Climate Change's Impact on Human Health & Policy: Lancet Countdown 2021 Report, Esquemas y mapas conceptuales de Economía

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Review The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future Marina Romanello, Alice McGushin, Claudia Di Napoli, Paul Drummond, Nick Hughes, Louis Jamart, Harry Kennard, Pete Lampard, Baltazar Solano Rodriguez, Nigel Amnell, Sonja Ayeb-Karlsson, Kristine Belesova, Wenjia Cai, Diarmid Campbell-Lendrum, Stuart Capstick, Jonathan Chambers, Lingzhi Chu, Luisa Ciampi, Carole Dalin, Niheer Dasandi, Shouro Dasgupta, Michael Davies, Paula Dominguez-Salas, Robert Dubrow, Kristie L Ebj, Matthew Eckelman, Paul Ekins, Luis E Escobar, Lucien Georgeson, Delia Grace, Hilary Graham, Samuel H Gunther, Stella Hartinger, Kehan He, Clare Heaviside, Jeremy Hess, Shih-Che Hu, Slava Jankin, Marcia P Jimenez, llan Kelman, Gregor Kiesewetter, Patrick L Kinney, Tord Kjellstrom, Dominic Kniveton, Jason K W Lee, Bruno Lemke, Yang Liu, Zhao Liu, Melissa Lott, Rachel Lowe, Jaime Martinez-Urtaza, Mark Maslin, Lucy McAllister, Celia McMichael, Zhifu Mi James Milner, Kelton Minor, Nahid Mohajeri, Maziar Moradi-Lakeh, Karyn Morrissey, Simon Munzert, Kris A Murray, Tara Neville, Maria Nilsson, Nick Obradovich, Maquins Odhiambo Sewe, Tadj Oreszczyn, Matthias Otto, Fereidoon Owfi, Olivia Pearman, David Pencheon, Mahnaz Rabbaniha, Elizabeth Robinson, Joacim Rocklów, Renee N Salas, Jan C Semenza, Jodi Sherman, Liuhua Shi, Marco Springmann, Meisam Tabatabaei, Jonathon Taylor, Joaquin Trinanes, Joy Shumake-Guillemot, Bryan Vu, Fabian Wagner, Paul Wilkinson, Matthew Winning, Marisol Yglesias, Shihvi Zhang, Peng Gong, Hugh Montgomery, Anthony Costello, lan Hamilton Executive summary The Lancet Countdown is an international collaboration that independently monitors the health consequences of a changing climate. Publishing updated, new, and improved indicators each year, the Lancet Countdown represents the consensus of leading researchers from 43 academic institutions and UN agencies. The 44 indicators of this report expose an unabated rise in the health impacts of climate change and the current health consequences ofthe delayed and inconsistent response of countries around the globe—providing a clear imperative for accelerated action that puts the health of people and planet above all else. The 2021 report coincides with the UN Framework Convention on Climate Change 26th Conference of the Parties (COP26), at which countries are facing pressure to realise the ambition of the Paris Agreement to keep the global average temperature rise to 1-5%C and to mobilise the financial resources required for all countries to have an effective climate response. These negotiations unfold in the context of the COVID-19 pandemic—a global health crisis that has claimed millions of lives, affected livelihoods and communities around the globe, and exposed deep fissures and inequities in the world's capacity to cope with, and respond to, health emergencies. Yet, in its response to both crises, the world is faced with an unprecedented opportunity to ensure a healthy future for all. Deepening inequities in a warming world Record temperatures in 2020 resulted in a new high of 3-1 billion more person-days of heatwave exposure among people older than 65 years and 626 million more person-days affecting children younger than 1 year, compared with the annual average for the 1986-2005 baseline (indicator 1.1.2). Looking to 2021, people older than 65 years or younger than 1 year, along with people facing social disadvantages, were the most affected by the record-breaking temperatures of over 40"C in the Pacific Northwest areas of the USA and Canada in June, 2021— an event that would have been almost impossible without human-caused climate change. Although the exact number will not be known for several months, hundreds of people have died prematurely from the heat. Furthermore, populations in countries with low and medium levels of UN-defined human development index (HDI) have had the biggest increase in heat vulnerability during the past 30 years, with risks to their health further exacerbated by the low availability of cooling mechanisms and urban green space (indicators 1.1.1, 2.3.2, and 2.3.3). Agricultural workers in countries with low and medium HDI were among the worst affected by exposure to extreme temperatures, bearing almost half of the 295 billion potential work hours lost due to heat in 2020 (indicator 1.1.4). These lost work hours could have devastating economic consequences to these already vulnerable workers—data in this year's report shows that the average potential earnings lost in countries in the low HDI group were equivalent to 4-8% of the national gross domestic product (indicator 4.1.3). Through these effects, rising average temperatures, and altered rainfall patterns, climate change is beginning to reverse years of progress in tackling the food and water insecurity that still affects the most underserved populations around the world, denying them an essential aspect of good health. During any given month in 2020, up to 19% of the global land surface was affected by extreme drought; a value that had not exceeded 13% between 1950 and 1999 (indicator 1.2.2). In parallel with drought, warm temperatures are affecting the yield potential of the world's major staple crops—a 6-0% reduction for maize; 3-0% for winter wheat; 5-4% for soybean; and 1.8% for rice in 2020, relative to 1981-2010 (indicator 1.4.1) —exposing the rising risk of food insecurity. Adding to these health hazards, the changing environmental conditions are also increasing the suitability for the transmission of many water-borne, air- borne, food-borne, and vector-borne pathogens. Although socioeconomic development, public health interventions, and advances in medicine have reduced the global wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 0t0O CromMark Published Online October 20, 2021 https: //doi.org/10.1016/ S0140-6736(21J01787-6 See Online/Editorial https: //doi.org/10.1016/ S0140-6736(21J02281-9 Forthe Chinese translation ofthe Executive Summary see Online forappendx1 Forthe French translation of the Executive Summary see Online forappendxc2 Forthe German translation of the aExecutive Summary see. Onlinefor appendix3 Forthe Spanish translation ofthe Executive Summary see Online forappendx 4 Institute forGlobal Health (M Romanello PhD, AMcGushin MSc, L jamart MSc, Prof Kelman PhD, Prof ACostello FMedSci), Institutefor Sustainable Resources (P Drummond MSc, IN Hughes PhD, CDalin PhD, Prof'P Ekins PhD, "MWinning PhD), UCL Energy Institute (H Kennard PhD, B Solano Rodriguez MSC, S-CHsu MSc, Prof Oreszczyn PhD, Profl Hamilton PhD), Institute for Environmental Design and Engineering (Prof M DaviesPhD, CHeaviside PRD, IN Mohajeri PhD), Department of Geography (L Georgeson PhD, Prof Mi Mastin PhD), The Bartlett School of Sustainable Construction (KHe MSc, Z Mi PhD),and Centrefor Human Health and! Performance (ProfH Montgomery MD), University College London, London, UK; School of Review Agriculture, Policyand Development (C DiNapoli PhD, ProfE Robinson PhD), Department of Meteorology (Prof NW Arnell PhD), The Walker Institute (L Ciampi PhD), University of Reading, Reading, UK; Department of Health Sciences, University of York, York, UK (P Lampard PhD, Prof Graham PRD); Institute for Environment and Human Security, United Nations University, Bonn, Germany (S Ayeb-Karlsson PhD); Centre on Climate Change and Planetary Health (KBelesova PRD), Centrefor Mathematical Modelling of Infectious Diseases (RLowe PhD), Department of Public Health, Environments, “and Society (] Milner PhD, Prof P Wilkinson FRCP), London School of Hygieneg: Tropical Medicine, London, UK; Department of Earth System Science, Tsinghua University, Beijing, China (W Cai PhD, Z Liv PhD, S Zhang PhD) Departmentof Environment, Climate Change and Health (0 CampbelleLendrurn DPhil, T Neville MSc), and Institute for Environmental Sciences ( Chambers PhD), World Health Organization, Geneva, Switzerland; Centre forClimate Changeand Social “ransformations, School of Psychology, Cardiff University, Cardiff UK (S Capstick PhD); Yale Center onClimate Change andHealth, Yale University, New Haven, CT, USA (LChu MPh, Prof R Dubrow PhD); School of Government, (N Dasandi PhD); Economic analysis of Climate Impactsand Policy, Centro Euro- Mediterraneo suiCambiamenti Climatici, Venice, Italy (SDasgupta PhD); Natural Resources Institute, University of Greenwich, London, UK (P Dominguez-Salas PhD); Department of Global Health (Prof K LEbi PhD), and Centre for Health and the Global Environment () Hess MD), rsity of Washington, Seattle, WA, USA; Department ofCiviland Environmental University, Boston, MA, USA (M Eckelman PhD); Department ofFish and Wildlife Conservation, Virginia Polytechnic Institute and State burden of infectious disease transmission, climate change could undermine eradication efforts. The number of months with environmentally suitable conditions for the transmission of malaria (Plasmodium _falciparum) rose by 39% from 1950-59 to 2010-19 in densely 'populated highland areas in thelowHDI group, threatening highly disadvantaged populations who were comparatively safer from this disease than those in the lowland areas (indicator 13.1). The epidemic potential for dengue virus, Zika virus, and chikungunya virus, which currently primarily affect populations in central America, South America, the Caribbean, Africa, and south Asia, increased globally, with a basic reproductive rate increase of 13% for transmission by Anopheles aegypti and 7% for transmission by Anopheles albopictus compared with the 1950s. The biggest relative increase in basic reproductive rate of these arboviruses was seen in countries in the very high HDI group (indicator 1.3.1); however, people in the low HDI group are confronted with the highest vulnerability to these arboviruses (indicator 1.3.2). Similar findings are observed in the environmental suitability for Vibrio cholerae, a pathogen estimated to cause almost 100000 deaths annually, particularly among populations with poor access to safe water and sanitation. Between 2003 and 2019, the coastal areas suitable for V cholerae transmission increased substantially across all HDI country groups—although, with 98% of their coastline suitable to the transmission of V cholerae in 2020, itis people in the low HDI country group that have the highest environmental suitability for this disease (indicator 1.3.1). The concurrent and interconnecting risks posed by extreme weather events, infectious disease transmission, and food, water, and financial insecurity are over- burdening the most vulnerable populations. Through multiple simultaneous and interacting health risks, climate change is threatening to reverse years of progress in public health and sustainable development. Even with overwhelming evidence on the health impacts of climate change, countries are not delivering an adaptation response proportionate to the rising risks their populations face. In 2020, 104 (63%) of 166 countries did not have a high level of implementation of national health emergency frameworks, leaving them unprepared to respond to pandemics and climate-related health emergencies (indicator 2.3.1). Importantly, only 18 (559%) of 33 countries with a low HDI had reported at least a medium level of implementation of national health emergency frameworks, compared with 47 (89%) of 53 countries with a very high HDI. In addition, only 47 (52%) of 91 countries reported having a national adaptation plan for health, with insufficient human and financial resources identified as the main barrier for their implementation (indicator 2.1.1). With a world facing an unavoidable temperature rise, even with the most ambitious climate change mitigation, accelerated adaptation is essential to reduce the vulnerabilities of populations to climate change and protect the health of people around the world. An inequitable response fails everyone 10 months into 2021, global and equitable access to the COVID-19 vaccine had not been delivered —more than 60% of people in high-income countries have received at least one dose ofa COVID-19 vaccine compared with just 3-5% of people in low-income countries. Data in this report exposes similar inequities in the global climate change mitigation response. To meet the Paris Agreement goals and prevent catastrophic levels of global warming, global greenhouse gas emissions must reduce by half within a decade. However, at the current pace of reduction, it would take more than 150 years for the energy system to fully decarbonise (indicator 3.1), and the unequal response between countries is resulting in an uneven realisation of the health benefits ofa low-carbon transition. The use of public funds to subsidise fossil fuels is partly responsible for the slow decarbonisation rate. Of the 84 countries reviewed, 65 were still providing an overall subsidy to fossil fuels in 2018 and, in many cases, subsidies were equivalent to substantial proportions of the national health budget and could have been redirected to deliver net benefits to health and wellbeing. Furthermore, all the 19 countries whose carbon pricing policies outweighed the effect of any fossil fuels subsidies came from the very high HDI group (indicator 4.2.4). Although countries in the very high HDI group have collectively made the most progress inthe decarbonisation of the energy system, they are still the main contributors to CO, emissions through the local production of goods and services, accounting for 45% of the global total (indicator 4.2.5). With a slower pace of decarbonisation and poorer air quality regulations than countries in the very high HDI group, the medium and high HDI country groups produce the most fine particle matter (PM, ,) emissions and have the highest rates of air pollution- related deaths, which are about 50% higher than the total deaths in the very high HDI group (indicator 3.3). The low HDI group, with comparatively lower amounts of industrial activity than in the other groups, has a local production that contributes to only 0-7% of global CO, emissions, and has the lowest mortality rate from ambient air pollution. However, with only 12% of its inhabitants relying on clean fuels and technologies for cooking, the health of these populations is still at risk from dangerously high concentrations of household air pollution (indicator 3.2). Even in the most afluent countries, people in the most deprived areas over whelmingly bear the burden of health effects from exposure to air pollution. These findings expose the health costs of the delayed and unequal mitigation response and underscore the millions of deaths to be prevented annually through a low-carbon transition that prioritises the health ofall populations. vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review Panel 1: Working group indicator Climate change impacts, exposures, and vulnerabilities 1.1: health and heat 1.1.1: vulnerability to extremes of heat 1.1.2: exposure of vulnerable populations to heatwaves 1.13: heatand physical activity 1.1.4: change in labour capacity 1.1.5: heat and sentiment 1.1.6: heat-related mortality 1.2: health and extreme weather events 1.2.1: wildfires 1.2.2: drought 1.2.3: lethality of extreme weather events 1.3: climate-sensitive infectious diseases 13.1: climate suitability for infectious disease transmission 13.2: vulnerabilityto mosquito-borne diseases 1.4:fo0d security and undernutrition 1.4.1: terrestrial food security and undernutrition 1.4.2: marine food security and undemutrition 1.5: migration, displacement, and rising sea levels Adaptation, planning, and resilience for health 2.1: adaptation planning and assessment 2.1.1: national adaptation plans for health 2.1.2: national assessments of climate change impacts, vulnerability, and adaptation for health 2.13; city-level climate change risk assessments 2.2: dimate information services for health 2.3: adaptation delivery and implementation 23,1: detection, preparedness, and responseto health emergencies 23.2: air conditioning: benefits and harms 23.3: urban green space 2.4: health adaptation-related global funding and financial transactions available (2019).* This composite HDI captures three dimensions: a long and healthy life (with life expectancy as a proxy), education (captured by the mean of years of schooling), and standard of living (measured by per- capita gross national income). In line with the priorities of The Lancel's Diversity Board, gender disparities are also considered wherever relevant. However, a scarcity of gender-disaggregated data means that few indicators can capture these differences quantitatively and often do so using sex disaggregation as a proxy for gender (see panel 2). The COVID-19 pandemic will alter the trends of many of the indicators reported; some of these trends can be identified in this report and others will become apparent in the coming years. COVID-19 has also altered population demographics, mortality rates, and the structure and size of the labour force. These changes are not reflected in the current indicators, presenting Mitigation actions and health co-benefits 3.1: energy system and health 3.2: clean household energy 3.3: premature mortality from ambient air pollution by sector 3.4: sustainable and healthy transport 3.5: food, agriculture, and health 3.511: emissions from agricultural production and consumption 3.5.2: diet and health co-benefits 3.6: mitigation in the healthcare sector Economics and finance 4,1: the economic impact of climate change and its mitigation 4,11: economic losses due to climate-related extreme events 4,12: costs of heat-related mortality 413; lossof earings from heat:related labour capacity reduction 4.1.4: costs of the health impacts of air pollution 4.2: the economics ofthe transition to zero-carbon economies 4.2.1: coal and clean energy investment 4.2.2: employment in low-carbon and high-carbon industries 4.2.3: funds divested from fossil fuels 4.2.4: net value of fossil fuel subsidies and carbon prices 4.2.5: production-based and consumption-based attribution of CO, and PM,, emissions Public and political engagement 5.1: media coverage of health and climate change 5.2: individual engagement in health and dimate change 5.3: coverage of health and dimate change in scientific journals 5.4: government engagement in health and climate change 5.5: corporate sector engagement in health and climate change methodological challenges in the assessment of the health impacts of climate change. How the COVID-19 pandemic affects the methods and assumptions of the Lancet Countdown's indicators will become clearer in future reports as more data will be available. The global reach of the Lancet Countdown is expanding. Two regional offices, one in South America (Universidad Peruana Cayetano Heredia, Lima, Peru) and one in Asia (Tsinghua University, Beijing, China), were established in 2020 and an office in Europe was established in 2021 (Barcelona Supercomputing Centre, Barcelona, Spain). These regional collaborators contributed indicators to the 2021 report and are working on nationally-relevant and regionally-relevant health and climate change research, accompanied by local communications and policy engagement. A third regional office, based at the University of the West Indies (Kingston, Jamaica), was established in September, 2021, and aims to build on the 'wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Departmentof Civil Engineering, Tampere University, Tampere, Finland (Taylor PhD); Departmentof Electronicsand Computer Science, Universidade de Santiago de Compostela, Santiago, Spain ( Trinanes PhD); Departmentof Geography, University of Hong Kong, Hong Kong Special Administrative Region, China (ProfP Gong PhD) Correspondence to: Proflan Hamilton, Energy Institute, University College London, London WC1HONN, UK ihamiltonQud.ac.uk Review For more onthe online data visualisation platform see https//wwwwelancetcountdown org/data-platform/ Panel 2: Gender, health, and climate change The health impacts of climate change are both underpinned and amplified by gender norms and gender inequities, with numerous examples cited throughoutthis report.* Gender also influences who sets the agenda and drives responses to climate change. Evidence shows that greater representation ofwomen in parliament is associated with stronger climate change policies.3*" However, only 41 (21%) oF196 heads of delegation to the UN Framework Convention on Climate Change (UNFCCC) Conference of Parties in 2019 were women, and women headed just 29% of national delegations tothe UNFCCC intersessional in June 2019. Additionally, ofthe 1000 scholars listed by Reuters as the most influential on climate change, only 122 were women.* There is an urgent need for gender-sensitive responses to the health dimensions of climate change. These responses are underpinned by the collection and reporting of data that is sufficiently disaggregated, granular, and intersectional to reveal local inequities—eg, data disaggregated not only by gender but also by geography, age, ethnicity, class, and other markers of marginalisation and vulnerability>*** However, in many cases, a scarcity of standardised, gender-disaggregated data hampers these efforts.*** It isthe very social structures that shape how gender is perceived and prioritised that undermine progress—eg, cultural norms often translate into weak political and financial support and limitthe capacity of researchers to engage with gender inequities.*** Only 6% of all scientific articles covering climate change and health in 2020 considered gender (indicator5.3), and, despite a workstream established for this purpose, only 6 of the 44 indicators in the 2021 report ofthe Lancet Countdown provide data by sex or gender. network and evidence base of health and climate change in small island developing states (SIDS). The Lancet Countdown is also working in collaboration with the European Environment Agency, incorporating policy- relevant data from its indicators into the European Climate and Health Observatory. National and regional reports were published for Australia (in partnership with the Medical Journal of Australia), China, and SIDS.”" For the third year, the data underpinning each of the Lancet Countdown's indicators have been shared through an online data visualisation platform, where they can be explored at finer spatial and temporal scales. The work of this collaboration is driven by the ongoing support from The Lancet and the Wellcome Trust, the Lancet Countdown's scientific advisory group and higherlevel advisory board, and, importanty, the Lancet Countdown's authors and collaborators. The collaboration welcomes offers of support from new experts and new institutions willing to build on this analysis as the Lancet Countdown monitors the world's response to the health effects of climate change during this decade. Starting to reverse this, the UN Entity for Gender Equality and the Empowerment of Women (UN Women) is leading global efforts to increase the availability of information on gender through its flagship programme, Making Every Woman and Girl Count. Through this programme, UN Women supports countries with the development of priority indicators to expose and record gender inequities (both through indicator selection and data collection).** A model questionnaire has been developed for this purpose, and several countries, including Bangladesh, Mongolia, and several Pacific island countries, have either begun (or are currently preparing for) their rollout. With the purpose of helping countries understand the connections between the environment and gender equality, the programme also supports data reprocessing and the integration of geospatial information with demographic and health surveys. The importance ofthis work is already materialising. Preliminary analysis shows the accentuation of gender inequities as a result of weather events, including drought episodes driving spikes in child marriage for girls in almost all Asian countries analysed. Gender, as a social construction, affects everyone in society.***-* A gender-sensitive response to climate change would generate benefits forthe whole of society. Ensuring gender is represented in national statistical strategies and regular data collection processes will expose the true dimensions of the challenge. Ensuring this representation, along with more diverse leadership, will inform and drive a commensurate response. Section 1: climate change impacts, exposures, and vulnerability Climate change threatens human health and wellbeing through effects on weather, ecosystems, and human systems. These effects increase exposure to extreme events, change the environmental suitability for infectious disease transmission, alter population movements, and undermine peoples livelihoods and mental health.*-* The resulting strains on health and social systems disproportionately affect the most disadvantaged in society, with climate change amplifying inequities.2% Section 1 of the 2021 report monitors the health impacts of climate change, with indicators tracking climate hazards, human exposure and vulnerabilities to climate hazards, and the resulting health outcomes of these. The first group of indicators addresses the direct implications of rising temperatures for health, exploring changes in the exposure and vulnerabilities of populations around the world to extreme heat and its impacts on health and wellbeing (indicators 1.11-1.16, see panel 1). Each of these indicators takes gridded heat data and overlays them with relevant exposure and vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review vulnerability data to reflect health outcomes. Two new indicators have been introduced since the 2020 report.” One of these indicators shows the effect of heat on time available for safe outdoor exercise (indicator 1.1.3) and the other indicator approaches the challenge of assessing the influence of extreme heat on sentiment with Twitter data to capture people's online expressions (indicator 1.1.5). The second group of indicators in this section sheds light on climate-sensitive extreme events, tracking exposure to wildfire and wildfire risk (indicator 12.1), the incidence of droughts (indicator 1.2.2), and the lethality of extreme weather events (indicator 1.2.3). Assessing the influence of environmental changes on ecological niches for human pathogens, the section also models the changing suitability for the transmission of climate-sensitive infectious diseases, expanding the analysis from previous years to include three diseases of global public health relevance (Zika, chikungunya, and Vibrio cholerae) and improving models from the 2020 report to reflect the reproduction number for arbovirus transmission. With health outcomes of vector- borne disease transmission being strongly influenced by socioeconomic factors and health-care access, indicator 13.2 incorporates considerations of implemented adaptation measures to assess the changing vulnerability of populations to arboviruses. Vector-borne disease transmission is followed by indicators of environmental pressure on terrestrial and marine food productivity. In this year's report, the anlaysis has been extended to assess the association between heat stress and severe food insecurity (indicators 1.4.1 and 14.2). The final indicator in this section focuses on exposure to rising sea levels and its implications for human mobility (indicator 1.5). Indicator 1.1: health and heat Indicator 1.1.1: vulnerability to the extremes of heat—headline finding: although vulnerability to heat in the low and medium HDI country groups is 27-38% lower than in the very high HDI group, ¡tis increasing in all groups and, since 1990, it has increased by 19% in the low HDI group and by 20% in the medium HDI group Exposure to extreme heat poses an acute health hazard, with individuals older than 65 years,*% populations in urban environments,”% and people with health conditions** being particularly at risk. Heat dispro- portionately affects people who are marginalised or under-resourced that have little access to cooling mechanisms and health care, amplifying health and social inequities.*“ This indicator tracks vulnerability to extreme heat through an index that combines the proportion of the population older than 65 years, the prevalence of relevant chronic diseases (respiratory disease, cardiovascular disease, and diabetes) in that group, and the proportion of the total population living in urban areas. With aging populations, high prevalence of chronic diseases, and increasing urbanisation, the countries with a very high HDI had the highest vulnerability to extremes of heat. However, vulnerability to heat is rising across all HDI groups, with countries of low and medium HDI having the largest increases in vulnerability to heat since 1990 (19% for the low HDI group and 20% for the medium HDI group). The worsening trends in extreme temperature, as exposed in other indicators from this section, highlight a need to identify populations who are vulnerable to the health impacts of heat at the national and local levels. Additional work will be done to capture other heat vulnerabilities for this indicator. Indicator 1.1.2: exposure ofvulnerable populations to heatwaves—headline finding: children younger than 1 year were affected by 626 million more person-days of heatwave exposure and adults olderthan 65 years were affected by 3-1 billion more person-days of heatwave exposurein 2020 than in the 1986-2005 average Young children and older people are especially susceptible to the health risks of high temperatures and heatwaves.” This indicator reports the total number of days adults older than 65 years and (for the first time) children younger than 1 year were exposed to life- threatening heatwave events. In an improvement from previous years reports, the definition of a heatwave now aligns with the World Meteorological Organization (WMO) and other scientific literature.“ Additional details are given in appendix 5 (pp 6-8). Results show a steady increase in the person-days of exposure for adults older than 65 years, with an annual average of 2-9 billion additional person-days of heatwave exposure in the past 10 years and 3-1 billion more (or an average of 4-1 days per person >65 years) in 2020, with respect to the 1986-2005 baseline average (figure 1). For children younger than 1 year, there were an estimated 626 million additional person-days of exposure (4-6 days per person <l year) affecting this vulnerable group in 2020 compared with baseline years. Indicator 1.1.3: heat and physical activity—headline finding: the past four decades saw an increase in the number of hours in which temperatures were too high forsafe outdoor exercise, with people in the low HDI country group having an average loss of3-7 h of safe exercise per day in 2020 Physical exercise provides mental health benefits and reduces the risk of cardiovascular disease, diabetes, cancer, cognitive decline, and allcause mortality” However, high temperatures can reduce the frequency of physical activity, duration of physical activity, and the desire to engage in exercise/*"* and even low amounts of physical activity in high temperatures can pose a risk to health.” This indicator estimates the loss of potential hours of safe physical activity per person due to ambient temperature, humidity, and radiant heat, by tracking the wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review O Negative expressions E 0301 E Positive expressions Ez B Ez 0-20, $É bg mm Y E E 55d ox FE 07 ¿ 0304 B 2 E 10000000004 vi E sooovoooo- E o , , 2015 2016 2017 2018 Number of geolocated tweets mao mao 140 20 mao 10000 1000 Figure 4: Heatwaves and sentiment on Twitter (A) Annual effectof heatwave exposure on the sentiment of Twitter users expressions from 2015-20. Boxes depict 95%-ls of the estimated average change in general sentiment expressions during days with heatwaves, relative to the median daily maximum temperature baseline range for each location and year. Sentiment was extracted from Twitter posts using a dictionary-based approach across multiple languages, see appendix5 (p 16). Grey bars depictthe geolocated Tweet count byyear of observation. (A) Country-level count oftotal geolocated tweets for 2015-20. 2018 and 2019, India and Brazil had the biggest absolute increase in heat-related mortality Although heat- related mortality decreased between 2018 and 2019 in the WHO European region (due to fewer attributable deaths in countries such as Germany, Russia, and the UK), this region is still the most affected, with almost 108000 deaths attributable to heat exposure in 2019. Indicator 1.2: health and extreme weather events Indicator 1.2.1: wildfires—headline finding: nearly 60% of countries had an increase in the number of days people were exposed to very high or extremely high fire danger in 2017-20 compared with 2001-04, and 72% of countries had increased human exposure to wildfires across the same period Hotter and drier conditions caused by climate change increase the risk of wildfires and the extent of their damage.” As in previous years, this indicator tracks wildfire exposure by combining satellite-observed active fire spots"” and human exposure to high and extremely high wildfire danger (considering a fire weather index score of worse than 5 and population data)."" The fire weather index, provided by the Copernicus Emergency Management Service for the European Forest Fire Information System,” combines air temperature, relative humidity, wind speed, and drought effects to capture the chances of a fire starting, its rate of spread, its intensity, and its difficulty of suppression. A full description of the methods used can be found in appendix 5 (pp 23-24). This indicator does not yet quantify exposure to wildfire smoke, which can affect much larger populations and have larger health conse- quences than direct exposure to the fire; it is estimated that smoke from the 2019-20 Australian fires affected 80% of Australia's population and resulted in hundreds of deaths and thousands of people admitted to hospital." Globally, in 2017-20, there was an average of 215531 more person-days of wildfire exposure than in 2001-04. Overall, 134 (72-49) of 185 countries had an increase in wildfire exposure in 2017-20 compared with 2001-04. But this increase was unequal—27 (83%) of 32 low HDI countries had an increase in wild- fire exposure compared with 40 (62-5%) of 64 very high HDI countries. The largest increases in wild- fire exposure were observed in the Democratic Republic of the Congo, India, and China. During the same time period, the climatological danger of wildfire increased in 110 countries, with the largest growth occurring in Lebanon, The Gambia, and Lesotho (figure 6). Indicator 1.2.2: drought—headline finding: in 2020, up to 19% of the global land surface was affected by extreme drought in any given month Climate change is increasing the frequency, intensity, and duration of drought events. These changes pose threats to water security, sanitation, and food productivity and increase the risk of wildfires and exposure of the environment to pollutants.*% This indicator tracks the land area affected by extreme drought events using the standardised precipitation- evapotranspiration index (extreme drought <1-6 and exceptional drought =2, in alignment with the Federal Office of Meteorology and Climatology MeteoSwiss'”), capturing the changes in precipitation and the effect of temperature on evaporation and moisture loss. More details about this indicator are provided in appendix 5 (pp 25-27). The global land surface area affected by extreme drought conditions has consistently increased since 1990. The proportion of the world's land surface with extreme drought in any given month reached a 10 vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review Number of deaths Attributableto heat. Changein number of days of exposure to very highor extremely highrisk ofwildfire IM -g00to-400 [21to50 110100 101to20.0 201t030.0 IE 30110600 [E Nodata BD ostoz0 Figure 6: Anual population-weighted mean change in the number of days with very high and extremely high risk of wildfire from 2001-04 to 2017-20 for each country or territory Large urban areas with a population density 2400 persons/kmY are excluded in the calculationsof population-weighted mean values. Very high and extremely high riskis defined by the fire weather index." maximum of 22% in 2010-19; a value that had only reached 13% in 1950-99 (figure 7). Furthermore, the 5 years with the most area affected by extreme drought have all occurred since 2015, and the Horn of Africa, a region impacted by recurrent extreme droughts and food insecurity,'* was one of the most affected areas in 2020. Indicator 1.2.3: lethality of extreme weather events— headline finding: the past 30 years have seen statistically significant increases in the number of extreme weather events; however, only the low HDI group had a statistically significant increase in the number of people affected by these events This indicator tracks the number of occurrences of weather-related disasters that are climate sensitive, and the number of people affected or killed per event. Data are taken from the Centre for Research on the Epidemiology of Disasters and have been presented as standard anomalies across the 1990-2020 period. All HDI country groups have had a consistent and statistically significant increase in the number of extreme weather events during the past 30 years, with the very high HDI group having the highest increase (appendix 5 pp 28-32). However, only the low HDI group has had a statistically significant increase of people affected per disaster eventa situation that might reflect a more rapid growth in the populations living in high-risk areas within low HDI countries or inequities between HDI groups in adaptive capacity and preparedness to respond to worsening climate change hazards. wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 For more onthe datafrom the Centrefor Research on the Epidemiology of Disasters see https://emdat.be/ u Review En 100, Drought severity Je extreme drought Exceptionaldrought Landarea affected by drought events (%) 1959 1969 1979 1989 1999 2009 2019 Year Figure 7: Global land area affected by drought events per month Extreme drought is defined by a SPEL of <1-6 and exceptionaldrought is defined by a SPEL of =2. SPEl=standardised precipitation-evapotranspiration index Indicator 1.3: climate-sensitive infectious diseases Indicator 1.3.1: climate suitability for infectious disease transmission—headline finding: in 2011-21, the area of coastline suitable for Vibrio bacterial transmission has increased by 35% in the Baltics, 25% in the Atlantic Northeast, and 4% in the Pacific Northwest; the number of months suitable for malaria transmission increased by 39% between 1950-59 and 2010-19 in highland areas of the low HDI group Climate change is affecting the distribution of arthropod- borne, food-borne, and water-borne diseases.” Together with global mobility and urbanisation, climate change is a major driver of the increase in the number of dengue virus infections,” which have doubled every decade since 1990.* Other important emerging or re-emerging arboviruses, transmitted by mosquitoes, are likely to have a similar response to climate change.” This indicator tracks the environmental suitability for the transmission of arboviruses (dengue, chikungunya, and Zika) with an improved model to assess the influence of temperature and rainfall on vectorial capacity and vector abundance, and overlays it with human population density data to estimate the reproductive number (R,; the expected number of secondary infections resulting from. one infection). The R, for all arboviral diseases tracked has increased with respect to the 1950-54 average, and, in 2020, was 13% higher for transmission by A aegppti and 7% higher for transmission by A albopictus than in baseline years (1950-54). The largest increases in epidemic potential for dengue, Zika, and chikungunya were in countries with very high HDI, mainly from the ongoing geographical expansion of Aedes mosquitoes. The influence of the changing climate on the length of the transmission season for Plasmodium falciparum. malaria was also tracked with a threshold-based model that incorporates precipitation accumulation, average temperature, and relative humidity.” There were substantial differences in the number of months suitable for transmission of malaria in highland areas (ie, areas =1500 m above sea level) in 2010-19 compared with in 1950-59, with a 39% increase in the low HDI country group and a 15% increase in the medium country HDI group. The difference between high and medium HDI areas is even more marked at a subnational level than at a national level, which suggests that climate change might make malaria eradication efforts increasingly difficult in already disadvantaged areas. This indicator also monitors the environmental suitability for the transmission of Vibrio bacteria in coastal waters. Vibrio pathogens can cause gastro- enteritis, life-threatening cholera, severe wound infections, and sepsis." Driven by changes in sea surface temperature and sea surface salinity, the area of coastline showing suitable conditions for the transmission of non- cholerae Vibrio species at any one point during the year increased by 56% (from 7-0% to 10-9% of the coastline) in latitudes of the northern hemisphere (40-70 north) in 2020 compared with the 1982-89 baseline. From 1982-89 to 2011-20, the area of coastline suitable for non- cholerae Vibrio species at any point during the year has risen from 47-5% to 82-4% in the Baltics, 29 9% to 54-9% in the Atlantic Northeast, and 1.2% to 5-1% in the Pacific Northwest (figure 8). Between 2003 and 2019, there was an increase in the proportion of coastline with suitable conditions for V cholerae across all HDI country groups, with the low HDI country group having the highest suitability for V cholerae on average (at 98-6% of countries” coastlines in 2019). However, the high HDI country group had the greatest increase in suitable coastline area during this period, at a rate of almost an additional 1% of their coastline area becoming suitable each year (coefficient of determination=0-78; df=15; p<0-01). Indicator 1.3.2: vulnerability to mosquito-bome diseases— headline finding: although vulnerability to arboviruses transmitted by A albopictus and A aegypti has decreased across all countries since 2000, peoplein countries in the low HDI group are still the most vulnerability on average As shown by indicator 1.3.1, climate change is making environmental conditions increasingly favourable for the transmission of some arboviruses. Although inter- ventions to reduce the vulnerability of people to infection can partly counteract the increase in risk of transmission, environmental pressures make these interventions increasingly challenging. This indicator combines the environmental suitability for the transmission of dengue (as described in indicator 1.3.1) with indicators of social vulnerability to this disease—ie, access to sanitation and water services, income level, and health-care quality." Due to improvements in sanitation, income, and health-care quality, vulnerability to mosquito-borne diseases is decreasing, even despite increases in their environmental suitability. Although the vulnerability of countries in the low HDI group to disease transmission by A aegypti has decreased by 34% between 2000 and 2017, the same time period has had a 61% decrease in vulnerability to disease transmission by A aegypti in the very high HDI country group and a 73% decrease in the vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review or wellbeing, but this mention was typically related to climate change effects rather than to the potential health effects of forced migration. Although these policies often accepted that mobility could be domestic and international, immobility was rarely acknowledged. National policies that recognise and respond to the health risks and health benefits of different mobility patterns will partly shape the overall health outcomes.'” Conclusion In this sixth iteration of the Lancet Countdown indicators, section 1 of the 2021 report highlights a continuous increase in the impacts of climate change on all monitored aspects of human health, providing additional evidence that climate change is having quantifiable and increasingly negative impacts on human health. Although its health impacts are felt across the world, climate change disproportionately affects disadvantaged populations, exacerbating their vulnerabilities. The stratification of indicators by HDI groups reveals the higher risks faced by low and medium HDI countries, particularly with regards to labour capacity and livelihoods, food security, and vector-borne disease transmission. Reporting the health impacts on disadvantaged groups and the necessary adaptation responses (described in section 2) represents a major challenge, made greater by the absence of disaggregated data.” With respect to gender, these challenges are explored in panel 2. Moreover, although section 1 considers the impact of heat on online sentiment expression, the difficulties of capturing the mental health effects of climate change have not been addressed. The Lancet Countdown will continue to focus on closing this gap. Section 2: adaptation, planning, and resilience for health The past year has affirmed the centrality of health and wellbeing to socioeconomic development, illustrating how health risks can compound and cascade across sectors and nations and highlighting the potential consequences of scarce investments into health systems that are climate resilient and environmentally sustain- able.» The COVID-19 pandemic has also exposed stark differences in the capacity of health systems and the resilience of populations to health emergencies,'*” highlighting the urgent need for health authorities to increase national and international coordination and preparedness. This coordination should include integrated surveillance and monitoring of emerging health threats, developing and deploying early warning and response systems, and financially supporting low- resource nations and communities." To be effective, public health responses must address the needs of the most vulnerable, reducing inequities and therefore benefiting the whole society. Building health systems that are climate resilient and environmentally sustainable would not only help reduce the health impacts of climate change explored in section 1, but also contribute to minimising the risk of future pandemics. This section reports eight indicators of adaptation, planning, and resilience, which are closely linked with the components of the WHO Operational Framework for Building Climate Resilient Health Systems: planning and assessment (indicators 2.1.1-2.1.3); information systems (indicator 2.2); delivery and imple- mentation (indicators 2.3.1-2.3.3); and funding and spending (indicator 2.4). Each of these indicators provide insights into inequities. Data on health adaptation funding from global financing mechanisms, which are necessary to help countries with a low or medium HDI to adapt to the worsening health impacts of climate change, have been reintroduced into this years report (indicator 2.4). An unaddressed challenge in section 2 is the scarcity of clear metrics to monitor adaptation progress. Although efforts were made to validate the indicators, selfreported data for adaptation plans, assessments, and services might be have reporting bias, particularly where COVID-19 resulted in the redeployment of public health resources and where surveys had a decline in participation. Indicator 2.1: adaptation planning and assessment Indicator 2.1.1: national adaptation plans for health—headline finding: in 2021, 47 (52%) of 91 countries reported having national health and climate change strategies or plans in place Health systems are under pressure to respond to the acute and long-term threats from climate change and other, simultaneous, public health risks. Comprehensive, implemented health adaptation plans can not only improve health resilience of populations to climate change but also contribute to a broader strengthening of health systems and catalyse effective collaboration with other health-determining sectors. Data for indicators 2.1.1 and 2.1.2 are from the 2021 WHO Health and Climate Change Global Survey,” which provides selfreported data on health sector response to climate change from 91 governments and is described in appendix 5 (pp 79-80). This indicator tracks the development of national health and climate change strategies and the barriers to implementation. In the 2021 WHO Health and Climate Change Global Survey, 47 (52%) of 91 countries reported that they have a national health and climate change strategy or plan in place, which is comparable to the proportion reported in 2018 by the WHO survey. Implementation is still a challenge for countries from all HDI levels, with less than a quarter of countries who responded to the survey reaching high or very high levels of implementation. Insufficient financing was identified as a main barrier to reaching full implementation by 31 (699%) of all 45 responding countries, with 10 (259%) wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review For more ondata fromthe Carbon Disclosure Project's 2020 survey of global cities see https:/data.cóp.net/ 16 reporting that they have no current sources of funding available for the priorities set out in their strategies and plans. Other barriers to implementation were insufficient human resource capacity (expressed by 24 [53%] of 45 countries), COVID-19 related constraints (23 [51%)), and insufficient research, technologies, or tools (20 [44%)). A desktop review of National Adaptation Plans (NAPs) submitted to the UNFCCC found that four of the 19 NAPs considered gender in health adaptation actions. However, although NAPs might mention the principles of gender equality, they often did not demonstrate they were integrating gender issues in a way that challenges gender norms, power, and structures. The recommendations in the WHO guidance, Mainstreaming gender in health adaptation to climate change programmes, provide countries with guidance for achieving gender mainstreaming, including through national health and climate change plans ms Indicator 2.1.2: national assessments of climate change impacts, vulnerability, and adaptation for health—headline finding: 45 (49%) of91 countries in 2021 reported having done a climate change and health vulnerability and adaptation assessment Evidence-based policy developmentand planning require a comprehensive evaluation of the climate change- associated health risks faced by populations and health systems. This indicator monitors the number of countries that report having done a climate change, health vulnerability, and adaptation assessment. These assessments are crucial as they not only allow countries to establish and re-evaluate health risks but also consider the vulnerabilities to climate hazards that contribute to health outcomes. Although 45 (49%) of 91 countries disclosed they had done a climate change and health vulnerability and adaptation assessment, only 8 (199%) of these countries reported that the findings strongly influenced the allocation of human and financial resources. In comparison, 17 (56%) of 43 countries reported that the findings strongly informed the development of health policies and programmes. Most countries specifically considered population groups vulnerable to the effects of climate change in their assessments, including children, women, older adults, workers, rural and urban populations, people living in poverty, and, to a lesser extent, indigenous groups, migrant populations, or displaced populations. However, the comprehensiveness of these assessments varied. As explored in section 1, health vulnerabilities to climate change are unevenly distributed and can exacerbate existing health inequities. As health vulnerability and adaptation assessments inform national healh and climate change plans and programmes, data gathered for these assessments must be disaggregated according to social determinants of health. This disaggregation will enable public health interventions to actively identify and support the populations most vulnerable to the effects of climate change and proactively reduce subnational health inequities relating to climate change. Indicator2.1.3: city-level climate change risk assessments — headline finding: in 2020, 546 (81%) of 670 cities reported having completed or being in the process of doing climate change risk assessments; heat-related illness was the most common climate-related health concern, identified by 169 (55%) of 308 cities The COVID-19 pandemic revealed the persistent health inequities and vulnerabilities of cities and urban sub-populations to health emergencies.'*" Home to more than half the world's population (a proportion projected to increase to 70% by 2050), cities have a crucial role in leading the local health adaptation to climate change." With data from the Carbon Disclosure Projects 2020 survey of global cities, this indicator shows the number of cities that report having completed a climate change risk or vulnerability assessment and the climate-related health impacts and vulnerabilities of these cities. In 2020, 546 (81%) of 670 cities that responded to this questionnaire reported that they had completed, or were currently doing, climate change risk assessments. For those cities that responded in both 2019 and 2020, an additional 45 (99) of 491 reported having completed a climate change risk assessment in 2020. However, 618 (949) of 654 cites responding to this particular question belonged to countries with a high or very high HDI, meaning that cities and countries with low and medium levels of HDI were under-represented in these data. 308 (629%) of 495 cities responded positively to the question on whether their city faces risks to public health or health systems associated with climate change. The most prominent perceived health concern pertained to heat-related illness, with 169 (55%) of 308 responding cities reporting this concern. The populations identified as most vulnerable to climate change were so-called elderly adults (reported by 213 [69%] cities), so-called children and youth (180 [58%)), and people in low-income households (170 [559%)), and 94 cities (319%) identified women as vulnerable to climate-related health impacts. Indicator 2.2: climate information services for health Headline finding: in 2020, national meteorological and hydrological services of 86 countries reported providing climate information to the health sector; only five of the 86 indicated that these climate services guide health sector policy and investment plans Health adaptation to climate change relies on accurate meteorological data and forecasts for the integrated surveillance and monitoring of emerging health threats, vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review the development and deployment of early warning and response systems, and the implementation of adaptation interventions. This indicator monitors the extent to which national health and meteorological services provide climate information services to the health sector with data reported to the WMO. In 2020, 86 national meteorological and hydrological services reported providing climate services to the health sector. Within the very high HDI group, 50% of countries that reported providing climate services to the health sector also reported that they were codesigning or providing tailored climate information services or products, compared with 36% of low HDI countries. Indicator 2.3: adaptation delivery and implementation Indicator 2.3.1: detection, preparedness, and response to health emergencies—headline finding: 124 (75%) of 166 countries reported medivm-to-high implementation ofa national health emergency framework in 2020; an increase Of 14% since 2019 The International Health Regulations (IHR) are legally binding instruments that define countries” rights and obligations in handling public health events and mergencies that could cross national borders.* Under the IHR, IHR state parties are required to provide self evaluations of emergency response preparedness against 13 core capacities published in the State Party Annual Report (SPAR). Limitations of the IHR in ensuring an effective response to the COVID-19 pandemic have been identified and these limitations continue to be evaluated,'* as discussed in appendix 5 (pp 89-90). However, countries with higher SPAR scores had lower incidence of COVID-19 and mortality per 100 000 population within 30 days of the first COVID-19 diagnosis, stressing the relevance of the IHR. This indicator tracks the degree to which countries have implemented a national health emergency framework under IHR core capacity 8, which include emergency preparedness and response planning, emergency management structures, and mobilisation of resources. IHR core capacity 8 assesses whether countries are prepared to respond to all public health events, including climate-related emergencies. In 2020, 166 (85%) of 196 IHR state parties completed the section of the SPAR that related to core capacity 8, and 124 (75%) of 166 state parties reported medium-to-high degrees of implementation of a national health emergency framework (a 14% increase since 2019). However, only 62 (37%) of the 166 state parties reported high levels of implementation, indicated by a capacity score of 75% or greater. The level of implementa- tion varied greatly by HDI group, with 89% of very high HDI countries reporting medium-to-high implementation compared with 55% of low HDI countries. To prepare for future health crises, it is essential that global institutions improve emergency response pre- paredness using the lessons learned during the COVID-19 pandemic. The ongoing review of the IHR is an important step in this direction to ensure that the IHR is effective when faced with health emergencies associated with climate change. Indicator 2.3.2: air conditioning: benefits and harms—headline finding; use of airconditioning, awidespread technology for indoor coolinginsome regions of the word, averted an estimated 195000 heat-related deaths among people aged 65 years or older in 2019; however, air conditioning also contributed to greenhouse gas emissions, air pollution, peak electricity demand, and urban heat islands Indoor cooling is an effective strategy for preventing heat-related mortality." In this years report, this indicator combines the prevented fraction of deaths'“ and heat-related death estimates from indicator 1.1.6 to track the number of heat-related deaths averted by air conditioning in people who are 65 and older. The methods for this indicator are described in appendix 5 (pp 92-102). Applying — country-specific and region-specific prevented fractions to the data from indicator 1.1.6 revealed that, in the absence of air conditioning, an estimated 195 400 more heat-related deaths would have occurred globally among people aged 65 years and older in 2019, in addition to the 345000 heat-related deaths that are estimated to have occurred. In this age group, air conditioning averted an estimated 69500 deaths in China (where 72 000 deaths attributable to heat exposure are estimated to have occurred in 2019 and 65% of households had air conditioning), 47800 in the USA (where 20500 deaths are estimated to have occurred and 92% of households had air conditioning), 30400 in Japan (where 12400 deaths are estimated to have occurred and 93% of households had air conditioning), but only 2400 in India (where 46600 deaths are estimated to have occurred and 6% of houscholds had air conditioning). These figures show the power of indoor cooling to prevent death and the inequities in access to indoor cooling across countries. Current air conditioning technology is unsustainable and leads to adverse health outcomes from increased air pollution, urban heat, and greenhouse gas emissions (see panel 3)." In 2019, an estimated 21000 deaths were attributable to exposure to PM,,, from fossil-fuel powered electricity used for air conditioning, estimated with the same approach as in indicator 3.3. Between 2000 and 2019, the global proportion of households with air conditioning rose 57% and CO, emissions from air conditioning use rose 61% (figure 10). Sustainable indoor cooling approaches are urgently needed, including strong, enforced codes that mandate wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review For more on the Climate Funds Update Data Dashboard see https:/climatefundsupdateorg/ data-dashboard/ Formoreonthe Adaptation andResilienceto Climate Change dataset see https:// kmatrixco/sector intelligence! 20 A 1007 HDIclassification Low HD! 25 E Wedivm HO! O High Hor E Very high HD! 57 Spending per capita (US$) 2015-16 2016-17 2017-18 Fiscal year 2018-19 — 2019-20 2015-16 2016-17 2017-18 Fiscalyear 2018-19 — 2019-20 Figure 12: Spending per capita for potential adaptation to climate change for health Data forthe health and health-care sector (A) and health-relevant sectors (B; see appendix 5 [p 109] fordefinition) in each 2019 HDI group. HDi=human development index, adaptation in the health and care sector and other sectors that are relevant to the determinants of health (eg, waste and water management, built environment, or agricultural sectors). The first element draws on data from the Climate Funds Update Data Dashboard, whereas the second uses the Adaptation and Resilience to Climate Change (AS*RCC) dataset produced by kMatrix. These complementary elements provide an evaluation of proactive adaptation funding that is potentially related to health and the global size of all economic transactions that can offer climate change adaptation potential for health. Between 2018 and 2020, US$5-1 billion of multilateral climate change adaptation funding was approved globally. Only $711 million (13-99) of this adaption funding was related to health. Adaptation funding that was related to health consisted of $14-0 million (0-3%) of approved funding directed specifically at health systems and $697 million (13-6%) of funding with potential secondary benefits for health. The value of all financial transactions with the potential to deliver adaptation for health (ie, adaptation- relevant transactions within the dataset-defined health and health-care sectors) increased by 14-0% from 2018-19 to 2019-20, reaching 5-6% of total adaptation spending. Spending in other sectors that could be relevant to health (eg, in the waste and water management, built environment, or agricultural sectors) is estimated to have increased by 7-6% from 2018-19 to 2019-20, representing 28-6% of total transactions. Grouped by HDI, $234 million (19) of spending was in low HDI countries, $1-8 billion (8%) was in medium HDI countries, $5-7 billion (27%) in high HDI countries, and $13-3 billion (64%) in very high HDI countries (figure 12). For spending in health- relevant economic sectors, a similar narrative emerges, in which $1-2 billion (19) of spending occurred in low HDI countries compared to $66-7 billion (629%) in countries with a very high HDI. As the data covers financial years, the data (up to March 31, 2020) in this indicator are unlikely to reflect the anticipated economic impact of the COVID-19 pandemic on adaptation spending. These findings highlight a growing global market for health-relevant adaptation transactions, but this growth has yet to translate into sufficient targeted health adaptation funding. As world economies recover from COVID-19, sufficient resources should be redirected towards health adaptation to build resilience to the increasing health threats of climate change. Conclusion The indicators in this section show a complex landscape of adaptation, planning, and resilience for health in the past 12 months, in which the small global improvements to adaptation planning and assessment (indicators 2.1.1, 2.1.2, and 2.1.3) and intersectoral collaboration (indicator 2.2) are overshadowed by slow progress in implementation (indicators 2.3.2 and 2.3.3) and insufficient investment (indicator 2.4). A key theme across all the indicators is inequity and, although these indicators mostly track inequities between countries, within-country inequity is a substantial challenge in moving towards resilience and sustainability. Although the world economy and health systems are recovering from a substantial acute global health crisis, climate change poses a much greater health threat in the coming decades. It is crucial that organisations and institutions capitalise on the insights generated from the pandemic to improve adaptability and resilience. Research is needed to identify current and future vulnerabilities, project risks from climate change at scales relevant for decision making in different climate and development scenarios, and identify and evaluate vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review Panel 4: Recovering from COVID-19: stimulus measures for a sustainable economy The COVID-19 pandemic, and measures to tackle it, triggered a global recession of a depth only exceeded in the past 150 years by two world wars and the Great Depression ofthe 1930s.** Governments with the fiscal capacity have responded with massive spending packages. By the end of 2020, the world's 50 largest economies had committed US$14-6 trillion in fiscal measures (many times higher than the value of global stimulus measures afterthe 2008-09 financial crisis). Although $12:7trillion (87%) ofthe $14-6 trillion was designed to prevent an even deeper health and economic crisis, ratherthan encourage recovery,”* promoting recovery will become the main objective as time goes by and additional measures are announced. How these measures are designed and targeted will determine whetherthis spending entrenches existing technical, economic, and social structures and systems, or promotes those that are more sustainable, healthy, and equitable. Evidence from stimulus measures introduced afterthe 2008-09 financial crisis shows that so-called green stimulus measures often have advantages over so-called brown or colourless measures.** So far, the signs of the current recovery commitments are not encouraging. Ofthe $19 trllion directed towards recovery by the end of 2020, just 18% is expected to reduce greenhouse gas emissions (or2-5% ofthe value ofall fiscal measures), and the overall impact of this investment on air pollution and natural capital —eg, through the expansion of road transport and adaptation options to prepare for and protect health in a changing climate. Adaptation plans should be reviewed and updated to consider medium-term and long-term risks of climate change for health and to build resilience. Greater collaboration and coordination are necessary across public and private sectors and global institutions, along with increasing investments in adaptation. Section 3: mitigation actions and health co-benefits Continuing an unbroken upward trend, global atmospheric CO, concentrations passed 415 ppm in January, 2021, and, for the first time, the CO, concentrations for much of 2020 are expected to be 50% higher than the 1750-1800 average.” Total emissions of all greenhouse gases in 2019 were 59-1 GtCOe (SD 5-9), which includes greenhouse gases generated by land-use changes. To limit warming to 1-5*C, annual global emissions must be reduced to 25 GtCO,e by 2030.” COVID-19 and the associated lockdowns across the globe have had profound impacts on the global economy, most prominently in the surface and air transportation and industrial sectors.”* Emissions from very high HDI countries, which account for 48% of the global total, defence services in particular—is likelyto be negative. Just a few. nations have positive measures, particularly countries in Europe” although measures announced so far in 2021 indicate some movement towards greater consideration of sustainability in other countries.”** However, despite the global CO, emissions dropping by a record 6% in 2020, they have rebounded quickly, and global CO, emissions in December, 2020 were about 2% higher than in December, 2019.*Therefore, the trillions of dollars for stimulus measures that are yet to be announced must be oriented toward a green and healthy recovery. In May, 2020, WHO published six prescriptions for a healthy and green recovery: protect and preserve the source of human health (ie, nature); invest in essential services, from water and sanitation to clean energy and health-care facilities; ensure a quick, healthy energy transition; promote healthy, sustainable food systems; build healthy, liveable cities; and stop the use of taxes to fund pollution (particularly through fossil fuel subsidies).** If governments are serious about their commitments under the Paris Agreement and Sustainable Development Goals, they should take note of these priorities, plan ahead, and learn from their own previous experiences and from those generated elsewhere to implement well-designed and context-appropriate policy. Where necessary, multilateral institutions, processes, and instruments should be galvanised in support of a global recovery that is both sustainable and equitable.*> were around 10% lower than 2019 levels.” However, without targeted intervention, emissions will rebound as the world recovers from the pandemic. Indeed, the 5-8% drop in energy-related CO, emissions seen in 2020 is forecast to be matched with an unprecedented 4-8% rise in 2021.” The necessity of steering the economic recovery to a lower-emissions pathway has been well publicised, but it has yet to be well-integrated into recovery plans (see panel 4).'" Nevertheless, the COVID-19 recovery presents the challenge and simultaneous opportunity to encourage action that yields benefits to health. Tracking this global challenge, section 3 covers the relationships between climate change mitigation actions and health. This section provides an overview of the global energy system (indicator 3.1) alongside the associated global exposure to ambient PM, , air pollution and its health impacts (indicator 3.3). Energy use in the home is also reported, with new detail on fuels used and estimates of indoor air pollution concentrations (indicator 3.2). Individual sectors are then examined— namely, transport (indicator 3.4), food and agriculture (indicators 3.5.1 and 3.5.2), and the global health-care sector (indicator 3.6). Where possible, the ways in which relationships between health and climate change wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review 22 mitigation influence, and are influenced by, societal inequities are explored. Indicator 3.1: energy system and health Headline finding: from 2014 to 2018, despite strong growth in renewable energy in countries with a very high HDI, the carbon intensity of the global energy system has seen an annual average decline of just 0-6%, which is a rateincompatible with meeting the ambitions of the Paris Agreement Fossil fuel combustion within the energy system is the largest single source of greenhouse gas emissions, with a global share of 65%.” The rapid shift from coal to renewable energy use is crucial, not only to mitigate these emissions but also to prevent deaths due to ambient air pollution (indicator 3.3) and eliminate other harmful pollutants related to coal mining and combustion.” With data from the International Energy Agency (IEA), this indicator tracks three components— namely, the carbon intensity of the global energy system, coal phase-out, and zero-emission electricity. Full details are described in appendix 5 (pp 111-117). The carbon intensity of the global energy system fell slightly for the fifth year in a row to 56-0 tCO,e/T] (excluding land use emissions) in 2018. However, progress remains very slow, with an annual rate of decline of just 0-6% from 2014 to 2018. At this rate, it would take more than 150 years to fully decarbonise the energy system (far from the 2040 deadline required to keep temperature rise to 1-5*C).* Progress has been made in the very high HDI country group since 1970 and carbon intensity in the high HDI country group could be at a possible peak. However, driven by the need to develop, the low and medium HDI country groups have had a sustained growth in emissions per unit of energy since 1970. China continues to dominate global coal consumption, representing 18-19% of the world's population and accounting for 53% of global coal use in 2019. While global coal use for all activities fell 1.2% in 2019, including a fall o£13-4% in the USA and 21% in Europe, China's usage grew by 1-1%. Between 2013 and 2018, electricity generation from renewable wind and solar energy increased by an annual average of 17%, with its global share of electricity generation reaching 7-2% in 2018. While total energy demand for coal, gas, oil, and nuclear fell in 2020, the production of electricity from renewable sources grew by a small amount (0-99). Global coal demand is expected to rise by 4-5% in 2021, 80% of which is due to rapid increases in coal-fired electricity generation, and demand for renewable energy is set to rise by more than 8%.” A redirection of efforts towards the decarbonisation of the energy system (see panel 4) could put the world on track to meet the 1.5*"C temperature goal and prevent deaths associated with climate change and air pollution. Indicator 3.2: clean household energy Headline finding: in 2019, only 5% of rural households in countries in the low HDI country group relied primarily on clean fuels and technologies for cooking (up from just 2% in 2000), putting them at risk of morbidity and mortality due to exposure to household air pollution Around 10% of the world's population, three-quarters of whom live in sub-Saharan Africa, do not have access to electricity for any service provision and 2-6 billion people do not have access to clean fuel for cooking." COVID-19 poses additional impediments to achieving SDG 7 (access to clean energy), with 2020 seeing a 2% rise in people without access to electricity in sub-Saharan Africa," driving low-income communities in places such as Nairobi to increase their usage of wood and kerosene.” Energy poverty remains a concern even in high and very high HDI countries and around 7% of people in the EU struggle to afford sufficient heat for their homes,'* putting them at risk of cold-related adverse health outcomes.'*” Energy poverty related to excess heat is also an important issue around the world (as highlighted in panel 3).»" This indicator tracks energy usage in the home using data from both the IEA and WHO."""" The WHO household energy database compiled data from national surveys, presented here from 2000 to 2017 and projected for 2019, which provides information on fuels and technologies used for cooking, heating, and lighting. With these data, this indicator also estimates household air pollution concentration for 29 countries. A full description of the methods, data, and caveats is given in appendix 5 (pp 118-121). In the low HDI country group, domestic energy use is dominated by biofuels. Primary reliance on clean fuels and technologies for cooking in households in the low HDI country group was estimated to have been at only 12% in 2019. This proportion is even lower in rural households in the low HDI country group, with only 5% relying on clean fuels and technologies—a marginal increase from 2% in 2000. In homes in the medium and high HDI country groups, the share of solid biofuel use has fallen more rapidly than in the low HDI country group, and clean cooking fuel and technology use has risen substantially; although, in rural areas, use of solid biofuel remains at 54% for the high HDI group and 39% for the medium HDI group. These patterns of energy use, ventilation practices, and the infiltration of air have implications on household air pollution concentrations. In rural households in several low and medium HDI countries, the average PM,, concentration in the main indoor cooking area is estimated to be more than 500 g/m. In Ethiopia, the average PM,,, concentration in indoor cooking areas is more than 1200 g/m, 120 times the WHO threshold of 10 ig m3.” Exposure to these harmful air pollutants in the home results in an estimated 2-31 million deaths per year elobally." vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review 455000 (10%) more men dying from preventable, diet- related diseases than women—a pattern reflected across each of the HDI country groupings (figure 14). Indicator 3.6: health-care sector emissions Headline finding: in 2018, emissions from the health-care sector increased slightly to 4-9% of global greenhouse gas emissions; health-care emissions are positivel y associated with HDI levels, mostly through health spending, but thereis little association after 400 kg CO, per capita The health-care sector is central to improving human development. In providing services, health-care systems mobilise a vast array of products and use energy in various forms, all of which result in emissions of greenhouse gases and other pollutants that can be calculated throughout global supply chains. With this contribution to greenhouse gas emissions and their important role in improving patient care in the face of climate change,”” health-care institutions are beginning to seriously commit to reducing emissions.” In this indicator, both direct and indirect emissions from the global health-care sector are modelled with environmentally extended multiregion input-output models combined with annual WHO data on national health-care expenditure. A full description of these methods is in appendix 5 (pp 141-142). In 2018, the global health-care sector contributed approximately 4-9% of global greenhouse gas emissions; a rise of 5-2% in health sector emissions since 2017. Expansion of health-care services in China contributed more than half of this global increase. Although China's national health-care emissions are now 35% greater than those of the USA's, on a per- capita basis, China ranks 21st among all major economies assessed. Per-capita comparisons do not account for differences in health-care access and quality, specifically those measured through health outcomes, such as life expectancy (which is one of the components of the HDI). Plotting per-capita health-care emissions against HDI reveals that emissions are positively associated with HDI level, an association strongest for lower emissions. For example, a wide range of HDI levels are associated with per-capita health-care emissions of 500-600 kgCO.e, reflecting both differences in health system efficacy and other development indicators, but also in emissions intensities. Additional emissions above 500-600 kgCO2e are not associated with improved HDI. Conclusion Before the pandemic, the rapid rate of growth in renewable electricity generation was insufficient to counteract the slow decline in coal use. The result of this was that the carbon intensity of the global energy system remained virtually unchanged. At the same time, there has been very little progress in increasing the use of clean household energy. These delays are costing millions of lives each year from household and ambient air pollution. Food-related agricultural emissions continue to rise and so do deaths attributable to dietary risk factors. Across this section, many inequities can be highlighted. Low HDI countries have the highest use of dirty fuels in the home, putting people in low HDI countries at greater risk of morbidity and mortality from exposure to household air pollution. As a result of higher industrial activity and inadequate emissions controls, countries of medium and high levels of HDI have the highest carbon intensity of energy and the greatest amount of deaths due to ambient air pollution. People in very high HDI countries have the most carbon-intensive diets, and, with high amounts of red meat consumption, they also have the most to gain from a shift towards a more plant-based diet. Although the effects of the COVID-19 pandemic are not yet fully known, there was a temporary, but substantial, drop in emissions due to lockdowns and the associated reductions in economic activities and international travel. However, emissions are already rebounding. The challenge moving forward will be to adopt measures that provide near-term economic relief while building towards long-term emission reductions and protecting future health—a challenge also explored in section 4. Section 4: economics and finance Avoiding the worst of the climate change impacts described in section 1 will require both sustained adaptation efforts (section 2) and a rapid transformation ofthe world's economies to cut greenhouse gas emissions (section 3). Section 4 examines the economic and financial implications of this transition. First, this section explores the economic impact of climate change and its mitigation (indicators 4.11 to 4.1.4). These indicators use a range of methods to estimate some of the costs that climate change might already be imposing on society through its impacts on human health. Indicators 4.2.1 to 4.2.5 investigate the economics of the transition to zero-carbon economies, which are fundamental to the improvement of human health and wellbeing. These indicators consider whether investments and jobs are beginning to move away from. fossil fuels and if the appropriate economic signals are encouraging this transition. A new indicator for this year's report (indicator 4.2.5) explores the effect of global trade on greemhouse gas and PM,, emissions, highlighting that harms might occur in countries different from the demands that drive those emissions. Achieving the required investments in the low-carbon transition requires clear and committed action from governments and private sector actors, and could result in health and economic benefits. Aiming for a green global recovery from COVID-19, rather than business-as-usual economic growth, will ensure economic recovery through wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review For more on the data from Swiss Resee https:/Jemdatbe/ 26 Panel 5: Compatibility of fossil fuel company strategies with the trajectories of well below 2*C Globally, CO, from the combustion of fossil fuels represents 65% oftotal greenhouse gas emissions.”” In the 2015 Paris Agreement, countries agreedto reduce their emissions to keep global warming to well below 2*C. The carbon budget for a 66% probability of limiting global warmingto 1-5*C by the endof the century has been estimated at 420 GtCO..** However, the potential CO, emissions from reserves held by the 200 largest public fossil fuel companies are at least 1541GtCO,, * and the carbon contained in global resources of fossil fuels is estimated at about 11000 GtCO, * well beyond the maximum that can be used ifthe world is to meet the Paris Agreement goals. Roughly 30% of oil reserves, 50% of gas reserves, and morethan 80% of coal reserves worldwide should remain unused to keep global warming below 2*C,2* representing stranded assets and useable carbon.”**> Future energy system scenarios with strict carbon constraints, low fossil fuel demand, high capital costs projects, and carbon- intensive reserves increasethe risk of stranding assets,”* with considerable financial consequences for their owners and industry stakeholders.*> Although the fossil fuel industry has begun to acknowledge that the energy system is transitioning away from unabated oil, gas, and coal, countries fossil fuel production plans until 2030 could exceed emissions consistent with limiting warmingto 2*C by 50% and by 120% in relation to 15*C.* Companies have diverging business strategies, with strategies falling short of what is required to mitigate transition risks. Although an increasing number ofoil and gas companies are announcing net-zero commitments, for these to be consistent with climate ambitions they should be framedoon theirtotal emissions ratherthan on their emission intensities, consider scope 1, 2, and 3 emissions ofthe greenhouse gas protocol,”* and account for activities on the basis ofa company's full equity share.?2*Those companies who better understand systemic risks, stress-test potential scenarios, and develop business strategies with interim targets and investments that align adequately with the targets of well below2*C (and preferably 1-5*C) are likely to become more resilient during the coming years as climate- risk scrutiny from investors and financial regulators increases. the generation of new jobs in low-carbon industries and accelerate progress towards the Paris Agreement goals and the SDGs, yielding health gains both by preventing the health impacts of climate change, and by maximising the health co-benefits directly associated with climate actions, including those of cleaner air, healthier diets, more active lifestyles, and increased exposure to green space.”* International economic cooperation will be essential to ensure that global emission targets are met and to prevent the widening of inequity gaps.” Therefore, this section also reflects on the extent to which COVID-19 recovery spending has prioritised green investment (panel 4) and discusses the alignment of fossil fuel companies” strategies with the requirements of the transition (panel 5). : economic losses due to climate-related extreme events—headline finding: when normalised by gross domestic product, economic losses from climate-related extreme events in 2020 were three times greater in the medium HDI country group than in the very high HDI country group The loss of physical infrastructure and the resulting economic losses due to climate-related extreme events can exacerbate the health impacts described in section 1. This indicator tracks the total annual economic losses (insured and uninsured) that result from climate-related extreme events with data provided by Swiss Re.*"The methods are described in appendix 5 (pp 143-145). In 2020, there were 242 recorded climate-related extreme events and absolute economic losses from these events totalled US$178 billion. Although two-thirds of these losses occurred in very high HDI economies, when normalised by gross domestic product (GDP), losses in the medium HDI country group were around three times greater than in the very high HDI country group. Although $76 100 million (669) of $115 300 million of the losses in the very high HDI country group were insured, almost $34200 million (93%) of $36 900 million of losses were uninsured in the high HDI group. The uninsured measurable losses rise to $24200 million (979%) of $25000 million in the medium HDI group and $576 million (100%) in the low HDI country group, which creates a larger economic burden and reinforces inequities for disadvantaged countries, as uninsured losses are either not replaced or are replaced through out-of- pocket expenses. Indicator4.1.2: costs of heat-related mortality—headline finding: the monetised value of global heat-related mortality increased by 6-7%, from 0-27% of gross world product in 2018 to 0-28% in 2019; Europe continued to be the worst affected region, facing costs equivalent to the combined average incomes of 6-1 million ofits citizens The increase in morbidity and mortality due to extremes of heat represents a high cost to all of society. This indicator uses data on years of life lost due to extremes of heat from indicator 1.1.6 to provide a measure of the costs of global deaths attributable to heat." Improved in the 2021 report, the indicator combines a value of statistical life- year with YLL to estimate the monetised loss caused by deaths attributable to heat. The valuation of life across varying HDI levels shows a methodological and ethical challenge, which this indicator addresses by presenting the cost of deaths attributable to heat as the proportion of GDP and the equivalent annual average income. vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review The monetised value of global heat-related mortality in people 65 years or older increased by 6-7%, from 0-27% of gross world product in 2018 to 0-28% in 2019 (figure 15). Reflecting the distribution of impacts found in indicator 1.1.6, the costs of heat-related mortality were found to be equivalent to the average combined incomes of 0-94 million of their citizens for the low HDI country group, 4:80 million of their citizens in the medium HDI country group, 8-20 million of their citizens in the high HDI country group, and 7-52 million of their citizens in the very high HDI country group. As in indicator 1.1.6, WHO's European region was the worst affected in 2019, with costs equal to the average income of 6-1 million of its citizens and 0-66% of regional GDP. However, the costs were lower in 2019 than in 2018 due to fewer estimated heat-related deaths in the European region (indicator 1.1.6). However, costs increased in other regions between 2018 and 2019, especially WHO's South-East Asia region. Indicator 4.1.3: loss of earnings from heat-related labour capacity reduction—headline finding: working in conditions of extreme heat is a health risk; such conditions could reduce the capacity for paid labour, with an impact on workers eamings equivalent to 4-8% ofGDP in the low HDI country group in 2020 As reflected in indicator 1.1.4, increased temperatures, driven by climate change, are affecting people's ability to work. This indicator considers the loss of earnings that could result from such reduced capacity. Losses of earnings could compound the health impacts of extreme heat through effects on the socioeconomic determinants of good health.” Indicator 4.1.3 combines the outputs of indicator 1.1.4 with data on average earnings by country and sector held in the International Labour Organization databases.*” The methods and additional analyses are described in appendix 5 (pp 148-154). In this year's report, the number of countries included in this indicator has been increased from 25 to 183. Indicators 1.1.6 and 4.1.2 found Europe to be the region most affected by heat-related mortality in people aged 65 years older. In contrast, this indicator focuses on working-age populations and, in alignment with the outputs of indicator 1.14, it finds that greater losses of earnings due to reduced labour capacity occur in low and medium HDI countries. Countries with lower HDI levels tend to have greater proportional losses of earnings, emphasising the impact of climate change on deepening inequities. In the low HDI country group, potential income losses in 2020 were equivalent to 3-9-7-6% of GDP, depending on the degree of shade or sun exposure during agricultural and construction work (figure 16). Potential income loss in 2020 was 2-2-4-1% of GDP in the medium HDI group, 0-9-1-5% in the high HDI group, and 0-3-0-5% in the very high HDI country group. These potential losses will mainly affect men who work in sectors such as construction, where they represent more than 90% 257 Ellow [EJ Medium IE High Very high Equivalent average annual incomes lost (milions) _ _ _ __- _ _ _ _ ___—a 200020012002 200320042005 2006 2007 2008 20092010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Year Figure 15: Monetised cost of heat-related deaths by 2019 HDI group Monetised costs are expressed as the equivalent number of annual incomes of the average person lost. HDi=human developmentindex, Services Agriculture (shade) Agriculture (sun additional) KE Manufacturing — IE Construction (shade) [EE Construction (sunadditional) 1007, 2 10: Equivalent of GDP (4%) a to St Lo Tool lo Tolo LE to ola ooo IIS SNS Year Figure 16: Average potential loss of earnings in the low HD! group asa result of potential labour loss dueto heat exposure Losses are presented as a share of GDP by sector of employment. The agriculture and construction (sun additional) blocks represent the losses that would have been incurred in addition to those from agriculture and construction (shade) ¡fall of the activities inthese sectors had been carried out in direct sunlight. GDP=gross domestic produc. of the global workforce, and in manufacturing and agriculture, where they represent more than 60% of the global workforce.” However, these data do not account for informal or unpaid domestic and agricultural work—a group in which women are often over-represented "2" The indirect economic impacts from reduced labour capacity extend well beyond the loss of earnings. For example, modelling both direct and indirect impacts, the heat-related economic cost of labour loss in 2020 was estimated to be 1.36% of Chinas GDP and 6-75% of the GDP in Hainan." 'wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 27 Review A Production-based Embodied CO, emissions Consuptiombased Vey ha mo Very high HDI 5 486% HighHDI44-3% HighHDI408% Medion HDI9:9% Medium HDI 9.596 LowHDIO7% LowHDI120 B Very high HD! Very high HDI High HDI 377% igh HDI 37. HighHDI35.0% MediumHDI276% MediumHDI260% LowHD117.6% LowHDI167% Figure 20:The flows of embodied CO2 and PM, ,emissions among HDI country groups in 2019 HDI=human development index. This indicator compares carbon prices and fossil fuel subsidies to calculate net-economy-wide average car- bon prices and revenues. The indicator includes 84 coun- tries, which are responsible for around 92% of global CO, emissions, and is based on data from the IEA,” Organisation for Economic Co-operation and Develop- ment,”* the World Bank,” and WHO, with methods and additional analysis in appendix 5 (pp 164-167).** In 2018, 65 (77%) of the 84 countries analysed had net- negative carbon prices, reflecting an overall subsidising of fossil fuels. The median value of the subsidy in these countries was US$1 billion, with some countries providing net subsidies to fossil fuels in the tens of billions of US dollars each year. 42 countries had a carbon pricing mechanism in place, but only 19 succeeded in discouraging fossil fuels with net-positive carbon prices (all of which were countries with a very high HDI). Nonetheless, most very high HDI countries still had net- negative carbon prices (figure 19). These net subsidies are equivalent to substantial proportions of national health spending in many countries. With low-income populations vulnerable to energy costs, removing subsidies can be a challenge, but redirecting spending from fossil subsidies to health- care and health-related services is likely to deliver net benefits to their wellbeing.”* Furthermore, international financing mechanisms to support low-income countries in their transition to sustainable energy sources are essential to safeguard all dimensions of human health.” Indicator4.2.5: production-based and consumption-based attribution ofCO, and PM, ; emissions—headline finding: in 2019, 18% of CO, and 17% of PM,. global emissions were embodied in trades between countries of different HDI levels The production of goods and services often drives greenhouse gas and PM,, emissions, thus contributing to impacts on health and wellbeing, Emissions from local production (ie, production-based emissions) occur within the geographical territories through the local production of goods and services. An alternative way of accounting for the burden of pollution is to assign emissions to the country that is the final consumer of the products that are made (ie, consumption-based emissions). A comparison of production-based and consumption-based emissions gives a better understanding of how emissions are embodied in global trade, which is essential to enable better international policy formulation that protects human health in all geographies. This indicator captures the pollution burden from a country's local production and from a nation's domestic final consumption, including the burden embedded in its imports. The indicator uses an environmentally extended multiregional input-output (EE-MRIO) model and the EXIOBASE database to estimate CO, emissions,'* and the greenhouse gas-air pollution interactions and synergies (GAINS) model to produce a PM,, emission inventory.” More details on the methods and additional analysis can be found in appendix 5 (pp 168-174). In 2019, 18% of the 35-6 Gt world total of CO, and 17% of 37.4 Mt world total of PM,, global emissions were embodied in trades among countries of different HDI levels (figure 20). The largest contributors to global consumption-based CO,and PM, , emissions were China (28% and 18%), the USA (17% and 5%), the EU (10% and 6%), and India (7% and 16%). The USA did the most outsourcing of emissions, with 1-2 Gt (21%) of their 5-9 Gt total CO, and 0-8 Mt (49%) of their 1.7 Mt total PM,, emissions resulting from its consumption of goods that were produced in other countries. In China, 1-8 Gt (16%) of the 10-8 Gt total CO, and 0-8 Mt (139%) of the 6-8 Mt total PM, , emissions that occurred within its borders resulted from the local production of goods that were ultimately exported to consumers in other countries. 30 vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review The very high HDI country group contributed the most production-based (45%) and consumption-based (499) CO, emissions in 2019. However, the high HDI country group was the biggest contributor to both production-based (38%) and consumption-based (35%) PM, , emissions. The very high HDI country group was the lowest emitter of PM, ,, partly as a result of stricter local air pollution regulations. Importantly, the very high HDI country group was the only group with higher consumption-based emissions than production-based emissions—ie, a high net outsourcing in terms of their consumption-related emissions. Conclusion The impacts of climate change on health are already having substantial economic consequences in different ways across countries of all HDI levels. The economic losses of climate-related extreme events are three times higher in medium HDI countries than they are in very high HDI countries. However, the monetised value of global heat- related deaths is highest in Europe and the greatest costs of premature mortality due to air pollution fall in countries with medium and high HD! levels. WHO's South-East Asia was the only region with increasing air pollution mortality costs between 2015 and 2019, relative to GDP. Extreme heat can create economic impacts by reducing labour capacity. In this case, people employed in low-wage, outdoor work in low HDI countries are likely to be most affected. Because of the potentially large and unequally distributed impacts of climate change on human health, incomes, and wellbeing, substantial and sustained investment in a low carbon transition is required. Overall, global investments in coal power continue to decline, although with worrying countertrends in particular countries. Investments in renewables and energy efficiency continue to grow as do divestments from fossil fuel assets; however, a considerable increase in the pace of change is required. Both governments and the private sector have crucial roles in bringing about the required transition. Governments across all HDI groups should address fossil fuels subsidies in countries. Although withdrawing energy subsidies is challenging when it affects people on low incomes, other forms of government spending, including on health services, can provide better and more targeted support to decrease inequities and maximise wellbeing. The global trade system means that almost a fifih of CO, and PM, ,emissions occur in the production of goods that are subsequently traded between countries of different HDI levels. This proportion underlines the importance of inclusive global agreements that facilitate cooperation on policies for the reduction of both production and consumption emissions. As governments begin to invest in recovery from COVID-19, there is a crucial window of opportunity to reduce fossil fuel subsidies, invest more in clean energy, and support a green recovery. Policies and regulations should be developed that greater scrutinise fossil fuel Panel 6: The place of health in the enhanced nationally determined contributions The 2015 Paris Agreement isthe only global framework for reducing greenhouse gas emissions to protect people's health.** Countries have committed to a reduction of 'emissions via nationally determined contributions (NDCs), which are to be enhanced every 5 years. In 2015-16, 185 countries, including an EU submission for 27 countries, submitted initial NDCs. By July, 2021, 87 countries, including an EU submission for 26 countries, had submitted enhanced or new NDCs.*% Compared with their initial NDCs, the proportion of countries referringtto health increased, from49 (56%) of 87 in 2015-16 to 79 (91%) of 87 in 2021. However, health engagement remained low in NDCs. Overall, in both initial and enhanced NDG;, less than 3% ofthetext related to health; inthe enhanced NDG, text relating to health was an average of 240 of 10466 words. Ofthe references to health, 249 (30%) of 832 references noted health impacts, challenges, orrisks of dimate change; for example, “the Kenyan economy is dependenton dimate-sensitive sectors, such as rain-fed agriculture, water, energy, tourism, wildlife, and health, whose vulnerabilityis increased by climate change” (Kenya, updated submission).* An additional 210 (25%) of 832 references related to health sector adaptation; for example, dimate change “threatensthe ability of health institutions and organizationsto maintain and improve health services into the future” (Marshall Islands, updated submission). The enhanced NDCs had an increased engagement with gender, health, and climate change, with 9 (10%) of 87 NDCs making a meaningful connection compared with just 2 (2%) in theirinitial contributions. The majority of the references to gender, health, and climate change are references tothe specific impact of climate change on women; for example, “further strain on the workload of women and climate change-related stress during pregnancy could contribute to low birth weight, leading to increases in risks of undernutrition and non-communicable diseases” (Cambodia, updated submission).* In summary, although health engagement remains low, there is greater recognition that climate change takes a disproportionate toll on women in the latest NDCs compared with those published in 2015-16. companies and ensure their alignment with a world below 2*C. Section 5: public and political engagement As sections 1-4 make clear, climate change is damaging people's health and increasing inequities, with the human costs amplified by COVID-19.2%*% The people least responsible for climate change are most exposed to its impacts, which are “hitting harder and sooner” than climate assessments indicated even a decade ago.** Action at the speed and scale that is needed to meet the ambitions of the Paris Agreement requires public and political engagement, particularly in industrialised countries (where most emissions originate).” This section tracks engage- ment in health and climate change by media, individuals, scientists, governments, and the corporate sector. The mainstream media is a major platform for public engagement. Mainstream media is the most widely-used source of information,“ shaping public perceptions,??7" and influencing the social media agenda.” Indicator 5.1 tracks coverage of health and climate change in 67 newspapers from 37 countries, including the People's Daily (in its Chinese-language edition, Renmin Ribao), which is Chinvs longest running national newspaper and the official outlet of the Chinese Government.?*”* 'wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 a Review Numberofclicks — Clicksfroma health-related pageto climate-related page — Total clicks from aclimate-related page to a health-related page — Total clicks between a health related page andadlimate-telated page Figure 21: Aggregate monthly clicks between a health-related article and a climate-related artide in Wikipedia, 201820 For moreonthe UN Global Compact see https:/fuwwnw unglobalcompactorg/ 2 The indicator also includes a content analysis of coverage in India and the USA, focusing on so-called prestige newspapers with influence on the countries” political and economic elites.” Individual engagement (indicator 5.2) is tracked through individuals searches on Wikipedia—the online information source with a wider reach and coverage than traditional encyclopaedias.”*-* The third indicator (Indicator 5.3) tracks engagement in peer-reviewed journals—the primary source of scientific evidence for the media, government, and the public." Government engagement (indicator 5.4) is tracked by statements made by national leaders at the UN General Assembly (the policy making body of the UN). The annual meeting opens with the General Debate, in which heads of government, or their high-ranking representatives, address the global community on issues they consider important** Indicator 5.4 also considers engagement with health in the enhanced nationally determined contributions (NDCs), submitted in compliance with the 2015 Paris Agreement“ Panel 6 compares health engagement in the initial and enhanced set of NDCs held on the UNFCCC NDC registry on April 1, 2021. Action by the corporate sector will be decisive in moving societies away from dependence on fossil fuels.>2=% Indicator 5.5 tracks engagement in health and climate change by companies within the UN Global Compact— the world's biggest corporate sustainability initiative.” Companies commit to shared principles of sustainable behaviour and submit annual reports on progress. With increasing acknowledgment of the need to recognise and investigate gender inequities in the representation, communication, and governance of climate change,” engagement with gender is incorporated where appropriate. Engagement with health, climate change, COVID-19, and analyses by WHO region and HDI country group are also included. Details of data sources and methods for all indicators are provided in appendix 5 (pp 175-267), along with additional analyses. Indicator 5.1: media coverage of health and climate change Headline finding: in 2020, the upward trend in coverage of health and climate change continued but did not match the increase seen in 2019; in 2020, most of the coverage of health and climate change referred to COVID-19 Newspapers provide an important forum for public engagement. Newspapers shape public understanding of dimate change, both through their influence on their readers and the wider political agenda.?”** This indicator tracks coverage of health and climate change from 2007, which is the year before the WHO World Health Assembly made a multilateral commitment to protect people's health from climate change.” The indicator includes 66 newspapers spanning 36 countries and four languages, together with an additional analysis of China's Peoples Daily. The indicator also examines the content of 2020 coverage in newspapers in India and the USA. Methods and additional analysis are provided in appendix 5 (pp 175-198) Across the 36 countries, the upward trend in newspaper coverage of health and climate change continued, reaching 11371 articles in 2020. However, the rate of increase was lower than that of2019, with a 6% increase from 2019 to 2020 compared with a 96% increase from 2018 to 2019. As in 2019, coverage was greatest in the WHO America and Europe regions and lowest in the African region. Engagement with gender and COVID-19 was examined in English language newspapers across 23 countries. Although the proportion of articles on climate change and health referring to gender increased from 97 (296) of 6044 articles in 2007 to 573 (6%) of 10092 in 2020, gender remains marginal to the representation of health and climate change in the mainstream press. In 2020, more than 60% (6238) of the 11371 articles referring to health and climate change also referred to COVID-19, and it was more than 80% in April and May, 2020. In China's People's Daily, the sparse coverage of health and climate change, noted in previous Lancet Countdown. reports, was again evident in 2020. Of the 1106 articles discussing climate change, 2% were related to human health. Across the 2008-20 period, no articles related to health and climate change engaged with gender issues. In 2020, no articles discussed the relationships between climate change and COVID-19 or how they influenced health together. Analysis of the content of coverage of health and climate change focused on India (medium HDI) and the USA (very high HDI). The selected newspapers, the Times of India, Hindustan Times, New York Times, and Washington Post, form part of the so-called prestige press, seen to exercise influence on political and economic elites and the wider policy agenda.7-% vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review Compact, which was established to promote corporate social and environmental responsibility. However, the effectiveness of the UN Global Compact has been critiqued with the suggestion that membership could be a form of so-called greenwashing and bluewashing for some companies.”* The Compact represents more than 12000 companies from 160 countries, with each submitting an annual communication on progress (Gobal Compact Communication of Progress) against a set of social and environmental principles. This indicator is based on the application of a keyword search in the text corpus of 17984 GCCOP reports submitted in English between 2011 and 2020. In the 2019 and 2020 Lancet Countdown reports, the focus was on the health-care sector. This report considers corporate engagement across all sectors. Figure 24 shows engagement in health and climate change in annual GCCOP reports published from 2011 to 2020. The large majority of reports refer to health (1742 [8496] of 2029 reports in 2020) and climate change (1547 [759%] reports in 2020) as separate topics. Only a minority of reports referred to the health dimensions of climate change (791 [38%] in 2020). However, this minority represents a large increase from 2014, the low point of engagement, when only 21% of corporations referred to the intersection between climate change and health. Three sectors stand out for their high levels of engagementin health and climate change—namely, food and drug retailers, oil and gas producers, and alternative energy. In 2020, more than 70% of corporations in these sectors made reference to health and climate change. However, in the health-care sector, this proportion was only 37%. Additional analyses examined references to gender in the GCCOP reports engaging with health and climate change. Only a minority of reports that engaged with health and climate change referred to gender. However, this proportion increased from 5% in 2014 to 19% in 2019. In 2020, gender engagement fell to 13% (appendix 5 pp 252-267). Conclusion Public and political engagement is essential if the ambitions of the Paris Agreement are to be reached.” Section 5 has focused on five areas of engagement— namely, the media, the public, the scientific community, national governments, and the corporate sector. Three conclusions can be drawn. First, health and climate change are increasingly addressed together. The trend is particularly pronounced for indicators relating to the media, science, government, and the corporate sector. In all these areas, engagement with health and climate change reached its highest recorded level in 2020. Gender is rarely integrated into engagement within the health and climate change nexus, although there is increased recognition in countries” enhanced NDCs. Second, the COVID-19 pandemic appears to be a major driver of engagement in 2020. For example, more than half of newspaper coverage of health and climate change was linked to COVID-19, and individual engagement in health and climate change was largely sustained by searches for articles related to COVID-19. Government engagement in the health dimensions of climate change was similarly underpinned by engagement in the pandemic. It is not known whether the heightened engagement in health and climate change will be maintained if, and when, pandemic-related crises are contained. Third, social inequities are deeply etched into public and political engagement. In the media and science, coverage of health and climate change engagement is greatest in the countries with a very high HDI (ie, the countries that are exerting the greatest pressure on the planet but that are also the most protected from the health impacts of climate change). Countries with medium and low HDIs have much smaller carbon and environmental footprints than countries with very high HDL, however, they are shouldering the immediate Durden of climate change and are far less represented in the scientific literature. As in previous years, the SIDS are leading global engagement with the health impacts of climate change at the UN General Debate. It is not known what is required for the leadership of SIDS to be matched by the countries and communities contributing most to climate change. Conclusion: the 2021 report of the Lancet Countdown The 2021 report of the Lancet Countdown finds a world overwhelmed by an ongoing global health crisis, which has made little progress to protect its population from the simultaneously aggravated health impacts of climate change. The inequities of these impacts and the response, including those of gender, are brought into sharp focus within each of the indicators presented. This exposes the urgent need for the collection of standardised data to capture inequities and vulnerabilities (panel 2). Climate-sensitive infectious diseases are of increasing global concern and the environmental suitability for the transmission of all infectious diseases is increasing (indicator 1.3.1). For non-cholerae Vibrio bacteria, the environmental suitability for transmission in northern latitudes has increased by 56% since the 1980s. The number of months suitable for malaria transmission has increased by 39% in highland areas of the low HDI country group and, during the past 5 years, the environmental suitability for the transmission of emerging arboviruses (eg, dengue, chikungunya, and Zika) was between 7% and 13% higher than it was in the 19505. The high temperatures in 2020, a year that tied with 2016 as the hottest year on record, resulted in wwwthelancet.com Published online October 20, 2021 https://doi.org/10.1016/50140-6736(21)01787-6 Review extreme heat-related health impacts, affecting the emotional and physical wellbeing of populations around the world (indicators 1.1.1-1.1.6). These higher temperatures and altered weather patterns are also leading to more frequent extreme weather events and increased wildfire exposure (indicators 1.21, 1.2.2, and 1.2.3) and are putting years of progress on food and water security at risk in many parts of the world. The 5 years with the greatest area of the world's surface affected by droughts have all occurred between 2015 and 2020 (indicator 1.2.2), the yield potential of all major staple crops continues to fall as a result of the rising temperatures (indicator 1.4.1), and 79% of all potential work hours lost to extreme heat in low HDI countries occurred in the agricultural sector in 2020 (indicator 1.1.4). However, measures to curb emissions have been grossly inadequate. Emissions are declining too slowly or heading in the wrong direction in the highest emitting sectors (indicators 3.1, 3.4, and 3.5.1). This delay in progress is contributing to millions of deaths each year due to exposure to indoor and ambient PM, , pollution and due to high-carbon, unhealthy diets (indicators 3.2, 3.3, and 3.5.2). Importantly, these effects manifest differently between HDI country groups and genders, underscoring profound inequities. Despite years of scientific reporting on the impacts of climate change, efforts to build resilience have been slow and unequal, with countries with low levels of HDI being the least prepared to respond to the changing health profile of climate change and funding remaining a consistent challenge (indicators 2.1.1, 2.3.1, and 2.4). At the same time, 65 of 84 countries reviewed continue to provide subsidies for fossil fuels that outweigh any revenue received from carbon pricing instruments. The resulting net carbon subsidies are, in many cases, equivalent to substantial proportions of countries national health budgets (indicator 4.2.4). Governments with the fiscal capacity have responded to the COVID-19 pandemic with massive spending packages, to cushion the impacts of the crisis and start to bring about economic recovery. But as the world approaches COP26, the response to climate change, and commensurate investment, remains inadequate. The opportunity for the green recovery is in danger of being missed. A fossil-fuel driven recovery, although potentially meeting narrow and near-term economic targets, could push the world irrevocably off course for the ambitions of the Paris Agreement, with enormous costs to human health. With government leaders more engaged with the health dimensions of climate change than ever before (indicator 5.4), countries across the globe should pursue low-carbon economic recovery pathways, implementing policies that reduce inequities and improve human health. The Lancet Countdown indicators show the evidence to support the urgency and opportunity of this transition, and that no people are safe until everyone is safe. Contributors The Lancet Countdown and the work for this paper were conducted by five working groups, which were responsible for the design, drafting, and review of their individual indicators and sections. All authors contributed to the overall paper structure and concepts and provided input and expertise to the relevant sections. ER, CDN, NA, SA-K, JC, LCh, LCi, SD, LEE, SHG, IK, TK, DK, BL, JKWL, YL, ZL, RL, JM-U, CM, KMi, MM-L, KAM, NO, MO, FO, MRa, JCS, LS, MT, JTr, BV, and MY contributed to Working Group 1. KLE, MN, LJ, DC-L, RD, LG, DG, CH, JH, MP], PLK, MM, KMo, TN, MOS, JR, and JS-G contributed to Working Group 2. TO, IH, HK, KB, CD, MD, PD-S, ME, SH, S-CH, GK, ML, NM, JM, DP, JS, MS, JTa, PW, and MW contributed to Working Group 3. PE, PD, NH, BSR, WC, KH, ZM, FW, and SZ contributed to Working Group 4. HG, PL, WC, SC, ND, SJ, LM, SM, and OP contributed to Working Group 5. AC, HM, PG, IH, MRo, AM, and RNS provided coordination, strategic direction, and editorial support. Declaration of interests We declare no competing interests. Acknowledgments We thank the Wellcome Trust and, in particular, Madeleine Thomson and Lukasz Aleksandrowicz (Wellcome Trust, London, UK), for financial and strategic support, without which this research collaboration would not be possible, The Lancet Countdowr's work was supported by an unrestricted grant from the Wellcome Trust (209734/Z/17/Z). Ten of the authors (IH, MRo, AM, CDN, LJ, HK, PD, NH, BSR, and PL) were compensated for their time while drafting and developing the Lancet Countdown's report. CH was supported by a NERC fellowship (NE/RO1440X/1) and funding from the Wellcome Trust HEROIC project (216035/Z/19/Z). CD was supported by the UK Natural Environment Research Council Independent Research Fellowship (NE/NO1524X/1) and contributes to the Sustainable and Healthy Food Systems (SHEFS) project supported by the Wellcome Trust (205200/Z/16/Z). MD was supported by the Wellcome Trust's Complex Urban Systems for Sustainability and Health (CUSSH) project (209387/Z/17/Z). TO was supported by the Engineering and Physical Sciences Research Council Centre for Research in Energy Demand Solutions (EP/R035288/1). YL, LS, and BV were supported by the US National Aeronautics and Space Administration (NASA) Applied Sciences Program (80NSSC21K0507). RL was supported by a Royal Society Dorothy Hodgkin Fellowship. JR and MOS were supported by the Swedish Research Council Formas (2018-0154 and 2017-0130). MW was supported by the UK Energy Research Centre research programme, which is funded by the UK Research and Innovation Energy Programme (EP/S029575/1). SHG and JKWL were supported by the Singapore's National Research Foundation, Singapore's Prime Minister's Office, Singapore's Campus for Research Excellence and Technological Enterprise (CREATE) programme, and a research grant from the National University of Singapore Initiative to Improve Health in Asia (NIHA) coordinated by the Global Asia Institute and supported by the Glaxo Smith Kline-Economic Development Board (Singapore) Trust Fund. Any opinions, findings and conclusions, or recommendations expressed are those of the authors and do not reflect the views ofthe National University of Singapore, Singapore, or the National Research Foundation, Singapore. While carrying outits work, the Lancet Countdown received invaluable technical advice and input from several individuals, including Heather Adair-Rohani, Miguel Gomez-Escolar Viejo, and Jessica Lewis (WHO, Geneva, Switzerland); Ginette Azcona and Antra Bhatt (UN Women, New York, NY, USA), and Sara Duerto Valero (UN Women, Bangkok, Thailand); Simon Bennett, Chiara Delmastro, Ryszard Pospiech, and Michael Waldron (International Energy Agency, Paris, France); Peter James and Catherine Ngo (Harvard University, Boston, MA, USA); Sebastian Ramirez Ruiz (Hertie School, Berlin, Germany); Nicholas Goh (National University of Singapore, Singapore); Kaixin Huang (Northeastern University, Boston, MA, vwwwthelancet.com Published online October 20, 2021. https://doi.org/10-1016/50140-6736(21)01787-6 Review USA); and Kai Chen and Amy Darefsky (Yale University, New Haven, CT, USA). 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