Climate Change and Social Determinants of Health

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ICCG Think Tank Map: a worldwide observatory on climate think tanks
Climate Change and Social
Determinants of Health: Innovating
Climate Policy
Sabrina Dekker, ICCG
Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
Climate Change and Social Determinants of
Health: Innovating Climate Policy
Sabrina Dekker (ICCG)
Abstract
Research has shown that human health is being adversely impacted by climate change. As such
governments are faced with the task of devising policy that simultaneously addresses the impacts
of climate change on the environment and human health. To understand the challenges facing
governments, the complex relationship between the social determinants of health, climate change
and human health is discussed. The objective is to provide a ‘new’ framework from which policy
on climate change and human health can be developed and maximize effectiveness; as the
social determinants of health consider health as a product individual lifestyle choices and the
external factors that shape choices.
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
Introduction
The environments in which people live play a role in their health, as such, changes to their
environments will influence their health, positively or negatively. Climate change has been a
negative influence on the environment, and human health is being adversely affected by it.
Moreover, research conducted by the WHO and other research bodies such as the Lancet1 has
shown that climate change adversely impacts human health in numerous ways; from contributing
to the re-emergence of diseases, to the spread of infectious diseases and increased mortality. The
mechanisms by which climate change impacts human health are as diverse and complex as the
impacts. There is no clear casual pathway between a climate change impact, such as air pollution
and a health issue such as asthma; rather it is a series of pathways. Climate change impacts,
namely, air pollution and air quality, extreme temperatures, extreme weather, and rising sea levels
and flooding, do not express themselves independently of each other. There are complex and
interconnected relationships between each for example high temperatures increase the
concentration of pollutants in the air thereby degrading air quality. Consequently, the relationship
between climate change and health is complex; moreover the range of factors that influence
health are complex too. Thus, the challenge now, is innovating current climate policy and plans so
that they address the health impacts of climate change. One means by which to achieve this is
through the social determinants of health (SDH), which have played a role in shifting the focus of
health policies to poverty reduction, sustainability and livelihood improvement the causal factors
associated with health outcomes2. Sustainability is one shared agenda with climate policy, there
are more3. This paper looks firstly looks at the SDH, their relationship to climate change, and finally,
their value and role in mitigating the health impacts of climate change through policy.
Social Determinants of Health
The social determinants of health are the factors that influence an individual’s health and wellbeing over the life course. There are three categories under which the SDH are classified: individual
life style factors, social and community network, and general socioeconomic, cultural and
environmental conditions4. Life style factors are the age, sex and constitutional (inherent) factors
that are unique to individuals. The social and community networks are characterized by a single
determinant, social inclusion/exclusion. General socioeconomic, cultural and environmental
conditions consist of the following determinants: agriculture and food production, education, work
environments, living and working conditions, unemployment, water and sanitation, health care
services, and housing5. The categories and determinants are not exclusive of each other, rather
the factors that shape the determinants are fluid, interacting and influencing each other.
The SDH listed here are not an exhaustive list. Depending on the geographical location of
individuals the determinants of health may include additional factors. For example, Mikkonen and
Raphael6 conducted research on the SDH in the Canadian context, additional determinants
included in their research were: aboriginal status, race, social safety net, disability. Thus depending
on where one is living the determinants of their health will vary. However, there is one factor that
plays a dominant role in determining the health status of an individual from birth, income7. Statistics
have shown that a child born into an impoverished household with little to no income already has a
WHO, 2008; WHO, 2013; Rydin et al, 2012; Marmot, 2005; Blas et al, 2008
Ritsatakis, 2012; Forde and Raine, 2008; Friel, et al. 2008
3 Friel, et al. 2008; Galvao et al, 2009
4 Putnam and Galea, 2008; Mikkonen and Raphael, 2010; WHO 2008; WHO, 2013
5 Mikkonen and Raphael, 2010; WHO 2013; Blas et al., 2008
6 (2010)
7 Mikkonen and Raphael, 2010; WHO 2008; Crawford et al. 2010; WHO 2013
1
2
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
lower life expectancy than a child born into a household that has a stable income8. This is
correlated to the individual’s and family’s ability to purchase basic necessities required for a
decent quality of life from stable housing, nutritious food, to the ability to send children to school
and receive an education9.
Income and financial status are not constant over the life course and there are numerous external
factors that will influence one’s income level: economic crises, wars, changes in labour
force/market demands10. As with income, other SDH fluctuate over the life course. Regardless of
these fluctuations, it has been shown that ‘negative’ determinants adversely affect human health
and well-being. To further clarify, the SDHs span a spectrum, from negative to positive, when the
determinants are in a negative state, they are detrimental to human health. In order to understand
how determinants can influence health outcomes over the lifecycle one can look at how income
or economic opportunity shapes health outcomes11.
Figure. 1 Social Determinants of Health
The ability of an individual to access secure and stable employment plays a significant role in the
ability of individuals to maintain their physical and mental health through the purchase of healthy
foods and access to physical activities. Employment that is fraught with instability and insecurity
tends to lead to poor mental health outcomes, such as depression and anxiety, which can have
compounding effects on physical health12. Research has shown that depression contributes to the
highest number of sick days13. As anticipated, a fluctuating income or lack of income adversely
affects the purchasing power of individuals/families; forcing the prioritization of income
expenditure, such as purchasing cheap foods with low nutritional value. It also contributes to
another determinant, poverty14. Figure 2. highlights probable outcomes when access to income
and employment are stable or unstable.
WHO, 2008; WHO, 2013
Friel, et al. 2008; Marmot, et al., 2008; Forde and Raine, 2009
10 Hutton and Menne, 2008; Mikkonen and Raphael, 2010; WHO 2008; Crawford et al. 2010; WHO 2013
11 Berger, 2013; Blas, et al., 2008
12 WHO, 2013; Barton, 2009; Grady and Goldblatt, 2012
13 WHO, 2008; Marmot, 2005
14 Grady and Goldblatt, 2012
8
9
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
Figure 2. Access to Income/Employment
Poverty is well known to have a negative impact on health outcomes, it is credited with being “a
cause of much of the global burden of disease”15. The causes and mechanisms of poverty interact
with each other and feed into the ‘cycle of poverty’ that traps individuals. However, it is primarily
an issue of “access”, access to: stable employment, affordable and safe housing, education, food
and water and healthcare16. The level access to these basic needs depends on where one lives.
For example, the urban poor in Mumbai face different challenges from the urban poor of New York
City. However, in both cities, those with precarious incomes face the risk of falling into the cycle of
poverty and vulnerability17. A cycle which is further perpetuated when climate change impacts are
considered.
Climate Change’s impact on the social determinants of health
The SDH provide a means by which to understand the impacts of climate change on health and
society; and provide insights on how policy can mitigate negative health outcomes18. Discussed
here are how the four key climate change impacts influence the social determinants of health:
extreme temperatures, air quality and pollution, rising sea levels and flooding, and extreme
weather and natural disasters.
While the SDH are in and of themselves issues of access to income and employment, stable
housing, nutritious food, safe living environments and other basic needs19. Climate change
compounds these access issues. Beginning with extreme temperatures, either heat or cold, there
are numerous pathways by which human health can be impacted. Food and water supplies are
the most adversely affected by temperature, resulting in damaged crops, low yields, and
drought20. Shortages lead to rising food costs which tend to adversely affect lower income groups,
thereby impeding their access to nutritious food and consequently setting the stage for
malnutrition. There is a tightening cyclical impact21.
Each of the three remaining impacts of climate change exert similar impacts; as, they are
interrelated. Decreased air quality and pollution are known to contribute to respiratory and
cardiovascular disease which affect an individual’s ability to work. Thus, contributing to the cycle
of vulnerability. However, while extreme temperatures and air quality and pollution tend to
WHO, 2013; Rydin et al. 2012; Harpham, 2008; Grady and Goldblatt, 2012
WHO, 2013; Rydin et al, 2012; Barton, 2009
17 Grady and Goldblatt, 2012
18 Blas, et al, 2008; Barton et al, 2009; Grady and Goldblatt, 2009; Galvao, et al, 2009
19 Stephenson et al, 2013; Grady and Goldblatt, 2012; Ritsatakis, 2012
20 Berger, 2013; Grady and Goldblatt, 2012
21 Berger, 2013; Grady and Goldblatt, 2012
15
16
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
adversely impact individuals in the lower income groups more so than higher income groups it is
rising sea levels and flooding, and extreme weather events, that impact all income groups22. Both
of these climate change impacts adversely affect physical infrastructure from roads to buildings.
Their immediate impacts on people are death and physical injury. In their aftermath the costs for
reconstruction are high, and their social costs in terms of wellbeing are even greater (and poorly
understood)23. For example, death or injury of the primary bread winner can result in negative
outcomes, beginning with loss of income necessary for sustaining basic needs. Which again
contributes to the cycle of poverty and poor health, for individuals and families. However the SDH
are not limited to individuals and have impacts on broader systems and communities.
Table 2. Climate Change Impacts on the Social Determinants of Health
Social Determinants of Health: General
socioeconomic, cultural and environmental
Climate Change Impact on SDH
Agriculture and Food Production
Decreased food yields, contributing to malnutrition, rising food costs
Education
This is a complex relationship; Lack of education can result in
behaviors/practices that perpetuate climate change, while climate
change affecting families can result in the early withdrawal of children
from school. Other indirect causal pathways
Work Environments
Unsafe working conditions, loss of employment, risk of death and injury
Living and Working Conditions
Quality of buildings; safety; hazards; working hours, other indirect impacts
Unemployment
Indirect, loss of income reduces the purchasing power of individuals and
households.
Water and Sanitation
Salination of water, compromised sanitation systems, spread of disease
Healthcare services
Impeded, stressed during times of emergency response
Housing
Loss of housing, damage to housing
To gain an understanding of the complex relationship between climate change, the SDH and
human health at the broader level of society; one can look at the effects of climate change on the
food supply chain, namely the production and distribution of wheat. Once wheat is grown and
harvested by farmers it is processed into flour, then distributed to various consumers to produce
various food products for consumption. Suppose that during the growing season there is a flood or
drought or an extreme weather event that results in low or no yields. This sets off a chain reaction,
beginning with a negative impact on the income of the farmer, thus affecting his livelihood. This
also impacts the mill that grinds the wheat into flour. Flourmill owners are forced to look elsewhere
for wheat, perhaps a destination further off, resulting in increased transportation costs that add to
the costs of the wheat/flour, which in turn raise the costs of the consumer who is turning the flour
into a product for sale. At this stage consumers/producers who are using the wheat/flour are faced
with two options; raise the cost of the product to cover the increased transportation costs or lay off
workers. Both are negative outcomes impacting livelihoods along the supply chain. Moreover
depending on the location of this flourmill the out of work –workers may be forced to change their
household income expenditures to accommodate for the lost income. Depending on the
prioritization of needs, children may be withdrawn from school and forced to work, and families
may choose to purchase food products with low nutritional value. Assuming that a producer of a
22
23
Berger, 2013; Grady and Goldblatt, 2012
Tol, 2009; Berger, 2013; Grady and Goldblatt, 2012
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
good values the employees and chooses to raise the price of their product, consumers of the
product may choose to not purchase the product and find a substitute, which will still have
prolonged negative impact on the workers. However, if the good is a necessity, then consumers
may have to adjust their consumption patterns, which may have negative health outcomes. A
short term climate event can have far reaching effects; a series of climate events can have a
lasting impact on individuals and whole populations.
The example demonstrates the complex relationship between climate change and the SDH.
Acknowledging this, the next consideration is how can policy mitigate these impacts. Marmot24
highlights a critical issue with current policy, which is focused on deprivation. For example policy
focuses on providing clean water and medical services to poor communities to mitigate negative
health outcomes25. While these interventions may work they miss the social causes, such as the
cultural and community influences that enable poverty or other conditions to persist, also known as
the causes of the causes26.This is where education, a SDH, plays a key role in policy interventions.
People need to understand why a policy is being implemented and how it impacts their livelihoods.
It is not enough to provide a sanitation system without educating people on how to maintain the
system, or at a basic level, how to treat water so that it is safe for consumption. The challenge for
policy makers now is developing policy that addresses climate change, and human health
simultaneously, the SDH provide the bridge.
Common Ground: Overlapping Policy Agendas
“Climate change, urbanization, rural development, agriculture and food security are
intertwined determinants of population health and health equity” – Galvao et al. 2009.
The focus of climate change policy and health policy stemming from the social determinants of
health are similar in their objectives, as illustrated in figure 3. Climate change policy is focused on
the mitigation of adverse impacts on the environment through actions that increase the resilience
of the environment. Embodied in the objectives of the policies are protection of the environment
in its current state and its sustainable management for present and future needs27. Whils
recognizing the need for economic growth that will support the demands of a growing population;.
Health policy based on the social determinants of health is focused on the prevention of ill health28.
This is achieved through the identification, mitigation and prevention of causal factors that impact
human health. Traditionally, health policy responds to immediate issues. However, the social
determinants have added a sustainability dimension that acknowledges that health policy is more
effective when the long run is considered. Finally, there is the objective of growth from the social
perspective; namely the growth healthy populations and communities.
Considering the objectives alone, it is evident that there is a common ground between climate
change policy and health policy based on the social determinants of health specifically,
mitigation, sustainability, and growth (Illustrated in figure 3 below). Further research conducted by
the WHO’s commission on the social determinants of health calls for integrated policy to
simultaneously address these two pressing issues for humanity. Galvao et al29 reiterated and
supported the recommendations made by commission emphasizing the following to link action by
actors in the climate change and health fields:
2005
Marmot, 2005
26 Marmot, 2005
27 Friel, et al., 2008; Galvao et al, 2009; Marmot et al, 2008
28 Friel, et al., 2008; Galvao et al, 2009; Marmot et al, 2008
29 (2009)
24
25
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
1. “Ensure that economic and social policy responses to climate change and other
environmental degradation take into account health equity”
2. “Widespread recognition of the disruption and depletion of the natural environmental
system.”
3. Acknowledging “the inescapable evidence of climate change and environmental
degradation have set clear limits to a future based on the status quo and are prompting
and increasing global willingness to do things differently”.
4. Consideration of “the health impact of agriculture, transport, fuel, buildings, industries and
waste strategies concerned with adaptation to and mitigation of climate change”.
5. “More analysis of the relationship between social determinants of health, environmental
change and health inequities… to inform policy and practice.”
The commission completed their work in 2008 and progress on their recommendations has been
slow30. With the release of the IPCC Fifth report on climate change and again the emphasis of
anthropogenic causes; there is a need to take action31. But what level of government has the
capacity to create policy that will affectively and simultaneously address health and climate
change32? International organisations have set the stage providing recommendations, and
national governments are committing politically to implement recommendations. But is that
sufficient and does it address the issues of access and cyclical problems inherent in the SDH and
exasperated by climate change? Further, recommendations at the international and national
levels are broad and tend to neglect the local context, which is where the impacts of climate
change on health are the greatest33. Local governments are consequently tasked with localizing
global policy; to meet the local contexts.
A subsequent paper will look further at the role of local governments in creating policies and plans
that mitigate the health impacts of climate change. Briefly, local governments have the greatest
potential for integrating policy and developing innovative policies that will see positive sustainable
outcomes34 . Central to this is their ability to create an environment for collaboration on policy.
Further, local governments have an intimate knowledge of the local context, specifically in relation
to the SDH and climate change, they know the health status of the local population. This is key in
the development of policy, as population health can serve as indicator of the success of climate
change policy that integrates the SDH. Granted, there are challenges with selecting appropriate
health indicators and linking them to climate change, but this is where the SDH can direct and
connect policy to appropriate indicators and measures.
WHO, 2008; Galvao et al, 2009
Friel, et al., 2008; Galvao et al, 2009; Marmot et al, 2008
32 Friel, et al., 2008; Galvao et al, 2009; Marmot et al, 2008; Grady and Goldblatt, 2012; Stephenson, et al., 2013
33 Marmot, 2005
34 Friel, et al., 2008; Galvao et al, 2009; Marmot et al, 2008; Grady and Goldblatt, 2012; Stephenson, et al., 2013; Ritsatakis;
2012
30
31
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
Figure 3. Connecting Climate Change Policy Objectives and Social Determinants of Health Policy
Objectives
Conclusions
It is evident that climate change has an impact on human health. While it is a challenge to identify
the exact casual pathways that link climate change to negative health outcomes, as they are
infinite and complex, the impacts cannot be ignored. All stakeholders, must work collaboratively to
create policies that will mitigate the vulnerabilities to human health that are posed by climate
change. As such the SDH provide a starting point from which innovative and active policy can be
developed to mitigate climate change and improve human health simultaneously.
The SDH provide a viable means by which to understand the broader implications of climate
change’s impact on human health. They provide the big picture and the probable ways that an
adverse impact of climate change can result in negative health outcomes, not just at the point of
impact. Further, the SDH bridge health policy and climate change policy, and potentially reforms
the way policy on climate change and health is developed. Climate change policy is more than
reducing greenhouse gas emissions and pollution with broad transportation policies; and health
policy is more than reducing asthma rates and incidence of cardiovascular and respiratory
diseases through physical exercise promotion. The SDH highlight interconnections between GHGs,
respiratory diseases and their broader social and economic implications. A policy based on
research into the causes related to the SDH would acknowledge the economic and social losses
stemming from sick days related to respiratory illnesses; then look for viable options such as tax
incentives for employers to initiate cycle to work schemes for employees.
Ultimately the social determinants of health provide a framework for creating policy that
simultaneously address climate change and human health. However, while income as a
determinant may have greatest impact on health outcomes it is education that will determine the
success of any policy. As such while policy makers must engage and invest in research to
understand the causal pathways between climate change and human health. While
implementation of policy must include education on why and how policy is intended to work and
its impacts for individuals in the broader context of their community.
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Climate Change and Social Determinants of Health: Innovating Climate Policy
ICCG Reflection No. 19/February 2014
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