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
e-mail: [email protected]
J. Gao
The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
National Engineering Laboratory for Internet Medical Systems and Applications,
Zhengzhou, Henan, China
e-mail: [email protected]

© The Author(s) 2020 295

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_23
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
298 Q. Liu and J. Gao

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).
23 Public Health Co-benefits of Reducing Greenhouse Gas Emissions 299

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
300 Q. Liu and J. Gao

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
23 Public Health Co-benefits of Reducing Greenhouse Gas Emissions 301

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;
302 Q. Liu and J. Gao

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).
23 Public Health Co-benefits of Reducing Greenhouse Gas Emissions 303

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
304 Q. Liu and J. Gao

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.
23 Public Health Co-benefits of Reducing Greenhouse Gas Emissions 305

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