I found this great resource while I was web-surfing the other day. It is the official site for CleanMed 2010, a sustainable healthcare conference held in Baltimore MD during May 2010.

Sustainable healthcare conference - CleanMed 2010

The interesting thing is that many of the posters and speaker-presentations are available online. Just click these links:
Home Page
Presentations
Posters

There is some very useful information there – check it out for yourself. Some of the titles include:

Climate and Health Literacy – A MUST see! DIRECT LINK

Waste Management in the Operating Room: Exploring & Improving the Environmental, Human Health & Economic Impacts

Envisioning the High-Performance Hospital: Implications for a New Low Energy, High-Performance Prototype

Healthcare Water Effluent & Potential Strategies

Building Green During Economic Turmoil

Pesticide and Pediatrics – How Hospitals Can Grow Healthy Food and Healthy Children

High Performance Hospitals in a Carbon Constrained World

Designing a New Emergency Department Around Daylight and Nature

How Nature Helps to Restore Body, Mind and Spirit

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Climate change is likely to affect mental health in several ways. Climate change is associated with increasingly frequent and severe weather events, which cause extensive infrastructure damage, economic slowdown, and interruptions of medical and psychiatric care. These events, and the lifestyle changes that can result, are associated with increased mental health burdens.

Climate change is already causing a range of mental health impacts.

Extreme weather events cause relocation and displacement and rupture people’s relationships with place. Other effects of climate change, including sea-level rise and other ecological changes, will also cause displacement and undermine longstanding human relationships with supporting local ecosystems.

From the loss of life, dislocation, infrastructure loss, and interruption of medical care, extreme weather events such as severe hurricanes can be associated with increases in depression, grief and post-traumatic stress disorder. Relocation and displacement can also have significant mental health effects, and are independently associated with major depression as well.

On another level, the magnitude of the climate crisis, and worry over future effects on health and the environment, have already generated concern in some parts of the general population. The degree of this health burden relative to other strains on mental health is unknown, but points to the necessity for effective public health communication that inspires action rather than stress and despair.

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1. Climate Change & Health – Part 2
2. Health Effects of Climate Change: Heat Waves
3. Specific Health Effects of Climate Change – Part 2

Climate change is not something that might happen in the future. It is happening now – since the middle of the 20th century, Australian average temperatures have risen about 1°C. This has been accompanied by an increase in the frequency of heat-waves, a decrease in the numbers of frosts and cold days, and a redistribution of rainfall from eastern Australia and southwest WA to the northwest (www.bom.gov.au/climate/change).

2009 was Australia's second warmest year on record.

Last year (2009) will be remembered for extreme bushfires, dust-storms, lingering rainfall deficiencies, areas of flooding and record-breaking heatwaves (BOM). It was Australia’s second warmest year since high-quality records began in 1910. Last year’s annual mean temperature was almost 1°C above the 1961-90 average, with Victoria, South Australia and NSW all recording their warmest July-December periods on record. The decade just ended (2000-2009) was our warmest on record, continuing a trend where each decade since the 1940s has been warmer than that preceding it (BOM 2010). The likelihood that this warming trend is due to anthropogenic causes is over 90% (IPCC 2007).

Anthropogenic climate change is predicted to have a range of effects on respiratory and allergic diseases over the coming decades, most of them negative.

The possible effects are wide-ranging, and predicted to occur in the following areas:

• Extreme temperature events
• Worsening air pollution
• Altered aeroallergens
• Extreme weather events

Extreme temperature events
The globe is warming and will continue to do so over the coming century. This process will continue, even if rapid and marked reductions in carbon dioxide emissions occur soon, due to the inertia of the global climate system. Mean temperatures will continue to increase, as will climate variability (the range of expected maxima and minima). The effect of this two-fold change will be to significantly increase the number of very hot days for many areas (IPCC 2007).

Each 1°C increase above long-term city averages increases all-cause mortality by up to 3%

The health effects of extreme heat are well-known. The record-breaking 2003 European heat-wave, for example, caused tens-of-thousands of premature deaths across several countries, especially France (McMichael et al 2006). Most affected were the elderly, disadvantaged or chronically ill (especially those with respiratory or cardiovascular disease). There is also evidence from a European study that each 1°C increase above long-term city averages increases all-cause mortality by up to 3% (and respiratory mortality up to 6% – Stafoggia et al 2008).

European temperature anomalies in summer 2003 compared to July 2001 temperatures.

As heat-waves are expected to become more severe, frequent and prolonged as global warming progresses, strategies to reduce the associated morbidity and mortality must become a public health priority (Ayres et al 2009).

A paradoxical effect of increased global temperatures is that winters should become warmer, leading to a modest decrease in cold-related morbidity and mortality .

Worsening air pollution
The relationship between air pollution, climate change and respiratory illness is complex, and more research is needed to allow better predictions to be made. Despite this, enough is known about ground-level ozone, nitrous oxides and particulates to inform future research and mitigation / adaptation strategies.

Ground-level ozone
Ozone is a potent oxidising substance known to have several adverse respiratory effects (Ayres et al 2009):

• Increased new onset asthma
• Decreased lung function
• Exacerbation of COAD
• Allergen sensitisation
• Increased hospital admissions
• Increased all-cause mortality

Ozone (O3) is a component of photochemical smog, produced by the action of sunlight on fossil-fuel combustion products (primarily vehicle exhaust in cities). Its production is increased by warmer temperatures (especially due to the urban heat-island effect), and it is this property that will probably lead to increased ozone formation during the coming century.

Produced by the action of sunlight on exhaust fumes (especially on hot days), high concentrations of ozone found in the Earth's lower atmosphere (troposphere) are hazardous to life.

Although urban areas are most affected, O3 crosses national and even continental boundaries (there is increasing evidence, for example, that Asia is “exporting” its ozone to the USA – Zhang et al 2008). The future effects of this issue are difficult to predict due to warming-induced changes in air circulation and wind patterns.

As hydrocarbon combustion is the main source of ground-level ozone, patterns and levels of future O3 concentrations also become difficult to predict with certainty if carbon-free fuels become dominant.

Other forms of air pollution
Nitrous oxides are produced by high-temperature hydrocarbon combustion (especially in vehicles). They are important, in part, because they produce an enhanced response to inhaled allergens, probably due to bronchial irritation and inflammation (Shea et al 2008).

Small ambient particles are also produced by fossil-fuel combustion. Short-term inhalation of these particles increases cardiopulmonary hospital admissions and mortality, while long-term exposure worsens paediatric asthma and causes higher mortality in adults (Ayres et al 2009). It is difficult to predict future patterns of particle production and exposure, as mitigation strategies (eg electric- or hydrogen-powered vehicles) may significantly reduce their production.

Conversely, expected increases in wildfires, droughts and desertification due to climate change may produce more particles, and they may spread over wider areas (Ayres et al 2009). Wildfires in particular pose many health risks. Apart from the direct threat to life, their smoke may contain plastic and toxic (ie herbicide & pesticide) residues (Shea et al 2008).

Altered aeroallergens
Global warming is already having demonstrable effects on plant behaviour and distribution (IPCC 2007). There has been a general shift polewards and upwards (altitude) of plant habitability zones in many regions, related to warmer conditions. There have also been changes due to altered precipitation patterns and land-use variations.

Flowering times are also changing, with a general trend towards earlier spring flowering (although paradoxically, plants that rely on a longer duration of winter chill to trigger budding are flowering later due to warmer winters).

Research suggests that pollen amount and allergenicity is increasing.

Additionally, pollen appears to be more allergenic, with higher levels of some core proteins (the molecules mainly responsible for triggering allergy – Rom et al 2008). As respiratory allergies may follow dose-response curves, more pollen + more allergenicity = more severe allergies.

Changes in the timing of the pollen season (longer and earlier) may produce worsening allergies if there is overlapping with peak ground-level ozone production in summer.

Other changes due to global-warming include (Reid & Gamble 2009):
Changed wind patterns may disperse pollens in new directions or further than before.

Changed local conditions may alter dust-mite and mould distributions.
Changed agricultural practices may alter the level of pollens related to farming activity (eg rye grass is a component of farm pasture; the mould Alternaria is related to agricultural production).

Changed species makeup of forests and grasslands (whereby one species is replaced by another due to altered microclimate or species invasion) may also change pollen type and load.

All of these phenomena are having the effect of changing pollen distributions. This exposes new populations to novel allergens that will trigger new-onset allergies, as well as worsening existing ones.

Climate change is happening now, and some of the changes described (such as changes in flowering times and geographical range) have already been documented by the IPCC. We know from paleoclimate research that plants react quickly to environmental changes – ice-core and ocean sediment data show that significant vegetation changes (in response to previous climate disruptions) have taken just a decade to occur.

Extreme weather events
Climate change is expected to magnify the hydrological cycle, causing more frequent drought but also more hurricanes, storms and extreme precipitation events (IPCC 2007). It has been known for some time that thunderstorms may cause asthma exacerbations (Ayres 2009). It appears likely that this is due to the disruption of pollen particles, thereby exposing their allergenic cores. Heavier rainfall has the potential to cause flooding and increased mould growth. Both occurred after Hurricane Katrina inundated much of New Orleans. Following such extreme events, it is likely that population displacement, crowding, drinking water contamination and malnutrition will increase respiratory infections, especially pneumonia, and possibly increase TB transmission (Ayres et al 2009).

More frequent flooding, expected as the hydrological cycle intensifies due to global warming, will have adverse health consequences.

Conclusions
The expected impacts on respiratory morbidity and mortality discussed in this article are just a small part of the adverse heath effects predicted to occur over the coming decades due to climate change. The barriers to accepting and acting on anthropogenic global warming are largely psychological rather than scientific, as climate change science is now very robust (IPCC 2007). As health professionals we are well-equipped to deal with risk, uncertainty and levels of evidence, as we do so on a daily basis in clinical practice. We have a unique opportunity to educate and inform our patients, communities, colleagues and politicians about these issues. I believe we have an ethical duty to do so, in order to limit, as far as possible, the expected increased burden of illness that is on the horizon.

Do doctors have an ethical duty to inform society about the health effects of climate change?

References
Ayres JG et al. Climate change and respiratory disease: European Respiratory Society position statement. Eur Resp J 2009; 34: 295-302.
BOM. http://www.bom.gov.au/announcements/media_releases/climate/change/20100105.shtml. Accessed 17.01.2010.
IPCC 2007. Summary for policy-makers (WGI). In Climate Change 2007: The Physical Science Basis. Cambridge University Press NY. 2007.
McMichael AJ et al. Climate change and human health: Present and future risks. Lancet 2006; 367: 859-869.
Reid CE and Gamble JL. Aeroallergens, allergic disease, and climate change: Impacts and adaptation. Ecohealth 2009; published online 12 Nov 2009; accessed 10.01.2010: http://www.springerlink.com/content/mqu4540p63284360
Rom WN et al. Global warming: A challenge to all American Thoracic Society Members (editorial). Am J Respir Crit Care Med 2008; 177: 1053-1057.
Shea KM et al. Climate change and allergic disease. J Allergy Clin Immunol 2008; 122: 443-453.
Stafoggia M et al. Factors affecting in-hospital heat-related mortality: a multi-city case-crossover analysis. J Epidemiol Community Health 2008; 62: 209-215.
Zhang L et al. Transpacific transport of ozone pollution and the effect of recent Asian emission increases on air quality in North America: an integrated analysis using satellite, aircraft, ozonesonde, and surface observations. Atmos Chem Phys 2008; 8: 6117-6136.

A version of this article appeared on the Medical Observer blog on 18.01.2010.

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Air Quality and Respiratory Disease
Air quality is highly affected by weather and climate conditions.

In turn, certain aspects of air quality are known to affect health. In particular, ozone and airborne fine particulate matter (PM2.5) have well documented human health effects.

Climate change will increase ground level ozone in some areas and increase the burden of respiratory illnesses as a result.

Ozone is formed in warm, polluted air in the presence of sunlight. It causes direct, reversible lung injury; increases premature mortality; worsens respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD); and may cause lasting lung damage.

Current science suggests that climate change is likely to increase the concentration of ground-level ozone in the US…..

PM2.5s are generated by a range of sources, but primarily from the burning of fossil fuels. They are associated with respiratory and cardiovascular diseases (including asthma, COPD, and cardiac dysrhythmias) and are responsible for increased school and work absences, emergency department visits, and hospital admissions.

Current science suggests that climate change is likely to increase the concentration of ground-level ozone in the US (particularly in Northeastern, Midwestern and Western cities). Increased ozone in these areas will produce an increased burden of respiratory disease.

While of great interest, there is currently insufficient evidence to determine the likely effects of climate change on PM2.5.

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Aero-allergens
Increased ambient temperatures over land and increased ground-level carbon dioxide concentrations, both of which are expected with climate change, result in increased plant metabolism and pollen production.

These factors may also be associated with increased fungal growth and spore release.

Climate change will increase allergic diseases due to pollen.

Pollen and mold spores are allergens and can aggravate allergic rhinitis and several respiratory diseases, including asthma and chronic obstructive pulmonary disease, though the latter diseases have other significant triggers.

Allergic diseases are the sixth leading cause of chronic disease in the U.S. and impose a substantial burden on the U.S. population.

Asthma alone affects approximately 20 million Americans. Some experts have suggested that the global rise in asthma is an early health effect of climate change.

Aeroallergens act with other harmful air pollution to worsen respiratory disease. While the magnitude of climate change’s impact on allergic disease in the U.S. is yet to be determined, preliminary evidence suggests that there could be a substantial effect.

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Extreme Weather Events
The direct effects of extreme weather events include drowning from floods, injuries from floods, and structural collapse. Indirect effects outnumber the direct effects and likely will be more costly.

Climate change will increase the likelihood of extreme weather events like floods and increase the burden on human health.

Potential indirect effects include aggravation of chronic diseases due to interruptions in health care service, significant mental health concerns both from interrupted care and geographic displacement, and socioeconomic disruption resulting from population displacement and infrastructure loss.

Sea level rise increases the risk from extreme weather events in coastal areas, threatening critical infrastructure and worsening immediate and chronic health effects. Salt-water entering freshwater drinking supplies is also a concern for these regions, and increased salt content in soil can hinder agricultural activity in coastal areas.

Other indirect exposures and health effects
Climate change is a complex phenomenon and a range of unanticipated ecological effects will result. Many of these ecosystem effects could have indirect health effects.

Increased concentrations of ground-level carbon dioxide and longer growing seasons could result in higher pollen production, worsening allergic and respiratory disease.

Increased carbon dioxide concentrations in sea water are causing oceans to grow more acidic and are already causing adverse ecosystem changes in the world’s  oceans. This will have potentially dramatic implications for fisheries and the food supply in certain regions of the world.

Major regional ecosystem stresses may result in mass population movement and conflict, with significant health effects. Some of these concerns are low-probability high-impact events, and could have significant health impacts on a global scale.

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Weather and climate have affected human health for millennia. Now, climate change is altering weather and climate patterns that previously have been relatively stable. Climate experts are particularly confident that climate change will bring increasingly frequent and severe heat waves and extreme weather events, as well as a rise in sea levels. These changes have the potential to affect human health in several direct and indirect ways, some of them severe.

Increased Temperatures
Heat exposure has a range of health effects, from mild heat rashes to deadly heat stroke. Heat exposure can also aggravate several chronic diseases, including cardiovascular and respiratory disease. The results can be severe and result in both increased illness and death. Heat also increases ground-level ozone concentrations, causing direct lung injury and increasing the severity of respiratory diseases such as asthma and chronic obstructive pulmonary disease.

Higher temperatures and heat waves increased demand for electricity and thus combustion of fossil fuels, generating airborne particulates and indirectly leading to increased respiratory disease.

Over a longer time period, increased temperatures have other effects ranging from drought to ecosystem changes that can affect health.  Drought may also strain agricultural productivity and could result in increased food prices and food shortages, worsening strain on those affected by hunger and food insecurity in the U.S. and elsewhere.

Droughts can result in shortages of clean water and may concentrate contaminants that negatively affect the chemistry of surface waters in some areas.

Ecosystem changes include migration of the vectors (organisms that do not cause disease but transmit infection by carrying pathogens from one host to another) and animal hosts that cause certain diseases prevalent in the U.S., such as Lyme disease and Hantavirus. The dynamics of disease migration are complex and temperature is just one factor affecting the distribution of these diseases.

Winters will also be warmer, which is likely to lead to a decrease in illness and death associated with exposure to cold. This may be one of the few positive health effects of global warming. In addition to this general warming trend, climate change will bring increased weather variability, the results of which are difficult to predict.

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Some of the world’s largest medical, nursing and public health organisations are calling on world leaders to take bold action to address climate change. They say that this is needed to avert what could become a global public health crisis.

The prescription for a healthy planet hopes to get health in the spotlight at Copenhagen

A giant placard, “Prescription for a Healthy Planet” symbolically represents the interests of millions of health professionals in more than 120 countries whose organisations have endorsed it. The placard will be handed to United Nations officials at the climate talks.

“With this Prescription, health care leaders from around the world are speaking with one voice, insisting that an agreement in Copenhagen must protect both the planet and public health.”

— Pendo Maro (Senior Climate and Energy Advisor, HCWH/HEAL)

The Prescription diagnoses the global threats to public health that climate change poses while urging the world’s governments to negotiate a strong, binding agreement. The groups are calling for the Copenhagen treaty to protect public health, set strong targets on emission reductions, promote clean energy, and mandate major funding for developing countries to address the climate crisis.

Sign the Prescription for a Healthy Planet by clicking this image.

In the past two months the Prescription for a Healthy Planet has been endorsed by many major health organizations including the International Council of Nurses, a global federation of national nursing organizations representing nurses in 128 countries.

“Nurses need to take every opportunity to influence governments in relation to climate change. As front-line professionals, we see both the acute and chronic impact that damage to our environment has on health and the well-being of citizens.”

-David C. Benton (ICN Chief Executive Officer)

Others who have endorsed the Prescription include International Society of Doctors for the Environment (ISDE) and the Standing Committee of European Doctors (CPME), which represents 27 medical associations in Europe. In the United States, a parallel initiative from health care leaders representing hundreds of hospitals and nearly three million health professionals is calling on President Obama to support the points made in the Prescription.

“As public health professionals, we have a duty to warn the world’s governments that if they do not take bold action now, we face the spectre of a future of global public health crises generated or exacerbated by climate change.”

-Dr. Paulo M. Buss (President of the World Federation of Public Health Associations)

At the Barcelona talks, the Prescription will be handed to Dr Roberto Bertollini, top climate expert at the UN’s specialist health agency, the World Health Organization.

Handing over the "Prescription for a Healthy Planet" at the Barcelona talks (Nov 2009).

“At the WHO, we would like to see greater attention given the social and health impacts of climate change in the current negotiations. Population adaptation will require the active involvement of health systems and the necessary human and financial resources. We hope that the new treaty will meet these needs, and we expect that this initiative from the health community in Barcelona will draw more attention to the health impacts of climate change and the necessary response,” Dr Bertollini says.

The World Health Organization predicts that climate change will likely lead to significant increases in illness and death related to a number of factors: intense heat, floods and other extreme weather events; the deterioration of air quality; increased transmission of vector-borne and infectious diseases such as cholera, malaria, and dengue; and the compromising of agricultural production and food security causing malnutrition.

Many health care leaders agree with this assessment. Dr. Dana Hanson, President of the World Medical Association said in his inaugural speech in New Delhi last month that he believes that, “climate change is likely eclipse the major known pandemics as the leading cause of death and disease in the 21st century.”

In a parallel advocacy initiative, HEAL, HCWH and CHC are sending a letter to the UNFCCC negotiators about the Prescription recommendations and the need to increase the focus on health in the agreement. The letter says that the costs of unchecked climate change on health necessitate a significant reduction in carbon emissions on the part of wealthy nations. The letter also recommends that a significant proportion of resources should be allocated to the health sector from the global action fund financed by national contributions.

The costs to public health of climate change are likely to be high. In Europe alone, the estimated annual public health savings resulting from a 20% reduction in carbon emissions (from 1990 levels) by 2020 would be 52 billion Euros each year from 2020. [4] This figure would be significantly higher if health benefits globally were taken into account.

Resources

-The Health and Environment Alliance (HEAL) aims to raise awareness of how environmental protection improves health. It brings together more than 60 organizations working at the European level. Read more about their climate change program.

-Health Care Without Harm is an international coalition of more than 470 organizations in 52 countries, working to transform the health care sector worldwide, without compromising patient safety or care, so that it is ecologically sustainable and no longer a source of harm to public health and the environment. Visit the HCWH homepage for more information, or their specific climate change pages (categorised by continent).

-Sign or learn more about the Prescription for a healthy planet.

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