EXECUTIVE SUMMARY

The sustained health of human populations requires the continued integrity of Earth's natural systems. The disturbance, by climate change, of physical systems (e.g., weather patterns, sea-level, water supplies) and of ecosystems (e.g., agroecosystems, disease-vector habitats) would therefore pose risks to human health. The scale of the anticipated health impacts is that of whole communities or populations (i.e., it is a public health, not a personal health, issue). These health impacts would occur in various ways, via pathways of varying directness and complexity, including disturbance of natural and managed ecosystems. With some exceptions, relatively little research has yet been done that enables quantitative description of these probable health impacts.

It is anticipated that most of the impacts would be adverse. Some would occur via relatively direct pathways (e.g., deaths from heat waves and from extreme weather events); others would occur via indirect pathways (e.g., changes in the range of vector-borne diseases). Some impacts would be deferred in time and would occur on a larger scale than most other environmental health impacts with which we are familiar. If longterm climate change ensues, indirect impacts probably would predominate.

Populations with different levels of natural, technical, and social resources would differ in their vulnerability to climateinduced health impacts. Such vulnerability, due to crowding, food insecurity, local environmental degradation, and perturbed ecosystems, already exists in many communities in developing countries. Hence, because of both the geography of climate change and these variations in population vulnerability, climate change would impinge differently on different populations.

An increased frequency or severity of heat waves would cause an increase in (predominantly cardiorespiratory) mortality and illness (High Confidence). Studies in selected urban populations in North America, North Africa, and East Asia indicate that the number of heat-related deaths would increase severalfold in response to two general circulation model (GCM)-modeled climate change scenarios for 2050. In very large cities, this would represent several thousand extra deaths annually. Although this heat-related increase in deaths would be partially offset by fewer cold-related deaths, there are insufficient data to quantify this tradeoff; further, this balance would vary by location and according to adaptive responses

If extreme weather events (droughts, floods, storms, etc.) were to occur more often, increases in rates of death, injury, infectious diseases, and psychological disorders would result (High Confidence).

Net climate change-related increases in the geographic distribution (altitude and latitude) of the vector organisms of infectious diseases (e.g., malarial mosquitoes, schistosome-spreading snails) and changes in the life-cycle dynamics of both vector and infective parasites would, in aggregate, increase the potential transmission of many vector-borne diseases (High Confidence). Malaria, of which there are currently around 350 million new cases per year (including two million deaths), provides a central example. Simulations with first-generation mathematical models (based on standard climate-change scenarios and incorporating information about the basic dynamics of climatic influences on malaria transmission) predict an increase in malaria incidence in Indonesia by 2070 and-with a highly aggregated model-an increase from around 45% to around 60% in the proportion of the world population living within the potential malaria transmission zone by the latter half of the next century. Although this predicted increase in potential transmission encroaches mostly into temperate regions, actual climate-related increases in malaria incidence (estimated by one model to be of the order of 50-80 million additional cases annually. relative to an assumed global background total of 500 million by 2100) would occur primarily in tropical, subtropical, and less well protected temperate-zone populations currently at the margins of endemically infected areas. Some localized decreases may also occur (Medium Confidence).

Increases in non-vector-borne infectious diseases such as cholera, salmonellosis, and other food- and water-related infections also could occur, particularly in tropical and subtropical regions, because of climatic impacts on water distribution, temperature, and microorganism proliferation (Medium confidence). The effects of climate change on agricultural, animal, and fisheries productivity, while still uncertain, could increase the prevalence of malnutrition and hunger and their long-term health impairments, especially in children. This would most probably occur regionally, with some regions likely to experience gains, and others losses, in food production (Medium Confidence). There would also be many health impacts of the phys

rising sea levels and by climate-related shortages in natural resources (especially fresh water) (Medium Confidence).

Because fossil-fuel combustion produces both carbon dioxide and various primary air pollutants, the climate change process would be associated with increased levels of urban air pollution. Not only is air pollution itself an important health hazard, but hotter temperatures, in urban environments, would enhance both the formation of secondary pollutants (e.g., ozone) and the health impact of certain air pollutants. There would be increases in the frequency of allergic disor ders and of cardiorespiratory disorders and deaths caused by various air pollutants (e.g., ozone and particulates) (High Confidence).

A potentially important category of health impact would result from the deterioration in social and economic circumstances that might arise from adverse impacts of climate change on patterns of employment, wealth distribution, and population mobility and settlement. Conflicts might arise over dwindling environmental resources (Medium Confidence). Stratospheric ozone is being depleted concurrently with greenhouse gas accumulation in the troposphere. Although there are some shared and interactive atmospheric processes between disturbances of the stratosphere and troposphere, both they and their health impacts arise via quite distinct pathways. A sustained 10-15% depletion of stratospheric ozone over several decades would cause increased exposure to ultraviolet radiation and an estimated 15-20% increase in the incidence of skin cancer in fair-skinned populations (High Confidence). Lesions of the eye (e.g., cataracts) also may increase in frequency, as might vulnerability to some infectious diseases via adverse effects on immune function (Medium Confidence).

Adaptive options to minimize health impacts include improved and extended medical care services; environmental management; disaster preparedness; protective technology (housing, air conditioning, water purification, vaccination, etc.); public education directed at personal behaviors; and appropriate professional and research training. It also will be important to assess in advance any risks to health from proposed technological adaptations (e.g., exposures that could result from using certain alternative energy sources and replacement chemicals for chlorofluorocarbons; effects of pesticide use on resistance of vector organisms and their predator populations).

There is immediate need for improved and internationalized monitoring of health-risk indicators in relation to climate change. Existing global monitoring activities should encompass health-related environmental and bioindicator-species measurements and, where appropriate, direct measures of human population health status. To assist the evolution of public understanding and social policy, the health sciences must develop improved methods, including integrated predictive models, to better assess how climate change (and other global environmental changes) would influence human health.

In conclusion, the impacts of global climate change, particularly if sustained in the longer term, could include a multitude of serious-but thus far underrecognized-impacts on human health. Human population health is an outcome that integrates many other inputs, and it depends substantially on the stability and productivity of many of Earth's natural systems. Therefore, human health is likely to be predominantly adversely affected by climate change and its effects upon those systems.