INSIDE THE GREENHOUSE

THE IMPACTS OF CO2 AND CLIMATE CHANGE

ON PUBLIC HEALTH IN THE INNER CITY

Paul R. Epstein and Christine Rogers

Report from the Center for Health and the Global EnvironmentHarvard Medical School

INSIDE THE GREENHOUSE

THE IMPACTS OF CO2 AND CLIMATE CHANGE

ON PUBLIC HEALTH IN THE INNER CITY

Edited by:Paul R. Epstein, M.D., M.P.H.1 and Christine Rogers, Ph.D.2

1. Associate Director, Center for Health and the Global Environment,Harvard Medical School

2. Senior Research Scientist, Harvard School of Public Health

Published by:

THE CENTER FOR HEALTH AND THE GLOBAL ENVIRONMENTHarvard Medical School

401 Park DriveBoston, MA 02115

617 384-8530http://www.med.harvard.edu/chge

April 2004

AcknowledgmentsThe collaborative work and this report were made possible through the generous support of theJohn Merck Fund, the Energy Foundation, and the Civil Society Institute.

Georges Benjamin, M.D., Executive Director of the American Public Health Association,contributed to this report. Sarah Meginness, John Rich, M.D., M.P.H., Margaret Reid and JohnAuerbach, M.B.A. (Commissioner) of the Boston Public Health Commission contributed to anearlier report, Urban Indicators of Climate Change, from which some of the material in this reportwas drawn. That report was based on a conference of Health Commissioners from around thenation held in October, 2002 at the Boston Public Health Department.

The greenhouse ragweed experiments with ragweed were initiated by Susannah Foster, workingwith Fakhri Bazzaz, Ph.D., Mallinckrodt Professor of Biology, Department of Organismic &Evolutionary Biology, Harvard University. This report also includes a contribution on heatwavesby Laurence S. Kalkstein, Ph.D., Center for Climatic Research, University of Delaware.

TABLE OF CONTENTS

Page

Executive Summary and Key Points 4

Oil and Environmental Justice: A Life Cycle Analysis 6

Carbon Dioxide, Climate Change and Aeroallergens 8

Overview of Climate Change and Urban Public Health 12

Introduction 12

Heatwaves 13

Case studies: Chicago: Summer 1995, Europe: Summer 2003 13

Cardio-Respiratory Disease and Air Quality 15

Emerging Infectious Diseases 16

Case study: West Nile virus 1999-2004 16

Traumatic Injuries and Extreme Weather Events 20

Gastro-Intestinal Infections and Water Quality 20

Case study: Cryptosporidiosis in Milwaukee 1993 21

Food Quality 21

Sea Level Rise and Storm Surges 21

References 22

Conclusions and Recommendations 24

Appendix: Strategies to Reduce Public Health Impacts of Climate

Change at the Local Level 25

EXECUTIVE SUMMARY

Rising levels of carbondioxide (CO2), inaddition to trappingmore heat, promoteplant pollen production,soil bacteria and fungi,and alter speciesc o m p o s i t i o n b yfavoring opportunisticweeds (like ragweedand poison ivy). Otheremissions from burningfossil fuels in cars,trucks and buses form

photochemical smog that causes andexacerbates asthma, while diesel particulateshelp deliver pollen and molds deep into lungsacs. The combination of air pollutants,aeroallergens, heatwaves and unhealthy airmasses, increasingly associated with achanging climate, causes damage to therespiratory systems, particularly for growingchildren, and these impacts disproportionatelyaffect poor and minority groups in the innercities.

The estimated cost in the U.S. of treatingasthma in those younger than 18 years of age is$3.2 billion per year.

The health impacts of a changing climateinclude asthma and other respiratory illnesses,infectious diseases, heat stress, andpreventative heart disease. Meanwhile thepreventative strategies include measures thatcould simultaneously improve air quality andenhance the livability of urban communities.

Combustion of fossil fuels (oil, coal and naturalgas) is responsible for air pollution and climatechange, and air quality is a particular problemfor urban centers worldwide. Traffic patternsand automotive exhaust, power plants, airportsand industrial emissions are the primarysources, while wind patterns can bring inpollution and unhealthy air masses originatingin other regions. Allergens (molds and pollen)originating in rural areas can reach high levelsin highly populated cities.

The impacts of air pollution can becompounded by extreme weather events, whoseintensity and frequency is increasing as climatechanges. These events include more heatwaves,drought-driven fires, and floods. The impactsof warming are exacerbated by “the heat islandeffect” generated in cement cities withinadequate green space.

Today, atmospheric concentrations of CO2 are379 parts per million. The earth has notexperienced levels of CO2 above 280 ppm for atleast 420,000 years. This report examines thedirect impacts of CO2, as well as climatechange, focusing on urban centers; examiningsynergies between air pollution and climatechange and connections between climatechange and emerging infectious diseases – inparticular, West Nile virus, a disease carried byurban-dwelling mosquitoes that presents newproblems for public health and mosquitocontrol authorities.

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Key Points

1. Ragweed (in vacant lots and otherdisturbed areas) pollen and tree pollens(e.g., maples, birches, poplars) arestimulated by increased carbon dioxide(CO2), and by warmer winters and earlyarrival of spring.

2. Molds are also stimulated by higherlevels of CO2. In addition, humidity,heavy rain and floods associated withclimate change foster fungal growth inhouses.

3. Diesel particles combine withaeroallergens (pollen and mold) todeliver them to immune cells in thelungs.

4. Fungal growth inside houses can affectrespiratory health and in surancecoverage.

5. Floods can drive rodents from theirnatural burrows into developed areas.

6. Photochemical smog (ground-levelozone) is a product of reactions betweentailpipe emissions (oxides of nitrogen(NOxs) and volatile organic compounds(VOCs)) and the chemical reaction isaccelerated during heatwaves, which areintensified with climate change.

7. Heatwaves, unhealthy air masses, highheat indices (a function of temperatureand humidity), plus lack of nighttimerelief all affect cardio-respiratory illnessand mortality.

8. Increased humidity and nighttimetemperatures (daily minimums) areassociated with a changing climate.

9. The Heat Island Effect can raiseambient temperatures in urban centersas much as 7ºF over those in rural areas.

10. Particulates, carbon monoxide (CO),ground-level ozone and carcinogenicpolycyclic aromatic hydrocarbons(PAHs) from drought-driven wildfirescan affect populations living far fromthe fires.

11. West Nile virus in the U.S. is a newphenomenon -- a mosquito-bornedisease in urban areas; one notpreviously faced by public health andmosquito control agencies.

12. The avian-mosquito cycle of West Nilevirus (WNV) is amplified by warmwinters, spring droughts and summerheatwaves. Bird-biting, urban-dwellingmosquitoes (Culex pipiens) breed inshallow pools in city drains withorganically-rich litter (e.g., leaves andpollen). The disease threatens humans,birds and other wildlife.

13. Severe and erratic weather – earlyand late snowstorms, ice storms anddense fog – present hazards forautomotive drivers and pedestrians.

14. Severe storms in coastal cities(intensified by sea level rise) candamage infrastructure, such as waterand sanitation systems, with wide-ranging implications for public health.

15. Early warning systems of conditionsconducive to large outbreaks of WNVcan facilitate environmentally-friendlypublic health interventions.

16. Roof gardens, urban parks, tree–linedstreets, “smart growth,” and improvedpedestrian, bicycle and public transportcan reduce the “Heat Island Effect.”

17. Developing alternatives to fossil fuelsis fundamental for the protection ofpublic health.

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OIL AND ENVIRONMENTAL JUSTICE: A LIFE CYCLE ANALYSIS

From extraction tocombustion, oil takes anenormous toll on theenvironment and onpublic health, and thei m p a c t s f a l ldisproportionately onpoor nations and poorand minority populationswithin developed nations.

Exploration for oil, viaroad construction and penetration intounexplored forested areas (e.g., in Ecuador),has introduced infectious diseases into isolated,indigenous populations. Exploration andextraction, via oil leaks and spills into riverdeltas (Nigeria) and permafrost (in Alaska),contaminate fisheries, water supplies anddisrupt wildlife. ‘Muds’ from off-shore drillingsites (e.g., in the Gulf of Mexico) containmercury (a neurotoxin) that contaminates fishand harms the humans that consume them. Poorpopulations are especially vulnerable due to theexposures and inadequate access to health care.

Oil refineries are most often located nearAfrican-American and Native Americanpopulations in the U.S. The cancer-causingchemicals (e.g., benzene) released, primarilyaffect those living in close proximity to thefacilities.

Coal-fired plants emit mercury that entersground water, waterways and fish.

Combustion generates a wide spectrum ofenvironmental and public health ills – acid rain,air pollution and climate change. Inner citypopulations suffer most from concentrated airpollution -- soot and ozone – and asthma ratesare especially high along inner-city truck andbus routes. The combined impacts of airpollution, aeroallergens and climate changeaffect growing children, and these healthimpacts disproportionately affect poor andminority groups.

Heat waves take a disproportionate toll onthose living in poor housing lacking airconditioning, and those with adequate socialsupports. The majority of those affected duringthe 1995 heat wave in Chicago, for example,were African-Americans living in substandardhousing.

Extreme weather events (such as the 1998Hurricane Mitch in Honduras, killing over10,000; severe storms and flooding in 1999 inVenezuela, killing 20,000 and leaving 150,000homeless; and extensive floods in 2000 inMozambique) take their greatest toll on poornations with inadequate resources for recovery(IPCC, 2001).

Poor nations are especially vulnerable todisasters, lacking adequate resources forcoping, adaptation, rebuilding and prevention.

FULL report on the Life Cycle Impacts of Oil available on:http://www.med.harvard.edu/chge/oil.html

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CARBON DIOXIDE, CLIMATE CHANGE AND AEROALLERGENS

Christine A. Rogers

Exposure, Epidemiology and Risk ProgramDepartment of Environmental Health

Harvard School of Public Health

CO2, Climate and Pollen

The Problem: Allergic diseases are the sixthleading cause of chronic illness in the US,affecting roughly 17% of the population, andcosting the health care system about $18 billionannually1. Approximately 40 millionAmericans suffer from allergic rhinitis (hayfever), largely in response to commonaeroallergens, resulting in 3.8 million lost daysof work and school. Asthma is a more complexand serious disease characterized by lunginflammation resulting in shortness of breath,or wheezing. It commonly begins in childhood,and frequently requires doctor visits,medications, emergency visi ts , orhospitalizations. Currently, the CDC estimatesthat the prevalence of asthma in the US adultpopulation is approximately 7.5% (16 million)2.The self-reported prevalence of asthmaincreased 75% from 1980-1994 in both adultsand children. However the largest increase of160% occurred for preschool aged children 3.Low income families and African Americansare disproportionately affected by increases inprevalence, morbidity and mortality2.

Causes: Although allergic diseases have astrong genetic component, such a rapid increasein disease occurrence is likely the result ofchanges in environmental exposures. Thefactors affecting the onset of allergic diseasesare complex, and considerable attention hasfocused on the indoor environment4, as well asoutdoor particle exposures5. Diesel exhaustparticles in particular have been shown to act

synergistically with allergen exposure toenhance the severity of clinical symptoms6 andsome suggest they may be the causal link forthe increase in allergic diseases worldwide7.While the role of allergen exposure in causingallergic diseases is unknown, allergens frompollen grains and fungal spores areunequivocally associated with exacerbation ofexisting disease and may also play a role inother diseases such as cardiovascular disease,chronic obstructive pulmonary disease andpneumonia 8. Hence, the combined effect of airpollution and outdoor allergen exposure mayresult in an enhanced allergic response 9.Projected changes in climate over the nextcentury will impact plant and fungalreproductive responses, and hence impact thetiming, production, and distribution ofaeroallergens and resulting exposures. Thiscase study summarizes known and potentialchanges in pollen and fungal spore exposure, asa result of global climate change.

Climate sensitivity: Several studies haveelucidated the potential impacts of globalwarming on plants. In general, as a result ofincreasing temperature and CO2, plants willrespond with enhanced photosynthesis,biomass, water use efficiency, and reproductiveeffort10. These are considered positiveresponses for agriculture, but for allergicindividuals it could mean increased exposure topollen allergens.

There are several potential climate changeimpacts on the timing and abundance of

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airborne pollen. First, climate warming hasresulted in phenological changes in plants, as inother biological systems, such that budburst inspring has advanced in recent decades 11,12,hence the allergenic pollen season for springflowering taxa also begins earlier 13,14,15. Therate of these advances (0.84 -0.9 days/year)16,17

provide some of the best evidence of thecurrent impacts of recent climate change. Whilethis is generally considered to be solely theeffect of temperature, some studies suggest thatCO2 can independently affect phenologicalstages 18.

Second, recent studies have shown increasedpollen production under conditions of elevatedCO2. Ragweed (Ambrosia artemisiifolia) is aweed of open disturbed ground that producespotent pollen allergens. In controlledenvironment experiments, plants grown at 2xambient CO2 had greater biomass, andproduced 40 to 61% more pollen 19,20. This wasvalidated in field experiments using a naturalurban-rural CO2 gradient but also showed thatallergen content was higher in rural (low CO2)sites21. Temperature and CO2 can also haveinteractive effects on pollen production. Inexperiments simulating early spring releasefrom dormancy, ragweed plants grew larger,had more inflorescences and produced morepollen than later cohorts. Early cohorts underhigh CO2 produced the same amount of pollenas under ambient CO2, but later cohorts at highCO2 differed by producing almost 60% morepollen than their ambient CO2 counterparts(Rogers 2004 in prep). Long-term records atpollen monitoring stations in Europe showincreasing annual totals for some types such ashazel, birch and grass 14,22. Understanding thetemporal and spatial effects of climate changeis critical for projections. Increased pollenproduction and release in plants are modulatedby weather conditions during the pollen season.Since pollen is washed out of the atmosphereby rain, increased rainfall in spring in particularregions could function to decrease overallairborne concentrations even if pollenproductivity increases.

Lastly, a likely result of climate change will beshifts in the distributions of taxa as somespecies are able to take advantage of newconditions while others are not23. Droughts maycreate open habitat that ragweed can colonize,and therefore expand the range of this highlyallergenic invasive species in Europe.Individuals may therefore be exposed to newallergens in their environment. Increasedclimate variability may amplify mastreproductive cycling in trees, which results inhuge fluxes of allergenic pollen into theatmosphere from year-to-year.

CO2, Climate and molds

Evidence for climate change effects on fungalgrowth and reproduction is less welldocumented, although the implications forallergic disease are just as important. As it isfor pollen, exposure to fungal spores (mold) isunequivocally associated with exacerbations ofallergy and asthma 4. Long-term fieldexperiments with elevated CO2 show that somefungi in arbuscular micorrhizal associationswith trees have enhanced growth andsporulation 24,25,26. While more evidence isneeded to establish the certainty of these effectsfor a wider range of fungi, plausible argumentscan be made for the likelihood of increasedfungal biomass which would be needed todegrade the increased plant biomass projectedunder climate change scenarios.

Fungi are also an important factor in indoorenvironment exposures leading to allergic andasthmatic events. Increased, and morewidespread, reliance on air conditioning willbecome common, and mismanagement ofbuilding ventilation and may lead toinappropriate moisture conditions in buildings.Changes in precipitation regimes areanticipated, with heavier downpours and morewidespread flooding. Increased flooding incoastal areas is also projected with increases insea level. All of these scenarios indicate ahigher likelihood of wet interior surfaces thatare prone to fungal growth. Several studieshave shown that home dampness is a

significant predictor of respiratorysymptoms27,28. Inequities are likely to occur aslower income families are less able to copewith expensive remediation or flood insurance(if available). Because of mold litigation andhigh jury awards, many home insurancepolicies currently have exclusions for moldgrowth.

For developing nations and poor communities,the health impacts may be significant. Asdeveloping countries incorporate moderntechnologies to cope with climate change (e.g.air conditioning, indoor plumbing) on a widerscale, the resulting problems associated withpoor building construction and maintenancealso increase unless there is an influx oftechnological and financial resources.

Summary of key issues

Increasing asthma prevalence worldwidesignals an expansion of the vulnerable

population. Climate change (with bothincreased temperature and CO2) will likelyresult in increased production of pollen (andpossibly fungal spores). Spring pollen allergyseasons are occurring earlier and shifts in plantranges will expose individuals to new allergens.Flooding and hurricanes increase potentialexposure to airborne fungal spores indoorsparticularly in populations ill-equipped tohandle remediation. Air pollution will actsynergistically with the allergens to furtherdeteriorate respiratory health.

Economic Implications

Beyond health care costs – clinic, ER visits,hospitalizations, and medications – are schoolabsences, work absences (adults as patients andparents) and lost productivity. The same issuescan contribute to Chronic ObstructivePulmonary Disease, susceptibility to Influenzaand increased mortality.

REFERENCES

1. The Allergy Report. Milwaukee, WI:American Academy of Allergy Asthma &Immunology; 2000.

2. Centers of Diseases Control andPrevention. Asthma prevalence and controlcharacteristics by race/ethnicity--UnitedStates, 2002. MMWR Morb Mortal WklyRep. 2004;Feb 27;53(7):145-148.

3. Mannino D, Homa D, Pertowski C, et al.Surveillance for Asthma Prevalence -United States, 1960-1995. MMWR MorbMortal Wkly Rep. 1998;47(SS-1):1-28.

4. Institute of Medicine. Clearing the air:Asthma and indoor air exposures.Washington, D.C.: National AcademyPress; 2000.

5. Peden DB. Air Pollution: Indoor andOutdoor. In: Adkinson NF, Yunginger,J.W., Busse, W.W., Bochner, B.S., Holgate,S.T., & Simons, F.E.R., ed. Middleton'sAllergy Principles and Practice. Vol 1. 6thedition ed. Philadelphia: Mosby; 2003:529-555.

6. Diaz-Sanchez D, Penichet-Garcia M, SaxonA. Diesel exhaust particles directly induceactivated mast cells to degranulate andincrease histamine levels and symptomseverity. J Allergy Clin Immunol.2000;106(6):1140-1146.

7. Diaz-Sanchez D, Proietti L, Polosa R.Diesel fumes and the rising prevalence ofatopy: an urban legend? Curr AllergyAsthma Rep. 2003;3(2):146-152.

8. Brunekreef B, Hoek G, Fischer P,Spieksma FTM. Relation between airbornepollen concentrations and dailycardiovascular and respiratory-diseasemortality. Lancet. 2000;355:1517-1518.

9. D'Amato G, Liccardi G, D'Amato M,Cazzola M. Outdoor air pollution, climaticchanges and allergic bronchial asthma. EurRespir J. 2002;20:763-776.

10. LaDeau SL, Clark JS. Rising CO2 levelsand the fecundity of forest trees. Science.2001;292:95-98.

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11. van Vliet A, de Groot R, Bellens Y, et al.The European Phenology Network. Int JBiometeorol. 2003;47:202-212.

12. Fitter A, Fitter R. Rapid changes inflowering time in Brittish plants. Science.2002;296:1689-1691.

13. Jäger S, Nilsson S, Berggren B, Pessi A-M,Helander M, Ramfjord H. Trends of someairborne tree pollen in the Nordic countriesand Austria, 1980-1993. A comparisonbetween Stockholm, Trondheim, Turku andVienna. Grana. 1996;35:171-178.

14. Frei T. The effects of climate change inSwitzerland 1969-1996 on airborne pollenquantities from hazel, birch and grass.Grana. 1998;37:172-179.

15. van Vliet A, Overeem A, de Groot R,Jacobs A, Spieksma FTM. The influence oftemperature and climate change on thetiming of pollen release in The Netherlands.Int J Climatol. 2002;22:1757-1767.

16. Frenguelli G, Tedeschini E, Veronesi F,Bricchi E. Airborne pine (Pinus spp.) pollenin the atmosphere of Perugia (CentralItaly): Behavior of pollination in the twolast decades. Aerobiologia. 2002;18:223-228.

17. Clot B. Trends in airborne pollen: Anoverview of 21 years of data in Neuchâtel(Switzerland). Aerobiologia. 2003;19:227-234.

18. Murray M, Ceulemans R. Will tree foliagebe larger and live longer? In: Jarvis PG, ed.European Forests and Global Change. Vol94-125. Cambridge: Cambridge Univ Press;1998.

19. Wayne P, Forster S, Connelly J, BazzazFA, Epstein PR. Production of allergenicpollen by ragweed (Ambrosia artemisiifoliaL.) is increased in CO2 enrichedatmospheres. Ann Allergy Asthma Immunol.2002;88:279-282.

20. Ziska LH, Caulfield FA. Rising CO2 andpollen production of common ragweed

(Ambrosia artemisiifolia), a known allergy-inducing species: implications for publichealth. Aust. J. Plant Physiol. 2000;27:1-6.

21. Ziska LH, Gebhard D, Frenz DA, FaulknerS, Singer B, Straka JG. Cities as harbingersof climate change: Common ragweed,urbanization and public health. J AllergyClin Immunol. 2003;11(2):290-295.

22. Spieksma FTM, Emberlin J, Hjelmroos M,Jäger S, Leuschner RM. Atmospheric birch(Betula) pollen in Europe: trends andfluctuations in annual quantities and thestarting date of the seasons. G r a n a .1995;34:51-57.

23. Ziska LH. Evaluation of the growthresponse of six invasive species to past,present and future atmospheric carbondioxide. J Exp Botany. 2003;54(381):395-404.

24. Wolf J, Johnson NC, Rowland DL, ReichPB. Elevated CO2 and plant speciesrichness impact arbuscular mycorrhizalfungal spore communities. New Phytol.2003;157:579-588.

25. Treseder KK, Egerton-Warburton LM,Allen MF, Cheng Y, Oechel WC.Alteration of soil carbon pools andcommunities of mycorrhizal fingi inchaparral exposed to elevated carbondioxide. Ecosystems. 2003;6(8):786-796.

26. Klironomos JN, Rillig MC, Allen MF, ZakDR, Pregitzer KS, Kubiske ME. Increasedlevels of airborne fungal spores in responseto Populus tremuloides grown underelevated atmospheric CO2. Can J Bot.1997;75(10):1670-1673.

27. Dales RE, Burnett R, Zwanenburg H.Adverse health effects in adults exposed tohome dampness and molds. Am Rev RespirDis. 1991;143:505.

28. Bornehag C-G, Blomquist G, Gyntelberg F,et al. Dampness in buildings and health.Indoor Air. 2001;11:72-86.

OVERVIEW OF CLIMATE CHANGE ANDURBAN PUBLIC HEALTH

Introduction

The U.S. National Assessment of the Impactsof Climate Change and Variability(www.usgcrp.gov/usgcrp/nacc/default.htm)projects that there will be changes in theclimate and in weather patterns in every regionof the United States in coming decades as aresult of increasing atmospheric concentrationsof greenhouse gases. These predictions are inkeeping with those of the U.N.Intergovernmental Panel on Climate Changefor the planet as a whole (Houghton et al.,[IPCC] 2001). Changes will involve warmingtemperatures -- with the largest increasesoccurring at higher altitudes and latitudes, andduring the winter and at night. The warming isalso associated with an increase in extremeweather events, with heavy rains (>2”/day) andflooding in some areas and prolonged droughtin others.

Accompanying the warming and anomalousweather, major impacts on urban infrastructureare projected, as well as impacts on terrestrialand marine ecosystems; affecting wildlife,forests, agriculture and human health. This

brief summary will outline the potential healthimpacts of climate change and variability andwill discuss in more detail three case studies inthe U.S. that provide useful models forunderstanding the relationship of human healthto climate and weather.

The following categories of diseases and otherhealth impacts may be affected by climaticconditions and weather. While each one (e.g.,heatwaves or emerging infectious diseases) canoccur in the absence of climate change, it isprojected that climate change and theassociated alterations in weather patterns willinfluence the frequency, intensity andgeographic distribution of these healtho u t c o m e s . U n d e r s t a n d i n g t h ehealth/climate/weather connections can:

a) Help generate early warning systemsfor environmentally-friendly publichealth interventions; and

b) Help monitor and understand the shortand long-term health consequences ofclimate change and the associatedchanges in weather patterns.

Areas Covered

ÿ Heat stroke, dehydration, heatexhaustion and heat waves

ÿ Cardio-respiratory disease and airquality

ÿ Emerging infectious diseases (EIDs)and climate warming and variability

ÿ Traumatic injuries and extreme weatherÿ Gastro-intestinal infections and water

quality

Additional issues include: morbidity andmortality associated with weather-relatedimpacts on food quality, especially seafood,and the health impacts of sea level rise andstorm surges (e.g., from flooding, salt waterintrusion of well water, etc.).

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Heatwaves

Recent record-high temperatures in many partsof the United States and Europe highlight theneed for an awareness of the health hazardsposed by global warming. Heatwaves cancause dramatic increases in overall morbidityand mortality, and they have increased thenumber of deaths per day 2 to 3-fold overbaseline levels in particularly severe episodes(http://www.cdc.gov/mmwr/preview/mmwrhtml/00000041.htm).

From 1979–1999, excessive heat exposurecaused 8,015 deaths in the United States.During this period, more people in this countrydied from extreme heat than from hurricanes,lightning, tornadoes, floods, and earthquakescombined(http://www.cdc.gov/nceh/hsb/extremeheat/).

The incidence of heat waves in most U.S. citiesis expected to approximately double by theyear 2050 by current climate change estimates(Kalkstein, 2000).

The health impacts of heatwaves are a functionof average temperatures, nighttimetemperatures (minimum), and the heat index(which is a measure of humidity andtemperature combined, where high humiditylevels interfere with the human body’s abilityto cool itself by transferring heat, throughradiation and evaporation, to its surroundings).Minimum nighttime temperatures have beenrising twice as fast as overall warming since1950 (Karl et al., 1993; Easterling et al., 1997),which is predicted by climate change models.The “heat island effect,” where the heatgenerated by cement streets, buildings and thecumulative activities of populations increasesthe ambient temperature 5-10o F above that ofsurrounding, less urbanized areas, is present inmost U.S. urban centers and adds to theintensity of heatwaves. It is, in turn, affectedby the presence of urban trees and parks, roofgardens, and heat reflective building colors,particularly on rooftops.

Case Study: The Chicago Heatwave of 1995

The Chicago heatwave in the summer of 1995well illustrates how heat waves influenced byclimate change will affect human populations.In this case, there was the lethal combinationof high humidity and unusually high nighttimetemperatures, so that Chicago residents hadlittle relief at night (CDC, 1995; Whitman etal., 1997). During July 12-16, 1995, Chicagoexperienced unusually high maximum dailytemperatures, ranging from 93oF to 104oF(33.9 oC to 40.0 oC). On July 13, the heat indexpeaked at 119 F (48.3 oC) -- a record high forthe city.

During July 11-27 the Cook County MedicalExaminer's Office (CCMEO) certified 465 asheat-related, compared with no heat-relateddeaths during the period of July 4-10. Thehighest number of heat-related deathspreviously certified by the CCMEO was 77 inassociation with a heat wave in the summer of1988. During July 13-21 (the period with themost heat-related deaths), a total of 1177deaths occurred in Chicago -- an 85% increaseover the same period in 1994 (637 deaths). Asubsequent analysis demonstrated that therewere at least 700 excess deaths in Chicago

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during the heat wave, most of which were heat-related (Semenza et. al., 1996). And recentreports have confirmed that there were long-term neurological effects among some of thosewho had heat stroke but survived (reference tobe obtained).

Those at greatest risk of dying from the heatwave were people with chronic medicalillnesses. But socioeconomic factors wereinvolved as well; poor and socially isolatedpeople without access to air conditioning weredisproportionately affected. Early warningsystems are now in place in some U.S. cities

(Kalkstein, 2000) and Canada (Smoyer-Tomicet al., 2001), with a program to identify thosewho live alone, particularly those who arechronically ill medically or psychiatrically.Effective measures for preventing heat-relatedillness and death include reducing physicalactivity, drinking nonalcoholic liquids, andspending time in air-conditioned environments.

Severe summer heatwaves, with numerousattributable deaths, have become increasinglycommon in developing nations as well, notablyNew Delhi, India.

Case Study:The European Heatwave of 2003:An Analog for the United States

Laurence S. Kalkstein, Center for Climatic Research, University of Delaware

Heatwaves in the northern hemisphere can bedefined as three consecutive days withtemperatures greater than 90ºF. Prolongedevents are often accompanied by droughts.Heatwaves and droughts are expected to bemore intense and more common with climatechange.

Disease outcomes of heatwaves include heat-related deaths, crop losses, wildfires, andhigh ground-level ozone (photochemicalsmog).

Current models project a doubling of heat-related mortality in many U.S. cities by 2020,and a tripling by 2050.

The devastating heat wave in Europe thispast summer was unprecedented for manymajor cities on the continent. As a result, anestimated 35,000 people died from the directresults of heat, with most deaths concentratedin Western Europe. Although it is uncertainwhether a long-term climate change was in

any way responsible for this highly unusualevent, it is now plausible to consider this heatwave as an analog – a possible example ofwhat might happen more frequently if ahuman-induced climate change becomesmore pronounced.

An even greater threat involving theEuropean heat wave has been brought to lightin a recent issue of Nature (Schar et al.,2004). The authors argue that a heat event ofthe magnitude of summer, 2003 in Europe is“…statistically extremely unlikely…”, andcan only be explained by a regime that leadsto increased summer temperature variability.From a human health standpoint, this is avery negative outcome, since many haveargued that the impact of heat upon humanmortality would increase most dramaticallyin a warmer world if climate variability alsoincreased (Kalkstein and Greene, 1997).

Initial observations developed for the U.S.EPA indicate that a comparable heat wave in

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the U.S. would be a devastating event.Transposing similar temperature deviationsthat occurred in Paris to Washington, DC, itis apparent that the heat wave would breakall-time records (Kalkstein, unpublished).The highest temperature ever recorded inWashington is 106º F. Using the same day-to-day deviations that occurred in Paris

transposed to Washington, there would havebeen an 11 consecutive day period in whicheach day would have broken this all-timerecord. Nine consecutive days would haverecorded temperatures exceeding 110o F, andone day would have reached 116o F.(Kalkstein, unpublished).

Cardio-Respiratory Disease And Air Quality

The following are examples of how climatechange may affect cardio-respiratory disease:

PollenPollen release from ragweed and some tress(e.g., birches and poplars) is increased byhigher levels of atmospheric CO2 (in the caseof ragweed, with a doubled CO2 concentration,60% more pollen is released) (Wayne et al.,2002). Warm winters and the early arrival ofspring may exacerbate this effect. Increasedpollen levels may explain some of theincreased incidence of asthma and respiratoryallergies.

Ground-level ozone or photochemical smogThe reaction of oxides of nitrogen (NOxs) andvolatile organic compounds (VOCs) (bothtailpipe emissions) is temperature-dependant;i.e., heat increases smog. Ground-level ozone,which is also increased by higher levels ofultraviolet B radiation from stratospheric ozonedepletion, has been shown to cause asthma inchildren and to trigger attacks (McConnell etal., 2002). Photochemical smog also causesincreased morbidity and mortality in those withchronic obstructive pulmonary disease.

Diesel exhaust particulatesThese particles (direct air pollutants fromburning fossil fuels) cause significant illness,especially when they are smaller than 10microns in diameter and can bypass the lung’sdefenses.

They can: (1) Clog airways and cause acute,and worsen chronic, cardiovascular andrespiratory illness; (2) Help deliver pollengrains and molds deep into the lung; (3) Helpcause lung cancer.

HeatwavesProlonged high temperatures can result intemperature inversions, leading to trappedmasses of unhealthy air contaminated by smog,particulates, and other pollutants.

FiresThe incidence of forest fires is increased bydrought secondary to climate change, and tothe lack of spring runoff from reduced wintersnows. These fires create smoke and hazewhich can settle over urban populationscausing acute and exacerbating chronicrespiratory illness (e.g., the Heyman fire inColorado, summer 2002). The extensive,severe forest fires in Indonesia in 1997/98 werethe result of small fires, started to clear theforests for agriculture, which quickly becameout of control due to a severe drought. Theresulting plume of smoke settled as haze overlarge down-wind populations in SoutheastAsia, causing widespread respiratory illness.

Ragweed15

Emerging Infectious Diseases

Since 1976, the World Health Organizationreports there are 30 infectious diseases that arenew to medicine. These include Ebola,Legionellas', Lyme disease, HantavirusPulmonary Syndrome, a new strain of cholera(Vibrio cholerae O139), E. coli O157:H7,HIV/AIDS, and a host of antibiotic-resistantorganisms. In addition, there is a resurgence ofsome old diseases (malaria, dengue fever,cholera), and a redistribution of others (e.g.,West Nile virus) occurring on a global scale.Many emerging diseases are zoonoses, oranimal diseases, that spill over to humans, andare responsive to environmental change andclimatic variability. For example, “explosions”of rodent populations can follow droughtspunctuated by heavy rains, because suchweather patterns can result in a decreasedpopulation of rodent predators and an increasedsupply of food (this was the case, for example,with the outbreak of Hantavirus Pulmonary

Syndrome in the four corners area of NewMexico in 1993).

Moreover, climate (especially winter minimumtemperatures) can restrict the geographic rangeof some infectious diseases by altitude and bylatitude (in the case of vector-borne infectiousdiseases, for example, by being too cold abovea certain altitude or latitude for a vector, host,or infectious agent to survive) (Epstein et al.,1998), while weather can affect the timing,intensity, and location of outbreaks. Risingminimum winter temperatures are particularlyimportant in allowing the over-wintering ofsome diseases vectors (e.g., ticks ormosquitoes), and in increasing the number ofreproductive generations (e.g., rodents). Inaddition, extreme weather events (especiallydroughts and floods) often precipitate clustersof rodent-, mosquito- and water-borne diseases(Epstein, 1999).

Case Study: West Nile Virus

West Nile virus (WNV), first reported inUganda in 1937, is a zoonosis (a diseaseinvolving an animal), with “spill-over” tohumans. WNV also poses significant risks forwildlife, zoo and domestic animal populations.While it is not known how West Nile virus(WNV) entered the New World in 1999,anomalous weather conditions appear to haveamplified this Flavivirus, which circulatesamong urban mosquitoes, birds and mammals.Analysis of weather patterns coincident with aseries of U.S. urban outbreaks of St. Louisencephalitis (SLE) -- a disease with a similarlife cycle that first occurred in the U.S. in1933, coincident with the ‘Dust Bowl’ era --and four recent large outbreaks of WNV,reveal that drought was a common feature.

Culex pipiens, the primary mosquito vector(carrier) for WNV, thrives in city storm drainsand catch basins, especially in the organicallyrich water that forms during drought, Theaccompanying warm temperatures alsoaccelerate the period of maturation of viruses(and parasites) within mosquito carriers,enhancing the potential for transmission. Asthe potential risks from pesticides for diseasecontrol must be weighed against the healthrisks of the disease, an early warning system ofconditions conducive to amplification of theenzootic cycle could help initiate timelypreventive measures, and potentially limitchemical interventions.

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Significant outbreaks of WNV in the pastdecade

Romania 1996: A significant outbreak of WNVoccurred in 1996 in Romania, in the DanubeValley and in Bucharest. This episode, withhundreds experiencing neurological disease and17 fatalities, coincided with a prolongeddrought and a heatwave.

Russia 1999: A large outbreak of WNVoccurred in Russia in the summer of 1999,following a warm winter, spring drought andsummer heatwave (Platanov et al., 2004).

Israel 2000: WNV was first reported in Israel in1951, a major stopover for migrating birds. In2000 the region was especially dry, as droughtconditions prevailed across southern Europeand the Middle East, from Spain toAfghanistan.

US 1999: In the spring and summer of 1999, asevere drought (following a mild winter),affected Northeast and Mid-Atlantic States, anda three-week July heat wave enveloped theNortheast. In the N.Y. area seven people died,and, of the 62 people who suffered neurologicalsymptoms and survived, the majority reportedchronic disabilities.

US 2002: In the summer of 2002 much of theWest and Midwest experienced severe springand summer drought. Lack of snowpack in theRockies (warmer winters are characteristic ofclimate change) contributed. An explosion ofWNV cases occurred (see chart), with humansor animal infection documented in 44 states andthe District of Columbia. WNV can betransmitted via organ transplants, in-utero andthrough blood transfusions.

Of greatest concern WNV spread to 230species of animals, including 138 species ofbirds and 37 species of mosquitoes. Not allanimals fall ill from WNV, but the list of hostsand reservoirs includes: dogs, cats, squirrels,bats, chipmunks, skunks, rabbits and reptiles.Raptors (owls, kestrels) have been particularlyaffected; West Nile virus likely causedthousands of birds of prey to die in Ohio andother states in July 2002. Some zoo animalsdied.

In the summer of 2003 cases clustered inColorado and other states west of theMississippi, where drought conditionsprevailed.

Note: The population impacts on wildlife andbiodiversity have been inadequately evaluated.Declines in raptors – condors, owls, hawks andeagles – could have dramatic consequences forhuman health, for raptors prey upon rodents,keeping their numbers in check. When rodentpopulations “explode”– when floods followdroughts, forests are clear-cut, or diseasesattack predators – their legions can becomeprolific transporters of pests and pathogens,including: Lyme disease, leptospirosis, plague,hantaviruses and hemorrhagic fevers.

As of April 2004, the Centers for DiseaseControl and Prevention (CDC) reported for2003:Human cases: 9,858Deaths: 262

Equine cases: 14,045Death rate (before vaccination): ~1/3

There is the potential for outbreaks throughoutthe Americas. In April 2004 birds werereported infected in California and, in Ohio, a79 year-old man developed the illness.

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West Nile Virus in the United States as of August 1, 2003

Public Health Implications

Factors other than weather and climatecontribute to outbreaks of these twodiseases disease. Antiquated urbandrainage systems leave more fetid poolsin which mosquitoes can breed, andstagnant rivers and streams do notadequately support healthy fishpopulations that consume mosquitolarvae in isolated standing pools. Suchenvironmental "vulnerabilities" presentopportunities for environmentally basedpublic health interventions followingearly warnings of conducivemeteorological conditions.

State plans to prevent the spread andcontain WNV have four components: (1)Mosquito and dead bird surveillance; (2)Community communications and mediaoutreach; (3) Source (breeding site)reduction though larviciding withbacteria (Bacillus sphaericus) andAltocid (methoprine) and neighborhoodclean-ups, and (4) Pesticide (pyrethrins,s y n t h e t i c l y d e r i v e d f r o mchrysanthemums) spraying, whendeemed necessary.

The information on predisposingclimatic conditions and predictions ofthem may be most applicable for areasthat have not yet experienced WNV, butlie in the flyway from Canada to the

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Gulf of Mexico. Projections of droughts(e.g., for Northeast Brazil during an ElNiño event) could help focus attentionon those areas, enhancing surveillanceefforts (including active birdsurveillance), public communication andenvironmentally-friendly, public healthinterventions. They may also help to setthe stage for earlier chemicalinterventions once circulating virus isdetected.

Finally, in terms of the public perceptionand concerns over the risks of chemicalinterventions: understanding the links ofWNV to climatic factors and mobilizingpublic agency departments, such aswater and sewage services, to address apublic health threat may prove helpful ingarnering public support for thecombined set of activities needed toprotect public health.

West Nile virus Cases and Deaths

0

1000

2000

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4000

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7000

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9000

10000

1999 2000 2001 2002 2003

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Traumatic Injuries And Extreme Weather Events

Anomalous weather and extreme events haveincreased in intensity, and they are projected toincrease in frequency, as climate changes(IPCC, 2001). Some events, like heat waves,have already become more common; droughtshave become more prolonged, and heavy rainevents (>2”/day) have increased over the pastcentury (Karl et al., 1995; Easterling et al.,2000). Storms can effect populations directly,but they can also do so indirectly, as they canincrease the number of breeding sites fordisease vectors; and drive nutrients,microorganisms and toxic chemicals intowaterways and water supplies, affecting boththe food and water supply. Fog, avalanches,ice, wind and hail storms are all potentiallyaffected by changes in ambient temperaturesand alteration of the hydrological cycle.

With warming, there is both an increasedevaporation of water from land and from theoceans, and an increased capacity of theatmosphere to hold water. As a result, there isincreased cloud formation and when it doesrain, the rains can be torrential. This has been

observed in recent hurricanes in the U.S. (e.g.,Hurricane Floyd, drenching the Mid-AtlanticStates in September 1999), and in HurricaneMitch in Central America in November 1998in Honduras (with six feet or rain over 3 days).Intense precipitation events have led toflooding, mudslides, the wash out of roads andbridges, and the resulting injuries and deathsfrom drowning, car accidents, and the collapseof homes and other buildings. The freezing rainand ice storms seen in winter are also the resultof warming temperatures, leading to drivingand pedestrian hazards.

Ice storm traffic deaths and power outages,such as those occurring in the winters of 2002and 2004 are examples of the potential impactsof anomalous weather. Freshening of the oceanin the North Atlantic – from melting ice andrain falling at high latitudes – may be alteringwinds and weather patterns in the Northeast ofthe U.S. and in Europe. If the Gulf Streamwere to change course, the climate in these tworegions would become like that of Siberia(NAS, 2001).

Gastrointestinal Infections And Water Quality

Water quality and availability are affected byclimate and weather. Some parts of the U.S. areexperiencing chronic shortages of precipitation(e.g., the West and Midwest), while others areexperiencing an excess (e.g., the Northwest).[Water withdrawals and competing uses are

contributing to water problems in many parts ofthe U.S., and changes in precipitation patternsare exacerbating the issues of shortages in someparts and excess in others.]

Case Study: The Milwaukee Cryptosporidium Outbreak: 1993

Floods are related to water-borne diseases. Thetorrential rains in 1993 (that led to the floodingof the Mississippi River valley) resulted in thelargest waterborne disease outbreak in U.S.

history in Milwaukee, Wisconsin. The rainswashed a protozoan called Cryptosporidiumfrom farm lots (it is present in the stools oflivestock) into surface waters that supply

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Milwaukee with drinking water. An estimated403,000 persons contracted Cryptosporidiosis,a gastrointestinal infection of varying severityin different populations. This constituted anincidence rate of 52% among all those servedby the South Milwaukee water works plant(MacKenzie et al., 1994). In most peopleexposed, the infection was mild and self-limited and did not cause serious illness. Inothers, especially in those with compromisedimmune systems (e.g., those with HIV/AIDS

infections or those being given chemotherapyfor cancer), the situation was very different. Inthis group, there were over 100 deaths (Vakillet al, 1996).

An extensive study of water-borne diseaseoutbreaks for the U.S. demonstrates the strongassociation with heavy rain events and flooding(Curriero et al., 2001) (Also see review ofclimate and disease: Patz et al., 2001).

Food Quality

Food quality is affected by heat. Episodes ofbacterial food contamination in Japan arehighest during the summer, and notableoutbreaks have accompanied prolongedsummer heatwaves (McMichael et al., 1996).

Seafood contamination with biotoxins(biological toxins) is associated with “redtides,” or harmful algal blooms (HABs). Excess

nutrients and the loss of filtering wetlands,combined with warm, stagnant seas can lead tored tides and outbreaks of shellfishcontamination (paralytic, neurological, amnesicand diarrheic shellfish poisoning). In addition,heavy rains can flush nutrients into estuariesand coastal zones, triggering HABs (Epstein etal., 1998; Harvell et al., 1999).

Sea Level Rise And Storm Surges

Sea level rise (SLR) presents a longer-termthreat to infrastructure and human health. SLRcan lead to salinization of underground water,with implications for hypertension and theavailability of potable water. SLR can also

increase the frequency of storm surges andassociated damage to infrastructure andsanitation systems, contamination of groundand surface water with farm animal wastes, andthe overflow of Combined Sewer systems.

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REFERENCES

Centers for Disease Control and Prevention (CDC):Heat-Related Mortality -- Chicago, July 1995.MMWR August 11, 1995;44:577-579.http://www.cdc.gov/mmwr/preview/mmwrhtml/00038443.htm

Curriero FC, Patz JA, Rose JB, Lele S. Theassociation between extreme precipitation andwaterborne disease outbreaks in the United States,1948-1994. Am J Public Health 2001; 91:1194-1199.

Easterling DR, Horton B, Jones PD, Peterson TC,Karl TR, Parker DE, Salinger MJ, Razuvayev V,Plummer N, Jamason P, Folland CK. 1997.Maximum and minimum temperature trends for theglobe. Science 1997:277:363-67.

Easterling DR, Meehl GA, Parmesan C, ChangnonSA, Karl TR, Mearns LO. Climate extremes:observations, modeling, and impacts. Science 2000;289:2068-2074.

Epstein PR, Sherman BH, Siegfried ES, LangstonA, Prasad S, Mckay B (Eds.). HEED 1998. HealthEcological and Economic Dimensions of GlobalChange Program. Marine Ecosystems: EmergingDiseases As Indicators Of Change. Health of theOceans from Labrador to Venezuela. Year of theOcean Special Report. NOAA-OGP and NASAGrant number NA56GP 0623. December 1998.Published by The Center for Health and the GlobalEnvironment, Harvard Medical School, Boston,MA. 85p.

Epstein PR, Diaz HF, Elias S, Grabherr G, GrahamNE, Martens WJM, Mosley-Thompson E, SusskindJ. Biological and physical signs of climate change:focus on mosquito-borne disease. Bull AmericanMeteorological Society, 1998:78:409-417.

Epstein PR. Climate and health. S c i e n c e1999:285:347-348.

Epstein PR. Is global warming harmful to health?Scientific American 2000:283:50-57.

Epstein PR, Defilippo C. West Nile virus anddrought. Global Change & Human Health2001;2:105-107.

Harvell CD, Kim K, Burkholder JM, Colwell RR,Epstein PR, Grimes J, Hofmann EE, Lipp E,Osterhaus ADME, Overstreet R, Porter JW, SmithGW, Vasta G. Diseases in the ocean: emergingpathogens, climate links, and anthropogenicfactors. Science 1999:285:1505-1510.

Houghton JT, Ding Y, Griggs DJ, Noguer M, vander Linden PJ, Dai X, Maskell K, Johnson CA.2001. IPCC Working Group I Third AssessmentReport: Climate Change 2001: The Scientific Basis.Cambridge University Press. New York, NY.

Kalkstein, L.S. and J.S. Greene, 1997. AnEvaluation of Climate/Mortality Relationships inLarge U.S. Cities and the Possible Impacts of aClimate Change. Environmental HealthPerspectives, 105(1):84-93.

Kalkstein, L.S., 2003. The Great European HeatWave of 2003. Presentation given to the U.S. EPAHeat Island Reduction Initiative Group(unpublished).

Kalkstein LS. Saving lives during extreme weatherin summer. BMJ. 2000; 321:650-651.

Karl, T.R., Jones, P.D., Knight, R.W., Kukla, G.,Plummer, N., Razuvayev, V., Gallo, K.P., Lindsay,J., Charlson, R.J., and T.C. Peterson. A newperspective on recent global warming: Asymmetrictrends of daily maximum and minimum temperature.Bull. Am. Meteorological Soc. 1993;74:1007-1023.

Karl, T.R., Knight, R.W., Easterling, D.R., and R.G.Quayle. Trends in U.S. climate during the twentiethcentury. Consequences 1995;1:3-12.

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MacKenzie WR, Hoxie NJ, Proctor ME, GradusMS, Blair KA, Peterson DE, et al. A massiveoutbreak in Milwaukee of Cryptosporidiuminfection transmitted through the public watersupply. N Engl J Med 1994;331:161-167.

McConnell R, Berhane K, Gilliland F, London SJ,Islam T, Gauderman WJ, Avol E, Margolis HG,Peters JM. Asthma in exercising children exposedto ozone: a cohort study. The Lancet 2002;359:386-391.

McMichael AJ, Haines A, Slooff R, Kovats S,(Eds.), 1996: Change and Human Health.[TaskForce: McMichael, A.J., Ando, M., Slooff, R.R.,Carcavallo, R., Epstein, P.R., Haines, A., Jendritzky,G., Kalkstein , L.S., Odongo , R.A.,

National Research Council, National Academy ofSciences, 2001: Abrupt Climate Change: InevitableSurprises. National Academy Press, Washington,DC.

Patz, J., Piver, W.T., and R.World HealthOrganization, World Meteorological Organization,United Nations Environmental Program, Geneva,Switzerland.

Patz JA, McGeehin MA, Bernard SM, Ebi KL,Epstein PR, Grambsch A, Gubler DJ, Reiter P,Romieu I, Rose JB, Samet JM, Trtanj J. Thepotential health impacts of climate variability andchange for the United States. Executive summaryof the report of the health sector of the U.S.National Assessment. J Environ Health .2001;64:20-28.

Platanov AE, Zhuravlev VI, Lazorenko VI. Theweather and the mosquito-borne infections: Whatwas wrong in 1999 in southern Russia? Postersession, International Conference on EIDS, Atlanta,Georgia, 2004.

Semenza JC, Rubin CH, Falter KH et al. “Heat-Related Deaths During the July 1995 Heat Wave inChicago. N Eng J Med 1996;335:84-90.

Schar C, Vidale Pl, Luthi D, Frei C, Haberli C,Liniger MA, and C. Appenzeller. The role ofincreasing temperature variability in Europeansummer heatwaves. Nature 2004, 427:332-335.

Smoyer-Tomic KE, Rainham DG. Beating the heat:development and evaluation of a Canadian hotweather health-response plan. Environ HealthPerspect. 2001;109:1241-1248.

Vakil NB, Schwartz SM, Buggy BP, Brummitt CF,Kherellah M, Letzer DM, et al. Biliarycryptosporidiosis in HIV-infected people after thewaterborne outbreak of cryptosporidiosis inMilwaukee. N Engl J Med1996;334:19-23.

Wayne P, Foster S, Connolly J, Bazzaz F, EpsteinP. Production of allergenic pollen by ragweed(Ambrosia artemisiifolia L.) is increased in CO2-enriched atmospheres. Annals of Allergy, Asthmaand Immunology 2002;8:279-282.

Whitman S, Good G, Donoghue ER, Benbow N,Shou W, Mou S. Mortality in Chicago attributed tothe July 1995 heatwave. Am J Public Health1997;87:1515-151.

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CONCLUSIONS AND RECOMMENDATIONS

Rising carbon dioxide levels in themselves pose health hazards, due to their impacts on plants and soilorganisms. As the primary fossil fuel-generated greenhouse gases, the rising levels are altering theearth’s heat balance. Local initiatives on individual, organizational, city, state and regional levels cango along way towards improving energy efficiency, group purchasing of energy from alternativesources feeding into the grid, upgrading fleets to hybrids, and many more such interventions with rapid“pay-back” periods.

Converting from fossil fuel use to greater energy efficiency, hybrid vehicles, alternative sources,“green buildings,” and improved public transport would reduce all the by-products of extraction andcombustion (including NOxs, SOxs, VOCs, particulates and mercury), reduce CO2 levels now alteringplant growth and soil organisms and help to stabilize the climate.

A properly-financed clean energy transition would produce many new industries, new jobs and boostinternational trade. The clean energy transition can become the engine of growth for the 21st Century,helping to alleviate poverty and initiate a more equitable, healthy and sustainable form of development.

APPENDIX

STRATEGIES TO REDUCE PUBLIC HEALTH IMPACTS OF CLIMATE CHANGEAT THE LOCAL LEVEL

This is a sector-by-sector list of measures local governments can implement to reducegreenhouse gas (GHG) emissions in their community and in their own facilities andoperations. The International Council for Local Environmental Initiatives (ICLEI)(including over 500 local governments worldwide; 130 cities and counties in the U.S.)has software to assist municipalities with the task of measuring GHG emissions anddeveloping local action plans.

Residential Sector

ß Setting energy efficiency standards fornew construction or major renovations

ß Requiring light colored, high albedorooftops and pavement

ß Ordinance for energy efficient retrofit inexisting building stock at time of sale

ß Solar access ordinanceß Solar hot water/pool heating and solar

PV applications, ordinance or incentivesß Passive solar design and solar

orientation incentives, guidelines,ordinances

ß Financial incentives e.g. tax incentives,rebates, loans, etc.:

ß For installation of photovoltaics, otherrenewable energy application

ß For more efficient appliances, e.g.refrigerators, lighting, water heaters

ß For improving efficiency in existing andnew buildings

ß Home insulation or weatherizationprogram

ß Distribute water saving devices, such aslow-flow shower heads and faucetaerators

ß Distribute compact fluorescent bulbs,other home energy saving devices

ß Education and promotion of "coolcommunities" type landscaping

ß Tree planting program to maximizeshading of buildings

Commercial Sector

ß Raising energy efficiency standards fornew construct ion, s ignif icantrenovations, remodeling, additions,other activities requiring permit

ß requiring light colored, high albedorooftops and pavement

ß Ordinance for energy efficient retrofit inexisting building stock at time of sale

ß Solar access ordinanceß Provide energy services to business, e.g.

audits, assessments for energyefficiency improvements, othertechnical assistance

ß Cooperative or aggregate purchase orbuyer program for lighting, efficientequipment

ß Distribute compact fluorescents,lighting occupancy sensors, othercommercial application energy savingdevices

ß Lower business fees or waive permitsfor energy efficiency improvements anduse of solar energy

ß Building Energy Tax Creditß Comprehensive municipal retrofit of

existing buildings, parks, stadiums,swimming pools and other recreationfacilities, e.g. lighting, insulation,HVAC systems25

ß Building-specific renewable energyapplications, e.g. installing solar hotwater heating for locker rooms ofrecreational facilities

ß Lighting efficiency improvementsß Energy efficiency standards for

renovations and new construction ofmunicipal buildings

ß Lighten colors of existing rooftops andstreet paving to reduce “heat island”effect

ß Rooftop gardens, greening of buildingssurroundings for cooling

ß Building-specific fuel switch fromelectricity to natural gas

ß Implement co-generation or heatrecovery

ß Procurement policies that specifyenergy efficiency standards in allpurchasing and bid specs for officeequipment, motors, lighting, appliances,etc

Industrial Sector

ß Ordinance establishing energyefficiency requirements for newindustrial permits

ß Ordinance requiring industries todevelop and implement energyconservation programs

ß Ordinance lowering business fees orwaiving permits for energy efficiencyimprovements and fuel switching(including use of solar energy), heatrecovery/co-generation systems

ß Provide energy services to industry, e.g.audits, assessments to recommendprocess changes, other energyefficiency improvements

Transportation Sector

ß Implement policy shifting funding awayfrom roads and highways to alternativetransit

ß Increase use of alternative transit -public transit, van-, carpooling, cycling,walking through:

o Funding for facility, systemand/or infrastructureimprovements

o Dedicated lanes for transit/HOVvehicles

o Implement free bike shareprogram

o Work with transit authority toreduce public transit fares

o Ordinance providing parking feeand road toll discounts for van-and car-pools

o Jitney or shuttle serviceconnecting neighborhoods tocommuter lines

ß Establish service center selling transitpasses, coordinating car/van pooling,ridesharing, etc.

ß Trip Reduction Ordinance or policiesrequiring or promoting programs toencourage use of transit, ridesharing,telecommuting, business-sponsoredparking cash-out programs

ß Establish solar PV or other electricvehicle charging station

ß Establish or facilitate road tolls todecrease motor vehicle use

ß Parking policies:o Implement program to remove

public parkingo Implement program of reduced

parking fees for HOVs or high-MPG vehicles

o Zoning ordinance that reducesminimum parking spacerequ i remen t s fo r newconstruction

o Parking fees to fund transit use,b i cyc l e o r pedes t r i animprovements

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Fleet

ß Downsize current and future vehiclesthrough procurement policy changes

ß Reduce fleet size, i.e., total number ofvehicles

ß Improve scheduling and routeefficiency

ß Change procurement policy to specifyhigh fuel efficiency for each vehicleclass

ß Improve maintenance regime forincreased efficiency, e.g., check tirepressure

ß Replace on-the-job driving withtelecommunications, transit, bicycling,walking, and car-pooling

ß Provide incentives to reduce municipalemployee travel, e.g., trip reductionpolicies like subsidized transit passes,elimination of free parking, preferredparking for carpools, vanpools

Land use

ß Zoning or land use policy changes topromote infill development

ß Zoning ordinance that promotes high-density development

ß Zoning change to reduce parkingrequirements and allowances

ß Density bonuses and incentives forhigh-density, infill, and transit-orienteddevelopment

ß Impact, facility, mitigation, and permitfees that discourage sprawl

Water

ß Energy-efficient retrofit of facilities,especially pumping processes

ß Energy-efficient specs for newconstruction of sewage and waste watersystem

ß Improve energy-efficiency ofequipment

ß Process changes to improve energy-efficiency of treatment of drinkingwater, wastewater and sewage

ß Change energy source from electricityto natural gas for existing operations

Waste

ß Increase office recycling, e.g., paper,cardboard, cans, toner cartridges

ß Recover food waste in cafeterias andkitchens of local government buildingsfor composting or other use

ß Waste prevention in day-to-dayoperations—two-side copying, reducedpaper requirements, etc.

ß Purchasing preferences for recycledmaterials

ß Compost park, street, and otherlandscaping debris for re-use by Parksand Recreation

ß Recover landfill methane for energyproduction

ß Establish a center for reusingsalvageable goods

ß Home composting education program,compost bin distribution

ß Collect curbside yard debrisß Implement or expand residential

curbside recycling collectionß Improve or expand commercial

recycling collectionß Community recycling drop-off sitesß Financial incentives to reduce waste

such as:o Pay-as-you-throw or unit pricingo Special taxes and tipping feeso Advance disposal fees

ß Implement landfill methane collectionprogram

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Others

ß Implement or participate in districtenergy programs, i.e. district heatingand cooling

ß Implement public education programs,e.g., special events, PSAs, curricula

ß Implement urban forestry projectsß Establish energy efficiency or climate

protection information clearinghouse

Measures affecting Gas and ElectricUtilitiesß Purchase “green power” and specify

renewable energy content for localgovernment operations

ß Negotiate minimum standards forrenewable energy portfolio

ß Negotiate aggregate purchasingcontracts that specify renewable powerfor commercial and residential sectors

ß Implement program offering residentsand businesses the option of purchasingrenewable power for a surcharge

ß Local Government Measures

Lighting

ß Replace existing lighting with energy-efficient and low-wattage lamps andballast

ß Reduce energy use through reducinghours of operation and/or number oflights

ß Solar Photovoltaic (PV) powered streetand emergency lighting

ß Switch traffic signals, exit signs fromincandescent bulbs to Light EmittingDiodes (LEDs)

Procurement

ß Modify purchasing policies to specifyenergy efficiency standards in allpurchasing and bid specs for office andheavy equipment, motors, lighting,appliances, etc.

ß Purchase “green power” and specifyrenewable energy content for localgovernment operations

Financing

ß Establish financing program forefficiency improvements in thecommunity, e.g., revolving loan fundsthrough bonds, energy taxes, etc

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