (Seif-Ennasr et al., 2016). The authors pro-
posed 38 adaptation measures to address the impact of climate change and demon-
strated that the most cost-effective measure is water preservation and management.
In Lebanon, there is a new direction towards conservation agriculture as an alterna-
tive to intensive conventional agriculture (Chalak et al., 2017). UAE is focusing on
renewable energy and proposed the development of renewable energy and nuclear
energy as partial replacement energy sources to reach 25% of its energy expenditure
by 2020 (Paul, Al Tenaiji, & Braimah, 2016). In Saudi Arabia, the focus is on water
conservation by developing desalination plants, expanding water recycling pro-
cesses and infrastructure, transitioning from domestic agriculture to outsourcing
food products, and taking the reins on solar development to phase out fossil fuels.
Saudi Arabia is doing just about everything it can to ensure domestic water resources
will be available and accessible, and that it will be able to sustain these practices
(DeNicola, Aburizaiza, Siddique, Khwaja, & Carpenter, 2015).
Emergency heat wave adaptation plans should be implemented in each of the
MENA countries by utilizing several such plans already in place elsewhere in the
world. The same should be done for dust storms that are becoming more frequent;
these storms require preparation and prevention for their health impacts on vulner-
able populations through education and collection of data.
Solutions to decrease the impact of this major water shortage are possible but
require much effort, better governance, and a shift in thinking towards new
approaches and water conservation. Because the teaching of Islam indicates that not
wasting water is part of the faith, this can be put into the context of climate change
consequences for the predominately Muslim followers in MENA. Recycling water
is another important approach that can help prepare populations to deal with water
scarcity. Grey water (GW), which is wastewater generated from domestic activities
such as laundering, dishwashing, and bathing used to meet rising water demands,
comprises 50–75% of residential wastewater and is distinct from black wastewater,

which is collected from toilets (Eriksson, Auffarth, Henze, & Ledin, 2002; Friedler,
2004). Adopting GW recycling practices on a large scale may lower freshwater
demands and decrease groundwater extraction rates by up to 30–50%; this can
result in a decrease in the risk of aquifer salinization (Jeppesen, 1996). It has been
found by our survey and review of the literature that the main limitation for use of
GW is cost (Leas, Dare & Al-Delaimy 2014). There is general cultural acceptability
in MENA to use GW and no health-related impacts are reported, although more
epidemiological studies are needed to document its safety for use. Further, scholars
of Islam have already addressed the type of uses for GW that are allowed in Islam,
including its use for irrigation (Leas, Dare & Al-Delaimy 2014).
Conclusions
The MENA region is the global ground zero for climate change. It will be suffering
catastrophic heat waves and, especially during several months in summer, will be
beyond human capacity to be outdoors. It will be the first region to run out of fresh
water, it has a population growth that will increase demand for resources, and it is
suffering ongoing wars and civil unrest leading to displacement of mass popula-
tions. All of these have serious health consequences for the populations living in the
region. Lower-income populations will suffer the most, as they are less likely to be
protected by infrastructure or the means to adapt to this new environment brought
by climate change. Water scarcity and frequent desert dust storms bring many
adverse health consequences. There is also lack of awareness and education by the
general population of these impending catastrophes in this century and local media
coverage is very limited.
There is a need to support and encourage individual countries to aggressively
address mitigation and adaptation measures for the sake of current and future gen-
erations living in this region. Civil unrest and wars will be a major barrier towards
such efforts. However, as was done elsewhere in Latin America and Africa regard-
ing vaccination programs to create peace, the climate change problem can become
a unifying source in finding ways to work together to address the impact of climate
change as the leading public health problem of the century. Religious bodies and
entities in the region need to be informed and educated about the association
between the Muslim faith and protection of the planet to prevent and reduce the
health consequences of climate change. There is much at stake for the livelihood of
the millions living in the MENA region, but also in the rest of the world, as wit-
nessed by the mass displacements and refugee crises that have affected other
regions.
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19–28.
CHAPTER 11
Climate Change Risks for Agriculture,
Health, and Nutrition
Joachim von Braun
Summary The stability of global, national, and local food systems is at risk under
climate change. Climate change affects food production, availability of and access
to food, food quality, food safety, diet quality, and thus people’s nutrition and health.
Climate change may further slow progress towards a world with food security for
all. Climate change impacts will exacerbate food shortages, especially in areas that
already show a high prevalence of food insecurity. Climate change will affect good
nutrition through complex indirect pathways, such as income shocks when droughts
or floods occur, loss of employment opportunities, health effects resulting from air
pollution and changed water systems. A conceptual framework for a food systems
analysis is presented here, and the linkages within the system and expected changes
among them are elaborated—some on a global scale and some on a micro scale.
Policy actions are proposed and research gaps are identified.
Introduction
The global food system is malfunctioning, leaving large segments of the population
undernourished or malnourished and causing large environmental damage. Climate
change adds to the challenge. Climate change and agriculture are in a reciprocal
relationship: Greenhouse gas emissions related to land use and animal production
make agriculture an important cause of climate change. In turn, climate change and
its related extreme events affect agriculture and the food system through changing
production conditions and complex environmental and economic externalities,
some of which have serious impacts on human health and nutrition.
It is well understood that food security has strong linkages to agriculture with its
multiple functions for economy, ecology, and people’s livelihoods. The more spe-
J. von Braun (*)

University of Bonn, Bonn, Germany

136 J. von Braun
cific linkages between agriculture, food security, health, and nutrition have received
more research attention recently (Fan & Pandya-Lorch, 2012; von Braun, Ruel, &
Gillespie, 2012). However, further research is needed as the complex linkages
between food security and health are dynamic in the context of global change pro-
cesses, including climate change, urbanization, and market integration (Ruddiman,
Ellis, Kaplan, & Fuller, 2015). The linkages are not easily quantifiable which, how-
ever, does not imply they are weak (Masset, Haddad, Cornelius, & Isaza-Castro,
2012; Webb & Kennedy, 2014).
The focus of this chapter lies on some of these linkages in particular, with an
emphasis on additional risks for agriculture, food security, and related nutrition and
health problems emerging from climate change. Climate change may slow down
progress towards a world with food security for all. The stability of whole food
systems may be at risk under climate change, through shocks and increased vari-
ability in markets. On a global scale, a pattern of the impacts of climate change on
crop productivity, and thereby on food availability, emerges. Unless public policy
actions are taken, these climate change impacts will exacerbate food shortages,
especially in areas that already show a high prevalence of food insecurity. Climate
change will also affect access to food and high-quality nutrition through indirect
pathways such as income shocks, when droughts or floods occur, burden on (wom-
en’s) time use, and loss of employment opportunities. Health effects are caused by
air pollution (indoor and outside) and possibly through changed water systems.
In view of the complex links through which climate change may have an impact
on global food security, a food systems approach is needed. A conceptual frame-
work for a food systems analysis is presented first, then linkages within the system
and expected changes among them are elaborated—some on a global scale and
some (if widely prevalent) on a micro scale. Finally, policy actions are proposed and
research gaps that warrant our attention are identified.
onceptual Relationships of Agriculture, Food Security,

C
and Health Under Climate Change
Agriculture is inherently sensitive to climate variability and change, whether due to

natural causes or human activities. Climate change due to emissions of greenhouse
gases is expected to directly impact crop production systems for food, feed, or fod-
der; to affect livestock health; and to alter the pattern and balance of trade of food
and food products. These impacts will vary with the degree of warming and associ-
ated changes in rainfall patterns, and from one location to another, but underpinning
these impacts are a number of direct effects on the physiology of crops grown for
food, feed, fuel, and fiber as well as on the pests and diseases of livestock and crops.
A conceptual framework is put forward here. The concept takes a broad perspec-
tive on agriculture, comprising crops, animal production, and connected value chains
as well as the natural resource base of land and water use, and the technological
11 Climate Change Risks for Agriculture, Health, and Nutrition 137
Fig. 11.1 Conceptual framework—a food systems perspective (Adapted from von Braun, 2017)
foundations of agriculture. Institutions, information, and behavior are interdependent

issues that influence linkages in all of the domains that describe the framework. The
linkages of food security and agriculture with health can be broadly grouped into six
domains as depicted in Fig. 11.1, and all of these are influenced by climate change
in various ways:
Link 1: Agricultural production- and processing-related health linkages are central,
especially in the long run. They entail, for example, diet-, nutrition-, and health-
sensitive agriculture, paying attention to food supply and access to nutrients with
diverse diets, quality and safety of foods, and production conditions (Pontifical
Academy of Sciences and Global Alliance for Improved Nutrition, 2018). To the
extent that climate risks add instability in production, the direct and indirect link-
ages to food security and health are adversely impacted. Technology is critical
for these links.
Links 2 and 3: Income- and employment-related linkages greatly determine access
to nutrition and health, especially by marginal farm households and agricultural
laborers (Gatzweiler & von Braun, 2016). If, under a climate shock, rural labor
markets contract for services and landless laborers, there may be adverse impli-
cations for health and nutrition. For instance, health services may become unaf-
fordable and often school fees are no longer paid. Agriculture and income and
employment links are fundamental for onward linkages to nutrition.
Links 4, 5, and 6: Linkages with markets and services drive nutrition and health via
income, but also directly via food price formation and forward and backward
market linkages. If services and infrastructures are malfunctioning under climate
stress, the adverse impacts of climate change increase. Markets and services are
138 J. von Braun
critical for delivering affordable nutritious food as well as nutrition and health-
related services. Under increased climate risks, investments in health and nutri-
tion services will need to expand to enhance the adaptation capacities of the poor.
Efficiency of markets and inclusive services with insurance mechanisms are key
forces behind income and employment generation and households’ capacity to
deal with risks and shocks. This, in turn, drives many aforementioned linkages.
Like any framework, simplifications and abstractions are implicit in order to
focus on key causal linkages. The linkages include various feedbacks among them,
such as from health to production through impaired labor productivity (which may,
for instance, be adversely affected by stress from heat waves), and from markets to
income through prices and consumption effects. Overarching, and surrounding
Fig. 11.1, are agricultural and environmental as well as macroeconomic framework
conditions. Related linkages exist on a global scale, such as links related to green-
house gas emissions and, on a local scale, water and sanitation in the context of
irrigated agriculture. All the links operate with diverse dynamics under short- or
long-term time lags, which require attention in policies and programs. This outlined
framework also demonstrates the need for attention to the complex causal linkages
and behavior change in food systems that need to be considered in modelling cli-
mate change impacts on populations and wellbeing. Neglecting these linkages and
indirect effects may over- or underestimate climate change threats for people.
The following sections of the chapter address selected components of the frame-
work in which food security, agriculture, and health/nutrition linkages may be
affected by climate change.
Climate Risks for the Stability of the Entire Global Food System
Before reviewing key linkages within the food system, the system as a whole is
considered because the stability of whole food systems may be at risk under climate
change. Important issues here are extreme events, especially in production, crop and
animal pests, and markets. Climate change is likely to increase food market volatil-
ity from the production and supply side. Demand-side shocks are also possible in a
political economy context, such as in the case of aggressive bio-energy subsidies
and quota policies. Policy shifts of the last decade in the USA and EU were partly
motivated by energy security and partly by climate mitigation objectives. The result-
ing destabilization effects in food markets, which contributed to large food security
problems, were therefore partly related to climate change policies. Climate change
may be one trigger of effects for broader destabilizations of food security, including
the risk of high and volatile food prices, which temporarily limit poor people’s food
consumption (Kalkuhl, Braun, & Torero, 2016); financial and economic shocks,
which lead to job loss and credit constraints; and the risks that political disruptions
and failed political systems pose for food security, such as conflicts over land and
water, which are increasing under climate change. These complex system risks can
assume a variety of patterns and can become high-risk combinations.
Landmark studies on climate change and agriculture since 1994 include those by
Parry, Rosenzweig, Iglesias, Livermore, and Fischer (2004), Cline (2007), and the
World Bank (2010). These studies focus mainly on production effects and, in some
cases, on the expected changes of average prices. More recent studies highlight the
roles of mitigation and adaptation interventions for the reduction of climate change
impacts (Richardson, Lewis, Wiltshire, & Hanlon, 2018). Baldos and Hertel (2015)
quantify the crucial role of a well-functioning global trade system for the reduction
of climate change impacts on food security. Extreme weather events need to be
considered in comprehensive climate change impact analyses (Lesk, Rowhani, &
Ramankutty, 2016). In a recent global modelling study, this is embedded in the
determinants of risks for global crop production for maize, wheat, rice, and soy-
beans over the period 1961–2013 (Haile, Wossen, Tesfaye, & von Braun, 2017).
Using seasonal production data, price change and price volatility information at the
country level, as well as future climate data from 32 global circulation models, it is
projected that climate change could reduce global crop production by 9% in the
2030s and by 23% in the 2050s. Climate change is expected to lead to 1–3% higher
annual fluctuations of global crop production over the next four decades.
Furthermore, Haile et al. (2017) found:
• A strong, positive and statistically significant supply response to changing prices
for all four crops. However, output price volatility, which signals risk to produc-
ers, reduces the supply of these key global agricultural staple crops—especially
for wheat and maize.
• Climate change has significant adverse effects on production of the world’s key
staple crops.
• In particular, weather extremes—in terms of shocks in both temperature and
precipitation—during crop growing months have detrimental impacts on the pro-
duction of the abovementioned crops. Weather extremes also exacerbate the
year-to-year fluctuations of food availability, and thus may further increase price
volatility with its adverse impacts on production and poor consumers.
The inclusion of volatility in the production and price developments (i.e., the
inclusion of risks associated with climate change) is the new aspect of this research,
which gives further insights. Combating climate change using both mitigation and
adaptation technologies is crucial for global production and hence food security on a
global scale. The projected effects of climate change on production (Fig. 11.2) use
the national climate data from country specific GCMs as forecasts with national reso-
lution to capture the heterogeneity of future climate change in the study countries.
The climate change impacts are more severe in the 2050s. Future climate change also
increases the risk associated with crop production: climate change increases the vari-
ance of crop production by 1.4% and 2.8% in the 2030s and 2050s, respectively.
Projected average crop production shows positive but small changes for coun-
tries such as the Russian Federation, Turkey, and Ukraine in the 2030s, whereas
production changes are negative and more pronounced for all countries in the 2050s.
140 J. von Braun
Fig. 11.2 Projected effect of climate change on food production (%) (Source: Haile et al., 2017)
These effects on the climate-induced average food production changes have signifi-
cant implications for global food security for two reasons: (1) wheat, rice, maize,
and soybeans make up about three-quarters of the food calories of the global popu-
lation; (2) our study countries produce more than 85% of the global production of
these crops. Technological advances for sustainable production systems and trade
for balancing regional and local deficits may need to expand to cope with the risks
for food security.
Functioning agricultural markets are important for access to food and services
and, thereby, also for income and health (Kalkuhl et al., 2016). However, volatility
in prices, even in efficiently functioning markets, may adversely impact consump-
tion capabilities and health. Price volatility is not a new phenomenon, though some
of its causes are. Several studies (e.g., Abbott, Hurt, & Tyner, 2011) have identified
the drivers of price upsurges, such as biofuel demand, speculation on future com-
modity markets, public stockholding, trade restrictions, macroeconomic shocks to
money supply, exchange rates, and economic growth. Tadesse, Algieri, Kahkuhl,
and von Braun (2014) found that a food crisis is more closely related to extreme
price spikes, whereas long-term volatility is more strongly aligned with general
price risks. In 2007–2008, the prices for almost all food commodities increased
significantly, inducing negative effects especially for low-income countries and the
part of their population that spends the biggest share of their income on staple foods.
To the extent to which climate shocks result in price spikes, health and nutrition
consequences can be serious for the poor (Kalkuhl et al., 2016).
Large parts of the world, where negative impacts of climate change on crop
production are expected, coincide with countries that currently have high levels
of food insecurity. There is a robust and coherent pattern at the global scale of the
impacts of climate change on crop productivity, and most likely on food avail-
ability. These impacts will exacerbate food insecurity in areas that currently show
Fig. 11.3 Climate variability and change, and food security (Sources: see inside the figure)
a high prevalence of hunger (Fig. 11.3) as identified by the Global Hunger Index

(Welthungerhilfe and Concern International, 2018).
gricultural Production- and Processing-Related Health

A
Linkages Under Climate Stress
Utilization of food depends much upon behavior and the health environment
(including water and sanitation), so any impact of climate change on the health
environment also affects this dimension of and pathway toward food security.
Research on these links and climate change is rather weak, but some meaningful
extrapolations can be derived from related research (Wheeler & von Braun, 2013):
• Links with drinking water may be the most obvious when climate variability
further strains clean drinking water availability. Hygiene may be equally affected
by extreme weather events (e.g., floods) in environments where sound sanitation
is absent.
• Additionally, the uptake of micronutrients is affected negatively by diarrheal dis-
eases, which strongly correlate with temperature.
142 J. von Braun
• Other pathways from climate change to nutrition potentially work through risks
from climate change for diet quality or, for example, increased storage costs and
pest attacks that may result from ecological shifts.
This brings out the importance of non-food inputs in food security, including
infrastructure and health services for adaptation and coping. While problems of
insufficient and poor-quality food persist, global changes are creating new nutri-
tional issues such as the “nutrition transition”—a process by which urbanization
and changes in lifestyle are linked to excess caloric intake, poor-quality diets, and
low physical activity, which together lead to rapid rises in obesity and chronic dis-
eases, even among the poor in developing countries. The nutrition transition will
unfold in parallel with the climate change process in coming decades. Very little
research on the potentially re-enforcing effects of the two has been conducted.
As pointed out in the framework above, agriculture-related health linkages are
direct through availability and indirect via income-related effects. In particular,
rural populations in low- and middle-income countries are significantly influenced
by the linkages between agriculture and health, as their economies are often highly
dependent on agriculture as a major provider of employment and income. Direct
agricultural production–health linkages need to take into account that the majority
of the world´s poor live on small farms. There are about 570 million farms world-
wide, the majority of which are very small and located in China, India, and Africa
(von Braun & Mirzabaev, 2015). Improving the productivity and incomes of small-
holder farmers can help significantly to reduce poverty. There are several ways how
this can be achieved. First, commercialization and technological innovations among
smallholders can help reduce poverty (Gatzweiler & von Braun, 2016).
Diversification from solely staple crop production to the production of commer-
cially high-value crops is another avenue for reducing poverty among smallholders.
Diversification typically may also involve specialization at the farm level, with
growing variety of production and processing at the regional level. Efficient storage
and food processing plants are as important as improving agricultural systems to
provide a diverse and safe diet (Keding, Schneider, & Jordan, 2013).
Part of the solution is nutrition-sensitive agriculture, which focuses on the causes
of malnutrition and is more long-term oriented (Balz, Heil, & Jordan, 2015). The
approach encourages production and consumption of a variety of foods, recognizes
and emphasizes the nutritional value of food, and considers the significance of food
production for the agricultural sector as well as for rural livelihoods (Thompson &
Amoroso, 2014). The provision of information for consumers is essential to the suc-
cess of this kind of intervention.
A host of studies are now available on communities and households on the micro-
level being exposed to climate shocks. These approaches tend to capture more adap-
tation capabilities than macro-models, such as assets draw down, job-switching
migration, social policy responses, and collective action, as shown in detail by Rakib
and Matz (2016) for rural Bangladesh. These studies should be a basis to expand
analyses into health effects. Taken together, macro modeling and micro-level analy-
ses of climate change linkages to food security are complementary.
I ncome- and Employment-Related Linkages of Climate

Change
Food access and utilization of foods may be impacted by climate change through
indirect but rather strong pathways. Access to food is largely a matter of household
and individual-level income, of capabilities and rights as well as of behaviors. Food
access issues have been studied through two types of approaches: top-down by
models that attempt to link macro-shocks related to climate change to responses and
adaptation outcomes (Nelson et al., 2010; van Meijl et al., 2018); and by commu-
nity- and household-level studies that try to assess climate change effects bottom-
up. Specific findings of top-down approaches are heavily dependent on the

assumptions made about future income and population growth, but in general clear
linkages between economic growth and resilience to climate change can be shown.
Springmann et al. (2016) modelled the relationships between climate change, diet
change, and related health outcomes at the global scale and found adverse health
effects.
Agricultural practices can also be the source of health hazards through the use of
toxic substances, such as pesticides and fertilizers. Mycotoxins are another case in
point, which evolve, for example, due to improper crop handling or use of inferior
seeds (Smith, Stoltzfus, & Prendergast, 2012). More unpredictable flooding and
strong rains are likely to increase the risks of mycotoxins.
In addition, there are several foodborne diseases that can occur through the mis-
handling of agricultural products. For this reason, effective food safety schemes are
just as important to promote health as are policies to reduce food insecurity
(Pontifical Academy of Sciences and Global Alliance for Improved Nutrition,
2018). Heat waves make food handling more difficult in low-income countries.
Cold chains may in the long run become more accessible for the poor due to decen-
tralized (solar) energy systems, but that is still in a distant future for many low-
income rural households. Facilitating access to safe foods by such means as cold
chains should increasingly be considered a matter of public health investment,
rather than consumer subsidies.
inkages of Climate Change and Health via Markets

L
and Services
A particularly complex set of agriculture-health linkages lies within the broader

ecological and public health context of farming communities. An important subset
of these is the environmental health linkages of partly agriculture-related water
quality and quantity problems interacting with farm populations’ sanitation and
hygiene behaviors. The importance of water quality for health is well known. The
impact of agriculture on both the water quality and quantity with respect to health
issues, though, is not well researched. The health costs of sanitation and water prob-
144 J. von Braun
lems are large. In addition, in peri-urban settings, farmers often have neither the
choice to use other water than wastewater for irrigation, nor do they have the knowl-
edge on the potential risks related to that resource (Qadir et al., 2010)—including
harm for human health and the environment through the introduction of pathogens
or contamination with chemical substances. There is also a clear linkage between
these health, environmental, and behavioral issues on the one hand and the nutri-
tional status and farming on the other hand (Usman, Gerber, & Braun, 2018).
The Water-Energy-Food Security Nexus surrounds the energy decision-making
process of rural households. The rural energy system and its impacts on environ-
ment, agriculture and health are connected in complex ways to climate change.
Attention is drawn here to just one of the complex relationships: The majority of
rural households in developing countries continue to depend on unreliable, ineffi-
cient, and harmful household energy technologies. As a consequence, many of the
poorest people are exposed to household indoor air pollution from cooking and
heating with dirty energy and inappropriate technology. This results in large mortal-
ity and disease rates, mainly among children and women of poor households who
cook and spend more time indoors than men (Smith et al., 2014). The problem is
old, but it may change further with increased climate risks. The link to climate and
environmental change is indirect but can be particularly strong for the poor, as it is
often based on collected fuel wood (mainly by women), cow dung cakes (South
Asia), and charcoal, with adverse effects on ecologies. Women’s time allocation for
energy production (such as fuel wood collection or producing dung cakes), for food
and for home goods production is a critical element of the linkages. When, for
instance, distance to collectable fuel wood increases due to deforestation and land-
use change—both being important forces of greenhouse gas emissions—women’s
time investments for collecting fuel wood increases, which may come at the cost of
sustainable local food systems. Development of village energy systems (e.g., solar
or bio-based) is important to facilitate the needed cooking, lighting, power, and
irrigation of the village community in sustainable ways, and this cannot be achieved
by individual household initiatives. Also, clean cooking stoves fit financially, tech-
nically, and according to the perceptions of communities, have a potential to reduce
the adverse health effects of indoor pollution from smoke in low-income communi-
ties in rural areas.
Policy Implications and Research Challenges
Action needs to be taken by policy-makers and practitioners confronted with the

prospect of climate change impacts on food security, nutrition, and health primarily
regarding these threats:
1. Climate change-related production and price volatilities will increase risks and
uncertainties within the global food system, and impact food and nutrition secu-
rity through food availability and price effects.
2. Climate change impacts on food security as well as related health and nutrition
aspects will be worst in countries already suffering from high levels of hunger,
and they will aggravate over time. Doing nothing in response to climate change
will have potentially large consequences for global undernutrition and malnutri-
tion, and this will worsen over time.
3. Inequalities and locations of food insecurity may change. People and communi-
ties who are currently vulnerable to the effects of extreme weather may become
more vulnerable in the future, as they are less resilient to climate shocks.
Action needs to be directed towards what could be termed a “climate-smart food
system”—not just climate smart agriculture—that addresses climate change impacts
on all dimensions of food and nutrition security. Research initiatives need to be part
of the action agenda (Campbell et al., 2016). Governance of food systems matters
too. Exploiting the positive linkages between agricultural production and health is
particularly constrained by intersectoral and disciplinary bias that impedes collabo-
ration (von Braun et al., 2012). A policy study of Africa found that intersectoral
collaboration for nutrition is enhanced when there is inclusive programming and
jointly agreed-upon and compatible monitoring and evaluation in place (Malabo
Montpellier Panel, 2017). Much more of that is needed under increased climate
risks. Considerable investment in adaptation and mitigation actions is needed to
slow the impacts of climate change on the progress of global hunger. There is a wide
range of potential adaptation and resilience options. These need to address food
security in its broadest sense and be integrated into the development of agriculture
worldwide.
Strengthening agricultural resilience through science, change in technology and
production systems is a key part of this. However, it is not sufficient on its own for
global food security. The whole food system needs to adjust with strong attention to
science-based insights, trade, stocks, nutrition and health, and social policy options,
as outlined by the InterAcademy Partnership (2018). Related priorities for research
include:
1. Climate change impacts on food access, nutrition, and health should be more
comprehensively considered.
2. Much of the climate change impacts on food security are rather indirect, but that
does not mean they are small. Understanding these indirect impacts requires
more comprehensive analytical approaches and sophisticated modelling, includ-
ing their political economy linkages.
3. Better integration of research on the human dimensions, including understand-
ing behavior and collective actions, together with biophysical changes will be
central to understanding and identifying policy options in support of food secu-
rity and healthy living under climate change-related risks.
Important is the strengthening of data basis and monitoring. The “Lancet
Countdown” aims to track the health impacts of climate hazards; health resilience
and adaptation; health co-benefits of climate change mitigation; economics and
finance; and political and broader engagement (Watts et al., 2017). This could also
strengthen capacities to integrate health in climate modelling.
146 J. von Braun
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CHAPTER 12
Sustaining Water Resources
Paolo D’Odorico and Ignacio Rodriguez-Iturbe
“As the rain and the snow

come down from heaven,
and do not return to it
without watering the earth
and making it bud and flourish, …”
(Isaiah 55:10)
Summary Life depends on water and there are no substitutes. Fundamental to the
functioning of the Earth’s system, water is a renewable natural resource that is avail-
able in finite amounts. Human appropriation of freshwater resources is mainly used
for agriculture. To prevent loss of natural habitat and biodiversity, the growing
demand for agricultural products will likely need to be met by enhancing crop yields
in currently cultivated land rather than through farmland expansion. Because of
local limitations in water availability, irrigation can be sustainably expanded only in
part by the currently rain-fed farmland. Any further withdrawal from water bodies
would deplete environmental flows or groundwater stocks. Local water deficits (i.e.,
gaps between availability and demand, including water for food) are often compen-
sated for by food imports from water-rich regions and the associated transfers of
“virtual water.” Thus, water is a strategic resource that has become strongly global-
ized and controlled by a few countries, while the rest of the world is in conditions
of trade dependency. Water-saving strategies—based on food waste reduction, mod-
eration of diets, use of more suitable crops, or increased water use efficiency—need
to be adopted in order to meet human needs without compromising water
sustainability.
P. D’Odorico (*)
University of California, Berkeley, CA, USA
I. Rodriguez-Iturbe
Texas A&M University, College Station, TX, USA

150 P. D’Odorico and I. Rodriguez-Iturbe
Background
Water is essential for life on Earth and plays a crucial role in determining the global
distribution of biomes as well as habitats for aquatic and terrestrial species (e.g.,
Whittaker, 1975). It also shapes the land surface through erosion and deposition
processes; transports sediments, nutrients, and pollutants; and drives the dispersal
of a number of species and pathogens (e.g., Dunne & Leopold, 1978). Water is also
an important determinant of the Earth’s climate because of heat storage in water
bodies, the impact of evaporation and transpiration on the surface energy balance,
and the effect of water vapor on atmospheric radiative transfer. Water availability
affects the productivity of terrestrial ecosystems, the rate of global biogeochemical
cycles, and the composition of plant, microbial, and animal communities (e.g.,
Rodriguez-Iturbe & Porporato, 2005). The impact of water resources on human
societies is evidenced by the critical role of water in a number of human activities,
such as agriculture, manufacturing, energy generation, and mining.
The majority of terrestrial ecosystems and most human activities rely on fresh-
water, which accounts for about 3% of the global water resources (with the remain-
ing 97% being in the oceans). Most of the freshwater on Earth is in ice caps (≈69%)
and groundwater (≈30%), while only about 1% is stored in surface water bodies and
vegetation.
Atmospheric water reaches the land surface as precipitation and then either flows
downhill as surface runoff or infiltrates into the ground, thereby contributing to root
zone soil moisture and groundwater recharge (Fig. 12.1). Water retained by capillary
Fig. 12.1 Blue water flows (i.e., runoff) and green water flows (i.e., evapotranspiration) out of
land masses
12 Sustaining Water Resources 151
forces in shallow unsaturated soils is often termed “green water” because it is largely
used by plants and soil microorganisms that can exert the suction required for extrac-
tion. The majority of terrestrial plants relies on green water. Conversely, groundwa-
ter (i.e., in the saturated portion of below-ground water stocks) and surface water are
often referred to as “blue water” (Falkenmark & Rockström, 2004).
Water leaves land masses either in the liquid phase as blue water flows, or as
water vapor fluxes associated with evapotranspiration (i.e., green water flows)
(Fig. 12.2). Globally, blue water flows account for about 40% and green water flows
for 60% of the water fluxes from land masses. These proportions, however, vary
across geographic regions and have been altered by human action.
The two major anthropogenic disturbances to the water cycle are associated with
land use change and irrigation. These phenomena have opposite effects on hydro-
logical processes. Land use change—typically in the form of deforestation and land
conversion to agriculture—tends to reduce evapotranspiration and increase runoff
(e.g., Bonan, 2008). In other words, it reduces green water flows and increases blue
water flows. Conversely, irrigation, which accounts for the majority (≈70%) of water
withdrawals for human activities, uses blue water from streams, lakes, and aquifers
to enhance agricultural yields by increasing crop evapotranspiration (i.e., turning
blue water into green water flows). In many regions of the world, the latter effect is
predominant and explains the observed reduction in river flows in major agricultural
regions. Indeed, some rivers (e.g., the Rio Grande, Colorado, Nile, and Yellow
Rivers) are so strongly depleted that they do not reach the ocean anymore. Particularly
emblematic are the cases of endorheic basins, such as Lake Chad, The Dead Sea,
The Aral Sea, and Lake Urmia, which are drying out because of water withdrawals
from their tributaries (e.g., Stone, 2015). Likewise, many aquifers around the world
are strongly depleted because withdrawals (often for irrigation or municipal uses)
Global Blue Water Uses Water Consumpon in Agriculture

(Blue + Green)
4%
4% 5%
30%
67%
87% 3%
Irrigation Domestic Food and Fiber Crops

Industrial Energy Biofuels
Livestock (feed + rangeland)
Fig. 12.2 Global blue water consumption (left) and total (blue and green) water consumed in
agriculture (data from Table 12.1 for years around 2000)
are occurring at rates exceeding those of groundwater recharge, a phenomenon often

known as “overpumping” (Konikow, 2011; Wada et al., 2010). Moreover, agriculture
may affect the water cycle through the impacts of irrigation and land use change on
precipitation, evapotranspiration and runoff (e.g., Bonan, 2008).
Changes in the water cycle are also emerging as a result of climate warming,
which causes a slight intensification of the water cycle with a 2–3% increase both in
global precipitation and evapotranspiration per Celsius degree of global tempera-
ture increase. These global averages, however, do not show how local precipitation
is expected to either substantially decrease or increase depending on the location.
As a general pattern, humid regions (e.g., at the equator and midlatitudes) are
expected to become wetter, while drier regions (e.g., the subtropics) drier (Held &
Soden, 2006). The impact on crop production, however, should also account for the
effect of increased atmospheric CO2 on photosynthesis and the nutritional proper-
ties of crops (Myers et al., 2014).
Thus, water is a renewable resource that is conserved within the earth system.
Some water stocks (e.g., glaciers, aquifers, and endorheic lakes), however, are
undergoing depletion. Likewise, in some areas, water quality is degraded by pollu-
tion from chemicals, suspended sediments, and pathogens. Despite its renewability,
water is available on Earth only in limited amounts. Therefore, some human activi-
ties are constrained by the pace of the water cycle, and competition often exists
between human uses and environmental needs.
Human Appropriation of Water Resources
Human societies use “blue” water resources for agriculture, industrial, energy, and
household needs. The majority of these uses are related to crop production, in the
form of irrigation water (Fig. 12.2). Therefore, contrary to common perception, the
global water crisis is all about finding solutions to mitigate and prevent hunger
rather than thirst (e.g., Falkenmark & Rockström, 2004). Thus, problems of water
scarcity are closely related to important constraints on food production. While eco-
nomic access is often recognized as the main cause for undernutrition, limited avail-
ability in periods of drought is typically the driver overlying spikes in food prices
and associated food crises. Insufficient caloric intake may cause acute malnutrition
(weight loss and/or inability to gain weight), a major cause for child mortality.
Insufficient protein intake in the first 1000 days in the life of a child can cause
chronic malnutrition (i.e., stunting) with permanent physical and cognitive impair-
ment in children. Overall, malnutrition affects about 800–900 million people world-
wide. Even though protein-rich food products tend to require three to six times more
water per calorie than plant food, this chapter shows how the water needed to eradi-
cate undernutrition can be sustainably met by the global water resources of the planet.
In this context, there is a difference between water withdrawals from water bod-
ies and water consumption (i.e., evapotranspiration) by agriculture. Only a fraction
of the water that is withdrawn from water bodies and applied to cropland is actually
evapotranspired. The difference between the two eventually contributes to return

flow to nearby water bodies and is available downstream for human uses or environ-
mental need. Conversely, the water lost through evapotranspiration (or “consump-
tive use”) will become available again after precipitation at a rate determined by the
pace of the water cycle.
The energy sector is also a major water consumer, though at much smaller rates
than that of agriculture. Almost all forms of energy production require water, both
for the extraction of energy resources and for power generation. It has been esti-
mated that energy production (2014 data) accounts for 400 km3/year of blue water
withdrawals and 50 km3/year of consumptive use (IEA, 2016). These estimates
include blue water for primary energy source extraction and power generation
(Table 12.1) but do not include green water consumption for energy production
from biomass (e.g., wood, bioethanol, and biodiesel) and losses from reservoirs for
hydropower generation. The total water consumption for biofuel production is
roughly 200 km3/year (Rulli, Bellomi, Cazzoli, Carolis, & D’Odorico, 2016), which
is about 2.4% of the water use in agriculture (Table 12.1).
Environmental Impacts of Water Withdrawals
The impacts of overpumping differ depending on whether it affects aquifers or sur-

face water bodies. Many regions of the world, including the North-American
Southwest, Northern Africa, the Indo-Gangetic Plain, the North China Plain, and
the Arabian Peninsula, are affected by groundwater depletion (Konikow, 2011).
Globally, groundwater depletion accounts for 20–33% of global groundwater with-
drawals (Table 12.1).
The case of overuse of surface water resources is different because it raises con-
cerns about the loss of aquatic habitat. Indeed, freshwater ecosystems exhibit high
levels of biodiversity but are susceptible to much greater extinction rates (about five
times) than those of other terrestrial ecosystems (Postel & Richter, 2003). To main-
tain biodiverse freshwater ecosystems, we need to ensure that suitable minimum
flow and water quality requirements are met and that the timing, frequency, and
magnitude of both high and low flows are not disrupted. Ecologists have defined
minimum flow requirements (or “environmental flows”) to place a cap on sustain-
able water use (e.g., Pastor, Ludwig, Biemans, Hoff, & Kabat, 2014; Richter, Davis,
Apse, & Konrad, 2012).
Water Use for Agriculture
Most of the agricultural production on Earth is rain-fed and does not rely on irriga-
tion. Roughly 18% of the global cultivated land is presently irrigated (Fig. 12.3) and
contributes to about 40% of global agricultural production (e.g., Rosa et al., 2018).
Table 12.1 Global water flows and demands in km3/year

Annual flow
(km3 year−1) Year Source
Precipitation over land 120,000 Chow (1988)
– Evapotranspiration from land 72,000
(green water flows)
– Global runoff (blue water flows) 48,000
Planetary boundaries of blue water 4000 Rockström et al. (2009)
Water withdrawal for irrigation 2560 2000 Sacks et al. (2009)
Water consumption for irrigation 1280 2000 Siebert and Döll (2010)
899 1996–2005 Mekonnen and Hoekstra
(2011)
Unsustainable water consumption from 336 2000 Rosa et al. (2018)
irrigation
Groundwater consumption for irrigation 540 2000–2010 Siebert and Döll (2010)
Groundwater withdrawals 730 2000 Wada et al. (2010)
Groundwater depletion 140 2001–2008 Konikow (2011)
200 2000 Wada et al. (2010)
Water consumption for crop production 6670 1996–2005 Mekonnen and Hoekstra
(green + blue water) (2011)
11,800 2010 Carr et al. (2013)
Green water consumption for food 5771 1996–2005 Mekonnen and Hoekstra
production (2011)
6150 2000 Rosa et al. (2018)
Water consumption in rangelands and 910 1996–2005 Mekonnen and Hoekstra
pastures (2011)
Water for livestock production (blue and 2260 1996–2005 Hoekstra and Mekonnen
green) (2012)
Freshwater used for biofuel production 220 2013 Rulli et al. (2016)
– Green water for biofuel crops 170
– Blue water for biofuel crops 11
Virtual water trade (food only) 2810 2010 Carr et al. (2013)
Water grabbing 450 2013 Rulli et al. (2013)
Freshwater withdrawals for energy 400
production
– Primary energy source extraction 50 2016 IEA (2016)
– Power generation 350
Freshwater consumption for energy 50
production
– Primary energy source extraction 34 2016 IEA (2016)
– Power generation 16
Freshwater withdrawals from domestic 400–450 2000–2010 Wada et al. (2016)
sector
Freshwater consumption from domestic 42 1996–2005 Hoekstra and Mekonnen
sector (2012)
“Year” denotes the period considered in each study (see also D’Odorico et al., 2018)
Fig. 12.3 Current irrigated land. Areas with less than 5% irrigation (based on data by Siebert,
Henrich, Frenken, & Burke, 2013) and where more than 90% of crop water needs are met by rain-
fed agriculture have been masked. According to these criteria, irrigated areas account for
2.5 × 106 km2, which is about 18% of the global cultivated land. (Based on Rosa et al., 2018)
Rain-fed agriculture relies only on green water resources, while irrigated agricul-
ture uses both green and blue water.
Green water is often taken for granted because it is directly acquired with the
land without requiring investments in infrastructure for its capture or institutional
arrangements to define the right to use it. The choice to plant certain crops may
strongly affect evapotranspiration losses, with an indirect impact also on runoff.
These effects of agriculture on croplands’ hydrologic response are often ignored.
Sustainable and Unsustainable Water Use for Irrigation
Estimates of global water consumption for irrigation (Table 12.1) vary between

900 and 1280 km3/year (Mekonnen & Hoekstra, 2012; Siebert & Döll, 2010),
while withdrawals range between 2410 (Jägermeyr, Pastor, Biemans, & Gerten,
2017) and 2560 km3/year (Sacks et al., 2009). Even though these values are well
within the sustainability limits (or “planetary boundaries”) identified by some
authors (≈ 1100–4500 km3/year, Gerten et al., 2013; Rockström et al., 2009) and
are way below the global estimates of blue water flows (4800 km3/year, see
Table 12.1), there are numerous instances of locally unsustainable water uses.
As a major form of human appropriation of blue water resources, agriculture is
the main reason why environmental flows have been strongly depleted in many riv-
ers worldwide. About 41% of water withdrawals for irrigation (Jägermeyr et al.,
2017) and 40% of irrigation water consumption (Rosa et al., 2018) are unsustain-
able because they occur at the expenses of environmental flows and/or groundwater
stocks (Fig. 12.3).
Fig. 12.4 The water

footprint of major crops
and animal products (based
on data in Davis et al.,
2016)
Livestock Production
About 30% of agricultural water consumption is used for livestock production,

mostly (>90%) in the form of green water for feed, fodder, and rangeland grazing
(Table 12.1). It takes much more water to produce a calorie of food from animal
products than from crops. The consumption of meat-rich diets remains a water-
intensive (and carbon-intensive) lifestyle (e.g., Davis et al., 2016; Tilman, Balzer,
Hill, & Befort, 2011). Thus, the observed trend of decreasing cereal consumption
and increasing reliance on animal products with increasing levels of affluence
(Tilman et al., 2011) is expected to enhance the human pressure on global freshwa-
ter resources (e.g., Davis et al., 2016). Are these hydrologic effects of dietary
changes on water consumption of the same order of magnitude as those of demo-
graphic growth? Using a GDP-based projection of dietary change, Davis et al.
(2016) estimated that by 2050 the average per capita water consumption for food
production will increase by 19% from the present level, while population growth is
expected to increase by 35%, reaching 9.8 billion people by 2050. Thus, the hydro-
logic impact of dietary shifts in the burgeoning developing societies is expected to
be of the same order of magnitude as demographic growth (Fig. 12.4).
Projections of Future Water Needs for Food Production
To meet the food needs of the increasing global population while eradicating under-
nourishment, humanity will likely need to reduce food waste and the consumption
of resource-intensive products (e.g., Foley et al., 2011). In fact, there are limits to
the sustainable increase in food production, and some of these limits are associated
with water resources (Falkenmark & Rockström, 2004).
Recent studies have stressed the danger of increasing food production by expand-
ing agriculture because it would result in habitat destruction, biodiversity loss and
CO2 emissions. Therefore, scientists have been advocating for the intensification of
agriculture in land that is presently cultivated (or “land sparing”) (Foley et al.,
2011). Intensification typically requires the use of fertilizers, irrigation, and other
modern technology to close the yield gap, which is the difference between actual
and maximum potential yields. Yield gap estimates are typically developed without
evaluating to what extent the local hydrologic conditions allow for a sustainable
development of irrigation. Indeed, large tracts of agricultural land are not suitable
for sustainable irrigation, while in 26% of currently rain-fed areas it is possible to
irrigate without depleting environmental flows or groundwater stocks (Rosa et al.,
2018). If at the same time current unsustainable irrigation practices (Fig. 12.3) were
eliminated, sustainable irrigation expansion would allow for a 24% increase in
global food production that could feed an additional 1.8 billion people (Rosa et al.,
2018). Collectively, these results demonstrate the existence of limits to the sustain-
able appropriation of water resources for agriculture and to humanity’s ability to
sustainably increase food production. Further needs for water resources for food
production will need to result from water conservation (D’Odorico et al., 2018).
Pathways to Water Conservation
A more sustainable approach to water and food security looks at a reduction of

consumption as an alternative to increasing production. The ongoing pattern of
overconsumption can be broken by reducing food waste, promoting the shift to diets
that are less resource intensive, and decreasing the amount of food intake in over-
nourished populations.
Waste Reduction
About 24% of the water used for food production is lost through food waste (Kummu
et al., 2012). These losses occur at different stages along the “farm to fork” supply
chain, depending on the type of food, access to refrigeration and transportation
facilities, and household habits. In the last few years, there has been a push toward
a circular economy of food to reduce resource consumption and waste accumulation
by repurposing and reusing food products (e.g., Stahel, 2016). In some countries,
the destruction of unsold food by retailers or distributors is avoided through timely
donations to food charities. Some food types can be reused to produce other food
commodities, or utilized as feed, compost or substrate for biogas production.

Likewise, nutrient-rich wastewater can be reused for irrigation, biogas production,
or to recover critical nutrients such as phosphorus (Cordell, Drangert, & White, 2009).
Changes in Diets
A reduction in human demand for water resources could result from a switch to less
meat-intensive diets. For instance, the shift to vegetarian or pescatarian diets would
save 18–21% of the water used for food production and improve human health
(Davis et al., 2016; Tilman & Clark, 2014). Human diets are the result of historical
habits and cultural heritages and are therefore hard to change (e.g., Wellesley,
Happer, & Froggatt, 2015). A positive sign can be seen in the ongoing livestock
transition, the replacement of resource-intensive bovine meat with pork and poultry
(Davis et al., 2016; Thornton, 2010).
Crop Water Management
While transpiration is a productive water loss from terrestrial ecosystems, evapora-

tion does not contribute to plant growth and can even negatively affect soil proper-
ties by increasing salinity. Therefore, to produce more food with less water,
agricultural practices need to reduce evaporation and maximize transpiration
(Falkenmark & Rockström, 2004). Improvement in water productivity based on soil
water management could reduce current water withdrawals for irrigation by about
1200 km3/year (Jägermeyr et al., 2016).
Improving Crop Suitability by Replacing Crops
Improvements in water use efficiency to produce “more crop per drop” can be
attained either by using new cultivars or by changing crop distribution. The current
distribution of crops often makes a suboptimal use of water resources. Water-
demanding crops are often planted in arid and semiarid regions. Perennial plants are
often cultivated in climates affected by episodic droughts that could kill what took
years to grow. Alternative crop distributions can maximize production and feed about
825 million additional people, while saving 12% of irrigation water without sacrific-
ing crop diversity, nutritional value, or land (Davis, Rulli, Seveso, & D’Odorico,
2017). This approach does not require major investments in modern technology that
small-scale subsistence farmers in the developing world might not be able to afford.
Water Savings through Trade
Another option to save water is through trade, that is, by producing crops in more
suitable areas and exporting them to other regions of the world. Indeed, the current
patterns of trade contribute to water savings for about 350 km3/year (Hoekstra &
Chapagain, 2008). Other studies found smaller savings and documented their
growth over time, from roughly 50 km3/year in 1986 to 240 km3/year in 2008 (Dalin,
Konar, Hanasaki, Rinaldo, & Rodríguez-Iturbe, 2012). Further savings could be
attained by reshaping trade patterns and future trade intensification.
Globalization of Water
When the withdrawal and consumption of freshwater resources are examined at the
global scale, human uses are dwarfed by the magnitude of global runoff and no
major environmental impact would seem to emerge from human action (Table 12.1).
At a local scale, however, water resources can be strongly stressed by agricultural,
municipal, and industrial uses. Several regions of the world are in a state of chronic
water deficit because their population by far exceeds the number of people the local
land and water resources are able to feed. The existence of countries that are strongly
water and food deficient appears to be paradoxical, as one would expect that these
conditions would trigger mass emigrations, social unrest, and conflict over the
scarce water resources. However, in general this is not the case because trade allows
societies to indirectly rely on water resources existing in other regions of the world
(Allan, 1998). In other words, the trade of food commodities is associated with a
virtual transfer of the water resources required for the production of those goods.
Known as “virtual water trade,” this mechanism contributes to the globalization of
water resources.
The international trade of virtual water accounts for about 25% of water use in
agriculture, including both green and blue water (Mekonnen & Hoekstra, 2012).
Thus, while 10–16% of the evapotranspiration by the terrestrial biosphere is contrib-
uted by agroecosystems, roughly one-fourth of it is virtually traded (Table 12.1). In
the last two decades and a half, virtual water trade has more than doubled in volume
and the trade network has become more interconnected. Net exports are mostly
contributed by a handful of countries, such as Brazil, the USA, Argentina, Thailand,
Canada and Australia (Carr, D’Odorico, Laio, & Ridolfi, 2013). These results sug-
gest that water is a strategic resource that is strongly globalized and controlled by
few countries, while the rest of the world is in conditions of trade dependency.
Water is also globalized though transnational land investments, a phenomenon
that has intensified over the last decade and a half. Since 2002, about half a million
square kilometers of land (i.e., 1.7 times the area of Italy) have been acquired for
agriculture and forestry (The Land Matrix, 2017). Land investors can be domestic,
foreign, or mixed domestic-foreign ventures that operate as private agribusiness
corporations, government-owned companies, or retirement funds (Cotula, 2013).

Investors often target both the land and the water that comes with it. Thus, land
acquisitions often become opportunities to secure access to both land and water
resources abroad (Dell’Angelo, Rulli, & D’Odorico, 2018; Rulli, Saviori, &
D’Odorico, 2013). “Water grabbing” is defined as the appropriation of water
resources by powerful investors at the expenses of local communities (Dell’Angelo
et al., 2018). Appropriation mechanisms may include the redefinition or realloca-
tion of water rights, river diversions, dam constructions, and virtual appropriation
of water resources through land acquisitions (Mehta, Veldwisch, & Franco, 2012;
Rulli et al., 2013). Interestingly, this phenomenon exceeds the rate of water grab-
bing from future generations through groundwater depletion (Table 12.1).
Conclusion
Freshwater is crucial to sustain ecological function, food security, energy produc-

tion, and investments in a variety of businesses. With challenges to water sustain-
ability emerging from growing societal pressures, humanity is facing the trilemma
of allocating water to food, energy, or environmental needs (D’Odorico et al., 2018).
How did we reach this point? There have been some major revolutions in the
food–water system. The industrial revolution brought about new sources of energy
and power, which allowed for the withdrawal and transport of unprecedented
amounts of water from surface water bodies and aquifers and the expansion of irri-
gation to areas not suitable for gravity-driven distribution systems. The green revo-
lution in the decades following World War II led to a major growth in agricultural
production with an incredible increase in crop yields. The early phases of the green
revolution hinged on the invention of nitrogen fertilizers (e.g., Erisman, Sutton,
Galloway, Klimont, & Winiwarter, 2008). At that point, water remained a major
limiting factor for crop production, which led to a renewed interest in irrigation
infrastructure and improvements in irrigation efficiency.
More recently, the water and food system have been transformed by a “trade
revolution.” The intensification of trade has allowed some populations to rely on
water resources existing elsewhere (Allan, 1998).
A “fourth food revolution” (D’Odorico et al., 2018) is associated with large-scale
land acquisitions, a phenomenon that has rapidly accelerated in the last few years,
likely in response to recent food crises (Cotula, 2013; Rulli et al., 2013). After some
trade-dependent countries experienced conditions of food insufficiency, several
agribusiness corporations started to look at regions of the developing world where
yields are low because of the lack of investments in modern agricultural technology.
This phenomenon contributes to the transition from subsistence or small-scale
farming to large-scale commercial agriculture and is often associated with large-
scale investments in agricultural land.
All these “revolutions” led to major changes in agriculture, through industrial-
ization, new technology, globalization, and transition in farming systems. With
these changes, humanity has been trying to meet the increasing needs of human
societies by sustaining ongoing growth trends in agriculture. Sadly, these changes
are frequently accompanied by unsustainable practices and acute social injustices
working against the poorest part of the populations. There is the need for new
approaches that focus on a reduction in consumption. The pathways to water saving
reviewed in this chapter could substantially reduce human consumption of water
resources.
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CHAPTER 13
Health Climate Justice and Deforestation
in the Amazon
Virgilio Viana
ummary Health is a dimension of tropical deforestation that deserves greater

S
attention in light of the current trends in climate change, environmental degradation
and national and subnational development policies. Forest fires are becoming more
frequent and larger in scale globally (Baccini et al., 2017). Deforestation fuels
global warming, and reducing forest fires is essential to meet the Paris Agreement
targets (UNEP, 2018).
Climate change is affecting rainfall regimes, including the length of dry seasons,
which fuels forest fires and thus creates a feedback loop mechanism. Increased fire
frequency results in air pollution, which is associated with a number of health prob-
lems. Ambient air pollution accounts for an estimated 4.2 million deaths per year
due to stroke, heart disease, lung cancer, and chronic respiratory diseases. Around
91% of the world’s population lives in places where air quality levels exceed World
Health Organization (WHO) limits (WHO, 2019).
The Amazon is home to 34 million people who are exposed to air pollution asso-
ciated with forest fires. This includes more than 380 indigenous groups of peoples
who suffer from one of the greatest climate injustices: despite having had a very low
carbon footprint, they are facing the consequences of climate change, including
health problems associated with air pollution from forest fires. Reducing deforesta-
tion and forest fires is relevant both for local populations and for mitigating global
climate change.
This chapter analyzes the linkages between health, air pollution and forest fires
in the Amazon. The goal is to highlight the importance of having an understanding
of the complexity of these linkages to encourage further research and policy
approaches.
V. Viana (*)
Sustainable Amazon Foundation (FAS), Cambridge, MA, USA

166 V. Viana
Deforestation and Fires in the Amazon
The Amazon is the largest tropical rainforest in the world, covering 6.7 million
hectares, spreading across eight countries and one province: Brazil (64.3%), Peru
(10%), Bolivia (6.2%), Colombia (6.2%), Venezuela (5.8%), Guyana (2.8),
Suriname (2.1%), Ecuador (1.5%), and French Guiana (1.1%) (RAISG, 2015).
While Brazil has 71.5% of the Amazon Basin, it has only 64.3% of the Amazon
Biome. The Amazon Basin represents 66% of the Brazilian territory, while the
Amazon Biome represents 58.8% of the country area. By contrast, Suriname and
French Guiana have practically no area in the Amazon Basin, while having 100% of
their territory in the Amazon Biome (Table 13.1). The Amazon is extremely diverse
in both biophysical and human dimensions. Therefore, this heterogeneity and com-
plexity has to be considered and generalizations for the region should be taken with
caution. This chapter focuses on Brazil, but most of the data and conclusions are
also relevant to other Amazonian countries.
The Amazon plays a vital role for the earth’s climate as a mega-provider of eco-
system services, including storage of live carbon (176.297 million tons/25% of
global storage) (FAO, 2011), conservation of biodiversity (over 10% of total spe-
cies) and a water pump to the atmosphere (over 20 billion tons of water every day)
(Nobre, 2014). The Amazon generates approximately half of its own rainfall by
recycling moisture five to six times as air masses move from the Atlantic across the
basin to the west (Salati et al., 1979).
Deforestation continues at an alarming rate: 7.900 km2 in 2018 in Brazil alone,
an increase of 13.7% from 2017 (INPE, 2019). Forest fires have increased similarly.
The Amazon has warmed, reaching 0.6–0.7 °C over the last 40 years, with 2016 as
the warmest year since at least 1950 (0.9 °C + 0.3 °C). The dry-season length
increased and more climate extremes affect the region with impacts on carbon
sequestration and storage, river streamflow, and biodiversity, even in the large for-
ested areas designated to conservation and protection (Marengo et al., 2018).
Recent studies have demonstrated that interactions between deforestation, fire,
and severe drought potentially lead to losses of carbon storage and changes in
regional precipitation patterns and river discharge (Davidson et al., 2012). A study
in the state of Rondonia, Brazil—a region that has been continuously deforested
since the 1970s—indicates that in areas highly deforested, the beginning of the
rainy season has significantly shifted to, on average, 11 days (and up to 18 days)
later in the year over the last three decades. However, in areas that have not been
heavily deforested, that did not happen. Delayed onset of rains may be a result of
land use change, and this signal may strengthen in future (Butt et al., 2011).
Amazon forest’s susceptibility to fires during extreme events is not only driven
by climate, but also the previous disturbance history, and modulated by forest struc-
ture. Heavily degraded forests with low canopy cover and biomass suffer water
stress and increased flammability earlier in the drought period than old-growth for-
ests (Longo et al., 2018).
13 Health Climate Justice and Deforestation in the Amazon 167
Table 13.1 Land and environmental profile of Amazon countries

% of total
% of total % of Amazon % of
Total area Amazon basin Amazon biome found Amazon %
(million found in each basin for in each biome for forest
Country km2) country each country country each country loss
Brasil 8,516,000 71.5 66 64.3 58.8 17.6
Bolivia 1,099,000 9.2 66 6.1 43.2 7.3
Colombia 1,142,000 4.4 30 6.2 42.3 9.9
Equador 283,560 1.8 51 1.5 41.1 10.7
Guyana 214,970 0.1 5 2.8 100 2.5
French Guiana 83,534 0 0 1.1 100 2.8
Peru 1,285,000 12.3 75 10.1 60.9 9.1
Suriname 163,821 0 0 2.1 100 4.2
Venezuela 916,445 0.7 6 5.8 49.5 3.3
Total 13,704,330 100 100 6.2
Source: SDSN-Amazonia at https://www.sdsn-amazonia.org/pt-plataforma
Amazon Tipping Point
A suite of general circulation model projections generally agrees, showing robust

cross-model drying in the Amazon and other regions (Cook et al., 2014). This can
generate feedback loops given the fact that the Amazon generates approximately
half of its own rainfall by recycling moisture five to six times as air masses move
from the Atlantic across the basin to the west (Salati et al., 1979).
Negative synergies between deforestation, climate change, and widespread use
of fire indicate a tipping point for the Amazon system to flip to non-forest ecosys-
tems in eastern, southern, and central Amazonia at 20–25% deforestation (Lovejoy
& Nobre, 2018). However, with the combined stress of rising temperature, defores-
tation, and increased forest fires, the tipping point may be reached significantly
earlier. To date, almost 18% of the Amazonian basin has been deforested (Gaffney
et al., 2018). While there is scientific uncertainty about the tipping point (Fig. 13.1),
the precautionary principle recommends setting a goal for zero net deforestation no
later than 2025—preferably earlier.
There are already signs of a transition to a disturbance-dominated regime in the
Amazon, driven by interactions between deforestation, fire, and drought, potentially
leading to losses of carbon storage and changes in regional precipitation patterns
and river discharge (Davidson et al., 2012).
The Amazon biodiversity is highly vulnerable to climate change. The Amazon
contains one of Earth’s richest assortments of biodiversity with recent compilations
indicating at least 40,000 plant species, 427 mammals, 1294 birds, 378 reptiles, 427
amphibians, 3000 fishes, and likely over a million insect species (Case, 2006). Even
a 2 °C rise would make the new average temperature hotter than previous extremes,
and would threaten more than one-third of species in all groups in the absence of
168 V. Viana
Fig. 13.1 Cumulative deforestation in the Brazilian Amazon (km2). Based on official deforesta-
tion data (http://www.inpe.br)
dispersal. A business-as-usual scenario would see this figure increase to around

two-thirds (WWF, 2018).
Forest Fires and Health
Forest fires increase air pollution, and this results in health problems. Evidence on
the nexus between forest fires, air pollution and health is not new. Human health
impacts of forest fires include biophysical effects, psychosocial impacts, occupa-
tional exposure issues among fire crew members, and visibility impairment (Fowler,
2003). A recent literature review of public health issues caused by forest fires
between 1990 and 2018 presented evidence on mortality, respiratory and cardiovas-
cular morbidity as well as other possible impacts on human health (Cancedo-
González & Viqueira, 2018).
A study of 13.5 years of data including 48 days affected by wildfire smoke in
Sydney, Australia, demonstrated a significant increase in mortality associated with
smoke-affected days (Johnston et al., 2011). An earlier study of mortality in Sydney,
using 8 years of data, found an increase in mortality associated with wildfire-related
PM10 (Morgan et al., 2010). An analysis of forest fires that blanketed the Indonesian
islands of Kalimantan and Sumatra in late 1997 found that individuals who were
exposed to haze experienced greater increases in difficulty with activities of daily
living and that haze had a negative impact on respiratory and general health
(Frankenberg et al., 2005). A meta-analysis of data from 2003 to 2010 in 10 cities
in southern Europe found increases in cardiovascular mortality associated with
PM10 that were stronger on smoke-affected days than on non-affected days (Faustini
et al., 2015).
Large-scale intentional forest fires in Indonesia cause haze in neighboring coun-
tries. The causal impact of these fires on Singaporean health outcomes had esti-
mated partial health and avoidance costs of US$184 million from September 2012
to August 2017 (Sankaran & Sheldon, 2018). A study on prenatal exposure to the
1997 Indonesian forest fires based on child nutritional outcomes found that mean
exposure to air pollution during the prenatal stage was associated with a 0.5 stan-
dard deviation decrease in height-for-age z score at age 17. Because adult height is
associated with income, this implies a loss of 4% of average monthly wages for
approximately one million Indonesian workers born during this period (Tan-Soo &
Pattanayak, 2019).
An analysis of hospitalizations due to respiratory diseases in people over 60
years of age who were residents of Cuiabá in the Brazilian Amazon during 2012
found significant correlations between exposure to these contaminants and hospital-
izations. There was a hospitalization risk increase of 31.8%, with an increase of
3.5 μg/m3 of PM2.5 concentrations and an increase of 188 in the total number of
hospitalizations (Machin et al., 2019).
The spatial variability of aerosols over Amazon Basin shows that large areas of
three to five million km2 are affected by high aerosol concentrations. The concentra-
tion of trace gases and aerosols from forest fires in the dry season increase by factor
of 2–8 in large areas (Artaxo et al., 2006).
A 10 μg/m3 increase in the level of exposure to particulate matter in the Amazon
was associated with increases of 2.9% and 2.6% in outpatient consultations due to
respiratory diseases in children on the sixth and seventh days following exposure,
respectively. Levels of particulate matter from biomass burning in the Amazon were
associated with adverse effects on the respiratory health of children (Carmo et al.,
2010). A cross-sectional analysis of cardiovascular mortality among people over 65
years in the Brazilian Amazon, where the predominant source of air pollution is
from wildfires, found a significant association between the percentage of hours of
PM2.5 over 25 μg/m3 and cardiovascular mortality (Nunes et al., 2013).
Implications for Public Policies and Research
Considering the fact that there is clear evidence that forest fires are directly corre-
lated to health problems, and that climate change is likely to increase the magnitude
of this problem, there is urgency for action.
Deforestation is a result of a complex sum of factors, which vary both in
space and time. Therefore, it is necessary to take into account this complexity to
understand the dynamics of deforestation. Drivers of deforestation can be grouped
into (1) economic factors (market structure, conditions and access to credit, incen-
tives, prize of commodities, international demand, etc.), (2) governance factors
(budget and structure of environmental institutions, efficiency of command and
170 V. Viana
control instruments, management efficacy of protected areas and indigenous lands);

(3) political factors (power of the lobby of the agricultural sector; changes in legisla-
tion at the federal, state and municipal levels), (4) infrastructure development (road
construction, hydroelectric dams, etc.) and development of extractive industries
(mining, oil, and gas), and (5) structural factors (population growth and migration,
poverty and inequality, etc.). Reducing deforestation and forests fires, therefore, is
no simple task (Viana, 2017).
A roadmap for action should include a mix of policy instruments to: (1) strengthen
governance in the frontier, (2) increase funding mechanisms for sustainable devel-
opment in the Amazon, (3) change the paradigm of financing for infrastructure, (4)
reduce corruption and increase transparency, (5) improve corporate behavior, (6)
strengthen civil society organizations, (7) education and communication, (8) eco-
system services and poverty, (9) promote community-based sustainable develop-
ment pathways, especially in protected areas and indigenous lands, and (10) build
political support (Viana, 2017).
Environmental policies have had a setback in recent elections in Brazil, both at
the national and subnational levels. There is a general perception that environmental
policies are slowing economic growth and thus need to be weakened (Viana, 2019).
The connection between deforestation, forest fires and health can be an impor-
tant tool to change environmental policies in the Amazon. Health relates directly to
the interests of all citizens and their family members. High air pollution is seen and
easily understood by the general public. Health problems are publicized in the
media, and this creates an opportunity to drive policy change.
Institutions engaged in the design and implementation of environmental public
policies should give greater emphasis to the health dimension of deforestation. The
same applies to those engaged in public health public policies: they should empha-
size the forest fire–health nexus. There is a need for a massive communication strat-
egy to create greater public awareness and thus influence policy-making on the
forest fire–health nexus.
There are some questions that require attention in the design and implementation
of sound public policies: How can we communicate effectively and promote dia-
logue on public policies associated with the forest fires, air pollution, and health?
How can we disseminate research results on the nexus between forest fires, air pol-
lution, and health?
Although the body of evidence is quite sufficient for practical action, there are
several research questions that deserve further work: How can we address the ethical
components of climate injustice towards indigenous peoples and isolated communi-
ties and their linkages to health and forest fires? How can we improve public health
systems to deliver health care to problems associated with air pollution in the
Amazon, especially for indigenous peoples and isolated communities? How can we
improve the understanding of the consequences of air pollution to public health in the
Amazon? What are the scenarios for forest fires, air pollution, and health in their
short term and long term in light of climate change?
Conclusions and Call to Action
Public policies in the Amazon aimed at reducing deforestation and forest fires are
traditionally driven by an environmental rationale, without appropriate consider-
ation to the human health dimension. Public health policies do not give due consid-
eration to air pollution derived from forest fires. Climate policies do not give the
necessary attention to forest fires. This needs to change if the Amazon is to succeed
in meeting the Sustainable Development Goals by 2030.
A better understanding of the nexus between forest fires and health can change
societal perceptions and become drivers of necessary change in public policies. This
is key to strengthen policies aimed at reducing forest fires in the Amazon.
There is a need for urgent action to avoid the tipping point of the Amazon forest,
which would have profound consequences for Brazil, South America, and the
planet. The following actions are recommended:
1. Policy dialogue, design, and implementation of cross-sectoral policies aim-
ing at zero deforestation in all nine Amazon countries by 2025. The process
should be informed by science and supported by massive communication about
the health–deforestation nexus, in all Amazon regions. Other regions of South
America should be informed about the importance of the Amazon to maintain
rainfall regimes. Zero net deforestation policies should include reforestation,
such as agroforestry systems to boost resilience and compensate for residual
deforestation. Research on the efficacy and efficiency of different policy instru-
ments should be supported.
2. New financial mechanisms to support implementation of zero net deforesta-
tion policies. These mechanisms should include a carbon tax and payments for
ecosystem services to compensate Amazon populations, especially indigenous
peoples, for the benefits (carbon, biodiversity, water, others) provided by their
forests. Research on the importance and value of the Amazon for rainfall regimes
and climate stability in the region and globally should be supported.
3. Health policies to improve care for air pollution-related diseases. These poli-
cies should have a special focus on indigenous peoples, who suffer from one of
the world’s greatest climate injustices, because they have not been part of the
problem of greenhouse gas emissions. Research on the health impacts and appro-
priate care for deforestation-borne air pollution should be supported.
4. Develop new partnerships engaging the business and civil society organiza-
tions in the design and implementation of practical solutions for sustain-
able development of the Amazon. These solutions should support national and
subnational governments to increase efficiency, efficacy and transparency.
These partnerships should be broad, including local, national and global actors.
The Amazon is too big to fail.
172 V. Viana
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174 V. Viana
Part IV
Climate Change and Health: Perspectives
from Physicians
CHAPTER 14
Psychological Impacts of Climate Change
and Recommendations
Lise Van Susteren and Wael K. Al-Delaimy
Summary Although the harm to our physical health from the climate crisis is
increasingly reported, still underrecognized is the harm the climate crisis is having
on us psychologically. Yet it is the psychological impacts of global overheating—
and the consequent cascading destabilization of ecosystems—that will carry the
biggest burden and be the most difficult to remedy. It requires our utmost attention.
Understanding the gravity of the mounting psychological harm underscores the
urgent need for all those concerned, especially public officials, to take action. The
devastating psychological and physical impacts of the tragedy of lead-tainted water
in Flint, Michigan, in microcosm, serves as a recent example to those who would
downplay harm to our health in the face of ongoing warnings and pleas for action.
The psychological aspects of the climate crisis are increasingly drawing the atten-
tion of mental health professionals. They are uniquely qualified and urgently needed
to address the denial, discounting, or distancing that feed inaction, and to point out
the deepening injustice of putting vulnerable populations at risk, especially our chil-
dren and future generations. They are also needed to advocate for programs that
address climate anxiety and trauma, and to design programs that build resilience.
The mounting risk of an epidemic of fear, outrage and despair calls for mental health
professionals to play a pivotal role in what has become a do-or-die effort to restore
humanity and the rest of the natural world to safety. All of the losses associated with
climate change—from extreme weather events and chronic climate conditions to the
devastating physical injuries, illnesses, and deaths and the attendant displacement,
disruptions and downstream indirect ripple effects—carry with them an emotional
toll. The magnitude and relentlessness of the destruction, as well as the insinuation
into every aspect of our lives—economic, personal, political—must be recognized as
we consider the mental health and psychosocial impacts of the deepening crisis.
L. Van Susteren (*)

Physicians for Social Responsibility, Washington, DC, USA
W. K. Al-Delaimy
University of California San Diego, La Jolla, CA, USA

178 L. Van Susteren and W. K. Al-Delaimy
Extreme Weather Events
The global rise in temperature is driving local spikes of searing heat waves and
increasing the frequency and intensity of storms, wildfires, and floods. In the last
two decades, extreme weather has wounded, displaced or required emergency assis-
tance for four billion people; half a million have died (United Nations Office for
Disaster Risk Reduction, 2015).
Extreme weather events drive emotional turmoil in every phase. Anticipatory
fear is experienced in the early stages, followed by the trauma of the event itself,
then sorrow and grief at the losses. Feelings of outrage may emerge—slowing down
the working through—when it is believed that government and institutions are not
providing enough help or didn’t undertake preventive measures. Despair and feel-
ings of helplessness deepen as reports surface that conditions will get worse.
Those in disaster-prone areas are the most affected. Anticipatory anxiety some-
times rises to the level of “pre-traumatic stress disorder” among those who fear that
another disaster may be just around the corner. In anecdotal reports, residents of
New Orleans report, for example, that sometimes just seeing a storm cloud triggers
deep anxiety (Hauser, 2015; Reckdahl, 2017). Communities under stress can fray
and decompensate—increasing violence and other psychosocial ills. Mental health
professionals are seeing a full range of psychiatric disorders and conditions emerge
as a result of these stressors: major depression, anxiety, PTSD, adjustment disorders,
a rise in drug and alcohol abuse as people attempt to cope, and domestic violence—
including child abuse (American Psychiatric Association [APA], 2017; World Health
Organization, 2005). In addition, the more destructive the event, the higher the inci-
dence of PTSD and the greater the risk of suicide (Edwards & Wiseman, 2011).
Processing disaster After a natural disaster, an identifiable low point is seen, fol-
lowed by the feeling that the worst is over, and the recovery process can begin. How
we process the event is determined in part by how we answer critical questions: why
did this happen, who or what is responsible, and could the disaster have been pre-
vented? Disasters experienced as natural are easier to reconcile because they are
experienced as “fate”—beyond our control. When disasters are no longer experi-
enced solely as natural, as “acts of God or nature,” but instead are experienced as
having arisen or been made worse because of the behavior of humans—due to a
mistake, carelessness, or worse, as the result of deliberate disregard for conse-
quences—then it is much harder for us to recover and the psychological harm is
more serious (Folkman, Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986).
How we “carry on” is influenced by our background, current mental state, per-
sonality, and life experiences. The nature of the event plays a role: the intensity of
the feeling of powerlessness, the “merciless” character of incidents, the pace, sud-
denness, degree of damage, loss of life and injury and the extent to which people
personalize these incidents will be factors influencing the extent of emotional injury.
Though studies quantifying it are limited, human empathy tells us of the emotional
toll: When the place you call home is burned down by wildfires, blown away by
tornados, flooded or overrun by hurricanes, when you lose your possessions, maybe
14 Psychological Impacts of Climate Change and Recommendations 179
your pets, your livelihood, the comfort of a familiar community, and witness the
injuries, illnesses, and deaths, the resulting mix of fear, anger, sorrow, and trauma
can easily send a person to a breaking point. Stress drives up the secretion of corti-
sol; high levels of this hormone are not damaging when they are short-lived, but
persistently elevated levels can be exceedingly damaging. Immune function can be
compromised, sleep patterns disturbed, digestion disrupted, memory impaired, and
the cardiovascular system harmed—all with an attendant emotional toll (Shaw
et al., 2019). Everyday life is full of burdens and anxieties; confronted by the addi-
tional stress of the climate crisis, some individuals will decompensate.
Exposed to repeated or ongoing disasters, victims may not have a chance to
recover emotionally before the next disaster hits, compounding the harm because
each incident deepens emotional vulnerability. Victims also contend often with the
realization that “no lessons have been learned”. The healing process is helped along
when we can look back, identify where we went wrong and take action to legiti-
mately say we are doing all that we can to prevent further injury. But on the con-
trary, even as the dangers continue to unspool at an ever-higher rate, the extraction
and use of fossil fuels continues, with recent US government policies promoting
their use—exacerbating the mounting psychological toll.
Wildfires Increasing temperatures from climate change dry out land and vegetation,
causing bigger, more frequent and intense wildfires. Homes and communities are
increasingly finding themselves in fire-prone areas. While the physical impacts of fires
can be measured as lives lost, structures burned, and communities disrupted, the psy-
chological damage is immeasurable. The acute phase is dominated by fear—or terror.
The mercilessness of flames, incinerating everything in their path, has a particularly
devastating effect on those who witness what has happened—and they may be unable
to shake loose from intrusive and horrifying thoughts of what it is like to burn to death.
When the flames are finally spent or defeated, seeing what was once a comforting
refuge but is now nothing or little more than a moonscape brings overwhelming grief.
Various phases of disasters have been studied, along with many common emo-
tional responses to them (SAMHSA Phases of Disaster, 2018). Based on the clinical
experience of the first author with victims of trauma, including of natural disasters,
many emotional stressors have not yet been measured but warrant being pointed
out. In an initial phase, vows to rebuild and faith in outside support do help in the
first steps towards emotional recovery, but fears of “next time” often plague survi-
vors. Wrenching, conflicting feelings about remaining in the vulnerable area, finan-
cial strain, and friction from different coping styles may erode family stability.
Lingering feelings of helplessness, despair, and foreboding make restoring a sense
of security more challenging. Emotionally charged triggers can reawaken traumatic
memories—in the case of wildfires, by the simple smell of smoke, the sound of
sirens, the once-pleasant crackling of an ordinary fire. Acute displacement may
become permanent—rupturing the comfort and stabilizing effect of familiar rela-
tionships, places, and daily routines. Some scars may be buried or disguised—
expressed in ways that make them not only hard to “count” but worse, harder to
confront and work through. The stress on individuals and communities is com-
pounded by mental health systems that are underprepared to deal with the trauma.
Violent storms and floods Violent storms and floods are responsible for half the
disasters from extreme weather events (UNISDR, 2015). Higher temperatures
increase the moisture content in the atmosphere, increasing the severity and fre-
quency of storms. As with other extreme weather events, violent storms and floods
unleash catastrophic physical and emotional harm—bringing about the disorders
and conditions cited earlier. Of all extreme weather events, flooding affects the
greatest number of people. The financially stretched are most vulnerable, with the
physical difficulty of getting to safety too great or the cost too high—which the
financially privileged may sometimes forget when they ask why people did not get
out of harm’s way. Even temporary housing is frequently beyond the reach of those
who live paycheck to paycheck.
The far-reaching psychological impacts of violent storms saw their prototype in
Hurricane Katrina in 2005, now “updated” by other storms, in particular the devas-
tating Hurricane Maria that leveled Puerto Rico in 2018. Grief, anxiety, violence,
outbursts of outrage, and blame at the government’s slow response are among the
acute emotional stressors of many victims. Many report feeling that the government
“doesn’t care” about them (Morin & Rein, 2005).
A flood-ravaged home brings a particular type of anguish. Based on experience,
violently being run out of one’s refuge from the outside world underscores the fear
that no place is safe. Seeing belongings a soggy ruin, often turning black and moldy
as they undergo the slow but inexorable process of rotting, brings unconscious asso-
ciations to dying and death. The sense of powerlessness over “nature unleashed”
can weigh heavily on victims.
The widespread presence of mold in homes and other buildings is common in the
aftermath of floods; the physical symptoms associated with exposure to mold are
well documented (Potera, 2007). Exposure to mold is also linked to psychiatric
disorders, especially depression, and reduced cognitive functioning (Shenassa,
Daskalakis, Liebhaber, Braubach, & Brown, 2007). Other impacts include anxiety,
irritability, and fatigue (Hope, 2013). Toxic mold-induced mental illness and cogni-
tive decline are rarely correctly diagnosed or treated.
Research confirms the association between the chronic stress of climate disaster
emotional trauma and cardiovascular health (Peters et al., 2014). Residents of New
Orleans suffered heart attacks at a rate three times higher than the rate reported
before the storm (Peters et al., 2014). The absence of social support when communi-
ties are torn apart is one of the strongest predictors of posttraumatic stress (Brewin,
Andrews, & Valentine, 2000; Ozer, Best, Lipsey, & Weiss, 2003).
Summer Heat Waves
As global temperatures rise, the incidence of extreme heat waves is increasing. Nearly
one-third of the world’s population is now exposed to deadly heat waves (Mora,
Counsell, Bielecki, & Louis, 2017). In the last decade, with less than 1% increase in
warming, the loss of human life has risen 2300% (Mora, Counsell, Bielecki, & Louis,
2017). Significant psychological stress is also associated with heat waves. With rising
temperatures comes rising rates of aggression (Bulbena, Sperry, & Cunillera, 2006;
Raj, 2014). It is linked to increased catecholamine release in response to the stress of
the heat (Al-Hadramy & Ali, 1989). For each standard deviation of increased tem-
perature or more extreme rainfall, studies show a 4% increase in conflict between
individuals, and a 14% increase in conflict between groups (Hsiang et al., 2013).
These findings are valid across all regions and among all ethnic groups. Increased
acts of aggression include assaults, murders, and suicides, especially violent suicides.
As temperatures continue to rise, a global increase in unrest should be anticipated.
Temperatures modestly above the human comfort zone are associated with a
decline in cognitive functioning: slowed response time, diminished accuracy, and
less sophisticated patterns of decision-making. Declining cognitive function could
become increasingly problematic for those unable to escape the heat (Goodman,
Hurwitz, Park, & Smith, 2018). The mental health toll from heat waves is hard to
measure. Like blizzards and storms, the disruptions of heat waves range from irritat-
ing inconveniences to profoundly stressful losses. Declining business and produc-
tivity—which drops at high temperatures—are consequences of extreme heat
(Somanathan, Somanathan, Sudarshan, & Tewari, 2018). Those who must work
outdoors or where AC is not available may not be able to work at all. With little
financial cushion, it may not be possible to pay bills or even buy food. The emo-
tional toll on families and the communities they live in can be horrendous. With the
persistent high temperatures and the ever-expanding desert that they create, scien-
tists predict that the Middle East may well become uninhabitable by the end of the
century (Funkhouser, 2016).
Particularly vulnerable are the poor, the elderly, the sick, and the very young.
Individuals with preexisting mental disorders are also especially susceptible. During
hotter-than-average periods, they appear to get sicker than expected, show greater
aggressiveness towards others, and require more frequent use of restraints (Bulbena
et al., 2006). The good judgment to stay cool and hydrated may be compromised;
some individuals in this population live outdoors and lack access to air condition-
ing. Many take medication (psychotropics) that impede the ability to perspire—the
body’s chief means of reducing internal temperature.
Chronic Climate Conditions
Drought Conditions
Drought conditions are worsening with rising temperatures, particularly in the west-
ern United States. Drought has its own attendant, often chronic, mental health
impacts (Stanke, Kerac, Prudhomme, Medlock, & Murray, 2013). An unrelenting
day-after-day anxiety and despair can descend on those who depend on nature’s
rains for their livelihood—farmers, day workers, owners of related businesses—

who watch and wait for water that does not come. A serious and protracted decline
in available water may force many to make life-altering changes, with stressful
impacts on individuals, families and communities (Vins, Bell, Saha, & Hess, 2015).
Suicide is the result of complex dynamics, but prolonged drought is considered
(in most studies) a major contributing factor among at-risk populations for suicide
among farmers in India, rural Australia, and South Africa (Carleton, 2017; Hanigan,
Butlera, Kokicc, & Hutchinson, 2012; Vins et al., 2015).The psychological toll on
families who have lost their fathers, sons, uncles and brothers, in addition to what is
often their sole source of income, is devastating. Entire countries now compete for
water from the once great rivers of the world—the Mekong, Jordan, the Brahmaputra,
the Tigris and Euphrates, the Nile—bringing rationing and water wars as tension
mounts (Bhalla, 2012). The decline in available water brings food insecurity—
unleashing a flood of its own woes—with individual impacts ranging from the per-
sonal stress of hunger and rationing to malnutrition, starvation and death when
conditions persist. In the crops the world’s poor are most dependent on, malnutrition
from higher concentrations of atmospheric CO2 alone causes malnutrition from
micronutrient deficiencies responsible for cognitive deficits and other physical
harms, carrying with them an emotional toll that can be lifelong (Smith &
Myers, 2018).
As climate change worsens and causes more droughts, millions will continue to
see their access to drinking water threatened. Access to water grips us emotionally
in ways other needs do not because we cannot survive beyond a few days without
water. When a community has a dwindling supply of clean water—from diminished
snowpack, accelerating and preseason melting of glaciers, drying up of rivers,
streams, lakes, and aquifers, or from saltwater intrusion or other climate-induced
contamination, a deepening sense of anxiety and foreboding follows.
In regions dependent on agriculture and already rife with ethnic tensions, strained
by poverty and political divisiveness, climate related disasters are “threat multipli-
ers” for outbreaks of violence (Schleussner, Donges, Donner, & Schellnhuber,
2016). Ongoing periods of water scarcity, spiked by periods of drought, particularly
in the growing season of these vulnerable regions, trigger not only spasms of vio-
lence but sustained cycles of conflict (Von Uexkull, Croicu, Fjelde, & Buhaug, 2016).
News reports have covered how new waves of migrations created by regional
conflicts often drive people to relocate in places that do not want them and cannot
help them (Baker, 2015). Those with the fewest resources are often unable to
relocate—“trapping them in high risk areas” (Randall, 2013). Although sometimes
controversial—and complex to assess, peer-reviewed reports specifically tie the
recent scarcity of water in Syria to increased migration and the geopolitical tensions
it spawned (Müller, Yoon, Gorelick, Avisse, & Tilmant, 2016).
An influx of refugees can stir fear, uncertainty, and anger—due to pressures that
mount from scare resources, inadequate infrastructure, problems adapting to chang-
ing circumstances and cultural differences, limited or absent health and mental
health services, along with pervasive and profound physical and psychological
trauma among refugees (Langlois, Haines, Tomson, & Ghaffar, 2016). Data from
157 countries demonstrated that drought severity and likelihood of armed conflict
played a role in explaining increased asylum seeking between 2011 and 2015 (Abel,
Brottrager, Crespo Cuaresma, & Muttarak, 2019).
Confrontations in southwestern and southeastern states over water are leading to
legal battles. In California, drought conditions have forced rationing, with news
reports that neighbors engage in “drought shaming,” fighting, and tattling on each
other over their water use, foreshadowing what may lie ahead (Huffaker, 2015).
Sea Level Rise
Global sea level is likely to increase 10–13 feet in as few as 50 years unless there is
a major rapid reduction in greenhouse gas emissions. “Parts of our coastal cities
would still be sticking above the water, but you couldn’t live there” (Hansen et al.,
2016). Already, many living in low-lying coastlines and small island states are being
displaced by sea level rise, but these numbers are dwarfed by predictions that the
accelerating pace of rising seas will flood some of the world’s most populous
cities—creating a tidal wave of psychosocial trauma as a bottleneck of climate refu-
gees compete for higher ground (Hearty, 2012; Parker, 2017). In the United States
alone, tens of millions live on coastlines and depend on coastline stability for their
livelihoods, well-being, and survival; worldwide hundreds of millions of people live
within 30 ft of sea level (McGranahan, Balk, & Anderson, 2007).
With some acute climate events, victims can “arm themselves” by taking actions
that help protect them should they face a similar event. Sea level rise is different.
Although governments can work to adopt measures to mitigate harm in the short
term, future sea level rise will continue, inundating low-lying cities, countries, and
islands. Fears of permanent displacement to unfamiliar places gnaw at victims, pro-
voking additional stress—financial, social, and personal. Current and future climate
refugees, who have been displaced from their homes, search for safety and security,
but chaos and violence often follow them, and can spread to others along the way.
Massive relocation will become necessary; it is already underway in places such as
Shishmaref in Alaska, St Charles Island in LA, and now Charleston NC. Parts of
Miami, FL are flooded nearly daily.
Believing that we can take action, that we are empowered to protect ourselves, is
critical to maintaining our mental health. Nurturing the hope of returning home,
restoring, and rebuilding after cataclysmic losses builds resilience. But no such
action or hope can undo the ravages of locked in sea level rise. Layered on are the
crushing financial losses of walking away from what is typically our biggest invest-
ment—our homes—now with little or no value. The plight of climate refugees is
increasingly the focus of mental health professionals. The psychological stress of
refugees is high. The refugees are often blamed for psychosocial ills. Katrina refu-
gees were initially accused of precipitating a crime wave in Houston, where many
were taken in, before a closer analysis showed this was a misreading of statistics
(Hamilton, 2010). A flare-up of anti-refugee sentiment has rocked countries and
governments across Europe and on the American border with Mexico where the
divisive battle over building a wall has further polarized the USA and precipitated a
record-breaking government shutdown.
Other Sources of Climate-Related Psychological Impacts
New Disease Threats
As ecosystems are altered by climate change, old diseases are expanding their reach
and new diseases are emerging. While physical health data is examined and reported,
the complex psychosocial toll—difficult to quantify—often is not addressed as
a result.
Warnings that new diseases and old diseases are emerging are heard frequently.
Deeply unnerving, they precipitate a pervasive if not always fully conscious sense
of vulnerability that adds to existing stressors in life. Millions worried, for example,
about exposure to the Zika virus—with widespread repercussions: local economies
took a hit as fears drove tourists away, pregnancies were put off; travel plans unrav-
eled; and decisions about family life and individual personal choices were driven by
fears of infection. Families suffered the anguish of having babies born with defor-
mities and with the knowledge that a baby who was exposed might appear normal
but have disabilities down the road.
Lyme disease is well known in some cases to leave its victims with long-lasting
and painful emotional wounds. Cognitive deficits and mood disorders with depres-
sion and anxiety are not uncommon. Individuals struggle with the torment of treat-
ments that are often ineffective, especially when the diagnosis—sometimes
difficult to make—comes after years of raging infection and unexplained symp-
toms. Other climate-linked viruses, parasites and bacteria storm on and off stage
depending on local weather conditions, or are waiting in the wings for their chance,
or continue their inexorable expansion: Dengue fever, also known as “bone-break
fever” because it is so painful; Chikungunya; Hantavirus; West Nile; Chagas dis-
ease; and of course, Malaria. All of them carry an attendant psychosocial toll that
must be addressed.
Air Pollution
The World Health Organization reports that nine out of ten people breathe unhealthy
air. Air pollution is primarily the result of our use of fossil fuels: when coal, oil, and
gas are burned, they create pollutants that undergo chemical reactions to form par-
ticulate matter. Warmer temperatures speed up these reactions, causing pollution to
become more concentrated. The presence of particulate matter in our bodies triggers
inflammation. Many diseases and conditions are linked to exposure to polluted air.
Ultrafine particulate matter is especially worrisome because it can cross directly
from lung tissue into the bloodstream and be carried throughout the entire body.
Already confirmed in nonhuman primates, initial studies suggest that ultra-fine par-
ticulate matter also crosses directly from the nasal mucosa via nerve endings that
transport it directly into the human brain (Obederdöster, Elder, & Rinderknecht, 2009).
Though more research is needed to address some inconsistencies, evidence is
mounting that inflammation of brain tissue from air pollution is linked to dementia,
including Alzheimer’s type; is linked as a comorbid factor in the development of
Parkinson’s disease and exacerbation of symptoms; and is linked to amyotrophic
lateral sclerosis (ALS) (Calderón-Garcidueñas & Villareal-Ríos, 2017; Chen et al.,
2017; Lee et al., 2017; Seelen et al., 2017).
The incidence of these diseases is expected to rise and already brings a crushing
economic burden in the hundreds of billions of dollars. The cost in human suffering
alone should be argument enough to make eliminating the burning of fossil fuels a
number one public health priority (Gladman & Zinman, 2015; Kirson et al., 2016;
Kowal, Dall, Chakrabarti, Storm, & Jain, 2013).
Evidence supports a link between neuro-inflammation and classic psychiatric
illness: major depressive disorders, bipolar disorder, schizophrenia, and obsessive-
compulsive disorders (Souhel, Pearlman, Alper, Najjar, & Devinsky, 2013). Air pol-
lution is also associated with increased psychosis in adolescents (Newbury,
Arseneault, Beevers, et al., 2019). Even low levels of pollution in Sweden—primar-
ily from traffic—are associated with an increased risk of mental illness in children
(Oudin, Bråbäck, Åström, Strömgren, & Forsberg, 2016).
The American Psychological Association reported children exposed to particu-
late matter in the air were more likely to have symptoms of anxiety or depression
(Weir, 2012). Emergency room visits for anxiety—including panic attacks and
threats to commit suicide—are significantly higher on days with poor air quality
(Szyszkowicz, Willey, Grafstein, Rowe, & Colman, 2010).
Vulnerable Populations
The elderly, the sick, the disabled, the poor, and those whose jobs are tied to the
natural environment (farming, fishing, forestry, etc.) are particularly susceptible to
the psychological impacts of climate disruption. Residents in areas destroyed by
climate disasters or where fossil fuel production has destroyed the natural landscape
are especially likely to suffer from “Solastalgia”: a gripping existential pain that
comes from seeing places that once gave the treasured feeling of “home” now lost
or irreparably damaged (Albrecht, 2005).
The mentally ill are especially vulnerable: they are less resilient, have fewer
resources, face disrupted services that put them at risk of decompensation, and take
psychotropic drugs that impede the ability to perspire—making them more prone to
overheating. Often overlooked groups include: first responders, who see the inju-
ries, deaths and devastation in its rawest state; climate experts, whose professional
lives are spent cataloguing the growing evidence of decline and with a growing
sense of doom see their life’s work damaged, destroyed or disappearing (Guest,
2014; Nicholls et al., 2014); and activists, the “Climate Cassandras”, who, desper-
ately issuing anguished warnings, and in the grip of images of future disasters they
cannot get out of their minds, may suffer from “pre-traumatic stress disorder” (Van
Susteren, 2013).
The poor and rural populations as well as those who live a day-to-day existence
face falling income, food shortages, and rising prices. Decisions must be made
about who eats and who does not. Families and communities fray when competition
erodes the sharing support system that was characteristically relied upon. The
world’s poor suffer the anguish of climate injustice far from the consciousness of
those whose overconsumption and disproportionate use of resources are most
responsible. Ten percent of the world’s richest are responsible for the emissions of
50% of the world’s greenhouse gases (Gore, 2015).
Ocean acidification, warming, and ocean deoxygenation are impacts from cli-
mate disruption that are responsible for dramatic declines in marine life. Experts
warn that without immediate dramatic action to improve the health of our oceans,
within a few decades oceans will no longer have the capacity to feed millions of
people who depend on them to survive. As catches dwindle from depleted sources,
food production falls, jobs decline, incomes fall, and hunger rises. Cascading eco-
nomic, health, social, and psychological ills follow (IPSO, 2013).
Children and young people are at special risk. The message that the planet is
dying and that the survival of future generations is on the line registers in climate-
aware young people. Though findings are sometimes inconsistent and more work is
called for, many are less likely to distance or discount the warnings of scientists,
educators and government agencies that the window on our ability to “act in time”
is closing. They know that conditions will worsen and the cumulative destructive
toll, emotional and physical, will fall on their shoulders. Children are frightened,
report they are sad and angry; a bleak and pessimistic view of the future may be
more prevalent in adolescents and young adults (Ojala, 2012; Strife, 2012). Chronic
childhood stress, persistently driving up cortisol levels, can alter brain development,
notably in the hippocampus and prefrontal cortex, with the potential to cause
impaired cognition and a life-long predisposition to anxiety, depression, and sus-
ceptibility to additional stress (Carrion & Wong, 2012; Simpson, Weissbecker, &
Sephton, 2011). Susceptibility to anxiety can be passed onto succeeding generations
through epigenetic inheritance (Skinner, 2014). Children who experience multiple
early life stressors are at greater risk for suicide (Björkenstam, Kosidou, &
Björkenstam, 2017).
The first reported case of climate crisis-induced psychosis occurred in an
Australian boy in 2009, who, in his drought-stricken country, refused to drink water
because he feared millions would die as a result. The doctor who treated him at
Melbourne’s Children Hospital said he has since seen many other children suffering
from climate anxiety in varying degrees of severity (Wolf & Salo, 2008).
Summary of Psychosocial Impacts
“Not everything that counts can be counted…” (William Bruce Cameron).

Personal anecdotal clinical expertise suggests that it is the inchoate, insidious,
complex, and unconscious psychological states driven by climate trauma—not
lending themselves to studies and precise numbers—that can be the most pro-
foundly damaging and drive systemic emotional conditions that society will find
difficult to treat and surmount. Just as the functioning of families breaks down in the
face of a chaotic home environment, in the face of the turbulence from declining
national security, without trust that our institutions can protect us, the fabric of soci-
ety can break down. The waves of injury from climate trauma and frustration from
inaction are reverberating across our communities, the workplace, and our families,
cumulatively taking a toll on the national mood. Repercussions from a stressed-out
national mood drive our economy, our politics, and our relations with other coun-
tries. It shapes our culture and increasingly affects how we treat each other. How
will we deal with a growing state of fear from diminished productivity, conflict
between haves and have-nots, callousness, and numbness in our response to suffer-
ing—“compassion fatigue”—an alienated citizenry, distrust of each other?
We can be anxious and not know why, and we can be anxious and not know it.
Sometimes anxiety is manifested as anger or another emotion or state that doesn’t
even suggest the root cause. We can be anxious and give it the wrong name—often
if the real source is especially unsettling. We don’t always recognize the psychologi-
cal toll anxiety is having on us. Much of the violence in the world can be explained
by unaddressed anxiety emanating from fears of impotence and vulnerability.
Climate change evokes a profound sense of both. Whether we know it or not,
whether we like it or not, whether we accept it or not, we believe the climate crisis
is causing varying degrees of anxiety among most of the population.
pecial Message to Mental Health Professionals:

S
Recommendations and a Call to Action
Trying to avoid thinking about climate-related issues, or other conditions that cause
anxiety, is an attempt to try to control our fears, but fear and avoidance are at the
root of denial and inaction.
Years of experience have shown mental health professionals how to move people
beyond this state, replacing resistance with the empowering realization that the solu-
tion is to take action. As mental health professionals we know the power of words—
we know how to break down defenses, put together messages that help people finally
begin to understand. We get science, we get suffering, we get urgency, we get life-
long consequences. We see the value of hope, we know how to engender it even in
dark times. We are good at encouraging people to grow, to be conscious of the needs
of others.
As we consider where the public needs to be on climate change and what we

have to offer, we can see that we have largely failed to realize the power of our
expertise.
It no longer makes sense, because of the challenges presented by the climate
crisis and the unique skills we have, to confine our professional lives only to tradi-
tional roles and services in our offices, academic settings and clinics. We need activ-
ism now to initiate services in this time of urgency—helping people out of their
denial, tending to their wounds, working to create resilience. Just as we have quali-
fications in other specialties—we need “Climate Mental Health Specialists”
(CMHSs), who are specifically trained to offer “trauma informed care” for the many
levels and kinds of distress generated by climate instability— both direct and indi-
rect, addressing the plight of refugees and the needs of newly blended populations,
helping to organize communities and collaborating with primary care and public
health experts, fanning out into settings to educate and advocate.
More research is needed to identify best practices, determining societal and
infrastructural resources that are truly helpful, and building upon this evidence base
to train the next generation of CMHSs.
Our efforts in every sector send the message—that the fight for sane climate
policy is not the exception, but the legitimate expected behavior in this time of cri-
sis. With our understanding of the social sciences, we know that people can be
persuaded to take action just because other people are, and promote and harness the
power of social norms to accelerate the pace of change.
Our canons of ethics tell us it is our duty to protect the health of the public and
to participate in activities that contribute to it.
Committed professionals are joining others to call upon our elected officials,
policy makers, and other leaders to show why the public’s health is in jeopardy,
what steps must be taken, and how we can use our expertise to speed up the process.
Many professional organizations and academic institutions are setting up curricula
for training and making collaborative declarations describing the dangers of climate
change and the urgent need for action.
But at this epic moment, our unique contributions and the urgent need for global
commitment have gone missing. But it does not have to stay this way—because we
can change that, too.
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CHAPTER 15
Air Pollution and Cardiovascular Disease:
A Proven Causality
Conrado J. Estol
“It was the best of times, it was the worst of times, it was the
age of wisdom, it was the age of foolishness, it was the epoch of
belief, it was the epoch of incredulity…”
Charles Dickens, A Tale of Two Cities
Summary Epidemiological data has shown that air pollution accounts for at least
six million deaths per year worldwide. Cardiovascular disease ranks first among the
causes of death from pollution, yet it is largely neglected. There is compelling evi-
dence from studies in different world regions showing a causal relationship between
air pollution and cardiovascular disease, but this information has not reached the
scientific community at large and much less the general public. Gaseous and parti-
cle pollutants access the circulation through the lungs and accelerate atherosclerosis
by altering blood pressure, lipids, oxidative processes, and insulin resistance. They
affect all individuals from the maternal uterus to old age. Almost the entire popula-
tion in Asian countries is exposed to severely elevated levels of pollutants and most
other countries have vascular-damaging levels. More than 80% of the affected indi-
viduals belong to emerging regions. The use of N95 masks reduces the exposure to
PM2.5, the most damaging particle. Physicians should consider air pollution as a
recognized risk factor for vascular disease and act accordingly with patients exposed
to different levels of pollutants. The only way to limit the worsening levels of pollu-
tion worldwide is to increase the joint efforts among science, governments and other
leadership to generate a climate change conscious society and increase efforts to
reach a decarbonized world by mid-century.
C. J. Estol (*)
Stroke Unit, Sanatorio Guemes, Buenos Aires, Argentina
Heart and Brain Medicine, Breyna, Buenos Aires, Argentina

194 C. J. Estol
Background
Climate change and air pollution pose a direct threat to human life on earth. The
amount of data supporting this notion is compelling and encompasses a broad spec-
trum of disciplines, including energy, hydrology, physics, chemistry, anthropology,
medicine, biology, economics, and philosophy, among others. Yet this is likely the
most neglected menace to humanity. In the popular quote that opened the chapter,
Dickens eloquently expresses the opposing forces of love and odium, seemingly in
a rather equal balance. Can we humans working as a group tilt these apparently
matched forces?
This is the era of communications and of the ubiquity of knowledge. So, why are
most of the data and messages about climate change and diseases caused by air pol-
lution missing their targets? Probably because we mostly preach to those who
already know and want to listen. Most of the world is simply not aware of this self-
caused health catastrophe. Air pollution is an epidemic and the medical community
is looking the other way. Breathing during our daily personal, working, and leisure
time accelerates the occurrence of heart and brain infarction, cognitive decline and
serious lung diseases, ranging from infections to cancer. The result is the occurrence
of millions of preventable deaths. Despite this appalling statistic, air pollution is a
significant risk factor for death that every human faces with indifference. Is this the
result of some form of misinformation? We are now celebrating 30 years since
evidence-based medicine radically changed “eminence”-based anecdotes and opin-
ions into information based on well-designed research. Those of us with a specific
knowledge in topics that most people fail to fully grasp and comprehend ought to
disseminate this information in a scientific, reliable, complete, and clear message.
In this chapter, I describe the data that show how air pollution damages the vascular
system and thus becomes a leading risk factor for cardiovascular disease and death.
The Impact of Cardiovascular Disease Worldwide
Cardiovascular disease leads to 50,000 deaths every day, representing a third of all
deaths worldwide. Such deaths include coronary heart disease (myocardial infarc-
tion), cerebrovascular disease (stroke), aortic aneurysm, peripheral vascular disease
of the legs, vascular kidney failure, and others. Coronary heart disease is the first
cause of death worldwide (Mozaffarian, Benjamin, Go, et al., 2015). In 2013, stroke
was the second cause of death globally, with 25.7 million people who survived a
stroke and 6.5 million people who died from stroke (Feigin, Norrving, & Mensah,
2017). Vascular disease is also a leading cause of cognitive decline and dementia,
affecting up to a third of patients with cerebrovascular disease (Mijajlović, Pavlović,
Brainin, et al., 2017).
More than 85% of strokes occur in developing regions, where prevalence of the
disease is lower compared to developed countries because case fatality rates are
15 Air Pollution and Cardiovascular Disease: A Proven Causality 195
higher due to suboptimal health systems. Cardiovascular disease incidence has

increased 100% in the developing world over the last decade (Feigin, 2005). A study
in 44 nations revealed that vascular risk factors are similarly distributed and largely
undertreated (Bhatt, Steg, Ohman, et al., 2006).
Stroke occurs one to two decades earlier in individuals in emerging countries
compared to developed countries with up to 50% of events affecting people under
70 years of age (20% in developed regions) (Strong, Mathers, Leeder, &
Beaglehole, 2005).
The aforementioned data suggest that cardiovascular disease could be a straight-
forward problem to tackle (Yusuf, Hawken, Ounpuu, et al., 2004). Supporting this,
various studies have shown that by following vascular disease management guide-
lines, adhering to treatment, avoiding cigarette smoking, having an appropriate
nutritional intake and exercising, up to 80% of vascular events could be avoided
(Chiuve, McCullough, Sacks, & Rimm, 2006; Hackam & Spence, 2007).
However, between 2005 and 2016, incidence of ischemic heart disease and stroke
increased by 53% and 25%, respectively (Global Burden of Disease 2015 Risk
Factors Collaborators, 2016). Unfortunately, most patients do not receive adequate
treatment (as an example, 80% of treated hypertensive patients are not controlled!).
ir Pollution: A Poorly Recognized Vascular Disease Risk

A
Factor
Although the deleterious effects of air pollution on human health were reported
almost three decades ago, this major health risk factor has only recently come to the
attention of the general medical community (Dockery, Pope, Xu, et al., 1993). In a
recent analysis, Feigin et al. studied all modifiable vascular risk factors included in
the Global Burden of Disease Study in 188 countries carried out from 1990 to 2013
(Feigin, Roth, Naghavi, et al., 2016). They analyzed the population attributable
fraction (PAF) of all risk factors to define their individual contribution to stroke.
More than three-quarters of the stroke burden could be avoided by controlling
behavioral and metabolic risk factors. Smoking, poor nutrition and sedentary habits
had a PAF of 74%. Hypertension, diabetes, cholesterol, and a high body mass index
accounted for 72% of the burden. However, the authors found an unexpected 29%
of the stroke burden attributed to air pollution, which was most significant in emerg-
ing regions (and highest in sub-Saharan Africa and South Asia) (Feigin et al., 2016).
Interestingly, when considering the health consequences of air pollution, cogni-
tive decline and dementia are rarely mentioned. However, population-based data
suggest that seven modifiable vascular risk factors accelerate cerebrovascular dis-
ease, which account for 50% of dementia cases. Because disease of the cerebral
microcirculation has been associated with the risk of Alzheimer disease, those same
modifiable risk factors have been shown to account for one-third of Alzheimer
dementia (Ashby-Mitchell, Burns, Shaw, & Anstey, 2017; Norton, Matthews,
Barnes, Yaffe, & Brayne, 2014). Cognitive disease should be included when mea-
suring the total disease burden associated with air pollution.
196 C. J. Estol
The World Health Organization (WHO), the American Heart Association (AHA)
and the European Cardiology Society have all formally declared air pollution as a
risk factor for vascular disease (Brook, Rajagopalan, Pope, et al., 2010; Newby,
Mannucci, Tell, et al., 2015).
Particulate Matter
Air pollution consists of a gaseous phase composed of carbon monoxide, ozone,

sulfur dioxide, and nitrogen dioxide, and a particulate phase that encompasses 10,
2.5, and 0.1 μm particle matter (PM). Fuel combustion accounts for 85% of PM and
100% of the gaseous toxins.
Different estimates reveal that ten million people die worldwide from all causes
of pollution, including air, water, soil, and occupational. Of them, between five and
six million died from air pollution in 2015; for approximately 60%, the cause of
death was cardiovascular disease (the remainder died from lung cancer, chronic
obstructive pulmonary disease, and respiratory infections). By 2050, the number of
deaths will have increased by 50% (Lelieveld, Evans, Fnais, et al., 2015). Air pollu-
tion currently represents the fifth leading cause of death, accounting for 7.6% of all
deaths; 92% of the affected population is located in low- and middle-income coun-
tries (Cohen, Brauer, Burnett, et al., 2017). It is also the fifth most common vascular
disease risk factor following hypertension, smoking, diabetes, and obesity (Global
Burden of Disease 2015 Risk Factors Collaborators, 2016). Available data show an
association between acute and chronic exposure to air pollution and different forms
of cardiovascular disease, such as congestive heart failure, myocardial infarction,
stroke, arrhythmias and sudden death (Brook et al., 2010; Ensor, Raun, & Persse,
2013; Link, Luttmann-Gibson, Schwartz, et al., 2013; Newby et al., 2015).
PM Toxic Levels: How Low is Harmless?
The WHO air quality guidelines suggest that a PM2.5 concentration of 10 μg/m3 is
“safe” to avoid a causal role with vascular and lung disease. However, if these par-
ticles are pathogenic, then only a zero level can be considered safe, just as any
number of cigarettes above zero is associated with disease caused by smoking.
However, beyond the fact that reaching a zero PM level is probably practically
impossible, the most recent estimation for the lowest mean PM2.5 concentrations
that could be considered a minimum risk exposure level is 4.2 ± 1.8 μg/m3 (Lelieveld
et al., 2019). This threshold value is significantly lower than that accepted by WHO
and the 8.8 μg/m3 advised by the Global Burden of Disease study, which explains
the significantly larger proportion of PM2.5-related deaths with current calculations
(Lelieveld et al., 2015; Lim, Vos, Flaxman, et al., 2012).
Worldwide Air Pollution
During the period from 1990 to 2015, the overall population-weighted exposure to
PM increased from 39.7 to 44.2 μg/m3. Air pollution’s toxic effects are most signifi-
cant in Southeast Asia, where 99% of the population is exposed to levels that are
beyond WHO air quality guidelines (van Donkelaar, Martin, Brauer, & Boys, 2015).
New Delhi and Beijing show averages of 100 μg/m3 with peaks of 1000 μg/m3. India
(with a population-weighted exposure of 74 μg/m3) and China (58 μg/m3) alone
account for at least 50% of all PM-related cardiovascular deaths.
In the USA, improvements have been achieved with an average exposure of
8.4 μg/m3 reached in 2015 from an average 14 μg/m3 in 2000, reflecting a 40%
decrease in PM2.5 concentration (Cohen et al., 2017). If this improvement were to be
replicated worldwide, deaths from air pollution would decrease by approximately
46% (Morishita, Thompson, & Brook, 2015). A 10 μg/m3 reduction results in a half-
year increase in life expectancy. A recent study in the USA that evaluated 61 million
individuals showed that increases of 10 μg/m3 were associated with a 7.3% increase
in mortality. Racial minorities and people with low incomes were most affected (Di,
Wang, Zanobetti, et al., 2017). When Cohen et al. in the Global Burden of Disease
study evaluated worldwide trends of average PM2.5 concentrations from 1990 to
2015, all countries had values above the WHO air quality guidelines of 10 μg/m3.
Many (mostly in Asia) reached five to almost ten times the average reported in the
USA, with evolution curves that have become steeper since 2010 in the most popu-
lated countries (Bangladesh, China and India); only Nigeria showed a trend above
the standard but with a decreasing projection (Cohen et al., 2017). Multiple efforts
with varying results have been made to fight and control air pollution in the USA. In
some areas, these efforts are counterbalanced; for example, in California, according
to the strength and direction of winds, 10–20% of air pollution may come from
China across the Pacific (Lin, Pan, Davis, et al., 2014).
Is PM2.5 Inhalation Currently Preventable?
The use of N95 breathing masks is the only method that has proven effective to
decrease particle inhalation by more than 95% (Münzel et al., 2017). One study
showed a significant reduction in mean blood pressure and electrocardiogram
changes in individuals wearing N95 masks (Langrish, Wang, Lee, et al., 2012). A
study to measure the stress hormonal response to air pollution was performed in
Shanghai in 55 healthy college students (Li, Cai, Chen, et al., 2017). A double-
blind, crossover analysis was performed using indoor air filter purifiers and sham
purifiers for 9 days with a 12-day wash-out period. The filters resulted in a 50%
decrease in PM, from 53 to 24 μg/m3. The students underwent measurements of
glucocorticoids, catecholamines, free fatty acids, blood pressure, and insulin
resistance to convey data on systemic inflammation and blood circulation status.
198 C. J. Estol
The comparison between students revealed that those not breathing purified air had
changes in most biomarkers indicative of increased oxidative stress, inflammation,
thrombosis and increased blood pressure. A relevant concern of this study is whether
the 50% reduction noted is enough, because the resulting PM levels are still signifi-
cantly above a safe threshold.
How Does Air Pollution Reach the Vascular System?
Fossil fuel emissions contribute to most of the PM associated with cardiovascular

disease. The gaseous contributors ozone and nitrogen oxide double the pathogenic
effects of PM. These toxins cause endothelium dysfunction due to increased reac-
tive oxygen species and decreased nitric oxide, increased blood pressure and insulin
resistance, abnormal lipid concentrations and arrhythmias that lead to increased
thrombosis (Brauer, Freedman, et al., 2016; Ostro, Hu, Goldberg, et al., 2015; Shah,
Lee, McAllister, et al., 2015). Arrhythmias may also lead to cardiac embolism to the
brain, and an increased sympathetic tone correlates with an abnormal cerebrovascu-
lar resistance that impairs cerebral blood flow. PM2.5 is one-third the size of red
blood cells and enters the body’s circulation via the lung alveoli; by directly trans-
locating across the lung–vessel barrier or by entering macrophage cells, they pene-
trate this barrier into the circulating blood to cause the aforementioned endothelial
changes (Nemmar, Vanbilloen, Hoylaerts, et al., 2001).
hat Is the Evidence Linking Air Pollution

W
and Cardiovascular Disease?
The effect of PM2.5 on atherosclerosis has been shown in animal models. In one
study, 28 mice were fed with normal or high-fat chow and exposed to PM2.5 or fil-
tered air for 6 h/day, 5 days a week for 6 months. A significant increase in the
amount of atherosclerosis, vasoconstrictor response and vessel inflammation was
measured in the mice aorta exposed to PM2.5 (Sung, Wang, Jin, et al., 2005). The
Multi Ethnic-Study of Atherosclerosis and Air Pollution (MESA) was conducted
over 10 years in nine locations from six USA states. A greater degree of coronary
calcification in multi-slice CT was determined in subjects exposed to PM2.5 and
nitrogen dioxide. Hypertensive and older subjects were the most vulnerable
(Kaufman, Adar, Allen, et al., 2012; Kaufman, Adar, Barr, et al., 2016). Significant
changes in forearm blood flow have been shown with smoking, which are
exacerbated when another variable such as high cholesterol is also present (Heitzer,
Yla-Herttuala, Luoma, et al., 1996). In another study, 31 subjects were exposed to
PM2.5, ozone, their combination, or filtered air. Diastolic blood pressure was lowest
in the filtered air group and most significantly elevated in the PM plus ozone group
(Brook, Urch, Dvonch, et al., 2009). In a double-blinded, crossover study, Kristen

et al. exposed 45 nonsmoking subjects (age 18–49) to diesel exhaust PM for 2 h or
to filtered air (exposure times were separated by 2 weeks). Blood pressure was mea-
sured every 30 min during exposure and four times during the first 24 h. Systolic
blood pressure was significantly and rapidly increased in the diesel group compared
to controls despite the short exposure time (Kristen, Cosselman, Krishnan, Oron,
et al., 2012). Short-term exposure to air pollution outside the laboratory has also
been shown to cause acute vascular events. A French study of the gaseous phase of
air pollution showed that people aged 55–64 years without prior clinically evident
vascular disease, exposed for 1–2 days to increased concentrations of ozone, had a
significantly higher risk of developing an acute coronary event (Ruidavets, Cournot,
Ferrières, et al., 2005). Other studies provide extensive evidence of the association
between air pollution and hospital admissions and emergency room consults for
vascular events, myocardial infarction, stroke, arrhythmias, and congestive heart
failure (Brook, Franklin, Cascio, et al., 2004; Claeys, Rajagopalan, Nawrot, &
Brook, 2017; Forastiere & Agabiti, 2013; Gold & Samet, 2013; Link & Dockery,
2010; Mustafić, Jabre, Caussin, et al., 2012; Stafoggia, Cesaroni, Peters, et al., 2014).
Epidemiological data also show that when deaths are compared for each month
of the year before and after smoke-free legislation was passed in the USA, a signifi-
cant reduction in the number of deaths was noted (Pell, Haw, Cobbe, Newby, et al.,
2008). Shah et al. performed a meta-analysis to assess exposure to air pollutants and
acute stroke (Shah et al., 2015). The authors reviewed approximately 100 articles
reporting 6.2 million vascular events in 28 countries. A robust association was found
between admissions/death from stroke with both PM and gaseous air pollutants
(except for ozone); the strongest association occurred on the day of exposure to
PM2.5. The most significant findings were seen in low- and middle-income coun-
tries. Previous studies had shown an association between long-term PM exposure
and stroke (Dockery et al., 1993; Miller, Siscovick, Sheppard, et al., 2007; Pope,
Burnett, Krewski, et al., 2009). A recent review analyzed the association between
air pollution and stroke focusing on the specific subtypes of stroke (hemorrhagic,
small and large vessel, cardioembolic), patient’s age, effect of temperature in the
cold and warm season, types of pollutants, duration of exposure, and the presence
of vascular risk factors or previous vascular events (Estol, 2019).
The Global Burden of Stroke study by Feigin et al. revealed a significant loss of
stroke disability-adjusted life-years (DALYs) from air pollution among metabolic
and behavioral risk factors (Feigin et al., 2016). The importance of the authors’ find-
ings was showing that 90% of stroke burden is due to modifiable risk factors. Air
pollution was the third largest contributor to stroke burden, with 33 million stroke-
related DALYs in 2013. Although the world average of stroke burden attributed to
air pollution was 30%, it ranged from 34% in low- to middle-income countries to
10% in high-income countries. Cohen et al. showed that stroke and coronary heart
disease represent a large proportion of deaths due to PM2.5 and have shown a steady
and significant increase since 1990 (Cohen et al., 2017).
200 C. J. Estol
The 2017 report by the Lancet Commission on pollution and health provides data
in support of pollution being the most important environmental cause of disease and
premature death worldwide (Landrigan, Fuller, Acosta, et al., 2017). Air pollution
causes more deaths than water, occupational and soil pollution combined; it results
in three times more deaths than HIV, tuberculosis and malaria combined and 15
times more deaths than those caused by war and other violence. In 2015, air pollu-
tion accounted for 26% of coronary heart disease deaths and for 23% of stroke
deaths, reflecting 21% of cardiovascular deaths overall (Landrigan et al., 2017).
These deaths have an age peak in children under the age of 5 years, although the
largest absolute number of deaths occurs over 55 years of age. Because of the sig-
nificant number of years in age expectancy, the largest number of DALYs lost affect
children.
Air Pollution and Congenital Heart Disease
The fetus offers the most vulnerable state for pathogenic effects of toxin exposure
and is exposed to a higher relative toxin dose compared to the mother. The most
robust correlation was found between the air pollutant nitrogen oxide and coarcta-
tion of the aorta, Fallot tetralogy, and ventricular and atrial septal defects (Jerrett,
McConnell, Wolch, et al., 2014; Mao, Sun, Zhang, et al., 2017). The causative
mechanism appears to be DNA hypomethylation from the interaction of nitrogen
oxide and methionine. It is also feasible that due to cardiac structural changes and a
greater incidence of metabolic syndrome, exposed fetuses remain predisposed to
have a higher risk of cardiovascular events (Chen, Zmirou-Navier, Padilla, &
Deguen, 2014).
Conclusions
The health costs of air pollution are hidden behind a myriad of heart attack and
stroke hospital admissions. A vast proportion of affected patients admitted for a first
episode have no known common vascular risk factors, so they are labeled as heart
or brain infarctions “of unknown etiology.” I have provided ample evidence to sup-
port the causality between acute and chronic exposure to air PM2.5 (and other pollut-
ants) and the occurrence of acute myocardial infarction and stroke. However, this is
rarely considered causative by physicians providing hospital care to patients and
much less by clinic administrators and politicians who are responsible for generat-
ing and implementing legislation for air pollution control. Air pollution accounts for
at least 6% of global health care expenses (Landrigan et al., 2017). However, the
increasing costs of health care, and especially those related to the growing epidemic
of noncommunicable diseases (led by heart disease and stroke) are easily identified
in hospital financial statements.
Investments in air pollution control are largely cost effective. Following the 1970
Clean Air Act in the USA, air pollution decreased by 70% with a greater than 210%
related GDP increase (U.S. EPA, n.d.). In contrast, in California for every 10 μg/m3
increase in PM, there is an associated 6% decrease in productivity. The myth pro-
moting the idea that pollution is an unavoidable consequence in the transition to
economic development, the so-called Kuznets hypothesis, has long been proven
wrong (Kuznets, 1955). The problem is large and complex enough that different
government areas, including financial, health, and environmental agencies, must
coordinate efforts to effectively tackle this enormous challenge. Efforts to educate
the general public and the medical community need to evolve in parallel with gov-
ernment, multinational, and corporate decisions to decrease the causes of air pollu-
tion and climate change as different components of the same problem that directly
endanger human life. In the encyclical letter “Laudato Si,” Pope Francis makes a
thorough analysis of the threat and danger posed to our planet by current human
behavior (Francis, 2015). The Holy Father reminds us that several popes before him
expressed concern about an ongoing destructive attitude of humanity towards our
“common home.” Pope Francis made an “urgent appeal” for dialogue about the
future of our planet dominated by a “throwaway culture” while being converted in
an “immense pile of filth.”
By thoroughly covering the broad spectrum of climate change, air pollution and
health, this book ought to be the tipping point to help reverse the present course of
this avoidable disaster facing both the current and future human generations.
Acknowledgements The author is grateful to Sarah MacKenzie, Ph.D., for editorial assistance.
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CHAPTER 16
Healthy People, Healthy Planet: Holistic
Thinking
Jamie Harvie and Erminia Guarneri
Summary In the context of our broad ecological calamity, we highlight the link-
ages between climate change and human health. Holism is offered as a unifying
model and process to align and foster individual, community, and planetary health
and thereby address our existential crisis. We explain healthcare’s significant cli-
mate footprint and the obligation and opportunity for the healthcare sector to think
and act holistically. Our linear economy is used as another example to explain how
mechanistic thinking fuels ecological degradation, inequality, and adverse health
outcomes. Action steps that support a healthy planet for all now and for all future
generations are offered along with guidance for healthcare systems and health
professionals.
Introduction
In the context of our planetary ecological calamity—climate change, stratospheric

ozone depletion and ultraviolet (UV) radiation, biodiversity loss, land degradation
and desertification, water pollution and water scarcity, and persistent toxic contami-
nation—(World Health Organization, 2014; EPA, 2017b) the global human com-
munity is facing an existential crisis. Indigenous communities have long understood
the indivisible relationship between individual, community, and ecological health.
In the Anthropocene, we are relearning this ancient wisdom by necessity as we
confront the stark reality that the health and survival of human populations is inti-
J. Harvie (*)
Institute for a Sustainable Future, Duluth, MN, USA
E. Guarneri
Pres. Academy Integrative Health and Medicine, Medical Director Guarneri
Integrative Health, La Jolla, CA, USA

206 J. Harvie and E. Guarneri
mately connected to the health and resilience of global ecosystems, both of which
are in crisis together. We cannot be healthy on an unhealthy planet.
Medical wisdom helps explain these crises as symptoms of an underlying prob-
lem, a root cause. What we discover is that we must think differently. With urgency,
we are called to relearn and adopt a new worldview. This call to action is central to
the emerging Great Transition, a global paradigm shift from a mechanistic anthro-
pocentric model to an ecological living systems model. Rather than focusing on
discreet parts, we must look at the world for what it is, a complex interrelated holis-
tic system of relationships. If we are successful, we will discover a host of strategies
that can release the emergence of powerful, compassionate, equitable approaches to
the multitude of problems confronting our common home, fostering health and cre-
ating livable communities for all and future generations.
Climate and Health
Climate change alone has been called the largest human health threat by public
health, medical, and healthcare organization across the globe (Watts, 2018; World
Health Organization, 2016). Direct and indirect health effects of climate change
include temperature-related death and illness, air quality impacts, mental health
effects, extreme weather events, water-related illness, and conflict. Food safety,
malnutrition, undernutrition, and food security are additional concerns, particularly
in relation to floods and drought. Rising temperatures increase ground-level ozone,
which in turn creates difficulty breathing, the aggravation of asthma and the devel-
opment of new cases of asthma, emphysema, chronic bronchitis, and pneumonia.
Ozone can also affect the heart, leading to cardiac arrhythmia and heart attacks as
well as increasing the number of low-birthweight babies (EPA, 2017a). Aeroallergens
such as pollen are higher in extreme heat. Higher levels of aeroallergens trigger
asthma, affecting close to 300 million people (Baxi & Phipatanakul, 2010). Heat
stress can make working conditions unbearable and increase the risk of cardiovas-
cular, respiratory, and renal diseases (U.S. Global Change Research Program, 2016).
Vulnerable populations include children, pregnant women, the elderly, and socially
marginalized groups, all of whom experience greater susceptibility to climate-
sensitive health impacts. Even animals are at risk; pollinators such as bees can
develop heat exhaustion and decreased immune response (McKinstry et al., 2017).
Climate change lengthens the transmission season and expands the geographical
range of many diseases like yellow fever, malaria, chikungunya, Lyme, West Nile,
and dengue.
Emotional, spiritual and mental health impacts are also recognized effects asso-
ciated with climate change and can include trauma, fear, fatalism and loss of loved
ones, livelihoods, social support, identity, and a sense of control (Clayton, Manning,
Krygsman, & Speiser, 2017).
It is estimated that up to 90% of health is accounted for by social and environ-
mental factors outside of healthcare (Minnesota Department of Health, 2014). In the
context of the global burden of chronic disease, the health sector is awakening to the
16 Healthy People, Healthy Planet: Holistic Thinking 207
limitations of the biomedical approach, which focuses on disease treatment

(Abelson, Rupel, & Pincus, 2008; Bendelow, 2013; Huber et al., 2011). Industrial
agriculture, a sector which contributes approximately 30% of global climate emis-
sions (Food and Agriculture Organization, 2011)—far greater than transportation—
employs a similar mechanistic model with an overwhelming array of unintended
impacts to individual, community, and planetary health. Our industrial economy is
another linear model that inaccurately assumes finite resources and unlimited
growth, ultimately contributing to resource depletion, ecological degradation, and
concentrated wealth (Ellen McArthur Foundation, 2013; Piketty & Goldhammer,
2017; World Economic Forum, 2014). If we can find solace in our climate emer-
gency, it is that the situation is forcing us to rapidly reevaluate the design of human
society and the necessity for the application of a holistic, or living systems, model.
Holistic Thinking
It is not surprising that we are experiencing profound challenges. Many of our insti-
tutions and approaches were built on a mechanistic, cause-and-effect scientific
model that does not fully explain the complexity of humans, our relationships and
the interconnectedness of all life (Rosas, 2015). Acknowledging this truth helps us
understand why, as Pope Francis states, “It cannot be maintained that empirical
science provides a complete explanation of life, the interplay of all creatures and the
whole of reality” (Francis, 2015). Moreover, a linear model precludes full systemic
awareness.
A systems worldview shifts our perception of critical matters in new and pro-
found ways. As this model requires us to change our focus from parts to the whole,
it is often described as a holistic approach. Some of its novel attributes include the
following shifts (Capra, 2012):
• From parts to the whole
• From objects to relationships
• From isolated knowledge to contextual knowledge
• From quantity to quality
• From structure to process
• From contents to patterns
Systems models support approaches and organizational paradigms that are
characterized by collaboration and connection, rather than hierarchy and control.
Systems thinking helps rebalance empirical scientific knowledge by re-prioritiz-
ing cultural wisdom and knowledge and by embracing diverse expertise and expe-
riential contexts. Through a shift in value from quantity to quality, an entirely new
holistic set of qualitative metrics can be developed. If we are going to succeed in
addressing the human-made challenges of our common home, it seems obvious
that this living systems model enables us to align our ways of operating in accor-
dance with life on a complex planet, reflective of our true nature and thereby
fostering health.
Holism: A Systems Model of Health
Efforts to better incorporate this holistic understanding into institutionalized defini-

tions of health are ongoing. International experts now recognize that the once-her-
alded World Health Organization definition of health, formulated in 1948, as “a
state of complete physical, mental, and social well-being and not merely the absence
of disease or infirmity” is insufficient, as the term “complete” suggests an unachiev-
able end state, unintentionally perpetuating the medicalization of society (Huber
et al., 2011). “Positive health” is one of the most recent definitions offered by inter-
national experts to reflect the dynamic nature of health, or “health as the ability to
adapt and to self-manage in the face of social, physical and emotional challenges”
(Huber et al., 2011). What we are uncovering is ancient learning from indigenous
cultures, from which we all are rooted. The health and well-being of individuals is
inseparable from nature and inseparable from the health of community (Fig. 16.1)
(Harvie, 2016).
The well-known US poet and farmer Wendell Berry made this thoughtful state-
ment about health:
“Health is not just the sense of completeness in ourselves but also is the sense of belonging
to others and to our place; it is an unconscious awareness of community, of having in com-
mon. It may be that this double sense of singular integrity and of communal belonging is
our personal standard of health for as long as we live.”
Fig 16.1 a Well-being model. b Ojibwe medicine wheel. http://www.curvelakeculturalcentre.ca/

culture/medicine-wheel/
Though not a clinician or healthcare expert, Berry’s observation is consistent

with ancient wisdom, modern science and most recent health concepts which under-
stand the indivisibility of individual, community, and planetary health (NACCHO,
2019; Adelson, 2007; Hermida, 2011). Solastalgia, or distress caused by environ-
mental change, negatively affects health, while views of nature improve health
(Albrecht et al., 2007; Ulrich, 1984). Similarly, a sense of connection, empathy,
spirituality and love confer intrinsic health properties (Egolf et al., 1992; Puchalski,
2001; Rakel et al., 2011). Studies show that when we experience a sense of awe
from viewing nature, we reduce stress, become more generous, and feel a sense of
plentitude (Bai et al., 2017; Joye & Bolderdijk, 2015; Rudd et al., 2012; Stellar
et al., 2015). We can infer from these studies that nature and relationship have
helped us co-evolve as a communal species.
Individuals and communities measure health qualitatively, which is different
(though equally valid) from those of public health and healthcare experts (Huber
et al., 2016), The respect for inherent individual knowledge and self-efficacy and
connection is a fundamental point, increasingly understood as a foundational prin-
ciple, an essential ingredient required to foster agency and thereby improve health.
Within North America, Europe and elsewhere, holistic medicine and nursing
approaches are being increasingly embraced. Functional medicine is a systems biol-
ogy based approach that focuses on identifying and addressing the root cause of
disease and sees health as homeodynamic, a function of dynamic balance between
internal and external factors. Integrative medicine (IM) is healing-oriented medi-
cine that takes into account the whole person—mind, body, emotion, and spirit—
including all aspects of lifestyle. It emphasizes the therapeutic relationship between
practitioner and patient.
Regardless of any specific health definition or clinical approach, these efforts to
elevate our resilience and our relationship to planetary health demonstrate the emer-
gence of collective wisdom. A holistic model of health better explains that we are
ever changing, social, sentient beings in intimate relationship with all living beings
on a dynamic planet. Individual, community, and planetary health are inseparable.
The holistic model of health care is fundamental to helping us unlock and galvanize
our efforts to support and protect planetary health and ecological integrity. What we
do to the planet, we do to ourselves.
Our challenge will be how to amplify our voices into collective action and resist
the allure of deeply entrenched mechanistic thinking across society. Across the
globe, we are witnessing the emergence of new paradigm models across society.
Our opportunity is to deepen our commitment to these systems models, strategies
and approaches and bring them to light. By so doing, we will foster healthy com-
munities and better align with the many values that ultimately make us resilient,
healthy and whole and allow us to thrive.
Towards a Health Commons
One manifestation of the industrial food system model is the obesity crisis and the
global burden of chronic disease, which have aggravated a financial crisis in the
healthcare sector. Climate change is anticipated to further exacerbate this financial
stress. These stressors are also leading to our increasing awareness of a broader
fragility of the healthcare sector itself. Much like the industrial food model, its
design and operations have largely been built on a mechanistic model, putting its
long-term health and that of the planet in peril.
For example, the way that health care is organized, financed and delivered may
contribute to health disparities by limiting access to certain populations, inadver-
tently incentivizing utilization. In addition, the health care sector has a sizable eco-
logical footprint including discharge of toxic chemicals, pharmaceuticals, air and
water pollution, and solid waste—all associated with negative health outcomes.
Healthcare is also a substantial contributor of greenhouse gas (GHG) emissions.
The U.K. National Health Service generates an estimated 39% of all public sector
emissions (Health and Care System (HCS) Carbon Footprint, n.d.). The US health-
care sector represents an estimated 10% of total US GHG emissions. If the US
healthcare sector were itself a country, it would rank 13th in the world for GHG
emissions, ahead of the entire UK (Eckelman & Sherman, 2016).
The pharmaceutical footprint is an estimated 21% of the UK healthcare foot-
print, greater than building energy (Fig. 16.2). Reducing the pharmaceutical impact
Fig. 16.2 National Health System Carbon Footprint Breakdown 2012 (NHS Sustainable
Development Unit, 2013)
by 2.5% is estimated to offer the highest carbon reduction impact (Bouley et al.,
2017), which offers strong insights regarding the potential of wellness or resiliency
as a powerful climate mitigation strategy.
Viewed systemically, it becomes clear that our focus on disease treatment has
caused us to lose sight of a more comprehensive whole, and has inadvertently cre-
ated a self-magnifying disease treatment sector with deleterious climate and eco-
logical health impacts that imperil its own sustainability.
Studies show that progress toward reducing health disparities and improving
well-being will involve support for community-based strategies, enhanced under-
standing of the social determinants of health and an increased diversity of the
healthcare workforce (Jackson & Nadine, 2014), Symposia convening healthcare
and community highlight the imperative to adopt a systemic approach to health,
emphasizing themes that include the concept that health is place-based, holistic
thinking and the need to include a diversity of community expertise. In parallel to
the failures of the industrial food model, the healthcare sector itself is called to think
holistically. Healthcare itself is but one part of a health commons—the collective
resources and relationships within a defined geographic boundary that foster health
(Fig. 16.3).
Across the world, medical professionals are among the most trusted occupations.
Yet we must remember that health as a biophysical process remains deeply embed-
ded in our collective psyche, including healthcare. This transition will challenge a
powerful medical industry with economic interests vested in supporting and main-
taining our attention on individualized treatment. Similarly, the idea that health is
transactional, something given, or received—rather than dynamic and relational—is
a powerful, alluring concept that is deeply entrenched and will remain difficult
to resist.
Fig. 16.3 Commons Health Model. http://www.isfusa.org

Nevertheless, in the context of climate change, we can no longer wait. There is

an urgency to radically redesign our communities to equitably foster health. To do
so, we must shift the locus of health to whole persons and the system of relation-
ships in which they exist.
Being Well Together: Towards a Livable Economy
The last 150 years of industrial evolution have been dominated by a one-way or
linear model of production and consumption in which goods are manufactured from
raw materials, sold, used, and then discarded or incinerated as waste (World
Economic Forum, 2014). This linear model has been supported by an economic
system requiring an endless growth of production, which itself is contingent on
consumption or consumerism (Movahed, 2016).
The nature of the economic system reinforces the primacy of economic growth,
which promotes the externalization of social and environmental costs. At the current
rate of consumption, only 58 years of minerals and metals remain available.
Additionally, our oceans and marine life are filled with plastics, and the web of life
is contaminated with persistent toxic chemicals. Ironically, CO2, the waste product
from the same fossil fuels that feed the global economy, is now predicted to destroy it.
Growth has been uneven, with extremes in inequality across the globe. Income
disparities have become so pronounced that America’s top 10% now average more
than 9 times as much income as the bottom 90%, while the top 1% average over 40
times more income than the bottom 90%. The world’s wealthiest individuals, those
owning over $100,000 in assets, total only 8.1% of the global population but own
84.6% of global wealth, while the world’s ten richest billionaires own $505 billion
in combined wealth, a sum greater than the total goods and services most nations
produce on an annual basis. The concentration of economic power and influence is
highly concentrated with 147 companies, the majority financial institutions, control-
ling 40% of the global economy (Vitali et al., 2011). In such a dominant system, it
is difficult to imagine how anyone might discover any hope in their ability to affect
change. It should come as no surprise that inequality negatively affects our health.
At the local level, high inequality can create a sense of personal and public inse-
curity (Phillips, 2016). Rich countries with higher inequality consume more
resources and generate more waste per person, influencing health through multiple
pathways (Dorling, 2011). In a vicious cycle, reducing the formation of human
capital, unequal access to education, poor health, and inadequate nutrition are both
causes and consequences of inequality. Those on the lower end of economic dispar-
ity experience higher infant mortality and decreased mental health, life expectancy,
levels of trust, altruism, social cooperation, reciprocity, and trust in political institu-
tions (Attanasio, Fitzsimons, Grantham-McGregor, Meghir, & Rubio-Codina, 2012;
Bowles & Gintis, 2013; Burns et al., 2014; Elgar & Aitken, 2010).
Viewed holistically, inequality may in fact represent one of the largest influences
on the health of individuals, communities, and the planet. Citizens across the planet
are experiencing a deepening spiritual emptiness as the economic model pulls us
away from a vital sense of connection and relationship with one another and the
planet; this connection helps make us resilient and well. The extremes in inequality
are rapidly eroding the sense of trust and cooperation necessary for the functioning
of civil societies and the global economy itself. In addition, in our singular quest for
economic growth, we have lost sight of what makes us healthy and whole. Our
hearts and minds tell us we need a new regenerative economic paradigm, designed
first and foremost to support the health and resilience of all living beings together
on our common home. This model is taking form.
Participatory budgeting is a democratic process in which community members
directly decide how to spend part of a public budget. Designed to include those
often left out of the democratic process such as low-income individuals and youth,
participatory budgeting has now spread to thousands of cities across the world and
been promoted as a best practice for democratic governance by the United Nations.
British Columbia, Canada, has adopted a tax (or fee) and dividend to regulate
carbon emissions. Tax and dividend improves health by equitably distributing finan-
cial benefits to all citizens, allowing for the just transition to a carbon-free economy
(Citizens’ Climate Lobby Canada, 2019).
Inequity is driving a renewed focus on cooperative and worker ownership mod-
els, especially as research demonstrates how employee-ownership offers significant
benefits including higher median wage income, job stability and household wealth,
and benefits such as flexible work schedules, retirement plans, parental leave, and
tuition reimbursement.
By including impacted communities and workers in their strategy, the Global
Alliance for Incinerator Alternatives (GAIA) and others have been instrumental in
helping shift policies towards zero waste and away from a “design for the dump” or
“built to be burned” approach. Across the globe, we have witnessed a necessary shift
away from plastic bags, Styrofoam, and other single-use polluting products. The
concept of a circular economy, an industrial system that is restorative or regenerative
by intention and design, is now rapidly advancing. Studies show that a shift to a
circular economy, in which waste is designed out, can reduce climate emissions by
up to 70%.
Global movements such as Transition Towns and Sharing Cities and nationwide
networks such as Businesses Alliance for Local Living Economies (BALLE) within
the USA are cultivating community-rooted enterprises, reclaiming the commons,
democratizing and reorienting finance and building an economy that works for all.
For this work to grow, it will require us to move beyond the singular economic mea-
sure of progress and the gross domestic product, and adopt holistic metrics such as
the Genuine Progress Indicator, Gross National Happiness Index, Inclusive Wealth
Index or co-create a new one that truly reflects the needs and aspirations of humans
for a healthy meaningful life.
Despite the debilitating climate change predictions, punishing inequality and all
the other crises affecting our planet, we are witnessing creativity, self-organization
and the worldwide emergence of a new economy that can work for all (Fig. 16.4).
Collectively, these are helping to demonstrate that we can change our current trajec-
tory and there are viable economic alternatives that put the health and resilience of
people and the planet at the center.
Fig. 16.4 Local economy ecosystem to build a healthy, equitable local economy (From BALLE,
https://bealocalist.org/local-economy-framework/)
Action Steps
Climate Justice
A holistic worldview informs us that climate change is not strictly an environmental

issue but one that also connects and links all of humanity. Strategies and approaches
must be grounded in a human rights framework that guards the rights of the most
vulnerable people and shares burdens and benefits of climate change equitably.
Organizations and approaches must be grounded in climate justice principles, such
as the Mary Robinson Foundation Climate Justice Principles.
Wealth Creation
We all do better when we all do better. Citizens, institutions and other purchasing
entities can use their purchasing power and investments to align their values by
preferentially supporting businesses with employee stock ownership programs
(ESOPs) or worker, consumer and other cooperative models that are designed to
feature principles of human well-being such as justice, equity, ecological steward-
ship, and community. Prioritize equity in hiring and job creation.
Dietary Wellness
Industrial meat production has an outsized global carbon footprint. Cities, hospitals,
churches, schools, and universities can initiate support for policies, practices, and
programs such as the global Meatless Monday’s Initiative and catalyze a global shift
towards plant-based diets. High-caloric beverages are significant contributors to
obesity with a direct and indirect climate footprint. Institutions can adopt policies to
phase-out sales. Examples from Mexico and the USA and other countries demon-
strate how sugary beverage taxes can increase consumption of healthy beverages
and indirectly mitigate climate change, while revenue can be directed to support
publicly owned water systems or be allocated through participatory budgeting.
Good Food Purchasing and Food System Models
Cities can encourage anchor institutions such as hospitals, schools, and universities
to adopt purchasing policies similar to the US-based Center for Good Food
Purchasing, which provides steps and metrics that catalyze good food production
and demand. Cities and economic development agencies can invest and support
community-owned holistic food systems models, such as The Food Commons.
Health Commons and Fostering Health
Governments, communities, healthcare, nursing, and medical schools can locally

adopt recommendations similar to the NHS Manifesto for Health Creation (NHS
Alliance, 2017), Manifesto for Sustainable Global Health (Manifesto for
Sustainable Global Health, 2017), Creating Health Collaborative or the Commons
Health. These suggestions encourage place-based community decision making,
agency and shift away from a disease model.
Integrative Health and Medicine
Governments should support and adopt the Stuttgart Declaration, which calls on
governments to recognize integrative health and medicine as a whole society
approach that will help to reach the Sustainable Development Goals. They should
encourage more holistic training in medical and nursing schools, including multi-
disciplinary fellowships such as the Academy of Integrative Health and Medicine
Fellowship.
Climate Neutrality and Climate Smart Healthcare
Citizens and governments can encourage hospitals across the globe to adopt climate
neutrality goals and climate-smart healthcare strategies such as those outlined in the
World Bank Group document, Climate Smart Healthcare (Bouley et al., 2017), or
adopt the 2020 Health Care Climate Challenge designed to mobilize health care
institutions around the globe to protect public health from climate change. Clinicians
can participate in the Medical Society Consortium on Climate and Health.
The Commons and the Healing Power of Nature
In the context of scarcity, it will be vital to develop strategies to embrace, preserve

and equitably share our commons. The commons include but are not limited to for-
ests, fisheries, parks, public-owned water treatment, renewable energy, libraries,
medicinal plants, and so on. It is vital that governments and citizens develop legisla-
tion, legal structures and self-governance strategies that maintain these assets for
our commonwealth and future generations. Clinicians can prescribe the healing
power of nature and advocate for equitable access to green space.
Active Living and Public Transportation
Communities and clinicians can advocate for accessible and affordable public trans-
portation and prioritize pedestrian and bicycle policies and practices, such as bicy-
cle lockers, showers and connectivity to public transportation.
Zero Waste
Together, citizens can adopt and mobilize their homes, communities, schools, uni-
versities, hospitals, and businesses to adopt zero waste policies and eliminate the
landfilling and incineration of waste. Food waste reduction strategies are a high
priority. Prioritizing reduction and reuse other strategies, such as those proposed by
GAIA, include municipal composting, phase-outs on Styrofoam, plastic straws, and
other single-use items such as carryout bags.
Being Well Together
On a planet in crisis, we will need to improve and hone lost skills for working in
community and in collaboration. This transition will require practices to open hearts
and open minds such as mindfulness, meditation and deep immersion in skills and
methods to harness the collective wisdom and self-organizing capacity of groups.

Take action on something together. Our health is a function of our relationships.
Skills for Health Professionals
Healthcare professionals should build belief in their own resilience and cultivate
active coping and self-regulation skills for themselves and their patients. They
should adopt and guide patients to maintain practices that help to provide a sense of
meaning and that foster optimism, as well as highlight and promote connectedness
to family, place, culture, and community. Clinicians should become climate-literate
professionals and engage with fellow health professionals. They should be vocal,
model leaders within their communities, and support national and international cli-
mate solutions (Clayton et al., 2017).
Conclusion
For the last half century or more, we have ignored the growing signs that our plan-
etary life support system is in peril. Through floods, drought, and storms, climate
change has cracked a dam of hubris and denial and is stirring an awareness about
the inter-relationship of all life. Now, we are awakening to the realization that
humanity’s challenges are our own doing, a function of linear models and associ-
ated hierarchical structures and operating systems incongruous with the complex-
ity of life.
One challenge that health professionals understand is that, in times of crisis, the
human body and mind may “freeze.” Immobilization is a natural defense mecha-
nism, yet it results in an incapacity to act. So while one inclination is to create a
heightened sense of fear and urgency about the climate emergency, it may, in fact,
create inaction.
Perhaps one of our biggest challenges is to understand the pervasive power and
influence of our dominant narrative. We are challenged by patterns of thought that
have been reinforced daily through our culture since birth. It makes us want to focus
on climate change or carbon as a singular issue, when climate change is a complex
product of multiple factors. Many of us have lost the skills to work in groups; with-
out these necessary skills, the notion of collaborating with individuals having
diverse perspectives can be paralyzing. We can be intimidated by a cultural belief in
the primacy of science and question our internal wisdom when something does not
feel right, even though deep-rooted human values will almost always offer the best
path forward hand-in-hand with scientific knowledge.
In fact, leading with one’s heart and an awareness of the connection to all life is
the essence of planetary health and resilience. Though we are challenged with little
time to spare, it is this awareness that offers us necessary direction. By adopting a
new regenerative operating system with health and well-being at the core, we have
the opportunity to elevate a new narrative together, and we can co-create a healthy
and resilient world for all.
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Part V
Climate Change and Health: Social
Impacts
CHAPTER 17
Climate Change, Public Health, Social
Peace
Hans Joachim Schellnhuber and Maria A. Martin
Summary Human well-being results from multiple interactions between highly

diverse issues and actors. Crucial factors range from basic hygiene to social cohe-
sion and environmental integrity. In this century, the development of a critical tri-
angle of challenges—consisting of climate change, public health, and social
peace—will determine whether a good life for all people on Earth is possible, at
least in principle. Those three challenges may seem rather unrelated at first glance,
but they are closely tied together and cannot be properly understood in isolation. In
this chapter, we highlight essential aspects and relationships according to the cur-
rent state of the respective arts.
Climate Change
With respect to the global mean surface temperature, the year 2017 was the second-
warmest on record, according to the European Centre for Medium-Range Weather
Forecasts (ECMWF) (Anon., n.d.-b). That is a remarkable event, since it happened in
the absence of El Niño, a recurring phenomenon in the tropical Pacific that transfers large
amounts of upwelling heat from the ocean to the atmosphere every 3–5 years, thus boost-
ing global tropospheric temperatures. Moreover, 2017 turned out to be an “annus horribi-
lis,” with a terrifying routine of breaking disaster records: unprecedented storms (Irma,
etc.), downpours (in Houston, etc.), floods (in Nepal, etc.), heat waves (Lucifer, etc.), and
wildfires (in California, etc.) shook societies around the planet, giving us a foretaste of
what the new environmental normal might look like in times of climate change.
In particular, the hurricanes of 2017 received worldwide attention. One after
another wreaked havoc with exceptionally high wind speeds (Hurricane Irma), slow
movement and record rainfalls (Hurricane Harvey), and dramatic economic impacts
H. J. Schellnhuber (*) · M. A. Martin

Potsdam Institute for Climate Impact Research, Potsdam, Germany

226 H. J. Schellnhuber and M. A. Martin
(Hurricane Maria). The basic mechanism of how the surface temperature rise affects
tropical cyclones is clear and undisputed: warmer ocean waters provide more energy
to the storms, making them increasingly powerful. But the amount of rainfall they
bring along will also increase: fundamental thermodynamics as expressed in the
notorious Clausius–Clapeyron relation implies that the atmosphere can hold about
7% more water vapor with every degree of warming. Thus, the physics sets the stage
for extreme rainfall events in the future, events that will be even more devastating
than the one that shook East Houston in the wake of Hurricane Harvey. The down-
pours were already so exceptional that the US National Weather Service had to
introduce a new color into its graphs in order to properly represent what happened.
Finally, coastal storm surges become far more dangerous with rising seas due to
global warming. One example that remains pertinent because it caused extensive
subway flooding was the impact of Superstorm Sandy in the year 2012: without the
roughly 30 cm of sea level rise that the New York area had already experienced by
2012, the flooding would have done significantly less harm.
And sea levels might rise even faster than anticipated by the most recent report
from the Intergovernmental Panel on Climate Change (IPCC, 2013). Newer research
findings, based on conceptual models that include the entire range of known contribu-
tions to the ocean rise, suggest that in a business-as-usual scenario we might have to
expect an average rise of about 1.3 m worldwide by the end of this century, which
would be twice that previously estimated (Nauels et al., 2017). Note, however, that
there is no academic consensus yet on the specific processes of ice cliff disintegration
that an earlier study (DeConto & Pollard, 2016) suggested could drive an accelerating
Antarctic contribution to the ocean surge. Nevertheless, exploring the consequences
of the assumption that those processes are real is quite illuminating: Nauels and col-
leagues connect the proposed ice physics with a new generation of emission scenar-
ios, the shared socioeconomic pathways, and conclude that the sea level rise could
still be limited to around 0.5 m in 2100—if an almost complete coal phaseout was
achieved by midcentury. In other words, the truly big inundation can still be avoided,
but the escape path becomes steeper every year without ambitious climate action.
One question, which is routinely raised in the media following extreme weather
events, is whether a specific event has been caused by climate change. Given the
complexity of the climate system and the nonlinearity of its dominant dynamics,
this question is impossible to answer (and almost meaningless) in the strict sense.
However, no-nonsense statistical statements can be made more and more often. The
field that courageously tackles this task is called attribution studies and usually
employs huge numbers of computationally expensive ensemble simulations (see,
for example, van Oldenborgh et al. (2017) for an analysis with respect to Hurricane
Harvey, and Mann et al. (2017) regarding planetary waves and extreme weather
events). Although great steps forward are being taken, one might remain skeptical
as to the ability of the models to capture the specific mechanisms involved in a
single extreme event’s formation. On the other hand, the scientific community may
waste its time anyway by trying to answer the unanswerable, so it should, rather,
focus on the impacts of events that are individually unaccountable but statistically
unavoidable on the basis of the first principles of physics. One tricky aspect in this
17 Climate Change, Public Health, Social Peace 227
context has recently been highlighted in the Bulletin of the American Meteorological
Society: in a warmer climate, not only is the damage arising from hurricanes likely
to become more severe but also the forecasting might become more difficult too, as
the storms intensify more rapidly just before landfall (Emanuel, 2017). The bulletin
also issues a popular and quite useful series titled Explaining Extreme Events from
a Climate Perspective (Anon., n.d.-c).
Not only American coasts are affected by hurricanes: Atlantic Storm Ophelia, for
example, struck Ireland after forming unusually far to the east in October 2017.
Actually, this might become more common in the future (Haarsma et al., 2013). The
impacts of that specific hurricane were spectacular in two ways. Firstly, desert parti-
cles from Africa were swirled up in the air and carried far north, such that for an
entire day the sunlight over England was transformed into a reddish glow, typical for
dawn or dusk only. Secondly, and far more dramatically, the winds fanned the flames
of devastating Iberian wildfires very late in the season. Wildfires are globally on the
rise and are becoming more destructive, also because new settlements keep on intrud-
ing into formerly untouched landscapes. The wildfires in California in 2018, for
example, brought about a huge loss of life, and this was probably only the beginning
on a warming planet. High temperatures and absence of rain, often in combination
with high winds, are basic ingredients for severe fire conditions, and more and more
land is affected by monthly heat extremes now (Coumou & Robinson, 2013; Coumou,
Robinson, & Rahmstorf, 2013). In fact, the number of record-breaking temperature
extremes is already about five times larger than it would be in an unperturbed climate.
This development enhances the risks of fire and drought, but the bitter irony of
anthropogenic climate change is that the contemporary rise in extremes also includes
rainfall (as mentioned above). Recently, Nature Climate Change published a study
applying interesting new diagnostics to computer simulations, involving both the
humidity in the air and its vertical motion. It demonstrated that the basic thermody-
namic relationships between temperature and precipitation intensity, which often
capture the local reality well, need to be complemented by atmospheric fluid dynam-
ics to get the big picture right. It turns out that in the midlatitudes (i.e., regions with
low to intermediate temperatures) hourly precipitation extremes might increase by
up to 15% per degree of warming (Fig. 17.1), roughly doubling the classical
Clausius–Clapeyron relation (see Pfahl, O’Gorman, & Fischer (2017); see also
Lenderink & Fowler (2017) for a “News & Views” contribution). This is in line with
the more general analysis that a weakening of midlatitude circulation leads to more
hot, cold, dry, and wet extremes (Lehmann & Coumou, 2015).
Returning briefly to the question about the anthropogenic causation of an indi-
vidual meteorological extreme event, we wish to highlight a recent heat wave with
an especially suitable name, Lucifer, which haunted the Mediterranean regions in
the summer of 2017: this specific disaster was found to have been made four times
more likely by anthropogenic climate change (World Weather Attribution Group,
WWA; Anon., n.d.-e). During that heat wave, temperatures stayed above 30 °C
around the clock for three consecutive days. Yet another record may have been
reached in the Iranian city of Ahvaz on an afternoon in June 2017, when the tem-
perature climbed to almost 54 °C. If that measurement was correct, it would practically
Fig. 17.1 The most extreme rainfall intensity will increase by up to 15% per degree of warming
(Pfahl et al., 2017)
tie with the hottest temperature recorded on Earth since the beginning of modern
measurements. The Ahvaz episode was made much worse by high concomitant air
humidity, as we will explain below.
Public Health and Social Peace
When one thinks about public health in the context of climate change, one of the
first questions that come to mind is if and how the human body will be able to adapt
to the altered conditions. Steven Sherwood and Matthew Huber have suggested that
unabated climate change might occasionally enforce the transgression of a rather
critical threshold for human physiology (Sherwood & Huber, 2010). A combined
measure of humidity and heat, called the wet-bulb temperature, sets limits to our
body’s acclimatization capacity. In a business-as-usual scenario, this limit might be
approached in some world regions by the end of this century and could even be
exceeded in a few locations, where unfavorable geographic conditions reign (Im,
Pal, & Eltahir, 2017; Pal & Eltahir, 2015). Two of these literal hot spots happen to
be in superdensely populated areas—namely, in the agricultural regions of the Indus
and the Ganges river basin. The wet-bulb temperature sets an upper limit to adapt-
ability; however, heat extremes with temperatures far below this threshold can cost
lives, especially those of the sick, old, and very young. A recent metastudy on
Fig. 17.2 Geographical distribution of deadly climatic conditions in different emission scenarios
(Mora et al., 2017). RCP representative concentration pathway
observed excess heat mortality (Mora et al., 2017) found that around 30% of the
world’s population is already suffering from potentially fatal climatic conditions on
more than 20 days of the year. In a business-as-usual scenario, this percentage is
estimated to rise to almost three quarters of the human population by 2100
(Fig. 17.2).
Beyond extreme heat, climate change affects and threatens public health in vari-
ous other ways (see, e.g., McMichael, Woodruff, & Hales (2006))—that is, through
storms, floods, and wildfires such as the 2017 events in North America, Europe, and
Asia, highlighted above. The impacts of climate change on public health also have
a crucial socioeconomic dimension: shifting environmental conditions will be felt
most strongly in poor and already risk-exposed communities. This applies both to
the socially disadvantaged within industrialized countries and to poor societies in
developing countries—a matter of social justice across scales. Within affluent coun-
tries, physical weakness and lack of monetary freedom reduce resilience against
extreme events such as heat waves, fires, or flooding. In developing countries, health
challenges related to diarrhea, vector-borne diseases, and childhood stunting may
become much more salient.
“The Uninhabitable Village,” a recent interactive report by the New York Times,
gives a vivid and shocking impression of quintessential humanitarian aspects of
global warming (Anand & Singh, 2017). It tells the story of families left behind by
their husbands and fathers—Indian farmers—who killed themselves because they
felt personally responsible for crop failures that climate researchers believe to result
mainly from rising temperatures and the associated extreme events (Fig. 17.3).
Suicides by farmers are part of an escalating tragedy on that subcontinent, with hun-
dreds of thousands of cases occurring over the past three decades. This sad phenom-
enon is partially rooted in local social and economic challenges that are tied to global
Fig. 17.3 Interactive reportage from the New York Times (Anand & Singh, 2017)
inequalities in intricate ways. However, the problem is not merely one of status,
wealth, and allocation; it is also one of fierce environmental reality. Hot days and the
number of suicides correlate, and researchers have estimated that nearly 60,000
cases during the last 30 years might have been caused by the warming trend (Carleton,
2017). The social ripple effects of the phenomenon propagate through space and
time: with women and children left behind and deprived of basic income, trauma is
passed on to the next generations and families are left with daunting choices. They
have to decide between staying and trying to survive under worsening conditions in
already nearly uninhabitable regions or, alternatively, migrating to the cities, where
their points of arrival are generally slums with dire living conditions and prospects.
Another major example of a climate change–related health threat is the rising
sea. Salinization and other associated impacts force communities to give up their
homesteads, which no longer provide them with essential nutrients. Some small
island developing states (SIDS), such as certain Pacific islands, are already becom-
ing uninhabitable as a result of the degradation of formerly fertile ground. Since
these secluded islands are difficult to reach, supply from the outside is not a reliable
alternative. Remoteness and a dire lack of adaptive capacity force islanders to con-
sider moving away decades before they actually lose their lands to the sea.
Environmental migration has actually become a global phenomenon now, which is
both embedded in and transforming the traditional movement patterns. This type of
migration is difficult to quantify, mainly because of a lack of data. Seasonal or perma-
nent movements following single extreme events or long-term environmental degra-
dation are poorly documented so far, not least because those movements happen
predominantly in developing countries without pertinent scientific communities.
Fig. 17.4 Climate impacts and possible migration routes in the Asia-Pacific region (Vinke et al., 2017).
ADB Asian Development Bank, UAE United Arab Emirates
Moreover, each migrfromion decision is based on a complex mix of very individual

motivations. There is, however, new impetus in the scientific community to gain a bet-
ter understanding of the overall phenomenon. Some of the most recent insights have
been compiled in the Atlas of Environmental Migration (Ionesco, Mokhnacheva, &
Gemenne, 2016): more than ten million people are forcibly displaced by weather-
related sudden-onset hazards (such as floods, storms, wildfires, or heat waves) each
year. Many others migrate in response to slow-onset hazards. Some households even
use migration to prepare for future crises looming because of natural disaster risks,
demonstrating that at least in certain cases, adaptation options can be realized by
mobility decisions—which does not necessarily mean, however, that the decision to
move is taken truly voluntarily (Melde, Laczko, & Gemenne, 2017). In 2015, 85% of
all displacement due to sudden-onset events happened in South and East Asia. A
recent report on the human dimensions of climate change in that region, issued by the
Asian Development Bank with major contributions by the Potsdam Institute for
Climate Impact Research (Vinke et al., 2017), sheds light on relevant aspects such as
human health, urban development, security, migration, and trade networks. Among
others, climate impacts and possible migration routes are explored (Fig. 17.4).
The potential indirect consequences of a single extreme event can sometimes be
enormous. The devastations wrought by Hurricane Maria, for instance, which hit
Puerto Rico exceptionally hard on September 20, 2017, and destroyed large parts of
the electrical infrastructure there, eventually may have significant political implica-
tions at a distance. The New York Times reported on the huge number of islanders
(estimated to have amounted to more than 200,000 in the first 2 months after the
event) flowing into the Orlando area as a response to the havoc left behind by the
storm (Tackett, 2017). Since Puerto Ricans are US citizens who predominantly favor
the Democratic Party, their inflow might tip political majorities in the swing state
Florida. Solomon Hsiang and Trevor Houser, directors of the Climate Impact Lab
(Anon., n.d.-a), calculated that it could take 26 years for the island’s economy to
return to its state before the storm (Hsiang & Houser, 2017). This implies that the
Puerto Ricans moving to Florida might not have a strong motivation to return home in
the foreseeable future. So, apart from the social injustice resulting from climate
change–related threats to the least resilient (the old, very young, and poor) within
industrialized countries, this provides a rather surprising example of how climate
change might impact those who are mainly responsible for it—industrialized countries.
It is quite evident that migratory movements can be a threat to social peace under
unfavorable circumstances. Even catastrophic developments such as the ongoing
Syrian civil war have been related to anthropogenic climate change. Colin Kelley
and colleagues analyzed the historic drought that prevailed in the years before 2011,
when the uprising started (Kelley et al., 2015). Their study emphasized that a
drought of that caliber has become more than twice as likely as a result of global
warming. This extreme event most likely contributed to certain migratory move-
ments toward the cities, yet it must be placed within a tangle of drivers that include
unsustainable water management, rising food prices, corruption, and political insta-
bility, as well as the specific motives of the different social and cultural groups
involved. Recently, a number of studies have shed light on pertinent aspects. One
study revealed that groups depending on agriculture and politically marginalized
people are particularly vulnerable to droughts and may resort to violence because of
their lack of coping capacity (von Uexkull et al., 2016). Another study found that
the risk of armed conflict in the aftermath of climate-related disasters is signifi-
cantly higher in ethnically fractionalized countries (Schleussner et al., 2016). Of
course, almost nowhere is climate change the single cause of conflicts, which gener-
ally result from complex socioeconomic dynamics and depend heavily on local con-
texts. This is reflected in a lively debate on the subject, especially with respect to the
Syrian case (Selby et al., 2017). However, in the sense of threat multipliers, climate
impacts have the potential to exacerbate certain existing conflicts or to push other
ones out of latency.
A Radically Logical Proposal
How can we deal with all of these challenges brought about by global warming,
even if the temperature rise is confined to “only” 2 °C? We do think that multilater-
ally arranged climate migration—not compulsory eviction—will be a key element
of an appropriate adaptation strategy. Defending all areas on Earth against sea level
rise, desertification, and increasingly intense “natural” disasters will not be possible,
so a relocation process of unprecedented dimensions needs to be considered
(WBGU, 2016). This cannot be organized rigorously top-down, however, and the
whole enterprise must be guided by humanitarian values. There are already ambi-
Fig. 17.5 Fridtjof Nansen

(1897)
tious projects such as the Nansen Initiative (Anon., n.d.-d), which was launched in
2012 by Switzerland and Norway, and is aimed at establishing an international con-
sultative process in order to raise awareness and build consensus among states on a
protection agenda for persons displaced by climate change.
But the challenges are enormous: identifying climate refugees among other
migrants is highly difficult, especially since voluntary and forced migration are not
easily discernible. There is also a legal gap in dealing with this group of people,
particularly when it comes to cross-border movements. So far, the very term climate
refugees (which suggests that it describes refugees in the sense of the 1951 Refugee
Convention and the obligation to grant asylum) has not been established in interna-
tional law, and the necessary debate is only beginning now.
However, climate migration is already a reality (in the South Pacific, for instance)
and the human calamities resulting from it may become unspeakable in the future
unless a novel institutional set of measures comes to the rescue. Here we mention
just one, which could become a true game-changer. Our suggestion departs from a
famous historical analogue and a name already mentioned above: Fridtjof Nansen
(1861–1930; see Fig. 17.5)—a top diplomat for the League of Nations, a Nobel
Peace Prize laureate, and arguably the most important pioneer of polar research
worldwide—created a certificate, called the Nansen Passport, for stateless persons
who were deprived of their citizenship in the cruel vagaries of the First World War
and its aftermath. The document was launched on July 5, 1922, and eventually
accepted by 53 countries, which opened their borders to the holders (such as Igor
Stravinsky, Rudolf Nureyev, and Aristotle Onassis) of that supranational passport.
Today, a similar certificate—a planet passport or climate passport—could become

a key instrument for dealing, in a liberal and humane way, with migration triggered by
climate change. The passport should give people who lose their home—and possibly
even their national territory—to the impacts of anthropogenic global warming access
to all countries bearing a significant responsibility for that loss. The fundamental idea
underlying this proposal can be epitomized by the following: If someone destroys the
house of another person, he should be obliged to open his own house to that person.
There are many evident and also more subtle aspects of our proposal that need to
be carefully discussed, not least by experts in international law and moral philoso-
phy. Here we confine ourselves to highlighting just two critical dimensions of such
a certificate—namely (a) eligibility and (b) accessibility. The first one is fairly
straightforward in the case of inhabitants of island states threatened in their entirety
by sea level rise or citizens of countries (such as Bangladesh) that will lose large
portions of their territory to the sea. However, things become more complicated
when one considers displacement due to heat, drought, or erosion, for instance, as
the previous discussion about the difficulties in attribution studies has shown. One
could think of setting up an international climate court that would decide on eligi-
bility on the basis of the best scientific evidence available. Secondly, a principle of
the perpetrator would have to lay the basis for identifying the states bound to accept
climate passport holders. For example, a 2% rule (in the vein of the 2 °C guardrail
for climate mitigation) could objectively name the few (and mostly economically
prosperous) countries (or blocs) that have been individually responsible for a
significant share of the global cumulative emissions since the industrial revolution
(see Fig. 17.6).
Fig. 17.6 Share of total cumulative emissions by country or political union. Source: World
Resources Institute
Fig. 17.7 Tipping elements of the Earth System and their potential disruption ranges in the context
of the global mean temperature development over the last 20,000 years (Schellnhuber et al., 2016).
EAIS East Antarctic Ice Sheet, ENSO El Nino southern oscillation, RCP representative concentra-
tion pathway, THC thermohaline circulation, WAIS West Antarctic Ice Sheet
A climate passport (or the already serious discussion of such a format) could
help set a countertrend against the currently observable race to the bottom of moral
standards in the treatment of refugees, manifesting itself not least in the rise of reac-
tionary, xenophobic, and nationalistic political parties in the developed world. Also,
if a given nation comes to the conclusion that the burden of giving shelter to climate-
displaced persons is too heavy, then it might at least raise its mitigation ambitions
and help reduce the very causes of the displacement abroad. Rapid decarbonization
is clearly the choice to be made then.
Conclusion and Outlook
What are the implications of the most recent climate research findings for our civi-
lization? If we step back a little and let our eyes roam over the possible future states
of the Earth System, we have to consider the fact that the changes humans are caus-
ing will not happen, as a rule, in a gradual and reversible manner. In particular, there
are tipping points in the global climate system (Lenton et al., 2008), where the
operation and interaction of crucial components of the planetary machinery, called
“tipping elements”—such as the large ice sheets, the Amazon and Congo rainfor-
ests, the major ocean currents, the monsoon patterns, and the jet streams—can
change their character in a highly nonlinear and possibly irreversible way (for more
information please consult our contribution to the Pontifical Academy of Sciences
(PAS) and Pontifical Academy of Social Sciences (PASS) publication Sustainable

Humanity, Sustainable Nature: Our Responsibility (Schellnhuber & Martin, 2014)).
Putting the latest insights on tipping elements into a relationship with the bygone,
stable environmental regime of the Holocene and with the new, rapidly changing one
of the Anthropocene, it becomes clear that the world might look very different in only
a couple of centuries (Fig. 17.7). A drastic change of course is essential to prevent mas-
sive climatic disruptions (Schellnhuber, Rahmstorf, & Winkelmann, 2016), which,
through tipping cascades, might eventually result in the Earth System locking into a
hothouse state (Steffen et al., 2018), with conditions similar to the climate 15–17 mil-
lion years ago.
Therefore, staying within the temperature range agreed upon in Paris will be
crucial for limiting the associated damage to public health and social peace.
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Der Umzug der Menschheit: Die transformative Kraft der Städte.
CHAPTER 18
Climate Justice and Public Health:
Practical Ethics in Urgent Times
Fonna Forman
We are faced not with two separate crises, one environmental

and the other social, but rather with one complex crisis, which
is both social and environmental. Strategies for a solution
demand an integrated approach to combating poverty, restoring
dignity to the excluded, and at the same time protecting nature.
—Pope Francis, Laudato Si’, 4, 139
Summary This chapter reflects on the disproportionate impact of climate change

on the most vulnerable people and argues that the language of “climate justice” may
not be the most effective language for communicating the urgency to the general
public and for changing attitudes and behaviors around climate change. Drawing on
theories of human motivation in the social sciences, the chapter argues that most
people, most often, tend to be motivated by what most affects them, their families,
their neighborhoods, and so forth. This suggests that focusing on the likely health
impacts of climate change might be a more effective way of communicating with
those who are not motivated by the narrative of social justice to change their atti-
tudes and behaviors. Because the health impacts of climate change can be general-
ized to all of us, this is likelier to motivate a shift in attitudes in behavior among
larger publics. The chapter concludes with reflections on how to integrate public
health more effectively into our communications about climate change.
F. Forman (*)
Center on Global Justice, University of California, San Diego, La Jolla, CA, USA

240 F. Forman
limate Change and the Bottom Three Billion: Injustice,

C
Not Misfortune
There is a distinction in moral philosophy between injustice and misfortunate. A

misfortune is something that happens through the fault of no one—an accident, a
serendipitous catastrophe, the “way of the world”—a calamity that causes destruc-
tion and human suffering. But when does misfortunate become injustice? What if
the calamity, for example, disproportionately harms those who are poor? And what
if these already vulnerable victims of harm have little capacity to adapt? Moreover,
let us imagine that there is a humanitarian response to the calamity but that it arrives
more slowly and sporadically in the precarious zones than in the less precarious
ones. This is a relevant theme following the hurricanes that tore through the
Caribbean and southeastern portions of the USA early in the autumn of 2017. Let us
imagine further that the harm caused by the calamity is not unpredictable or seren-
dipitous at all; it is instead the result of human decision or neglect—a poorly or
inadequately designed levy that breaks, for example, or crumbling infrastructure
that finally fails, or building practices that ignore the risk of placing human settle-
ments in vulnerable places. And let us imagine finally that the calamity is a long-
term environmental impact of the behaviors and habits of a wealthy minority that
make this type of calamity more frequent and the harms it inflicts on the poor
more severe.
Where to draw the line between injustice and misfortune must be understood as
a political act. As the late political theorist Judith Shklar (1990) noted,
We must recognize that the line of separation between injustice and misfortune is a political
choice, not a simple rule that can be taken as a given. The question is, thus, not whether to
draw a line between them at all, but where to do so …” (Shklar, 1990, p. 5)
It is not uncommon in environmental politics that those responsible for causing

harm and those asked to remediate it will try to characterize the harm as misfortune,
with arguments like “calamities like this have always happened,” “they have noth-
ing to do with my actions,” “they are the way of the world,” “an act of nature,” “an
act of God,” and so forth. And as power goes, those who cause environmental harm
typically have more capacity and political agility than the victims of harm, who
often are already vulnerable and marginalized from a society’s circle of moral
concern.
But let us be clear: the impacts of climate change on the most vulnerable people
are not a misfortune; they are an injustice. The idea of climate justice embodies all
of the disparities and gaps mentioned above, and many more. Climate justice is
about an “adaptation gap” between rich and poor. It is about a “humanitarian
response gap” between rich and poor. It is about a “planning gap.” It is also about a
“transparency gap,” an “education gap,” a “health access” gap,” a “development
gap,” and an “energy access gap.” And, most fundamentally, climate justice is about
a “responsibility gap.” Climate change is caused disproportionately by the produc-
tion and consumption habits of the world’s richest populations. The richest one
18 Climate Justice and Public Health: Practical Ethics in Urgent Times 241
billion people on the planet are responsible for about 50% of greenhouse gas emis-
sions, while the poorest three billion, without access to affordable fossil fuels, are
responsible for about 5%. In contrast, the “bottom 3 billion” suffer the greatest
harms associated with climate change (Dasgupta & Ramanathan, 2014).
Climate change is projected to cause widespread and serious harm to human
settlements on the planet, threatening to unravel many of the development gains
of the last century (UNICEF, 2015). The effects of climate change cluster and bear
down hard on the global poor, those who are both least responsible for the causes
and who are least capable of adapting. The health impacts of climate change, par-
ticularly on the poor, are predicted to become catastrophic by midcentury if sig-
nificant reductions in greenhouse gas emissions do not occur (Lancet
Commissions, 2015).
The adaptation gap is perhaps most evident in the acceleration of climate-related
human displacement in recent years. While metrics are still being refined to causally
isolate climate change as a driver of migration, the United Nations Commission for
Refugees (UNHCR) already predicted in 2009 that climate change would become
the largest driver of population displacements both inside and across national bor-
ders (UNHCR, 2009). The global rate of displacement has more than doubled since
1970, from fewer than 2000 persons per million to more than 4000 persons per mil-
lion in 2014 (NRC/IDMC, 2015, p. 22). The most commonly cited estimate is that
200 million people will be displaced by 2050 (IOM, 2008, pp. 11–12; Myers, 2005).
These displacements, even if temporary, have a profound impact on individuals’
lives, often involving the loss of a home or crops, and disproportionately harming
individuals at the very bottom, who lack the resources to adapt and who become
susceptible to human trafficking and forced labor.
In a recent paper on climate migration, Forman and Ramanathan (2018) paid
special attention to the disproportionate impacts of slower progressive effects like
droughts, soil erosion, forest loss, and the sea level rise (Forman & Ramanathan,
2018). While extreme weather events often cause sudden mass displacements and
are increasing in frequency, slower processes seem to have a stronger predictive
effect on the likelihood of climate migration (McLeman, 2014). Those living in
rural or low-lying coastal areas, whose livelihoods are linked with climate-sensitive
sectors like agriculture and fishing, are the most vulnerable and at highest risk, as
they are typically the least capable of either adapting in situ or migrating out, since
the capacity to leave one’s home entails certain financial and social capital such as
education, language skills, and support networks (Biermann & Boas, 2008).
In 1991, the Intergovernmental Panel on Climate Change (IPCC) predicted that
climate change would accelerate urbanization in developing countries, with popula-
tions migrating from coastal lowlands—in particular, densely inhabited delta
areas—to inland areas (IPCC, 1990). The world is now urbanizing at a rate of 32
million people each year, exerting unmanageable “demands on urban services” and
“increasing political pressure on the state” (Barnett & Adger, 2007, p. 642). In the
developing world, rapid urbanization in recent decades has produced dramatic
“asymmetrical” growth patterns as the poorest populations have amassed by the
millions in precarious informal settlements, often periurban and along rivers and
242 F. Forman
lagoons, uniquely exposing them to the effects of climate change—floods, drought,

food and water shortages, and disease (Gadanho, 2014). The explosion of slums at
the peripheries of cities across the planet is a humanitarian crisis of gargantuan
proportion that cities in the developing world today are unprepared to confront
(Davis, 2007). As we have witnessed in Syria, these climate-induced stressors can
exacerbate civil unrest and even revolution (Kelly et al., 2015).
Climate Justice: Redistributing Harms and Responsibilities
Viewed through the lens of human suffering, climate change is not only an envi-
ronmental crisis but also an ethical and political one. Climate justice demands that
those who cause harm, and especially those who benefit from that harm, bear
primary responsibility for remediating it and for preventing further harm in the
future. In other words, climate justice has a temporal dimension that is both
backward-looking and forward-looking. The wealthy, polluting population has an
ethical responsibility to remediate human suffering in the present, accelerating aid
to populations disproportionately struggling to adapt. The polluting population
also has an ethical responsibility to mitigate future harm by doing everything
necessary to mobilize a low-carbon global economy. This imperative includes
helping developing populations leapfrog a carbon-based economy and tempering
the promotion of our wasteful, petroleum-based lifestyle as the epitome of human
happiness. It could be said that climate justice redistributes responsibilities and
harms for the common good. The Mary Robinson Foundation—Climate Justice
(MRFCJ), the first international organization committed to climate justice as a
human right, frames this ethical mandate as “sharing benefits and burdens equitably”
(MRFCJ, n.d.).
There has been perhaps no greater advocate in our generation for the cause of
climate justice than Pope Francis in his encyclical letter, Laudato Si’, of May 24,
2015. He has become a great ally in the integral fight against poverty, the fight for
tolerance and human dignity, and the fight against climate change. In this now well-
known passage, he described the two-headed beast we are confronting:
Today we have to realize that a true ecological approach always becomes a social approach;
it must integrate questions of justice in debates on the environment, so as to hear both the
cry of the earth and the cry of the poor. (Pope Francis, Laudato Si’, 1, 49)
After the release of Laudato Si’, Pope Francis called for urgent coordinated
action. It is not surprising that he began by convening mayors. Across the world,
municipalities have led the way, demonstrating deeper commitment to coordinated
climate action and social justice than nations, with agile, environmentally progres-
sive mayors who know how to mobilize cross-sector partnerships and get things
done (Barber, 2013). As the late political theorist and founder of the Global
Parliament of Mayors, Benjamin Barber, put it, “Cities are the coolest political
institutions on Earth”1 (Barber, 2017). The mayors who convened at the Vatican in
July 2015 ended their meeting with a pledge, which urged world leaders to pass a
bold climate agreement that confines global warming to a limit safe for humanity, while
protecting the poor and the vulnerable from ongoing climate change that gravely endangers
their lives. (Pianigiani, 2015)
Climate Justice: Latin American Living Laboratories
I suspect there was also something distinctively Latin American about why Pope
Francis began with mayors, a history with which he was quite familiar as a young
Argentine. Latin American cities in recent decades have been particularly success-
ful at transforming attitudes and behavior around climate change and environmental
health while producing more equitable outcomes in the city—advancing social jus-
tice and climate justice together.
Some Latin American cities have become almost mythical as living laboratories
of equitable green urbanization. The philosopher Antanas Mockus became the
mayor of Bogota, Colombia, during its most intense period of violence in the late
1990s and early 2000s. It was a scene of social chaos and urban breakdown, unem-
ployment, poverty, and choking air quality, the worst anywhere on the continent.
People referred to Bogota as the most dangerous city on the planet. Mockus declared
that urban transformation must begin with civic strategies designed to transform
social behavior, to change hearts and minds. He became legendary for using arts,
culture, and performance to dramatically reduce violence and lawlessness, recon-
nect citizens with their government and with each other, increase tax collection,
reduce water consumption, and ultimately improve the quality of life for the poor.
Shifting social norms and renewing public trust paved the way for Mayor Enrique
Peñalosa’s renowned TransMilenio bus rapid transit system, at the time the most
advanced multinodal transportation system in the world, linking retrofitted bus
lanes with bicycle hubs, cyclovia (bikeways), and dedicated walking paths that liter-
ally stitched that troubled city together. Bogota revolutionized public transportation
in Latin America. What is notable here, however, is that shifting social norms came
first; the infrastructure and environmental interventions followed (Forman & Cruz,
2017; Forman, 2018). For Peñalosa, like Mockus before him, changing beliefs and
social norms was essential to launching a successful egalitarian transportation
agenda. He observed,
A developed country is not a place where the poor have cars; it is a place where the rich ride
public transportation. (Peñalosa, 2014)
Mockus and Peñalosa emerged from a long tradition of participatory green

urbanization across Latin America, stewarded by mayors who were committed to
robust agendas of civic participation to ignite a sense of collective agency and dig-
On the Global Parliament of Mayors, see https://globalparliamentofmayors.org/.

1
244 F. Forman
nity among the poor, and ultimately to produce greener and more equitable cities:
from the Worker’s Party mayors in Porto Alegre, Brazil, who experimented with
participatory budgeting in the 1980s; to Jaime Lerner in Curitiba, Brazil, who pio-
neered bus rapid transit and dozens of green interventions across the city; to the
“social urbanism” of Mayor Sergio Fajardo in Medellín, Colombia, in the early
2000s, which transformed public spaces and green infrastructure into sites of educa-
tion and citizenship building, and transformed Medellín into a global model of
urban social justice (Forman & Cruz, 2017, 2018; McGuirk, 2014). This tradition
still thrives in cities across the continent, from La Paz to Quito to Mexico City, and
carries important lessons for equitable green urbanization in cities across the
world today.
The Next Step: Public Health as a Social “Lever”
The Bending the Curve report produced by the University of California in 2015
devoted a full chapter to the public health impacts of climate change, giving special
emphasis to the idea of “climate justice” and the disproportionate public health
impacts of global warming on the world’s most vulnerable demographics. Titled
“Bending the Curve and Closing the Gap,” the chapter argued that climate change
and global poverty are intricately intertwined and that they must be tackled simulta-
neously (Forman et al., 2016). We understood public health as an impact requiring
urgent intervention. But we did not yet appreciate that public health predictions
themselves could be deployed as a lever for social change, to stimulate changes in
attitudes and behaviors about global warming and the urgencies we are all facing as
a planet.
This section reflects further on the ethical implications of integrating public
health more robustly as a mechanism for changing public opinion and expediting
policy to keep global warming below 2 °C, particularly among those demographics
in wealthy, polluting societies that have proven themselves resistant to scientific or
ethical arguments. Among the like-minded, we do not need to deploy arguments
about the hardships of poverty or the fact that climate change complicates and deep-
ens them. Those working on the front lines in the global health arena tend to be
committed already, on ethical grounds, to remediating disproportionate impacts and
urgently redistributing resources to assist vulnerable people. But when we engage
publics and policy makers who disagree, passively or surreptitiously, we must
become realists. Our ethics must become practical and strategic. We must be willing
to travel alternative paths—paths that are ethically incomplete, partial, incremental,
and circuitous. When the harms we seek to address are severe and urgent, and when
tipping points are in sight, ideals can become a hindrance. As development econo-
mist Amartya Sen has long argued, we need to welcome “partial realizations” in
times of urgency, since ethical compromises can save lives and reduce human suf-
fering. This was the central theme of his 2009 book, The Idea of Justice, which
sought to chasten the more idealistic and transcendental theories of global justice
associated with John Rawls and his followers:
I would like to wish good luck to the builders of a transcendentally just set of institutions
for the whole world, but for those who are ready to concentrate on reducing manifest injus-
tices that so severely plague the world, the relevance of a merely partial ranking [of distri-
butional priorities] for a theory of justice can actually be rather momentous. (Sen, 2009,
p. 263)
When we speak to publics and politicians today who are not motivated by altru-
istic or collective ends, who do not share our distributional priorities (to use Sen’s
language), and who through habit or agenda are inured to the status quo, we must
find the right “lever” to turn them as they are, in very practical ways, toward the
ends we seek. We can motivate change at the margins, along ethical lines, when the
opportunity costs are low enough. But more fundamental societal changes in atti-
tudes and behavior require a shift in how we communicate.
We know, for example, that people become more receptive to climate-friendly
public policy when they better understand the specific impacts of climate change on
their own lives and communities (Furth & Gantwerk, 2013; Pincetl, 2010). A study
of attitudes and behaviors among residents of low-lying coastal communities in
South Florida, commissioned by the Union of Concerned Scientists, found that cli-
mate-friendly attitudes and behaviors are likelier when the negative effects of cli-
mate change are made concrete and relevant for people, rather than something
far-off like melting ice caps and polar bears. Researchers have found that when
people understand precisely how the sea level rise will affect their own city and their
own neighborhood, their attitudes change (Cosgrove, 2012). They are likelier to be
receptive to the concept of global warming and supportive of local climate-friendly
public policy. This was even true for a majority of individuals self-described as
politically “conservative.” Second, the same study found that people are likelier to
change their behaviors as well—not just beliefs but behaviors too—when concrete
opportunities for local climate action are made available to them. Knowing the risks
without having opportunities to act can produce paralysis, so the conclusion from
public opinion research is Go Local: Start with Impact, End with Action.
Given this, it seems we will be more effective if we reframe our message about
climate change from a language of duty to a language of prudence, from a language
of climate justice (which motivates only those who are already religiously, ethically,
or publicly inclined to change their behavior for the betterment of the least well-off)
to a language of personal and local well-being, and from a language of the other to
a language of the self. Climate justice is a language of disproportionate impact and
blame, and it is not the best vehicle for instigating broad social change. Those who
are already immune to the urgencies of human suffering, and to the appeals of social
justice sui generis, will not be moved by the addition of a threat multiplier like cli-
mate change. In fact, as noted at the beginning of this chapter, the language of cli-
mate justice can trigger defensive retrenchment in some audiences and ethical back
peddling into the mindset of “misfortune.”
246 F. Forman
The early modern idea of “enlightened self-interest” can be instructive here. In

The Passions and the Interests, Albert Hirschman explored the way early modern
thinkers used the idea of “enlightened self-love” as a motivational proxy for altru-
ism (Hirschman, 1977). This helps explain why individuals sometimes sacrifice
immediate benefits for social or collective ends though they are not motivated by
social or collective reasons to do so. Starting with a realist’s concession that only a
small subset of us will be reliably motivated by altruism, selfish individuals never-
theless can produce pro-social ends by exercising prudence, or foresight, to pursue
interests that coincide with the interests of others; in a selfish world, private and
public can still converge. Prudence can restrain present gratification for greater grat-
ification in the future.
The idea of enlightening selfishness is obviously not new to the climate change
discussion. The use of carrots rather than sticks to motivate climate-friendly behav-
ior is one of California’s great, though sometimes controversial, success stories
(“cap-and-trade”) for the ethical compromises incentives always entail.
But along these lines of thinking about carrots, why not also think creatively
about another powerful motivation: the personal health risks of climate change.
Maria Neira suggests (see Chap. 8 in this book) that we frame climate change not as
an environmental crisis but as a public health crisis. This section concludes with five
thoughts about this.
First, we need to convince people and politicians where their true interests lie.
This requires a pervasive shift in our norms (Griskevicius et al., 2008). “Mitigating
climate change” needs to become synonymous in people’s minds with “preserving
health and well-being”—for me, and for all. According to a 2017 Gallup poll, only
42% of Americans presently believe that climate change will pose a serious threat
in their lifetime (Saad, 2017). We need to increase public knowledge about very
concrete and broad public health threats in order to enlighten self-interest.
Second, relatedly, we need to “equalize impacts” as a matter of practical ethics,
to stimulate a more generalized sense of public urgency. Focusing on health dispari-
ties for the poor does not get us there. We need to talk about the relation of air qual-
ity, for example, to stroke, cardiovascular disease, respiratory disease, and so forth.
This is a powerful equalizing tool. Advancing the idea that we are all in peril,
regardless of our wealth and social position, expansion of the circle of potential
victimhood is a powerful equalizing tool. Again, those of us committed to climate
justice need to make compromises like this. We are distraught over the disparities in
our world. But the language of disparity and ethical duty to others does not move
people who are already numb to global justice. We need to be strategic.
Third, we need to think about who is best situated to communicate public health
risks. The issue of public trust here is essential. In our brave new fact-free world,
politicians, journalists, scientists, and intellectuals have all been castigated as
biased, corrupt, detached from reality, and untrustworthy. This may be a very
American (and indeed increasingly European) phenomenon, but these are the popu-
lations we are struggling to reach. Faith leaders have been effective messengers in
some places, framing the perils of climate change through scriptural inspiration,
respect for Mother Earth, and divine compassion for our fellow creatures. Religious
communities can also help to promote new social norms among their ranks—an
important dimension of sustainable behavioral shift, since norms always have a
social regulatory component. The argument here is that public health might help us
intervene at even broader scales, motivating through different channels, by tapping
into very conventional concerns about personal health and well-being, and moving
people from what they love—not Mother Earth, not common humanity, but their
well-being and the well-being of those they love.
To accomplish this, fourth, health practitioners will need to get on board. For the
most part they have been less publicly tarnished than the other relevant professions.
And health practitioners are also capable of engaging people where they are: in the
intimacy of an examination room. It may well be that the general practitioner (GP)
the pediatrician, the obstetrician/gynecologist, the midwife, and the nurse practitio-
ner are our most important soldiers on the ground right now and potentially our
most effective climate educators.
This entails, fifth, an important shift in the way we train our health professionals
today—practitioners as well as researchers, policy makers, and community-based
activists—in the public health arena. Medical schools and public health institutes
will need to become increasingly more collaborative, interdisciplinary, community
engaged, and better insulated from corporate agendas. They will need to commit
themselves to integrating environmental health education, and policy agendas more
explicitly into their mission.
Take, for example, the Community Stations at the University of California San
Diego, a network of research and teaching stations (located in four disadvantaged
neighborhoods on both sides of the US–Mexico border) that focus on community-
engaged climate action and environmental health education.2 At these sites, teach-
ing and research are conducted collaboratively with local environmental nonprofit
organizations. The Community Stations are committed to three main public health
agendas: (1) providing community-based environmental health education for uni-
versity students, teaching them to become climate communicators and educators;
(2) increasing environmental health literacy among adults and especially children in
partner communities (with the idea that educating children is our most essential
task); and (3) stewarding participatory climate action at the neighborhood scale—
from small-scale activities (like raising awareness of consumption habits and stimu-
lating a walking and cycling culture) to designing and financing zero–net energy
solutions and retrofits of homes, schools, and businesses.
One of these stations, the EarthLab Community Station, is located in Encanto,
San Diego’s most challenged inner-city neighborhood, and situated near Chollas
Creek, the city’s most polluted waterway.3 EarthLab is a 4-acre outdoor environ-
mental classroom with community gardens, solar houses, water-harvesting facili-
2
Led by the author in collaboration with Teddy Cruz, Professor of Public Culture and Urbanism at
the University of California, San Diego.
3
EarthLab is a partnership between the University of California, San Diego, the Encanto-based
environmental nonprofit organization Groundwork San Diego, and the San Diego Unified School
District. For further discussion, see Forman et al. (2016).
248 F. Forman
ties, an energy “nanogrid,” and other green infrastructure designed by university

researchers as learning tools for the six public schools within walking distance of
the site. Thousands of low-income youth and their families circulate through
EarthLab each year, learning about the public health effects of climate change and
environmental degradation in their own neighborhoods and participating in climate
action in concrete ways.
This is highly replicable and scalable activity. This project began as an experi-
mental coalition between a university, a school district, and a community-based
environmental nonprofit organization—precisely the kind of integral action Pope
Francis advocated in Laudato Si’. Universities everywhere, large and small, are
positioned to facilitate this kind of local collaborative work for the benefit of stu-
dents, local communities, and the planet.
Conclusion
This chapter acknowledges the urgent and disproportionate impact of climate

change on the bottom three billion among us. But it argues that the language of
climate justice is not the most effective framework for communicating about cli-
mate change to the larger public. Those who are not receptive to social justice sui
generis will not be motivated to change their attitudes and behaviors about climate
change on the grounds that it disproportionately harms the vulnerable. The chapter
argues that most people are motivated most often by what most impacts themselves,
their families, and their neighborhoods. This suggests that a more generalizable
language about the health impacts of climate change might be a more effective way
of communicating with those who are not motivated by the narrative of social jus-
tice to change their attitudes and behaviors. The chapter closes with some reflec-
tions about who is best positioned to communicate these impacts. The takeaway
from these reflections is that those of us who are committed to mitigating climate
change to lessen the impacts on the most vulnerable ought to consider that narra-
tives about generalizable health impacts might just be a more expeditious path
toward the ends we are seeking.
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CHAPTER 19
Health of People, Health of the Planet,
Health of Migrants
Marcelo Suárez-Orozco
You shall neither vex a stranger, nor oppress him: for you were
strangers in the land of Egypt.
—Exodus 22:21
Summary Migration is as old as mankind. Modern humans are the children of

immigration (Antón, Potts, & Aiello, 2014). Today’s migrations unfold in complex
ecologies involving demographic factors, economic variables, social practices, politi-
cal processes, historical relationships, the environment itself, and various combina-
tions thereof (McLeman, 2014). In the twenty-first century, mass migration is the
human face of globalization—the sounds, colors, and aromas of a miniaturized, inter-
connected, and ever-fragile world. Above all, migration is a condition of all humanity.
atastrophic Migrations of the Twenty-First Century:

C
A New Cartography
Mass migrations are increasingly defined by the slow-motion disintegration of fail-

ing states with feeble institutions, war and terror, unchecked climate change, envi-
ronmental degradation, and demographic imbalances (IDMC, 2016; McLeman,
2014). Symbiotically, these forces are the drivers of the catastrophic migrations of
the twenty-first century (Betts, 2010; Chapter 2 in Suárez-Orozco, 2019) (Fig. 19.1).
In the first quarter of the twenty-first century, the world witnessed forcible dis-
placement of the largest number of human beings in history: while precise numbers
M. Suárez-Orozco (*)
UCLA Graduate School of Education and Information Studies, Los Angeles, CA, USA

252 M. Suárez-Orozco
Fig. 19.1 Forced
displacements (IDMC,
2016). IDPs internally
displaced persons
are both elusive and changing (see “Data on Movements of Refugees and Migrants
are Flawed,” 2017), United Nations (UN) data show that more than 68 million
people—the equivalent of every man, woman, and child in Lagos, Sao Paulo,
Seoul, London, Lima, New York, and Guadalajara combined—have escaped home
into the unknown (UNHCR, 2017). The majority of those seeking shelter are inter-
nally displaced persons (IDPs), not formal refugees displaced across international
borders (Suárez-Orozco, 2019). In addition, approximately nine in ten international
asylum seekers remain in a neighboring country; Asians stay in Asia, Africans in
Africa, Americans in the Americas (Fig. 19.2).
While migration is normative, it is increasingly catastrophic: “The majority of new
displacements in 2016 took place in environments characterized by a high exposure to
natural and human-made hazards, high levels of socioeconomic vulnerability, and low
coping capacity of both institutions and infrastructure” (IDMC, 2017). By the end of
2016, there were 31.1 million new internal displacements due to conflict and violence
(6.9 million) and disasters (24.2 million), the equivalent of “20 people [being] forcibly
displaced every minute” (IDMC, 2017), and it was noted that “an unknown number
remain displaced as a result of disasters that occurred in and prior to 2016” (IDMC,
2017). Internal displacement associated with war and terror has been growing since
the beginning of the millennium, and by 2017, most “displacement [had] occurred in
sub-Saharan Africa, with the Democratic Republic of the Congo (DRC) overtaking
Syria in the top ranking.” Today the number of internally displaced persons is signifi-
cantly larger than the number of refugees; in 2017 it was estimated that worldwide,
there were 22.5 million refugees under the United Nations High Commissioner for
Refugees (UNHCR) mandate (UNHCR, 2017c).
In sum, catastrophic migrations unfold at the interstices of war and terror, “fossil
fuel use, the pollution of the atmosphere and the oceans, climate change, [and crises
in] public health, the health of ecosystems and sustainability” (Pontifical Academy
of Sciences, 2017).
19 Health of People, Health of the Planet, Health of Migrants 253
Fig. 19.2 Refugees by region (Source: United Nations High Commissioner for Refugees, Global
Trends: Forced Displacement in 2015, UNHCR, Geneva, 2016 and United Nations Relief and
Works Agency for Palestine Refugees in the Near East, Annual Operational Report 2015 for the
Reporting Period, 1 January–31 December 2015, UNRWA, 2016)
Environmental Dystopia
Forman and Ramanathan (Chapter 1 in Suárez-Orozco, 2019) argue that unchecked
climate change and geophysical hazards increase morbidity and mortality, disrupt
production, decrease agricultural yields, decimate livestock, and forcefully displace
millions the world over (see also McLeman, 2014). According to the Global Report
on Internal Displacement, South and East Asia were the regions most affected in
2016, as in previous years (IDMC, 2017). The 2016 data continued an alarming
trend in extreme weather patterns and weather-related hazards: in 2015, rising sea
levels and floods, droughts, high-intensity cyclones, monsoons, hurricanes, heat
waves, and forest fires triggered 14.7 million displacements, and “4.5 million dis-
placements were brought on by large-scale geophysical hazards.” The 2017 Global
Report on Internal Displacement stated that “over the past eight years, 203.4 mil-
lion displacements have been recorded, an average of 25.4 million each year”
(IDMC, 2016). By 2017, the majority of new displacements had occurred in “low-
and lower-middle-income countries and as a result of large-scale weather events,
and [had] predominantly [occurred] in South and East Asia. While China, the
Philippines and India [had] the highest absolute numbers, small island states [suf-
fered] disproportionally once population size [was] taken into account. Slow-onset
disasters, existing vulnerabilities[,] and conflict also [continued] to converge into
explosive tipping points for displacement” (IDMC, 2017).
Documented displacements due to environmental factors took place in 113 coun-
tries across all regions of the world. Floods, storms, cyclones, monsoons, hurricanes,
earthquakes, volcanic eruptions, wildfires, landslides, and extreme temperatures dis-
placed millions of people in 2015 (Chapter 1 in Suárez-Orozco, 2019). India, China,
and Nepal accounted for the largest numbers of people displaced, “with totals of 3.7
million, 3.6 million, and 2.6 million[,] respectively.” The Philippines experienced
three massive storms, which together displaced two million people (IDMC, 2016).
In Myanmar, Cyclone Komen “displaced more than 1.6 million people[,] . . . the
fifth highest figure worldwide in absolute terms. . . . Twelve of the country’s fourteen
states and regions suffered widespread destruction”. In Central America, millions
have been affected by environmental factors (Durham, 1979; Chapter 2 in Suárez-
Orozco, 2019). By 2017, the world witnessed ferocious hurricanes in the Atlantic
that devastated entire regions of the Caribbean, including Antigua and Barbuda.
According to Prime Minister Gaston Alphonso Browne, after the largest storm ever
in the Atlantic Ocean in September 2017, “the island of Barbuda [was] decimated[,]
its entire population left homeless[,] and its buildings reduced to empty shells” (UN
News Centre, 2017a, 2017b). The entire island of Puerto Rico was left without
power. A month earlier (in August 2017), devastating monsoons in South Asia killed
more than 1200 people; forced millions from their homes in India, Nepal, and
Bangladesh; and shut 1.8 million children out of school.
The UNHCR predicts that climate change will perhaps become the biggest driver
of population displacements, both inside and across national borders. Though there
is a general consensus that quantitative estimates are presently unreliable, Forman
and Ramanathan (Chapter 1 in Suárez-Orozco, 2019) make a plea for an ethical
global policy response to the emerging climate migration crisis. They argue that we
simply cannot await reliable metrics. International cooperation on climate mitiga-
tion is more urgent than ever as the USA, under President Trump’s leadership, is
moving toward an ever more retrograde agenda on climate issues. Establishing
international protocols that outline the rights of climate refugees and the responsi-
bilities of industrialized nations toward them cannot wait.
Jeffrey Sachs (2017) has argued that in addition to the physical environment,
demography itself is a main driver of mass migrations. Africa and the Middle
East are a case in point. In the 1950s, Europe had twice the combined popula-
tions of the Middle East and all of Africa, so migration to Europe was not a
problématique of significance; with labor shortages and the need to rebuild after
World War II, immigration was a solution, not a problem. In an epic reversal, the
Middle East and Africa now have twice the population of Europe. Europe now
has about 740 million people. The Middle East and Africa combined have about
1.4 billion people. Furthermore, according to UN forecasts, Europe’s population

will remain level because of aging and low fertility rates, whereas the population
of the Middle East and Africa combined is on its way to four billion people by
2100 (Sachs, 2017).
War and Terror
War and terror are pushing millions of human beings from home. Millions of people
linger in camps far away from the wealthy cities of Asia, Europe, North America,
and Australia. Indeed, the world is witnessing what Sánchez Terán (2017) calls the
great “forced confinement crisis” of the twenty-first century. Millions have been
internally displaced, millions are awaiting asylum, and millions more are living in
the shadow of the law as irregular or unauthorized immigrants.
In the aftermath of antigovernment uprisings beginning in 2010, the Middle East
and North Africa had the largest number of human beings displaced by war and ter-
ror. But by the end of 2016, sub-Saharan Africa led the way, with the Democratic
Republic of the Congo (DRC) overtaking Syria in the top ranking with “the most
new displacements by conflict and violence.” Ongoing conflict “in North and South
Kivu and an increase in intercommunal clashes in southern and central regions such
as Tanganyika, Kasai, Kasai-Oriental, Ituri[,] and Uele caused more than 922,000
new displacements in total during the year. Some people were forced to flee more
than once.” War and terror in Syria resulted in more than 800,000 new displace-
ments recorded during 2016. In Iraq, almost 680,000 new displacements occurred
as a result of nine military campaigns. In Yemen, at least 478,000 new displace-
ments took place against the backdrop of a persistently dynamic and volatile secu-
rity situation (IDMC, 2017).
In Syria, an estimated 12 million people have fled their homes since 2011. By
2016, more than half of the Syrian population lived in displacement either across
borders or within their own country. “In the sixth year of war, 13.5 million [were] in
need of humanitarian assistance within the country. Among those escaping the con-
flict, the majority [had] sought refuge in neighboring countries or within Syria itself.
According to the United Nations High Commissioner for Refugees, 4.8 million
[had] fled to Turkey, Lebanon, Jordan, Egypt, and Iraq, and 6.6 million [were] inter-
nally displaced within Syria. Meanwhile, about one million [had] requested asylum
[in] Europe. Germany, with more than 300,000 accumulated applications, and
Sweden, with 100,000, [were] the EU’s top receiving countries” (UNHCR, 2017c).
In 2017, just three countries—Syria, Iraq, and Yemen—accounted for more than
half of all internally displaced persons (IDMC, 2016). Likewise, in 2017, more than
half of all international refugees under the UNHCR mandate originated in four
states: Syria (approximately 5.5 million), Afghanistan (2.5 million), South Sudan
(1.6 million), and Somalia (900,000). The conflicts in these countries [have been]
disparate and incommensurable in nature but have shared a chronic, protracted qual-
ity. By 2017, Syria’s descent into a Dantesque inferno had been six years in the
making; the Afghanistan conflict had gone on for twice as long. In Somalia, “more
than two million Somalis [were] displaced by a conflict that [had] lasted over two
decades. An estimated 1.5 million people [were] internally displaced in Somalia[,]
and nearly 900,000 [were] refugees in the near region, including some 308,700 in
Kenya, 255,600 in Yemen[,] and 246,700 in Ethiopia” (UNHCR, 2017b). In Sudan,
war and terror displaced almost a million people in 2016 alone. These conflicts
[had] endured longer than World War I and World War II. In each case, environmen-
tal dystopia and extreme weather patterns anteceded and accentuated the cata-
strophic movement of people.
Syria has continued to represent “the world’s largest refugee crisis” (Suárez-
Orozco, 2019) and, in its collapse, has embodied the noxious synergies among the
environment, war and terror, and mass human displacement. A report published in
2016 cited NASA data showing that Syria was experiencing the driest drought on
record. The NASA scientists found that “estimating uncertainties using a resam-
pling approach, [they could] conclude that there [was] an 89 percent likelihood that
this drought [was] drier than any comparable period [in] the last 900 years and a 98
percent likelihood that it [was] drier than the last 500 years” (Cook, Anchukaitis,
Touchan, Meko, & Cook, 2016). According to UN data, the drought caused “75
percent of Syria’s farms to fail and 85 percent of livestock to die between 2006 and
2011. The collapse in crop yields forced as many as 1.5 million Syrians to migrate
to urban centers like Homs and Damascus” (Stokes, 2016).
Long-term conflicts, unchecked climate change, extreme weather patterns, and
environmental degradation in Africa are generating massive forced migrations.
“Four countries in Africa—Nigeria, the Democratic Republic of the Congo, the
Central African Republic, and South Sudan—were among the top ten globally for
new violence-induced internal displacements in 2015. . . . In total, more than 12
million people [had] been internally displaced by conflict and violence within
Africa—more than twice the number of African refugees” (UNICEF, 2016).
In 2017, the UNHCR observed that in South Sudan, “some 1.9 million people
[had been] displaced internally, while outside the country there [were] 1.6 million
South Sudanese refugees [who had been] uprooted, mainly in Ethiopia, Sudan, and
Uganda” (UNHCR, 2017a). Again , environmental concerns loomed large: “Drought
and environmental degradation, and a food crisis that became a famine because of
government neglect and changing regional demographics” were behind the collapse
in Sudan (IDMC, 2016). The UN noted that “a famine produced by the vicious com-
bination of fighting and drought [was] now driving the world’s fastest growing refu-
gee crisis. . . . The rate of new displacement [was] alarming, representing an
impossible burden on a region that [was] significantly poorer [than other African
regions] and [was] fast running short of resources to cope. Refugees from South
Sudan [were] crossing the borders to the neighboring countries. The majority of them
[were going] to Uganda[,] where new arrivals spiked from 2,000 per day to 6,000 per
day in February [2017] and averaged more than 2,800 people per day” (UNHCR
News Centre, 2017a). The UN World Food Program estimated that by 2017, 4.9 mil-
lion people (40% of South Sudan’s population) were facing famine (UNHCR News
Centre, 2017b).
Indeed, famine lurked as a macabre specter. In 2017 the UNHCR stated that:
In all, more than 20 million people in Nigeria, South Sudan, Somalia[,] and Yemen are
experiencing famine or are at risk. The regions in which these countries sit, including the
Lake Chad basin, Great Lakes, East, Horn of Africa[,] and Yemen[,] together host well over
4 million refugees and asylum seekers. Consecutive harvests have failed, conflict in South
Sudan coupled with drought is leading to famine and outflows of refugees, insecurity in
Somalia is leading to rising internal displacement, and rates of malnutrition are high, espe-
cially among children and lactating mothers. In the Dollo Ado area of southeast Ethiopia[,]
for example, acute malnutrition rates among newly arriving Somali refugee children aged
between six months and five years are now running at between 50 [and] 79 percent.
(UNHCR, 2017b)
By large margins, African refugees [have stayed] on the continent: “Some 86

percent . . . [have found] asylum in other African countries. Five of the largest refu-
gee populations in the world are hosted in Africa, led by Ethiopia, Kenya, and
Uganda. The protracted nature of crises in sending countries means that some of
these host countries have shouldered responsibilities for more than two decades.
Generations of displaced children have been born in some of the longest standing
camps” (Dryden-Peterson, chapter 10 in Suárez-Orozco, 2019).
Only small numbers of refugees have made it to the high- and middle-income
countries. Europe is a case in point. By the end of 2015, Europe had approximately
one in nine of all refugees under the UNHCR’s mandate, a total of 1.8 million
people (UNICEF, 2016). Of these, most were “divided in nearly equal measure
among Germany, the Russian Federation[,] and France (17, 17[,] and 15 percent of
refugees in Europe, respectively). In 2015, more than one-third of the refugees liv-
ing in Germany were from the Syrian Arab Republic, with smaller proportions from
Iraq and Afghanistan (38, 17[,] and 10 percent, respectively). Nearly all of the
315,000 refugees hosted in the Russian Federation by the end of 2015 were from
Ukraine. By the end of 2015, Germany had become the world’s largest recipient of
new individual applications for asylum—receiving more than twice as many as the
next closest country” (UNICEF, 2016).
In the Americas, a new migration map has also taken shape. First, by 2015,
Mexican migration to the USA, the largest flow of international migration in US
history, was at its lowest in over a quarter of a century. Second, for the first time in
recent history, more Mexicans were returning (voluntarily and involuntarily) to their
country than were migrating to the USA. According to data analyzed by the Pew
Hispanic Center,
more Mexican immigrants [had] returned to Mexico from the [United States] than [had]
migrated here since the end of the Great Recession . . . . The same data sources also show
the overall flow of Mexican immigrants between the two countries [was] at its smallest
since the 1990s, mostly due to a drop in the number of Mexican immigrants coming to the
[United States].
From 2009 to 2014, one million Mexicans and their families (including US-born chil-
dren) left the [United States] for Mexico, according to data from the 2014 Mexican National
Survey of Demographic Dynamics. (ENADID, 2014)
Third, as Mexican migration decreased, uncontrolled criminality (Chapter 2 in

Suárez-Orozco, 2019), terror, and environmental dystopia put Central Americans at
the center of the new map. Indeed, the Americas gave the new immigration map a
new nomenclature: mass unauthorized immigration (Pew Research Center, 2016)
and unaccompanied minors.
The sources of the forced movements of people in Central America have dispa-
rate and complex histories, finding their distal origins in the Cold War, inequality,
uncontrolled criminality, and environmental malfeasance. In the case of Central
America, 1998 began a new cycle of catastrophic migrations. That is the year
Hurricane Mitch hit Honduras and the rest of the region. Hurricane Mitch was the
second-deadliest Atlantic hurricane on record, causing over 11,000 fatalities in
Central America, with over 7,000 occurring in Honduras alone because of the cata-
strophic flooding due to the slow motion of the storm. The hurricane left severe
environmental and psychosocial scars. Data from the School of Medicine at Brown
University estimated that of the total of 3.3 million adult (15 years of age or older)
inhabitants of Honduras, more than 49,000 suffered posttraumatic stress disorder
(PTSD) due to Hurricane Mitch. The near-savage deforestation of Honduras left a
country with weak institutional capacity extremely vulnerable to devastation in the
wake of the hurricanes. Hondurans then began an ecological exodus north.
A generation before, La guerra del fútbol—the so-called Soccer War of 1969
between El Salvador and Honduras—had more to do with environmental factors
flowing from extraordinary inequality in land holdings than with the region’s
beloved game. Running out of cultivable land, some 300,000 Salvadoreans packed
up and migrated over the border to Honduras. The ensuing war lasted 100 h and
forecasted the noxious synergies between environmental malfeasance, war and ter-
ror, and mass migrations (Durham, 1979).
The New Face of Catastrophic Migrations
Crying children are the face of the catastrophic migrations of the twenty-first cen-
tury. Worldwide, one in every 200 children is a refugee, almost twice the number of
a decade ago (UNICEF, 2017). According to UN data, in 2016 there were 28 million
forcefully displaced children. Another 20 million children were international
migrants (UNICEF, 2017). Their total number is now larger than the populations of
Canada and Sweden combined. Millions of children are internal migrants. In China
alone there were an estimated 35 million migrant children in 2010 and a staggering
61 million children who were left behind in the countryside as their parents migrated
to the coastal cities.
[Children] are a sign of hope, a sign of life, but also a ‘diagnostic’ sign, a marker indicating
the health of families, society[,] and the entire world. Wherever children are accepted,
loved, cared for[,] and protected, the family is healthy, society is more healthy[,] and the
world is more human. (Pope Francis, 2014)
Yet, few forcefully displaced children ever make it to safety in the high- or mid-
dle-income countries. In 2016, UNICEF (2016) reported that 900,000 children had
been forcefully displaced within South Sudan and more than 13,000 had been
reported as “missing” or separated from their families. The vast majority of children
seeking refuge remain internally displaced or settle in a neighboring country.
Jacqueline Bhabha (chapter 3 in Suárez-Orozco, 2019) notes that of the more than
600,000 South Sudanese refugees currently sheltered in Uganda, some 300,000 are
under age 18, and the majority are girls and women.
By 2015, the world had witnessed a record number of unaccompanied or sepa-
rated children, with 98,400 formal asylum applicants—mainly Afghans, Eritreans,
Syrians, and Somalis—being lodged in 78 countries. “This was the highest number
on record since UNHCR started collecting such data in 2006” (UNHCR, 2016). By
the end of 2016, a new record had been set, with at least “300,000 unaccompanied
and separated children moving across borders[. They] were registered in 80 coun-
tries in 2015–16—a near fivefold increase from 66,000 in 2010–11. The total num-
ber of unaccompanied and separated children on the move worldwide [was] likely
much higher” (UNICEF, 2017).
Conclusions
Mass migration and demographic change are, under the best of circumstances,
destabilizing and generate disequilibrium. Catastrophic migrations produce multi-
ple additional layers of distress. The forcefully displaced undergo violent separa-
tions and carry the wounds of trauma. Millions of human beings are caught in
permanent limbo, living in zones of confinement. In these zones “humiliation is
re-created in the camp environment when individuals are not allowed to work, grow
food, or make money” (Mollica, Chapter 5 in Suárez-Orozco, 2019). Catastrophic
migrations assault the structure and coherence of families in terms of their legisla-
tive, social, and symbolic functions.
The outright rejection of unwanted refugees, asylum seekers, and unauthorized
immigrants compounds trauma. In many countries of immigration, too, we have
identified zones of confinement where de facto and de jure policies are forcing mil-
lions of immigrant and refugee families to live in the shadow of the law. In the USA,
the country with the largest number of immigrants, millions are separated, millions
are deported, millions are incarcerated, and millions more inhabit a subterranean
world of illegality (Chapter 4 in Suárez-Orozco, 2019).
Catastrophic migrations and violent family separations disrupt the essential
developmental functions necessary for children to establish basic trust, feel secure,
and have a healthy orientation toward the world and the future. Catastrophic migra-
tions tear children from their families and communities. Furthermore, physical,
sexual, and psychological abuse are normative features of forced migrations, espe-
cially when they involve human trafficking and subhuman conditions prevailing in
many migrant camps. The health of children in such contexts is the existential crisis
of our times (Chapter 7 and Chapter 5 in Suárez-Orozco, 2019).
Catastrophic migrations remove children and youth from the prescribed path-
ways that enable them to reach and master culturally determined developmental
milestones in the biological, socioemotional, cognitive, and moral realms required

to successfully make the transition to adulthood. Catastrophic migrations are life
thwarting, harming children’s physical, psychological, moral, and social well-being
by placing them in contexts that are inherently dangerous.
When immigrants and refugees manage to settle in new societies, they bring new
kinship systems, cultural sensibilities (including racial, linguistic, and religious sen-
sibilities), and identities to the forefront. These may misalign with (and even contra-
vene) taken-for-granted cultural schemas and social practices in the receiving
societies. The world over, immigrants and refugees are arousing suspicion, fear, and
xenophobia. Immigration is the frontier pushing against the limits of cosmopolitan
tolerance. Immigration intensifies the general crisis of connection and flight from
the pursuit of our inherent humanitarian obligations concerning the welfare of oth-
ers (Chapter 14 in Suárez-Orozco, 2019).
Reimagining the narrative of belonging, reclaiming the humanitarian call, and
recalibrating the institutions of the nation-state are a sine qua non to move beyond
the current immigration malaise the world over. In the long term, we must retrain
hearts and minds, especially younger ones, for democracy in the context of demo-
graphic change and superdiversity. We need to convert a dread of the unfamiliar
“Other” into empathy, solidarity, and a democratizing desire for cultural difference.
We must endeavor to cultivate the humanistic ideal to find oneself “in Another”
(Ricoeur, 1992/1995) in the refugee, in the asylum seeker, and in the forcefully
displaced.
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Part VI
Overarching Solutions: The Role of
Religion
CHAPTER 20
Faith in God and the Health of People
Leith Anderson
Summary Engaging religious groups in environmental stewardship for human

health begins with their theological presuppositions and is most persuasive when
influenced by those leaders who share their faith.
Faith in God and the health of people are universal. Eighty-four percent of the
world’s 7.3 billion people are affiliated with some religion (Christians 31.2%;
Muslims 24.1%; unaffiliated 16%; Hindus 15.1%; Buddhists 6.9%; folk religions
5.7%; other religions 0.8%; Jews 0.2%) (Hackett & McClendon, 2017). While not
everyone in the world is religious, about eight in ten are religious and the rest are
affected by the religious beliefs of the many around them. However, the health of
humans involves everyone. One hundred percent of the world’s population are
somewhere on the continuum of good health to poor health.
While religion and health usually are studied under different academic disci-
plines, practical experience combines them in most lives. As Pope Francis asserted
in Laudato Si’, “everything is interrelated” (Catholic Ecology, 2015). We cannot
conflate religion and human health, but we can seek to connect them. It is a chal-
lenging task because there is generally greater consensus on health than on reli-
gion. Moreover, there are different starting points. In broad terms, religion tends to
start with God and faith, while science starts with research and predictability. That
said, Christians are more likely to begin with God and move on to health and the
environment, while “some non-Western religious traditions, like Hinduism, make
a tighter link between representations of the divine and nature” (Ecklund &
Scheitle, 2018).
L. Anderson (*)
National Association of Evangelicals, Washington, DC, USA

266 L. Anderson
The Protestant Evangelical Perspective
As an American Protestant Evangelical Christian, my perspective is rooted in one

segment of Christian faith and one nation’s current engagement in the “Health of
People, Health of Planet and Our Responsibility” (Pontifical Academy of Sciences,
2017). Evangelicals worldwide total around 600 million, with nearly 100 million in
the USA (about 30% of the population of the USA) (Wikipedia, n.d.). It is more of
a movement than an institution; there are thousands of independent subsets with
diverse sub-beliefs, organizations, and ethnicities without direct knowledge of or
connection to one another. They all share four Christian beliefs, which mark their
identity: the Bible, Jesus Christ, salvation, and activism/evangelism (Anderson &
Stetzer, 2016).
Beginning with God and the Bible, there are foundational beliefs that God is
eternal and sovereign, and that God created the Earth and all on the Earth. The pin-
nacle of God’s creation is humans, who were created in God’s image of rational
intellect, emotion, and volition (Biblica Inc., 1973a). Since God created the Earth,
he is the owner, who has delegated stewardship/management responsibility to his
human creatures. We are the beneficiaries of God’s creation but also accountable to
God for the care of his creation (Biblica Inc., 1973b). This becomes the theological
basis for Christian environmentalism—humans are responsible to God for the pres-
ervation, protection, and thriving of all God has created, including air, land, water,
animals, plants, and especially our fellow humans. There are great challenges in
fulfilling this calling, but the calling is to be considered an honor and a privilege to
serve as agents of God.
The Bible does not start with environmental stewardship. It starts with God and
is therefore theocentric. In other words, environmental stewardship is not an end in
itself but grows out of who God is, what God has created, and all God has assigned
for us to do in the care of his creation. Loving and serving God is always first. When
Jesus was asked what our highest human responsibility is, he said, “Love the Lord
your God with all your heart and with all your soul and with all your mind. This is
the first and greatest commandment” (Biblica Inc., 1973c). On the basis of the pri-
macy of God and the authority of the Bible, Christians are also called to love our
fellow humans. After the first commandment to love God, Jesus added, “And the
second is like it: ‘Love your neighbor as yourself’” (Biblica Inc., 1973d). These
core expectations of Christians did not originate with Jesus; they also are written in
the Hebrew scriptures of the Old Testament (Biblica Inc., 1973e). On the basis of
these principles, the moral code of Jesus in the New Testament includes care for the
poor and vulnerable (Biblica Inc., 1973f).
Although not all Christians have adhered to the teachings of the Bible on the care
of God’s creation or the moral imperatives of Jesus on the care of the poor and vul-
nerable, these are foundational doctrines and expectations. As millions of Christians
take these callings seriously, they are immediately challenged with prioritization.
What if environmental stewardship hurts the poor? What if helping the poor hurts
the environment?
20 Faith in God and the Health of People 267
When Hurricane Maria devastated the island Commonwealth of Puerto Rico,

97% of the electrical power grid was knocked out. Transportation was curtailed;
hospitals ran on diesel generators or closed; patients on ventilators or dialysis died.
Puerto Rico is primarily powered by fossil fuels (U.S. Energy Information
Administration, 2017). Generators and fossil fuels were shipped, airlifted, and car-
ried to sustain human life and to improve living conditions. Of course, cataclysmic
crises should not be the standard for deciding between protecting the environment
from pollution and protecting human life, but, in everyday choices, decisions are
often made between good competing values. Sadly, too many decide their priorities
first and then unnecessarily choose to harm one and help another when options are
available that will harm neither.
In 2010, Evangelical Christian leaders from 198 countries met in Cape Town,
South Africa, under the auspices of the Lausanne Movement and issued the Cape
Town Commitment (Lausanne Movement, 2010). Included in Part II of the lengthy
Commitment is a statement on caring for God’s creation and caring for the poor and
suffering:
All human beings are to be stewards of the rich abundance of God’s good creation. We are
authorized to exercise godly dominion in using it for the sake of human welfare and needs,
for example in farming, fishing, mining, energy generation, engineering, construction,
trade, or medicine. As we do so, we are also commanded to care for the earth and all its
creatures, because the earth belongs to God, not to us. We do this for the sake of the Lord
Jesus Christ who is the creator, owner, sustainer, redeemer and heir of all creation.
We lament over the widespread abuse and destruction of the earth’s resources, including
its bio-diversity. Probably the most serious and urgent challenge faced by the physical
world now is the threat of climate change. This will disproportionately affect those in
poorer countries, for it is there that climate extremes will be most severe and where there is
little capability to adapt to them. World poverty and climate change need to be addressed
together and with equal urgency.
We encourage Christians worldwide to:
A) Adopt lifestyles that renounce habits of consumption that are destructive or polluting;
B) Exert legitimate means to persuade governments to put moral imperatives above political
expediency on issues of environmental destruction and potential climate change;
C) Recognize and encourage the missional calling both of (i) Christians who engage in the
proper use of the earth’s resources for human need and welfare through agriculture, indus-
try and medicine, and (ii) Christians who engage in the protection and restoration of the
earth’s habitats and species through conservation and advocacy. Both share the same goal
for both serve the same Creator, Provider and Redeemer. (The Lausanne Movement, 2011)
This statement was subsequently adopted by the National Association of
Evangelicals (USA) in 2015 (National Association of Evangelicals, 2015).
Engaging in the Issue
In the USA, issues related to climate change have become politically polarized, with
politics often eclipsing scientific, religious, and moral teaching. Many explanations
are offered to interpret this polarization, including the divide between those who
268 L. Anderson
trust government and institutions and those who do not share that trust. There are so
many complex presuppositions and group identities involved that simple answers
are hard to find and are often rejected, especially during a time of political transition
and disruption. It is not that sources of political polarization are unimportant, but
our discussion here focuses on description and possible paths to solutions.
Religion Versus Science
What Religious People Really Think, written by Elaine Howard Ecklund and
Christopher Scheitle (New York: Oxford University Press), reports surveys of
10,000 Americans and interviews with nonreligious persons, religious persons, and
science professionals. Funded by the John Templeton Foundation, in collaboration
with the American Association for the Advancement of Science, and based at Rice
University, this extensive research included questions on climate change.
Consider the breakdown of responses to just two of the many questions asked:
“Please tell me how interested you are in the following things: the environment
(‘Very interested’).” All respondents 32.0%; Evangelical Protestants 27.8%;
Mainline Protestants 31.2%; Catholics 32.0%; Jews 34.3% (Ecklund &
Scheitle, 2018).
“The climate is changing and human actions are a significant cause of the
change.” All respondents 41.8%; Evangelical Protestants 34.7%; Mainline
Protestants 41.6%; Catholics 42.4%; Jews 43.8%; non-Western 55.4%; unaffiliated,
atheists, agnostics 49.9% (Ecklund & Scheitle, 2018).
The differences are statistically significant but fall short of a majority on both
questions in all groups except for adherents to non-Western religions, with 55.4%
agreeing that the climate is changing with human action as a significant cause.
Overall, most Americans of all religious affiliations say they are not “very inter-
ested” in the environment and they do not affirm that the climate is changing and
human actions are a significant cause of the change. While it is worth noting that
Evangelical Protestants are on the lower end of “very interested” in the environment
and on the lower end of affirming climate change caused by human action, they are
among the majority of all respondents in both categories. This indicates that raising
concern and commitment on these issues relates to the majority of Americans
although mostly so among Evangelical Protestants.
Ecklund and Scheitle give suggestions on how to engage different religious com-
munities in the issues of environment and climate change. Here are a few that spe-
cifically relate to American Evangelical Protestants (because they are 30% of the
US population and less likely to engage in these issues):
• Evangelicals are also more likely to say either that the climate is not changing at all
or that the climate is changing but not because of human actions. So, while politics
does contribute to lower levels of acceptance of the scientific consensus in climate
change among evangelicals, politics does not appear to be the sole factor. So, for
those conducting outreach to evangelical communities on this issue, the message

needs to reach beyond the political issues to address the distinct faith concerns of
evangelicals.
• Attitudes on climate change are also strongly influenced by factors like political
ideology. Over and over, we found, particularly among evangelical Christians, that
environmentalism was tied in their minds to political ideologies they want to distin-
guish themselves from. Evangelicals are the religious groups most likely to be suspi-
cious of scientists, so they need to hear about climate change from voices they trust.
Religious leaders can help here, making climate change action about theology not
politics.
• Congregations not only can draw connections between theology and environmental
care, but they also can provide opportunities for members to practice and reinforce
environmentally conscious behaviors.
• Scientists can help make environmental issues more salient for religious believers by
focusing on the human impacts of climate change, and religious leaders can use
those impacts to provide people of faith with a religious rationale for climate change
action. (Ecklund & Scheitle, 2018)
Practical steps to address faith, poverty, suffering, human health, and the care of
the Earth’s environment begin with the presuppositions of faith and lead to actions
based on faith.
• Faith communities may organize study groups, meeting over several weeks.
Provide study guides that begin with Bible teaching on God’s creation and God’s
call to care for his creation. Next, study Bible teachings on God’s call to protect
and provide for the poor, suffering, and vulnerable. Introduce information on the
impacts of climate change that degrade God’s creation and contribute to suffer-
ing and poverty. Provide stories of positive outcomes where the care of God’s
creation and mitigation of climate change contribute to human health and flour-
ishing. Discuss individual and collective actions that fulfill the mandates of faith
in the context of a changing climate.
• Provide persons of faith and communities of faith with theological and scientific
information that comes from respected leaders who share their faith. Prioritize
scientists who have strong faith commitments and are active in local faith com-
munities. Utilize theologians, pastors, authors, and other known faith leaders
who write and speak about the care of creation and climate change. Connecting
with these trusted persons of influence from both the theological and scientific
perspectives may be multisourced by engaging them as guest speakers in
churches, authors of books and brochures, bloggers, and social media communi-
cators, and also via other modes of communication. This approach builds on
already established trust, which is leveraged to communicate information and
specific practical calls to individual and collective action.
• Encourage grassroots decisions rather than prescribing personal or political
action lists. This is not to preclude suggestions and recommendations. Stories,
examples, and action ideas are powerful tools of influence. However, groups
brainstorming how to act out their faith can lead to bottom-up movements that
are often not possible when there is a concern over top-down external prescrip-
tions and pressure.
270 L. Anderson
Conclusions
Interfaith dialogue on the health of people, the health of the planet, and our respon-
sibility is most valuable and important when focused on humanitarian needs.
Collaboration and cooperation are best suited to helping those suffering from floods,
droughts, crop failures, famines, migration, and other cataclysmic events, regardless
of the causes. When crises come to countries and communities of varied religions,
all people of faith should step forward to rescue and restore together.
Interfaith dialogue and cooperation may be least valuable when one seeks to
inform and persuade each religion’s constituents. The lesser value is rooted in dif-
ferent theologies, presuppositions and historical ignorance, and lack of trust of each
other’s religious faith. While dialogue among leaders is frequently valued and prac-
ticed, it has minimal predictability of influence among the masses in foreseeable
generations. In other words, cooperation in practical humanitarian actions is good in
that it helps those in need, but the trajectory from practical meeting of needs to per-
suasion of differing religious groups is best accomplished unilaterally rather than
multilaterally. It comes down to matters of prioritization and deployment of
resources. The priority of each religious community on issues of the environment
and humanitarianism and the use of resources will produce greater effects when
largely focused on separate religious traditions and communities.
This most applies to the continuum from individuals and communities of faith to
individuals and communities of agnostics, atheists, and the unaffiliated. The belief
systems and worldviews are at such a distance that they are a substantial barrier and
distraction to dialogue and collaboration on environmental concerns. The same may
be said of the distance between Western and non-Western religions. However, this
conclusion is less applicable to groups within Christianity. For example, many of
the doctrinal presuppositions and social teachings of the Roman Catholic Church
and American Evangelicalism align (e.g., cardinal Christian doctrines and prolife
social teaching).
The strategies for increasing engagement and action within each religious tradi-
tion are most likely to succeed when (1) leaders give voice to those who trust them
as leaders; (2) persuasion begins with the tenets of the faith and not just current
events or scientific consensus; (3) environmental catastrophes dominate the news
and create opportunities for engagement and persuasion (preparing plans for com-
munication before such catastrophes occur and quickly seizing the news cycle); and
(4) scientists within the faith have disproportionate influence because of their under-
standing and terminology of both their faith and their science. And, finally, all of
this takes a long time.
References
Anderson, L., & Stetzer, Ed. (2016, March 2). Defining evangelicals in an election year. Christianity
Today Magazine.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973a, 1978, 1984,
2011 Biblica, Inc., Genesis 1–3.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973b, 1978, 1984,
2011 Biblica, Inc., Genesis 1:27–31.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973c, 1978, 1984,
2011 Biblica, Inc., Matthew 22:37–38.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973d, 1978, 1984,
2011 Biblica, Inc., Matthew 22:39.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973e, 1978, 1984,
2011 Biblica, Inc., Deuteronomy 6:4–5 and Leviticus 19:17–18.
Biblica, Inc. The Holy Bible, New International Version®, Niv® Copyright © 1973f, 1978, 1984,
2011 Biblica, Inc., Matthew 25:36–44 (God’s judgment), Luke 10:25–37 (Parable of the Good
Samaritan) and approximately 2000 references in the Bible to advocacy and care of the poor.
Catholic Ecology. (2015, June 18). With Laudato Si, “Everything is connected”. Catholic
Ecology. Retrieved September 30, 2017, from https://catholicecology.net/blog/
laudato-i-everything-connected
Ecklund, E. H., & Scheitle, C. P. (2018). Religion vs. science: What religious people really think.
Oxford, UK: Oxford University Press. Chapter 6.
Hackett, C., & McClendon, D. (2017, April 5). Christians remain world’s largest reli-
gious group, but they are declining in Europe. Pew Research Center. Retrieved
September 30, 2017, from http://www.pewresearch.org/fact-tank/2017/04/05/
christians-remain-worlds-largest-religious-group-but-they-are-declining-in-europe/
National Association of Evangelicals (2015). Caring for God’s creation: A call to action.
National Association of Evangelicals. Retrieved October 1, 2017, from https://www.nae.net/
caring-for-gods-creation/
Pontifical Academy of Sciences (2017, November 2–4). Health of people, health of planet and our
responsibility. The workshop of the Pontifical Academy of Sciences, Vatican.
The Lausanne Movement (2010, October 17–24). Cape Town 2010: The third Lausanne Congress
on World evangelization. Lausanne Movement. Retrieved October 1, 2017, https://www.laus-
anne.org/gatherings/congress/cape-town-2010-3
The Lausanne Movement (2011). The Cape Town Commitment, Section IIB, 6. The Lausanne
Movement. Retrieved October 1, 2017, from https://www.lausanne.org/content/ctc/
ctcommitment
U.S. Energy Information Administration (2017, September 21). Puerto Rico. U.S. Energy
Information Administration. Retrieved September 30, 2017, from https://www.eia.gov/
state/?sid=RQ
Wikipedia. (n.d.). Evangelicalism. Wikipedia. Retrieved September 30, 2017, from https://
en.wikipedia.org/wiki/Evangelicalism
272 L. Anderson
CHAPTER 21
Caring for Creation: The Evangelical’s
Guide
Mitchell C. Hescox
Summary Understanding creation care as prolife helps the Evangelical and Catholic
communities relate to environmental concerns as more than interest in fauna and
flora, and as a primary matter of life for our children, the Majority World’s poor, and
even many of the economically disadvantaged in the United States, whose homes
border some of our country’s most toxic air, foulest water, and most polluted soil.
Introduction
The religious landscape is changing in the United States. Today, only 43% of
Americans identify as white and Christian, in comparison with 81% in 1976. Yet
even amid these shifting demographics, white Evangelicals still comprise 35% of
the Republican Party (Cox & Jones, 2017). Together, Evangelicals and Catholics
represent approximately 28% of the American populace, yet they consistently vote
in disproportionately high numbers. Over 80% of white Evangelicals voted for Mr.
Trump in 2016, representing 28% of actual voters. More broadly, the last three US
presidential elections saw prolife voters average 45% of the electorate (Evangelicals
26%, Catholics 19%), and for many of these voters, their antiabortion (prolife)
stance overrode all other electoral considerations.
With the American populace more conservative than progressive, it is not sur-
prising that climate change continues to be a polarizing issue. Exacerbating the
issue is the failure to recognize that values are the driving force behind these differ-
ing ideologies. Most attempts to mobilize Americans for a bright future utilizing
clean energy and addressing climate change utilize language and value appeals that
are inconsistent with the core values of conservatives. The Righteous Mind: Why
M. C. Hescox (*)
Evangelical Environmental Network, New Freedom, PA, USA

274 M. C. Hescox
Good People Are Divided by Politics and Religion by Jonathan Haidt provides
insight into how people formulate their moral foundations (Haidt, 2012).
Haidt’s research on moral frames compares favorably with our experience in
using messages geared toward the Evangelical community. These frames—tested in
over 1000 presentations in churches, town halls, and Christian colleges around the
nation—have been used to drive our education, which has resulted in over 3,500,000
prolife Evangelical Christians acting on climate, clean energy, and other related
initiatives within the past 3 years.
Values/Morality-Based Messaging
Attempting to prove the science and pushing for government-based solutions as the
major goal remain problematic for our community. While anecdotal, the following
encounter described by one of our Creation Care Champions typifies our hypothesis.
Yesterday, I had an experience that was simultaneously so strange and yet so emblematic
when it comes to encountering fellow Evangelical Christians on the issue of climate
change.
The context of the situation was our town’s monthly “First Friday” event, which is
staged April through October, in Warrenton, VA, to stage a kind of block party between
5:00 and 9:00 p.m. Local craft and food vendors and all sorts of civic organizations set
up booths along the street to advertise and sell their products or to publicize their organi-
zations and causes. For the past several years we have participated in First Friday.
While manning the booth, I engaged a local pastor in conversation over climate
change. The man leads a well-established local congregation and as we entered a conver-
sation he resorted to many of the highly predictable tropes of climate change denial, e.g.,
“the science isn’t settled,” “there’s no consensus,” “it’s a liberal political plot,” “God
granted us dominion over creation,” and “the oceans aren’t warming.” On each point I
summoned substantial and substantive reference to either publicly verifiable empirical
data or actual reference to Scripture to counter his propositions, at which point he would
immediately move on to the next denial trope without any rebuttal to the response I’d
given him.
But, when we got to the matter of the warming oceans, why they are warming, the role
that warming plays in modifying global climate patterns, and the mountain of empirical
data that directly and unequivocally links this warming to the rise in atmospheric green-
house gases resulting from increasing consumption of hydrocarbon fuels, things started
down a path into certifiable weirdness.
At first, he flatly denied the cause of the atypical rise in ocean temperature as a thor-
oughly documented unnatural phenomenon with more than 70 years of direct observa-
tions correlating it with a commensurate rise in atmospheric CO2, which is further
correlated with increased hydrocarbon fuel consumption—i.e., a verifiable “given ‘A,’
then ‘B,’ then ‘C’” chain of observation leading to causation. He then demonstrated no
understanding of the relationship between climate and weather, citing that it was “hot”
when he visited Africa and “it’s always been hot in Africa” so there was no truth to what
I just told him regarding what we’re seeing in the oceans and the linkage to what we’re
seeing play out in climate. Then, as I had to busy myself with other tasks at the booth, he
delivered his final assessment that, contrary to what he just asserted, the oceans are in
fact warming after all, but the cause is that Hell is expanding and that is what is heating
up the oceans, and that he could factually substantiate that from Scripture.
21 Caring for Creation: The Evangelical’s Guide (Rev. Hescox) 275
Some have asserted that simply being more winsome and compelling in com-
municating the science is the key to overcoming the climate conundrum in the
United States. However, as exemplified in the story from our grassroots champion,
this assumes both that science is well understood by the general population and that
scientific evidence has an equally weighted value in our decision-making processes.
However, that supposition is not correct for many in the Evangelical community.
Instead, reframing climate change and clean energy within an existing moral
framework and adding individual action help to engage a much wider audience
(Wolsko, Ariceaga, & Seiden, 2016). When solutions are presented as involving
multiple sectors and actions, and are framed according to existing values and priori-
ties, many previously disengaged individuals willingly engage and act on climate
change. Change depends on engaging existing faith and moral frameworks. These
frames must include children’s health (unborn and born), the potential harm to
future generations, business opportunities, efficient and limited government action,
and hope. Solutions must also include practical and meaningful individual
engagement.
Sanctity (the sacredness of life) and purity (being morally untainted) remain the
top moral values for the conservative community. Therefore, any meaningful com-
munication and education in our community must focus on these two primary con-
cerns. And the best and most common messages for our community, as well as in
the Catholic Communion, center on life (Feinberg & Willer, 2012).
Source: Feinberg and Willer (2012)

276 M. C. Hescox
Creation Care: It’s a Matter of Life
Modern man [sic] has been upsetting the balance of nature and the problem is drastic and
urgent. It is not just a matter of aesthetics, nor is the problem only future; the quality of life
has already diminished for many modern men. (Schaeffer, 1970)
Most people live lives as a seesaw, trying to balance work, family, values, and
faith. Individuals change only when everyday life balance and values are impacted
in such a way as to upset that tipping point; only as issues touch the center of our
being and who we care most about are changes initiated and actions taken. When
issues like climate change arise, it’s very easy to dismiss them or deny them because
it feels like one more additional stress on our already hectic everyday lives.
Most Americans understand that climate change is real and are concerned about it. But most
still see climate change as a faraway threat, in both time and place, and as something that
threatens the future of polar bears but not necessarily people. (The Medical Society
Consortium on Climate and Health, 2017)
In introducing our theme, “Creation Care: It’s A Matter of Life,” one must be
cognisant that for many US Evangelicals, there is a psychological distance between
the impacts of climate change and their everyday lives. And recognizing this reality
helps to explain why previous education attempts have failed and have allowed
denial to exacerbate climate change inaction, as described by Naomi Oreskes and
Erik M. Convay’s book, Merchants of Doubt.
The Evangelical Climate Initiative (2006), The Cape Town Commitment (2010)
by the Lausanne Movement (founded by Billy Graham & John Stott), and the
Encyclical Letter, Laudato Si’ of the Holy Father Francis on Care for Our Common
Home (2015) all make persuasive biblical and moral arguments for addressing cli-
mate change. These documents remain central to a biblical understanding of cre-
ation care. However, all three documents most strongly highlight climate impacts in
the Majority World. None would disagree that most impacts are already occurring
in the developing world, and these statements address what should be a biblical
priority; however, for conservative Evangelical Christians, it has provided an easy
way to disassociate themselves from the threat. The perception of distance with
respect to climate impacts allows climate change to be disregarded as irrelevant to
one’s family or to one’s immediate concerns.
Polling yields conflicting results on the impacts of Laudato Si’. The higher
impact end suggests increases in climate concern among American Catholics of
15% and perhaps as much as 13% among American Evangelicals (Mills, Rabe, &
Borick, 2015). However, other polling indicates little or no impact of the encyclical
on US Catholic and Evangelical thought. Perhaps the most telling survey came from
the Center for Applied Research in the Apostolate at Georgetown University,
Washington, DC, which discovered that 11 months after Laudato Si’ was published,
only 32% of Catholics and 28% of Evangelicals had ever heard of or read the encyc-
lical (CARA, 2016).
What matters is not the movement or the polling but how climate change threats
and opportunities are made real to Evangelicals and others in the conservative faith
community. And for that we must return to the message of life.
The Evangelical Environmental Network understands that a consistent, holistic
prolife position requires care and concern for all life, and this perspective reflects
others in our community as well. As Focus on The Family put it recently, “pro-life
is not a political statement, it’s a way of life” (The Dignity of Life, n.d.). In a
National Association of Evangelicals (NAE) statement on end-of-life concerns, the
NAE states, “we are pro-life from womb to the tomb” (National Association of
Evangelicals, 2014). This whole-life view expresses the best of our theological tra-
dition, and it certainly reflects Catholic social teaching as well. The unborn child is
very important to us, but so is each child of God at every stage of life.
If we believe Jesus’s words in John 10:10—“I have come that they may have life,
and have it to the full”—or, as other translations phrase it, “abundant life” or “life
abundantly”—how can Christians not be concerned about quality of life? Who
would not pray for our children or grandchildren to have a high quality of life? An
abundant life includes health, faith, family, and a fulfilling career in serving God
through loving our neighbors. Without doubt, prolife should be about not ending
pregnancy, but it must also be about assuring the right to have the opportunity for
abundant life. We must have a whole-life theology that cares for the unborn and
born alike.
As prolife Evangelicals, we want children to be born healthy, unhindered by the
ravages of pollution even before they take their first breath. The medical community
has long known the environmental impacts on our unborn children. The once-held
belief that a pregnant mother gives her developing child complete chemical protec-
tion is untrue. One of the body’s protective shields against brain damage, called “the
blood–brain barrier,” is not fully developed until after the first 3 years of life. Thus,
in the unborn child, toxins can cross this incomplete barrier and accumulate in the
brain, causing developmental disabilities and brain damage, resulting in lowered
intelligence and learning problems. One study found that “the resulting loss of intel-
ligence causes diminished economic productivity that persists over the entire life-
time of these children” (Trasande, Landrigan, & Schechter, 2005). In economic
terms, the poisoning of our unborn children’s brains costs between US$60 billion
and US$106 billion in the United States every year (Trasande & Liu, 2011).
Besides the critical neurodevelopment that occurs before birth, the other major
reason babies in the womb are so vulnerable is bioaccumulation. Chemicals readily
pass from the mother through the placenta. Unfortunately, a developing fetus, unlike
the mother, cannot eliminate toxins through normal biological processes. In fact,
one method by which a pregnant woman’s body removes chemicals is by passing
them into her uterus.
Recent studies have shown that smog, air toxins, and volatile organic compounds
(VOCs) like hydrocarbons, benzene, and formaldehyde have a disproportionate
impact upon life in the womb. Stacy et al. at the University Of Pittsburgh found
evidence that low birth weight in babies was associated with proximity to uncon-
ventional natural gas wells in Butler County, PA (Stacy et al., 2015), and McKenzie
278 M. C. Hescox
et al. at the Colorado School of Public Health published peer-reviewed medical
findings linking birth defects to methane production (McKenzie et al., 2014).
The American Lung Associationʼs State of the Air 2019 report stated that more
than four in 10 Americans, approximately 43.3% of the population, live in counties
that have monitored unhealthy ozone and/or particle pollution, and 141 million
people live in counties with unhealthy levels of pollution. The latest childhood epi-
demics with strong links to petrochemicals and fossil fuel energy—that is, asthma,
autism, attention deficit–hyperactivity disorder (ADHD), and allergies—impact as
many as one in three children in the United States (Bock & Stauth, 2007). Dr.
Philippe Grandjean states, “We are facing massive prevalence of brain dysfunction,
autism, and many other signs of ill health due to development insults. Because the
exposures to toxic chemicals happen worldwide, the adverse effects are appearing
now as a silent pandemic” (Grandjean, 2013).
In the 1960s, a woman living in the United States had a 1:20 chance of develop-
ing breast cancer in her lifetime; now the frequency is 1:8. Unfortunately, the breast
cancer news is not good. According to Dr. Philip Rosenberg at the National Cancer
Institute, breast cancer rates are expected to increase by 30% by 2030 (Rosenberg,
Barker, & Anderson, 2015). The number of women diagnosed with breast cancer
will soar (in the United States) from 283,000 in 2011 to 441,000 in 2030. The one
glimmer of light in the research shows a slightly lower mortality rate due to more
effective treatment.
While the modern medical field understands a great deal about breast cancer,
much is still unknown. Doctors know that breast cancer rates are higher in the
developed world than in the Majority World. They also know that only 30% of
women with breast cancer have known risk factors such as genetics, late meno-
pause, or having children later in life. The causes of 70% of breast cancer diagnoses
are, as yet, unclear. Nevertheless, a growing body of research points to the environ-
ment, and especially suspect are chemicals and plastics that act like hormones in
the human body. A large body of plastics such as bisphenol-A (BPA), high-density
polyethylene (HDPE) and a host of other resins used in plastic bags and packaging
(including bottles labeled BPA free), other plastics, and common fertilizers and
pesticides all mimic estrogen (Yang, Yaniger, Jordan, Klein, & Bittner, 2011).
These same chemicals have also been linked to potential male reproductive issues,
including low sperm counts, malformed genitalia, and an increased frequency of
undescended testicles (Jeng, 2014).
We are poisoning ourselves and our children, but, unfortunately, many in our
pews have not yet made the connection. Until our communities understand and
identify the problems using the language of their existing values, our communities
have no way to internalize, accept, and act on the threats facing our children.
In a world where our children are poisoned by pollution, climate change is add-
ing insult to injury. With rising temperatures, smog will get worse—impacting those
with asthma and making life more difficult. Dengue fever (also known as bone-
break fever because of the pain it causes)—a mosquito-borne disease never native
to the United States—is now present in Florida, Texas, and Hawaii, at least in part
because of our changing climate and warming temperatures. And in Pennsylvania,
my home state, Lyme disease has become almost epidemic as a result of earlier
springs and later autumns. Just recently, the Centers for Disease Control stated that
the number of counties with high rates of Lyme disease—including counties in
Pennsylvania, New York, Maryland, Connecticut, and Massachusetts—increased
by more than 320%.
Lyme disease and other health outcomes offer the best opportunity for awareness
and engagement in our Evangelical community. One could add related outcomes
from extreme weather or any number of health catalysts. The critical takeaway is
this: for the threat of climate change to be accepted, it must become real and per-
sonal. As numerous studies and simple human nature testify, until people recognize
local impacts, the reality of crises in other regions or countries is easily discounted.
The Bible as the Source of Moral Value
If prolife values and children’s health are the emotional key to opening the door for
addressing creation care and climate, the Bible remains the door itself. Throughout
the history of Protestantism, and especially in its Evangelical wing, the Bible has
always been our primary rule of faith. Sola Scriptura remains our central theological
statement. All Christians have open access to the Bible. While doctrine, tradition,
experience, and scholarship play important roles depending on individual denomi-
nations or congregations, sharing Scripture’s concern for creation care is paramount.
Although it must be admitted that biblical interpretations do cause a fair amount of
chaos, the Bible remains the basis for life in Christ. And, as such, scriptural biblical
knowledge among US Evangelicals remains woefully lacking.
Some time ago, I led a community men’s morning bible study in a conservative
area of the United States. The teaching was based on the following:
For in him all things were created: things in heaven and on earth, visible and invisible,
whether thrones or powers or rulers or authorities; all things have been created through him
and for him. He is before all things, and in him all things hold together. And he is the head
of the body, the church; he is the beginning and the firstborn from among the dead, so that
in everything he might have the supremacy. For God was pleased to have all his fullness
dwell in him, and through him to reconcile to himself all things, whether things on earth or
things in heaven, by making peace through his blood, shed on the cross. (Colossians 1:16–
20 (New International Version))
The key verse is “For in him all things were created: things in heaven and on
earth, visible and invisible, whether thrones or powers or rulers or authorities; all
things have been created through him and for him.” This Scripture tells Christians
that we are not the owners of the Earth. The Earth, God’s creation, was formed by
and for God—by and for Jesus. Unfortunately, too many Christians, especially
Evangelicals, do not understand the imperative to “tend the garden.”
As a case in point, immediately after sharing my thoughts and during a time set
aside for reflection and discussion, one gentleman said, “I’ve read the Bible all my
life, and I never saw this Scripture in the light of caring for the Earth.”
280 M. C. Hescox
Humanity has been given a precious gift, a planet that can provide for all our
needs if we only follow God and use it wisely. Just as we are called to love our
neighbor, not subjugate him or her, the same applies to creation. Never does the
Bible support the Earth being trashed or misused. Genesis states just the opposite.
The Earth supplies the necessities for biological life; God designed creation for
exactly this purpose. God created the garden and was the first gardener. For life to
prosper, humans are to empower the garden to flourish. We have been clearly given
the responsibility, being created in God’s image, to reflect his image—Godʼs pres-
ence—by caring for creation.
The sad reality is that our stewardship reflects our relationship with God. Upon a
close reading of Genesis 3, we understand that original sin was the temptation to be
god-like, to be in control. When we look back at human history, our principal failing
always seems to be the desire to be in charge, combined with the inability to live
within God-given limits. The Genesis account describes a universal order with God
as the loving and very good creator, humans cast in his image as partners in main-
taining creation, and all creation living in a sustainable relationship.
Our desire to be in control, however, breaks the order, attempts to bypass the
limits, and injures our relationship with God, leading to a broken and unsustainable
world. Each time we use more than we need or consume greater than our share, we
perpetuate our brokenness, support our vanity, and continue disregarding God’s lim-
its. This distorts the creation and impacts all.
Throughout the Old Testament, God defines and provides deliberate instructions
for tending the Earth. Although most Christians have not made the connection, the
Bible provides definitive mandates to live in a reciprocal relationship with the
nonhuman creation. In Deuteronomy, Numbers, and Leviticus, God gives clear
instruction for Sabbath rest for the land, indications of crop rotation, and animal
husbandry. There are strict ordinances regarding farming, livestock management,
and land use in general. These conditions define the parameters for living in rela-
tionship with God, people, and the Earth in an integrated approach to abun
If you follow my decrees and are careful to obey my commands, I will send you rain in its
season, and the ground will yield its crops and the trees their fruit. (Leviticus 26:3–4 (New
International Version))
Overcoming our sin, our failure, requires a renewed study of Scripture and the
resources to help both clergy and laity grasp the critical importance of creation care
as an act of discipleship in following our Risen Lord. A renewed understanding of
the Biblical mandate for creation care is central to our relationship with God, each
other, and all creation. As John Stott—one of the great Evangelical leaders of the
twentieth and early twenty-first centuries—wrote in his last book, The Radical
Disciple, creation care is one of the “neglected aspects of our calling” (Stott, 2010).
Hope
May the God of hope fill you with all joy and peace as you trust in him, so that you may
overflow with hope by the power of the Holy Spirit. (Romans 15:13 (New International
Version))
Hope should be the paramount aspiration for any Christian. We believe in a God
who healed the sick, who proclaimed that the greatest commandment was to love,
and who overcame death to restore humanity and all creation. However, hope—
while solidly based in faith—must have tangible and physical realities. One need
only consider the well-known Biblical passage of “Doubting Thomas” as an
example.
Compounding our inaction is the doom so readily served up by many in the cli-
mate space. This is not to minimize climate threats or impacts, but gloom instills
doom, and combining the two in the human heart often leads to paralyzing fear.
Climate impacts are already bad, but we must not make them worse by spreading
apathy and cynicism. Strides have already been made in addressing climate, but to
mobilize the world, a real prescription of hope is required (Ojala, 2012).
Climate change is the greatest moral challenge of our generation, as each of
God’s children worldwide is impacted. However, properly addressing climate solu-
tions provides the greatest opportunity for hope. As we address the threats posed by
a changing climate, the potential exists to turn energy poverty into energy prosperity
and to replace resource scarcity with sustainable economies.
Clean energy is the foundation for a sustainable world, and that energy transition
is well underway. Remarkably, the pace and scale are greater than experts have
forecasted. According to Michael Liebreich at Bloomberg New Energy Finance
(BNEF), from 2016 to 2017 the United States saw wind installations increase by
262%; solar installations by utilities increase by 4645%; solar installations by
homeowners and businesses increase by 143%; utility power purchase agreements
for solar and wind increase by 83% and 71%, respectively; and investment in energy
efficiency grow by 100%. Moreover, households paid 20% less for electricity and
natural gas. Climate pollution in the United States is down 23%, and our 2025 Paris
Climate Agreement Goals have been halfway reached (https://about.bnef.com/sum-
mit/event/new-york/new-york-highlights/).
While not wishing to oversell technological advances, the decline of fossil fuels
is happening quicker than many anticipated. In a recent meeting with a family-
owned fossil fuel company, the chairperson stated, “Our family has benefited eco-
nomically for three generations in the petroleum business. However, our business
will not survive into a fourth generation, and we are doing everything possible to
divest and reorganize our family’s holdings.”
A close second to renewable energy in the work toward a sustainable, abundant
future is sustainable and nutritious food. As National Geographic reported in 2017,
the Netherlands is already meeting the sustainable food challenge (http://www.
nationalgeographic.com/magazine/2017/09/holland-agriculture-sustainable-farm-
ing/). It is the world’s second largest “exporter of food as measured by value, second
282 M. C. Hescox
only to the United States, which has 270 times its landmass,” and has reduced its
water needs for growth of key crops by up to 90%, eliminated pesticide use almost
entirely, and reduced antibiotics in poultry and livestock by up to 60%.
The above are just a few examples of the hope that is possible as we continue to
decouple fossil fuels from our economy and build a sustainable world that offers
abundant life for all creation. Hope alone does not change our future, but without
hope we will never rise to overcome the challenges. In our book, Caring For
Creation: The Evangelical’s Guide to Climate Change, my coauthor, Paul Douglas,
writes, “We are not hopeless and we are not helpless.”
Conclusion
Securing a total commitment to solving the global climate crisis requires the engage-
ment of the United States. A primary reason for the lack of leadership to date has
been the inability to motivate Evangelicals. As Evangelicals remain the largest sin-
gle political force in conservative American political life, it is paramount that a
substantial portion of our community become climate champions.
While recent polling suggests that over 60% of Evangelicals understand climate
science, the failure to properly communicate climate change within the communi-
ty’s existing value sets keeps climate action from becoming a priority. This is not a
surprise. Very few systemic changes have ever occurred without a personally per-
ceived threat to one’s values or way of life. US engagement in World War II would
likely have never occurred had the naval base at Pearl Harbor never been attacked.
Facing the fear of losing one’s way of life (i.e., a fossil fuel–based economy),
coupled with conservative philosophical concern regarding big government over-
reach, makes it easy to understand how denial and confusion campaigns have
worked so extremely well in the Evangelical community.
However, the Evangelical Titanic is turning. By using values consistent with our
community and by helping Evangelicals understand climate impacts more person-
ally, we are opening hearts to realize the danger, to understand the clear biblical
message, and to hope for a better future for our children.
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284 M. C. Hescox
CHAPTER 22
Call to Action from Faith Leaders
Alastair Redfern
Summary This chapter considers the responsibilities of faith leaders in pursuing

the agenda of the health of people and the health of the planet—not least because of
the particular opportunities and contributions available to faith communities at this
significant moment in our global history. Consideration is given to two key areas:
first, the context in which faith leaders are challenged to contribute to this crucial
agenda, and second, some possible responses, challenges and perspectives that faith
leaders might offer.
The Context of Faith
Other chapters in this book highlight the amazing variety of expert insights into
climate change, health, and their interrelationship. Many contributions in this area
of concern display the marks of what might be called missionary fervour. It could
be that climate change and health professionals are being called to be the evangelists
of our times. Further, we can discern two contrasting models of such a mission. One
calls for small-scale, local, measurable engagement to offer demonstrable signs to
encourage and influence others: a micro-plus approach. In my terms, this is a model
often associated with a Protestant understanding of the church, small local groups
being the key areas for action.
By contrast, other contributors have emphasized “structural sin” and call for sys-
temic universal action—a more “Catholic” approach to the making of the church,
seeking complete fulfilment while acknowledging the reality and inevitability of
some interpretations and differences of pace and enthusiasm: a macro-minus
approach.
A. Redfern (*)
Bishop Alastair Redfern, Church of England, London, UK

286 A. Redfern
Of course, as with the mission of Christian faith more generally, both approaches
are valuable, and an important endeavour is to discern and develop the right balance
between local, personal engagement and the broadest vision and ideals. Citizens
need a kingdom, and a kingdom needs citizens in their local contextuality.
A second feature of the context that should be carefully considered revolves
around indications that the Enlightenment liberal project could be unravelling.
Freedom for and within society has become translated into freedom for the indi-
vidual, thus creating huge issues about the possibility of cohesion and connectivity.
We retreat into self-reinforcing “echo chambers” of our own choosing. Pope Francis
describes this phenomenon as “the globalization of indifference”, a “liberal” tolera-
tion of others subtly moving into a way of living that does not even recognize the
“other”, let alone feel any responsibility towards them.
“Freedom” now seems to deliver an expectation of so many different, and often
apparently contradictory, possibilities and therefore has tended to become focused
upon power being manifested through education and progressiveness. Power
becomes knowledge and resides with liberal elites, whose rhetoric about freedom
and rights masks increasing poverty and exclusion. This is a challenging political
context—an ever-sharpening reality within which responses to health and climate
change need to be crafted.
There is a contemporary stream of critique that accuses politicians of not know-
ing enough, of being too easily swayed by wealthy vested interests. Of course, there
is some truth in these accusations, but from my own experience in the English
Parliament, I want to be clear that politics is a vocation for some, and there are thus
important allies within the structures of policy making who need to be sought out
and encouraged.
Another element of the context into which we seek to bring change is an increas-
ing concern for what is sometimes called the power of populism. Nietzsche was
clear that popular agitations, beginning in his time in the nineteenth century with the
development of mass media, created “moments” of public concern and connectivity,
which were in fact “headless”—that is, with no tradition or detailed vision for the
future (Hansard, 2017). Such “moments” or emotional expressions were dangerous
because of the way they fuelled incoherence. The task in such times is to turn
“moments” into movements, with a sense of tradition/continuity and a coherent
vision for future well-being. Such wisdom will be very important for the future of
our own aspirations. Faith aims to convert moments into movements, which is an
urgent and vital contribution needed to counter increasing confusion and division.
Two other factors are important in helping us understand our context in a way
that will enable a more effective contribution. In my work on modern slavery it is
clear that the ever-expanding trade in children for sexual exploitation is a sign of
what one American law enforcement officer described as a world that now has no
“moral stops”. Until recently, the liberal agenda of free choice was checked by an
instinct to preserve and protect children. There is much evidence that even this
“moral stop” is disappearing fast—which creates a challenging environment for the
common discourse in this area of global concern for a “moral case” to be made for
radical change in relation to climate change and health care.
22 Call to Action from Faith Leaders 287
Finally, in terms of the context into which we are aiming to reach, there are
strong signs of what Hannah Arendt termed “the banality of evil”. She used this
phrase in relation to Eichman and the Holocaust—pointing to the sense in which,
despite the enormously evil outcomes, he and his colleagues could feel that they
were simply doing their jobs, cogs in a system for which others were ultimately
responsible (Arendt, 1963). This mentality could be part of what the Holy Father
has called the globalization of indifference.
The Contribution of Faith
Given such a complex and challenging context, what might be the contributions of
faith and of faith leaders? There are a number of key contributions.
At the most fundamental level, faith calls all people to recognize the common
ground upon which we all exist. A strong theme in our concern for the health of
people and the health of the planet is the issue of air pollution. In the Bible, life
begins by God breathing into a human form. The “breath” of God is the mystery that
gives life to every creature. It is universal and inclusive—in faith terms, “Catholic”.
And such a reality reminds every human creature that to live is to be dependent—on
God, on creation, on others. This is an important reality for measuring our own
efforts and confidence.
Further, faith leaders have a great ability to convene people to work together
around significant issues. In the work I do with Bishop Marcelo Sánchez Sorondo
in fighting the evil crime of modern slavery, through the Global Sustainability
Network, we can gather people from different faiths or none, and from significant
sectors such as government, business, media, academia and nongovernmental orga-
nizations (NGOs). At these gatherings, Bishop Sánchez Sorondo sometimes reminds
participants that there is something in every human heart that can recognize and
respond to the values of the Beatitudes—the importance of being pure, meek, hum-
ble and thirsty to offer justice, and the need to reach out to any who are poor, suffer-
ing or in mourning. These values are the basis of the golden rule to do to others as
you would have them do to you.
Faith leaders can convene people around such values because we are generally
credited with being on the side of goodness but lacking a particular expertise or
agenda in terms of detailed responses to the challenges facing society. Thus, faith
leaders can invite others to make their various and necessary contributions in a
space of mutual commitment to goodness and mutual flourishing. This is a unique
kind of convening power.
This potential is recognized in the chapter by Professor Dasgupta, calling our
attention to recognize the importance of what is “within us”. This is the deep desire
for goodness that embraces others as well as ourselves and yet needs the wisdom
and expertise of numerous disciplines in order to proceed effectively.
Another important contribution of faith is the primary focus on “salvation”. This
word comes from salvus, which means health. Salvation and health are the same
288 A. Redfern
thing—for creation, for creatures, for our endeavours in this crucial and urgent
project of preserving the planet. There is an interplay between health being prop-
erly understood and pursued and our care for the planet and its inhabitants, which
are two sides of the same coin.
Sin, which is both structural and personal, is recognition that human efforts often
miss the mark and fall short because of our selfishness and short-sightedness. Sin
requires judgment and a robust response, not least in terms of tackling corporate
corruption and individual greed. But the Christian understanding of sin also involves
an invitation to recognize the miracle of forgiveness and the gift of new life. This
mystery needs to inform our relationship with others, especially those who might
seem to be perpetrators of the trends we so urgently need to challenge regarding
global warming and approaches to health care. In a sinful world, all parties need to
know our need for God’s grace through forgiveness and new life. Profound humility
and self-criticalness must inform a faith approach. In his chapter, Governor Brown
eloquently captures this deep truth in his powerful call for “transformation”.
The Journey of Faith
A key New Testament word used to describe the ministry and mission of Jesus is
hodos (the way). Faith calls us in a direction—a journey during which we will con-
tinue to learn new things, and within which none of us is immune from making
mistakes. This should provide the comfort that no one set of tools or answers will
suffice. Often, new insight or energy can come from unexpected sources. Thus, faith
can provide a context that is both creative and critical, a common ground inhabited
with humility, openness to others and graciousness towards fellow sinners who may
hold different visions and values. In this way, faith groups are often more open to
diversity and debate than “purist” organizations offering “perfect” solutions. The
latter approach is important in offering a prophetic element but always needs embed-
ding in the complex and sometimes seemingly contradictory agendas so prevalent
amongst God’s diverse children.
Moreover, the Gospels make clear that the prism through which faith pursues its
calling is not one of perfection (as can be the dangers of an Enlightenment project
that has become reduced to the power of knowledge). Rather, Christian faith is a call
to see and act through and with the poorest: those suffering, threatened and excluded.
Faith is a power that unfolds through the unpowerful. Worship is an enactment of
this reality about human dependency and imperfection called into greater wholeness
or health. Jesus is clear that wisdom resides with the unlearned, not the worldly wise.
In this way, very much reinforcing the emphasis of climate change concern upon
the link between air pollution and health, faith invites us into the narrative of the
breath. Life begins with breathing: the life of God breathed into the creature to give
life within creation. Breath gives life and needs to be pure and holy/healthy. But, for
Christians, when on the cross, Jesus, who represents every creature, gives up His
breath—a process that will happen to each of us and to every human being. Life,
inspired or breathed into by God, will end in this mortal setting. The miracle and
mystery is that God breathes new life into the mortality of human life: resurrection.
And on the day of Pentecost the breath of the Holy (healthy or whole) Spirit is
breathed into the disciples to enliven the seeds of eternity in souls touched by this
faith in the resurrection of the body.
This miracle is not an excuse to give up on our challenges and leave everything
to God; rather, faith recognizes this mystery of the breath of resurrection as a power
to sustain and nourish human life through adversity, failure and challenge. Thus,
faith invites engagement with all the complexities of the penultimacy of our endeav-
ours—an arena needing hope and love to sustain and encourage, even when the
direction seems less than perfectly clear and plans struggle to be adequately
comprehensive.
In this way, faith can help to create an atmosphere that enables ideals and the
frustrating realities of limitation to exist creatively together in hope as much as in
demonstrable “answers”, bound together in the greater purposes of a love that can
flow through us and between us, connecting more closely with the fuller purposes
of creation in its proper healthiness (or holiness/wholeness).
Of most obvious significance regarding the role of faith is the fact that all believ-
ers are citizens and consumers. The potential “power” of mobilizing believers and
faith communities to practise and support appropriate action for climate change and
proper approaches to health is enormous. The congruence between the teaching of
faith about salvation/health in this world as stewardship and preparation for a greater
wholeness (health), with the values and visions so powerfully expressed in this
book, should provide a proper challenge to faith leaders to pursue these possibili-
ties. The fact of a common ground (breath) for all creatures and the convening
power of faith to call different people together in the service of goodness, reliant on
the expertise of others, need to be replicated in local contexts too. Faith leaders can
initiate raising awareness of key issues related to climate change and health, and
encourage appropriate action as witnesses to the Gospel of salvation.
This strategy does not need to wait until appropriate “answers” have been fully
formed and agreed on; it can proceed while the “movement” we are trying to form
continues “on the way”.
The Paris Agreement and the Sustainable Development Goals (SDGs) of the
United Nations provide important and internationally agreed frameworks. Faith can
give energy, perspective, commitment and essential humility for the journey—a
hope that will set out in the right direction ahead of “conclusive” evidence, model-
ling appropriate lifestyles and embracing the wisdom or perspective of the
“unlearned” by human standards. Perhaps most significantly, faith empowers its
adherents to give themselves for the good of others, sacrificially, at cost to the self—
for the health (salvation) of all.
This is the Catholic doctrine for a deeply connected creation, inviting recognition
of and participation in the purposes of the Creator and the fulfilment of creation.
Moreover, to act in faith is to trust that just a small contribution can play a key part;
the fraction at the Eucharist reminds us that broken bits can be joined to give health
to creation.
290 A. Redfern
Given the urgency of the issues highlighted in this book and a deep recognition
of the interconnectivity of so many factors that together can make or break our
health on this planet, faith leaders have a huge responsibility to practise what has
been preached for 2000 years by Christian churches.
The Role of Faith Leaders
In response to this context, and the contribution and journey that faith might offer,
there are a number of key roles that faith leaders need to consider in terms of our
contribution to the health of people and the health of the planet.
First is the importance of authoritative guidance. Many people do not believe that
climate change is an urgent matter, and evidence shows that it has a very low prior-
ity for voters. Those in positions of leadership need to provide appropriate guidance
and challenge—always substantiated with credible evidence and clearly connected
to the teaching and values of the faith.
Second, places of worship and congregations can play a key role in the formation
of community life, providing sophisticated networks for mobilizing views and val-
ues, and possessing the ability to organize potential action at both the policy and
grass-roots levels. Careful consideration needs to be given to how this resource can
be utilized in a way that does not seem merely idealistic, while inviting people to
make appropriate and manageable responses. Important areas include the transition
to a low-carbon economy and recognition of the inalienable link between climate
change and human health.
Current research shows that there are key groups who are relatively less engaged
with the matter of climate change. These include older citizens, parents, right-wing
voters and the less scientifically educated. Any response of faith leaders and groups
needs to be particularly targeted in terms of work with these sectors.
Finally, in terms of targets, any strategy must highlight the reality of perceived
social norms, the need for creating higher political priorities in this area and the skill
to present opportunities rather than burdens to those who might respond. Faith lead-
ers and communities can also have considerable influence in the world of industry/
business, particularly in convening spaces for conversation and a commitment to
progress that is realistic about pace and possible outcomes. There is also huge
potential for faith values to be translated into citizen action through voting and par-
ticipating in political debate. Faith leaders could be more proactive in convening
spaces for discussion and debate.
Faith creates “households of commitment”, domestically and institutionally. The
ultimate human household is Planet Earth. Our values, commitments and care need
to be fully expressed for the best ordering and stewardship of this place of residence.
It is a particularly human responsibility and one that faith leaders need to help pres-
ent as a divine mandate too. We are stewards of the environment into which life is
born, not owners or proprietors. Humility, wonder and thankfulness should energize
our efforts, not simply calculation and self-interest.
The health of all God’s people is directly and deeply related to the health of the
planet we are privileged to inhabit. Faith in the future owns this privilege and
pledges a responsible stewardship in return.
This challenge and call need leadership to best identify and articulate a response
appropriate for each “faith” so that cooperation and companionship can be devel-
oped and human flourishing can be joined to a common concern for the well-being
of our shared household. Such witness will offer encouragement and an invitation
to all people of goodwill and good sense to play their part too—a common human
cause for a common human flourishing in a common human household.
This is not an option but a divinely given duty. We each need to take a deep breath.
We have to recognize the responsibility of stewardship of the household we
inhabit, join our teaching and our actions in a common work of praising our Creator
and cherishing creation, and invite others to discover this call and to join in our
endeavour.
References
Hansard Column 385 (2017, January 19). Vol 778. Retrieved January, 16, 2019, from
https://hansard.parliament.uk/lords/2017-01-19/debates/D7DB9D5E-0078-4ED2-81D2-
106C40E59DA4/PopulismAndNationalism
Arendt, H. (1963). Eichmann in Jerusalem: A report on the banality of evil (Volume 165 of
Compass books). New York: Viking Press.
Part VII
Overarching Solutions: The Role of
Science and Technology
CHAPTER 23
Public Health Co-benefits of Reducing
Greenhouse Gas Emissions
Qiyong Liu and Jinghong Gao
Summary The public health co-benefits that curbing climate change would have
may make greenhouse gas (GHG) mitigation strategies more attractive and increase
their implementation. The primary purpose of this chapter is to review the evidence
on GHG mitigation measures and the related health co-benefits; identify potential
mechanisms, uncertainties, and knowledge gaps; and provide recommendations to
promote further development and implementation of climate change response poli-
cies at both national and global levels. Evidence of the effects of GHG abatement
measures and related health co-benefits has been observed at regional, national, and
global levels, involving both low- and high-income societies. GHG mitigation
actions have mainly been taken in five sectors—energy generation, transport, food
and agriculture, households, and industry—consistent with the main sources of
GHG emissions. GHGs and air pollutants to a large extent stem from the same
sources and are inseparable in terms of their atmospheric evolution and effects on
ecosystems; thus, reductions in GHG emissions are usually, although not always,
estimated to have cost-effective co-benefits for public health. Some integrated miti-
gation strategies involving multiple sectors, which tend to create greater health ben-
efits, have also been investigated, and this chapter discusses the pros and cons of
different mitigation measures, issues with existing knowledge, priorities for
Q. Liu (*)
State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation
Center for Diagnosis and Treatment of Infectious Diseases, National Institute for
Communicable Disease Control and Prevention, Chinese Center for Disease Control and
Prevention, Beijing, China
Shandong University Climate Change and Health Center, School of Public Health, Shandong
University, Jinan, Shandong, China
J. Gao
The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
National Engineering Laboratory for Internet Medical Systems and Applications,
Zhengzhou, Henan, China

296 Q. Liu and J. Gao
research, and policy implications. Findings from this study can play a role not only
in motivating large GHG emitters to make decisive changes in GHG emissions, but
also in facilitating cooperation at international, national, and regional levels to pro-
mote GHG mitigation policies that protect public health from climate change and
air pollution simultaneously.
Climate Change
There is robust evidence that climate change is occurring and that anthropogenic
greenhouse gas (GHG) emissions, primarily from human activity–related burning
of fossil fuels, are the main drivers (Stocker et al., 2013). According to the Fifth
Assessment Report (AR5) from the Intergovernmental Panel on Climate Change
(IPCC), the evidence of climate change is unequivocal. During the period
1880–2012, there was a warming of 0.85 °C in the global average surface tempera-
ture (Pachauri et al., 2014a; Stocker et al., 2013). Without further mitigation actions,
the average temperature may rise by 2.6–4.8 °C by the end of this century (Watts
et al., 2015). In addition, it has been suggested that even if CO2 emissions abruptly
ceased, climate change would continue for hundreds of years because of the inertia
in the global climate system (Solomon et al., 2009).
Anthropogenic GHG emissions—primarily from human activity–related energy
generation, transport, food and agriculture, household, and industrial processes—
are considered the main driver of climate change (Pachauri et al., 2014a; Stocker
et al., 2013). In order to hold the increase in the global average temperature to less
than 2 °C relative to preindustrial levels to avoid the risk of potentially catastrophic
climate change impacts, it was reported that total anthropogenic CO2 emissions
needed to be kept below 2900 billion tonnes (Gt) by the end of this century (Watts
et al., 2015; Whitmee et al., 2015). However, in the years 2003–2011, an average
global annual emissions growth rate of 3% per year was observed, whereas the
growth figure over the 1980–2002 period was 1.2% annually (Netherlands
Environmental Assessment Agency, 2007). In 2014, emissions from the combustion
of fossil fuels and industrial processes totaled 35.7 Gt of CO2, with current trends
expected to exceed the required emissions target over the next 15–30 years (Watts
et al., 2015).
Health Effects of Climate Change
The health of human beings is sensitive to shifts in weather patterns and other
changes in climate systems (e.g., temperature, precipitation, and occurrence of
extreme weather events) (Smith et al., 2014). To date, converging evidence from
different lines of research generally suggests that climate change, both directly and
indirectly, has already started to damage human health and is expected to cause
increasingly adverse impacts in the future (Field et al., 2014; Pachauri et al., 2014b;
23 Public Health Co-benefits of Reducing Greenhouse Gas Emissions 297
HUMAN ACTIVITIES
Energy generation Transportation Agriculture Household Industry and economy

CAUSES
Anthropogenic greenhouse gas emissions Natural climate forcings
GLOBAL WARMING AND CLIMATE CHANGE

EFFECTS
Extreme Air Ultraviolet Increased Ecosystem Rising

weather pollutions radiation temperature disruption and sea-level
events environment
and disasters degradation
Injury/death from Respiratory Emerging and re-emerging Malnutrition and

floods, storms, system diseases; vector-, food- and diseases because of
CONSEQUENCES
hurricanes, bushfires; asthma and water-borne infectious impaired food and

illness and deaths allergies; heat diseases; heat-related fresh water supply;
caused by thermal exhaustion and diseases; malnutrition and physical risks and
and posttraumatic stroke; sunburn illness due to impaired mental ill-health
stress; populations and skin cancer; crop yield and fresh water caused by unstable
displacing; impaired decreased crop supply; exposure to social/political and
food supply yields environmental toxicants displacement, etc.
Fig. 23.1 Schematic summary of climate change determinants and potential pathways through
which climate change affects human health
Patz et al., 2008; Smith et al., 2014). Climate change can affect public health via
various pathways (Fig. 23.1) (Field et al., 2014). Directly, climate change can
increase the frequency and intensity of extreme weather events such as heat waves,
floods, droughts, and other weather-related natural disasters, which will lead to
increased injury, morbidity, and mortality, especially for vulnerable populations
(Field et al., 2014; IPCC, 2007; Smith et al., 2014). Indirectly, health impacts may
result from climate change–related ecosystem alterations and environmental degra-
dation, as well as the corresponding decline in air quality and impairment of fresh
water and food supplies, which, in turn, influence the distribution and incidence of
water-, food-, and vector-borne infectious diseases and respiratory system diseases,
and can degrade nutritional status (Barros et al., 2014; Field et al., 2014; Patz et al.,
2008; Smith et al., 2014). In addition, climate change may play a role in other less
direct health outcomes by mediating societal systems. These outcomes include

physical risks and mental illness caused by unstable social or political status, violent
conflict, and population displacement associated with rising sea levels (Barros et al.,
2014; IPCC, 2007; Pachauri et al., 2014b); malnutrition due to impaired crop yields
and food insecurity due to ecosystem disruption and rising sea levels (Barros et al.,
2014; Pachauri et al., 2014b); and loss of workforce, economy, and health care sys-
tems due to extreme weather events (Field et al., 2014; Pachauri et al., 2014a; Smith
et al., 2014).
If no further climate change mitigation actions are undertaken, the combined
effects of the selected impacts on the global annual gross domestic product (GDP)
are expected to rise over time to likely levels of 1.0–3.3% by 2060, with the largest
negative economic consequences being suffered by regions in Africa and Asia
(Organization for Economic Co-operation and Development (OECD), 2015).
Climate change has been described as the biggest global threat confronting public
health in the twenty-first century (Costello et al., 2009).
Existing Response and Challenges
Although there are now several policy initiatives, lifestyle and other recommen-
dations, and technology instruments that can help mitigate climate change
(Pachauri et al., 2014b; Smith et al., 2014; Watts, 2009; Xia et al., 2015), many
countries (especially developing countries) remain reluctant to make decisive
changes (Edenhofer et al., 2014a). Of the worldwide efforts to reduce GHG
emissions, active participation and decisive actions of developing countries are
essential to limit the increase in GHG concentrations and prevent dangerous
anthropogenic interference with the climate system (Pachauri et al., 2014a).
However, developing nations are concentrating so much on economic develop-
ment, air quality improvement, and poverty reduction that they have limited eco-
nomic resources and allocate a low priority on their political agenda to tackling
the challenges posed by GHG emissions and climate change (Barros et al., 2014;
Field et al., 2014). Additionally, developing countries often insist that the “com-
mon but shared responsibility” principle of the 1992 United Nations Framework
Convention on Climate Change (UNFCCC) should be applied, meaning they
should not have the same obligations to reduce GHG emissions as developed
countries until they have achieved certain level of human development (Costa,
Rybski, & Kropp, 2011). Low- and middle-income countries point out that they
are only retracing the same development path taken in the past by present-day
high-income countries. This highlights the worldwide challenge of balancing
environmental and public health concerns against economic growth. Thus, the
issue of how to balance countries’ rights to sustainable development and eco-
nomic growth—especially the rights of developing nations—with enforceable
reductions in GHG emissions may be the key challenge of ambitious global
mitigation action (Watts et al., 2015).
The Potential Opportunity: Public Health Co-benefits

of Reducing GHG Emissions
According to the IPCC, mitigation strategies not only act to curb the emissions of
climate-warming pollutants (mainly GHGs) but also, if well chosen and imple-
mented, deliver substantial simultaneous improvements in public health, indepen-
dent of the effects on climate change, with most of these impacts being beneficial
(Field et al., 2014; Gao et al., 2018a; Pachauri et al., 2014a; Smith et al., 2014). A
series of studies published in The Lancet has also shown that appropriate climate
change mitigation strategies (mainly targeting reductions in GHG emissions) can
have additional, independent, and largely beneficial effects on public health (Watts,
2009). For example, actions like reducing fossil fuel combustion and improving
energy efficiency, aimed primarily at cutting GHG emissions, can also produce
ancillary health benefits from decreased air pollution (West et al., 2013). One of the
mechanisms of these so-called health co-benefits of mitigation measures is that
GHGs and air pollutants are, to a large extent, emitted from the same sources and
are interlinked in terms of their atmospheric behavior and effects on the ecosystem
and human beings (Fig. 23.2) (Haines et al., 2009; Lelieveld et al., 2015; Pachauri
et al., 2014a; Stocker et al., 2013). Moreover, some air pollutants such as black
carbon (BC) and ozone (O3) are also greenhouse gas pollutants (climate-warming
agents) with even higher radiative forcing (RF) per unit than CO2 (Stocker
et al., 2013).
These so-called co-benefits from simultaneously curbing climate change and
improving ancillary public health may make GHG mitigation strategies more attrac-
tive to developed and developing countries, and may encourage their implementa-
tion (Edenhofer et al., 2014a; Field et al., 2014; Shindell et al., 2012). They also
bridge the development gap between high- and low-income countries and thus can
play an important role in future international negotiations on the climate convention
(e.g., the Conference of the Parties) (Haines et al., 2009; Watts, 2009). At the very
least, co-benefits can reduce the costs of taking actions against climate change
(under certain conditions, the value of health gains may be comparable to or exceed
Air pollutants Air pollution
Sources of Human
co-emitters Health
Greenhouse gas Climate change
Mitigation Co-control of GHGs and air pollutants Health co-benefits
Fig. 23.2 Potential mechanisms and pathways through which reductions in greenhouse gas
(GHG) emissions result in public health co-benefits
abatement costs) and therefore can strengthen the case for climate change mitiga-
tion policies in the face of scientific uncertainty (Nemet, Holloway, & Meier, 2010).
Thus, with a view to filling some of the knowledge gaps on the topic of GHG
emissions and related mitigation measures, the main purposes of this study are to
(1) synthesize the current evidence of the public health co-benefits of reducing
GHG emissions to improve our understanding of the economic sectors involved in
GHG mitigation measures, how and through which pathways reductions in GHG
emissions can bring ancillary health benefits (mechanisms), and the relevant uncer-
tainties and knowledge gaps associated with the process of assessing health
co-benefits; and (2) discuss the potential policy implications.
ublic Health Co-benefits of Measures to Mitigate GHG

P
Emissions
Here, we define public health co-benefits as measures to reduce the emissions of

climate-warming pollutants (mainly GHGs), which also hold the potential to simul-
taneously deliver significant improvements in human health, independent of the
effects on climate change. Although there are intersections and overlaps, the asso-
ciations between reductions in GHG emissions and health co-benefits are based
almost entirely on modeling studies and are drawn primarily from five sectors:
energy generation and provision, transportation, agriculture and food, households,
and industrial and economic processes. According to studies conducted in both
high- and low-income countries, GHG mitigation policies in the five domains are
often (but not always) estimated to have net co-benefits in terms of public health,
and comprehensive measures across various sectors tend to provide greater health
benefits. In some cases, the positive health consequences seem to be substantial,
cost effective, and attractive to multiple parties (Haines et al., 2009).
The health co-benefits of mitigation measures appear in a number of forms,
depending on the sources of the GHG emissions being reduced. The main health
co-benefits of reducing GHG emissions in the energy generation sector are linked to
the corresponding reductions in common air pollutants (Fig. 23.2), and the most
significant pollutants impacted are particulate matter (PM), black carbon (BC), SO2,
and nitrogen oxides (NOx) (Crawford-Brown, Barker, Anger, & Dessens, 2012). In
the transportation sector, in addition to the co-control of GHGs and air pollutant
emissions, and the health gains from improved air quality (Fig. 23.3), GHG mitiga-
tion activities such as active travel can also increase physical activity, social contact,
and the opportunity to interact with the natural environment, which may reduce the
risks of a range of diseases (e.g., cardiovascular disease, type 2 diabetes, colon and
breast cancer, and depression) (Woodcock et al., 2009; Xia et al., 2015). A combina-
tion of agricultural technological improvements and reductions in consumption of
foods from animal sources in high-consumption populations could provide an effec-
tive contribution to meeting targets to reduce GHG emissions and substantially ben-
efit public health—for example, via reductions in type 2 diabetes, ischemic heart
Air pollution
CO, PM,
Energy
NOx, etc.
consumption
CO2, BC,
and others
Various adverse
health impacts:
• Respiratory diseases
• Cardiovascular diseases
• Climate-sensitive diseases
•Cancer, premature deaths
Climate change
Fig. 23.3 Co-control of greenhouse gas (GHG) and air pollutant emissions and the corresponding
health gains due to GHG mitigation measures in the transportation sector (adapted from the work
of Chong, Yim, Barrett, & Boies, 2014). BC black carbon, NOx nitrogen oxides, PM particulate
matter
disease, and the prevalence of obesity (Friel et al., 2009; Macdiarmid, 2013).
Mitigation actions in the residential and household sector—such as improvements
in combustion energy efficiency (Dora, Röbbel, & Fletcher, 2011), substitution of
traditional cooking and space-heating practices with clean fuel technology and
lower-emission household appliances (Venkataraman, Sagar, Habib, Lam, & Smith,
2010; Wilkinson et al., 2009), and energy saving through improvements in fabrics,
fuel switching, behavioral changes, etc. (Wilkinson et al., 2009)—could bring about
cost-effective health co-benefits (especially for women and children) in addition to
reductions in GHG emissions (Anenberg et al., 2013). With regard to industrial and
economic processes, co-benefits of GHG abatement, air quality improvements, and
health gains could be expected through a series of measures such as improving
energy efficiency, promoting the use of clean and renewable energy, and adjusting
the industrial energy structure (Crawford-Brown et al., 2012; Gao et al., 2018b).
hallenges and Uncertainties in Estimating Health

C
Co-benefits
Estimating the full range of the health co-benefits of reducing GHG emissions pres-
ents several common challenges to conventional epidemiological approaches and
assessment studies (Haines et al., 2009; Pachauri et al., 2014a; Patz et al., 2008;
Watts et al., 2015), including the following: (1) development of credible scenarios
for GHG emissions under “business-as-usual” and mitigation projections over the
relevant time course; (2) the fact that rapid development of the energy structure,
transportation patterns, land use, building construction, technology innovation, lev-
els of exposure to health drivers, and demographic characteristics (population
growth, baseline mortality rates, and value of statistical life) in some societies can
change substantially in a short time with major implications for public health; (3)
the fact that different subgroups of populations (e.g., age, gender, racial, or socio-
economic groups) may face disproportionate health impacts from air pollution or
other health drivers; (4) the large number of health outcomes potentially affected by
reductions in GHG emissions; (5) the short- to medium-term and long-term health
benefits associated with GHG mitigation actions; (6) the varying lag times between
changes in exposure and changes in health outcomes; (7) different economic valua-
tions of health outcomes between developed and nonindustrialized countries; and
(8) controversial aspects of key parameters such as discount rates and the terms
involved in the concentration–response functions.
Knowledge Gaps
On the basis of a review of the current literature involving GHG emissions, mitiga-
tion strategies, and the related health co-benefits, several knowledge gaps have been
identified. First, although several studies have attempted to model or quantify the
associations between reductions in GHG emissions and health co-benefits, few stud-
ies have tried to establish a thorough performance appraisal system for the evaluation
of environmental, socioeconomic, and public health co-benefits in relation to GHG
mitigation measures and low-carbon policies (Gao et al., 2018a; Haines et al., 2009;
Pachauri et al., 2014b; Smith et al., 2014). It has been indicated that an integrated
performance appraisal system, including preimplementation analyses of interven-
tions and follow-up cost–benefit appraisals of program implementation and related
results, is crucial to comprehensively assess the performance of specific GHG abate-
ment strategies and could help enhance the efficiency of decision-making processes
and help programs to compare and prioritize potential options (McMichael, Barnett,
& McMichael, 2012). Second, to date, most of the health benefit assessments have
been performed in developed societies, with insufficient research having been carried
out in developing regions, especially in areas like Africa and Asia, where the least
GHG emissions are generated while the most severe climate change consequences
are suffered (Haines et al., 2009; OECD, 2015; Pachauri et al., 2014b; Smith et al.,
2014). These already susceptible areas—affected by conflicts, unstable politics, and
impaired water supplies, as well as poor health infrastructure and limited economic
resources—may become more vulnerable because of further climate change and the
projected increasing frequency and intensity of extreme weather events (Barros
et al., 2014; IPCC, 2007; OECD, 2015; Pachauri et al., 2014b; Shindell et al., 2012;
West, Fiore, & Horowitz, 2012; Whitmee et al., 2015).
In addition, according to the present review, to date there is little evidence in the
scientific literature of cost-effectiveness analysis, in practice, of health-promoting
interventions to reduce GHG emissions (Haines et al., 2009). Most of the studies are
descriptive or modeling investigations, and a conspicuous gap in the scientific
research on the health co-benefits of GHG mitigation is the lack of intervention
studies and assessments based on actual surveillance data (Pachauri et al., 2014a).
Finally, despite potential health benefits of urban green space having been sug-
gested by some studies (Salmond et al., 2016), the quantitative relationships between
reductions in GHG emissions associated with green space and human health gains
have not been fully evaluated. In order to take advantage of the public health oppor-
tunities offered by climate change mitigation measures (Wang & Horton, 2015), all
of these areas for future research need to be explored.
Policy Implications
To date, although health co-benefits of GHG mitigation strategies in different sec-

tors and countries have been modeled or quantified to a certain extent, their poten-
tial to provide cost-beneficial solutions has not been widely recognized, especially
in developing nations, and this may hamper international cooperation for global
reductions in GHG emissions (Haines et al., 2009; Pachauri et al., 2014a). Therefore,
it is crucial to promote education and raise awareness on this topic among policy
makers, health professionals, and other stakeholders, particularly in countries and
regions confronted with multiple challenges from development, urbanization, popu-
lation growth, air pollution, and climate change (Haines et al., 2009; Jiang
et al., 2013).
Given the complexities of the challenges posed by climate change, major medi-
cal associations and nongovernmental health organizations have been calling for
integrated multisectoral and multidisciplinary policies and actions to protect human
health from dangerous climate change (Edenhofer et al., 2014b; Gao et al., 2018b;
Haines et al., 2009). The existing evidence has suggested that comprehensive miti-
gation strategies generally provide greater health gains and larger reductions in
GHG emissions (Friel et al., 2009; Shindell et al., 2012; West et al., 2012; Woodcock
et al., 2009). Thus, interdisciplinary mitigation frameworks linking energy genera-
tion, transport, agriculture, household, and industrial processes are essential for
curbing GHG emissions and improving public health simultaneously. However, we
argue that in order to work toward the target of GHG mitigation, joint actions and
collaborations—not only by different governmental departments at the national
level but also between high- and low-income countries at the international level—
are crucial (Edenhofer et al., 2014b; IPCC, 2007; Pachauri et al., 2014b; Whitmee
et al., 2015).
In addition, studies have suggested that health professionals could play an impor-
tant role in combating climate change and GHG emissions. For instance, they could
advocate for comprehensive local, national, and international policies to reduce
GHG emissions and achieve the corresponding health co-benefits (Haines et al.,
2009). Professionals can also serve as role models for practices in their own work-
places, communities, and even regions, to help inform and educate the local and
national public and policy makers about the health risks posed by climate change
and the health co-benefits of GHG mitigation (Watts, 2009).
Although numerous studies have focused on the roles of governments and of
various economic sectors in mitigating climate change, relatively limited attention
has been paid to the effects of individual behavioral change on reductions in GHG
emissions (Gao et al., 2018a; Macdiarmid, 2013). In terms of the potential health
co-benefits resulting from behavioral changes—such as limiting car trips in favor
of active travel, limiting consumption of foods from animal sources, using lower-
emission stoves, and reducing energy use—the collective impact of small behav-
ioral changes may result in a considerable reduction in global GHG emissions
(Friel et al., 2009; Haines et al., 2009; Venkataraman et al., 2010; Xia et al., 2015).
Conclusion
This chapter has summarized the available evidence on quantitative associations

between reductions in GHG emissions and health benefits. The results generally
suggest that GHG mitigation strategies in the energy generation, transport, agricul-
ture and food, household, and industrial sectors could bring ancillary health benefits
at the same time, while comprehensive measures across various sectors would tend
to provide greater health gains. In addition to raising awareness, the findings of this
review can provide valuable information for central and local governments, nongov-
ernmental organizations, and policy makers, as well as for other relevant stakehold-
ers concerned with the development and implementation of low-carbon technologies
and policies. Besides, the anticipated cost-effective health co-benefits produced by
GHG mitigation actions could make climate change mitigation policies more
appealing and true “no-regrets” options for policy makers and GHG emitters, espe-
cially in low-income countries with finite economic resources. This could play a key
role in motivating large GHG emitters to make voluntary and decisive changes that
would help reduce emissions while prioritizing mitigation measures with optimal
health gains. It would help in facilitating cooperation and co-action at the interna-
tional, national, and regional levels on the basis of traditional situations, social
expectations, and resource availability to protect human health from dangerous cli-
mate change and air pollution simultaneously.
Acknowledgments External funding for this study was obtained from the China Prosperity
Strategic Programme Fund (SPF) 2015-16 (Project Code: 15LCI1) and the National Basic
Research Program of China (973 Program) (Grant No. 2012CB955504). The funders played no
role in the design, development, or interpretation of the present work. The views expressed in this
chapter are those of the authors and do not necessarily reflect the position of the funding bodies.
The authors also want to thank Alistair Woodward, Sotiris Vardoulakis, Sari Kovats, Paul
Wilkinson, Jing Li, Shaohua Gu, and Xiaobo Liu for their kind and constructive suggestions and
comments on this chapter.
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CHAPTER 24
Good Health in the Anthropocene Epoch:
Potential for Transformative Solutions
Andy Haines
Summary Unprecedented environmental changes threaten to reverse progress on

health and development unless they are addressed by decisive actions. The implemen-
tation of policies to reduce the environmental impact of human societies can reduce
risks and also bring a range of near-term health benefits—for example, from lowered
emissions of pollutants co-emitted with greenhouse gases. This chapter outlines poten-
tial transformative policies in sectors such as energy, transport, urban development and
food systems, which can reduce their environmental footprint and improve health.
Introduction
Humanity faces multiple environmental challenges dominated by climate change

but also encompassing ocean acidification, air pollution, biodiversity loss, declining
fisheries, deforestation and depletion of freshwater supplies, which together charac-
terise the Anthropocene epoch. The Anthropocene reflects the dominance of one
species, our own, over the Earth’s natural systems and is leading to rapid changes in
these systems with potentially far-reaching implications for human health and
development. Humanity flourished in the Holocene epoch, a relatively stable cli-
matic period of about 11,500 years, and there is concern that the dramatic gains in
life expectancy over recent decades could be undermined by these multiple environ-
mental stressors acting in concert. Although this chapter largely addresses the chal-
lenge of climate change, it does so within the broader context of “planetary health”,
which acknowledges that the health of human civilisation depends on the state of
underpinning natural systems (Whitmee et al., 2015).
Transformative approaches imply that health and development must increasingly
be achieved at much lower environmental impacts than the current fossil fuel–inten-
sive and inequitable world economy.
A. Haines (*)
London School of Hygiene and Tropical Medicine, London, UK

310 A. Haines
The Imperative of Transformative Change
In order to attain the aims of the Paris Agreement, it will be necessary to decarbo-
nise the world economy and implement deep cuts in short-lived climate pollutants
(SLCPs) as a matter of urgency. In the absence of deep cuts in both CO2 and SLCP
emissions, temperature increases are likely to exceed 1.5 °C during the 2030s and
exceed 2 °C by mid-century (Ramanathan & Xu, 2010; Shindell et al., 2012). After
3 years of stable greenhouse gas (GHG) emissions, in 2017 global GHG emissions
from energy and industry increased (UNEP Emissions Gap Report, 2018).
The perception that transformative change towards a clean economy based on
non-polluting renewable sources of energy is prohibitively expensive and politically
unachievable in the near term is a major barrier to progress. An alternative view is
that it is both inevitable and welcome because it brings many benefits in the near
term as well as creating the opportunity to promote a sustainable and productive
economy for the future. Health co-benefits of the “zero-carbon” economy can arise
from a range of policies in sectors such as transport, energy, housing, and food and
agriculture, and through several pathways, including reduced air pollution expo-
sure, healthy low-environmental-impact diets and increased physical activity
(Haines et al., 2009). These policies must be complemented by others that halt and
reverse the profound damage to a range of natural systems whilst safeguarding
health and development (Whitmee et al., 2015).
ealth Co-benefits of Reduced Air Pollution from Clean

H
Renewable Energy Sources
A growing body of evidence attests to the major health co-benefits that accompany
policies to reduce GHG/SLCP emissions. A major pathway is through the reduction
in exposure to fine particulate air pollution from a combination of ambient and
household air pollution, and from tropospheric ozone. The sources of ambient air
pollution vary by country, as shown in Fig. 24.1, which compares the USA and
India. Ambient air pollution has been estimated to cause over 4.5 million premature
deaths annually worldwide (Lelieveld, Haines, & Pozzer, 2018).
The Global Burden of Disease (GBD) study estimated that 2.9 million deaths in
2015 were associated with household air pollution (Forouzanfar, Alexander,
Anderson, et al., 2015), whereas the World Health Organization (WHO) estimated
that there were 4.3 million related deaths in 2012 (WHO, 2014). This difference is
partly due to the approaches used to quantify exposure–outcome associations (see
Landrigan et al., 2018, for further discussion of differences between the GBD and
WHO approaches). The magnitude of these health effects shows the potential
improvements from universal access to clean renewable energy sources, which can
be further augmented by indirect health benefits—for example, from reduced time
collecting firewood for domestic use (a task that falls disproportionately on women
and girls, exposing them to risks of sexual violence).
24 Good Health in the Anthropocene Epoch: Potential for Transformative Solutions 311
Fig. 24.1 Sources of mortality from air pollution. The percentages are the proportions of deaths
attributable to ambient air pollution. Excess deaths attributable to air pollution in 2015 were esti-
mated at 120,000 (95% confidence interval 81,000–156,000) in the USA and 967,000 (753,000–
1,150,000) in India. “Natural” refers to natural sources of air pollution, predominantly aeolian
dust. (Source: Lelieveld et al., 2018, with permission from The Lancet Planetary Health)
A growing number of studies have estimated the health co-benefits of policies to

scale up access to clean energy from low-carbon and renewable sources. The
International Energy Agency estimated that a 7% increase in total energy invest-
ment over the period to 2040 in a clean air scenario would lead to a dramatic
improvement in health in comparison with a main reference scenario. Premature
deaths from outdoor air pollution would be 1.7 million lower in 2040, and those
from household pollution would be 1.6 million lower. Furthermore, there would be
additional benefits in terms of energy security, CO2 emissions and import bills
(IEA, 2016).
Co-benefits may be particularly large in countries with a large burden of disease
from air pollution; for example, the implementation of climate mitigation strategies
in China could result in about a 50% reduction in months of life lost as a result of
air pollution exposure by 2050 (Markandya et al., 2009).
Implementing a range of SLCP mitigation actions could result in between
700,000 and 4.7 million annually avoided premature deaths, mainly from reductions
in black carbon, together with increases in annual crop yields of 30–135 million
metric tons due to ozone reductions in 2030 and beyond (Shindell et al., 2012). The
measures to reduce black carbon emissions include reduced agricultural burning,
replacement of domestic solid fuels with clean sources of energy and use of
improved-efficiency brick kilns. Methane reductions could be achieved by reducing
leakage of natural gas, improved rice paddy management and so on. A rapid phase-
out of fossil fuels to reduce CO emissions, together with policies to cut SLCPs, offer
the best prospect of achieving the targets in the Paris Agreement and will provide
both near- and long-term benefits to health (Shindell et al., 2017).
There are a number of potential approaches to reducing exposure to household
air pollution, including improved-efficiency cookstoves, electrification (preferably
312 A. Haines
from low-carbon sources) and use of liquefied petroleum gas (LPG). LPG is a fossil
fuel and therefore would result in a small increase in CO2 emissions but much lower
particulate air pollution exposure (Pachauri, 2014).
Careful evaluation of effects is necessary because the anticipated benefits are not
inevitable. A large-scale trial evaluating the effects of use of a cleaner-burning bio-
mass-fuelled cookstove and solar panel versus continuation of open-fire cooking on
pneumonia in children living in two rural districts of Malawi showed no effect on
childhood pneumonia, probably because of low usage of the stoves, the failure of
the stoves to reduce air pollution emissions sufficiently and the persistence of other
sources of local air pollution (Mortimer et al., 2017). Integrated solutions are needed
that address all major local sources of fine particulate air pollution, using affordable,
culturally acceptable technologies that can be easily repaired and maintained.
Access to electricity generated from clean renewable sources or stoves that use
clean renewable fuels such as ethanol and biogas can bring large climate change and
SLCP benefits (WHO/CCAC, 2016). The replacement of kerosene lamps with solar
lamps reduces emissions of black carbon, resulting in benefits to the climate and to
health, as well as reducing poor householdsʼ expenditure on kerosene (Climate and
Clean Air Coalition, 2014).
aluation of the Air Pollution Co-benefits of Mitigation

V
Strategies
A study comparing a reference scenario with a global GHG mitigation scenario

projected that the latter would avoid 0.5 ± 0.2 million and 1.3 ± 0.5 million prema-
ture deaths in 2030 and 2050, respectively. The global average marginal co-benefits
of avoided mortality were estimated to be valued at US$50–380 per metric ton of
CO2 (using the value of a statistical life), which would exceed marginal abatement
costs in 2030 and 2050 (West et al., 2013) and would tend to be largest in locations
where the current air pollution health burdens are greatest. A comparison of a cli-
mate change mitigation policy scenario that is consistent with the European
Commission’s 2° target and a baseline medium-high emissions scenario showed
major health and economic co-benefits (Holland et al., 2011).
The monetised human health benefits associated with air quality improvements
from reduced ozone and fine particulate pollution resulting from GHG mitigation
policies could offset 26–1050% of the cost of US carbon policies. Larger net co-
benefits could result from policies that minimised costs, such as cap-and-trade stan-
dards, than from specific sectoral policies (electricity and transportation) (Thompson,
Rausch, Saari, & Selin, 2014). An assessment of fine particulate and ozone reduc-
tions from a US emissions trajectory consistent with 2 °C warming from energy and
vehicles showed that by 2030, clean energy policies could prevent about 175,000
premature deaths, with 22,000 (95% confidence interval 11,000–96,000) fewer
annually thereafter (Shindell, Lee, & Faluvegi, 2016). Furthermore, clean transpor-
tation could prevent ~120,000 premature air pollution–related deaths by 2030 and
subsequently 14,000 (9000–52,000) annually.
A retrospective analysis of the effects of implementation of US state–level
renewable energy (RE) portfolio standards in 2013 showed that in addition to reduc-
tions in life cycle GHG emissions estimated at 59 million metric tons of carbon
dioxide–equivalent (CO2e), there were substantial air pollution, health and environ-
mental benefits (Wiser et al., 2016).
Cities
Most of the world’s population now lives in cities, and an additional 2.5 billion
people are projected to live in cities by 2050, largely in sub-Saharan Africa and in
Asia (United Nations Environment Programme, 2013). Cities provide multiple and
interconnected routes for realising environmental and health benefits. These include
lower GHG emissions and air pollution, and non-communicable disease (NCD)
reduction through improvement of the urban and built environment, including mod-
ifications to housing, transport and energy systems (Milner, Davies, & Wilkinson,
2012; Wilkinson & Haines, 2015).
A large prospective study in Ontario, Canada (Creatore et al., 2016), showed that
greater neighbourhood walkability was associated with a decreased prevalence of
overweight and obesity and a decreased incidence of diabetes between 2001 and
2012. A large-scale cross-sectional study (Flint & Cummins, 2016) and a nationally
representative longitudinal study in the UK (Martin, Panter, Suhrcke, & Ogilvie,
2015) both demonstrated health benefits of active travel, including a reduced risk of
overweight and obesity.
The modelled effects of low-emission vehicles and increased active travel in
London and Delhi showed major benefits to health, which outweighed the increased
risk of exposure to road injuries (Woodcock et al., 2009). In the case of London, the
main health benefits were projected to result from increased active travel, although
the GHG benefits resulted largely from the introduction of low-emission vehicles.
In cities with high air pollution levels, such as Delhi, a larger proportion of the
health benefits is likely to be due to air pollution reduction. However, even where
concentrations of particulates with a diameter of 2.5 µm (PM2.5 concentrations)
reach 100 μg/m3, harms from increased inhalation of air pollution would exceed the
benefits only if individuals exceeded 1 h 30 min of cycling per day or more than
10 h of walking per day in comparison with staying at home. In comparison with
driving, the benefits of physical activity would exceed harms from air pollution at
up to 3 h 30 min of cycling per day (Tainio et al., 2016). There could be substantial
benefits to national health services; for example, if urban populations in England
and Wales had patterns of walking and cycling similar to those achieved in
Copenhagen, about £17 billion of costs to the National Health Service (NHS) could
be averted over 20 years, increasing beyond that period because of the lag between
increased physical activity and disease prevention (Jarrett et al., 2012).
314 A. Haines
The introduction of very-low-emission vehicles (e.g. electric or electric hybrid

vehicles) would result in increased health benefits from reductions in air pollution.
Autonomous vehicles would bring the added benefit of reduced accidents. Electric
bicycles may increase the range of travel and encourage older, unfit or physically
disabled people to take up cycling (Johnson & Rose, 2015).
Provision of accessible and secure green space may provide a number of benefits
to health and the environment, including improved mental health (Bowler, Buyung-
Ali, Knight, & Pullin, 2010); reduced risks of fatal and non-fatal cardiovascular
disease, obesity and diabetes; and improved pregnancy outcomes (WHO, 2016).
The mechanisms may include reduced psychological stress; increased physical
activity; and reduced air pollution, noise and heat exposure. Urban sprawl and less
mixed land use (which poses a higher risk) are consistently associated with obesity
in North American studies, but elsewhere the associations are more heterogeneous
(Mackenbach et al., 2014). In the UK, a study of over 400,000 people showed that
below 1800 housing units per square kilometre higher residential density was asso-
ciated with higher adiposity, whereas above 1800 units per square kilometre, resi-
dential density was associated with significantly lower body mass index and waist
circumference values and with decreased odds of obesity (Sarkar, Webster, &
Gallacher, 2017). Areas of high residential density may promote greater physical
activity because of the proximity of shops and other facilities, and perhaps because
they provide greater social support and community engagement. Urban sprawl may
also be associated with increased risks of urban heat exposure (Stone, Hess, &
Frumkin, 2010) and with higher transport GHG emissions. A study of US cities
found that doubling population-weighted density was associated with a 48% reduc-
tion in CO2 emissions from household travel and a 35% reduction in CO2 emissions
from residential energy use (Lee & Lee, 2014).
Health in the Circular Economy
There is growing interest in transforming the economy from the current, inefficient,
resource-intensive, polluting approach to one based on recycling, reuse and remanu-
facturing, encouraging the use of renewable and biodegradable resources. Such
approaches can greatly reduce exposure to hazardous waste and inefficient use of
resources, ensuring that human progress is achieved at much lower levels of envi-
ronmental damage than today’s wasteful and inequitable economy. One example
would be the introduction of policies to reduce food waste; currently about 30% of
agricultural land is used to grow food that is never eaten but contributes to climate
and other environmental changes. Another priority is to reduce exposure of mainly
poor populations to hazardous waste dumps (Landrigan et al., 2018). The circular
economy—if designed to address health, development and environmental sustain-
ability in an integrated fashion—could both address pollution and help mitigate
climate change whilst promoting decent work and livelihoods.
A recent paper, using data from 637 Chinese cities, demonstrated the potential to
combine the circular economy and climate change mitigation by capitalising on
urban–industrial symbiosis, including the use of waste heat from industry in the
commercial and residential sectors (Ramaswami et al., 2017). Industrial cities have
high direct CO2 emissions intensity and are hot spots for interventions to reduce
emissions and capitalise on the potential symbiosis.
Food and Agriculture
There are a range of potential solutions to the threats posed by environmental

change to crop yields, food security and nutrition, including reduction of food
waste, biofortification of crops, sustainable intensification of agriculture, sustain-
able aquaculture, more efficient use of water and fertiliser, and promotion of low-
environmental-impact, healthy diets (Whitmee et al., 2015). A systematic review
has shown the potential to reduce GHG emissions, together with land and water use,
from shifting current intakes to environmentally more sustainable diets, suggesting
that median reductions of 20–30% across these indicators are possible in high-
income settings (Aleksandrowicz, Green, Joy, Smith, & Haines, 2016). The per-
calorie environmental impacts were largest with consumption of ruminant meat,
followed by other animal products, and smallest with consumption of plant-based
foods (Green et al., 2015). Dietary shifts also resulted in modest estimated reduc-
tions in the all-cause mortality risk (Milner et al., 2017). More evidence from low-
income settings is needed.
A study using data from 555 life cycle analyses on 82 types of crops and animals
showed that in comparison with the global-average income-dependent diet pro-
jected for 2050, three comparator diets—Mediterranean, pescatarian and vegetar-
ian—resulted in 30%, 45% and 55% reductions in per capita GHG emissions,
respectively (Tilman & Clark, 2014), and required much less cropland than the
income-dependent diet. Compared with conventional omnivorous diets, the three
alternative diets were estimated to reduce incidence rates of type 2 diabetes by
16–41% and ischaemic heart disease by 20–26%. Sustainable aquaculture needs
scaling up to meet increased fish requirements, as much current aquaculture depends
on inputs of antibiotics, pesticides and food from unsustainable sources such as krill.
ricing Greenhouse Gas Emissions to Reduce Climate Change

P
and Improve Health
Removing fossil fuel subsidies and implementing carbon taxes could, if properly
designed, improve health, reduce GHG emissions, redistribute wealth and stimulate
employment (Cuevas & Haines, 2015), but recent disturbances in France show the
316 A. Haines
adverse effects of policies that increase inequalities. Estimated nationally efficient

carbon prices based on self-interest (i.e. including consideration of the resulting
domestic co-benefits) in 2010 prices averaged around US$57 per ton for the top 20
emitting nations (Parry, Heine, Lis, & Li, 2014), but there are wide differences
between countries, depending on their mix of energy sources. Implementing taxa-
tion that reflects the costs of carbon dioxide emissions, local air pollution and addi-
tional transport-related externalities (such as congestion and accidental injury) from
burning fossil fuels could yield additional revenues, equivalent to about 2.6% of
global gross domestic product (GDP), while simultaneously reducing carbon diox-
ide emissions by 23% and pollution-related mortality by 63% (Parry et al., 2014).
By 2050, food-related GHG emissions could take up half the remaining GHG
emissions to keep the world on track for 2 °C warming in the absence of decisive
actions to address the food system. An analysis of the role of GHG-related food
taxes showed that food-related GHG emissions would be reduced by 1.0 GtCO2e
(9.3%) under full tax coverage and by 919 MtCO2e (8.6%) in a regionally optimised
tax scenario. About two thirds of the emissions reductions were due to reduced
consumption of beef and one quarter were due to reduced milk consumption
(Springmann, Godfray, Rayner, & Scarborough, 2016). However, care would be
needed to avoid potential negative health effects, particularly in low-income set-
tings, by omitting food groups known to have health benefits from the tax regime or
subsidising healthy low-emission food groups. The health benefits identified in this
study (100,000–500,000 avoided deaths globally) were broadly similar to the poten-
tial health benefits of 500,000 ± 200,000 avoided premature deaths per year by 2030
that global climate policies could have on air pollution associated with coal-fired
power generation (West et al., 2013).
otential Adverse Effects of Policies to Address Environmental

P
Change
Assessments of health co-benefits of policies to mitigate environmental change

should specifically consider the potential for unintended adverse consequences
(Haines et al., 2009). Some types of biofuels, such as corn alcohol, compete directly
with important food crops and may contribute to food price increases, but others,
such as sugar cane alcohol, do not compete directly. Increasing the energy effi-
ciency of houses by better insulation and draught proofing may increase exposure to
household air pollution unless it is accompanied by improved ventilation. Diesel
engines have been promoted in some countries because of their reduced GHG emis-
sions but have higher emissions of fine particulates and nitrogen oxides (NOx)
(Wilkinson & Haines, 2015).
The Post-2015 Development Agenda
The post-2015 development agenda represents a major opportunity to improve

health through the lens of sustainable development (Dora et al., 2015; Haines,
Alleyne, Kickbusch, & Dora, 2012). The Sustainable Development Goals (SDGs)
of the United Nations will shape the development agenda until 2030, and a recent
paper has outlined the links between interventions and policies to reduce the emis-
sions of short-lived climate pollutants and the SDGs (Haines et al., 2017).
There are opportunities to harness some of the climate funding of US$100 billion
annually that was previously pledged to be provided by 2020 for mitigation and
adaptation (http://www.greenclimate.fund/). This funding could help countries cap-
italise on the health co-benefits of climate change mitigation policies and reduce
climate change impacts on health by preventing dangerous climate change.
SDG target 3.7 aims to “ensure universal access to sexual and reproductive
health-care services, including for family planning, information and education, and
the integration of reproductive health into national strategies and programmes.”
This, together with improved education of women (SDG goal 4), can improve preg-
nancy outcomes and the prospects for child survival through birth spacing. Although
per capita GHG emissions in regions such as sub-Saharan Africa are currently low,
these will grow if development is powered by fossil fuels, and population growth in
vulnerable regions makes adaptation to climate change more difficult.
Conclusion
Whilst global environmental change poses major challenges to human health, there
are opportunities to address disease prevention and environmental sustainability
through integrated transformative policies. However, in order to realise this poten-
tial, unprecedented collaboration across sectors will be required in the coming
decades. The economic and social drivers responsible for the challenges faced by
humanity in the Anthropocene epoch must be addressed, including by removal of
harmful subsidies, realignment of taxes to focus on health-damaging externalities,
and reduction of inequities in health and wealth. Better health cannot be achieved
and sustained without the recognition that human health ultimately depends on the
integrity of natural systems.
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CHAPTER 25
Well Under 2 °C: Ten Solutions for Carbon
Neutrality and Climate Stability
V. Ramanathan, M. L. Molina, D. Zaelke, and N. Borgford-Parnell
Summary Climate change is becoming an existential threat with warming in excess

of 2 °C within the next three decades and 4–6 °C within the next several decades.
Warming of such magnitudes will expose as many as 75% of the world’s population
to deadly heat stress in addition to disrupting the climate and weather worldwide.
Climate change is an urgent problem requiring urgent solutions. This chapter lays out
urgent and practical solutions that are ready for implementation now, will deliver
benefits in the next few critical decades, and place the world on a path to achieving
the long-term targets of the Paris Agreement. The approach consists of four building
blocks and three levers to implement ten scalable solutions described in this chapter.
These solutions will enable society to decarbonize the global energy system by 2050
through efficiency and renewables, drastically reduce short-lived climate pollutants,
and stabilize the warming well below 2 °C both in the near term (before 2050) and in
the long term (after 2050). The solutions include an atmospheric carbon extraction
lever to remove CO2 from the air. The amount of CO2 that must be removed ranges
from negligible (if the emissions of CO2 from the energy system and short-lived cli-
mate pollutants have started to decrease by 2020 and carbon neutrality is achieved by
2050) to a staggering one trillion tons (if the carbon lever is not pulled and emissions
of climate pollutants continue to increase until 2030).
V. Ramanathan (*)
Scripps Institution of Oceanography, University of California, San Diego,
San Diego, CA, USA
M. L. Molina
University of California, San Diego, San Diego, CA, USA
D. Zaelke
Institute for Governance and Sustainable Development, Washington, DC, USA
Institute for Governance and Sustainable Development, Paris, France
N. Borgford-Parnell
Climate and Clean Air Coalition, Paris, France

322 V. Ramanathan et al.
ending the Curve: Four Building Blocks, Three Levers,

B
and Ten Solutions
The Paris Agreement is an historic achievement. For the first time, effectively all
nations have committed to limiting their greenhouse gas emissions and taking other
actions to limit global temperature change (Fig. 25.1). Specifically, 197 nations
have agreed to hold “the increase in the global average temperature to well below
2 °C above pre-industrial levels and pursue efforts to limit the temperature increase
to 1.5 °C above pre-industrial levels” and achieve carbon neutrality in the second
half of this century (UNFCCC, 2015).
The climate has already warmed by 1 °C (IPCC, 2013). The problem is running
ahead of us, and under current trends we will likely reach 1.5 °C in less than
15 years (Xu and Ramanathan 2017) and surpass the 2 °C guardrail by midcentury
with a 50% probability of reaching 4 °C by the end of the century (IPCC, 2014b;
Ramanathan & Feng, 2008; World Bank, 2013). Warming in excess of 3 °C is likely
to be a global catastrophe for three major reasons:
Fig. 25.1 Four building blocks to achieve climate policy success. HFC hydrofluorocarbon, MOU
memorandum of understanding, NDC nationally determined contribution, SLCPs short-lived cli-
mate pollutants
25 Well Under 2 °C: Ten Solutions for Carbon Neutrality and Climate Stability 323
• Warming in the range of 3–5 °C is suggested as the threshold for several tipping
points in the physical and geochemical systems; warming of about 3 °C carries a
>40% probability of crossing over multiple tipping points, while warming close
to 5 °C increases the probability to nearly 90% in comparison with baseline
warming of less than 1.5 °C, which carries just over a 10% probability of exceed-
ing any tipping point (Ramanathan & Feng, 2008).
• Health effects of such warming are emerging as a major if not dominant source
of concern. Warming of 4 °C or more will expose more than 70% of the popula-
tion—that is, about seven billion people by the end of the century—to deadly
heat stress (Mora et al., 2017) and expose about 2.4 billion to vector-borne dis-
eases such as dengue, chikungunya, and Zika virus, among others (Proestos
et al., 2015; Ramanathan et al., 2017; WHO, 2016; Watts et al., 2015).
• Ecologists and paleontologists have postulated that warming in excess of 3 °C,
accompanied by increased acidity of the oceans with the buildup of CO2, could
become a major causal factor for exposing more than 50% of all species to extinc-
tion. Twenty percent of species are in danger of extinction now due to population
increase, habitat destruction, and climate change (Dasgupta et al., 2015).
The good news is that there may still be time to avert such catastrophic changes.
The Paris Agreement and supporting climate policies must be strengthened substan-
tially within the next 5 years to bend the emissions curve down faster, stabilize the
climate, and prevent catastrophic warming. To the extent those efforts fall short,
societies and ecosystems will be forced to contend with substantial needs for adap-
tation—a burden that will fall disproportionately on the poorest three billion people,
who are least responsible for causing the climate change problem (Pope Francis, 2015).
Here we propose an emissions pathway and a policy roadmap with a realistic and
reasonable chance of limiting global temperatures to safe levels and preventing
unmanageable climate change—an outline of specific science-based policy path-
ways that serve as the building blocks for a three-lever strategy that could limit
warming to well under 2 °C. The projections and the emission pathways proposed
in this summary are based on a combination of published recommendations and
new model simulations conducted by the authors of this study (see Fig. 25.2).
We have framed the plan in terms of four building blocks and three levers
(Fig. 25.1), which would be implemented through ten solutions. The first building
block would be full implementation of the nationally determined mitigation pledges
under the Paris Agreement of the United Nations (UN) Framework Convention on
Climate Change (UNFCCC). In addition, several sister agreements that provide tar-
geted and efficient mitigation must be strengthened. Sister agreements include the
Kigali Amendment to the Montreal Protocol to phase down hydrofluorocarbons
(HFCs), efforts to address aviation emissions through the International Civil
Aviation Organization (ICAO) and maritime black carbon emissions through the
International Maritime Organization (IMO), and the commitment by the eight coun-
tries of the Arctic Council to reduce black carbon emissions by up to 33% (Arctic
Council, 2017a, 2017b; ICAO, 2016; IMO, 2015; UNEP, 2016a). There are many
other complementary processes that have drawn attention to specific actions on
Dangerous Catastrophic Existential

Probability density (°C–1)
0.8 3 Levers
4 blocks +
0.6
BL
(CI
)
-50
%
0.4 %&
80
)
%
Car
I-
bon
0
-5
(C
fee
dba
I
BL
(C
0.2 cks
)
BL
0
0 1 2 3 4 5 6 7 8
2100 Warming (°C)
Fig. 25.2 Projected warming in four different scenarios from the preindustrial era to 2100,
adopted from Xu and Ramanathan (PNAS, Vol. 114. No. 9, PP 10315–10323; Xu & Ramanathan,
2017). The warming is shown in terms of probability distribution instead of a single value because
of uncertainties in climate feedbacks, which could make the warming greater or lesser than the
central value shown by the peak probability density value. The three curves on the right side indi-
cated by BL (for baseline) denote projected warming in the absence of climate policies. The
baseline with a confidence interval of 80% (BL (CI-80%)) is for the scenario in which the energy
intensity (the ratio of energy use to economic output) of the economy decreases by 80% in com-
parison with its value in 2010. For BL (CI-50%), the energy intensity decreases by only 50%.
These scenarios bound the energy growth scenarios considered by Intergovernmental Panel on
Climate Change Working Group III (IPCC-WGIII) (2014). The extreme right curve, BL (CI-50%
and carbon feedbacks), includes the carbon cycle feedback due to the warming caused by the BL
(CI-50%) case. The carbon cycle feedback adopts IPCC-recommended values for the reduction in
CO2 uptake by the oceans as a result of the warming, the release of CO2 by melting permafrost,
and the release of methane by wetlands. The green curve adopts the four building blocks and the
three levers proposed in this chapter. There are four mitigation steps: (1) Improve the energy effi-
ciency and decrease the energy intensity of the economy by as much as 80% from its 2010 value.
This step alone will decrease the warming by 0.9 °C (1.6 °F) by 2100. (2) Bend the carbon emis-
sion curve further by switching to renewables before 2030 and achieving carbon neutrality within
three decades. This step will decrease the warming by 1.5 ºC (2.7 ºF) by 2100. (3) Bend the short-
lived climate pollutants curve, beginning in 2020, following the actions California has demon-
strated. This step will decrease the warming by as much as 1.2 ºC (2.2 ºF) by 2100. (4) In addition,
extract as much as 1 trillion tons (about half of what we have emitted so far) from the atmosphere
by 2100. This step will decrease the warming by as much as 0.3 ºC to 0.6 ºC (0.5 ºF to 1 ºF). The
50% probable warming values in the four scenarios are (from left to right) 1.4 °C (2.5 °F), 4.1 °C
(7.4 °F), 5 °C (9 °F), and 5.8 °C (10.4 °F), respectively. There is a 5% probability that the warming
in the four scenarios could exceed (from left to right) 2.2 °C (4 °F), 5.9 °C (10.6 °F), 6.8 °C
(12.2 °F), and 7.7 °C (14 °F), respectively. The risk categories shown at the top largely follow Xu
and Ramanathan (2017), with slight modifications. Following the IPCC and Xu and Ramanathan
(2017), we denote warming in excess of 1.5 °C as dangerous. Following the burning embers dia-
gram from the IPCC as updated by O’Neill et al. (2017), warming in excess of 3 °C is denoted as
catastrophic. We invoke recent literature on the health effects >4 °C warming, impacts including
mass extinction with >5 °C warming, and a projected collapse of natural systems with warming in
excess of 3 °C, to denote >5 °C warming as exposing the global population to existential threats
climate change, such as the Group of Twenty (G20), which has emphasized reform
of fossil fuel subsidies, and the Climate and Clean Air Coalition (CCAC). HFC
measures, for example, can avoid as much as 0.5 °C of warming by 2100 through
the mandatory global phasedown of HFC refrigerants within the next few decades,
and substantially more through parallel efforts to improve the energy efficiency of
air conditioners and other cooling equipment, potentially doubling this climate ben-
efit (Shah, Wei, Letschert, & Phadke, 2015; Xu et al. 2013; Zaelke, Andersen, &
Borgford-Parnell, 2012).
For the second building block, numerous subnational and city-scale climate
action plans have to be scaled up. One prominent example is California’s Under 2
Coalition, signed by over 177 jurisdictions from 37 countries in six continents, cov-
ering a third of the world economy. The goal of this memorandum of understanding
is to catalyze efforts in many jurisdictions that are comparable with California’s
target of 40% reductions in CO2 emissions by 2030 and 80% reductions by 2050—
emission cuts that, if achieved globally, would be consistent with stopping warming
at about 2 °C above preindustrial levels (Under2MOU, 2017). Another prominent
example is the climate action plans devised by over 50 cities and 65 businesses
around the world, aiming to cut emissions by 30% by 2030 and 80–100% by 2050.
There are concerns that the carbon-neutral goal will hinder economic progress;
however, real-world examples from California and Sweden since 2005 offer evi-
dence that economic growth can be decoupled from carbon emissions, and the data
for CO2 emissions and gross domestic product (GDP) reveal that growth in fact
prospers with a green economy (Saha & Muro, 2016).
The third building block consists of two levers that we need to pull as hard as we
can: one for drastically reducing emissions of short-lived climate pollutants
(SLCPs), beginning now and completing this by 2030, and the other for decarbon-
izing the global energy system by 2050 through efficiency and renewables. Pulling
both levers simultaneously could keep the global temperature rise below 2 °C
through the end of the century (Shindell et al., 2012, 2017; Shoemaker, Schrag,
Molina, & Ramanathan, 2013). If we bend the CO2 emissions curve through decar-
bonization of the energy system such that global emissions have peaked in 2020,
decrease steadily thereafter, and reach zero in 2050, there is less than a 20% prob-
ability of exceeding 2 °C warming (IPCC, 2013; Xu & Ramanathan, 2017). This
call for bending the CO2 curve by 2020 is one key way in which this chapter’s pro-
posal differs from the Paris Agreement, and it is perhaps the most difficult task of all
those envisioned here. Many cities and jurisdictions are already on this pathway,
thus demonstrating its scalability. Achieving carbon neutrality and reducing emis-
sions of SLCPs would also drastically reduce air pollution globally, including air
pollution in all major cities, thus saving millions of lives and over 100 million tons
of crops lost to air pollution each year (Shindell et al., 2012). In addition, these steps
would provide clean energy access for the world’s poorest three billion people, who
are still forced to resort to nineteenth-century technologies to meet basic needs such
as cooking (Dasgupta et al., 2015; IPCC, 2014a).
For the fourth and final building block, we are adding a third lever, ACE (atmo-
spheric carbon extraction, also known as carbon dioxide removal (CDR)). This
lever is added as insurance against unwanted surprises (due to policy lapses, mitiga-
tion delays, or nonlinear climate changes) and would require development of scal-
able measures for removing the CO2 already in the atmosphere. The amount of CO2
that must be removed will range from negligible (if the emissions of CO2 from the
energy system and SLCPs have started to decrease by 2020 and carbon neutrality is
achieved by 2050) to a staggering one trillion tons (if CO2 emissions continue to
increase until 2030 and the carbon lever is not pulled until after 2030) (Xu &
Ramanathan, 2017). This issue is raised because the NDCs (nationally determined
contributions) accompanying the Paris Agreement would allow CO2 emissions to
increase until 2030 (UNEP, 2016b). We call on economists and experts in political
and administrative systems to assess the feasibility and cost effectiveness of reduc-
ing carbon and SLCP emissions beginning in 2020, in comparison with delaying it
by 10 years and then being forced to pull the third lever to extract one trillion tons
of CO2 from the atmosphere.
The fast mitigation plan of requiring emissions reductions to begin by 2020—
which means that many countries already need to be cutting their emissions now—
is urgently needed to limit the warming to well under 2 °C. Climate change is not a
linear problem. Instead, we are facing nonlinear climate tipping points that can lead
to self-reinforcing and cascading climate change impacts (Lenton et al., 2008).
Tipping points and self-reinforcing feedbacks are wild cards that are more likely
with increased temperatures, and many of the potential abrupt climate shifts could
happen as warming goes from 1.5 °C in 15 years to 2 °C by 2050, with the potential
to push us well beyond any possibility of achieving Paris Agreement goals (Drijfhout
et al., 2015).
Ten Scalable Solutions to Bend the Curve
The four building blocks and the three levers require global mobilization of human,
financial, and technical resources. For the global economy and society to achieve
such rapid reductions in SLCPs by 2030 and carbon neutrality and climate stability
by 2050, we will need multidimensional and multisectoral changes and modifica-
tions to bend the warming curve, which are grouped under the ten scalable solutions
listed below. We have adapted these solutions with some modifications from a book
chapter titled “Bending the Curve,” written by 50 researchers from the University of
California system (Ramanathan et al., 2015). The ten solutions are grouped under
six clusters as listed below:
Science Pathways Cluster
1. Show that we can bend the warming curve immediately by reducing SLCPs and
long-term by replacing current fossil fuel energy systems with carbon-neutral
technologies.
Societal Transformation Cluster
2. Foster a global culture of climate action through coordinated public communica-

tion and education at local to global scales.
3. Build an alliance among science, religion, health care, and policy to change
behavior and garner public support for drastic mitigation actions.
Governance Cluster
4. Build upon and strengthen the Paris Agreement, and strengthen sister agree-
ments like the Montreal Protocol’s Kigali Amendment to reduce HFCs.
5. Scale up subnational models of governance and collaboration around the world
to embolden and energize national and international action. California’s Under 2
Coalition and the climate action plans devised by over 50 cities are prime
examples.
Market-Based and Regulation-Based Cluster
6. Adopt market-based instruments to create efficient incentives for businesses and

individuals to reduce CO2 emissions.
7. Target direct regulatory measures—such as rebates and efficiency and renewable
energy portfolio standards—for high-emissions sectors not covered by market-
based policies.
Technology Cluster
8. Promote immediate and widespread use of mature technologies such as photo-

voltaics, wind turbines, biogas, geothermal energy, batteries, hydrogen fuel cells,
electric light-duty vehicles, and more efficient end-use devices, especially in
lighting, air conditioning and other appliances, and industrial processes.
Aggressively support and promote innovations to accelerate the complete elec-
trification of energy and transportation systems and improve building
efficiency.
9. Immediately make maximum use of available technologies combined with regu-
lations to reduce methane emissions by 50%, reduce black carbon emissions by
90%, and eliminate hydrofluorocarbons with high global-warming potential
(high-GWP HFCs) ahead of the schedule in the Kigali Amendment while foster-
ing energy efficiency.
Atmospheric Carbon Extraction Cluster
10. Regenerate damaged natural ecosystems and restore soil organic carbon.

Urgently expand research and development of atmospheric carbon extraction,
along with carbon capture, utilization, and storage.
Concluding Remarks: Where Do We Go from Here?
A massive effort will be needed to stop warming at 2 °C, and time is of the essence.
With unchecked business-as-usual emissions, global warming has a 50% likelihood
of exceeding 4 °C and a 5% probability of exceeding 6 °C in this century, raising
existential questions for most, but especially the poorest three billion people.
Dangerous to catastrophic impacts on the health of people (including generations
yet to be born), on the health of ecosystems, and on species extinction have emerged
as major justifications for keeping climate change well below 2 °C, although we
must recognize that the intrinsic uncertainties in climate and social systems make it
hard to pin down exactly the level of warming that will trigger possibly catastrophic
impacts. To avoid these consequences, we must act now, and we must act fast and
effectively. This chapter sets out a specific plan for reducing climate change in both
the near and long terms. With aggressive urgent actions, we can protect ourselves.
Acting quickly to prevent catastrophic climate change by decarbonization will save
millions of lives, trillions of dollars in economic costs, and massive suffering and
dislocation of people around the world. This is a global security imperative, as it can
avoid the migration and destabilization of entire societies and countries, and reduce
the likelihood of environmentally driven civil wars and other conflicts.
We must address everything from our energy systems to our personal choices to
reduce emissions to the greatest extent possible. We must redouble our efforts to
invent, test, and perfect systems of governance so that the large measure of interna-
tional cooperation needed to achieve these goals can be realized in practice. The
health of people for generations to come and the health of ecosystems crucially
depend on an energy revolution beginning now that will take us away from fossil
fuels and toward the clean renewable energy sources of the future. It will be nearly
impossible to achieve other critical social goals—for example, the UN’s Agenda
2030 and Sustainable Development Goals—if we do not make immediate and pro-
found progress in stabilizing the climate, as we are outlining here.
Fortunately, there is momentum behind climate mitigation. Twenty-four coun-
tries have already embarked on a carbon-neutral pathway, and there are numerous
living laboratories, including 53 cities, many universities around the world, and the
state of California. These laboratories have already created eight million jobs in the
clean energy industry; they have also shown that emissions of greenhouse gases and
air pollutants can be decoupled from economic growth. We have a long way to go
and very little time to achieve carbon neutrality. We need institutions and enterprises
that can accelerate this bending by scaling up the solutions that are being proven in
the living laboratories. We have less than a decade to put these solutions in place
around the world to preserve nature and our quality of life for generations to come.
The time is now.
Acknowledgements This chapter is based on a full report, which can be accessed at: http://www.
ramanathan.ucsd.edu/about/publications.php. The authors of the report include, in addition to the
four authors of this chapter, the following: Ken Alex, Max Auffhammer, Paul Bledsoe, William
Collins, Bart Croes, Fonna Forman, Örjan Gustafsson, Andy Haines, Reno Harnish, Mark
Jacobson, Shichang Kang, Mark Lawrence, Damien Leloup, Tim Lenton, Tom Morehouse, Walter
Munk, Romina Picolotti, Kimberly Prather, Graciela B. Raga, Eric Rignot, Drew Shindell,
K. Singh, Achim Steiner, Mark Thiemens, David W. Titley, Mary Evelyn Tucker, Sachi Tripathi,
David Victor, and Yangyang Xu.
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CHAPTER 26
Defeating Energy Poverty: Invest
in Scalable Solutions for the Poor
Daniel M. Kammen
Energy and persistence conquer all things.

—Benjamin Franklin
Summary Energy poverty is arguably the most pervasive and crippling threat
society faces today. Lack of access impacts several billion people, with immediate
health, educational, economic, and social damage. Furthermore, how this problem
is addressed will result in the largest accelerant of global pollution or the largest
opportunity to pivot away from fossil fuels onto the needed clean energy path. In a
clear example of the power of systems thinking, energy poverty and climate change
together present a dual crisis of energy injustice along gender, ethnic, and socio-
economic grounds, which has been exacerbated if not outright caused by a failure
of the wealthy to see how tightly coupled our global collective fate is if addressing
climate change fairly and inclusively does not become an immediate, actionable
priority.
While debate exists on the optimal path or paths to wean our economy from fos-
sil fuels, there is no question that technically we now have sufficient knowledge and
a sufficient technological foundation to launch and to even complete decarboniza-
tion. What is critically needed is an equally powerful social narrative to accelerate
the clean energy transition. Laudato Si’ provides a compelling foundation built on
the narrative around the health, climate, and social benefits of a global green energy
transition. The Green New Deal in the USA is a political movement that grows from
this new understanding of sound stewardship and respect for the planet and its
inhabitants.
This chapter presents examples and formulation of an action agenda to defeat
energy poverty and energy injustice.
D. M. Kammen (*)
Energy and Resources Group & Goldman School of Public Policy,
University of California, Berkeley, Berkeley, CA, USA

334 D. M. Kammen
The Multifaceted Nature of Energy Poverty and Injustice
In what has become one of the most important and widely quoted assessments of the
current state of energy poverty, we now hear daily that “over one billion people
today lack access to modern energy services.”
This striking statement has become the rallying cry of the United Nations, the
World Bank, and a myriad of nongovernmental groups. What is less widely discussed
is how central energy poverty is related to lack of food quality, high levels of indoor
air pollution, and lack of quality water resources. Energy poverty is health poverty.
A Framework for Learning and Innovation
A variety of factors—all shameful in hindsight—have retarded the progress of a

pro-poor, pro-environment agenda for research, testing, and action. The problems of
household particulate pollution—black carbon—and trace gas pollution from
indoor cooking and heating have been known and studied since the 1950s, and yet
only recently has there been any significant scale-up of the solutions.
These are many examples of neglected yet critically needed science for these
seemingly commonplace or mundane issues. Cookstoves, clean energy, climate
change, and social, ethnic, and other injustices all fall squarely into this area and
have arguably been under-researched. One useful theoretical framework in which to
assess the impact of innovations is to distinguish between “fundamental science”
and “use-inspired” or applications-motivated science. In his seminal book Pasteur’s
Quadrant, the political scientist Donald Stokes summarized this value in a classic
2 × 2 matrix of opportunities (Fig. 26.1).
It is clear that raising the mundane to an intellectual, political, and commercial
level comparable to other texts and tenets of society is vitally needed for the natural,
social, psychological, and policy tools required for energy access sustainability. If
we utilize it effectively, Laudato Si’ can be one of these grand ethical and intellec-
tual levers.
Energy poverty exists at many scales: from the classic “three-stone fires” of rural
homes in the poorest nations to rapidly growing urban communities, to rich nations
that deny their own citizens even the most basic forms of energy infrastructure. In
the next three sections, we illustrate the power of an approach that values the
Pasteur’s quadrant perspective for (a) rural cookstoves, (b) mini-grids for commu-
nity energy services, and (c) the need and opportunity to transform the dirtiest large-
scale grids to meet both household and industrial energy needs. Sadly, while
attention is often focused on the lack of energy for the poor, we recently found that
even where rooftop solar power is expanding rapidly, such as in parts of the USA,
access is often socially uneven and unjust. In a survey across the USA, we recently
found 40–70% lower rates of photovoltaics (PV) in deployment in Latino and
African American neighborhoods than the average, and 20–30% higher rates of
deployment in white majority areas (Sunter, Castellanos, & Kammen, 2019).
26 Defeating Energy Poverty: Invest in Scalable Solutions for the Poor 335
Fig. 26.1 Pasteur’s quadrant and the power of formulating formerly applied research as funda-
mental (Stokes, 1997). The empty “Low–Low” quadrant has been variously and humorously
described, generally with self-deprecation as the zone of “university presidents” or of “social
media gadflies”
The Intra-household Scale: Cookstoves, Women, and Health
Women—who gather or purchase fuel, cook, and handle fire considerably more fre-
quently than men—also have much higher exposure to the health impacts of energy
use, including respiratory or eye diseases due to indoor smoke, burns, or back pain,
and injuries from carrying heavy loads. While these increased health risks have long
been recognized (Kammen & Lankford, 1990; Kammen, 1995), detailed analysis
illustrates that even the scientific tools used for quantifying exposure and disease
relationships need to pay attention to details of women’s work to properly assess the
magnitude of the health risks associated with household energy tasks.
A rich literature exists on the exposure to indoor smoke under actual conditions
of use and has shown that stove emissions are highly episodic and that peaks in
emissions commonly occur when fuel is added or moved, the stove is lit, the cook-
ing pot is placed on or removed from the fire, or food is stirred (Fig. 26.2; Ezzati &
Kammen, 2001, Bailis, Ezzati, & Kammen, 2005). Quantitative and qualitative data
on time–activity budgets also indicate that female household members are consis-
tently closest to the fire when the pollution level is the highest. Other household
members may be outside or away from the house at such times, especially during
the hours when the fire is lit or extinguished.
In a long-term study of 500 villagers in central Kenya, we explored both indoor
air pollution and health impacts on families using a range of stove and fuel combi-
nations (Bailis et al., 2005; Ezzati & Kammen 2001).
336 D. M. Kammen
Fig. 26.2 Women collecting firewood in Kitui District, Kenya. Ethiopian injera stoves showing a
common open access design with ease of use but also high energy loss. (Photo credits: Daniel
M. Kammen)
6000
High-intensity exposure
Low-intensity exposure 61%

PM10 ex posur e concentration ( µ g / m )
3
4000
40%
31%
8%
2000
0% 0%
2% 11%
0
F M F M F M F M
0-5 6 - 15 16 - 50 > 50
Demographic group
Fig. 26.3 Total daily exposure to particulate matter 10 µm or less in diameter (PM10), subdivided
into high-intensity (darker shade) and low-intensity (lighter shade) exposure of each demographic
subgroup (Females and Males, by age), where the total height of the column is the group average
exposure concentration divided into the average for high- and low-intensity components. The per-
centages indicate the share of total exposure that is high-intensity exposure. The high-intensity
component of exposure occurs in less than 1 h, emphasizing the intensity of exposure in these
episodes. For details, see Ezzati and Kammen (2001)
Figure 26.3 shows the exposure data obtained using an approach that considers
the full exposure patterns and profile of individuals, divided into exposure during
high-intensity and low-intensity episodes, respectively.
Increased access to clean energy sources can improve the day-to-day and long-
term welfare of female household members. In fact, it has been argued that the
increased prominence of biomass as an economic commodity (e.g., as a source
of energy for small-scale manufacturing) has attracted local entrepreneurs and
business actors—mostly men—driving women to assume more marginal social
roles and depend on inferior sources of energy (Kammen, 1995). In our study, we
found that the transition from traditional wood-burning stoves to the cleanest
charcoal-burning stoves could cut pollution levels so significantly—largely for
women and children—that there was literally no more cost-effective intervention
(Ezzati & Kammen, 2001) on a DALY (disability-adjusted life year) than childhood
immunizations and improved cookstoves.
Cookstoves and cookstove programs have also been the subject of repeated criti-
cisms that the stoves do not reduce pollution in practice in the field and thus the
claimed benefits are illusory (see, for example, Gunther, 2015). As comes as no
surprise to those who have studied not only stoves but the full life-cycle of mainte-
nance, deployment, and education, stove/fuel/community partnerships that use the
best stoves and focus on human economic and health benefits, and not just hard-
ware, have proven successful (Goodman, 2018). Here again, we see a need to look
beyond a technical fix and embrace the needed evolution from mundane science
(Dove & Kammen, 2015; Kammen & Dove, 1997) to fulfil the full narrative of use-
inspired basic research—namely, that of Pasteur’s quadrant.
The Community Scale: Mini-grids
The International Energy Agency (IEA) projects that over 900 million people in
rural areas will remain without electricity by 2030, in contrast to only about 100 mil-
lion in urban areas, with the vast majority being in sub-Saharan Africa (Alstone,
Gershenson, & Kammen, 2015). Sustainable Energy for All (SE4ALL, 2013), using
data from the IEA, expects that achieving universal access will require grid exten-
sion for all new urban connections and 30% of rural populations, with the remaining
70% of rural people gaining access through decentralized solutions (via mini-grids,
solar home systems (SHS), and intra-household (or “pico-”) products, known
widely as “pay-as-you-go” [PAYG] energy access technologies). In fact, a legiti-
mate argument exists that despite “utility apologist” arguments, mini-grids will in
time be cheaper, more reliable, and cleaner than large-grid systems (Casillas &
Kammen, 2010).
The economic limitations of the rural poor are reflected in their low energy con-
sumption, struggle to pay connection fees, and challenges in procuring household
wiring and appliances. In fact, many households and businesses in “electrified”
areas lack access, even directly beneath power lines. People and communities with-
out property rights may lack the stability to justify investments in fixed i nfrastructure,
or may not have permission from central authority to do so. Figure 26.4 presents a
representative mini-grid in Sabah, Malaysian Borneo, showing solar power (and
micro-hydropower) powering telecommunications hardware and village lighting.
Figure 26.5 provides an overview of energy service provision from PAYG, mini-
grid, and large-grid systems. The battle for customers is one that distributed PAYG
and mini-grid systems are increasingly winning—one home and 1 kW at a time.
Fig. 26.4 A village micro-grid energy and telecommunications system in the Crocker Highlands
of Sabah, Malaysian Borneo. The system serves a community of 200 and provides household
energy services, telecommunications, and a satellite communications (dish shown), water pump-
ing for fish ponds (seen in the center), and refrigeration. The supply includes micro-hydropower
and solar generation (one small panel is shown here; others are distributed on building rooftops).
(Photo credit: Daniel M. Kammen)
Fig. 26.5 Mapping of pay-as-you-go (PAYG), mini-grid, and large-scale grid technologies and
levels of service provision (Alstone, Gershenson, and Kammen, 2015). IDCOL Infrastructure
Development Company Limited, LED light-emitting diode, SHS solar home systems
Fig. 26.6 Map of existing and planned utility grids and the proliferation of mini-grid systems
across Tanzania. (Source: http://www.wri.org/resources/maps/tanzania-energy-access-maps). For
additional mini-grid assessments, see Schnitzer et al., 2014. Similar maps are emerging
worldwide
Globally, utility-scale grid expansion has roughly kept pace with the increase in
the global population. In 2016, about 1.2 billion people were completely off-grid
and many ostensibly connected people in the developing world experienced signifi-
cant outages that ranged from 20 to 200+ days a year. Current forecasts are that this
number will remain roughly unchanged until 2030, which would relegate a signifi-
cant portion of the population and the economies of many of the neediest countries
on earth to fragile, under productive lives, with fewer options than they could other-
wise have (IPCC, 2011) (Fig. 26.6).
Scientific Advances in Off-Grid Systems
Mini-grids and products for individual user end-use, such as solar home systems,
have benefited from dramatic price reductions and performance advances in solid-
state electronics, cellular communications technologies, and electronic banking,
and from the dramatic decrease in solar energy costs and more recently in storage
costs (Kittner, Lil, & Kammen, 2017). This mix of technological and market inno-
vation has contributed to a vibrant new energy services sector, which in many
nations has outpaced traditional grid expansion.
High-performance, low-cost photovoltaic generation paired with advanced bat-
teries and controllers provide scalable systems across much larger power ranges
340 D. M. Kammen
than central generation, from megawatts down to fractions of a watt. As these mini-
grid and reliable utility-scale grid systems become more common and affordable,
electrified cooking and thus very-low-pollution home environments become possi-
ble—further improving health outcomes.
he Utility Scale: Grid Expansion and Its Dramatic

T
Alternatives
In 2008, I was approached by a consortium of nongovernmental organizations in

Sabah, Malaysia, to offer alternatives to a coal-fired power plant. Sabah, a small and
generally well-managed state, is the former British North Borneo, famous for rare
megafauna and Mount Kinabalu. Our report Clean Energy Options for Sabah
(McNish, Kammen, & Gutierrez, 2010) (Fig. 26.7) and a great deal of community
Fig. 26.7 Top left: The Renewable and Appropriate Technology Laboratory (RAEL) report, Clean
Energy Options for Sabah. Top right: Presenting the Report to the environment minister. Bottom left:
Coverage in The Borneo Post: “Anti-coal stand has support.” Bottom right: Large public turnouts at
events to discuss and debate the report’s findings
education and outreach helped to overturn a decision to purchase a 300-megawatt

(MW) used coal-fired power plant from China in favor of investment in expanded
distributed renewables, an improved grid, and natural gas. This victory helped to con-
nect our team to a more challenging case, that of the larger and more ecologically and
culturally brutalized state of Sarawak.
The victory against big coal in Sabah inspired a new kind of discussion around
energy to happen across the region. Activists from throughout Asia working on
campaigns against “dirty” energy projects like coal and dams were talking to clean
and appropriate energy practitioners.
In 2002, as Sarawak was completing the Bakun Dam, one indigenous group—
the Kenyah-Badang community—that would have been displaced refused to accept
the resettlement package and instead relocated their settlement just outside the
dam’s reservoir. Gara Jalong, the tenacious and charismatic leader of Long Lawen,
had led the village against the many timber companies encroaching on indigenous
lands in the 1980s, then against dam developers in the 1990s. Gara also sought out
professionals with experience in rural electrification via micro-hydropower, to pro-
vide a sustainable source of energy for his people.
Clever Deception: The Sarawak Corridor of Renewable

A
Energy
Malaysian Borneo, like much of Southeast Asia, has experienced not only a brutal
wave of deforestation but also a surge in mega-hydropower projects, ostensibly to
facilitate industrial productivity and consumption. The Three Gorges Dam in China
was completed in 2006, while the Nam Theun Dam (completed in 2010) and the
Xayaburi Dam (under construction) in Laos were the first of a series of dams to be
built in the trans-boundary Lower Mekong Basin. The island of Borneo, too, has
abundant natural resources, immense global ecological importance, exotic megafauna
(orangutans, dwarf rhino, and pygmy elephants) and hornbills, a largely rural human
population (some of them former headhunters), and an agrarian economy, which is
also on the cusp of major industrial dislocation due to hydropower development.
The Sarawak Corridor of Renewable Energy (SCORE) is a corridor in central
Sarawak, an East Malaysian state on the island of Borneo. SCORE differs funda-
mentally from the other Malaysian economic corridor projects in its predominant
emphasis on hydropower. At least 12 large hydroelectric dams and two coal power
plants, together constituting 9380 MW of capacity, were scheduled to be built before
2030 (Sovacool & Bulan, 2012). Six dams were scheduled to be completed by 2020,
with three major dams already at different stages of development.
In 2012, the 2400 MW Bakun dam became operational. At 205 meters high, it is
Asia’s largest dam outside China. The dam’s reservoir submerged 700 km2 of land
and displaced about 10,000 people. In 2013, the 944 MW Murum Dam was com-
pleted and the 1200 MW Baram Dam was scheduled for construction.
342 D. M. Kammen
These projects—SCORE—summed to a targeted ninefold increase in energy

output between 2010 and 2020, or from 5921 to 54,947 GWh, representing a 16%
annual growth rate. In terms of installed capacity, this would translate into an expan-
sion from 1300 MW in 2010 to between 7000 and 8500 MW in 2020. No extant
demand existed for this power, yet the ecological and community damage would be
extreme.
The story of SCORE was further complicated because with so many proposed
dams but little quantitative analysis of the energy options or cost and benefit trade-
offs in the literature or the public discussion over this conflict, it was very hard for
opposition to develop a clear narrative.
In response, we developed a modeling tool to examine the energy costs and land
impacts of different energy choices. While that model is not described in technical
detail here, the interested reader is directed to our papers that detail the analytic tool
itself, the data sets, and many of the specific results (Shirley & Kammen, 2015). Our
results appeared locally in late 2015, and we immediately began to hold open meet-
ings to present these models and our findings (Fig. 26.8).
Our findings were stark and robust: Sarawak’s already installed capacity includ-
ing Bakun already exceeded expected demand in 2030 under the business-as-usual
(BAU) growth assumption, so there was no additional need to build more capacity
under the government’s own BAU growth forecast. The Bakun Dam itself could
provide more than 10,000 GWh per annum. Under a 7% electricity demand growth
assumption, this represented half of the expected demand in 2030. Even under the
more aggressive 10% growth assumption, Bakun alone would satisfy a third of the
demand in 2030. Completion of the two additional dams already under construction
(Murum and Baram) would oversupply the 2030 demand under 7% growth, leading
to a large excess capacity, and would require only a marginal amount of additional
generation under 10% growth. Community energy—mini-grids—would preserve
forests and provide local energy without household pollution.
Fig. 26.8 Left: Activist team dinner with Dr. Rebekah Shirley (second from left) and Prof. Daniel
Kammen (middle), flanked by community activist leaders from across Sabah and Sarawak. Right:
Peter Kallang, the chairman of SAVE Rivers (far left), Gabriel Sundoro Wynn, the Asia regional
director for Green Empowerment (second from left), Prof. Daniel Kammen (second from right),
and See Hee Chow, a lawyer and Sarawak assemblyman (far right)
Fig. 26.9 Protesters citing (and holding) copies of the Shirley and Kammen study add ammuni-
tion to the wider social dialogue around the need for mega-dams and the dubious possibility of
billions in foreign investment (from the article in The Borneo Post)
In response to the new study, press coverage (Fig. 26.9), indigenous protests, and
a meeting I had with the chief minister, something remarkable and unexpected hap-
pened. On July 30, 2015, a moratorium on further work on the Baram Dam was
announced by the chief minister.
Then, on March 21, 2016, a legal decision to solidify this position was announced:
the Government of Sarawak revoked the classification of the land that the dam
developers had used to extinguish the native rights of ownership of the contested
dam site. This remarkable turnaround victory was a demonstration of local com-
munity activism and the importance of science communication, as research pub-
lished by the Renewable and Appropriate Energy Laboratory, identifying financially
viable commercial power production alternatives for the state, played a major role
in the developments.
No environmental victory is ever final, of course. One moment’s victory then
demands constant vigilance, as anything can be overturned by a change in a political
party, a shocking election result, or illegal land grabs and invasions. In the case of
the Baram Dam, the paper was clear, but shortly thereafter the chief minister passed
away. While the law stands, what was once final is never quite so final with the
inevitable change of officials. For now, however, things are in a good place.
ssessment: The Benefits of Diverse Technology Options

A
to Provide Energy Services
With these technological cornerstones at the household to community to large scales,

aid organizations, governments, academia, and the private sector are developing and
supporting a wide range of approaches to serve the needs of the poor, including pico-
344 D. M. Kammen
lighting devices (often very small 1- to 2-watt solar panels charging lithium ion
batteries, which in turn power low-cost, high-efficiency light-emitting diode [LED]
lights), solar home systems, and community-scale micro- and mini-grids.
Decentralized systems are clearly not complete substitutes for a reliable grid con-
nection, but they represent an important level of access until a reliable grid is avail-
able and feasible. They provide an important platform from which to develop more
distributed energy services. By overcoming access barriers, often through market-
based structures, these systems provide entirely new ways to bring energy services
to the poor and formerly unconnected people.
Meeting peoples’ basic lighting and communication needs is an important first
step on the “modern electricity service ladder” (Masera, Saatkamp, & Kammen,
2000; Saatkamp, Masera, & Kammen, 2000). Eliminating kerosene lighting from a
household improves household health and safety while providing significantly
higher quality and greater quantities of light. Fuel-based lighting is a $20 billion
industry in Africa, and tremendous opportunities exist to both reduce energy costs
for the poor and improve the quality of service. Charging a rural or village cell
phone can cost $5–10/kWh at a pay-for-service station but less than $0.50/kWh via
an off-grid product or on a mini-grid.
This investment frees up income and also tends to lead to higher rates of utiliza-
tion of cell phones and other small devices. Overall, the first few watts of power
mediated through efficient end-uses lead to benefits in household health, educa-
tion, and poverty reduction. Beyond basic needs, there can be a wide range of
important and highly valued services from decentralized power (e.g., television,
refrigeration, fans, heating, ventilation and air conditioning, and motor-driven
applications), depending on the power level and its quality along with demand-side
efficiency.
Testing laboratories that rate the quality of lighting products and disseminate the
results are an invaluable step in increasing the quality and competitiveness of new
entrants into the off-grid and mini-grid energy services space. The Lighting Global
(https://www.lightingglobal.org) program is one example of an effort that began as
an industry watchdog but has now become an important platform that provides mar-
ket insights; steers quality assurance frameworks for modern, off-grid lighting
devices and systems; and promotes sustainability through a partnership with
industry.
As we explore the human and environmental impacts of pollution, it comes as no
surprise that the range of costs only rises. In a recent study of the legacy of coal in
Kosovo, the trace metals recorded in both the coal and coal dust that are deposited
in the local area (which contains Pristina, the capital city, only 10 km from the mine
and power plant) are at health-damaging levels, and have been for decades (Kittner,
Fadadu, Buckley, Schwarzmann, & Kammen, 2018).
n Action Agenda for Clean Energy for Human

A
and Environmental Health and Energy Access
Exploit Information Technology
The information technology revolution has dramatically closed the gap between
off-grid, mini-grid, and utility-grid-scale management solutions and costs. In fact,
the diversity of new energy service products available and the rapidly increasing
demand for information and communication services, water, health, and entertain-
ment in villages worldwide have built a very large demand for reliable and low-cost
energy. Combining this demand with the drive for clean energy brings two impor-
tant objectives, which were for many years seen as being in direct competition with
alignment around the suite of new clean energy products that can power village
energy services.
To enable and expand this process, a range of design principles that can form a
roadmap to clean energy economies emerges:
Establish clear goals at the local level: Universal energy access is the global goal
for 2030, but establishing more near-term goals that embody meaningful steps from
the present situation will show what is possible and at what level of effort. Cities and
villages have begun with audits of energy services, costs, and environmental
impacts.
Empower villages as both designers and consumers of localized power: Village
solutions necessarily vary greatly, but clean energy resource assessments, evalua-
tion of the needs of the community, planning infrastructure, and training are all key
to making the village energy system a success. In a pilot project in rural Nicaragua,
once the assessment was complete, movement from evaluation to implementation
quickly became a goal of both the community and a local commercial plant.
Make equity a central design consideration: Community energy solutions have
the potential to liberate women entrepreneurs and disadvantaged ethnic minorities
by tailoring user materials and energy plans to meet the cultural and linguistic needs
of these communities. National programs often ignore business specialties, cultur-
ally appropriate cooking, and other home energy needs. Thinking explicitly about
this is good business and also makes the solutions much more likely to be adopted.
Each of these steps warrants a further narrative, one that relies not only on sci-
ence and technology but also centrally on the narrative. Laudato Siʼ is such a text: a
compelling argument that blends science, technology, and economics in a larger
integral ecology that is as respectful of culture as it is of community and social jus-
tice, but one that at the same time presents a vision of the positive nexus of science,
technology, policy, and, above all, culture and community.
346 D. M. Kammen
Acknowledgements This research was conducted in partnership with Dr. Rebekah Shirley, Green
Empowerment, and the community nongovernmental organization TONIBUNG. The Save
Sarawak Rivers Network (SAVE Rivers) was the central coordinating group that brought together
community leaders, researchers, and public officials, and ensured continued attention and efforts
over the years of work, and blockades, of the dams. SAVE Rivers was the group that proposed that
the study be carried out and then involved the Bruno Manser Fonds. This research was funded by
the Bruno Manser Fonds, the Rainforest Foundation Norway, the Karsten Family Foundation, and
the Zaffaroni Family. Gabriel Sundoro Wynn and Peter Kallang provided much-needed correc-
tions, added details, and have been inspiring colleagues throughout this work.
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Sunter, D., Castellanos, S., & Kammen, D. M. (2019). Disparities in rooftop photovoltaics deploy-
ment in the United States by race and ethnicity. Nature Sustainability, 2, 71–76.
CHAPTER 27
Sensor-Enabled Climate Financing
for Clean Cooking
Nithya Ramanathan, Erin Ross, Tara Ramanathan, Jesse Ross,

Martin Lukac, and Denisse Ruiz
Traditional mud stove (left) and improved cookstove with sensor (right). Source: Nexleaf Analytics
Summary Household indoor air pollution kills approximately four million people
every year. Affordable access to usable clean energy technologies is essential for
the poorest three billion, who rely on solid fuels for cooking, heating, and lighting,
to protect themselves from air pollution and to adapt to devastating climate changes.
Project Surya has developed an innovative, collaborative approach, called Sensor-
enabled Climate Financing (SCF) (Ramanathan et al., 2017), that aligns the objec-
tives of clean energy implementers, stove manufacturers, governments, and
multinationals with the needs of the individual women and families they strive to
impact. SCF is a verified solution to the sector-wide problems of clean cookstove
affordability and adoption.
N. Ramanathan (*) · E. Ross · T. Ramanathan · J. Ross · M. Lukac · D. Ruiz

Nexleaf Analytics, Los Angeles, CA, USA
e-mail: [email protected]; [email protected]; [email protected]; [email protected];
[email protected]; [email protected]

350 N. Ramanathan et al.
Fig. 27.1 SCF model. Source: Nexleaf Analytics
In the SCF implementation model (Fig. 27.1), a woman secures a microloan from a
local bank to purchase an improved biomass cookstove equipped with a sensor that
transmits objective cooking data in near real time to a Nexleaf server. Small pay-
ments to women are made through a donor-based climate fund established at the
University of California at San Diego.
Women receive payments through a mobile money app, and clean cooking pay-
ments are deposited electronically. This approach funnels results-based financing
directly to the individual women who cook, financing the purchase of the cleaner-
burning cookstove.
Sustained adoption of clean cooking technologies is required to bring about any
of the promised health- or climate-related impacts of these innovations. With SCF,
we are seeing sustained improved cookstove adoption in multiple villages (over
89% for over 18 months).
Background
Reducing harmful emissions from traditional solid biofuel (firewood, dung, and
crop residues) cookstoves is at the forefront of global efforts to improve the lives of
the approximately three billion people worldwide who depend on biofuels for their
basic needs. Close to four million people die every year from health complications
27 Sensor-Enabled Climate Financing for Clean Cooking 351
attributable to household smoke (World Health Organization, 2018). Women and

children are particularly impacted by polluting stoves inside the home.
hat’s More, Traditional Cooking Is a Major Contributor

W
to Global Climate Change
Burning biomass in inefficient handmade stoves, a common practice in more than

600 million households worldwide, contributes to the carbon crisis through carbon
dioxide emissions and deforestation. Even more damaging are the short-lived cli-
mate pollutants (SLCPs), including soot, also known as black carbon (BC), emitted
by traditional cooking. These pollutants have a warming impact many thousands of
times greater per unit than carbon dioxide (Ramanathan & Carmichael, 2008).
Since the 1970s, scientists have been working to study the scope of the house-
hold smoke crisis, and stove designers have been designing cleaner-burning bio-
mass cookstoves for scale.
Project Surya researchers, through our field work deploying advanced stoves and
advanced wireless cookstove usage and soot monitoring systems (Graham et al.,
2014; Ramanathan et al., 2011), have published several peer-reviewed papers that
document the extent of pollution from stoves (Kar et al., 2012), their impacts on
indoor human exposure and ambient levels of BC (Patange et al., 2015; Praveen,
Ahmed, Kar, Rehman, & Ramanathan, 2012; Rehman, Ahmed, Praveen, Kar, &
Ramanathan, 2011), and the cooking technology that can drastically reduce BC
emissions. Our data indicate that among available clean cookstoves, forced-draft
stoves, also known as forced-air or fan stoves, burn most efficiently and reduce cli-
mate-warming particulates the most. We found that forced-draft stoves, which burn
locally available biomass, can reduce cooking-related emissions of BC by approxi-
mately 90% (Kar et al., 2012) and, when completely displacing traditional cooking,
can reduce the overall concentration of BC in the kitchen by approximately 40%
(Patange et al., 2015) (with kerosene lamps and outdoor emissions continuing to
contribute to overall kitchen BC concentrations).
Alternatives to forced-draft stoves include gas (or LPG) stoves and electric
induction cookstoves, which are among the cleanest technologies. However, the
associated fuel costs are prohibitive, and there is no reliable fuel supply or supply
chain to deliver the required energy to all. For the many off-grid communities and
villages around the world, waiting for grid power or an LPG distribution channel is
simply not possible. Forced-draft stoves are relatively cheaper, at a cost of approxi-
mately US$80 (which includes the cost of delivery), but still unaffordable for a
majority of the underserved, many of whom earn less than US$2 a day. However,
these stoves will likely remain the best option until a more cost-effective and feasi-
ble solution becomes available for large-scale adoption.
A Data-Driven Approach to Adoption and Impact
Project Surya, launched in 2009, is an international collaboration between NGOs,

academic institutions, and the private sector. Given the potential impact of forced-
draft stoves, Project Surya set out to understand women’s adoption of these stoves
and to develop a methodology to tie adoption to impact. Project Surya was also
convinced that getting climate financing directly into the hands of low-income
women was a moral imperative. Because the world’s poorest three billion will bear
the brunt of dislocation and disruption caused by global climate change, it is espe-
cially important to ensure that the financial benefits of their climate stewardship
reach them directly.
Clean-energy implementers often use surveys to verify the adoption of newly
introduced clean technologies in remote places. Project Surya’s early research
included an investigation into the accuracy of using self-reported stove usage data.
StoveTrace sensors—wireless thermal sensors attached to stoves in household
kitchens that transmit, using local cellular networks, in near real time information
about stove use —were deployed in households with traditional cookstoves. Women
in those same households were then asked to report how much time they spent cook-
ing each day (Ramanathan et al., 2017). The data (reproduced in the plot in Fig.
27.2) show the lack of correlation between individual stove users’ self-reported
Fig. 27.2 Self-reported cooking data vs. sensor data. Source: Nexleaf Analytics
cooking (y-axis) and sensor-verified measurements of actual cooking (x-axis) in

households.
These early data demonstrated the importance of employing objective sensors
for measuring usage of the improved cookstoves. The objective sensor data on
cookstove usage are crucial not only to verify the use of improved cookstove inter-
ventions, but also to validate feedback from women to better understand what is
working in terms of cookstove technologies and last-mile service and to address
barriers to adoption.
Surya researchers developed the SCF methodology to use objective sensor data
from both improved and traditional stoves to more accurately quantify the reduc-
tions in emissions generated when women switch from a traditional mud stove to an
improved biomass stove. Surya researchers published the SCF methodology, which
translated emissions reductions into tons of carbon dioxide equivalents, or CO2e
(Ramanathan et al., 2017), based on objective data on the usage of the stove. CO2e
includes reductions of SLCPs, including BC, which contribute to global climate
change, and cooling agents such as organic carbon. The methodology integrates
available knowledge from peer-reviewed publications with data collected by the
Surya team on air pollution levels in the field, compliance on the use of clean tech-
nologies, and types and amount of fuel consumed to quantify the emissions reduc-
tions achieved. Because clean energy implementers seek to measure impact and hit
emissions reduction targets, quantifying baseline emissions for existing traditional
cookstove technologies is crucial.
Climate Credit Pilot Project:

Findings from a Woman-Centered Approach
Using the SCF implementation model, real-time sensor technologies, and method-
ology described earlier, Project Surya launched the Climate Credit Pilot Project, or
C2P2, in 2014 in Odisha, India.
Project Surya implementers distributed over 4000 forced-draft cookstoves—the
cleanest available biomass-burning cookstoves—to households in Odisha, India.
Implementers equipped over 450 of the forced-draft cookstoves with Nexleaf’s
StoveTrace remote wireless sensors. These sensors uploaded cooking event data
automatically to Nexleaf’s servers in real time, and the data were immediately avail-
able on display on the web-based StoveTrace data dashboard.
In 2016–2017, we published findings from the C2P2 stove distribution pilot in
India in Nature Climate Change (Ramanathan et al., 2017). Analysis of pilot data
verified that our financing mechanism works. However, the sensor measurements of
cookstove usage by women (y-axis) showed low usage of the forced-draft cookstove
over time (Fig. 27.3).
Fig. 27.3 Cooking over time, C2P2 pilot in Odisha. Source: Nexleaf Analytics
Quantitative and qualitative follow-up with stove users identified key challenges
that likely plague most clean cooking interventions.
First, there is a need for last-mile distribution and service. Like any household
appliance, clean cookstoves sometimes break. Technicians need to be trained,
resourced with tools and spare parts, and paid to ensure that stoves are repaired and
continue to operate.
Second, distributing results-based financing through rural banks alone is ineffec-
tive. The individual women enrolled in C2P2 rarely if ever visited their banks to
check their balance or verify their receipt of the micropayments they were receiving
for their clean cooking.
Third, stoves must be usable, and stove users want consumer choice. Too many of
the clean cookstoves available on the market do not adequately reduce emissions,
and those that do are often difficult or inconvenient for women to use. Stove users
want the opportunity to select a stove among multiple options that best fits their
lifestyle. Therefore, a variety of clean, usable stove models must be available to
women if they are to switch away from traditional cooking.
Fortunately, an analysis of these data revealed the path to sustained adoption.
Improved Sensor-Enabled Climate Financing Model:

2016–2017 Implementations
Project Surya improved the SCF model to address the gaps identified.
Implementations in Odisha beginning in 2016 demonstrated the effectiveness of
SCF in India in promoting sustained usage of improved cookstoves. Initial data on
adoption (Fig. 27.4) suggest that the improved model leads to sustained usage of the
clean cookstoves at levels commensurate with scientific data on cooking behavior.
The aforementioned data set is small, but success has continued beyond these
initial pilot homes. By the time of the Vatican meeting in November 2017, program
households were using their improved cookstoves consistently, achieving 93%
adoption. A full report can be found at nexleaf.org/impact/iot-for-development-
stovetrace/. The following modifications made this quantifiable improvement
possible.
Introducing Mobile Money Instead of obliging women to visit distant banks to
see the rewards of their clean cooking, we worked with Vodafone M-Pesa to register
the women on the M-Pesa mobile money application. The women then received
payments via their cell phones. For women without a cell phone, a local M-Pesa
cash-out agent provides payments in cash.
Fig. 27.4 Cooking over time, SCF pilot in Kontakoli. Source: Nexleaf Analytics
Strengthening Supply Chains by Mobilizing Clean Energy Entrepreneurs

Drawing upon existing networks of rural women entrepreneurs, we developed a
distribution and after-sales service model for cookstoves that employs women
entrepreneurs. Women energy entrepreneurs want the chance to work with their
community to increase access to great products.
Independent Stove Testing We designed a laboratory testing protocol to evaluate

improved cookstoves for BC reductions and emissions.
Achieving adoption of new technologies such as improved cookstoves requires
multidimensional interventions. However, the dearth of clean, usable biomass
stoves in the marketplace continues to pose a critical and persistent challenge.
In recent months, Nexleaf has developed a mechanism for in-home usability test-
ing using StoveTrace sensors and detailed, data-enabled user feedback to continue
to identify promising technologies for potential scale. This new standard for clean
cooking evaluation helps ensure that manufactured stoves meet women’s needs
before deployment at scale:
1 . Rigorous independent lab testing of stove emissions, including BC;
2. In-home usability testing conducted by women in their homes for at least 3
months to identify the most user-friendly stoves;
3. Due diligence with stove manufacturers to determine whether they can meet last-
mile distribution demands, including fulfilling warrantees and providing training
and capacity building to last-mile technicians;
4. Long-term cost of ownership, including purchase, financing, maintenance and
fuel, to evaluate true affordability.
These four measures inform our evaluation process for clean cooking implemen-
tations, which focuses on an incremental scale-up of cooking technologies. We
begin with pilots of ten households and deliberately increase the program size only
after evaluating the performance of the cookstove and proving 80% adoption.
Recent data confirm sustained adoption (above 89%) of improved cookstoves in
SCF households for more than 18 months. A 2018 report including data from SCF
households and explaining Nexleaf’s adoption metric can be found at nexleaf.org/
reports/joint-learning-series/beyond-monitoring-and-evaluation.pdf.
The Future of SCF
Moving forward, Project Surya aims to preserve the environment, empower women,
improve health, and bolster the market for clean and usable cooking solutions, orga-
nizing our actions around operationalizing objective data. In the future, we will test
the SCF model’s resilience at greater scale and continue using data and analytics to
reveal and help us resolve any challenges that arise. We will expand SCF by scaling
the best stove models we have identified, and we will continue lab and usability
testing to identify more SCF-eligible stoves to address the broader market failure
and increase women’s choice.
Our SCF method has sparked interest across multiple sectors because it addresses
10 of the 20 United Nations Sustainable Development Goals.
onclusion: Transparency in Clean Energy Interventions Is

C
Key to Climate Justice
One key to our success has been an unflinching dedication to the power of data.
Even—and perhaps especially—when the data contradict our assumptions, we must
continue to adjust and iterate based on objective and transparent measures of impact.
In the clean energy sector as in other sectors Nexleaf works in, we have seen how
introducing sensor data can bring about anxiety. Too many development initiatives
have faced punitive measures or encountered censure for falling short of their objec-
tives. Changing the world for the better is difficult, complicated work, and we
assume good will on the part of all global stakeholders, from multinationals to gov-
ernments to stove manufacturers. That’s why, for example, Nexleaf provides feed-
back to stove manufacturers whose stoves do not pass our evaluation standards.
Clean energy stakeholders can embrace the power of data to reveal both unfore-
seen problems and their potential solutions. Additionally, small and well-measured
pilots must be scaled at a pace that aligns with the capacity of the data and the
implementation team to reveal and react to the objective truth. Every village, dis-
trict, province, state, and country has its own context, and data-driven implementa-
tions provide the flexibility necessary to serve cookstove users with many different
preference and behavior profiles.
Data not only help steer clean cooking implementations in the right direction;
they also enable all stakeholders to tap into new and exciting avenues of financing.
From corporate social responsibility campaigns to individual buyers who wish to
offset their carbon expenditures, an objective feedback portal will serve eager
donors and climate credit buyers.
SCF has the power to accomplish three primary objectives critical to successful
climate change interventions, climate justice, global emissions reductions, and eco-
nomic inclusion for the world’s poorest:
1. Align incentives and provide feedback loops necessary to bring about sustained
adoption of clean cooking technologies.
2. Provide verification of climate impact of interventions against agreed-upon
emissions reductions targets (i.e., Paris Accords).
3. Revolutionize access to results-based financing driven by objective data. This
funding can be used to reward individual rural women and women entrepreneurs
with results-based financing for their roles as climate stewards.
Ultimately, we believe in unlocking this financing for the world’s poorest and
using cutting-edge technology both to verify and to disburse these funding streams.
Acknowledgements Project Surya is an international collaboration between NGOs, academic

institutions, and the private sector, initiated by the Scripps Institution of Oceanography, UCSD, the
Energy Resources Institute, and Nexleaf Analytics, and now led by Nexleaf Analytics. The authors
would also like to thank Drs. Pattanayak and Jeuland for leading the survey data collection for the
women’s self-report in the early investigation of the accuracy of stove usage sensors.
References
Graham, E. A., Patange, O., Lukac, M., Singh, L., Kar, A., Rehman, I. H., et al. (2014). Laboratory
demonstration and field verification of a Wireless Cookstove Sensing System (WiCS) for
determining cooking duration and fuel consumption. Energy for Sustainable Development, 23,
59–67.
Kar, A., Rehman, I. H., Burney, J., Puppala, S. P., Suresh, R., Singh, L., et al. (2012). Real-time
assessment of black carbon pollution in Indian households due to traditional and improved
biomass cookstoves. Environmental Science and Technology, 46, 2993–3000.
Patange, O. S., Ramanathan, N., Rehman, I. H., Tripathi, S. N., Misra, A., Kar, A., et al. (2015).
Reductions in indoor black carbon concentrations from improved biomass stoves in rural India.
Environmental Science and Technology, 49, 4749–4756.
Praveen, P. S., Ahmed, T., Kar, A., Rehman, I. H., & Ramanathan, V. (2012). Link between local
scale BC emissions in the Indo-Gangetic Plains and large scale atmospheric solar absorption.
Atmospheric Chemistry and Physics, 12, 1173.
Ramanathan, N., Lukac, M., Ahmed, T., Kar, A., Praveen, P. S., Honles, T., et al. (2011). A cell-
phone based system for large-scale monitoring of black carbon. Atmospheric Environment, 45,
4481–4487.
Ramanathan, T., Ramanathan, N., Mohanty, J., Rehman, I. H., Graham, E., & Ramanathan, V.
(2017). Wireless sensors linked to climate financing for globally affordable clean cooking.
Nature Climate Change, 7, 44.
Ramanathan, V., & Carmichael, G. (2008). Global and regional climate changes due to black car-
bon. Nature Geoscience, 1, 221.
Rehman, I. H., Ahmed, T., Praveen, P. S., Kar, A., & Ramanathan, V. (2011). Black carbon emis-
sions from biomass and fossil fuels in rural India. Atmospheric Chemistry and Physics, 11,
7289–7299.
World Health Organization (2018). Household air pollution and health. Fact Sheet 292. Geneva:
World Health Organization.
CHAPTER 28
Research Is Vital to Tackling Climate
Change, But It Cannot Succeed Alone
Jeremy Farrar
Summary Our Planet, Our Health is Wellcome’s contribution to the growing field of
planetary health. The world needs focused research to better understand how health
is affected by global environmental changes, including climate change, and how we
can mitigate these health impacts and the environmental changes. We call on research-
ers to work with us, and on civic society, industry and governments to support
researchers, apply their findings and build an equitable movement of research into
practice to improve our health. We call on governments, industry and civic society to
support these researchers—commit to acknowledging and employing their findings
and recommendations. Through policies and legislation, governments can do what
no one else can, while foundations like Wellcome and others complement their work,
taking risks and doing what governments cannot, and together we can help industry
play its part, secure in the knowledge that there is a pipeline of great people and ideas
coming through. But if governments step back from progress in planetary health, the
gaps cannot be filled by anyone else. There is reason for optimism, if our optimism
drives us all to act now for the sake of current and future generations.
Background
In Bangladesh, the dry season runs from November to early May. Less rainfall
means shrinking rivers, and what water there is becomes more saline as a result.
When the ponds have dried up completely, people can pump groundwater to use for
drinking and cooking. But the groundwater, especially in coastal areas, is contami-
J. Farrar (*)
Wellcome Trust, London, UK

362 J. Farrar
nated with salt, too. Seawater has infiltrated the natural aquifers, a problem that is
likely to get worse as climate change threatens to bring even higher sea levels, more
floods and tidal surges, and more cyclones (Naser et al., 2017a).
The high salinity of available water in the dry season means people consuming
anything from double to eight times the World Health Organization’s (WHO) rec-
ommended daily intake of sodium. This has important health implications: research
has revealed associations between salinity and high blood pressure in adults and
preeclampsia in pregnant women. On the other hand, saving and storing rainwater
from the wet season may also pose a health risk, as rainwater lacks minerals such as
calcium and magnesium, which help protect against heart disease but are often defi-
cient in Bangladeshi diets.
In the 1970s, millions of tube wells were dug to provide new sources of fresh
water in Bangladesh. While this reduced gastrointestinal infections and cases of
diarrhoea from contaminated surface water, it inadvertently and disastrously
exposed the population to naturally occurring arsenic deeper underground (Siddiqi,
2017); arsenic is a major risk factor in heart disease, stroke, cancer and other serious
health conditions.
So what solutions are available today? As with all water, sanitation and hygiene
(WASH) challenges, any response will require many different sectors of society and
will rely on the active engagement and participation of individuals, governments
and non-governmental organisations (NGOs). People will need to change the way
they obtain, treat and store water, as will farmers and factories, just as governments
will have to take on responsibility for implementing and maintaining any new infra-
structure, physical or political.
One new idea for securing healthy drinking water in Bangladesh is to recharge
the natural underground aquifers with rainwater or surface water—effectively put-
ting fresh water into the ground to dilute the high-salt water already there. Before
this can be rolled out everywhere, however, we need to know whether it works.
Wellcome has funded a research study to find out (Naser et al., 2017b). It is the first
study to assess the health impact of an environmental intervention to reduce the
salinity of groundwater in Bangladesh. The randomised controlled trial design
being used by Mahbubur Rahman and colleagues at the International Centre for
Diarrhoeal Disease Research, Bangladesh, will determine whether managed aquifer
recharge lowers the blood pressure of people in communities adopting the new
approach. If the results are positive, it can be adopted elsewhere with confidence,
supporting more people as the effects of climate change intensify.
Humanity’s response to climate change will define the twenty-first century.
Pressures on water and sanitation are far from the only issues we face. We expect
increased heat stress and droughts as well as floods and more frequent, more power-
ful storms. Land use and ecological systems will change as the environment changes.
Food and nutrition will be harder to provide for all, and more people will migrate or
be displaced, experiencing more mental health conditions as a result. Insects will
spread to new territories, bringing infectious diseases with them. Air pollution will
rise, especially as more people move to cities and other urban locations (Watts et al.,
2015, 2016).
28 Research Is Vital to Tackling Climate Change, But It Cannot Succeed Alone 363
People in every part of the world are now coping with increasing challenges.
Those in communities that are already vulnerable will be hit hardest, and in recent
months and years, we have seen that many people are already suffering and dying
from the effects of climate change. That includes severe storms on the southern
coast of the USA as well as saline drinking water on the southern coast of Bangladesh.
It includes islanders dealing with hurricanes and Europeans responding to intense
heat waves (Christidis et al., 2015). The WHO predicts that by 2050 there will be an
extra 250,000 deaths a year due to increases in malnutrition, heat stress, diarrhoeal
diseases and malaria as a direct result of climate change (WHO, 2017).
To save those lives and avoid further risks to our health, we must act now to pro-
tect and sustain the planet. We have to come together to collaborate on devising and
delivering solutions to everyone’s benefit. We have to change our own behaviour
and persuade others to do the same.
Our Planet, Our Health
In 2015, following an earlier exploratory programme, Wellcome launched Our

Planet, Our Health as a priority project, with the aim of developing and supporting
focused research in the growing field of planetary health (Wellcome Trust, 2017b).
The world needs more and higher-quality research, combining different disciplines
and spanning all geographies, in order to understand the effects of global environ-
mental change and the actions we might take in response.
The climate change community has done a remarkable job providing research
evidence to inform policy. But it has perhaps too often presented the impact of cli-
mate change as something that will affect our grandchildren in decades to come. We
want to support and spearhead research to show the impact today of climate change
on human and animal health and through research help provide answers that we
hope will inform policy and behaviour.
Wellcome is by no means the only organisation committed to this area. But we
are in a unique position to make a significant contribution. Our experience as an
international research funder with global networks across science, innovation and
society mean we can bring people together and broker innovative activities.
Our Planet, Our Health has three inter-related pillars. The first pillar is under-
standing the impact of climate change on human health now and in the future. In
partnership with The Lancet, we have set up the Lancet Countdown (Watts et al.
2016) an international research collaboration that tracks global progress on climate
change (Costello et al., 2017; Watts et al., 2016). This is a first step towards lessen-
ing the effects of climate change on health and adapting to its impact.
The second pillar of Our Planet, Our Health is the role of global urbanisation as
a major driver of health. More than half the people in the world now live in urban
areas—by 2050, it will be close to 70% (United Nations Department of Economic
and Social Affairs, 2014). The intersection of social, natural and built environments
364 J. Farrar
in cities brings many benefits but also challenges for human health. We have invested
£17.8 million in research looking at how urban design and policy can work to
improve health and make cities environmentally friendlier.
The third pillar of Our Planet, Our Health is feeding the world healthy diets with-
out destroying the planet. For example, people tend to switch to eating more meat
as they get wealthier, but too much meat consumption is far more damaging than a
plant-based diet for both humans and the environment. Food and land use already
account for more than one-quarter of greenhouse gas emissions and 70% of water
use. We co-founded the EAT Foundation, bringing together scientists, businesses
and policy-makers to transform food systems for the future.
We have funded focused research across all of these areas, generating new knowl-
edge, data and models for understanding current and future effects of environmental
changes (Wellcome Trust, 2017a). Fifteen pilot projects galvanised collaboration
across the globe and across disciplines, from economics and social sciences to epi-
demiology and ecology. To complement these open funding calls, four major themed
programmes were established to nucleate focused centres of excellence and provide
a thriving, supportive environment for research, mentorship, policy and training.
For example, one project explored innovative designs for healthy and sustainable
low-income housing in the UK, India, Mexico and South Africa. Another looked at
the health impacts of poor-quality urban development, from fast-emerging effects
like air pollution and heat waves to slower ones such as changing weather patterns
and the rise of non-communicable diseases.
A recent paper from another group we funded explored the influence of climate
change on infectious disease dynamics (Metcalf et al., 2017). Infections are sensi-
tive to climate change for a variety of reasons—environmental contamination can
expose more people to water-borne diseases, while the survival patterns of insects
and other disease vectors may change, putting different populations at risk (Altizer
et al., 2013). The research led to the conclusion that we need to move beyond simple
statistical correlation and association between environmental factors and disease
and must develop more mechanistic models to predict trends in incidence.
This year, Our Planet, Our Health announced four major new partnerships, all
focusing on providing policy-makers with innovative and interdisciplinary research
evidence. Two are in the area of global food systems, looking at everything from
farm production to consumer choices and testing how changes could be made. The
other two concern urban environments, learning from South America what makes
cities healthy or not and looking at greener ways to provide clean water to informal
settlements in Indonesia and Fiji.
This last partnership is a good example of how researchers and funders will have
to work together if we are to adapt to our changing world. More than a billion peo-
ple live in slums and other informal settlements around the world. They face serious
public health challenges relating to WASH issues. The “big pipes” traditionally
used to provide water and sanitation to cities are extremely costly in financial, envi-
ronmental and social terms and especially impractical in informal settlements.
Revitalising Informal Settlements and their Environments (RISE), a programme
led by Rebekah Brown at Monash University in Melbourne, Australia, is testing eco-
logically sustainable water infrastructure—such as grass channels, wetlands and natu-

ral filters—in 24 locations in Indonesia and Fiji (Monash University, 2017). In addition
to research funding from Wellcome, RISE has received support from the Asian
Development Bank and from partners in government, industry and academia. They
will determine whether these alternative solutions improve environmental and human
health outcomes, such as gastrointestinal infections in children under five. If they do,
the challenge will quickly become one of scaling up the solutions and employing them
elsewhere without delay.
We see this combination of focused centres of excellence and open research
funding calls linked with communication, public engagement, advocacy and policy
and framing this as an equitable, civil rights issue as the best way to ensure research
will be supported in the best environments, open to a diverse range of new ideas and
linked by a commitment to impacting and enhancing all our lives.
Together, Science Can
Our challenge now is to support and encourage more research like this—much
more, and of a consistently high quality such that it can be relied on and used at all
levels of political decision-making. As we look forward, Our Planet, Our Health
must grapple with questions of standards, knowledge sharing, interdisciplinarity
and scale.
How do we achieve standards of excellence so that governments and communi-
ties can trust and apply research findings? How can we share methodologies and
findings so that research can be combined to create a clear and useful picture of the
situation and potential actions? How do we make sure research is fully interdisci-
plinary, in order to get the most complete and accurate view of the situation we
face? How do we accelerate the translation of research findings into policies and
actions that work at scale for communities, cities and countries?
For example, an intervention designed to reduce greenhouse gas emissions that
focused on one area, such as food or transport, could have negative impacts on water
or land use. Joining up our thinking will help create lasting solutions and avoid
shifting potential unintended problems onto other sectors.
This extends across Wellcome’s other priority areas, too. We know that issues
around migration, water use and farming will affect the emergence of drug-resistant
and emerging infections and impact people’s mental health. Our priority area around
research ecosystems in Africa and Asia is ensuring that the necessary skills, evi-
dence and expertise are supported in regions where climate and environmental
change will have the biggest impact. And we must make much more significant
progress in the areas of diversity and inclusion in science and research, given that
these challenges affect everyone, across every continent and all sectors of society.
366 J. Farrar
Wellcome’s Current Platforms

• Diversity and Inclusion
• Drug-Resistant Infections
• Education for Science
• Mental Health
• Our Planet, Our Health
• Research Ecosystems in Africa and Asia
• Vaccines and Epidemics
These are the focused challenges Wellcome is taking on, but we cannot do it alone.
No one can.
We call on researchers to accept the challenge with us—apply your skills to the
most fundamental health challenge of our time.
We call on governments, industry and civic society to support these research-
ers—commit to acknowledging and employing their findings and recommenda-
tions. Through policies and legislation, governments can do what no one else can,
while foundations like Wellcome and others complement their work, taking risks
and doing what governments cannot. Together, we can help industry to play its part,
secure in the knowledge that there is a pipeline of great people and ideas coming
through. But if governments step back from progress in planetary health, the gaps
cannot be filled by anyone else.
And we call on communities to engage with research—participate, shape, even
lead the development and direction of research. Tell us what you need to be studied,
use the results and share your successes. None of the great challenges of our time
will be solved by technology alone. We must break down barriers within science,
barriers between nations, across industries and especially barriers between science
and society. We need the greatest diversity of thought to solve these problems.
The world is changing at an unprecedented rate. Climate and environmental
change, demographic shifts, the rise of non-communicable diseases, emerging and
endemic infectious diseases, and drug-resistant infections, and mental health—
these interconnected challenges are putting our health, and the health of the planet,
at risk.
Solutions to the health effects of climate change will be, on the whole, “no
regret” solutions (Watts et al., 2015). They will improve people’s health no matter
what the climate does. And what is good for us will generally be good for the planet
as well and we can be both pro-growth and pro-planet; they are not mutually exclu-
sive and indeed can be mutually reinforcing. Such hope, optimism and confidence
have too often been missing from political debates that characterise the options as
economic growth versus a sustainable future—it does not have to be so; we can
ensure a sustainable future whilst also ensuring more equitable economic growth.
We do not have to make people poorer to ensure a healthy planet and build a sustain-
able future.
Increasing the resilience of national healthcare systems and strengthening health
infrastructure through the Sustainable Development Goals and Universal Health
Coverage; reducing poverty and offering support to vulnerable communities; main-

taining surveillance of existing and potential health threats and changing cities into
places that support and promote healthy lifestyles; creating sustainable food and
water systems—such actions will improve the health of our generation but also
those of our children, our grandchildren, and all those who will follow.
A commitment to preventing a potential global catastrophe has been made by
196 countries (Costello et al., 2017), and in many places cities have led the way with
empowered local government, responsive to the needs of its citizens to be able to
make locally driven solutions to enhance sustainability and improve health and
well-being. It will be our collective failure if we cannot now use that commitment
and goodwill. Science and research are integral to the world’s combined response,
and science can also help to bring people together. It can be a force for breaking
down barriers, building social cohesion and reducing inequality. If we stand together,
science can help us understand and define the challenges we all face and, together,
solve them.
References
Altizer, S., Ostfeld, R. S., Johnson, P. T., Kutz, S., & Harvell, C. D. (2013). Climate change and
infectious diseases: From evidence to a predictive framework. Science, 341, 514–519.
Christidis, N., Jones, G., & Stott, P. A. (2015). Dramatically increasing chance of extremely hot
summers since the 2003 European heat wave. Nature Climate Change, 5, 46–50.
Costello, A., Gong, P., Montgomery, H., Watts, N., & Wheeler, N. (2017). Christiana Figueres
joins the Lancet countdown—Delivering on the promise of Paris. The Lancet, 389, e16.
Metcalf, C. J. E., Walter, K. S., Wesolowski, A., Buckee, C. O., Shevliakova, E., Tatem, A. J., et al.
(2017). Identifying climate drivers of infectious disease dynamics: Recent advances and chal-
lenges ahead. Proceedings of the Royal Society B, 284.
Monash University. (2017). Monash awarded grant to lead global slum revitalisation research.
Retrieved October 16, 2017, from Monash University website https://www.monash.edu/news/
articles/monash-awarded-grant-to-lead-global-slum-revitalisation-research
Naser, A. M., Martorell, R., KMV, N., & Clasen, T. F. (2017a). First do no harm: The need to
explore potential adverse health implications of drinking rainwater. Environmental Science and
Technology, 51, 5865–5866.
Naser, A. M., Unicomb, L., Doza, S., Ahmed, K. M., Rahman, M., Uddin, M. N., et al. (2017b).
Stepped-wedge cluster-randomised controlled trial to assess the cardiovascular health effects
of a managed aquifer recharge initiative to reduce drinking water salinity in southwest coastal
Bangladesh: Study design and rationale. BMJ Open, 7, e015205.
Siddiqi, Y. (2017). Empty reservoirs, dry rivers, thirsty cities—and our water reserves are running
out. The Guardian..
United Nations Department of Economic and Social Affairs (2014). 2014 revision of the World
Urbanization Prospects. Retrieved October 16, 2017, from UN website http://www.un.org/en/
development/desa/publications/2014-revision-world-urbanization-prospects.html
climate change: Policy responses to protect public health. The Lancet, 386, 1861–1914.
Watts, N., Adger, W. N., Ayeb-Karlsson, S., Bai, Y., Byass, P., Campbell-Lendrum, D., et al.
(2016). The Lancet countdown: Tracking progress on health and climate change. Lancet, 389,
1151–1164.
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Wellcome Trust (2017a). Understanding the links between human health and the environment.
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understanding-links-between-human-health-and-environment
Wellcome Trust (2017b). Our planet, our health: responding to a changing world. Retrieved
October 13, 2017, from Wellcome Trust website https://wellcome.ac.uk/what-we-do/our-work/
our-planet-our-health
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credit to the original author(s) and the source, provide a link to the Creative Commons licence and
Commons licence, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter’s Creative Commons licence and your intended use is not permitted by
Part VIII
Call to Action
CHAPTER 29
Governor of California
Edmund G. Brown Jr.
It is a privilege to participate in one of the crucial steps in the process of making the
turn to a climate-sustainable world, which is to call attention to the catastrophic
health impacts of climate change. Much has been said about California, and that is
appropriate because California, in fact, has been doing quite a lot.
But before I write about that, I want to mention the Pontifical Academy of
Sciences meeting held in November of 2017: Health of People, Health of Planet
and Our Responsibility – Climate Change, Air Pollution and Health. This book on
climate and health resulted from that meeting. It really was all said right there and
very clearly in the document which was prepared in connection with the meeting.
The same is true of the declaration which resulted from that meeting, reproduced in
this book. The declaration, which I signed along with astrophysicist Stephen
Hawking, several mayors, Nobel laureates, and prominent faith leaders, fully cap-
tures the essence of what we are up against and what we need to do.
The Pontifical Academy meeting and this book that resulted from it are uniquely
important. Of course, there are the annual conferences of the parties and many other
meetings around the world dealing with climate change, but until the religious sen-
sibility is engaged, until religious leaders from every part of the globe and from
every denomination take up the challenge, we are not going to move aside the huge
rock of indifference, complacency, and inertia. So I want to pay my respect for
everything that the Pontifical Academy has already put in place, and will put in
place, to further this cause.
The connection of health to climate change is central because climate change is
an abstraction. Very few people can actually grasp it—or certainly be moved by
it—but the air pollution from carbon emissions is visible and affects people directly.
They get that. At the Vatican meeting, people were asking me: Why California? You
might add, why is China getting so aggressive all of a sudden? It is called pollution.
E. G. Brown Jr. (*)

Honorable Former Governor of California, Williams, CA, USA

372 E. G. Brown Jr.
It is the impact. It is the experience of the health effects of very serious air pollution.
California had perhaps the worst air pollution, which was called smog, and this
smog affected people in a very important part of America: Los Angeles, California.
And that smog then led to the creation of the California Air Resources Board during
the governorship of Ronald Reagan and the presidency of Richard Nixon. But it was
the problem that created the solution, and the pollution in Shanghai and Beijing
have created a more heightened and ambitious response on the part of China—dif-
ferent from just a few years ago.
So I believe the authors of this book and the World Health Organization itself are
right on track in focusing on health and disease, on what air pollution is doing to
people. And of course, there is the element of injustice that the people who have
done the least to cause the injury are the ones who suffer the most. It is all laid out
in this book. We know what the world faces, and going forward, we are going to find
the pathway to awaken people, to get done what needs to be done.
So, in the declaration, you lay out four points. First, we have got to get to carbon
zero by 2040 or 2045. That is number one. Secondly, we get there in the most expe-
ditious and efficient way by getting rid of short-lived climate pollutants. We do that
and we will gain a few more years to get to zero carbon. Thirdly, after we get to
zero, which hopefully comes sooner rather than later, then we have to extract a tre-
mendous amount of carbon from the environment itself. So that is an utterly daunt-
ing undertaking, and we are not going to get there with just science and technology.
Tragically, there is no technical fix adequate to the challenge we face. That is why
in the declaration there is a call for transformation, which is both the most important
and the most difficult.
I know about the idea of transformation because I entered the Jesuit seminary in
the world of 1956, pre-Vatican II. We spoke Latin, we were told we had embarked
on the practice of perfection. We meditated, we underwent self-discipline, we morti-
fied ourselves. We tried our best, and I can tell you, I did not achieve perfection. I
was not transformed. In fact, some of my bad habits, which I will not reveal, are the
same today as they were when I entered the Jesuit seminary when Pius XII was
pope. So it is a word that is easy to use but a state that is profoundly difficult to
achieve.
The image that comes to my mind is Saul of Tarsus, riding to Damascus and
being thrown off his horse. A lot of powerful people have to get thrown off their
horse—the horse of affluence, the horse of power, the horse of inertia. So we do
need an illumination. Taking a slightly different metaphor, we could use a 12-step
program because our task cannot be achieved by mere self-will.
There is a power greater than ourselves, and in understanding that, and in orient-
ing ourselves to that greater power, we will find the power to get done what we need
to do. So much of this is technical fixes, but the big fix is really not a fix, it is a
transformation. It is a reorientation, a paradigm shift. That transformation—or the
context of that transformation—is best captured in the words of Pope Francis that
are placed right on the early pages of this document. And I want to quote just these
few words: “Seeing the mysterious network of relations between things.” So it is the
network of things—the connection, the connectivity.
29 Governor of California 373
In connection with the Vatican, I could mention the term “mystical body”—the
Mystical Body of Christ. Everyone is part of the body whatever, wherever, and who-
ever you are. It is a connectivity. The biosphere is connected, there is not a separa-
tion. We can never be separated from, we are always connected to. We are a part and
so our individualistic assumptions that we are going to conquer nature, we are going
to become the greatest power on Earth, become the greatest church, the greatest
university, the greatest politician, that all is a delusional binary framework. In point
of fact, we live in nature, that mysterious network of connections. Our very being is
embedded in and dependent on other beings; the network is the interactions that
sustain life.
We solve one problem yet create another one unless we reach an understanding
about our relationship to nature, to creation. How are we going to do that? Not
merely by “cost–benefit” analysis and not just with “evidence-based.” We do not
want a no-evidence-based approach, we do not want superstition, we do not want
ignorance, but we cannot rely on data and evidence alone.
Ultimately, it gets down to something like belief or faith. In the approach to Zen
practice, three aspects are relevant here: great doubt, great faith, and great
commitment.
If you want to be enlightened, you need great doubt, you need great faith, and
you need great commitment. If we want to get the job done, we have to have great
doubt. Doubt about what we are doing, where we are, to stand back and see clearly.
But that is not enough. We need faith, faith to move forward, faith to take action
based on insufficient evidence. But faith is useless without works, so you have to
have commitment. You have to do things. It is that three-part approach that we have
to have. It is true of all of life, but it is profoundly true with respect to the challenge
before us. We first have to see what it is—and it is not a technical fix. It’s a transfor-
mation of the relationship of human beings to all the mysterious network of things.
But let me say something concretely, because it is not only this larger idea of our
place in the world and in creation, but also concrete steps. In California, we have
done seven things that are replicable and could be used throughout the world.
First, we have a clear commitment to promoting zero-emission vehicles. We have
a commitment not only to zero-emission vehicles but also to reducing the emissions
of fossil fuel cars. In that respect, the car companies and the federal government are
all increasing the pressure on California to change the regime that we have and the
standards that are now in place. But we will resist that, politically and in the courts.
As part of the transportation challenge, we also have to deal with land use and
how people live together, and, in fact, our whole relationship to things, to packag-
ing, to moving stuff around. All that is tied in.
I was in Vladivostok recently for an East Asian economic conference, and we
heard speeches by the presidents of Russia, Mongolia, and South Korea and the
prime minister of Japan, and they talked about trade and building pipelines and
bridges and all sorts of things, but not one word was mentioned about climate
change. Yet to talk of trade and not talk about the carbon impacts misses a funda-
mental point. It indicates to me that in the highest circles, people still do not get it.
At least they do not get it at the level that we have to get it if we are really to get to
374 E. G. Brown Jr.
carbon neutrality and stabilize our climate. So it is not just a light rinse, but we need
a total, I might say brainwashing. We need to wash our brains out and see a very
different kind of world.
The second thing we have in California is energy efficiency, including building
and appliance standards. We are doing that, we have the strictest rules in the United
States—I would say probably in the Western hemisphere. That can be done, it is just
making better buildings. There is a problem, of course; it costs money, it is compli-
cated. Our building code, which was relatively short in length, is now very, very
long. So it is not a free good here. Everything we do has a price and requires a tre-
mendous overcoming of inertia.
Third, we have a low-carbon fuel standard. It is what the oil companies have
defeated in the state of Washington. They fight it here in California as well. So far,
we have it. But this is real combat, and to maintain any real standard that bites
means you are going to have fierce opposition.
Fourth, we have our cap-and-trade program that was recently extended to 2030.
This program, begun under Governor Schwarzenegger, puts a price on carbon and
generates billions of dollars for climate-related investments.
Fifth, we have a renewable portfolio standard. We are now about 30% renewable
electricity, not counting hydro or nuclear. The San Diego electric utility is over 40%
renewable electricity. I can remember just a few years ago the private utilities—and
the public ones as well—said they could not get to 20% renewable electricity by
2020. Soon they are going to be at 50%, so we are making it. And by the way, the
utilities, from being major opponents of what I am talking about, are now major
cheerleaders, and they are very much engaged in expanding the electrification of the
California economy. In fact, there is now competition between renewable electricity
and oil, between the conventional vehicle and the zero-emission vehicle. The role of
utilities, charging stations, and other businesses makes it all possible.
Sixth, we are cutting short-term pollutants such as methane, black carbon, and
chlorofluorocarbons, which will see more rapid reductions in the warming over the
next 20–30 years. If the whole world follows California’s super pollutants bill
(SB1383), the rate of warming over the next 25 years can be cut by half.
Seventh, California and Baden-Württemberg have started the Under2 Coalition
to keep global warming under 2 °C. That initial partnership has now grown to over
200 states and regions throughout the world.
America itself is very much in line with the Paris goals—the American people
are, as are cities, corporations, nonprofits, and universities. The American people
are more than their government. I can tell you that the majority of Americans are
very much in support of serious climate action, following the Paris accords.
The federal government put out a report in November 2017, a report mandated
by federal law, that laid out very clearly the human causation behind global warm-
ing and all the dangers. In the United States we do not have just a top-down struc-
ture. There are many elements in our federal system. We are a “country of laws, not
men,” as stated by U.S. President Adams, and we have states, we have cities, we
have a very vibrant private sector, we have a vibrant civil society.
29 Governor of California 375
In many respects, if you try to measure President Trump’s contribution, I would

have to say that his attempted withdrawal from Paris has actually put the matter
much more at the forefront. It is now more salient, because of the contrast between
what he is saying, what the laws of America allow, and what other states are doing.
So I would say over time, given the commitments that we saw at the 2017 Vatican
meeting and that we are seeing all around the world, the Trump factor is very small,
very small indeed.
But that is nothing to cheer about because if it was only Trump that was our
problem, we would have it solved. But that is not the only problem. The problem is
us, it is our whole way of life, it is our comfort, it is the greed, it is the indulgence,
it is the very pattern of modern civilization. It is the inertia. And that is why the
transformative solutions have to be present alongside, and informing, all the techni-
cal points and the political agreements that we make.
Let me conclude by saying that there is nothing more important than mobilizing
the religious and theological spirit, but even more important than that is the pro-
phetic spirit. It was not a pope who did the work of St. Francis. I recall being at the
Vatican when Mother Teresa opened up one of her homes, right in the Vatican, and
all the important people, the Italian politicians were there in the Piazza and the pope
walked by, and no one paid much attention. Then this little woman in blue and white
walked by, and all eyes turned to Mother Teresa.
So the power here is prophecy, the power here is faith, and that is what the
Pontifical Academy is supposed to be about. So let us be about it—the technical, the
scientific, the political—but never let us forget that our challenge is transformation,
transformation in the profoundest way possible.
The images or other third-party material in this chapter are included in the chapter’s Creative
CHAPTER 30
United States Congressman
Scott Peters
I will discuss the imperative of addressing the world climate from my perspective as
a member of the United States Congress.
You are familiar with the warnings of scientists, including my friend Dr.
Ramanathan of Scripps Institution of Oceanography in San Diego, California,
which I represent. I need not add to those insights. Instead, I will offer observations
on how Washington, DC is dealing with climate change and ways in which I think
we can do better.
Climate action used to be bipartisan. In his 2008 campaign for president,
Republican Senator John McCain ran advertisements in which he “sounded the
alarm on global warming” and said his credentials on climate were stronger than
those of his opponent, Barack Obama (“How G.O.P. Leaders Came to View Climate
Change as Fake Science,” New York Times, June 3, 2017).
Soon after that election, however, there began a well-funded campaign to change
this. Many conservative groups, including one called the Cooler Heads Coalition,
have waged campaigns to cast doubt on climate science and to intimidate Republican
candidates from supporting climate action. According to reports, the Cooler Heads
Coalition has received more than $11 million in donations from oil and gas compa-
nies and from foundations controlled by wealthy families, including the Kochs
(“A two-decade crusade by conservative charities fueled Trump’s exit from Paris
climate accord,” The Washington Post, September 5, 2017). The television advertis-
Scott Peters represents California’s 52nd Congressional District, including the cities of Poway,
Coronado and most of San Diego. He is a member of the House Energy and Commerce Committee,
and is a former environmental attorney, San Diego City Council President and Port Commission
Chairman.
S. Peters (*)
La Jolla, CA, USA

378 S. Peters
ing, social media campaigns, and political events across the country raised doubts in
the minds of voters and fear in the hearts of politicians. For representatives of coal
regions, it became easier to accept alternative facts than it was to accept a climate
action policy that would phase out carbon emissions.
About 74,000 Americans work in the production and distribution of coal, and more
than 812,000 work in oil and gas (U.S. Department of Energy, 2017, see Table 1, p.
29). (To be fair, that workforce barely exists in California.) If you visit Midland,
Texas, as I did, you see an entire community and culture invested in and proud of their
oil and gas production. For them, many climate action policies mean rethinking the
economic system that has supported them, their families, and their town for decades.
In 2008, anti-climate-change groups began asking Republicans to sign a “No
Climate Tax” pledge (Mayer, 2013). In 2009, cap-and-trade legislation died in
Congress. The climate denial lobby went after Democrats who had voted for cap
and trade, and then they took on Republicans who were sympathetic to green energy
or climate action.
Today, according to Republican strategist Whit Ayres, “most Republicans still do
not regard climate change as a hoax. But the entire climate change debate has now
been caught up in the broader polarization of American politics. A denial of the
human contribution to climate change has become yet another litmus test issue that
determines whether you’re “a good Republican” (Mayer, 2013).
When I have a beer with my Republican colleagues, they will generally acknowl-
edge that they are aware of climate change and that human activities are driving that
change. But they fear losing their elections.
Yet their voters are not necessarily climate deniers. In a study conducted by the
Yale Program on Climate Change Communication, about 70% of Republicans think
that climate change is happening and 53% think it is caused by human activity
(“How G.O.P. Leaders Came to View Climate Change as Fake Science,” New York
Times, June 3, 2017).
So why does America not elect more Republicans who are as open-minded as
their Republican voters on climate? Let me illustrate how moderation is penalized
by the American electoral process in most places.
In most American Congressional districts, there is no competition between
Republicans and Democrats. At least 350 seats are so-called safe seats, where vot-
ers will only elect a Democrat, as in San Francisco, New York, or Boston, for
instance, or a Republican, as in most of Texas or Alabama or Kansas. In a safe
Republican district, there is no chance that a Democrat will ever win the seat. Thus,
the real contest is over which Republican will win the Republican Party election
and make the run-off against the Democrat, who will certainly lose. This has led to
a race to the right—on guns, taxes, the environment, and even science—so that only
the most right-wing Republicans can get elected from these safe Republican seats.
In this safe seat competition, moderate stances on climate hurt a Republican’s
chances.
The remaining few congressional districts are known as swing districts, where
the number of Republican and Democratic voters is relatively even, and the seat can
30 United States Congressman 379
“swing” from Republican to Democrat from election to election. These competitive

general elections, between a Democrat and a Republican, can cost tens of millions
of dollars. This money comes from private donations and from outside spending by
political action groups. I represent a competitive swing district; as an example, my
own 2014 reelection was the fifth most expensive race that year. My campaign
raised $4 million from private donors, as did my opponent’s. Outside groups spent
about $4 million trying to reelect me, and other groups spent about $4 million trying
to defeat me. All told, $16 million was spent on television ads, mail pieces, and staff
salaries for one 2-year term in one of 435 Congressional seats. My friend Brad
Schneider was defeated that year in suburban Chicago, in a race that cost over $23
million in all.
In competitive races, candidates need both to energize their base voters and to
raise money. For Republicans, the base voters are usually the most conservative.
Often, the donors who want to support Republican candidates are similarly conser-
vative. In a swing race, a moderate stance by a Republican on climate may limit the
ability to raise campaign money.
So there is a lot of pressure on Republican office holders—who must fend off
other Republican challengers—not to stray from the most conservative positions. A
case in point recently was Representative Eric Cantor, the number 2 Republican in
Congress, who offered a mildly conciliatory position on immigration. He was
defeated by a more rabidly anti-immigrant Republican in central Virginia’s 7th
Congressional District. Every Republican Congress member took note, and most of
them took cover.
Thus, despite the overwhelming science and public interest, the road to climate
action for a Republican office holder is a precarious one.
Washington Republicans are finally acknowledging that climate is changing.
Water is rising from the ground in Florida; hurricane after hurricane is bashing
Texas, and the deep red Republican South. When Miami streets are wet on sunny
days and when “500-year storms” are happening every 3 years, people take notice.
As of October 2017, 60 members of the House of Representatives have joined a
bipartisan Climate Solutions Caucus, with an equal number of Democrats and
Republicans, “to educate members on economically-viable options to reduce cli-
mate risk and to explore bipartisan policy options that address the impacts, causes,
and challenges of our changing climate” (Derby, 2017). Secretary of Defense James
Mattis continues to warn that climate can be a driver of instability. That is why in
this year’s defense spending bill, adopted by a vote of 344–81, the House of
Representatives declared that climate change is a “direct threat to national security.”
The bill also calls for a report on how climate change affects the military, including
identifying the 10 bases most susceptible to flooding from sea level rise
(Lardner, 2017).
Last month, Energy Secretary Rick Perry (who is from oil-producing Texas) tes-
tified to my Energy Subcommittee of the Energy and Commerce Committee and
asserted that there was insufficient evidence to support the case that humans were
the cause of climate change. However, he did state that he agrees the climate is
warming. That is a start.
380 S. Peters
These events together at least offer some hope that the USA can agree on some
steps toward climate adaptation. If we acknowledge that seas are rising, tempera-
tures are warming, storms are more frequent and violent, and fires are happening
more often and are brutal, we at least agree on a common set of facts that can help
us prepare. We may consider new building standards that defend better against flood
or fire or zoning laws that will keep buildings from expanding flood zones. Our
Navy can adjust its strategy to reflect melting ice. We can reform government flood
and fire insurance programs to incentivize investments in resiliency and discourage
bad decisions.
It is great that the effects of climate change are sinking in. However, the refusal
by Secretary Perry, the administration, and the vast majority of elected Republicans
to acknowledge the basic scientific consensus that this change is human-driven
remains an obstacle to the steps we need to take now.
What voices can move America to act on climate—not just to gird ourselves as
the planet dies—but move us to save the planet?
ho Are the Trusted Voices That Can Turn the American

W
Public and Our Government to Action?
First, Scientists
Americans rely on science every day, whether they are taking medications pre-
scribed by a doctor or following a recipe for baking a cake. It must be discouraging
for scientists to encounter the current irrationality, but rigorous climate science is
still the most important input for our policymakers.
Second, Our State and Local Governments
They continue to demonstrate to Washington, DC, that the choice between a pros-
perous economy and a healthy environment is a false choice. More likely, we cannot
have one without the other.
Third, the United States Armed Forces
While the United States military may be affected by domestic politics, it remains on
mission. We are fortunate to have military leaders who are patriotic, brilliant, and
honorable. It is within the Department of Defense where climate policy has been the
least politicized and where our federal government has made the most progress.
In fact, the 2014 Quadrennial Defense Review identified climate change as a

significant security risk:
As greenhouse gas emissions increase, sea levels are rising, average global temperatures are
increasing and severe weather patterns are accelerating. Climate change may exacerbate
water scarcity and lead to sharp increases in food costs. The pressures caused by climate
change will influence resource competition while placing additional burdens on economies,
societies, and governance institutions around the world. These effects are threat multipliers
that will aggravate stressors abroad such as poverty, environmental degradation, political
instability, and social tensions – conditions that can enable terrorist activity and other forms
of violence (Department of Defense, 2014, Chapter 1, Future Security Environment, p. 8).
The Department of Defense is one of the largest fossil-fuel users on earth, and
the United States Navy has always been an innovator in energy—from sails to coal,
from coal to oil, to nuclear, and now to alternative energy. In 2009, Navy Secretary
Ray Mabus set a goal that by 2020, 50% of Navy energy consumption would come
from alternative sources, and 50% of Navy and Marine Corps installations would be
net zero. Since then, the Navy has launched the “Great Green Fleet,” powered in
part by advanced biofuels derived from beef fat, purchased at a competitive price
even when oil prices were low. And they have secured contracts for 1.1 GW of
renewable energy. And, in partnership with the State of California, the Navy
acquired 400 electric vehicles for its bases in California.
Even changing to LED light bulbs is saving the Navy 20,000 gallons of fuel per
year in its destroyers, with longer lives, better light, and reduced maintenance costs.
Of course, as Secretary Mabus himself said, “The goals I set were not about mak-
ing us ‘greener,’ though that is an added benefit – they were and remain about
making us better warfighters. Optimizing our energy use is a force multiplier,
increasing our capabilities, our impact and our endurance across platforms and
disciplines.”1
Fourth, American Businesses
Business is not waiting for Congress to say it is okay to compete in the renewable
economy. For instance, now that China has called for one out of every five cars sold
there to run on alternative fuel within 8 years (“China Hastens a Global Move to
Electric Cars,” New York Times, October 10, 2017), every worldwide automaker will
have to compete in that space. American politicians will see that it is not just Tesla,
but all US carmakers, and all their voting employees, who are part of the climate
revolution.
Shareholders in American companies are themselves demanding climate respon-
siveness. This May, ExxonMobil shareholders, with a vote of 62% of its shares,
1
“Biofuel blend powers Navy’s Great Green Fleet deployment,” Governors’ Biofuels Coalition,
January 21, 2016.
382 S. Peters
instructed the company to analyze and report on how the company would respond
to global efforts to achieve the 2 °C target (“Financial firms lead shareholder rebel-
lion against ExxonMobil climate change policies,” Washington Post, May 31, 2017).
The two largest shareholders in ExxonMobil are BlackRock and Vanguard, major
Wall Street investment firms.
Fifth, Respected Republicans
Republican leaders who are no longer in office are important advocates for climate
action. This year, the Climate Leadership Council (www.clcouncil.org) called for a
tax on carbon, labeling it the “Conservative Case for Carbon Dividends.” The plan
would impose a gradually increasing tax on carbon, fully refunded to American
taxpayers, combined with the repeal of regulations like the Clean Power Plan that
would be redundant and less efficient at encouraging renewables than the carbon tax
itself. The proposal is not novel, but the identity of its authors is. The council is led
by James A. Baker III, George P. Schultz, Henry M. Paulson, Martin Feldstein, all
former members of the Reagan and Bush administrations, and respected conserva-
tive economists and businessmen.2
Former US Representative Bob Inglis has formed RepublicEn.org, an effort to
educate the country about free-enterprise solutions to climate change. His EnCourage
Tour 2017, a series of town hall style meetings across the country, engaged voters
across America in discussions of the “conservative case” for climate action.
Sixth, the News Media
A free press is a foundation of American democracy, and we need its help on

climate. Our news media must be more honest about the severity of the climate
crisis and the real facts. The media seems more concerned about being “balanced”
than being accurate. This has led to needless confusion about the validity of
undisputed science. And our media tend to focus on the issues, tweets, and scan-
dals of today to the detriment of the long-term challenges, even existential threats
like climate change.
2

The Climate Leadership Council is sponsored by formidable businesses, including BP,
ExxonMobil, General Motors, Johnson & Johnson, Procter & Gamble, PepsiCo, Santander,
Schneider Electric, Shell, Total, and Unilever.
Finally, The Church
The church can show the moral imperative of action on climate. The Vatican’s lead-
ership is critical as we try to change minds and turn hearts in the USA. It is even
more significant as we try to influence policy in the United States Congress.
Here’s why:
According to the Pew Research Center, while the number of adults in the USA
“who describe themselves as Christian has been declining for decades, the
U.S. Congress is as Christian today as it was in the early 1960s.” Ninety-one percent
of the Congress identifies as Christian, and one-third of the Christians in Congress
identify as Catholic. And while the number of Christians in Congress has been vir-
tually unchanged in the past 50 years, the number of Catholics in Congress has
increased dramatically—from 19 to 31%.3
So nearly one-third of Congress has a direct connection to this church, which is
why Pope Francis’s commitment to making environmental stewardship a priority of
his papacy has such potential to affect US climate policy.
Something else is happening, too. Evangelical Christians, who typically align
with conservative Republicans, are weighing in on the need for climate action. If we
understand the impact these voters have on the American electorate, we see that this
is potentially transformative. As Rev. Mitch Hescox explains in his companion
chapter:
The religious landscape is changing in the United States. Today, only 43% of Americans
identify as white and Christian compared to 81% in 1976. Yet even amid these shifting
demographics, white evangelicals still comprise 35% of the Republican party (Cox and
Jones, 2017). Together, evangelicals and Catholics represent approximately 28% of the
American populace, yet they consistently vote in disproportionately high numbers.
Over 80% of white evangelicals voted for Mr. Trump in 2016, representing 28% of
actual voters. More broadly, the last three United States Presidential elections saw pro-
life voters average 45% of the electorate (evangelicals, 26%, Catholics, 19%) and for
many of these voters, their anti-abortion (pro-life) stance overrode all other electoral
considerations.
Like this pope, who is named for the saint from Assisi who considered all living
things his brothers and sisters, many leading evangelical Christians are taking up the
cause of climate because they, too, believe we have a moral imperative to save the
planet given to us by God and to preserve His creation for our children.
I want to thank the Vatican and Pope Francis for your moral clarity and commit-
ment to climate action and for including me in this historic event. I am very grateful
to have been selected to represent the United States Congress in this book.
Pew Research Center. Jan. 3, 2017, “Faith on the Hill”.

3
384 S. Peters
References
Cox, D., & Jones, R. P. (2017). America’s changing religious identity. Washington, DC: Public
Religion Research Institute. Retrieved on February 16, 2020 from https://www.prri.org/
research/american-religious-landscape-christian-religiously-unaffiliated/
Department of Defense (2014). Quadrennial Defense Review 2014. Retrieved February 16,
2020 from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=
0ahUKEwiQ0OeXwfXWAhWIQiYKHULD1oQFggmMAA&url=http%3A%2F%2Farchive.
defense.gov%2Fpubs%2F2014_Quadrennial_Defense_Review.pdf&usg=AOvVaw1b7Pyfby1
OhUA3KggNaQwk
Derby, K. (2017, September 26). Stephanie Murphy Joins Carlos Curbelo’s, Ted Deutch’s climate
solutions caucus. Retrieved on February 16, 2020 from http://sunshinestatenews.com/story/
stephanie-murphy-joins-climate-solutions-caucus-group-nears-60-members
Mayer, J. (2013, June 30). Koch pledge tied to congressional climate inaction. The New
Yorker. Retrieved on February 16, 2020 from https://www.newyorker.com/news/news-desk/
koch-pledge-tied-to-congressional-climate-inaction
Lardner, R. (2017, July 14) Defense bill calls climate change a national security threat. Associated
Press. Retrieved October 16, 2017 from https://apnews.com/c119aa0ef87446108ab-
d2aa637e91b7f/Defense-bill-calls-climate-change-a-national-security-threat
U.S. Department of Energy (2017). 2017 U.S. Energy and Employment Report. Retrieved on
February 16, 2020 from https://energy.gov/downloads/2017-us-energy-and-employment-
report
CHAPTER 31
Challenges and Opportunities
for a Sustainable Planet
Yuan T. Lee
Summary We know that population and consumption are the two primary drivers
of dangerous environmental changes. And we already possess the technologies and
capabilities required to address them. It is well past time for us to translate that into
determined global action. Politically, we must shift from a nation-based approach to
one of true global solutions. Socially, we must realize that the world is already over-
developed and that averting crisis means reducing unsustainable consumption as
well as improving the lives of the poor. Technologically, as we pursue innovations
that will take us back to sunshine as the dominant source of energy, we must also
develop ways of sharing and distributing renewable energy across borders. It is not
too late for us to turn things around, but we do not have much time left.
Introduction
Some years ago, on a long-haul flight, I struck up a conversation with the business-
woman sitting next to me. She was interested in my work on climate change and
sustainability, so I explained to her that it really came down to population and
consumption.
I said that between 1900 and 2000, the number of people in the world grew by four
times, while the amount that each person consumed doubled. This meant, of course,
that human consumption overall grew eightfold within a century.
This is dangerous on a planet of finite space and resources, I explained. The
Earth might seem rather big to us, but humans really only inhabit a thin layer of it,
like the skin of an apple. And our voracious appetite for resources and our dumping
of waste has already put a tremendous burden on this thin layer.
Y. T. Lee (*)
Institute of Atomic and Molecular Sciences, Academia Sinica, Taipei City, Taiwan

386 Y. T. Lee
Two Forms of Pollution
Today, this burden is manifested in two forms of pollution. One is visible: the air
pollution that is literally choking our cities and killing people.
The Lancet Commission on Pollution and Health just released its landmark eport,
which concluded that, despite being a neglected topic for decades, “pollution is the
largest environmental cause of disease and death in the world today, responsible for
an estimated 9 million premature deaths.” The report found air pollution to be the
deadliest of them all, having caused 6.5 million premature deaths in 2015. In my
native Taiwan, it is estimated that over 9% of deaths can be attributed to air pollution.
The second form of pollution is less visible but no less dangerous: greenhouse
gases that have contributed to an energy imbalance in the Earth system. More energy
is coming in than going out. We have heard the incredible numbers from the likes of
former US Vice President Al Gore—that the heat being trapped by greenhouse gases
is equal to 400,000 Hiroshima-class atomic bombs going off every single day and is
driving dangerous environmental changes.
An Unsustainable Trajectory
At the root of both forms of pollution is the rising number of people in the world and
the rising amount of resources they are consuming. And this is by no means a new
insight. In 1994, 58 academies of sciences from around the world had already pub-
lished a statement pointing out that “If current predictions of population growth
prove accurate and patterns of human activity on the planet remain unchanged, sci-
ence and technology may not be able to prevent irreversible degradation of the natu-
ral environment and continued poverty for much of the world.”
The trajectory we are on will take us past 9.5 billion people globally by 2050,
over 470 ppm in atmospheric CO2 concentration, and a ruinous level of consump-
tion. The potential impacts have been well covered, including by the participants of
this important book: mass coral reef and forest die-off, extinction of a substantial
fraction of the species on Earth, ever more frequent and extreme weather events,
sea-level rise, a sharp decline in food production, and so forth.
What Are We Doing About It?
As you might imagine, my conversation with that businesswoman on the plane was
not the most cheerful. But she continued anyway. She asked me: “So, if it really
comes down to population and consumption, then that must be what your organiza-
tion is working on right?”
I thought for a moment, and I said, “No.”
31 Challenges and Opportunities for a Sustainable Planet 387
I was the president of the International Council for Science (ICSU), and we were
doing a lot of important work, but we were not working directly on population and
consumption.
She had a point. We already know what the key drivers of environmental change
and unsustainable development are. We already possess technologies and capabili-
ties to begin addressing them. But taken together, all of our efforts across the world
are still insufficient to make our development sustainable. Collectively, all of the
intended nationally determined contributions would still be insufficient for us to
avert the climate crisis.
So how do we do better? I would like to offer five points for consideration.
Global Responses for Global Problems
First, climate change has regional and local manifestations, but at its heart it is a
global problem, and it requires global solutions. The intended nationally determined
contributions (INDC) are a prime example of this. Each country has determined for
itself the level of its contribution to cutting emissions, based on factors like its
domestic economic goals and politics. But it is ultimately the global-level result that
will matter. If all the nationally determined efforts succeeded in taking us to 2.5 °C,
we would still be in deep trouble. So our solutions must be global.
Another example is in energy. Getting to 100% renewable energy is quite a dif-
ferent challenge depending on where you live. In California, the population density
is about 90 people per square kilometer, while in my native Taiwan, we have over
650 people per square kilometer. That is a whole lot of energy demand and not much
land to deploy renewable energy supplies. And Taiwan is hardly alone in this regard.
Left to their own devices, densely populated places will have a hard time getting
to a fully renewable future. So it would be wise for us to develop a cross-border
system for trading renewable energy.
Back to Nature, Back to Sunshine
Second, whatever solutions we devise, they must take us back to nature and back to
sunshine. Our societies and governments are used to putting the economy at the
center of our decision-making. Even when sustainable development is on the agenda
at the UN, and people talk about the economic, the social, and the environmental,
everyone knows that the economy sits at the top. The first five sustainable develop-
ment goals are clearly economic and social.
But all this must change. We must come around to the realization that without the
environment, there would be neither society nor economy. We must put the
environment at the center of our decision-making. This will require a deep decarbon-
ization of our societies and economies by, for instance, establishing a carbon tax or fee.
388 Y. T. Lee
And we have to go back to sunshine. Instead of digging down for more fossil-
based energy, we must now reach up for solar energy. It is the most powerful fuel
source we have. One hour of sunlight on Earth can meet one year of global energy
needs! We must restore the direct relationship between people and the sun.
Live Better for Less
The third point is that while we need to improve the lives of billions of people, we
can do so in a way that uses far fewer resources than the rich countries are using
today. For instance, we can design our systems to be radically efficient in their use
of resources. We can design our buildings to be net producers of water and energy.
And we can design our neighborhoods so that all of our daily needs are easily met
by walking or short public transit rides.
Innovators have proven again and again that human life can be improved by
using fewer resources, not more.
Control the Population Explosion
Fourth, we need to reduce the explosive growth in human numbers. This has been a
rather unpopular and neglected topic in sustainability discussions. Whenever we
make projections for the coming decades, we almost take it as a given that global
population will shoot past 9.5 billion and even 10 billion by 2050. And we calculate
resource needs based on that. But is this really inevitable? Is it really fate? I would
be inclined to say no.
We can bring human numbers to a more sustainable level by, for instance,
improving the economic conditions of the poor and needy around the world. Some
people argue that we should worry about consumption rather than population, but
that is a false dichotomy. Humans are collectively having such an enormous impact
on the environment that we must work on both population and consumption.
Improve Inequality Around the World
Fifth and finally, reducing inequality is a priority, but there are different ways of
going about it. When we look at the discussions around sustainable development
and the Sustainable Development Goals, the idea seems to be that we should reduce
inequality by pulling the poor’s living standards up to those of the rich.
But what would that do to the environment? And while we are busy getting the
poor up to a higher level of consumption and income, the rich are getting richer still.
31 Challenges and Opportunities for a Sustainable Planet 389
What about curtailing the unsustainable consumption of wealthy societies? If we

wish to avert environmental catastrophe, then as we reduce inequality and improve
the living standards of the poor, we must also curtail the unsustainable consumption
of wealthy societies. That would be the proper way to reduce global inequality.
CHAPTER 32
Sustainable Development Goals
and Health: Toward a Revolution in Values
Jeffrey D. Sachs
All of this shows the urgent need for us to move forward in a bold cultural revolution.
Science and technology are not neutral; from the beginning to the end of a process, various
intentions and possibilities are in play and can take on distinct shapes. Nobody is suggesting
a return to the Stone Age, but we do need to slow down and look at reality in a different way,
to appropriate the positive and sustainable progress which has been made, but also to recover
the values and the great goals swept away by our unrestrained delusions of grandeur.
Pope Francis, Laudato Si’, 114
Pope Francis calls for a revolution in governance, to manage technologies for the
common good. In my mind, this brings us back to politics in the tradition of Aristotle
rather than the tradition of Machiavelli. For Aristotle, politics is about wellbeing
(eudaimonia) of the polis, the political community. For Machiavelli, politics is
about the struggle for power, little more. It should be clear that we are today living
in Machiavelli’s political world, not in Aristotle’s.
To return to Aristotle’s politics, we need a shared conception of the common
good based on human nature. It seems to me that our great moral traditions, and in
particular the Church’s social teachings, offer us deep guidance. We should give
priority to the poor; defend human dignity; promote the cardinal virtues of justice,
fortitude, prudence, and practical wisdom; and dismantle the structures of sin,
including pervasive corporate cheating, corporate lobbying, corporate campaign
financing, and tax havens that facilitate global corporate and personal tax evasion of
the rich on an unfathomable scale.
The 17 Sustainable Development Goals (SDGs), shown in Fig. 32.1, were
adopted by all 193 UN member states in September 2015 to cover the period
2016–2030. The SDGs provide the best opportunity for a new cooperative global
politics oriented around the common good. The SDGs aim for economies that are
prosperous, socially inclusive, and environmentally sustainable. In the jargon of the
J. D. Sachs (*)
Columbia University and Director of the UN Sustainable Development Solutions Network,
Columbia University, New York, NY, USA

392 J. D. Sachs
Fig. 32.1 The 17 sustainable development goals
UN, the SDGs should “leave no one behind,” including future generations and
indeed other species and Earth itself.
There are two intersecting themes to consider. The first theme is that we must
move to a clean energy system, one that stops the emission of greenhouse gases
and cleans the air for human health. The energy goals are covered by SDGs 7 and
13. The goals on human health are covered by SDG 3 (healthy lives for all at
all ages).
The second theme is that we must move to a sustainable food system, one that
promotes healthy diets for all while eliminating the massive environmental destruc-
tion caused by current farming practices. These food-sector objectives are covered
especially by SDG 2 (sustainable agriculture), SDG 14 (sustainable marine ecosys-
tems), and SDG 15 (sustainable terrestrial ecosystems). Again, one priority is that
healthy diets reduce disease and premature mortality, especially by combatting the
worldwide obesity and metabolic disease epidemics caused by “fast food.” Both for
energy and food, the biggest challenge we face is the structures of sin, namely, the
power of corporate food and agricultural giants whose greed and irresponsibility
undermine the common good.
When it comes to energy, the challenge is rather easily expressed. The world
should decarbonize the global energy system by 2050 in order to achieve the Paris
Climate Agreement goal of keeping global warming below 1.5 °C. This means, at
the core, a shift from fossil fuels (coal, oil, and natural gas) to renewable energy,
especially wind, solar, hydro, and geothermal energy. This shift is feasible and even
economical if carried out rigorously and expeditiously over the period to 2050.
In a nutshell, all electricity should be produced by zero-carbon energy. All trans-
port should be electrified (as with light-duty vehicles) or should transition to using
synthetic fuels produced by zero-carbon electricity. Such fuels include hydrogen
and synthetic liquid hydrocarbons. All buildings should be electrified for heating
and cooking. All heavy industry should find alternatives to carbon emissions.
Technological solutions exist or are within reach in each case.
32 Sustainable Development Goals and Health: Toward a Revolution in Values 393
These energy shifts will have two benefits: saving the climate and cleaning the
air. Zero-carbon energy sources will reduce PM2.5 aerosols and other environmental
pollutants, and the co-benefits of health are an enormously important reason to
accelerate the shift to clean energy. India, for example, currently loses more than a
year of life expectancy from massive air pollution, and in some states, more than
2 years of life expectancy.
Despite the urgent need for rapid decarbonization of energy, the process contin-
ues to be blocked by the corporate greed of companies such as ExxonMobil,
Chevron, Gazprom, BHP, and the like. These companies will cause massive detri-
ment to populations vulnerable to air pollution unless they are decisively brought
under regulation, yet in the United States, Australia, Canada, Russia, and other
countries, the oil industry rather than the common good directs politics. We are in
the political world of Machiavelli rather than Aristotle.
The same tendency is clear in the food sector. Current global agricultural prac-
tices are wholly inadequate, indeed in crisis, for three reasons. First, the agricultural
sector is a huge contributor to environmental catastrophe: deforestation, eutrophica-
tion, chemical pollutants, massive greenhouse gas emissions, invasive species, and
others. Second, the agriculture sector is undermining its own long-term viability by
destroying the land and soil and increasing its own vulnerability to climate change.
Third, the diet produced by today’s food industry is disastrous, especially through
the spread of obesity and food addictions caused by sugar additives, saturated fats,
and heavy food processing.
Once again, the solutions are rather easily described. We need to move from heavy
beef consumption to diets that are based far more on plant proteins, notably nuts,
legumes, and fruits. We need to enforce strong land-use regulations that protect biodi-
versity and stop the conversion of forests and grasslands into new pasturelands for beef.
As with energy, these changes are scientifically sound, morally correct, and tech-
nologically feasible, yet they are being stalled or slowed by the likes of Coca Cola,
PepsiCo, McDonald’s, Kentucky Fried Chicken, Kraft Heinz, and other food giants.
These companies are massive lobbyists and major campaign contributors in the
United States. They are part of the structures of sin, since they carry on with their
destructive products even when the evidence is overwhelming that they are the cre-
ators of the global obesity epidemic and much else that is wrong with the world’s diets.
What, then, will be the path of the bold cultural revolution called for by Pope
Francis? It will have the following steps:
1 . Putting the common good and human dignity in the highest purpose of politics;
2. Choosing the preferential option for the poor;
3. Adopting the SDGs and the Paris Climate Agreement as guiding principles for
the world’s governments and businesses;
4. Preparing plans to achieve the SDGs and the Paris Climate Agreement based on
the best scientific information and in processes marked by transparency, justice,
and public inclusion;
5. Adopting SDG and climate indicators to ensure accountability of governments
and businesses;
6. Dismantling the structures of sin that have placed corporate greed above the
common good.
394 J. D. Sachs
CHAPTER 33
A Call to Action by Health Professionals
Edward Maibach, Mona Sarfaty, Rob Gould, Nitin Damle,

and Fiona Armstrong
Summary We contend that the goal of the Paris Climate Agreement—limiting

global warming to no more than 2 °C (and if possible 1.5°C)—is the world’s most
important public health goal. Failure to achieve the goal will lead to a sustained
public health disaster, worldwide, lasting many generations. While the leaders of
most nations have committed to the goal, with few exceptions, their actions thus far
have been grossly insufficient to achieve it. In this chapter, we argue that the world’s
health professionals—doctors, nurses, midwives, and other allied health profession-
als—are uniquely suited to lead the effort to persuade the world’s leaders to increase
their commitments to the goal of the Paris Agreement and to rapidly initiate the
actions necessary to fulfill their commitments.
If not us (health professionals), who? If not now, when? We are among the most
trusted members of every society worldwide. We speak with not just scientific but
also ethical and moral authority. We have—or can get—the attention of our nation’s
leaders. We are free of conflicts of interest with regard to climate change and health
and are scrupulously evidence-based. And most importantly, we are powerful advo-
cates for the very thing that people worldwide care about most and is most threat-
ened by climate change: our health and well-being and that of our children and their
children.
E. Maibach (*) · R. Gould

George Mason University Center for Climate Change Communication, Fairfax, VA, USA
M. Sarfaty
George Mason University Center for Climate Change Communication, Fairfax, VA, USA
Medical Society Consortium for Climate and Health, Washington, DC, USA
N. Damle
Brown University School of Medicine, Providence, RI, USA
F. Armstrong
Climate and Health Alliance (Australia), Melbourne, VIC, Australia

396 E. Maibach et al.
Efforts are already under way in many nations to activate health professionals as
advocates for climate and health. Each of these efforts is important, but they are not
yet tightly focused on achieving the global goal of limiting warming to no more than
2 °C. We therefore propose an initiative to rapidly engage, organize, and empower
a movement of health professionals and health organizations to convince the leaders
of every nation to double their commitment to the Paris Agreement. By establishing
a simple, clear worldwide objective—and a parallel objective for every nation—
linked directly to the Paris Agreement, and by identifying an exact date by which
these objectives must be met, concerned health professionals in every nation will
become compelling guides for the difficult but necessary pathway to protect the
health and well-being of all the world’s people, especially those most vulnerable to
climate change impacts, now and for generations to come.
To achieve the goal of the Paris Climate Agreement—limiting global warming to
no more than 2 °C (and if possible 1.5 °C)—and thereby avoid the most harmful
impacts of climate change on human health and well-being, the global community
must dramatically reduce its use of fossil fuels in the very near future (Allen et al.,
2018; Figueres et al., 2017). This goal can be achieved if global carbon emissions
peak by 2020 and fall rapidly to near zero over the next several decades (Rockstrom
et al., 2017; Rogelj et al., 2018). Approximately half of the necessary emissions
reductions have already been pledged by the nations of the world in the Paris
Agreement, assuming that all nations remain in the agreement. If success is to be
achieved, nations must collectively double current global commitments over the
next few years. Realizing the 1.5 °C goal will require even bolder action (Hoegh-
Guldberg et al., 2018). Building the political will necessary for this to happen will
not be easy, but doing so is imperative. Health professionals are in a unique position
to help build the necessary political will.
The most important actions that any individual, any organization, any group of
concerned citizens can take to protect the world’s climate—and with it, the health
and well-being of all people alive today and for countless generations to come—are
those that will help build the political will necessary to persuade the world’s leaders
to double their nation’s current carbon pollution reduction commitments and to ful-
fill those commitments as quickly as possible. Fulfilling those commitments will
require nations to embrace policies, regulations, and technologies capable of greatly
accelerating the inevitable transition to clean energy and rapidly eliminating the
emission of short-lived climate pollutants (methane, HFCs, and black carbon).
For a myriad of reasons, the world’s health professionals, including doctors,
nurses, midwives, and other allied health professionals and public health profes-
sionals are uniquely suited to lead the effort to persuade nations of the world to
double their emission reduction commitments. They are among the most trusted
members of every society worldwide. They speak with not just scientific but also
ethical and moral authority. They have—or can get—the attention of their nation’s
leaders. They are free of conflicts of interest with regard to climate change and
health and are scrupulously evidence-based. And most importantly, they are power-
ful advocates for the very thing that people worldwide care about most and is most
threatened by climate change: our health and well-being and that of our children and
their children.
33 A Call to Action by Health Professionals 397
The world’s health professionals have—or should have—ample motivation to

play this role. The health harms of climate change are already significant contribu-
tors to many of the leading causes of morbidity and mortality worldwide, and as the
planet continues to warm, these impacts are projected to become far worse (Field
et al., 2014; Levy & Patz, 2015; McMichael, Woodward, & Muir, 2017; Woodward
et al., 2014). Moreover, the single most potent driver of climate change—burning of
fossil fuels—also creates air pollution, which is another of the leading causes of
morbidity and mortality worldwide, distinct from climate change (Ciesielski, 2017;
Perera, 2017). As was made clear by The Lancet Commission on Health and Climate
Change in 2015, “Responding to climate change could be the greatest global health
opportunity of the 21st century” (Watts et al., 2015). Each nation that doubles it com-
mitment to reducing carbon pollution will accomplish two important public health
goals: (1) dramatically and rapidly improving the health of its citizens by embracing
clean energy and gaining cleaner air, soil, and water and (2) protecting its citizens—
and all people—by doing its part to avert further dangerous climate disruption.
Efforts are already under way in many nations to activate health professionals as
advocates for climate and health. These include the work of the Climate and Health
Alliance (Australia), the Canadian Association of Physicians for the Environment, the
UK Health Alliance on Climate Change, the US Climate and Health Alliance,
Physicians for Social Responsibility (US), the American Public Health Association,
the Alliance of Nurses for Healthy Environments (US), and the Medical Society
Consortium for Climate and Health (US). Many of these organizations collectively
represent a substantial proportion of their national health and medical workforces. At
the regional or global level, the Health and Environment Alliance is engaging health
actors around energy choices across the European Union, and the Healthy Energy
Initiative is working with health professionals globally on shifting public funds away
from fossil fuels and into health and climate action. Also at the global level, the Global
Climate and Health Alliance is working to tackle climate change and protect and pro-
mote public health, and through its Global Green and Healthy Hospitals Network,
Health Care Without Harm is working to transform hospitals and health systems
worldwide so they reduce their environmental footprint and become anchors for sus-
tainability and leaders in the global movement for environmental health and justice.
Each of these efforts is important, but they are not yet tightly focused on achiev-
ing the global goal of limiting warming to no more than 2 °C. We therefore propose
an initiative to rapidly engage, organize, and empower a movement of medical,
nursing, midwifery, allied health professional, and public health experts and organi-
zations that will seek to convince the leaders of every nation to double their commit-
ment to the Paris Agreement. By establishing a simple, clear worldwide objective
and a parallel objective for every nation, linked directly to the Paris Agreement—i.e.,
doubling the current level of emission reduction commitments—and by identifying
an exact date (to be determined) by which these objectives must be met, concerned
health professionals in every nation will become compelling guides for the difficult
but necessary pathway to protect the health and well-being of all the world’s people,
especially those most vulnerable to climate change impacts, now and for genera-
tions to come.
Strategy One: Engage
The first and most important action that must occur is to engage with and recruit the
support of a broad cohort of health stakeholders to build on and amplify the current
set of climate and health initiatives and activities around the world. This should
include the following groups of professionals.
Doctors
As noted earlier many medical societies and medical society consortia already
understand and focus on this issue. Some of these consortia and their participating
medical societies have substantial global reach. For example, the American College
of Physicians has chapters in 19 nations (including Brazil, Canada, India, Mexico,
and Saudi Arabia), and the American Academy of Pediatrics, the American Academy
of Allergy, Asthma, and Immunology, the American Thoracic Society, and the
American College of Obstetrics and Gynecology also have chapters in many nations
around the world. Other important medical organizations with global footprints—
including the World Medical Association and the World Organization of National
Colleges, Academies and Academic Associations of General Practitioners/Family
Physicians—have strong climate change policies and can be brought into the move-
ment. Other medical organizations with a substantial international presence, such as
the Interacademy Medical Panel and the International Pediatric Association, are also
excellent candidates to join the movement.
Nurses, Midwives, and Allied Health Professionals
Nurses and midwives constitute the largest group of health professionals globally,
with approximately 19.3 million nurses and midwives worldwide. These profes-
sionals—who provide care to almost every person in the world at some point during
their lives—offer the potential for influencing significant global change through
their size and scale and through their capacity to reach a large and diverse propor-
tion of the global population.
Along with other allied health professionals (e.g., psychologists, physiothera-
pists, social workers, occupational therapists), these professions offer the opportu-
nity to bring large numbers of health professionals to the movement, people who are
on the ground providing health care and who possess organizational clout in virtu-
ally every community worldwide.
Around the world, nurses are often at the top of the list of the public’s most trusted
sources on health issues. Nurses are taking the lead in supporting climate action in
many nations, such as the Association of Nurses for a Healthy Environment in the
USA that is developing the Nursing Collaborative on Climate Change and Health,
which aims to engage national nursing organizations and elevate nursing leadership
in addressing climate change; the Australian Nursing and Midwifery Federation that
offers educational and professional development training on climate change to thou-
sands of nurses each year; and the Canadian Nurses Association Code of Ethics that
supports and encourages nurses to promote climate adaptation and mitigation.
Globally, in 2018 the International Council of Nurses (ICN)—with members in
130 countries, representing nearly 20 million nurses around the world—issued a
position statement calling for government action and nursing leadership on climate
change; this followed a focus on the health impacts of climate change at its inaugu-
ral Health Policy Summit in 2017. This cohort, including organizations such as ICN,
can add significant size, scope, and power to the global climate and health movement.
Public Health
In the USA, the American Public Health Association declared 2017 the year of cli-
mate and health. Other public health organizations, such as the World Federation of
Public Health Associations (WFPHA)—with member associations in over 100
countries—and many of their national counterparts, have also been active on the
issue. WFPHA’s 2015 World Congress on Public Health had a strong focus on
climate change, energy policy, and health. Also in 2015, WFPHA conducted the first
ever global survey on national climate change and health policy, with a subsequent
report documenting the actions of 38 respondent countries on addressing the health
impacts of climate change.
Existing Climate Health Alliances and Initiatives
Several important organizations are already working at the intersection of climate

and health worldwide—including Health Care Without Harm, Health and
Environment Alliance (HEAL), Global Climate and Health Alliance, the Lancet
Countdown, and the Global Consortium on Climate and Health Education. Each has
established architectures and missions that are synergistic with this initiative and
will provide it with a cadre of leaders and bridge builders.
While the aim is to quickly recruit medical, nursing and midwifery, allied health,
and public health professionals and organizations worldwide to actively participate
in the initiative, there are obvious advantages to initially targeting institutions and
individuals in those nations that emit the highest levels of carbon pollution (e.g., the
top 15 emitting nations: China, the USA, European Union, India, Russia, Japan,
Brazil, Indonesia, Canada, Mexico, Iran, South Korea, Australia, Saudi Arabia, and
South Africa).
Strategy Two: Organize
A team must be assembled to work directly with health professionals, organizations,

and consortia to organize and empower health professionals and institutions to build
this movement. They must also recruit and mobilize significant communication and
advocacy assets for the initiative.
The organizing team—to be composed of the organizations that have the greatest
strategic and operating capacity to build and lead the movement—should be guided
by an advisory board of leading climate and health, strategy, and communication
experts worldwide. The advisors will help provide guidance and insight on strategy,
while the organizing team will help implement the strategy and tactics. With the
help of these experts and collaborators, the organizing team will take the lead in
planning, organizing, and implementing the movement’s activities in each partici-
pating country and in identifying health leaders in each country who will be sup-
ported to become the public face of the movement locally and nationally. They will
also work to ensure the visibility of these efforts and those of the broader movement
and work to embed key messages on climate change and health in global and
regional news media outlets.
Strategy Three: Empower
Our proposed initiative will work to empower health professionals to deliver key
messages on climate change and health—repeatedly and forcefully—with the aim
of reaching audiences in every nation of the world. Through educational meetings,
materials development, research, information sharing, and media relations support,
concerned health professionals will be empowered to become powerful advocates
for the health and well-being of their patients and the public at large.
Key Messages and Engagement Strategies
1. The health harms of climate change and air pollution are happening now. Our
health is already being harmed by climate change and air pollution, and it’s
almost certain to become dramatically worse unless we take action now. This is
especially true of medically vulnerable people including pregnant women, chil-
dren, the elderly, people with chronic illnesses, disadvantaged persons of color,
and the poor.
2. We must take immediate action to protect our communities. Communities should
be taking action to protect people’s health from the impacts of climate change
that are already with us. For example, communities can reduce the health harms
associated with climate change by developing early warning systems for impend-
ing heat waves, providing resources to protect vulnerable populations, and edu-
cating their members about the health effects of climate change.
3. Prevention offers the most powerful protection against future harms. To prevent
these harms from getting worse, the most important actions we must take—as
individuals, communities, businesses, and nations—are those that will greatly
accelerate the inevitable transition to clean energy and limit emission of toxic
short-lived carbon pollutants.
4 . Preventive actions will create immediate health and economic benefits. Taking
these actions will not only protect the health of the population and our off-
spring—and their offspring—from a dangerously unstable climate in the future,
they will also help clean up our air, soil, and water almost immediately, thereby
enabling everyone alive today to enjoy better health for the remainder of our
days and ensuring the well-being of future generations.
5 . We must double our commitment to reducing carbon pollution—and then live up
to it. The most important action every country can take is to ensure it is commit-
ting to—and then delivering—its fair share of the global responsibility to emis-
sions reductions in order to collectively achieve our shared goal under the Paris
Climate Agreement. This is the surest path to ending air pollution, limiting cli-
mate change, promoting health and well-being, and ensuring a prosperous future
for humanity.
In each targeted nation, the organizing team will work to break down the barriers
to public engagement and build political will through four complementary national
strategies:
1. Educating the public, other health professionals, the media, business leaders, and
policymakers about the relevance of air pollution, climate change, and climate
solutions to human health.
2. Advocating for a doubling of their nation’s emissions reduction commitment.
3. Mobilizing individual health professionals to join the effort.
4. Building or joining coalitions of other national, regional, and local organizations
that will support the advocacy goal and spread the initiative’s key messages.
The Critically Important Role of Health Professionals
Historically, the potential for health professionals to convince the world’s political
leaders to redouble their climate stabilization efforts is clearly reflected in the piv-
otal role they have played with regard to preventing nuclear war. In 1980, American
and Soviet physicians established the International Physicians for the Prevention of
Nuclear War (IPPNW), which in 1985—a mere five years after its creation—was
awarded the Nobel Peace Prize for its central role in helping to open arms control
discussions between the USA and the USSR.
In his 1987 book Perestroika, Mikhail Gorbachev specifically pointed to the
influence of IPPNW on his decision to stop testing nuclear weapons and to enter a
nuclear arms reduction treaty with the USA: “Their work commands great respect.
For what they say and what they do is prompted by accurate knowledge and a pas-
sionate desire to warn humanity about the danger looming over it. In light of their
arguments and the strictly scientific data they possess, there seems to be no room
left for politicking. And no serious politician has the right to disregard their conclu-
sions.” Later, he thanked and credited IPPNW even more directly: “I want to thank
you for your great contribution to preventing nuclear war. Without it and other
effective antinuclear initiatives this [INF] Treaty would probably have been impos-
sible” (Gorbachev, 1987).
Obviously, humanity is not yet free from the existential threats associated with
nuclear war. In 2007, adapting to the evolving global situation, IPPNW organized and
launched an even more aggressive campaign—the International Campaign to Abolish
Nuclear Weapons (ICAN)—to advocate for a nuclear weapons convention that would
ban the development, possession, and use of nuclear weapons. Since then, more than
450 partner organizations in over 100 countries have become members of ICAN. In
2014, ICAN launched its Humanitarian Pledge, asking nations to commit to creating
a nuclear ban treaty, a call that was subsequently endorsed in a UN resolution by more
than 125 countries. This resolution created the foundation for the 2017 UN Treaty on
the Prohibition of Nuclear Weapons, which 50 member states have now signed and 3
have ratified. In 2017, ICAN, like IPPNW before it, was awarded the Nobel Peace
Prize for its work, “a driving force when it comes to disarmament issues.”
Other examples of the influence of health professionals on global treaties include
their role in successfully advocating for and securing the Minamata Convention—a
global legally binding instrument to protect human health and the environment from
the adverse effects of mercury. The Minamata Convention includes a ban on mer-
cury mining, the phase-out of products containing mercury, the introduction of con-
trol measures on air emissions and releases of mercury to the environment, and
regulation of artisanal and small-scale gold mining (WHO, 2015). Adopted in
October 2013, the Minamata Convention has been signed by 128 countries and rati-
fied by 119 of them (as of April 2020) (United Nations Environment Program, n.d.).
The health sector played a crucial role in the development of the convention, iden-
tifying risks to health and sources of exposure to mercury, assessing the burden of
disease, developing guidelines for food, air, and water, and developing tools and
guidance for action (WHO-Europe, 2017).
In a recent article in the AMA Journal of Ethics, Macpherson and Wynia (2017)
make a strong case that physicians as a group (and presumably other professionals),
and many individual physicians—especially those with unique climate- and health-
relevant expertise, such as pulmonary and infectious disease specialists, and those
practicing in affected regions (which, as they state are “increasingly everywhere”)—
have a professional responsibility to speak out about the health impacts of climate
change. More recently, Law, Duff, Saunders, Middleton, and McCoy (2018) asserted
that medical organizations must divest from investments in fossil fuel companies—
because the “(e)vidence that fossil fuels pose serious threats to public and planetary
health is overwhelming” and “(t)he fossil fuel industry has a long record of under-
mining climate science and continues to spread misinformation and obstruct climate
action.” They praise the growing number of medical organizations who are leading
by example in this way, including the Royal College of General Practitioners, the
American Medical Association, the Royal Australasian College of Physicians, the
Canadian Medical Association, the Australian Medical Students’ Association, the
UK Faculty of Public Health, and the British Psychological Society. (Other organiza-
tions that are leading in this manner include the American Public Health Association,
the British Medical Association, the Chicago Medical Society, Gunderson Health
System, Healthcare Without Harm, Mediabank, Practice Greenhealth, the Royal
Australasian College of Physicians, Society for the Psychology Study of Social
Issues, the UK Health Alliance on Climate Change, UNISON Cambridge Hospitals,
and the World Medical Association.) Law and colleagues concluded, “We cannot
afford to remain silent when the health of so many is at stake.”
A current Australian initiative, led by the Climate and Health Alliance, nicely illus-
trates the potential of the approach we have proposed here. Through a 2-year consul-
tation process, the initiative engaged, mobilized, and empowered health and medical
experts, professional associations, and other groups in the development of a compre-
hensive national policy roadmap on climate change and health—called the Framework
for a National Strategy on Climate, Health and Well-being for Australia. This policy
framework, released in 2017, was designed to support the Australian government in
fulfilling its international obligations under the Paris Climate Agreement.
The framework’s clear demonstration of a substantive consensus on policy
among key influential health and medical groups provided an important mandate for
the Australian Labor Party to adopt the policy, which they did, pledging to imple-
ment it when elected to government. Public opinion polls currently (at the time of
this writing) show that the Labor Government is very likely to be elected in 2019,
and they are actively promoting this policy position.
The issue of climate change had long been politically toxic in Australia—a
nation that is heavily dependent on fossil fuel—having contributed to the downfall
of at least three prime ministers. We believe that the leadership recently provided by
the health and medical community has created a unique and effective bridge to
overcome the climate policy divide.
Conclusion
The voice of health professionals in putting an end to politics as usual regarding

climate change is particularly important because, for many people, recognizing the
need for—and appreciating the promise of—dramatically decarbonizing our energy
future has been hampered by a perceived “distance” from climate change. It is seen
as something that will happen far in the future, somewhere else, and not to people
but rather to plants, polar bears, and penguins. In contrast, the fundamental message
of our proposed initiative is that climate change and air pollution are happening
now, everywhere, and are harming us in profound ways—and that we have an
extraordinary opportunity, right now, to ensure a better, healthier future for our-
selves, our children, and their children. Achieving the goal of the Paris Climate
Agreement will lead to better health and more sustainable wealth.
By making clear what’s at stake and what must be done about it, the world’s
health professionals can—to paraphrase Archimedes—create a lever long enough
(using their trusted voices, en masse), and a fulcrum on which to place it (the Paris
Agreement), to move the world.
Philanthropic foundations, corporations, and agencies for international develop-
ment (to support work in developing nations) should step forward to provide the
necessary funding for this vitally important initiative. The health and well-being
(and the future) of humanity may depend on it.
Acknowledgments We wish to thank MSPH student Marc Trotochaud (Johns Hopkins

University) for his research assistance with this chapter.
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Index
A health, 51, 64, 168

Accessibility, 234 hospital admissions, 199
Accounting prices, 41–42 lead, 75
Adaptation capabilities, 142 longitudinal studies, 68
Adaptation gap, 240 mechanisms, 77
Advocacy, 400, 401 NO2, 73
Aeroallergens, 206 ozone, 71, 72
Aerosols, 53, 169 PAR, 75
Agricultural crops, 7 particles, 50
Agriculture PM, 196
conceptual framework, 136 pollutants and health effects, 64
and environmental, 138 sulfur oxides, 74–75
income and employment, 137 vehicle emissions, 69
linkages, 137 Air pollution reduction, 105, 313
markets and services, 137, 140 Air quality improvements, 111
natural causes/human activities, 136 Algeria, 121, 130
production-and processing-related health Allergic diseases, 85
linkages, 136, 141–142 Alliance of Nurses for Healthy Environments
rainfall patterns, 136 (US), 397
Airborne particles, 71, 72 Allied health professionals, 398–399
Air pollutants, 82, 84, 86, 299, 300, 328 AMA Journal of Ethics, 402
Air pollution, 26, 49, 65–67, 69, 94, 114, 165, Amazon, 165
194, 195, 197, 303, 314, 316, 362, actions, 171
371, 386, 400, 403 biodiversity, 167
atmospheric winds, 50 biophysical and human dimensions, 166
carbon dioxide, 64 deforestation, 166
climate impacts, 52, 53 disturbance-dominated regime, 167
CO, 73 tipping point, 167
congenital heart disease, 200 American Congressional districts, 378
COPD, 64 American democracy, 382
ecosystem impacts, 52 American Heart Association (AHA), 196
epidemiological and toxicological American Lung Association, 278
investigation, 71 American Protestant Evangelical
forest fire, 26, 165 Christian, 266
fossil fuels, 77 American Public Health Association, 397
global and regional distributions, 76 Anthropocene, 82, 89, 205–206, 236

Health of Planet and Our Responsibility, https://doi.org/10.1007/978-3-030-31125-4
408 Index
Anthropocene epoch, 309 Carbon dioxide (CO2) emissions, 296

Anthropogenic air pollution, 80 Carbon dioxide removal (CDR), 325
Anthropogenic climate change, 227 Carbon emissions, 371, 396
Anxiety, 178, 180, 181, 184–187 Carbon monoxide (CO), 73–74
Arabian Peninsula/farming rural Carbon neutrality
communities, 122 climate policy success, 322
Arsenic, 362 climate stability, 326
Asian Development Bank (ADB), 231, 365 emissions pathway and policy
Atmospheric aerosol, 80 roadmap, 323
Atmospheric carbon extraction (ACE), SLCPs, 325
325, 328 Carbon pollution, 397, 401
Cardiovascular disease, 194–195
Catastrophic changes, 323
B Catastrophic migrations, 251, 258–260
Bahrain, 122, 130 Catastrophic risks, 55–56
Bangladesh, 361 Catholic Communion, 275
Bending the Curve, 244, 326 Catholic doctrine, 289
Behavioral economics research, 28–29 Catholic Social teaching, 277
Biodiversity loss, 27 Cellular and molecular interactions, 87
Biogeochemical and metabolic processes, 82 Cellular communications technologies, 339
Biological and technological research, 6 Center for Applied Research, 276
Biological diversity, 12, 13, 17 Cerebrovascular disease (CEV), 110
Biological evolution, 5, 7 Chemical pollutants, 21, 23, 28
Biological extinction Christian beliefs, 266
climate change, 12 Christian environmentalism, 266
consumption, 14 Chronic climate conditions
key factor, 13 drought, 181–183
pollution, 12 sea level rise, 183–184
species, 13 Chronic obstructive pulmonary disease
Biomedical ethics (COPD), 64, 110
principles, 30 Church’s social teachings, 391
Biomedical knowledge, 6 Circular economy, 314
Bipartisan Climate Solutions Caucus, 379 Civic society, 361, 366
Bisphenol-A (BPA), 278 Clausius–Clapeyron relation, 226
Black carbon (BC), 334, 351 Clean air, 115, 311
Bloomberg New Energy Finance (BNEF), 281 Clean cooking, 354, 356, 357
Blue water flows, 150, 151 Clean energy, 281, 334, 345
Bolstering, 97 entrepreneurs, 356
Boundaries, planetary, 21 implementers, 352, 353
Breast cancer, 278 transparency, 357–358
Burning embers diagram, 56 Clean Energy Options for Sabah, 340
Business-as-usual (BAU), 109 Clean energy system, 392
emissions, 328 Clean energy transition, 333
growth, 342 Climate adaptation, 380
Businesses Alliance for Local Living Climate and Clean Air Coalition (CCAC), 323
Economies (BALLE), 213 Climate and Health Alliance (Australia), 397
Climate change, 21, 22, 27–29, 49, 50, 206,
281, 285, 334, 361
C and agriculture (see Agriculture)
Canadian Association of Physicians for the air pollution, 184–185, 403
Environment, 397 effects, 241
Cap-and-trade program, 374 and environmental, 366
Capital goods, 41 food and high-quality nutrition, 136
Capital stocks, 45 food production, 139, 140
Index 409
food security, 135, 136 Climate migration, 233

food systems, 135, 138–141 Climate mitigation, 328
fossil fuels, 397 Climate neutrality, 216
global crop production, 139 Climate parameters, 86
greenhouse gas emissions, 135 Climate passport, 234, 235
and health, 143–145 Climate pollutants, 50, 57
health effects, 366 Climate refugees, 233
health environment, 141 Climate-sensitive sectors, 241
health harms, 397, 400 Climate-smart food system, 145
health impacts, 239, 402 Climate-sustainable world, 371
and health policy, 399 Climate variability, 141
health professionals (see Health Coastal areas, 361
professionals) Cold chains, 143
human and animal health, 363 Collective action, 142
human health and well-being, 395 Commons Health Model, 211
impacts, 53, 54, 240 Communicable and noncommunicable
income-and employment-related diseases, 95
linkages, 143 Communities, 400
mitigation and adaptation Community scale, 337, 339
technologies, 139 Congenital Heart Disease, 200
negative effects, 245 Congressional seats, 379
nursing leadership, 399 Cookstoves, 334–337
nutrition, 142 Cooler Heads group, 377
personal health risks, 246 Corporate campaign financing, 391
policies, 398 Corporate cheating, 391
populations, 185, 186 Corporate lobbying, 391
psychological impacts, 184 Corporate responsibility, 392, 393
public health effects, 248 Cost–benefit analysis (CBA), 373
quantitative estimates, 254 Cultural revolution, 391, 393
risk
catastrophic, 55–56
dangerous, 55 D
ethical issues, 56–57 Data driven approach, 352–353
existential, 56 Data sets, 107
and sustainability, 385 Decarbonization, 392, 393
Climate change mitigation, 312 Deforestation, 26, 166, 167, 169–171
Climate change politics, 375 drivers, 169–170
Climate change solutions policy, 170
ACE, 325, 328 Dementia and air pollution, 195
building blocks, 323 Demand-side shocks, 138
economic growth, 325 Democratic process, 213
governance cluster, 327 Democratic Republic of the Congo (DRC),
market-and regulation-based cluster, 327 252, 255
science pathways, 326 Democrats and Republicans, 379
SLCPs, 325 Department of Defense, 380, 381
societal transformation, 327 Depression, 178, 180, 184–186
subnational and city scale, 325 Desert sand, 125–126
technology cluster, 327 Diarrheal disease, 26
warming, 322 Diesel engines, 316
Climate Impact Research, 231 Dietary shifts, 315
Climate justice, 214 Dietary wellness, 215
harms and responsibility, 242–243 Direct agricultural production, 142
social change, 245 ‘Dirty’ energy, 341
social urbanism, 244 Disability-adjusted life-years (DALYs), 199
410 Index
Disaster, 178, 225, 227, 231, 232 Environmental changes, 364, 387
Disease burden, 75–77 Environmental conditions, 3–4
Distributed generation, 338, 341, 344 Environmental degradation, 96
Diverse technology, 343–344 Environmental disease, 97
Downpours, 225, 226 Environmental dystopia, 253–255
Drinking water, 141, 362 Environmental flows, 153, 157
Drug-resistant and emerging infections, 365 Environmental intervention, 362
Drug-resistant infections, 366 Environmental migration, 230–231
Dry season, 362 Environmental policies, 170
Dust storms, 125–126 Environmental stewardship, 266
Epidemiological approaches, 68
Epithelial lining fluid (ELF), 84
E Equity, 345
Earth system chemistry model, 107 Ethical issues, 30, 56–57
EAT Foundation, 364 European and Japanese manufacturers, 112
Ecological systems, 362 European emission controls, 113
Economic benefits, 401 European emission standards, 113
Economic commodity, 336 European technology development, 114
Economic development, 46 Evangelical and Catholic communities, 273
Economic system, 212 Evangelical Christian leaders, 267
Education, 399 Evangelical Climate Initiative, 276
Education gap, 240 Evangelical Environmental Network, 277
Egalitarian economy, 43 Evangelical Protestants, 268
Egypt, 121, 129, 130 Evidence-based analysis, 373
Electric bicycles, 314 Evidence based policy, 363–365
Electric induction cookstoves, 351 Evolution genes, 6
Electronic banking, 339 Existential risks, 56
Emission Database for Global Atmospheric Extinction rates
Research (EDGAR), 107 calculation, 14
Employee stock ownership programs climate change, 16
(ESOP), 214 danger, 15
Endocrine disruption, 25 hotspots, 15
Energy access, 345 population, 15
Energy efficiency, 374 vegetation, 15
Energy infrastructure, 334 Extreme heat waves, 122–125
Energy injustice, 334 Extreme weather events, 139, 178
Energy poverty
assessment, 343–344
clean energy, 345 F
community scale, 337, 339 Faith and moral frameworks, 275
and injustice, 334 Faith communities, 269
innovation, 334–335 Faith leaders
intra-household scale, 335–337 atmosphere, 289
learning, 334–335 climate change, 288
off-grid systems, 339–340 climate change and human health, 290
utility scale, 340–343 climate change and proper approaches, 289
Energy production, 144 evil outcomes, 287
Energy revolution, 328 freedom, 286
Energy security, 138 fundamental level, 287
Energy shifts, 393 globalization, 287
Enlightenment Liberal project, 286 goodness, 287
Environmental allergens, 87 moments, 286
Environmental and climate change, 98 mystery, 288
Environmental and health challenges, 95 power, 286
Environmental catastrophe, 393 privilege and pledges, 291
Index 411
salvation, 287–288 Fuel-based lighting, 344

SDGs, 289 Fuel quality and flue gas desulfurization, 112
society, 286 Functional Medicine, 209
structural and personal, 288
wisdom, 287
worship and congregations, 290 G
Feeding, 364 Gas/LPG stoves, 351
Financial and economic shocks, 138 Gas molecules and aerosol particles, 80
Fine particulate matter, 80, 84, 106 Gastrointestinal infections, 365
Fisheries, 27, 28 Genetic information, 3, 5
Floods, 180, 225 Genetic variation, 6
Food access, 143 GHG/SLCP emissions, 310
Foodborne diseases, 143 Global Burden of Disease, 77, 107, 110
Food contamination, 23 Global Burden of Disease Study, 195,197
Food market volatility, 138 Global Climate and Health Alliance, 397
Food poisoning, 23 Global climate change, 351
Food safety Global dimming, 52
schemes, 143 Global excess mortality rates, 110
Food sector, 393 Global food systems, 364
Food-sector objectives, 392 Global Green and Healthy Hospitals
Food security, 141, 157 Network, 397
agriculture, 135 Global health and welfare, 96
climate changes, 136, 142, 144, 145 Global responses
destabilizations, 138 global problems, 387
food systems, 136 Global Sustainability Network, 287
and health, 136–142 Global urbanisation, 363
linkages, 136 Global warming, 328, 395
non-food inputs, 142 climate change, 54–55
political disruptions and failed political present and future, 53–54
systems, 138–139 Global weather patterns, 53
risks, 140 Greenhouse gas (GHG) emissions, 97, 138,
Food System Models, 215 144, 322, 365
Food systems agricultural technological
adaptation interventions, 139 improvements, 300
agriculture, 135, 139 air pollutants, 299, 300
average crop production, 139 anthropogenic, 296
behavior change, 138 climate change, 297–298, 303
conceptual framework, 136, 137 climate change and air pollution, 304
cost of sustainable, 144 climate convention, 299
demand-side shocks, 138 co-benefits, 299
food market volatility, 138 economic sectors, 304
global trade system, 139 global annual emissions, 296
governance, 145 health, 297
mitigation, 139 health benefit assessments, 302
policy shifts, 138 health co-benefits, 301–302
seasonal production data, 139 high-and low-income countries, 300, 303
stability, 136, 138 industrial and economic processes, 301
volatility, 139, 140 IPCC, 299
Forced-air, 351 knowledge gaps, 302
Forced-draft stoves, 351 low-and middle-income countries, 298
Framework for a National Strategy on malnutrition, 298
Climate, Health and Well-being for mitigation actions, 296, 302
Australia, 403 mitigation strategies, 299
Fresh water, 150, 362 multisectoral and multidisciplinary
Freshwater resources, 159 policies, 303
412 Index
Greenhouse gas (GHG) emissions (cont.) efforts, 397

pathways, 300 empower, 401
performance, 302 Framework for a National Strategy on
public health co-benefits, 300 Climate, Health and Well-being for
public health opportunities, 303 Australia, 403
quantitative associations, 304 global treaties, 402
quantitative relationships, 303 ICAN, 402
reduction efforts, 298 individual, 396
reductions and health co-benefits, 300 IPPNW, 401–402
UNFCCC, 298 midwives, 398–399
Greenhouse gases, 51, 328, 386 Minamata Convention, 402
Grey water (GW), 130 nurses, 398–399
Gross domestic product (GDP), 298 public health, 399
and well-being, 396
Healthy Energy Initiative, 397
H Heat, 21, 22
Hand-made stoves, 351 Heat waves, 180, 225
Healing power of nature, 216 High biodiversity, 5
Health, 98, 206, 335–337 High Density Polyethylene (HDPE), 278
agricultural production-and High-intensity/low-intensity exposure, 336
processing, 141–142 Hinduism, 265
air pollution, 110–112, 136 Holistic thinking, 207
challenging task, 265 community expertise, 211
and climate change distress, 209
energy decision-making process, 144 health, 208
environmental change, 144 medical industry, 211
policy implications, 144–145 shifts, 207
research challenges, 144–145 Horizontal gene transfer, 5
rural energy system, 144 Household air pollution (HAP), 51, 52
rural households, 144 Household energy, 334, 338
village energy systems, 144 Human and environmental health, 345
water quality, 143 Human flourishing, 291
environment, 265 Human health benefits, 312
environmental stewardship, 266 Human influences, 96
environment and climate change, 268 Humanitarian response gap, 240
and food security, 136, 137 Humanity, 280, 309
investments, 138 Human rights and equity, 100
markets and services, 143–145 Hurricane Maria, 267
and nutrition, 135, 140 Hurricanes, 227
outcomes, 143
population, 265
religion, 265 I
Health Care Without Harm, 397 Immobilization, 217
Health co-benefits, 299–302 Implicit assumption, 44
Health & Environment Alliance, 397 Inclusive investment, 40
Health of people and planet, 287 Inclusive wealth, 41, 42
Health professionals, 217 Income shocks, 136
allied health professionals, 398–399 Indigenous people, 165, 170, 171
AMA Journal of Ethics, 402 Industrial food system, 210
Climate and Health Alliance Inequity, 213
(Australia), 397 Infections, 364
climate stabilization efforts, 401 Infectious disease, 22
commitments, 396 Information technology, 345
doctors, 398 Injustice vs. misfortunate, 240
Index 413
Innovation, 363, 364 Lancet Commission on Pollution, 200

Institute for Health Metrics and Evaluation Lancet Commission on Pollution and
(IHME), 75 Health, 25
Integrated exposure-response (IER) functions, Land use, 362
107, 110 Land use changes
Integration, 367 disruptions, 28
Integrative health and medicine, 215 effects, 26
Integrative Medicine (IM), 209 human health, 26
Intelligence and learning problems, 277 impact, 26
Intended Nationally Determined Contributions Large-scale intentional forest fires, 169
(INDC), 130 Lausanne Movement, 267
Inter-faith dialogue and cooperation, 270 Lead, 75
Intergenerational well-being, 40, 42 Lebanon, 121, 126, 129, 130
Intergovernmental Panel on Climate Change Libya, 121, 127
(IPCC), 241, 296 Light-and heavy-duty vehicles, 112
Internal displacements, 252, 257 Lighting Global programme, 344
Internally displaced persons (IDPs), 252, 255 Living organisms, 6
International Campaign to Abolish Nuclear Local air pollution, 316
Weapons (ICAN), 402 Low-carbon fuel standard, 374
International Centre for Diarrhoeal Disease Low emission vehicles, 313
Research, 362 Lower respiratory infections (LRI), 76
International Civil Aviation Organization Lyme disease, 279
(ICAO), 323
International Council for Science (ICSU), 387
International Council of Nurses (ICN), 399 M
International Maritime Organization (IMO), 323 Macro-minus approach, 285
International Physicians for the Prevention of Macro-models, 142
Nuclear War (IPPNW), 401–402 Marine anoxia, 17
Intra-household scale, 335–337 Market-and regulation-based cluster, 327
Investment Mass migration, 259
government, 43 Medical Society Consortium for Climate and
human capital, 43–44 Health (US), 397
nutritional status, 43 Mental health, 181–183, 366
Iraq, 121, 123, 125, 126, 129 Mental health professionals, 178, 187
Ischemic heart disease (IHD), 76 Methane reductions, 311
Islam, 122, 130 Mexican immigrants, 257
Mexican migration, 257–258
Microbiomes, 4
J Micronutrients, 141
Job-switching migration, 142 Middle East and North Africa (MENA)
John Templeton Foundation, 268 Arabian Peninsula/farming rural
Jordan, 121–123, 127, 129, 130 communities, 122
desert sand, 125–126
dust storms, 125–126
K extreme heat waves, 122–125
Kerosene lighting, 344 GW, 130
King, Martin Luther, 29 heat wave adaptation plans, 130
Kuwait, 121, 125, 126 historical severe drought, 122
INDC, 130
Quran, 122
L recycling water, 130
Labor Government, 403 refugees, 128
Lancet Commission on Health and Climate water scarcity, 127–128
Change, 22 World Bank criteria, 122
414 Index
Migration, 251 Palm oil, 26

Migration map, 257 Particulates, 334, 336
Minamata Convention, 402 Paris Agreement, 98, 289, 322, 323
Mini-grids, 334, 337–340, 342, 344 Paris Climate Agreement, 392, 393, 395, 401,
Mitigating climate change, 246 403, 404
Mobile money, 355 Particle matter (PM), 69, 71, 196
Model calculations, 107 Pay-as-you-go (PAYG) energy access
Modern electricity service ladder, 344 technologies, 337, 338
Morbidity and mortality, 110 Persistent organic pollutants (POPs), 24
Morocco, 121, 130 cancers, 25
Multi Ethnic-Study of Atherosclerosis and Air distribution, 25
Pollution (MESA), 198 endocrine disruption, 25
Multiple investigational approaches, 68 Pew Research Center, 383
Multi-pollutant Index (MPI), 108–110 Pharmaceutical footprint, 210–211
Mutual flourishing, 287 Photovoltaic generation, 339–340
Mycotoxins, 143 Physicians for Social Responsibility (US), 397
Pico-lighting devices, 343–344
Planetary boundaries (limits), 28
N Planetary Health, 21, 24, 28–30, 361
National Ambient Air Quality Standards Planning gap, 240
(NAAQS), 64, 69 Plastics, 23–24
National Association of Evangelicals (NAE), Plastics permeate ecosystems, 24
267, 277 PM2.5 concentrations, 197–198
National Cancer Institute, 278 Policy-makers, 364
National healthcare systems, 366–367 Policy perspective, 76
Nationally Determined Contributions Policy shifts, 138
(NDCs), 326 Political community, 391
Natural capital, 44 Pollination, 27
Natural disaster, 178 Pollution, 23, 371, 386
Navy and Marine Corps installations, 381 Polychlorinated biphenyls (PCBs), 25
Neurodevelopment, 277 Polycyclic aromatic hydrocarbons (PAH), 84
Nexleaf, 356 Pontifical Academy, 371
Nitrogen dioxide (NO2), 73 Poor air quality, 111
N95 masks, 197 Population and consumption, 385–388
Noncommunicable diseases, 25, 95 Population attributable fraction (PAF), 195
Non-Western religions, 268 Population attributable risk (PAR), 75
Nutrition Population-based public health approach, 96
health, 135, 140 Population weighted multi-pollutant
high-quality, 136 index, 108
markets and services, 137–138 Post 2015 development agenda, 317
security, 144 Poverty, 142
transition, 142 Power production, 112, 113
Nutrition-sensitive agriculture, 142 Pressures, 362
Pro-life evangelicals, 277
Protestant evangelical perspective, 266–267
O Protestantism, 279
Occupational health, 23 Protestant understanding, 285
Off-grid systems, 339–340 Psychosocial impacts
Oman, 121 mental health professionals, 187–188
Ozone, 71, 88 trauma, 187
Public goods, 45
Public health, 23, 107, 112, 114, 228, 399
P agendas, 247
Paleontologists, 323 climate change, 244
Palestine, 121, 130 ethical implications, 244
Index 415
partial realizations, 244 Riyadh, 123

risks, 246 Rockefeller Foundation – Lancet Commission
Public Health and Air Pollution in Asia On Planetary Health, 28, 30
(PAPA) Project, 77 Rooftop solar power, 334
Public health policies, 171 Rural energy system, 144
Public infrastructure, 41 Rural households, 144
Public policies Rural populations, 142
factors, 169
implementation, 170
Public transportation, 216 S
Public vs. personal health, 247 Saline drinking water, 363
Salvation, 287–288
Sarawak Corridor of Renewable Energy
Q (SCORE), 341–343
Qatar, 121, 130 Saudi Arabia, 121, 123, 125, 130
Qualitative growth, 8 Science pathways, 326
Quantitative and qualitative data, 335 Seasonal production data, 139
Quran, 122 Seawater, 362
Self-discipline, 372
Self-reported cooking data vs. sensor data, 352
R Sensor-enabled Climate Financing (SCF), 350
Radiative forcing (RF), 299 cooking over time, 355
Reactive oxygen and nitrogen species data driven approach, 352–353
(ROS/RNS), 82 data set, 355
atmospheric and physiological evaluation process, 356
chemistry, 82 global climate change, 351
cellular and molecular interactions, 87 implementations in Odisha, 355–356
ELF, 84 independent stove testing, 356
and oxidative stress, 88 methodology, 353
ozone, 82 mobile money, 355
physiological sources, 84 Nexleaf, 350, 356
production, 84 resilience, 356
reactive pollutants, 84 solid biofuel, 350
redox-active substances, 84 supply chains, 356
Recycling water, 130 woman-centered approach, 353–354
Reframing climate change, 275 Shared socioeconomic pathways, 226
Refugees, 255, 256, 260 Short-lived climate pollutants (SLCPs), 310,
climate change, 128 324–326, 351, 353, 372
health, 129 Sleep, 23
political instability, 128 Small island developing states
Relationship with creation and nature, (SIDS), 230
372, 373 Smoke, 26, 27
Renewable energy, 97, 130, 310–312, Social environment, 42
341–343, 387, 392 Social policy responses, 142
Research Social urbanism, 244
challenges, 365–367 Societal transformation, 327
health implications, 362 Society, 361–363, 365, 366
industry and civic society, 361 Socioeconomic factors, 26
“Our Planet, Our Health”, 363–365 Soil water management, 158
Resilience, 206, 209, 213 Solar home systems (SHS), 339, 344
Responsibility gap, 240 Solid biofuel, 350
Revitalising informal settlements and their Solid-state electronics, 339
environments (RISE), 364–365 Soot monitoring systems, 351
Rio Declaration on Environment and Spirit, 289
Development, 98 Stewardship, 291
416 Index
Storms, 180, 225 Threat multipliers, 232

StoveTrace sensors, 352 Thrombosis, 198
Stress, 276 Total factor productivity (TFR), 45
Stroke, 195 Toxic mold-induced mental
DALYs, 199 illness, 180
Global Burden of Stroke study, 199 Toxic substances, 143
robust association, 199 Transformational changes for sustainable
Styrofoam, 213, 216 living, 371
Sudan, 121, 130 Transformative approaches, 309
Suicide, 22 Transformative change, 310
Sulfur oxides, 74–75 Transnational land investments,
Sustainable aquaculture, 315 159–160
Sustainable development, 40 Transparency gap, 240
Sustainable development goals (SDGs), 42, Transportation challenge, 373
317, 366 Trauma, 178–180, 182, 187, 230
beef consumption, 393 Tunisia, 121, 126, 130
clean energy system, 392 Turkey, 129
decarbonization, 392, 393
description, 391, 393
economies, 391 U
electricity, 392 UK Health Alliance on Climate
energy shifts, 393 Change, 397
environment, 394 UN Framework Convention on Climate
food sector, 393 Change (UNFCCC), 323
food-sector objectives, 392 United Arab Emirates (UAE), 121–122, 130
human health, 392 United Nations Commission for Refugees
sustainable food system, 392 (UNHCR), 241
Sustainable diets, 315 United States Congressman
Sustainable food system, 392 American electorate, 383
Sustainable planet anti-climate change groups, 378
back to nature, 387–388 carbon emissions, 378
back to sunshine, 387–388 church, 383
challenges, 387 climate action, 377
environmental change, 387 climate change, 382
explosive growth in human competitive races, 379
numbers, 388 conservative groups, 377
global responses, 387 election, 377
lives of billions of people, 388 political action groups, 379
our responsibilities, 386, 387 renewable energy, 381
pollution, 386 shareholders, 381–382
population and consumption, 385–388 Universal Health Coverage, 366–367
reducing inequality, 388–389 Urban environments, 364
unsustainable trajectory, 386 Urban–industrial symbiosis, 315
Sustainable transport, 99 Urgency, 29
Sustainable urban transport systems, 99 US Climate and Health Alliance, 397
Synthetic chemicals, 23 US Environmental Protection
Syria, 121, 123, 128, 129 Agency, 71
System of National Accounts (SNA), 43 Utility scale, 340–343
Systems thinking, 29
V
T Value of a statistical life (VSL), 44
Technology cluster, 327 Vascular Disease risk factor, 195
Testing laboratories, 344 Village energy systems, 144
Index 417
Violence, 22 diets, 158

Virtual water, 154, 159 trade, 159
Volatile organic compounds waste reduction, 157–158
(VOCs), 277 Water sustainability, 160
Wealth
composition, 46
W creation, 214
War and terror, 255–258 Wealth/well-being equivalence
Warming, 323, 324 theorem, 41, 44
Warming particles, 52 Wet-bulb temperature, 228
Warm Spell Duration Index (WSDI), 122–123 Wildfires, 179, 225, 227
Waste reduction, 157–158 Wireless cookstove, 351
Water Women, 335–337
atmospheric, 150 exposure, 336
availability, 150 health, 335, 337
blue and green water flow, 150 Workers, 23
capillary forces, 150–151 World Health Organization (WHO),
renewable resource, 152 69, 85, 372
Water consumer, 153
Water cycle, 151, 152
Water grabbing, 154, 160 Y
Water management, 232 Yale Program on Climate Change
Water quality, 143 Communication, 378
Water resources Years of life lost (YLL), 111
environmental impacts, 153 Yemen, 121, 127
food production, 156
irrigation, 154, 155
livestock production, 156 Z
Water scarcity crises, 127–128 Zero carbon, 372
Water security Zero-carbon energy, 392, 393
crop improvement, 158 Zero-emission vehicles, 373
crop management, 158 Zero waste policies, 216

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What are some of the health hazards discussed in the document?

What are some of the health hazards discussed in the document?

What are some of the sustainable development goals mentioned?

What are some of the sustainable development goals mentioned?

Wael K.

Health of People, Health

ISBN 978-3-030-31124-7 ISBN 978-3-030-31125-4 (eBook)

This book is an open access publication.

Some forms of pollution are part of people’s daily

O God of the poor,

The notion of the Anthropocene—the age of humans—comes from the observation

t­ransformational change in people’s attitudes toward nature and that an alliance

La Jolla, CA, USA  Veerabhadran Ramanathan

Veerabhadran Ramanathan (PAS & UCSD), Monsignor Marcelo Sánchez

ety’s most vulnerable communities. There are numerous living laboratories—

Signatories: This declaration was signed by members of the Pontifical Academy of

This book provides a unique perspective on the multidimensional aspects of the

La Jolla, CA, USA  Wael K. Al-Delaimy

Part I The Anthropocene: Human–Nature Interactions

Part II Air Pollution, Climate Change, and Health:

Part III Climate Change and Health: Sustainability and Vulnerable

Part IV Climate Change and Health: Perspectives from Physicians

Part V Climate Change and Health: Social Impacts

Part VI Overarching Solutions: The Role of Religion

22 Call to Action from Faith Leaders���������������������������������������������������������� 285

Part VII Overarching Solutions: The Role of Science and Technology

Part VIII Call to Action

Nobel Laureate, Medicine/Physiology 1978.

© The Author(s) 2020 3

Symbiosis and Nutritional Interdependencies

I mpacts of Nonliving Environmental Factors on Terrestrial

Many living organisms depend, to some degree, on environmental factors such as

Value of High Biodiversity

Insight into the Laws of Nature for Biological Evolution

Biological evolution is a very slow, continual process; it cannot be easily perceived.

Improvement of Life Expectancy

Improvement of Nutritional Diets for Better Health

It is important for scientific researchers to explore other adverse health effects

Intensive Agriculture or Protection of the Rich Biodiversity?

Reflection on Future Living Conditions on Our Planet Earth

As we have already discussed, a steadily, but very slowly, progressing biological

From Quantitative to Qualitative Growth

As members of the human species, we have the privilege of a high intellectual

Summary What are the current dimensions of biological diversity? Taxonomists

© The Author(s) 2020 11

How Many Species Exist Now?

Factors Driving Extinction

Particularly since the acceleration of the Industrial Revolution some 250 years

of extinctions per million species-years (E/MSY). With a historical extinction rate

DeWeerdt, S. (2017). Sea change. Nature, 550, S56–S58.

Summary Our planet is infinitely beautiful, complex, and precious. As each of us

© The Author(s) 2020 21

A third example of global environmental change that affects human health is

Ways of Thinking and Knowing

© The Author(s) 2020 39

The Idea of Sustainable Development

In this chapter intergenerational well-being refers to not only the well-­being of

Accounting Prices and the Social Environment

Sustainable Development Goals

transformational change in people’s attitudes toward nature and that an alliance

La Jolla, CA, USA Veerabhadran Ramanathan

La Jolla, CA, USA Wael K. Al-Delaimy

Part I The Anthropocene: Human–Nature Interactions

Part II Air Pollution, Climate Change, and Health:

Part III Climate Change and Health: Sustainability and Vulnerable

Part IV Climate Change and Health: Perspectives from Physicians

Part V Climate Change and Health: Social Impacts

Part VI Overarching Solutions: The Role of Religion

22 Call to Action from Faith Leaders�� 285

Part VII Overarching Solutions: The Role of Science and Technology

Part VIII Call to Action

Symbiosis and Nutritional Interdependencies

I mpacts of Nonliving Environmental Factors on Terrestrial

Insight into the Laws of Nature for Biological Evolution

Improvement of Life Expectancy

Improvement of Nutritional Diets for Better Health

Intensive Agriculture or Protection of the Rich Biodiversity?

Reflection on Future Living Conditions on Our Planet Earth

From Quantitative to Qualitative Growth

How Many Species Exist Now?

Factors Driving Extinction

Ways of Thinking and Knowing

The Idea of Sustainable Development

In this chapter intergenerational well-being refers to not only the well-being of

Accounting Prices and the Social Environment

Sustainable Development Goals

Wealth in India: Estimates

Science of Air Pollution and Climate Change

Air Pollutants and Climate Pollutants: Similar Impacts

Air Pollution Impacts

Climate Pollution Impacts

Concluding Remarks: Common Solutions

The Health Effects of Air Pollution

The Disease Burden from Ambient Air Pollution

Reactive Oxygen and Nitrogen Species

Air Pollution: A Major Killer

he Public Health Response to Climate and Environmental

Concluding Remarks: The Transformation Needed

Methods: Earth System Chemistry Model

Multi-pollutant Index (MPI)

Health Impacts of Air Pollution

World Avoided by Improving Technology in the EU

Historical and Religious Relevance

Extreme Heat Wave Events

Desert Sand and Dust Storms

limate Change and Political Instability in Relation

Solutions and Level of Preparedness

onceptual Relationships of Agriculture, Food Security,

foundations of agriculture. Institutions, information, and behavior are interdependent