Friday, December 26, 2014

Health of Populations set to Worsen in the Climate Change Era. Can Developing Nations like India Cope?

Health of Populations set to Worsen in the Climate Change Era
Can Developing Nations like India Cope?
-          Jagannath Chatterjee
Presented at the Odisha Environment Congress 2014 at Bhubaneswar
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.[1] Despite tremendous growth in medical science, over the years the world has been witnessing a steady decline in health status of populations to a point where healthy individuals are difficult to find.According to a 2012 WHO report, India accounts for 21% of the world’s global burden of disease. Non Communicable Diseases (NCDs) are responsible for two-thirds of the total morbidity burden and about 53% of total deaths in India. This figure is up from 40.4% in 1990 and is expected to rise to 59% by 2015.[2] India is losing more than 6% of its GDP annually due to premature deaths and preventable illnesses, according to a 2010 World Bank report. The per capita expenditure on health has more than doubled between the years 2000 to 2009 and out-of-pocket payments have increased, with impoverishment of nearly 2.2% of population taking place annually due to catastrophic illness-related expenditure. Hospitalization for major illnesses is a major cause of indebtedness, especially for those living below the poverty line.[3]
The Changing Climate & It’s Impact on Public Health
Climate change and its impacts on people and ecosystems are set to add to the pressure of rising illnesses and increasing treatment costs besides adding to deaths and disabilities due to climate change induced natural disasters. The Synthesis Report of the Fifth Assessment Report of the Intergovernmental Panel on Climate Change (IPCC) states unequivocally that recent climate changes have widespread impacts on human and natural systems. The report has noted warming of the atmosphere and oceans, diminishing snow and ice covered regions, and rise in sea levels. Changes in the oceans have been observed as increased warming of ocean surface, increase in ocean surface salinity, and acidification of oceans. The report points out the increasing concentration of greenhouse gases in the atmosphere, changes in rainfall patterns, adverse changes in availability and quality of water, negative impacts on agriculture and crop yields, and effects on marine and estuarine ecosystems leading to drop in fish and related catch. Increase in heat waves and extreme rainfall events, the report warns, would lead to droughts, floods, cyclones and wildfires.[4]
Public health experts warn that the major threats – both direct and indirect – to global health can be outlined through changing patterns of disease, water and food insecurity, vulnerable shelter and human settlements, extreme climatic events, and population growth and migration. Vector borne diseases will expand their reach and death tolls, among the sick and elderly, will increase because of heat waves and extreme weather events. The indirect effect of climate change on water, food security, and extreme climatic events are likely to have the biggest effect on global health (Costello et al, 2009). Climate change has set in and will alter spatial and temporal distribution of vector borne diseases; exacerbation in heat related morbidity, air pollution related respiratory illnesses, and water borne diseases, if current scenario continues. In tropical countries like India, most of the identified health effects due to climate change are already experienced (Singh et al, 2012). The direct impact of weather on human health is mortality due to increased temperature, disasters resulting in flood, loss of life and infrastructure due to cyclones etc, impact on water and vector-borne diseases, malnutrition and respiratory diseases (WHO, 2003).
In addition to these direct health effects, climate change will have indirect substantial consequences on health. Economic collapse due to climate change induced losses will devastate global health and development. Mass environmental displacement and migration will disrupt the lives of hundreds of millions of people, exacerbating the growing issues associated with urbanisation and reverse successes in development. Conflict might result from resource scarcity and competition, or from migration and clashes between host and migrant groups (Costello et al, 2009). Moreover the devastating effects of disasters can have considerable psychological effects on those affected and on survivors. The stress experienced can also lead to physical ailments. These effects are likely to be more pronounced on women and children.
The impact on developing nations like India will be severe as climate change impacts have been observed to widen social and health inequalities. Though gearing up to face disasters, shaken by incidents in recent times, India lacks financial capacity, infrastructural requirements, and enough skilled manpower to respond to climate change impacts.
Extreme Temperature & Human Health
Extreme temperatures can cause heat waves where summer temperatures can climb from the normal of 36 to 40C to more than 45C and remain so for more than two days.  Normally the body can handle up to 37C without stress. However beyond that the body starts gaining heat from the atmosphere which can cause uncontrolled physiological stress and can even lead to death. The State of Odisha experienced an unprecedented heat wave in the year 1998 which killed 2042 people mostly in coastal regions. Despite awareness measures and remedial steps taken, heat waves continue to take their toll on the state and the cumulative figure since 1998 has touched 3000. Andhra Pradesh, Odisha, Punjab, Uttar Pradesh, Rajasthan, Bihar and Madhya Pradesh are the most affected states. Changes in temperature and humidity patterns have also been linked to eye and skin diseases besides increasing the discomfort of people suffering from malnutrition and chronic illnesses and the elderly. The impacts of heat waves are more pronounced on the poor, particularly farmers, construction site workers, and daily wage earners.
Diseases Resulting from Poor Air Quality and Pollution
India has a heavy burden of respiratory illnesses, particularly in children and adolescents. Rural women who burn fuel for cooking and tobacco smokers are also heavily burdened. A study from rural India published in the Journal of Global Infectious Diseases found the prevalence of acute respiratory infections in 26.22% of the sample of infants surveyed with female children more affected. Inadequate ventilation, overcrowded living conditions, use of biomass fuel, and lack of adequate nutrition were determined to be the risk factors.[5] An ICMR study conducted in 2010 on 15 to 85 year old's found chronic respiratory symptoms in 8.5% of respondents. The incidence of asthma was 2.05%, and chronic bronchitis was found in 3.49%. Advancing age, asthma in first degree relatives, use of any smoking product, exposure to tobacco smoke in childhood or adulthood, and using LPG, coal, wood or dung cake for fuel in cooking were determined to be the risk factors. The rural population was found to be disproportionately affected.[6] This trend will continue upward as climate change threatens to adversely affect air quality and lead to more pollution levels in the atmosphere.
A study in Nature Climate Change points out that climate change induced air stagnation is set to worsen air quality in many parts of the globe. Air stagnation arises from three meteorological ingredients: light winds, a stable lower atmosphere and a day with little or no precipitation to wash away pollution. Stationary air masses develop and allow soot, dust, pollutants and ozone to build up in the lower atmosphere. The study pointed out that large swathes of India, Mexico and the Amazon could see up to 40 more stagnant air days per year compared to the average annual tally from 1986 to 2005, representing increases of 40%, 19% and 28% respectively. The largest increase in overall human exposure will be in India due to the country's enormous population, along with the increases in atmospheric stagnation.[7] Outdoor air pollutants are a major contributor to stroke, heart disease, lung cancer and respiratory diseases including asthma. The World Health Organization estimates that outdoor air pollution caused 3.7 million premature deaths globally in 2012. 
Impact of Food & Nutritional Insecurity on Health
Malnutrition induced low body mass index and stunting have been in the spotlight in India ever since the HUNGaMA Survey Report was released in the year 2011. The study revealed alarming findings related to the all the three indices of malnutrition; stunting, wasting and underweight. The study was undertaken in the most backward districts of six states – Bihar, Jharkhand, Madhya Pradesh, Odisha, Rajasthan and Uttar Pradesh. The report, which had the largest sample size for a nutrition study since 2004, revealed that 59% of the children were stunted, 42% underweight and 11.4% wasted.[8]
With the most severe impact of climate change noticed in agriculture, particularly on the major crops of India (rice, wheat, maize, sorghum) climate change induced droughts and floods, and the crop destructive effects of extreme weather events like heavy rainfall and cyclones, the negative impacts on the economy leading to reduced purchasing power of the people, food and nutrition security is severely threatened. Hunger, illness and death due to under nutrition are set to worsen as climate change affects crops, forestry, livestock, fishery, aquaculture and water systems. Sea level rise and flooding of coastal lands will lead to salination or contamination of fresh water and agricultural lands and loss of areas for fishing as is being witnessed in the coastal areas across the Bay of Bengal in India.
Disruption in Water and Sanitation
Access to safe drinking water and good sanitary conditions are vital for a healthy population. Climate change induced erratic rainfall, rising temperatures and increased salinity in coastal regions will add to India’s water and sanitation woes aggravated by deforestation, floods and droughts, and the declining water table due to the unsustainable use of water by both agriculture and industry. Sharing of river waters have been the source of dispute among states in India and even with its neighbours. According to the IPCC Synthesis Report 2014 climate change may further complicate the unsustainable consumption of groundwater for irrigation and other uses in some locations, such as the Indian states of Rajasthan, Punjab, and Haryana.Approximately 73% of the rural population in India does not have proper water disinfection (International Institute of Population Sciences and Macro International, 2007) and more than 50% do not have sanitation facilities (NSSO Survey, 2012). With 638 million people defecating in the open and 44 per cent mothers disposing their children’s feces in the open, there is a very high risk of microbial contamination (bacteria, viruses, amoeba) of water (UNICEF, 2011). Freshwater availability in India is a concern and the available water is expected to decrease drastically by 2025 in response to combined effects of population growth and climate change (IPCC, 2007). Increase in incidence of cholera – particularly in coastal regions due to warming of oceans – diarrhea, digestive disorders, and worm infestations would result. According to a recent report by the Research Institute of Compassionate Economics poor sanitation and not malnutrition may be the reason behind stunting in India’s Children (Time, September 09, 2013).
Case Study from Satyabadi Block of Puri District in Coastal Odisha – Post Flood Scenario
A team visited the Community Health Centre at Satyabadi Block and also the Government Area Hospital at Sakhigopal to know firsthand about the diseases faced by the villagers in the post flood scenario. According to the hospital staff the main complaints seen among those visiting the health centre were diarrhoea and other stomach complaints, skin problems and minor injuries. Among children who were brought in by their parents, diarrhoea, fever with or without cold, giardiasis, asthma and gastric complaints were common. It was specified by them that only people with treatable acute illnesses visited the health centre. Those with chronic illnesses and other illnesses of a serious nature preferred to visit the nearby Government Area Hospital at Sakhigopal or go to the District Hospital at Puri, some 15kms away. In the Government Area Hospital the doctor on duty informed that diarrhoea and fever were the two main complaints in visiting patients. Acute respiratory infections in children were common. Snakebite victims were seen after the floods. The doctors blamed poor quality of water and lack of sanitation facilities during the calamity as the prime causal factors.
Health Impacts of Disasters
Major disasters caused by extreme weather events can have a considerable impact on health. Associated health problems can arise from the loss or contamination of potable water leading to disease, destruction of crops leading to food shortages, poor nutrition and malnutrition. Health problems are compounded by general infrastructure breakdown, notably with respect to water supply, sanitation and drainage. In the long term mental health conditions after a disaster, such as depression and anxiety can also present serious problems.[9] Women and adolescent girls become particularly vulnerable in such periods and sexual aggression against them affects both their physical and mental health.
Proposed Action – Prime Minister’s National Action Plan on Climate Change[10]
·         Provision of enhanced public health care services
·         Assessment of increased burden of disease due to climate change
·         Providing high resolution weather and climate data to study the regional pattern of diseases
·         Development of a high-resolution health impact model at the state level
·         GIS mapping of access routes to health facilities in areas prone to climatic extremes
·         Prioritization of geographic areas based upon epidemiological data and the extent of vulnerability to adverse impacts of climate change
·         Ecological study of air pollutants and pollen (as the triggers of asthma and respiratory diseases) and how they are affected by climate change
·         Studies on the response of disease vectors to climate change
·         Enhanced provision of primary, secondary, and tertiary health care facilities and implementation of public health measures, including vector control, sanitation and clean drinking water supply
The potential of climate change to aggravate existing disease conditions and add to the mental health problems of already stressed populations is real and cannot be ignored. However there is need to stay away from literature that offers readymade medical fixes to exploit the situation and increase the market for products of multi-national drug corporations – particularly for vector borne illnesses. Such fixes can aggravate the problems faced by severely malnourished populations living in underdeveloped nations like India. Public health investment on clean water, sanitation, locally available safe food and nutrition, housing, poverty reduction through climate resilient livelihood models and awareness on safe and healthy habits has historically led to decrease in the incidence of diseases that threaten populations in the climate change era. Incorporating AYUSH into the mission will lead to decrease in national investment on health and also reduce out of pocket expenditure of impoverished sections besides being more conducive to health. Health and safety education to vulnerable groups, local health care workers and institutions is needed. Local practices being practiced by the communities to face challenges like floods, heat strokes and protection from disease vectors should be documented and encouraged as adaption measures.

[1] Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.
[2] WHO, Country Cooperation Strategy at a Glance,
[3] ibid
[4] Climate Change 2014, Synthesis Report, edited by Rajendra K Pachauri, Chairman IPCC; accessed on 08.12.2014
[5] Farzana Islam, Profiling Acute Respiratory Tract Infections in Children from Assam, India, Journal of Global Infectious Diseases, Jan-March 2013.
[6] INSEARCH Study, ICMR, 2006-09
[7] Horton, D. E., Skinner, C. B., Singh, D. & Diffenbaugh, N. S. Nature Clim. Change (2014).
[8] Nandi Foundation, The HUNGaMA Survey Report 2011
[9] Climate Change and Water, Technical Paper of the IPCC, Geneva, IPCC Secretariat, 2008

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