Acknowledgments 3 The Conference on Human Health and GlobalClimateChangethat is the subject of this summary was the product of a collaborative effort between the Institute of Medicine, the National Science and TechnologyCouncil( NSTC), and the NationalResearchCouncil'sBoardon Atmospheric Sciences and Climate, Board on Sustainable Development, and Polar Research Bead. It ., would not have been possible without the concerted efforts and contributions of many individuals and organizations. The conference planners and, organizers are listed in Appendix By including the NSTC Working .Group, the sponsoring agencies, the IOM/ NAS Steering Committee, and the responsible staff. The .conferencespeakers, background paper' authors,. andsessionchairsdeservespeciiil recognition and thanks for 'their efforts ,and arelisted in Appendix. C. The approximately 300 conference participants were zin important part of this activity, especially in stimulating discussion, providing ideas, 'and developing the strategies that were the products of the individual working group panels. These individuals are included in the list of conference registrants in Appendix C. Of particulafnote, Eric Chi& n, Bob Shope, and ,Mary Wilson are acknowledged for their contribution in both raising and discussing these issues with Vice President Albert' Gore, Jr., in the formative stages of the conference's development and for their participation in the conference itself. We. also would like to acknowledge Vice President Gore for his initiative in requesting .that this conference take place, and for his contribution as a participant and 'qeaker. ..

.I ... 111 .I Contents I 3 EXECWIVE SUMMARY .................................................................................................................. 1 BACKGROUND AND OVERVIEW ....... ,... i .......... .. .......................................................................... 2 Greenhouse Warming, 5 Ozone Depletion, 6

POTENTIAL HUMAN HEALTH EFFECTS OF GLOBAL CLIMATE CHANGE ..... ..: .... : ........ I... 7 Infectious Disease, 8 .

Vector Borne Infectious Diseases, 8 Non Vector Borne Infectious Diseases, 9 Heat Stress, 9 Skin Cancer, Cawacts, and Immune Suppression, 12 Food Production and Nutritiond' Health, 13 FreshWater Quality andQuantity, 13 ..

Air Pollution and Allergens, 13 Weather Diskters and Rising Sea Level, 14 Social and Demographic Dislocations, 14 Direct Effects on Human Health, 9 .

Indirect Effects on Human Health, 13 POLICY IMPLICATIONS .................. ........................ ...................................................................... 15 , Panel Reports, 15 Global Surveillance and Response, 16 Disease Prevention, 17 Education for the Medical and Public. Health Communities; 19 InternationalCooperation, 22 . .

.I .

v .. ""* U ,/p I ~ . Research and DevelopmentNeeds, L Public Outreach and Risk Communication, 24 s w y OF PRIORITIES AND STRATEGIES ..................................................................

&FERENCES AND FURTER READING .............................................................. ................

APPENDIXES A National Science and Technology Council (NSTC) Sponsoring Members, Interagency Working Group, Institute of Medicine (IOM) Steering Committee, and Staff, 3 1 B Conference Agenda, 35 C Speakers, Authors, Chairs, and ConferenceRegistrants, 41 D AbstractsofConferencePresentations, 57 4 c * ..

Conference on Human, Health and ' . Global Climate Change Summary of the Proceedings J J ..

. .. ..

. , /

4 Conference on Human Health and Global Climate Change: Summary of the Proceedings I i EXECUTIVE SUMMARY Observed changes in the Earth's climdte over the past 100 years appear to be consistent with '

theoreticalmodels ofgreenhousewarming, accordingtotheparticipants in arecentscientific conference on Human Health and Global Climate Change, cosponsored by the National Science and TechnologyCouncil OIJSTC) andtheInstituteofMedicine (IOM). ' Thesemodelssuggestthat, without major changes in environmental policy, we could expect to see even greater changes in global climate over the next 100 years. These changes could produce 'alterations both &physical systems (e. g., higher temperatures, heavierrainfall, and risingsealevel) and in ecosystems( e. g., forests, agriculture, marine ecologies, and the habitats of various insects and animals). In addition to the global changes associated with greenhouse warming, a continuing depletion of stratospheric ozone would increase the amount of ultraviolet radiation that reaches the Earth's surface, causing increased rates of skin cancer, cataracts, and i m u n e suppression. The focus of concern to .the conference participants was the substantial risks to human health, including both direct risks (e. g., death in heat waves or floods, skin ckcer) and indirect risks (e. g., changes in foodproductionorthedistributionandincidenceofvector bornediseases) that are believed to be associated with changes in global climate. The indirect risks appear to be the most difficult to cope with, particularly those posed by emerging and reemerging infectious'diseases such as cholera, malaria, dengue fever, and Hantavirus. These risks are of particular concern in regions and populations that are already 'vulnerable due to crowding, malnutrition, poor sanitation, and political or economic instability. , . '

The general agreement that emerged during the conference was that changes in the global climate could pose significant risks to human health. Much remains to be done to clarify the exact linkages between human activities, global climate change, and human health, but the lack of complete . .

data should not be used as an excuse for inaction. Instead, the precautionary principle should apply: If the risk to public health is great, even if there is uncertainty, both policy and action should be biased infavor of precaution. ,.

In discussing the poIicy implications of global climate change for h m health in the United Skates and thc international community, participants identified a number of actions that should be taken, including( a) thecreation of a globalsurveillanceandresponsenstwork; (b) increased 'The conference was held at the National Academy of Sciences on September 11 12, 1995, and was attended by more than 300 people (see Appendix C). .1 cu~ vPEREiVCE ON Xfhl2 4J HEALTH AND GLOBAL CLIUq TE Ci coordinab among nations and scientificdiscipl 3; (c) multidisciplinaryresearch on. th. between ~

,bal climate change and human health; (d) improved environmental health kifi health professionals; and (e) an outreach program to inform and educate the public about the of global climate change on human health. In the face of current fiscal constraints, these effofi be, based on identifylng and linking together existing activities, facilities, organizations, and fi Zgencies. i / i BACKGROUND AND OVERVIEW In October 1994, following a meetingwithconcernedscientists and medical experts Chivian, BobShope, and Mary Wilson), VicePresidentGoreasked therOffice of Science TechnologyPolicy (OSTP) and theCouncil on Environmental Quality (CEQ) to orgmi; conference on the potential human health risks posed by global climate change, and strategic address them such as global health surveillance, public outreach, and education. Members of NSTC, OSTP and CEQ formed a working group to develop a preliminary agenda for the confert andlaterrequestedthatthe l d M join inplanning, organizing, andconductingthe confers (Appendix A presents a list of the sponsoring agencies, the IOM steering committee, and confere orgikizing staff.) The purpose of the conference was twofold: I 1. To, bring togetheradiverse, interdisciplinarygroup of expertstoaddressthe poten1 effects of global climate change and ozone depletion on the current and fkture incidence of &sea heat stress, food and water supplies, and air pollution; and 2. To discuss initial strategiesforimprovingresearch and deveIopment (R& D), glot: health surveillance systems, htalth care and disease prevention, medical and public health communi education, international cooperation, and public outreach.

It is important to note that the focus of the `conference was human health. Presenting evidenc of whether or not global climate change is, has, or will OCCW, was not the primary focus. Participant were asked rather to work within an "if/ then? type of scientific .exercise: If global .climate chang occurs, what are the potential adverse human health effects and what strategies should be developec to address them? The first day of the two day conference was filled with scientific presentations and a plenary discussion on the current state of knowledge about global climate change and its potential risks for human health (see the agenda, Appendix B), including a presentation by Vice President Gore (see Box 1). On thesecond day, participants` discussedhealthpolicyimplicationsandpotential intervention strategies in a series of panels. Each panel's, findings were presented and discussed by the conference participantslin a final plenary `session. Approximately 300 scientists, health care providers, policymakers, academicians, federal and state officials, industry representatives, and others attended the conference and participated in developing the strategies (see Aypenoix C). BOX I. The Interplay of Climate Change, Ozone Depletion, and Human Health' 3  Albert Gore, Jr: 'Vice President of the United States I've spoken before about the radical changes that have occurred in our environment just in my lifetime. As i s often the case, when a fundamental change takes place, one can't point to a single causal factor to explain it. In this case, I've come to believe, that this radical change in the relationship between civilization and the Earth has come about because of the confluence of three factors at the same time, the first being the population explosion, which is now adding the equivalent of one China's worth of people every 10 years. Thesecond change is the scientific and technological revolution, which has dramatically magnified the average impact that each of the billions of people on Earth can potentially have on the Earth's environment. And the third factor, the most subtle in some ways but the most important in other ways, .'. . there has been a change in thinking about our duty to consider the future consequences of our present actions and a sometimes willful asdrtion that we can't possibly have any meaningful impact on the Earth's environment, therefore we shouldn't think about it much less wow about it or study it in detail. Together, these three elements have combined to produce what some of youwouldcall a discontinuity: a fundamental. change in the relationshipbetweenhuman civilization and the earth. There is a scientific consensus on the most salient issues, a revisionist few not withstanding: We* know that human activities are causing the atmospheric concentrations of greenhouse gases to increase dramatically in the atmosphere. Carbon dioxide has increased nearly 30 percent since the industrial revolution, methane has more than doubled, and nitrous oxide has gone up by 15 percent. We also know that the current trends are leading to an^ even :

more rapidaccumulation of greenhou'se gases and that, as this trend continues, the concentration of greenhouse gases will dontinue to mount. Now, in addition to the greenhouse gases, human activities have increased the atmospheric concentrations of sulfate aerosols the keyingredient in acid rain especially over industrialized areas in the Northern Hemisphere, '

warmest years this century have all occurred since 1980. There are plentyof other measures from the tree ring .record to the record in land based . glaciers thatall demonstrate that the current period is by far the hottest that we have been able to measure. And the evidence is getting ever stronger that this warming nowunderway is not due to natural variability, but to human activities. ..

The real question is: "What will happen i n the future?" Without climate change policies that limit global emissions of greenhouse gases, there is no doubt that the Earth's climate will change. It's not a question ofwill it change, it is a question of when, by how much, and where. The question of when is now being answered. It has already begun to change significantly. And the best evidence is consistent with a prediction that, in the lifetimes of people now living, we will commit the world to an increase of up to 3 O and 4° C up to 8OF. The scientists warn us that change is coming. In just the last century, the Earth's temperature has risen by about 0.5OC, or I° F. The nine ' ..

Continued '

*Excerpts from remarks at the Conference on Human Health and Giobal Climate Cnange, September 11, 1995.

. 'i c .Hc till globalwarmingaffect US? There a ;lea@+ profoundimplications at the regie level f ood security, water supplies, natural eCOSystemS, loss of land due to sea level r andhumanhealth. A temperature increase of 2" to 8° F is projected to double heat rela deaths in NewYork City andtriplethenumberof deaths in Chicago, LOS Angeles, 2 Montreal, Andan increase of 8OF maybeGoKeiated with an increase in theheauhumic So will those withchroniccardiovascularandrespiratory diseases. The past Summe stunning number of deaths in Chicago over 500 in just a few days make these hypothes all f30 real. Changing temperatures and rainfall patterns are predicted to also increase the spread infectious diseases. Insects that carry disease organisms may now move to areas that we. once toocold for themtosurvive. These newbreeding sites and higher temperatures mz also speed reproduction. Diseases we hadhopedwere just a memory in this county ar suddenly a renewedthreat. Cholera is resurgent in our hemisphere. After years ofbein contained in much of the world, Dengue Fever has returned to countries that had not seen th disease in 50 years. Malaria, too, is a global concern, and some of the new strains are mort troubling thananythathavebeen seen. Malariaalready infectsseveralhundred millior people each year mainlydn the Tropics. But this July, for the first time in 40 years, more thar 100 people contracted maIat4 in a Russian city. And besides the return of old diseases, there are new ones on the U. S. scene, such as the hantavirus in the Southwest. Unfortunately, ignoring the news does not make it better. Closing your eyes to a problem doesn't make it vanish. You can't simply wish ozone holes away. SO it astounds me, in light of all the data that has been collected over the years, that some are once again challenging'the fact that there is ozone depletion. And what's even more amazing is that some people are listening. Ladies and gentlemen, we have an extraordinary international consensus: We have thousands and thousands of atmospheric measurements linking manmade CFCs toglobal ozone depletion. We all know that depletion of the ozone layer increases the amount of UV B radiation that reaches the Earth. And so nowwehave to confront the fact that the observed depletion of ozoneof 5 10 percent in summertime, whenpeople are outdoors a lot, will' increase nonmelanoma skin cancer in fair skinned populations by about 10 20 percent.

and cataracts are already the third largest cause of preventable blindness in the United States. These numbers would be much higher yet were it Rot for the success of the Montreal Protocol.. We must not forget though, that evenwith that world wide action, it will be until the middle of the next century before the ozone layer recovers. Well, for the past 25 years, the United .States has been committed to the bipartisan effori to protect the environment. . . . President Clinton has . . . fought to make sure that the United States is at the forefront of a globalenvironmentalmovement. We'restriving to return greenhouse gas emissions to 1990 levels by the year 2000. We're striving to convince others to make as much progress as is possible. We're engaged in internationathegotiations to address this globalproblem. We'rehelpingtodevelop treaties notonly for the protection of our awn nation, but for the health and welfare of the world community of which we are a part. ' We know that science is essential to our understanding of global problems. Ladies and gentfernen, the role of the scientific community in articulating cleariy the best accepted understanding of what we know and what, we can say with sufficient confidence to enable the American people to takeprudent measures 10 safsguard our future is abso! y? e! y critical. ". .I , index of 1 2 O to 15OF. The very young, the elderfy, anb the poor will be the ones most at  In addition, there w i l l be an increase in the incidence of cataracts and other eye lesions, 5 ..' Greenhouse Warming T.

4 Without the naturallyoccuning" greenhouseeffect," Earth would be toocoldtosustain life as we know it. The greenhouse effect results from water vapor, carbon dioxide, and other trace gases in the atmosphere that trap solar heat as it is reradiated from the Earth's surface. The net effect is to keep the, ph. net about 33° C (60° F) wannerthan it wouldbeotherwise. Inthepast century, however, human activities have added substantially to this effect by releasing additional greenhouse gases into the akosphere, primarily through combustion of fossil fuels. Carbon dioxide concenkations have increased nearly 30 percent, nitrous oxide about 15 percent, and methane approximately 100 percent. The principalsource of the emissions thatproducetheatmosphericconcentrationshasbeen the burning of fossil fuels (coal, oil, and gas), although agriculture and deforestation contribute a share. There is a growing consensus in the scientific community that the increase in greenhouse gases has contributed to a warming of the earth's surface by between 0.3" and 0.6" C (0.5" and 1. l0F), on average, over the past 100 years (see Figure 1). In some regions, particularly in the industrialized areas of the Northern Hemisphere, this warminghas been masked by increased concentrations of air . pollutants such as sulfate aerosols, which reflect solar radiation (and thus serve to counter balance, in part, the warming that might be seen otherwise). Nevertheless, the nine warmest years in this century have occurred since 1980, andthereisconsiderableevidencetosupportthis warming trend (see "References and Further Reading," p. 28): decreases in Northern Hhsphere snow cover and Arctic sea ice, the retreat of glaciers in all of the world's mountain ranges, and a measurable rise in average sea. level 10 to 25 centimeters (4 to 10 inches) over 'the past 100 years mainly due to the& expansion of water. m i l e emissions of greenhouse gases ' 4 1 certainly continue in the future, the exact amounts will depend. on population growth, economic development, energy technologies, and policy variables. Nevertheless, according to the participants, it seems reasonable to expect that global emissions of carbon dioxide will rise in the .short term from the current level of approximately, 6 billion tons of carbon per year, to between 8 billion and 15 billion tons per yeaf in 2025, 'and could range from 5 billion to 36 billion tons per year by 2100. This 'would mean that atmospheric concentrations of carbon dioxide which were 200 parts per million (ppm) during the last ice age and about 280 ppm in preindustrial times could rise from today's 350 ppm to'anywhere from 500 to 900 ppm by 2100. The scientific community has growing confidence in the ability. of computerized general circulation models to predict the climate impacts of such changes in greenhouse gases. These models, whichprovide an increasinglygood fit betweentheoryandobservationofpastglobalclimate changes, indicatethat, in a worldwithapproximatelytwicethecurrentconcentrationofcarbon '

dioxide, the global mean temperature will increase by 1" to 4° C (2" to 7" F), with significant regional variations (e. g., somewhat less warming in the Northern Hemisphere due to air pollution). Average .evaporation will also increase, and hence average precipitation, again with regional variations (more rain in some places, especially in winter, less rain in others, especially in summer). Sea level will rise by another 15 to 90 centimeters (6 to 35 inches) over the next 100 years. 6 . ., CONFERENCE ONHU MX~ EALTHAND GLOBAL CLIMATE c m partA $ ants noted that the impact of such changes on natural and human systems mixed. Increased .carbon dioxide concentrations would have a "fertilizer" effect for some plants, not for others, leading to changes in natural plant communities and ripple effects on animal spec Overall, the balance would probably be tilted in favor of "weedy'' species those with higher rate reFoduction and dispersal to the detriment of biological diversity. Tropical forest communities be affected, .and there will probably be some die off in boreal foress as well. Temperature re12 changes in the oceans will affecttheworld'scoralreefs and oceanfisheries. Global agricdh production may be unchanged, although increased production in northern latitudes might be offset decreases in tropical regions where many populations are already malnourished. Coastal populatic may be dislocated by changesinsealevel, andthere .will likelybeincreasednumbers of 06 "ecological refbgees" as well.

ir Ozone Depletion A thin layer of ozone h i g h the atmosphere (the stratosphere) protects life on earth. shie :I dir the Surface by absorbing much of the ultraviolet radiation from the &. However, surface' ozone ( the 1ower. atmosphere or troposhpere) is a major component of urban smog and ca. also serve as I Temperature change PC)

4 I '

20,000 10,000 5000 1,000 200 . 100 18, OOO vcan  A 1.800 w a r s  ` 300vean >

Number of years befori p r m n t (note: quasi iog scale)

FIGURE I . Variations in average global temperature' over the past 20,000 years and predictions for the next century. (McMichael, 1993) . . SUMIUARY OF THE PROCi' XVGS 7 greenhouse gas; the protective ozone layer resides some 10 to 40 kilometers, or 6 to 25 miles, above ,. the .Earth's surface. Solar energy recombines diatomic oxygen (03 into triatomic ozone (OJ;. these ` molecules are broken down to 0, by naturally occurring compounds containing nitrogen, hydrogen, and chlorine; and ihe cycle begins again. In the past 50 years human activities have added millions of tons of ozone depletingchemicalstotheatmosphere, primarilythrough the widespread use of chlorofluorocarbons (CFCs) in refrigerators, spray cans, foam insulation, and cleaning compounds. In theory, these ozone depleting chemicals rise up in the atmosphere and destroy the ozone layer faster than it is' naturally restored. Indeed, in 1985, researchers reported dramatic declines in ozone concentrations over Antarctica during the southern spring. This seasonal "hole" in the ozone shield has grown larger and appeared earlier in subsequent years. Many other factors might contribute "

to these findings, including sunspot cycles and the isolation and extreme cold of the Antarctic weather system, but CFCs and other ozone depleting compounds were clearly implicated. ' More recentmeasurementshaveconfirmedthatozonedepletion is in facta global phenomenon; ` although it is lessacute in th troicsand more pronouncedtoward the poles, particularly in the Southern Hemisphere. At present there is a 5 to 7 percent ozone depletion over the United States during the summer, when people are most likely to be outdoors; about 11 percent over southern temperate areas; and more than 50 percent over Antarctica. Every 1 percent decrease in ozone can lead to a 2 percent increase in nonmelanoma skin cancer. This phenomenon is. expected to continue for the next decades, despite international efforts to ban CFCs and to phase out other ozone destroying compounds. Peak ozone depletion will occur around the turn of the century; recoveqis expected to occur over the following 50 year period. i.

J P POTENTlwL HUMAN HEALTH EFFECTS OF GLOBAL CLIMA'IE CHANGE Conference participants noted that the anticipated human health risks caused by global climate change will not be localized; instead, they willoccur on alargescale, impinging on entire populations. In additiontoincreasingthefamiliar, direct6ffectsofclimate( i. e., extreme weather events such as heatwavesandfloods), globalchangewillalsoinvolveavarietyof indirect risks arising from the disturbance ofnaturalsystems( e. g., the. ecologyofinfectiousdiseases, food production, andfresh `water supplies). Forecastingtheserisks is acomplex, uncertaintask, and encompasses a long time horizon. ( Box 2 summarizes a pair ofpresentations on El Nifio as an analogue for long term global climate change.) The health effects ofglobalclimate. changespanacontinuumfromdirectto indirect, as shown in Figure 3. In the long run, the indirect effects of disturbing natural systems may have greater cumulative impacts on human health, and most of those impacts will be adverse. As summarized in the most recent assessment of the United Nations Intergovernmental Panel on Climate'Change (IPCC, 1995) and by various speakers during the first day of the conference, the most likely and most serious health risks and health effects of globalclimatechangeandozonedepletionwould be adverse changes in the following: I . ..

'The 1995 Nobel Prize for. Chemistry. was awarded to Molina and Rowland for this research.

.. heat stress; skin cancer, cataracts, and immune suppression; vector borne infectious diseases; non vector borne infectious diseases; food production and nutritional health; water quality and quantity; airpollutionandallergens; weather disasters and rising sea level; and social and demographic dislocations.

Infectious Disease Climate influences the distribution, fiequency, types, and severity of infectious &seas humans. The interaction between climate and infectious diseases derives from the impact of cli oninfectiousorganisms (w h as bacteriaandviruses), on the humanhost, and onvectors reservoir hosts and their ecosydms. Climate change can increase the probability of contact be& humans and infectious organisms.

Temperatureandrainfallinfluencetheabundance anddistribution of insectvectors i animals" one source of infectious diseases in humans. Global climate change is likely to affect geographic distribution of a n i m a l s and insects and could expand transmission of infectious disea carriedbymosquitoes( e. g. z malaria, dengue, andyellowfever) andothervectors, such as tic: sandflies, and fleas. Altered distributions of vectors are likely to involve expansion of vector bor diseases into new geographic areas `md populations and disappezkance from other areas. For a vectc borne disease to persist in a n ' i r e a , climatic conditions must support a complex interaction that rn; involve plants, animals, insects and human activities. Extreme events, such as flooding and hurricanes, that lead to displacement of populations in1 crowded, temporary shelters, or movement into previously uncleired lands, could also contribute t an increase in vector borne infections. Vector borne diseases are already a major cause of illness and death in tropical countries I where 2.4 billion people are at risk from malaria and 1.8 billion from dengue fever (see Table 1). The numbers of people at risk from theseand other diseases will .increase with warmer temperatures and humidity, particularly because these changes are occurring &nultaneously with changes in ,human behaviorthatincrease the dangers of infectious disease mostnotably international travel, population growth, rapid urbanization, poor sanitation, and changes in land use patterns :that increase habitator bring humans in contactwith insect. or rodent vectars. Climate related migrations could also contiibute to the dissemination of previocsly localized diseases. Several vector borne diseases have been increasing rapidly in recmt yexs, including some that were previously ccnsidsicii to be under control, such as dengue fever and malaria. Strong support for public health programs both domestically and internationally would help to reduce this risk. .,/  , .

Suh. fMRY OF THE PROCJLDINGS Non Vector Borne Infectious Ddeases i 9  * Changes in watertemperatureandtheresultingproliferationofaquaticmicroorganisms would tend to increase the range and. severity of cholera and other. food and water related diseases that can cause epidemics of diarrhea and dysentery. Cholera epidemics are typically associated with seacoasts and rivers, for instance, where the cholera organism, Vibrio cholerae, &ves by sheltering under the mucous coating of tiny invertebrates called copepods. These hosts, in turn, respond both to water temperature and to nutrients (fertilizer, wastewater) in stream runoff. Researchers are currently evaluating the connection between water temperature, coastal currents, algal blooms, and subsequent ,; outbreaks of cholera like those in Peru in 1991 and Bangladesh in 1992. Higher temperatures contribute to faster reproduction by disease organisms. Rates of genetic mutation also increase in times ofstress. Furthermore, diseasecausingorganismsareremarkably resilient and can respond rapidly to changes in the physicochemical awironmknt. Climatic and other environmental changes are contributing to thgselection and. emergence of genetic strains that are resistant to drugs and other controls.

Direct Effects on Human Health Heat Stress

, An increase in average temperature would probably be accompanied by an increase in the number and seventy of extreme heatwavesin some Teas. This would cause an increase in illness and death, particularly among the young, the elderly, the frail, and the ill, especially in large urban areas. Climate change would exacerbate an already large urban heat island effect that exists in many large cities. In fact, heat related mortality may prove to ,be the largest direct health threat from global climate change. The deathsof 726 people that were attributed to a heatwave in Chicago i n the summer of 1995 may be an extreme example, but it serves as a possible indicator of what might occur if climate change scenarios &e correct. Mid latitudecitiesthatexperienceirregular, butintense, heatwavesappearto' be most susceptib1e" citie. s like, St. Louis, Washington, D. C., and New York. Tropical and subtropicai cities seem to be less susceptible, in part because populations have acclimatized to the regularity of hot weather (although a 1995 incident in New Dehli indicates the susceptibility of tropical populations as well). People in mid latitude cities mi@ also acclimatize, and air conditioning can mitigate perhaps 25 percent of heat relatedmortality( while also requiringincreasedenergyandrefrigerantuse, thereby increasing greenhoLisegasemissions). In addition, summermortalityincreasesmight be.. partially offset by declines in winter mortality. However, much of the research points to a substantial increase in weather related mortality der climate chapge conditions. Despite these uncertainties, there is a clear need to develop an adequate warning system. to alert the public and governmint ztgencies when oppressive air masses are expected" extended periods of extreme high tqerature, light winds, high humidity, and intense solar radiation. TABLE 1 lrlajor Tropical Vector Borne Diseases and the Likelihood of Change of Their Dkmbution with Climate Change Likelihood of Altered Currently Population 8: Infectedor New Present with C h a r  NO. of PeopIe Disease Vector Risk (million) 'Cases per Year Distribution Change Malaria Pllosquito 2,400b 300 500 million TropicdSubtropics +t)

Schistosomiasis Water Snail 600 200 million TropicdSubtropics U Lymphatic Filariasis Mosquito 1,094' 117 million TropicdSubtropics +

African Tsetse Fly 5 9 250,000 300,000 Tropical Africa f Trypanosomiasis casedyr (Sleeping Sickness)

Dracunculiasis Cmsaceau 100' 1oo, ooo/ yr South AsidArabian (Guinea Worm) (~ PePQd) ? 3 PeninsuldCentral West Africa Leishmaniasis Phlehtomine 350 Sand Fly Onchocerciasis Black R y 123 (River Blindness)

American Triatomine 100' Trypanosomiasis Bug. (Chagas'disease)

Dengue ,Mosquito 1,800 12 million infected, 500,000 new .cases/$

17.5 million 18 million 10 3Omilliodyr  AsidSouthern +

Americas EuTopefAfricd

Africa/ Latin America ++

Central and South + America All Tropical Countries tt Yellow Fever. Mosquito 450 4,000 casedy r Tropical, South +i

. . hericaand Africa NOTE: + = likely, "I = very likely, ++ t = highly likely, and ? = unknown.

'Top three entries are population prorated projections, based on 1989 estimates. 'WHO, 1995. .e Michael and Bundy, i995. 'WHO, 1994a Ranque, personal ccmmunication. 'Annual incidence of viscerai leishmaniasis; annual incidence of cutaneous leishmaniasis is 1 million 1.5 million casedyr (PAHO, 1994). 'WHO, 1995 ... ,z SOURCE: PCC, 1995. ~,

I 1 " , I SUMhMY OF THE PROCEL NGS BOX 2. El Niiio: Analogue for Long Term Global Climate Change? '

J. Michael Hall Director, Office of Global Programs, National Oceanic and Atmospheric, Administration and Paul Epstein Harvard Medical School

The El Nitio southern oscillation (ENSO) may represent an analogue not only for larger scale globalclimate change and its consequences, but also for the steps that might be taken to monitor and respond to globalclimate changes that threaten human health. Prevailing winds in the tropics create a pool of warm water in the western Pacific Ocean, a regionthatdrivesmuch of the atmospheric heating that controls the world's weather. Periodically, .however, the trade winds 'relax or even reversethemselves, releasing this pool of warm water and setting in motion changes in water temperature, sea level, and coastal currents off South Americathat becausetheyhappenaround Christmas are known by the name of "El Nitio." This oscillation in atmosphericand ocean conditions, whichnormally happens every 3 to .7 years, causes notonly the collapse of ocean fisheries in the eastern Pacific, but also characteristic changes in the weather in otherregions, including drought in northeastern Braziland increased precipitation in the southeastern United Sjates (see Figure 2). The international scientific community has linked a huge network of ocean buoys and remote sensingsatellitestoobserve and. study the dynamics of the. ENSO phenomenon. Interdisciplinary research andanalysishave led to thecreationof multisector models that can predict the occurrence and effects of these changes. The ENSO forecasts made by these models are alreadyreliableenough to support major policy decisions. In both Peruand Brazil, .for example, governments are making decisions about which cropsto plant, and how many acres to'cultivate, based on 12 month forecasts of ENSO related rainfall. .More research and refinement will be needed before these predictive models will be useful in' regions outside the tropics and in sectors other than agriculture, including public health. Nevertheless, this predictive approach .to .short term ENSO changes may have major relevance to the study of long term'changes i n the. globa1 climate. ' . ENSO related algal blooms off Peru; for instance, are part of what appears to be a global epidemic of algal blooms caused in part by warmer oceans everywhere. These blooms represent "environmental reservoirs" for microbes, such as Vibrio cholerae, the cause of cholera in humans. Similarly, insect and rodent populations also have increased following the mild, wet winters associated with El Nitio, and this can have serious impacts in areas wh, ere these animals act as pests in agriculture or as vectors for diseases such as malana and Lyme disease. Consequently, the ability to understand and anticipate the relations between globalclimats changes, environments! responspc, 2nd threlts to human health may have significant value in developing early warning systems to protect vulnerablepopulations. Multidisciplinary, multisectoralresearchto . developreliable indicators could have extremely broad benefits for public health. ..

"Excerpts from a special briefing at the Conference on Human Health and Global Climate Change, 11, ,1995. . . i 11 ,/ ' i ,

12  60" N 40" N 20" N EQ 20" s 40" s Northern Hemisphere Winter J 120" E 160" W a o 0. w :*= dry _. = dry & warm m= wet mm = wet & warm ma = warm ma= wet & cool "

FIGURE 2. Pictoral representation of global climate impact anamolies due to ENSO. (Provided by NOM, based on work of C. Rppelewski and collaborators)

Skin Cancer, Cataracts, and Immune' Suppression ..

Ozone 'depletion can have' both direct p d indirect effects on ecological systems and hum2 health. Increased exposure to .ultraviolet radiation (especially UV B) can have harmful effects e photosynthesis (on land and sea), with potejntidy disruptive impacts on food production and th stability of ecosystems. The most important direct human .health effect would be an increase i nonmelanoma skin cancers, espe& ally in fair skinned populations. Such cancers are already a majc problem in the United States, ' w i t h about 1 million new cases per year. Furthermore, cwent model. suggest a two percent increase in incidence for every one percent decrease in stratospheric ozone. The current scenario for phaseout of CFCs predicts a 25 percent increase in skin cancer by 2050 at 50" N latitude, relative to the 198Oincidence. Melanoma is a less fiequent but far more deadly skin cancer, whose relationship to W B exposure remains uncertain. Both types of skin cancer have ' a long lag time betweenexposure and disease; the effects of increased W B &y not be seen until after 2050, Idcreased W B can also be expected to increase the frequency of cataracts, which can lead to blindness in all populations. Current estimates indicate a 0.3 to 0.6 percent increase in new cataractcasesforevery 1 percent decreaseinstratosphericozone. Ozone depIetion may also contribute to the frequency, severity, and duration of someinfectious diseacs &e io dhaviolet's ability to suppress the ilmune system. There are m y ~c z t t i i t k s about the effect of W B on i m u n e responses, althoughitappearsthatneitherpigmentationnor m s c r m s offer gffective protection. _ . I /

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sI/&€ A4ARY OF THE PROCLdIiVGS ,

Indirect Effects on Human Health ' Food Production ind Nutritional Health 13 Global climate change would have mixed effects on the productivity of agriculture, livestock, and fisheries. In tropical and subtropical areas, global climate change may lead to droughts, flooding, and the emergence of new plant diseases, decreasing food production in many areas where food supplies are already insecure. Meanwhile, crop productivity may increase in other regions, mostly in the higher temperatelatitudessuch as Canada, Siberia, andPatagonia. However, agricultural f. projectionsarestronglydependentonassumptionsabouttechnologicaladvancesandpatterns of consumption. Over 800 million people are chronically undernourished today, particularly in the developing world, andmalnutritionisanunderlyingcause of childhoodmortality. Withfurtherpopulation growth, malnutrition may increase the vulneraJhty of these populations to endemic diseases and epidemics. Some areas may need to change crops, planting practices, and diet, further increasing vulnerability during the period of transition. Such regions might be helped by. advance warning of .conditions that might cause crop failures. Overall, : modelsprojecttheworldmay be abletoproduceenoughfoodtofeedfuture populations.. However, .changes in regional patterns of production could be significant, and in &e long term, nutritional security can only be ensured through education and training, higher incomes,  favorable market mechanisms, political stability, and population controls.

Fresh Water QuaZiv. and. Quantiv Great spatial' and temporal variability characterize water availablility. Climate change m y exacerbate such variations. Today 1 billion people lack access to clean and abundant drinking water, and even more are without adequate sanitation. Adjustments to .'water shortages can be managed where physical infrastructixe (reservoirs, pipelines, and canals) and water management institutions exist. Increasing populations dependent on limited sources served by isolated systems are at more risk. Landscapes may erode or' stabilize as precipitation alters vegetative cover, thus affecting runoff ,and transport of sediment and pollutants.

Air Pollution I .. ..

The sameindustrialprocessesthatproducegreenhousegases will alsoproduceincreased urban air pollutants, 'and they too can pose major health risks. Levels of fine particulates (from fossil fuels and. wood smoke) and ozone (from photochemical reactions) are known to be asocizted with highx !z: e! s of hss? itd admissions far respirzttoq diseases. Fine pahculates also appear to' be associated with admissions for heart 'disease and with general mortality. In the United States, where air pollution is relatively low .compared with Mexico City .and some Asian cities, it nevertheless contributes to 70,000 excess deaths and 1 million additional hospitalizations annually. In the firture, as globalincreasesinenergyproductionlead to higherlevels of particulates, andincreases in .. .. "

temper& nd ultraviolet radiation accelerate the reactions that produce ozone and other SecO pollutants, thehealtheffectsof air pohtion on aglobalscalecould bestaggering. E temperatures and humidity may also lead to higher concentrations of plant pollen and fungal s that cause allergic disorders such as asthma and hay fever.

Weather Disasters and Rising Sea Level

El Nifio is associated with increased rainfall and floods in some regions. Long term cli~ change over the entire planet may result in an increase in extreme weather events, such as &OUC_

floods, and cyclones. These events could increase the number of deaths and injuries and the incid;; of infectious diseases and psychological disorders, as well as causing indirect effects thou& f shortages and the proliferation of disease vectors. A 40 centimeter rise in sea level would approximately double the number of people who currently exposed to flooding each year in areas like Bangladesh. It could also contribute to the 1 of coastal and delta farmland, 3 in Egypt, and to the destruction of food supplies. Rising sea le also increases the vulnerability of costal cities, low lying areas, and small islands to damage duri storms.

Social and Demographic Dislocations ,

 Global ' climatechangewouldalterpatterns of employment, wealth distribution, ax populationsettlementthroughouttheworld. Physical. conflictsmight also ariseoverdeplete environmental resources such ds farmland, surface water, and coastal fisheries. Biodiversity woul also be affected (see Box 3). The greatest destabilizing effects would likely be experienced in areas c Africa which are dready highly vulnerable. At the same time,. populations may be moving out o L ' How climate change may affect health DIRECT EFFECTS IErDIRECP EFFEcrS 1 + Y ?

FIGURE 3. Ways in which global climate change may affect human health. (Adapted from IPCC, 1995)  i .. /

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tropicalandcoastal areas and into coolerwildernessareaswheretheywillbeexposedto new and 2.

Unfdar health threats. From anGther point of view, the difficulty of responding to global climate change lies in the rapid pace of the change the projected rate of change is greater than has occurred on earth in the p a t 10,000 years. Although it appears that some of the global climate .changes may be dealt with by the industrial world, adaptation will be more difficult in the developing world. The pace of global climate change may be complicated by an inadequate pace of institutional change. 8 POLICY IMPLICATIONS At the end of the first day of the conference, presentations were made on potential policy implications for health surveillance, diseaseprevention, andhealthprofessionaleducation. In addition, a special address was made by Briar@ twood, administrator of the Agency for International Development, on "Implication's for InternationalCooperation" ( seeBox 4). Thesepresentations served as background and introduction for the breakout and working group panel discussions that occurred on the second day; infomiation from those'presentations has been integrated into the panel reports that follow.

 Panel Reports The second day of the conference wak organized around six concurrent breakout and. working group panels that considered the policy implications of global climate change and human health. The six panels were: (1) Global Surveillance and Response, (2) Disease Prevention, (3) Education for the Medicaland Public HealthCommunities, (4) InternationalCooperation, (5 ) Researchand Development Needs, and (6) Public Outreach and Risk Communication. These panels were asked to work fiom the assumptionthatglobalclimate change would occur, and that its impacts on human health would be more or less as described in the foregoing ,

discussion. Working from .that assumption, the panels were charged with addressing. the question, .`` What do we do about it? ' That is, what, strategic actions could, and should, be taken to anticipate adverse health effects before they occur and to reduce or mitigate those effects when they do occur? In addition, the panels were asked to identify both short term (1. to 5 years) and long term (5  to 25 years) strategies. ..

The following summariesreflecttheindividual group chairs'sense .of theparticipants' discussion in their respective working groups, further illuminated by the material presented in plenary sessions on the ,.

.. .. .. . Global Surveillance and Response'

The emergence of new diseases and the reemergence of familiar diseases represent a seric threit to many regions and, indeed, .in a shrinking world, to the entire human species. In the f~ ru therefore, it will be criticaltohaveinplaceanintegrated, worldwidesurveillance and respon mechanism for emerging infectious diseases. The purpose of such a system would be to shorten t: timebetween the detectionofthefirst caseand theimplementation of effectivemeasures f treatment, prevention, andcontrol. To thedegreepossible, therefore, itshouldalso i n c h surveillance for the various changes in climate and environment that may provide early warning sigr of the possible outbreak of dxease. The vitalelements of suchasystemare( a) arapid and comprehensivecommunicatior network; (b) accurate, reliable, laboratory based diagnosis capabilities in host countries or region: centers; and (c) a mechanism for rapid response. The functioning of this system would also be aide by heightenedcooperation among nationalandinternationalhealthorganizations. In the end, th ,creation of an integrated, worlddde system to monitor the occunence and emergence of diseas could become the most important international health policy initiative of the twenty first century. The breakout panel reported that the most important problem in this area is the creation an(

maintenance of a critical mass of multidisciplinary expemse. Short term strategies to address thi: problem include personnel exchanges, cross training, a d the establishment of a Vice Presidentia Fellowship Program. Long Term strategies include the encouragement of multidiscipllllary training a The panel also endorsed earlier reports calling for the creation of an international consortium toaddressclimate relatedissuej: Onedifficulty in doingthisistheneedforpoliticalwilland interagency and global coordination. A short termstrategywouldlietocompiIeaninventory of existing resources and facilities that might become part of the effort, including sites and projects studying the environment and climate that could provide remote sensing data and other indicators for health surveillance. There was no consensus on which agency should serve as the focal point for this coordination within the United States, although the Centers for Disease Control and Prevention, the NAS, the IOM, and the interagency Committee on International Science Engineeringand Technology @art of NSTC) were offered as candidates. There was agreement, however, that the United States could not carry out this mission alone; it will be necessary to work with the resources, facilities, and Finally; the importance of global surveillance and response was discussed as being critical to national security because military forces might need to be deployed to virtually any area of the world on short notice. Knowledge of emerging diseases and their potential impact on rnih y operations is of great importance in the preparation of countermeasures to avoid such threats, riduce their impact, and provide a rapid response to outbreaks. levels of relevant fields.

. I institutions of other countries and international organizations. :

3 Dr. RuthBerkelman, deputydirector, NationalCenterforInfectious Diseases, Centers for Disease Control and Prevention, cochaired this panel and summarized their discussion and findings.

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S U M W Y OF THE PROCEEDINGS .. 17 Strategies (see also Table 3). I  Short term strategies: Create and maintain a critical mass of multidisciplinary expertise. Commission the NAS or the IOM to conduct a study of the problem.

Long term strategies:

' Encourage multidisciplinary training at all levels of relevant fields.

Disease Prevention4 The reemergence in the Americas of infectious diseases that had been controlled in the past, such as cholera, plague, and dengue, as well =@ e emergence of new infectious agents, such as Hanta and Guanarito viruses, E. coli: O: 157, and cgptosporidia, have had a direct impact on health policy and prevention efforts. Over the past several years, governmental and nongovernmental organizations have been working closely to modify health policy to place more emphasis on disease prevention. A majorconcern of theseeffortsarethechangingdynamicsofdiseasetransmission, which are . influenced by migration, land use, and environmental degradation.

any response will be flexible management within the health sector closest to the viherable population to allow it to adapt to changing patterns of disease. In addition, the wide impact of infectious diseases such as AIDS requires a policy of increasd intersectorial cooperation that is, there must be fluid and open communication and management of health problems among health, environmental, and agriculturalsections, supportedbycompetentresearchthat is basedoncarefulpolicyanalysis. Participants believed that policy reform, combined with broad public support gained by effective use of the mass media, will allow us to confront the health problepx caused by global climate change and environmental degradation. Policies for disease prevention and control usually involve three responses: (1) removal of the hazardousexposure, (2) earlydetection( andinvestigationoftheoccufrenceofdiseases), and (3) ,

treatmentandcontrolmeasures, such as prophylactic ther'dpy. Primarypreventionmightinclude vaccinating children or draining stagnant. pools where, mosquitoes breed. In dealing with the health effects of global climate bhange, however, it would require preventing and even reversing greenhouse warming itself. This kind of "preprimary" or `` primordial" prevention would be desirable but was beyond the scope of this conference. Nevertheless, there are still many actions that might be taken to mitigate the health effects ofglobalclimatechange, especially in terms of anticipating what those ,

effects will be and which populations are most at risk. ,Secondary prevention involves surveillance and early screening the collection, analysis, and dissemination of 'pertinent data and tertiary prevention involves responses plans and facilities for rapid diqposis and effective treatment to keep a disease from progressing. Secondary and tertiary Many lines of action are being examined as ways to prevent diseases. One' requirement for .

4Dr. Jonathan Patz, research& ociate, Johns Hopkins ichool of Public Health, cochairedthis . panel ahd summarized their discussionandfindings.. I BOX. 3. Ecology, Epidemiology and Climate Change'

Thomas E. Lovejoy  Smifhsonian Institution I Altered levels of greenhouse gases like C02 constitute an important environmental change by themselves in addition to those changes driven by thealteredlevels. Field studies of the effects of elevated COz on natural Communities are limited at this point. Bert Drake'stwo speciesmarshcommunityatthe Smithsonian Environmental Research Center the longest running field experiment shows that plants with a Cq photosynthetic pathway (e. g., a sedge) have a'definite competitive edge over % pathway species (e. g., a grass), Within a group of C4 or C3 plants, however, it is not possible to predict in advance how various species will respond to higher levels, of (2 0 2 . An initial study of part of a tree subjected to 2 months of elevated C02 in a Panamanian rainforest ledtoyellowing of its leaves andreducedphotosynthesis. It appears thattheexcessiveaccumulationof carbohydrates ' inhibits photosynthesis, with consequent high irradiation stress, photodamage, and loss ofchrdrophyll. The rest of the tree seems incapable of drawing off the excess photosynthates. This, is, of course, different from a treeexperiencing a coz increase occurringover yearsand decades or a tree thatgrows up in a high C02 environment. Of course, climate change willincludenotonly C02 elevation but also changes in temperature regimes, .rainfall, and other hydrologicalpatterns. There are almostnofield experiments yet that combine more than a single one of these factors. Nonetheless, it is clear from the above findings that it is a mistake to think of elevated C02 alone as a benign fertilizing factor for plants. Rather, it is importanttorecognizethatelevated C02 and associated climate change will instigate a cascade of effects that will ripple through natural communities withhard to en'visionepidemiological consequences. '

Paleoecologicalevidencerelating to. climatechange during glaciallinterglacial swings indicate rates of dispersal for plant species, especially trees, that are much slower (l/ lOth) than those projected by climate models. It is simply not known whether species couldmove faster. In addition, it is wellknown in NorthAmericaandEurope, and to a lesser extent in the less studied tropics, that biological communities disassembled during thoseclimate changes anddifferent species movedat differentratesand in different directions. Ultimately, species assembled in communities of differentcomposition. The implications for epidemiology are difficult to envision, although worrisome. . '

Climate change, whether human or naturally driven,. will take place in landscapes that have been highly modified by human activity. This ,will dramatically lower opportunities for dispersalandconsequentlygenerateconsiderableextinction of species that is, a reduction in biological diversity. , " What are the implications for human .health?. lt is hard to be precise ana to provide a. lot of detaif. Nonetheless, an .abundance of changing relationships between species will undoubtedly affect epidemiology. Some changes, of course, may bebeneficial, but the balance are likelyto be detrimental because weedy species such as white tailed deer will be favored overnonweedy species., It seems reasonable to anticipate epizootics and epidemics without any precedents. In addition, loss of biodiversity wi!! impoverish the potentialofbiotechnology to contribute to the wealth of nationsand willsimilarlydiminishthepotential of thelife sciences to contribute to human health, weaith, and well being.

*Excerpts from a special briefingat the Conference onHumanHealthandGlobal Climate Change, September I I , 1995. SUMMARY OF THE PROL DINGS 19 preventionstrategies are needed in. most if notallnations. However, thecreation of aglobal +.

surveillance and response capability will require unprecedented international 'collaboration, including ' a softening of the' traditional boundaries between sectors, agencies, and nations. Nongovernmental organizations and the media also have a important role to play in educating the population, without frightening them, and possibly changing some of theirmoredestructivebehaviors( see ' "Public Outreach and Risk Communication," p. 24). The breakout group recommended that prevention activities focus on anticipatory, rather than reactionarymeasures. It identifiedsixpriorityareasthatoverlapandincorporatethose of other breakout groups:

1. targeted, integrated nuveillance thatfocuses on transitionalzonesandvulnerable 2. changes in medical education that incorporate environmental health into curriculum and 3. international cooperation through information sharing and surveillance networks; 4. methodologicalresearch toevaluatepreventionandinterventionprogramsandto 5. public education and outreach aimed at policymakers as well as vulnerable popu lations,

6. public health inffastruchlre toconduct( a) researchand (b). vaccineand expome populations;

board u identify vulnerable populations, transition areas, and other risk factors;

especially children and the elderly; and reduction programs. .

e .

Strutegies (see also Table i . 3).

Short term strategies: Compile 'an inventory of existing resources and facilities to study the environment and climate that could provide remote sensing data'and other indicators for health, surveillance.

Long termstrategies: ' . Refocus or develop the public health infrastructure. ..

Education for the'hedical and Public Health Communities5 Despite increasing evidence that global climate change. and ozone depletion may have serious consequences for human health, there is little' understanding, both among policymakers; and the public, of the extent of this potential threat. Physicians and public health professionals should be central figures in helping to promote an understanding of the health effects associated .w i t h climate change, but they are by and large uninformed about the topic, as their education does not, .in general, cover the relationship o f global environmental change to h u m . healtin. I , ..

'Dr. Max Lum, director, Office of HealthCommunications, NationalInstitute of Occupational Safety and Health, cochaired this panel and summarized their discussion and findings.

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I . ,. CONFERENCE ON HUUdN fF I TH A flD GLOBAL CLIM TE CHANGE ,I Physicia, J, nurses, and other health professionals have a vital role. to play in responding tb the health effects of global climate change. At present, however, physicians donotreceiveadequate training in occupational and environmental medicine, much less in the medical problems arising from . global climate change, such as tropical diseases appearing in ternperature zones. In the United States, for exbple, although two thirds of medical schools include occupational and environmental hed& in their curricula, the average student receives only 6 hours of exposwe to these subjects over 4 years of study. The situation is somewhat better in schools of public health. Yet for both medical and public health students in the United States there is essentially no time available in the curriculum to address thepotential human healthconsequencesofglobalclimatechange. Formostprofessionalstheir principal source of information on global environmental health are articles in the scientific literature and conferences sponsored by nonprofit organizations. The breakout group agreed that health professionals should play a critical role in addressing the health effects of global climate change. The central questions panelists posed were (a) what do health professionals already know, (b) what do they want to know, and (c) what should they know. As a short term strategy, the group re3ommended that the IOM and NAS conduct a study to identify core competencies and training mechanisms in'the area of human health effects of global climate change, similar to a recent IOM study of environmental medicine (1995). Global climate and health issues should be incorporated into medical board exams, reflecting the importance of this subject for the training of physicians. The IOM and NAS might also broker efforts to promote faculty development in this area and to create centers of excellencein medical schools that would develop curricula in huinan health and global climate change. The group also recommended conducting a study to identify existing government and indytry progrzms that protect workers from the effects of ultraviolet exposure. Such an activity could also increase awareness of the h v d s of stratospheric ozone depletion. These effortsshould be cbordinated. withthose of professional, educational, andpublic service organizations. Health professionals should also help in developing educational materials and in presenting information to policymakers and the general public to help increase understanding of .' thehealthimplicationsofenvironmentalpolicies. Theseeffortsshouldincludethespecialneedsof populations such as migrant workers and minorities that might not have adequate access to health care information. In the long term, it will be important to monitor the effectiveness of these and other programs and, more importantly, to disseminate their results.

Strategies (see also Table 3).

Short term strategies: Y . Have the IOM or NAS conductastudy to identify corecompetencie$. andtraining mechanisms in thearea of globalenvironmentalhealth, similartoarecent IOM studyof environmentalmedicine. f Identify and study *existing government and industry programs designed to protect workers from the effects of exposure to the sun. ' . . ' / ,..,

BOX 4. Implications for international Cooperation* Brian Atwood U. S. Agency for lnfernafional Development

By workingclosely with ourdevelopingcountry partners, the U. S. Agency for International Development is able to facilitate the subtle but critically important changes that raise awareness of the threats of climate change andhelp to. shape preventative and responsive measures', Our work has informed other donors and encouraged them to invest in solutions we need. Developingcountries in particular are . on the precipiceofglobal environmental change. Theysoon will be the leading source of greenhouse gas emissions,, and the resultingclimate change will take a heavy toll on theircrowded coastal areas and fragile ecosystems. Theextraordinarybiologicalwealth of these countries is already threatened by poorly planned development that undercuts the natural capital they and we need for the future. 9 Energy consumption and one of its unwelcomeby products, pollution in the formof carbon emissions, are growing fastest in developingcountries and in countries whose economies are in transition. Developingcountries are also experiencingrapid rates of deforestation and ecosystem degradation, which 'eliminates a primary sink for, greenhouse gases. For example, over the last decade, 154 million hectares of tropical forests, equivalent to more than three times the land area of France, have been lost to other uses. The rate of that loss of biomass, especially in developing countries, is alarming. The resultingenvironmental degradations and misuse ofnatural .resources create opportunities for new diseases, or old ones, to takehold. We use the phrase "emerging diseases," yet for millions of people. the'new viruses have already emerged, and they have already claimed the lives of loved ones. The word" emerging" simply does not convey the urgency we sense. Only yesterday we were convinced that science had overcome the assault of these infectious diseases. Advances in antibiotic drugs, vaccines against childhood diseases, and improved sanitation technology all seemed to be winning the day. The incidence of polio, whooping cough, and diphtheria were declining. Fast acting antibiotics reduced the threat of meningitisandbacterialpneumonia. ' But we nowknow that our euphoria was premature. We did not take into account the extraordinary resilience of infectious microbes, which. have a remarkable ability to evolve, adapt, and develop resistance to drugs. Thus,. diseases that were once thought to be under control have reemerged. There are many of these reemerging diseases, andthey just do not' appear only in the developingwodd nowadays. We find them in NewMexico, in Minnesota, in Virginia, and in New York. Around the world there is a resurgence of cholera, malaria, and yellow fever, often in drug resistant forms. And of course, there is HIV and AIDS. We believe that global problems must be resolved at. the local level. We know that 'these efforts must be aided by new breakthroughs in science and technology. Investment in research is essential if we are to keep up with the effects of ecological change. The battles we must fight against new microbes, new forms of crop blight, the spread of desertification, new forms of pestilence, and the rapid population growth make research more important than ever. ;

VJa face'a dynamic, rapidly accelsr?! ing set of n w challenges, yet we are at risk of falling desperately behind the curve, as the changes we advertently and inadvertently introduce run far ahead of our resources and our knowledge base. Research is not like tap water. It cannot be turned off and on again without serious consequences. To be successful in these efforts,

Conjiriued 'Excerpts from remarks at the Conference on Human Health and Global Climate Change, September 11, 1995. 22 . . y.

CONFERENCE ONHUMANF. LTHAND GLOBAL CLIMATE c m c BOX 4. C otinued governments must continue their support Of t h e scientific community. This will require considerable efforts by federal agencies, by our university partners, and by nongovernmental organizations. The private sector is our natural partner. However, it does not cover the entire I t is dangerous to assume that the unfettered hand of Adam Smith will lead to the investments we need to deal with international health and environmental threats to the United States. That. will require a coherent and cost effective foreign assistance program backed by sound policies and global cooperation. We are uniquely placed as a nation to help the rest of the world meet these challenges. Our quality of fife in the next century will be determined in large measure by how we meet the global challenges of today. Science and technology give u s t h e tools we will need to meet the challenges of tomorrow. a spectrum of research.

%

3 Long term strategies: Monitortheeffectivenessoftheseandotherprogramsand, moreimportantly, dissem

Incorporate questions about climate related health issues on medical board examinations. inate their results.

 International Cooperation6 Global climate change is .bqlieved to cause a wide variety of deleterious effects including desertification, changes in agricultural patterns, and disease. These effects are both direct and indirect, and the causes may be either nahiral or manrnade. TO the extent that global climate change and its impacts are influenced by human activity, methods must be found to mitigate, adapt to, or respond to them. The U. S. govemment 3s obligated to exercise leadership at home and abroad to ensure that responses are appropriate and timely. .Every human being is vulnerable to the effects, of global climate change, but the citizens of developing countries and regions face the most immediate dangers. In those areas, both climatic change and the need for responses to it 'may be greatest, but the available resources for addressing .' them is most limited. Clearly, thepreventiveandresponsivemeasuresweusetodealwith global climate change and its effects must involve every affected person .and operate society wide. The breakoutpanelreportedthatmany of thenecessarysystems . andnetworksfor . internationalcooperationarealreadyin place theUnitedNationsEnvironmentalPrQgrarnme, the World Health Organization, UNICEF, and networks of collaborating centers. WhaGis required is improved coordination among existing systems to place the health effects of global climate change on their respective agendas and to ensure a two way flow of information among them. The panel found a particular need to . improve'. thelinksbetweenagenciesandorganizationsthatconductclimate forecasting, health planning, health surveillance, and the implementation of health pro, gniis.

I I I 6 Dr. Rudi Slooff, Division of Environmental Health, World Health Orgkization, cochaired this panel &d summariz. ed their discussion and findings. , . ,/ I \

' . .4 . S U M M Y OF THE PROCi?, JNGS 23 One short term strategy would be to incorporate health effects monitoring and reporting into existingglobalclimatechangeactivities, such as theFrameworkConvention on ClimateChange $o g m and the Uiited Nations sponsored,". Climate Agenda." Another strategy would be to look for the health effects of global climate change in the information already gathered for the ongoing U. S. Country Study Program. These efforts will be ineffective, however, unless they are accompanied by increased efforts to provide relevant infomation to national and international policymakers. In the long term, the panel recommended that global climate change and health issues be incorporated into sustainable development planning, not only by individual nations, but also by the World Bank, the United Nations Development Program, the Food and Agriculture Organization, and similar organizations. By the same token, health and climate planning should be broadened to include "

related environmental issues such as biodiversity. This, in turn, requires that stakeholders have better accessto the information gathered, analyzed, anddisseminatedbytheglobalsurveillancesystem discussed by other breakout panels. .3 Strategies (see also Table 3).

Short term strategies: Incorporatehealtheffectsmonitoringandreportingintoexistingglobalclimatechange Look for the health effects of global climate change in the information already gatherzd programs.

for other programs.

. Long termstrategies: Incorporate, globalclimate . changeandhealth . issuesintosustainabledevelopment planning, not only by individualnations, butalsobytheWorld Bank, theUnitedNations Development Program, the Food and Agriculture Organization, and similar orgapizations.

. Broaden health and climate planning to include environmental issues such as biodiversity.

Research and Development Nee& '

Rather than enumerate the many specific research topics that need to be addressed,. the breakoutpanelemphasizedtheneed for, an integrated, interdisciplinary R& D program that will encourage collaboration among experts and. organizations from a wide range of fields and disciplines. Achieving this will probably require a concerted effort to overcome the boundaries that Currently ieparate scientificdisciplines, researchinstitutions, budgetaryprograms, h d i n g agencies, and internationalsponsors. IntheUnitedStates, forexample, fundingwouldprobablycome from a consortium of federal agencies rather than from a series of small, fragmented programs. The researchproblemsaddressedbythisprogramshouldincludeclimaticvariationsthat already pose health risks, as well as future effects of global climate change.

..

'Dr. David Rall, foreign. secretaq, Institute of Medicine, cochaired this panel and summarized their discussion and. findings.

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CONFERENCE ONKUMAN HEALT 1~~ GLOBAL CLIMATE CHANGE 24 Strategies (see also Table 3).

Short term strategies. In the short term, the panel proposed that the program undertake pdot projects involving c a e studies that integrate three sets of variables:

1. infectious diseases (e. g., cholera, dengue, malaria, and Lyme disease); 2. mechanisms ufmcqtibilily (e. g., W B and immune suppression, fine pdcdates, and 3. global change driyers that might exacerbate or mitigate these problems (e. g., population cardiovascular or pulmonary disease); and growth, economic development, and urbanization).

 Possible models for these case studies are the Technical and Scientific Assessment and the United Nations Intergovernmental Panel on Climate Change. The case studies themselves could be performed by international organizations,$ y private groups, or by the IOM or NAS. .

Long term strategies. The long termgoals of thisprogram wouldbeto identify andaddressgaps in current ..

knowledge, and to disseminate and apply the lessons learned from the case studies;

Public Outreach and Risk Communication`

Despite a wealth of scientific &dies and technical information, the general public is not well informed on the relationship between global climate change and human health. Several participants made the analogy to the difficulties of informing the public about the dangers of nuclear war: Such information is highlytechnical, far' removed from thecommonexperience, disconcerting to contemplate, and often undermined by a vocal opposition. AS a result, the first step in any outreach campaign. would be to. assess the information( anddisinfonnation) that is alreadyavailable to determine what further steps might be appropriate. The breakout panel endorsed the principles of risk communication that are embodied in the 10 step strategy outlined in Table 2. The primary long term goals ofihis strategy are (1) involving the public by encouraging awareness' and discussion, and (2) building .bridges between the medical and environmentalcommunities. In bothcases, the panelrecommended working through existing nemorks and infrastructures, initially targeting opinion leaders but making use of the full range of formal and informal intermediaries to reach broader audiences not only churches ana newspaper eilitors, `for example, but also Boy/ Girl Scouts andtelevisionweathemeri, as well as medical associations, senior citizens' aisociations, and schools.

. Dr. William Farland, director, National Center for Environmental Assessment, Environmental 8 Protection Agency, cochaired this panel and summarized their discussion and findings.

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S U ~~R Y OF THE PROCET {V G ~ r?

TABLE 2. Developing a Risk Communication Strategy for Global Climate Change 25 Step 1:

Step 2:

, Step 3:

Step 4:

Step 5:

Step 6:

Step 7:

Step 8:

Step 9: .Review background information. (What messages are already out there?)

Set communication objectives. (What do we want to accomplish?) Example: Increase public awareness about the public health implications of global climate change.

Analyze and segment target audiences. (Whom do we want to reach?) Example: Construct communications based on audience attitudes.

Develop and pretest message concepts. (What do we want to say?)

Select communication channels. (Where do we want to say it?)

Create and pretest messages and produd'. (How do we want to say it?)

Develop a promotion plan. (How do we get it used?)

Implement communication strategies and conduct a process evaluation. (Let's do it!)

Conductoutcomeandimpactevaluations. (How well did we do?) . ..

Step 10: Feedback to improve communication effectiveness. (Wheredowe go from here?)

Strategies (see alsoTable 3). The panelideritifiedthefollowingshort termactionitems, which might serve as the foundation for long term efforts: ...

Identify, contact, . andinfuseexistingnetworkswithhealth. concernsrelatedtoglobal climate change. Use these networks as a feedback mechanism to find out what further information the public or needs. t Distilltheinformationgenerated by thepresentconference for dissemination through joumal articles, editorials, op edpieces, targetedbrochures, publicserviceannouncements, informational videos, or a home page on the World Wide Web.

. Establish a volunteer group or fonun to continue the communication activities suggested or actually begun during the present conference. Develop a response capability to counter disinfomtion.

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.I .. ..

.... ." .. Participants voiced a clear message throughout the conference: Changes in global climate their efforts would help mobilize opinion and action toward the implementation of strategies that would occur 'as far "upstream" as possible. '

Confermce participants identified and described a number of'actions that could be taken to address these potential threats. These strategies are summarized in Table 3 and share certain common threads: e would pose substantial risks to h k a n health, both in the near andlong term. They also hoped that 'identify and work with existing resources, facilities, networks, and information; encouragegreatercoordination and collaboration amoqg relevantorganizations,

create from these institutions and funding sources an integratedworldwidenetworkfor support multidisciplinaryresearchtodeterminelinkagesamongglobalclimatechange,

provideappropriatetraining for researchers and healthprofessionals, includingthe establishinformation and outreachprograms.  disciplines, nations, and funding agencies;

surveillance and response to indicators o@ lobal climate change and emerging diseases;

food production, and human health;

creation of centers of excellence and the enhancement of faculty; and . 0 E a 3 c a *

d a   c c 27 i I  i References and Further Reading I The interestedreadercan find more detailedinformationaboutthetopicscovered by &is conference by referring to the following publications:

Centers for Disease Control and Prevention. 1994. Addrasing Emerging Infectious Disease Threats: A Prevention Strategy for the United Stata. Atlanta: CDC. Chivian, Eric, Michael McCally, Howard Hu, and Andrew Haines (eds.). 1993. CriticaZ Condition: Human Health and the Environment. Cambridge, MA: MIT Press. CISET( Committeeon International. Science, Engineering, andTechnology) WorkingGroup on Emerging and Re emerging Infectious Diseases. 1995. h. fectious Diseme: A Global Health Threat. Washington, DC: National Science and Technology Council. Epstein, Paul R 1995. Course Reader: Global Climate Change, Ecology and Public Health. Prepared for the NSTC IOM Conferencan HumanHealthandGlobalClimateChange, 11 12 September 1995. IOM (Institute of Medicine). 1995. Environmental Medicine: Integrating a Missing Element into Medical Education. Andrew M. Pope and David L. Rall (eds.). Washington, DC: National Academy Press. IOM. 1992. EmergingInfections: MicrobialThreats to HealthintheUnitedStates. Joshua Lederberg, Robert E. Shope, andStanley C. Oaks, Jr. (eds.). Washington, DC: National Academy Press. IPCC (Intergovernmental Panel on Climate Change). 1995; Climate Change 199.5: Impacts, Adapta tions andMitigatiun of ClimateChange: Scienhpc Technical Anabsa. Contribution of WorkingGroup I1 to theSecondAssessmentReportoftheIntergovernmentalPanelon ClimateChange. . Watson, R. T.; .M. C. Zinyowera, and RH. Moss (eds.). ' Cambridge: CambridgeUniversityPress. . McMichael, Anthony J. 1993. Planetary Overload: Global Environmental Change and the Health of the Human Species. Cambridge, UK: Cambridge University Press. Michael, E., and D. A. P. Bundy. 1995. The global burden of lymphatic filariasis. In: World Burdei of Diseases. C. J. L. Murray and A. D. Lopez (eds.). World Health Organization, Geneva. NationalResearchCouncil. 1989. Improving Risk. Communication. ' Washington, DC: National Academy Press. UnitedNationsEnvironmentalProgram. i994. Environmenful Efects of OzoneDepletion: 1994 Assessment. Nairobi, Kenya: UNEP. Wilson, Mary Elizabeth, Richard Levins, and Andrew .Spielman (4s.). 1994. Diseuse in: Evolution: Global Changes and Emergence of Infectious Dbeam. Albany: NewYork Academy of Sciences. WHO (World Health Organizkon). In press. ClimateandHeaith iri a Changing World. Geneva: WHO. WHO. Ant'lmny J. Mc? kichsd st d. .(&.). i n press. Human Hea! th and Global Climate Change. Geneva: WHO. WHO. 1995. Action Planfor Malaria .Control 1995 2000. Unpublished document. ' WHO. 1995. Chaga. sDisease: Important Advances in Elimination of Pansmission in Four Countn'es 28 .,

in Latin America. WHO Press Office Feature No. 183, Geneva: WHO.

\

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.REFERENCESAND FURTF' . ~~ EADING WHO. 1994. Progress Report Control document. . ,/ ' ...

29 of Tropical Diseases (CTD/ MIP/ 94.4). Unpublished ,WHO. 1990. Potential Health Eflects of Climatic Change. Geneva:. WHO.

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APPENDMA ,/ ' .

 National Science and Technology Council (NSTC) Sponsoring Members, Interagency Working Group, Institute of Medicine @OM) Steering Committee, and Staff NSTC SPONSORING MEMBER AGENCIES Centers for Disease Control and Prevention National Science Foundation Environmental Protection Agency .4 . Pan American Health Organization National Aeronautics and Space U. S. Department of Agriculture Administration U. S. Department of Defense National Institutes of Health U. S. Department of Energy. ~,

National Oceanic and Atmospheric U. S. Global Change Research Program Administration U. S. A g e n c y f o r International . .

Development . '

. NSTCINTERAGENCY WORKING GROUP Maurice Averner, Advanced Life Support, Life and Biomedical Sciences and Applications Division, National Aeronautics and Space Administration, Washington, DC Lois Beaver, Office of Extemal Affairs, Food and 'Drug Administration, Rockyille, MD Rosina Bierbaum, Environment Division, Office of Science and Technology Policy, Executive Office of the President, Washington, DC ,

Jim Buizer, Office of Global Programs, National Oceanic and Atmospheric Administration, Silver Spring, MD Dennis Carroll, Office of Health and Nutri tion, Agency for International Development, Washington, DC Jack C.. Chow, Division of International Relations, Fogarty International ..

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.. . . . ~ ' .. .. .. .. . ~. .. Center, National Institutes of Health, Bethesda, MD Robert' Corell, Geosciences Division, .. National Science Foundation, Arlington, VA ..

Jackie Dupont, Agricultural Research Service, U. S. Department of Agriculture, Beltsville, MD Elaine Esber, Center for Biologics Evalua tion and Research, Food and Drug . Administration, Rockville, MD Gary Evans, Office of the Secretary, U. S. Department of Agriculture, Washington, DC Mike Finley, Office of External Relations, 'Pan American Health Organization, Washington, DC Karen Gallegos, Office of Global Programs, U. S. Department of State, Washing ton, DC . ..

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31 ..

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. .. .. .. _. . .: ,:. Luiz Galvao, Division of Health and Envi  ronment, Pan American Health Organization, Washington, DC Mary GantYNational Institute of Environ mental Health Sciences, National Institutes of Health, Bethesda, MD Ann Grambsch, Climate Change Bureau, Office of Policy, Planning, and .

Evaluation, Environmental Protection Agency, Washington, DC Duane Gubler, Vector Borne Infectious Diseases Division, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Fort Collins, CO 3 Debbie Hanfman, Science Division, Office o f Science and Technology Policy, Executive Office of the President, Washington, DC cal Research and Materiel .. Command, Ft. Detrick, MD Carla Kappell, Office of Energy, Environ Col. Jerry Jam, United States Amy, Medi

ment, and Technology, Burequ of Global Programs, Field Support, and Research, Agency for International Development, Washington, DC Hiram Larew, Office of Policy and Evalua tion, Agency for International Development, Washington, DC Orville Lavander, Nutrient Requirements and Functions Laboratory, Agricultural Research Service; U. S. Departkent of Agriculture, . '

Beltsville, MD nology and Health, U. S. Department of State, Washington, .DC Ed Malloy,, Office of Science, Technology, and Hea1th; U. S. Department of State, Washington, DC . ' . Alexandra Leviti, Office of Science, Tech

., ,. .

.. .. . .. .. .. .. :. q Patrick McConnon, Centers for Disease Control and Prevention, Atlanta Mike McCracken, US. Global Change Research Program, Washington, DC Roscoe M. Moore, Development Support and African Affairs, Office of. International Health, U. S. Department of Health and Human Services, Rockville, MD Jonathan Patz, Johns Hopkins School of Public Health, Environmental Protection Agency, Office of Policy, Planning, and Evaluation, Climate Change Division, Washington, DC Karen Peterson, Division of ,International Relations, Fogarty International Center, National Institutes of Health, Bethesda, MD Hemah Rosenberg, Office of External Re

' lations, Pan American Health Organization, Washington, DC David Sandalow, Council on Environmental Quality, Executive Office of the President, Washington, DC Joel Scheraga, Climate Change Bureau, Office of Policy, Planning, and Evaluation, Environmental Protection Agency, Washington, DC Artie Shelton, Office of Allergy, Immunol ogy and Oncology, U. S. Department of Veterans .Affairs, Washington, DC Phillip L. Sims, Agriculture Research Ser

 vice, U. S. Department of  ,

.Agriculture, Beltsville, MD Anthony Socci, U. S. Global Change Re search Program, Washin$ on, DC Macol Stewart, Office of Global Programs, National Oceanic and Atmospheric Administration, Silver Spring, MD Col. Ernie Takafkji, U. S Army Medical Research Institute for Infectious Diseases, Fort Detrick, MD ,.

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33 David Thomassen, Office Health and Envi ronment Research, Office of Energy Energy, Washington, DC Beth Viola, Council on Environmental Quality, Executive Office of the President, Washington, DC I Research, U. S. Department of Robert Watson, Environment Division, Office of Science and Technology Policy, Executive Office of the President, Washington, DC Catherine Woteki, Science Division, Office of Science and Technology Policy, Executive Office of the President, Washington, DC INSTITUTE OF MEDICINEBIATIONAL ACADEMY OF SCIENCES STEERING CO" 3[ TTEE David P. Rall (Chair), IOM foreign secretary; ad director (Retired), National Institute of Eric 'Bq on, Earth System Science Center, Pennsylvania State University, University Park, PA; Environmental Health Sciences, Washington, DC Board on Atmospheric Sciences and Climate Boston; Board on Health Sciences Policy .

Medicine, Mount Sinai School of Medicine, New York City; Board on Sustainable Development Research Board . Deborah Cotton, assistant professor, Infectious Disease Unit, Massachusetts General Hospital,

Philip J. Landrigan, Ethe1. H. Wise, professor and chairman, Department of Community .

Diane M. McKnight, US. Geological Sury~ y, Water Resources Division, Boulder, CO; Polar INSTITUTE OF MEDICINENATIONAL ACADEMY OF SCIENCES STEERING COMr$ ITTEE ..

Bill Colglazier, executive officer, National . Loren Setlow, director, Polar Research Academy of Sciences, 'National Re Board, National Academy of search Council ' .  Sciences Linda DePugh, administrative assistant, , Valerie Setlow, director, Division ofHealth' Division of Health Sciences Policy, Sciences Policy, Institute of Institute of Medicine , Medicine Division of Health Sciences Policy Medicine Human Health and Global Climate Change, Kenneth Shine, president, Institute of Karen Hein, executive officer, Institute of William Sprigg, 'director, Board on Atmo

John Perry, staff director, Board on Sus David Westbrook, manager, Federal Con I .. Medicine spheric Sciences and Climate, David tainable Development, National tracts, National Academy of Sci ,nces Academy of Science .. National Academy of Sciences Rosina Bierbaum, senior policy analyst Brett Orlando, intern _.

Jason Randall, intern Robert Watson, associate director for environment I Jack Gibbons, assistant to the presidentforscience and technology J ...

.$ . .. a .

APPENDIX B Conference Agenda Conference on Human Health and Global Climate Change The National Science and Technology Council, the Institute of Medicine, and the National Academy of Sciences September 11 12, 1995 National hademy of Sciences Main Auditorium 2 1 0 1 Constitution Avenue, N. W. Washington, DC 2041 8 AGENDA MONDAY. SEPTEMBER 11.1995 7: 30 9: 00 aim. . REGISTRATION . ' 9: OO 9: lO a. m. WELCOMING REMARKS .

Kenneth I. Shine, M. D. ..

President, Institute of Medicine John H. Gibb0ns; Ph. D. Assistant to the President for Science and Technology ' .. ..

9: 10 9: 50 a. m. PANEL I: OVERVIEW . .

Kenneth. 1. Shine, M. D. (Chair) President, Institute of Medicine n e Science and Impacts of Climate Change and Ozone Depletion Associate Director for the Environment, Office of Science and Technology Policy, Executive Office of the President , ' Robert Watson, Ph. D: . .

Climate Change and Human Health Risks  Anthony McMichael, Ph. D. Professor of Epidemiology, London School of Hygiene and Tropicai Mehcine 950 10: lO a. m QUESTION AND ANSWER SESSION .. : J U L WNFERENCE ON iiVMN HEALTH ANI) GLdBAL CLh4. i TE CHANGE i "

10: 10 11: 10a. m. PAP. 11: CLIMATE CHANGE AND INFEC? .JS DISEASES Mar, A. Wilson, M. D. (Pond (3ilair) Assistant Professor, Hiward University Vector Borne Diseases  Duane Gubler, Sc. D.

' Centers for Disease Control and Prevention Emerging and Reemerging Di. wuycs Steven Morse, Ph. D. Assistant Professor Of Virology, Rockefeller University 11: 10 12: OO p. m. QUESTION AND ANSWER SESSION 12: 00 12: 30 p. m. LUNCH (Provided in the @rent Hall)

12: 30 1: OO p. m. SPECIAL BRIEFING El Niiio: Analogue for Long Tt` m Climate Change J. Michael Hall, Ph. D. Director, Office 0fGloba. I Progrinls, National Oceanic and Atmospheric Administratzn Paul Epstein, M. D., M. P. H. Harvaxd Medical School ,

1: OO 1: 30 p. m. PANEL 111: DIRECT HEALTH EFFECTS FROM CLIMATE CHANGE AND OZONE DEPLETION Terri Damstra, Ph. D. (Pmel c'ltojr) . Deputy Director, National Institute of Environmental Health Sciences Climate Change and Heat Srr~.~.~ Larry Kalkstein, Ph. D. Professor of Geography, Univ. er; ity of Delaware 1: 30 2: 00 p. m. QUESTION AND ANSWER SESSION c .. . ,I APPENDXB 2: OO 2: 45 p. m. PANEL IV: INDIRECT HEALTH EFFECTS OF CLIMATE CHANGE . ,. ' 37 '

Andrew Haines, M. D. (Panel Chair)

8  Professor of Primary Care, Universityof London MedicalSchool Impacts on Nubitional Health David Oot, Ph. D. Director, Office of Nutrition and Health, United States Agency for International Development Impacts on Fresh Water Quality and Quantity Reds Wolman, Ph. D., M. A. Professor of Geography, Johns Hopkins University 2: 45 3: 15 p. m.

3: 15 3: 30 p. m.

3: 30 4: 00 p. m. I 4: 00 4: 30 p. m.

4: 30 5: 15 p. m.

. Impacts on Air Quality Joel Schwartz, Ph. D. Professor of Environmental pdemiology, Harvaxd University QUESTION AND ANSWER SESSION COFFEE BREAK  .

SPECIAL ADDRESS Implications for International Cooperation Mr. J. Brian Atwood Administrator, United States Agency for International Development INTRODUCTION OF KEYNOTE SPEAKER John H. Gibbons, Ph. D. Assistant to the President for Science and Technology KEYNOTE ADDRESS The Interplay of Climate Change, Ozone Depletion, and Human Health ,

Albert Gore, Jr., Vice President of the United States PANEL V: POLICY IMPLICATIONS Anne Solomon, M. P. A. (Panel Chair) . .

Deputy Assistant Secretary for Science, Technology and Health, Cepartment of State Implicationsfor Global Health Suheillance and Response Stephen Joseph; M. D., M. P. H. ' Assistant Secretary for Health Affairs, Department of Defense Implications fo; Disease Prevention Sir George A. O. Alleyne, M. D. Director, Pa0 American Health Organization 1

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._ . Inrylications for Education in the Medical and Public Health Communities Eric Chivian, M. D. Chair,. Physicians for S. ocial Responsibility a 5: 15 5: 45 p. 15 QUESTION AND ANSWER SESSION 5: 45 6: 00 p. m. WRAP U p , INSTRUCTIONS FOR THE NEXT DAY 600 p. m. ADJOURN ..

6 1 .5 p. m. RECEPTION GREAT HALL TUESDAY, SEPTEMBER 12.1995 7: OO 8: OO a. m. CONTINENTAL BREAKFAST NAS GREAT HALL 8: 0019: 00 a. m. BREAKOUT SESSION& OCHAIRS CONVENE TO DISCUSS GOALS AND STRATEGIES 9: OO 9: 15 a. m. MORNING PLENARY Charge to Breakout Groups Bernard Goldstein, M. D. (Chair)

9: 15 1230 p. m. BREAKOUT GROUP SESSIONS *,

GROUP 1: IMPLICATIONS FOR GLOBAL HEALTH SURVXILLANCE AND RESqONSE .Ruth Berkleman, M. D. (Government Cochair) Deputy Director, National Center for Infectious Diseases, Centers for Disease Control and Prevention Demise Habte, M. D. (Nongovernment Cochair) `Director, Centre for Health and Population Research GROUP 2: IMPLICATIONS FOR DISEASE PREVENTION ,. Sheila Newton, Ph. D. (Government Cochair) Coordinator for Environment, Disease Prevention and Health Promotion, Department of Hedth agd Human Services . J.

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' Jonathan Patz, M. D., M. P. H. (Nungovernment Cochair) _ Johns Hopkins University .. APPENDLXB GROUP 3: IMPLICATIONS FOR EDUCATION OF THE MEDICAL AND PUBLIC HEALTH COMMLMlTIES  Max Lum, Ed. D., M. P. A. (Government C h a i r ) Director, Office of Health Communications, National Institute of Occupational Safety and Health Bernard Goldstein, M. D. (NongovernmentCochair) '

Chair, Department of Environmental and Community Medicine, Robert Wood Johnson School of Medicine GROUP 4: IhlPLTCATIONS FOR INTERNATIONAL COOPERATION Rafe Pomerance (Government Cochair) Deputy Assistant Secretary fo the Environment ind Development, State Department d Rudi Slooff, Ph. D. (Nongovernment Cochair) .Division of Environmental Health, World Health Organization 39 GROT" 5 : IMPLICATIONS FOR RESEARCH AM) DEVELOPMENT NEEDS Robert Corell, Ph. D. (Govehment Cochair) Chair, Subcommittee on Global Change Research and Development, United States Global Change Research Program '

David P. Rall, M. D., Ph. D. (Nongovernment Cochair) Foreign Secretary, Institute of Medicine GROUP 6: IMPLICATiONS FOR PUBLIC OUTREACH AND RISK

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COMMUNICATION Bill Farland, Ph. D. '( GovernmehtCochair) . .. Director of National Center for Environmental Assessment, Environmental Protection Agency Thomas Malone, Ph. D. ( NingovernmentCochair) .

Director of Sigma Xi Center's Human Development Program 12: 30 1: OO p. m. LUNCH (PROVIDED IN THE GREAT HALL)

1: OO 1: 30 p. m. SPECLAL ADDRESS Biodiversity, Climate Change, and Human Health Thomas Lovejoy, 'Ph. D. Counselorto the S ~C T C W ~ for Biodiversity and Environmental hiairs, Smithsonian Institution .. / ,I!

40 x, CONFERENCE ONHUM HEALTH% GLOBAL CLIAZATE CHANGE 1: 30 3: 30 p. m. ' CLOSING PLENARY _.

Bernard Goldstein, M. D. (Plenary Chair)

Robert Wood Johnson School of Medicine Breakout group Cochairs report on strategies for addressing potential health effects of global climate change developed during their discussions.  Chair, Department of Environ.& ental and Community Medicine,

3: 00 4: 00 p. m. OPEN DISCUSSION 4: OO p. m. ADJOURN ., ,. . .. . .. ..

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APPENDIX C I

Speakers, Authors, Chairs, and Conference Registrants SPEAKERS George A. O. Alleyne Bernard Goldstein Director Pan American Health Organization 4 Director J. Brian Atwood Administrator ,

United States Agency for International Development Eric Chivian Physicians for Social Responsibility .;

Rita Colwell President American Association for the Advancement of Science Teni Damstra Acting Deputy Director International Programs '

National Institute of Emironmental Health Sciences.

Paul Epstein. Harvard Medical School .

, , John H. Gibbons Assistmt to the President for Science' and Technology ..

 Environmental &d Occupational Health Sciences Institute UMDNJ Robert Wood Johnson Medical School Albert Gore, Jr;  Vice President .

United States of America Duane Gubler .Director Division of Vector Borne Infectious Diseases Ceniers for Disease Control and Prevention,

Demisse Habte Director Centre for Health and Population Research ., Andrew Haines : Professor of Primary Care University of London Medical School ,

J. Michael Hall Director Office of Globs1 .Progms National Oceanic &d Atmospheric Administration 41 ..

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.. ,. . . . .~, . Stephen Joseph Assistant Secretary for Health Affairs U. S. Department of Defense Larry Kalistein Department of Geography University of Delaware Margaret Kripke Department of Immunology Anderson Cancer Center Thomas E. Lovejoy Secretary for Biodiversity and Environmental Affairs Smithsonian Institution Max Lum Associate Director for Health Communications .

National Institute for Occupational Safety and Health 9 Anthony McMichael Department of Epidemiology and  Population Science London School of Hygiene and Tropical Medicine Steven Morse Associate Professor `Rockefeller University David Oot Director Office of Nutrition and Health United States Agency for International Development I . Ari Patrinos Associate Director Office of Health and Environmental Research U. S. Department of Energy David Rall Foreign Secretary Institute of Medicine Joel Schwartz Associate Professor Environmental Epidemiology Program Harvard University School of Public Health Kenneth I. Shine President Institute of Medicine Rudi Slooff Division of Environmental Health  World Health Organization Anne Soloman Deputy Assistant Secretary of Science Technology and Health US. Department of State Robert Watson Associate Director for the Environment Office of Science and Technology Policy Executive Office of the President Mary E. Wilson Assistant Professor Himaid University P p M. Gordon "Reds" Wolman Professor of Geography Johns Hopkins University " . ,/ I ".. ,/ APPENDX C , 43 John M. Balbus Kornfeld ' Assistant Professor of Medicine George' Washington University Ann Bostrom School of Public Policy I Georgia Institute of Technology Eric Chivian Assistant Clinical Professor Department of Psychiatry Harvard Medical School Paul R. Epstein Professor The Cambridge Hospital Harvard University Medical School Duane Gubler Director Division of Vector Bourne Infectious Diseases Center for Disease Control and Prevention' 19 r .. AUTHORS James A. Harrcli Deputy Director Office of Disease Prevention and Health Promotion' Public Health Service .I Hiram Larew Policy Specialist Agency for International Development Jonathan A. Patz Research Associate Johns Hopkins School of Public Health Warren T. Piver Adjunct Professor National Institute of Environmental Health Sciences Marla Salmon Director Division of Nursing Department of Health and Human Services Rudi Slooff ..

Division of Environmental Health World Health Organization '

Tim Tinker . ..

Health Education Specialist Agency for Toxic Substances and Disease Registry I .

Continued CHAIRS Ruth L. Berkleman Deputy Dkector National Center for Infectious'Disease Centers for Disease Control and Prevention I Robert W. Core11 Subcommittee on Global Change Research and Development U. S. Global Change Research Program Terri Damstra Acting Deputy Director International Programs 3 National Institute of Environmental Health Sciences William H: Farland Director National Center for Environmental Assessment Environmental Protection Agency '

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Bernard D. Goldstein Director Environmental and Occupational Health Sciences Institute .

Robert Wood Johnson Medical School . Demisse Habte Director Center'for Health Population Research Andrew Haines Professor of Primary Health Care University College of Middiesex Max Lum Director , .

Office of Health Colmuications National Institute of Oc'cupational Safety and Health Thomas F. Malone. ,

.. Founding Director The Sigma Xi Scientific Research Society Sheila A. Newton Coordinator for the Environment Office of Disease Prevention and Health Promotion, Public Health Service Jn .  +7 :alth Lb ". /'

Foreign . . 0 .q , . '\

Institute of Medicine

Kenneth I. Shine President ,'

Institute'of Medicine Anne K. Solomon j ' '

Deputy Assistant Secretary for Science, Technology and Health U. S. .Department of State Rudi Slooff . . ~.

Division of Environmental Health World HealthOrganization .

Mary E. Wilson Assistant Professor Harvard University . Y p Colin L. Bradford, Jr. Agency for International Deveiopment  Lynn Bradley '  I Association of State and Territorial Health Officers David Brandling Bennet Pan American Health Organization Bryna Brennan Pan American Health Organization Mary J. Brooks Greencool .

Allen Buckingham American Association of Retired Persons .. Jim Buizer National Oceanic and Atmospheric Administration Joy E. Carlson Children's Environmental Health Network Gregory R. Carmichael Center for Global and^ RegionalEnvironmegt '

Fran Cm' Agency for International ' Development t I . ..

1'

MichaelD. Carr , . ,

U. S. Department of Interior ..

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,. ..  . _..~ .. .... ... ..  . . , , . .: i 1 '_  , ... ........ ..... ....... " . . .. .... .. .. . .~ .. ... ................... .. ... .. Wiiline can Grantmakers in Health Dennis Can011 Agency for International Development James C. Cecil The Pentagon D. W. Chen '

Health Resources and Services Administration Shoulquan Cheng University of Delaware Mary Ann Childs Universal Healthwatch, Inc.

Eunyong Chung U. S. Agency for International Development Christopher Chyba Princeton University Eric Chivian Harvard University Medical School David L. Clark University of Wisconsin, Madison " .

Emery T. Cleaves Geological Society of America Daniel G. Colley Cezters foT Disease Control and Prevention Rita R. Colwell University of Maryland Nugent Conn ,Liberty Tree Alliance Elizabeth Cook World Resources Institute Leslie B. Cordes Agency for International Development Anthony Cortese Consortium for Environmental Education in Medicine Robert W. Core11 U. S. Global ChangeResearch Program Lisa Cruz Avalos . .

Nurse Consultant Owen Cylke Tata Energy and Resources Institute John Daly Agency for International Development Tem Damstra National Institute of Environmental He4lth Sciences i David Danzig Sierra Club ..

......... Lora E. Fleming University of Miami Dana A. Focks US. Department of Agriculture Loren B. Ford Environmental Protection Agency Michael Fosberg U. S. Department of Agriculture, Forest Service Marvin Frazier U. S. Department of Energy Kenneth Frederick Resources for the Future Clifford' J. Gabriel American Institute of Biological Sciences Ashok Gadgil Lawrence Berkeley National Laboratory Steven K. Galson, Environmental Protection ..

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. Agency .

Mary M. Gant National Institute of Environmental Health ' Sciences t i David Gardiner Environmental Protection Agency Bronsoh Gardner Global Climate Coalition ., "

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1 . .. Martha Geores University of Maryland Brigitta Genven .Netherlands National Institute of Public Health . .

Herman. Gibb Environmental Protection Agency John H. Gibbons The White House Len$% E. Gilbert Columbia University.

William H. Glaze University of North Carolina Patricia Glick Sierra Club L* nR. Goldman . .

Environmental Protection Agency Bemkd D. Goldstein University of Medicine and Dentistry of New Jersey and Robert Wood. Johnson Medical School Robert Gordon Institute of International Education '.

Anne Grambsch Environmental Protection Agency Erick'Gray Universal Healthwatcg; Inc. ..

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.. .. .. . . .. Robert H. Gray University of Michigan Gina C. Green The Nature Conservancy Harry L. Greene I1 Massachusetts Medical Society Nancy Greenspan Environmental Network Priscilla C. Grew University of Nebraska, Lincoln Francesca T. Grifo 'Center for Biodiversity and .Consewation Museum of Natural History John T. Grupenhoff National Association of Physicians for the Environment Duane J. Gubler Centers for Disease .Control and Prevention Audrey Haaf Coaland Synfuels ' : Technology Craig Haas Environmental Protection Agency Demisse Habte Center for Health and Population Research j%. 5' ..

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, ,. .. 50 CONFERENCE ON HU'NHEA HAND GLOBAL CLIMATE CmNGE Richard J. Jackson Centers for Disease Control and Prewntion . .,

Paul F. Jamason University of Delaware Christer T. Jansen University of Turku, Finland Nyka Jasper US. Agency for International Development Jim Jensen U. S. Agency for International I Development .e ..

James Jessleman ..

Academy for Educational Development Stephen C. Joseph U. S. Department of Defense John R. Justus Library of Congress Peter R. Jutro Environmental Protection Agency

Laurence S. Kalkstein University of Delaware '~ :. Carla Kappell Development John 'Kallos .  1 Agency for International ..

. Columbia Business School I Timothy P. Kanaley Institute of Medicine ., . .. .

. .. .. ..

.. Tim R. Kramer U. S. Department of Agriculture .

Kalee Kreider Ozone Action Sally Kane Council of Economic Advisers Thomas R. Karl National Climatic Data Center Eileen Kennedy Center for'Nutrition Policy and Promotion Charles Kennel National Aeronautic and S p v Administration John L. Kermond National Oceanic and Atmospheric Association Katherine Kirkland Association of Occupational and Environmental Clinics fiornas M. Kirlin American Petroleum Institute Heidi M. Klein National Association of City and County Health Officials Edward Knipling US. Department of Agriculture ..

Andrei P. Kozlov National Institutes of Health Katharine Kripke Stanford University Margaret Kripke M. D. Anderson Cancer Center Jon Kusler Association of Wetland Manager'

Sandra L: LaFevre Reinsurance Association of America '

Carol Lancaster Agency for International Development Stephen Landry  . ,\

Agency for International Development Hiram Larew Agency for International Development Daniel Lashof Natural Research Defense Cougcil Sharon LeDuc' . : Environmental Protection Agency ; Alexander Leaf Harvard University Medical School Joel M . Leyy National Oceanic and Atmospheric Administration .. L . . .. Harry Moses U. S. Department of Energy * Richard Moss Intergovernmental Panel on Climate Change Jeryl L. Mumpower Rockefeller College Robert K. Musil . Physicians for Social Responsibility Charles E. Myers National Science Foundation Carolyn Needleman Bryn Mawr College Elvia E. Neibla U. S. Department of Agriculture, Forest Service Henry Newhouse Atmospheric Administration . National Oceanic and Sheila A. Newton '.

U. S. Departinent of Health and Human Services CIaudia Nierenberg National Oceanic and Atmospheric Administration Frances P. Noonan George Washington r University School of Medicine i Michael Northrop Rockefeller Brothers Fund Susan Norwood US. Department of Energy Edward W. Novak Army Environmental Policy Institute Christine O'Brien Environmental Protection Agency James J. O'Brien Florida State University Robeft O'Keefe Health Effects Institute Tara O'Toole U. S. Department of. Energy Ellen Odgen Agency for International Development David Oot Agency for International Development .. ..

Michael Oppenheimer Environmental Defense Fund Brett Orlando Office of Science and Technology Policy Joseph V. Osterman Defense Research and Acquisition Horst Otterstetter Pm Amcricm Health Organization Countess Alicia Paoloui National Association of Physicians for the Environment John Passacantmoo Ozone Action Ari Patrinos U. S. Department of Energy Jonathan A. Patz Johns Hopkins School of Public Health David Pelletier Cornell University Michele Pena . ' . . Climate Institute .

John S. Perry National Academy of Sciences . ..

Jonathan Pershing. U. S. Dep ent of State Anne C. Petersen ,

National Science Foundation Karen. Peterson National Institutes of Health Annie Petsonk . ,

Environmkntal De& se, Fund Paul B. Phelps Science Writer Winfred M. Phllips University of Florida .. . 54 CONFERENCE UNH" 4NHE. [HAND GLO3AL CLIWTE CHANGE Gabriel Schmunis  Dave Sharma Anthony Socci Pa& American Health U. S. Department of u s. Global Change Research OrganizatiodWorId Health Transportation Program Organization Joe Schwartz Physicians for Social Responsibility Joel Schwartz Harvard University School of Public Health John Kimball Scott National Association of Physicians for the Environment Louise Scott Consultant Glenn E. Schweitzer .

National Research Council Jeff Seabright. Agency for International Development Stephen Seidel .

Council on Environmental Quality Loren W. Setlow National Research Council Valerie P. Setlow Institute of Medicine Moira Shannon I U. S. Department of Health a d Human Services ,.

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.. Eileen L. Shea Rosemary Sokas Institute of Global .George Washington Environmental Society University Clive Shiff Jo$ s Hopkins University Martha Shimkin Pan American Health  Organization,

Kenneth I. Shine Institute of Medicine John .ShIaes Global Climate Coalition Robert Shope University of Texas Michael Simpson Library of Congress .

Holly Sims State University of New York James B. Sitrick .

Agency for International Development Rudi Slooff World Health Organization Meta Snyder Registered Nurse .

.

" . . .. ..

. . .. . William Sprigg National Academy of Sciences Ray Squitieri U. S . Treasury William Sprigg National Academyof Sciences Jennifer Steinbeig ..

Journal of NIH Research Macol Stewart '

National Oceanic and Atmospheric Ahinistration Paul. S tolpman Environmental Protection Agency _.

Richard E. Stuckey Center for Application of Sciences and Tec& ol~ m Nicholas Sundt Global Change Mark Sutton U. S. Global Climate Change Research Program ,. ". c.

56 CONFERENCE ONl% JiM"&? .THAND GLOBAL CLIMATE CMNGE Natalie Williams Byron L. Wood Timothy Yarling University of Delaware National Aeronautics and Japan International Mark L. Wilson Ames Research Center Yale University School of Teny F. Yosie Medicine Robert C. Worrest EnvironmentalDevelopment Mary E. Wilson Information Network Space Administration a * Cooperation i 1 Consortium for Earth Science Group Harvard University cy C. Wilson Climate Institute Tom Wilson Electric Power Research Institute Robert Wolcott Environmental Protection Agency M. 'Gordon Wolman Johns Hopkins University Stephen W. Wyatt Centers for Disease Control and Prevention Tagny R. Wyles Georgia Pacific Corporation Ann G. Wylie University of Maryland Roger E. Wyse University of Wisconsin Madison Elizabeth Younger Younger and Rata Eve Carroll Zentrick Uniformed Services University Brigitta Zuiderna van Gerwen Netherlands National Institute Environmental ProEction ' of Public Health and  i ERIC CHNIAN, M. D.

Despite increasing evidence that climate change and ozone depletion may have disastrous consequences for human health, ' there is little understanding, either among policy makers o r the public, of the extent ofthe possible threat to human life. Physicians and public health professionals should be central figures in helping to promote this understanding, but they are by .and large uniformed, as their education does not in general coverthe relationship of global environmental change to human health. This presentation shall look at the role of the medical and public health communities in global environmental issues, such as climate change and Ozone depletion, and shall address the grswing need for their education and involvement.

' ._ 4 RITA R. COLWELL, Ph. D The origin and cyclical nature of cholera has intrigued scientists and public health officials. Robert Koch postulated environmental origins'of cholera, but proof was not established until the tools of molecular biology and immunology were available. Work on environmental aspects of cholera during the past 20 years has revealed an association of Vibrio cholerae with zooplankton and marine and estuarine systems. Furthermore, the capability of K cholerae to  .enter a dormant, that is, viablerbut noncultuiable state, has offeredan explanation for the inability to isolate it between epidemics. With .fluorescent monoclonal antibody and gene probes, coupled with PCR implification, it has been possible to detect and monitor K cholerae in the environment. Furthermore, it has been shown that plankton blooms are correlated with increased incidence of I? cholerae, Studies carried out in Bangladesh provided the link between cholera outbreaks and plankton populations. Studies in progress, employing satellite imagery, will permit retrospective and prospective analyses of marine plankton and the cholera outbreak in Latin America during 1991 1992. The El Niiio event. appears to be closely associated with this cholera outbreak. Perturbations of the marine ecosystem may be the key to the eratic, cyclical nature of cholera epidemics.

STEPHEN C. JOSEPH, M. D., M. P. H. .. f" Y Global surveillance is critical to national security and plays a vital role in the mission of the Department .of Defense ~DoD). Military forces can be deployed to virtually any area of the world on short notice; knowledge of emerging diseases and their potcntial impact on military operations greatly assist us, in preparing countsmeasures to avoid such threats, reduce their impact,. and provide a rapid response to. outbreaks. Ai present, three things need to be I :.

60 . CONFERENCE ON&?. JMNHEAI" 'Ab GLOBAL CLIUATE CHANGE ANTHONY J. MciMCHAEL, L k A ., Ph. D Three thmgs about this topic need emphasis: scale, context, and &certainty. First, the anticipated health risks are not of a localizedkind; they are of large scale, impinging at the same" (more heatwaves, air pollution, etc). Rather, they would arise substantially via indirect pathways (by disturbance of natural systems, e. g., the ecology of infective agents, food production, and freshwater supplies). Third, forecasting them entails complexity, .uncertainty, a populatioii level, and tianscending national boundaries. Second, the risks are not just. "more of 1 1 and a long time horizon. It is tempting to focus on the more familiar risks; increased deaths from 1 heatwaves (especially in the very young, frail, and elderly), trauma from floods and storms, and from stratospheric ozone depletion morecases of skincancer. However, in the long term, sustained changes in climate and in climate dependent natural systems (particularly if also subjected to other environmental or ecological stresses) would result in: (a) altered patterns of infectious diseases, especially vector borne diseases (malaria, dengue, etc); (b) some regional declines in food production; and (c) population displacement (rising seas, declining agriculture, food shortages, and weather disaster9 and its many public health consequences. Combinations of mobile infections, malnutrition, andsocial stress especially in displaced arid migrating groups" cou1d amplify the health impacts of climate ch'ange. ' ..

STEPHEN S. 'MORSE, Ph. D ,I

. "Emerging infectious diseases" are those that are newly appeared in the population or are rapidly increasing their incidence or geographic range (e. g., HIVIAIDS, cholera in South . America and Africa, Ebola in Africb, and Hantavirus pulmonary syndrome and Lyme disease in the United States). Most emerging infections are caused by pathogens that are present in the environment but are newly introduced into humans, often from another species as a result of ' changing ecological or environmental conditions that increase the chance of human contact, or ' are infections that were once geographically isolated but now have an opportunity to reach larger human populations. Climate may often be .a factor. For example, with Hantavirus pulmonary syndrome in the southwestern United States in 1993,. the virus probably was long present in local rodent populations, but unusual local weather conditions .. led to an exceptionally large rodent ' population, with greater opportunities for people to come in contact with infected rodents (and, . hence, with the virus); 'the weather anomaly itself may have been due to large scale climatic effects. Human population. movements, whichcan introduce remote infections to a large. population, also are often a factor in the emergence of disease. The mass, movement of workers from rural areas to cities, largely driven. by economic conditions, cm. allow a previogsly isolated infection to reach larger numbers of people (this probably happened k t h H W . Climate changes, by potentially decrkasing productivity of local rural. agriculture, could accelerate this migration. As a final exardple, epidemiologists have long documented a close relationship ..

behveen climatic conditions and epidemics of childhood bacterial meningitis (which can also sprsad loba all^^ by trave!) in parts of Africa whzre the dmase naFaily occurs. * ,/ n. ' I ,"

62 CONFERENCE O N H W HEALTHAND GLOBAL CLIMATE C ~N G E changescould have adverse effects on ecological systems, human health, andsocioeconomic sectors.

. AccGulation of CFCs in the upper atmosphere has already led to world wide depletion of the ozone layer and an ozone hole in springtime over Antarctica. Ozone filters out harmful ultraviolet radiation andkeeps it from'. reaching the Earth's surface. Recentinternational agreements to phase out CFCs are beginning to show results; we now expect peak depletion to occur about the tum of the century, and the ozone layer should recover over the next several decades. Ozone depletion and climate change are complex problems that will affect the economy and the quality of life for this and future generations. The lag time between emission of the gases and their impact is on the order of decades to centuries; SO, too, is the time needed to reverse any effects. Thus, decisions in the near term will have long term consequences.

3 M. GORDON "REDS' WOLMAN, Ph. D The geologic' recordprovides clear evidence ofclimaticallyinducedchangesinthe quantity and quality of fresh water on the globe. Major fluctuations in climate, in the last 10,000 yearsand before, have resulted in the creationanddemiseoflakesand river, systems. Temperature perturbations of only a few degrees have also been accompanied bysignificant increases in the frequency of floods, and similar flood events are associatedwith El Niiio oscillations in some regions. Increasing seasonal runoff at some locations in 'the United States may be associated with a warning'trend during this century, but the record is not consistent. Climate change influences . water. quality directly an'd indirectly; directly .through changes in water temperature and associated chemical and biochemical phenomena (e. g., dissolved oxygen, algae), and indirectly through alterations of vegetationand the' erosionalprocessonland. .. Sediment yield and accompanying organic' and inorganic constituents may alter the quality of ambient flow aid the characteristics of the habitat. Human impacts acting on both landscape and climate are often inseparable from the variable'behavior of natural processes.

i D A W OOT, Ph. D. .. ..

I Morethan 800 millionpeople, .or 15 percent oftheworld'stotalpopulation, are food insecure. .They lack the economic and physical access to adequate food to meet 'their dietary needs and to lead healthy and productive lives. inadequate food consumption is a vary 6. cause of malnutrition along with infection and poor health. For 1993, the UN reports that over 34 hercent of all preschool children i n developing countries are malnourished. From recent research we know that protein energymalnutrition (PEM), even in its mild to moderate forms, contributes to 56 percent of'child deaths in 53 developing countrizs. Tht tsmbk budes ofPEh1 onchild survival is evengreaterwhenthetollofhiddenhunger due tomicronutrient i. i I *

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64 water resourczs management, and agriculture (`` FamineEarly Warning Systems"). wi additional investigation, the potential exists to extend these application efforts to human heal (" Health Early Warning Systems"). While climate circumscribes the distribution of m a disease vectors, extreme events may determine the timing of outbreaks.

learned from El Niiio's effects on extreme events: changes in droughts, floods, and minimur and maximum temperatures. Study of the linkage between ENS0 and health is beginning t reveal important threshold effects and provide tools for predicting the impacts of global climat change that can be tested and perfected on verifiable timescales. The significance of ENSO ma: be greater still, as some scientists believe that global climate change may be experienced in largr part through changes in climatic extremes and climate variability., For some diseases, changes ir climatic extremes may be even more important than changes in average temperature and average precipitation. CONFERENCE ON H U M ACTH AND GLOBAL C L I m TE CMN(

In considering El Nifio as an analogue for long tern climate change, lessons can 5 , ,/ .P. i " .

1 The 1997 U S Jimate Action Reporl, Chapter 3,

, submitted .by the United States of America * Under the United NationsFramework ....

Convention on Climate Change.

3 This document has beenreformatted to facilitate electronic distribution.

Released July, 1997 ......... ~..

Plaintiff Exhibit No. .3 + . .. . . .

1997 U. S Climate Action Report. Chapter 3 I . .... Table of Contents Greenhouse Gas Inventory (Title Page) ........................................................................... 1 Greenhouse Gas Inventory (Introduction) ....................................................................... 3 Recent Trends in .U. S. Greenhouse Gas Emissions ........................................................ 4 Carbon Dioxide Emissions ................................................................................................ 7 The Energy Sector ................................................................................................................................... 7 Fossil Fuel Consumption ...................................................................................................................... 7 Fuel Production and Processing .................... iii ............................................................. : ..................... 9 Biomass and Biomass Based Fuel Consumption ........... : ..................................................................... 9 Industrial Processes ..........................................................................................................  ..................... 9 Cement Production (10.5 MMTCE) ....................................................................................................... 9 Lime Production (3.7 MMTCE) ............................................................................................................. 9 Soda Ash Production and Consumption ................................................ : ............................................... (1.6 MMTCE) ...................................................................................................................................... ;; 9 Limestone Consumption (1.2 MMTCE) ....................................................... ....................................... 10 Carbon Dioxide Manufacture (0.4 MMTCE) ........................................................................................ 10 Changes in Forest Management and Land Use .................................................................................... 10 Methane Emissions ......... I ................................................................................................ 10 Landfills ......................................................... ......................................................................................... 11 Agriculture ............................................................................................................................................... 11 Enteric Fermentation in Domestic Livestock (34.9 MMTCE) ............................................................... 11 Manure Management (17.1 MMTCE) ............... i ................................................................................. 12 Rice Cultivation (2.8 MMTCE) ........................................................................................................... 12 Field Burning of Agricultural Wastes (0.04 MMTCE) ........................................................................... 12 Oil and Natural Gas Production and Processing .................................................................................. 12 Coal Mining .............................................................................................................................................. 12 Other Sources ......................................................................................................................................... 13 Nitrous Oxide Emissions .................................................................................................. 13 Agricultural Soil Management and Fertilizer Use ................................................................................ 13 Fossil Fuel Combustion ........................................................................................................................ 13 Adipic Acid Production .........................................................................................................  ................. 13 Nitric Acid Production ........................................................................................................................... 14 Other Sources of N20 ............................................................................................................................ 14 Emissions from HFCs, PFCs and SF6 ............................................................................ 14 Emissions of Criteria Pollutants ..................................................................................... 16 References ........................................................................................................................ 17 2 .. U. S. Climate Action Report ..

......... ,i ,., , ,'?

The 1997 U. S. ClimateActionReport, Chapter 3, submitted by the United States of America Under the `United Nations Framework Convention on Climate Change. I Greenhouse Gas Inventory 4 Central to any study of climate change is the development of an emission inven tory that identifies and quantifies a country's primary sources and sinks of green house gases (GHGs). This inventory provides both (I) a basis for the ongoing development of a comprehensive and detailed methodology for estimating sources and sinks of greenhouse gases, and (2) a common, consistent mechanism that enables all signatory countries to the United Nations' Framework Convention on Climate Change (FCCC) to e'stimate emissions and to compare the relative contribution of different emission sources and greenhouse gases to climate change. Moreover, systematically and consistently estimating national and international emissions is a prerequisite for evaluating the cost effectiveness and feasibility of mitigation strate gies and emission reduction technologies.