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Adaptation and Solutions

Adaptation and Solutions

Community-Based Adaptation to the Health Impacts of Climate Change

Kristie L. Ebi, PhD, Jan C. Semenza, PhD

Abstract: The effects of and responses to the health impacts of climate change will affect individuals, communities, and societies. Effectively preparing for and responding to current and projected climate change requires ongoing assessment and action, not a one-time assessment of risks and interventions. To promote resilience to climate change and other community stressors, a stepwise course of action is proposed for community-based adaptation that engages stakeholders in a proactive problem solving process to enhance social capital across local and national levels. In addition to grassroots actions undertaken at the community level, reducing vulnerability to current and projected climate change will require top-down interventions implemented by public health organizations and agencies.

(Am J Prev Med 2008;35(5):501–507) © 2008 American Journal of Preventive Medicine

Introduction

ain’t what it used to be” ( www.quotationspage.

com/quote/27223.html ). Climate change is

changing the landscape of people’s lives in ways that can be beneficial, detrimental, or neutral. As such, climate change is challenging the mission of public health to promote physical and mental health, and prevent disease, injury, and disability. Recent reviews of public health responses to climate change in the U.S. identified, for selected health outcomes, interventions either known or highly likely to be effective in reducing climate change–related morbidity and mortality, and the responsible parties. 1 4 The focus has been on interventions that are the responsibility of national and state public health agencies. Although these interven- tions are critical, they will not be sufficient, even with optimal resources and engagement. Additional activi- ties will need to be taken by individuals within their communities. Preparing for and effectively responding to climate change will be a process, not a one-time assessment of risks and likely effective interventions. Considerable attention has focused on the importance of reducing emissions of greenhouse gases, with many communities and states developing and implementing mitigation initiatives (e.g., U.S. Mayors’ Climate Protection Agree- ment; www.usmayors.org/climateprotection/agreement.

From the ESS, LLC (Ebi), Alexandria, Virginia; and the European Centre for Disease Prevention and Control (Semenza), Stockholm, Sweden Address correspondence and reprint requests to: Kristie L. Ebi, PhD, ESS, LLC, 5249 Tancreti Lane, Alexandria VA 22304. E-mail:

krisebi@essllc.org.

htm). However, failing to address adaptation will leave communities poorly prepared for the climatic changes expected over the next few decades. There is a “climate change commitment” that arises because carbon diox- ide (CO 2 ), the main anthropogenic greenhouse gas, remains in the atmosphere for decades to centuries. 5 Global average surface temperature increased 0.8°C (1.4°F) over the past century, with most of the warming occurring in the past 3 decades, and at least that much additional climate change will occur before effective mitigation policies affect atmospheric CO 2 concentra- tions. Failure to cope with the climate change that has already occurred and to anticipate and prevent the consequences of projected climate change over the next few decades are expected to affect human health and security. 6 P u b l i c h e a l t h a d a p t a t i o n t o c l i m a t e c h a n g e i s b r i e fl y r e v i e w e d h e r e . C o m m u n i t y - b a s e d a d a p t a t i o n i s d i s c u s s e d n e x t , a s a n a p p r o a c h t o p r o a c t i v e i m p l e - m e n t a t i o n o f p r o g r a m s a n d a c t i v i t i e s n e c e s s a r y t o c o p e w i t h a c h a n g i n g c l i m a t e , i n c l u d i n g u s i n g s t o r y - l i n e s t o f a c i l i t a t e c o m m u n i t y p r e p a r e d n e s s .

Public Health Adaptation to Climate Change

The climate change community uses the term adapta- tion to refer to the process of designing, implementing, monitoring, and evaluating strategies, policies, and measures intended to reduce climate change–related impacts and to take advantage of opportunities. 7 In public health, the analogous term is prevention . Adapta- tion can be actions taken in advance of climate change impacts or reactions in response to perceived or real health risks. The capacity of local communities to minimize adverse health effects through adaptation is

Am J Prev Med 2008;35(5) © 2008 American Journal of Preventive Medicine Published by Elsevier Inc.

0749-3797/08/$–see front matter 501

doi:10.1016/j.amepre.2008.08.018

in part a function of social capital as discussed below, but also of such factors as socioeconomic conditions, infrastructure, government accountability, and institu- tional responsiveness. Thus, adaptation can encompass both spontaneous responses by affected individuals and communities and planned responses by governments and institutions. P u b l i c h e a l t h i n t e r v e n t i o n s a r e g e n e r a l l y c l a s s i fi e d i n t o p r i m a r y , s e c o n d a r y , o r t e r t i a r y p r e v e n t i o n . I n t h e c o n t e x t o f c l i m a t e c h a n g e , m i t i g a t i o n o f g r e e n - h o u s e g a s e m i s s i o n s c a n b e c o n s i d e r e d z e r o o r d e r p r e v e n t i o n . 8 P r i m a r y p r e v e n t i o n a i m s t o r e d u c e e x p o - s u r e s p r o j e c t e d t o o c c u r w i t h c l i m a t e c h a n g e , s u c h a s r e d e s i g n i n g c i t i e s t o r e d u c e u r b a n h e a t i s l a n d s ,

t h e r e b y i n c r e a s i n g r e s i l i e n c e t o r i s i n g t e m p e r a t u r e s a n d m o r e f r e q u e n t a n d i n t e n s e h e a t w a v e s . Secondary prevention aims to prevent the onset of adverse health outcomes, including approaches such as strengthening disease surveillance programs to provide early intelli- gence of the emergence or re-emergence of vector- borne disease (e.g., Lyme disease along the northern edges of its current range). Ter-

tiary prevention consists of measures (often treatment) to reduce long-term impair- ment and disability and to minimize suffer- ing caused by existing disease. For each health outcome, there may be multiple possible primary, secondary, and tertiary interventions. 1 4

i c a l l y f o r t h e o b e s e ; s i n g l e m e s s a g e s w i l l n o t s e r v e a l l v u l n e r a b l e g r o u p s e q u a l l y . W o r k i n g w i t h s t a k e h o l d - e r s c a n h e l p e n s u r e i n d i v i d u a l a n d c o m m u n i t y a c c e p - t a n c e o f t h e i n t e r v e n t i o n , a l o n g w i t h r e d u c i n g c o n - s t r a i n t s t o i m p l e m e n t a t i o n . 1 2 To be successful, interventions often need to address the societal, cultural, environmental, political, and eco- nomic contexts that increase vulnerability. 13,14 Tack - ling these broader determinants of public health might be daunting, but necessary and potentially very effec- tive. 15 Engaging communities in this broader process of adaptation will not only enhance their resilience to climate stressors, but will likely increase their ability to cope with a wide range of other societal issues. C o m m u n i t y o r g a n i z i n g i s a p r o c e s s o f b r i n g i n g p e o p l e t o g e t h e r t o a d v a n c e t h e c o m m o n g o o d a n d i n c r e a s e t h e i r d i r e c t r e p r e s e n t a t i o n i n t h e d e c i s i o n - m a k i n g p r o c e s s . 1 6 C o m m u n i t y e m p o w e r m e n t e n - c o u r a g e s n e i g h b o r h o o d s t e w a r d s h i p t h a t c a n b e t r a n s l a t e d i n t o c o n c r e t e a c t i o n , s u c h a s p h y s i c a l i m p r o v e m e n t s o f t h e u r b a n e n v i r o n - m e n t . 1 7 Factors that influence community

organizing efforts include sense of social connectedness and sense of community among neighborhood residents. 18,19 Al - though engagement and funding remain challenges for community organizing, strat-

egies are available to overcome these obstacles. 14 The theoretic underpinning of commu- nity-based adaptation lies in the concept of social capital , which is the potential embedded in social relationships that enables residents to coordinate community action to achieve shared goals, such as adaptation to climate

change. 20 22 It includes two complementary compo- nents. Structural social capital, described through social networks, is intrinsic to the social organization of communities. Cognitive social capital consists of the norms, values, attitudes, and beliefs that emerge, for example, during community meetings, and thus can be described as peoples’ perception of the level of inter- personal trust, sharing, and reciprocity. This two-di- mensional construct can be further categorized into bonding (localized), bridging, and linking social capital. 23,24 Bonding social capital is the normative content of homogeneous groupings, such as religious, cultural, professional, racial, or ethnic groups. Bonding social capital is necessary but not sufficient to address the threats from climate change. Homogeneous groups, even with rich social capital, may not have sufficient problem-solving capacity because they lack the exper- tise, authority, and financial resources to enact neces- sary changes. 25 Bridging social capital arises from connecting socially heterogeneous groups and can provide a host of ben- efits to community groups. Different societal groups

ben- efits to community groups. Different societal groups Community-Based Adaptation to Climate Change Adaptation to

Community-Based Adaptation to Climate Change

Adaptation to climate change risks will need to take place at the individual, family, community, and govern- ment levels. Top-down interventions include programs and activities implemented by local, state, or national public health and environmental agencies. Stakeholder engagement in the design, implementation, and mon- itoring of these interventions is needed because the potential health impacts of climate change, and there- fore the actions to reduce these impacts, are intimately interwoven with specific population and regional vul- nerabilities. These actions may receive financial and/or technical assistance from state and national agencies. A largely uninformed and unengaged public, unrespon- sive government, and other hurdles hamper efforts. 9 Public health interventions generally have been less effective in populations with a lower SES. 10 S t a k e - h o l d e r e n g a g e m e n t i s n e e d e d t o e n s u r e t h a t m e s - s a g e s d e s i g n e d t o r e a c h v u l n e r a b l e g r o u p s p r o v i d e t h e i n f o r m a t i o n a n d m o t i v a t i o n n e c e s s a r y f o r i n d i - v i d u a l s t o m a k e a p p r o p r i a t e c h o i c e s . F o r e x a m p l e , o b e s i t y , i n a d d i t i o n t o i t s o t h e r h e a l t h i m p l i c a t i o n s , i n c r e a s e s t h e l i k e l i h o o d o f s u f f e r i n g a d v e r s e h e a l t h c o n s e q u e n c e s d u r i n g a h e a t w a v e . 1 1 T h e r e f o r e , p u b l i c s e r v i c e a n n o u n c e m e n t s a n d o t h e r i n t e r v e n t i o n s d u r - i n g h e a t w a v e s s h o u l d b e d e v e l o p e d a n d t e s t e d s p e c i f -

vary in skills and talents and can generate new strategies for addressing risks. For example, lessons learned from adaptation actions in one community may prove help- ful to other communities. In the context of adaptation to climate change, linking social capital is particularly important because it connects people at different levels of power, such as community members and government officials. 24 Re- sponding to the challenges of climate change relies on a wide range of expertise, not all of which can be found within the communities themselves; to ensure effective interventions, a wide variety of government agencies and scientific experts should engage with communities. For example, effectively addressing the possible health impacts of increases in the frequency and intensity of floods will require not only community engagement, but also coordination across many agencies, including those responsible for public health and infrastructure planning. Social capital is based on connections across multiple systems, including the microsystem (individual), the me- sosystem (interrelation among individuals and higher social contexts), the exosystem (settings in which the person does not actively participate but in which signif- icant decisions are made that affect the individual), and the macrosystem (“blueprints” for defining and organiz- ing the institutional life of society, including overarch- ing patterns of culture, politics, economy, and the environment). 26,27 Social capital can be enhanced by organizing individuals into neighborhood groups, con- necting different groups, and eventually linking these groups with government officials when implementing interventions to prepare for and respond to the chal- lenges posed by climate change.

Framework for Community-Based Adaptation to Climate Change

Because the effects of and responses to climate change will depend on the local context, including geographic, demographic, social, economic, infrastructural, and other factors, many adaptation options will be more effective if designed, implemented, and monitored with strong community engagement. Although some adap- tations will require a more top-down approach (e.g., standards to ensure safe air and drinking water), put- ting the community at the center of other adaptation activities will facilitate their effectiveness (e.g., disaster response plans). Figure 1 shows a framework for facil- itating community-based adaptation to the health im- pacts of climate change, with each step designed to enhance components of social capital. Ideally, individ- uals, communities, and government will work together to ensure the broadest support for adaptation activities. The first step is community outreach, to determine the broad project outline based on concerns of the

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Situation Situation Evaluation Evaluation Analysis Analysis Community- Community- Asset Asset Based Based Mapping
Situation Situation
Evaluation Evaluation
Analysis Analysis
Community- Community-
Asset Asset
Based Based
Mapping Mapping
Adaptation Adaptation
Resource Resource
Stakeholder Stakeholder
Mobilization Mobilization
Involvement Involvement
Intervention Intervention
Prioritization Prioritization

Figure 1. Framework for community-based adaptation

possible health impacts of climate change. Community organizations or activists, city managers or leaders, state or national organizations, or agencies aiming to in- crease local adaptive capacity may initiate community- based adaptation. Broad management decisions will need to be made, such as which health outcomes of concern to include, geographic boundaries for the analysis, and other relevant issues. A management structure will need to be established to facilitate the process. The second step is a situational analysis, to describe community needs and constraints to adaptation. This step describes the health consequences of climate change to identify any current adaptation deficit and highlight potential future problems. The characteriza- tion can be qualitative (e.g., the health burdens are small, intermediate, or large based on simple climate scenarios, such as a 1°F increase in temperature over the next few decades) or quantitative (e.g., based on model projections of the health impacts of climate change). A situational analysis also assesses factors that could influence vulnerability, such as land use and demographic characteristics. One product of the situational analysis can be story- lines of possible local climate change impacts. Story- lines, as opposed to quantitative projections that focus on impacts in one sector over long time frames, can enhance community engagement in discussing shorter- and longer-term risks and possible interventions, in- cluding where, when, and how interventions could be implemented. Taking a future perspective, these story- lines can highlight compound vulnerabilities, such as the possibility of an extended heatwave during which the power grid fails, or a continuing increase in the

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number of cases of salmonella affecting older adults and small children. The third step is mapping the community assets, including financial and human resources, actors whose expertise and talent could support adaptation activities (e.g., colleges and universities; national, state, and local agencies; nongovernmental organizations), and other relevant factors. For example, if heatwaves and urban heat islands are an issue, then one solution may be installing green roofs, and assets would include individ- uals with the technical knowledge to design, install, and maintain such roofs. People from other communities may also have experience in installation. As more communities engage in adaptation, opportunities for enhancing adaptation through sharing of best practices and case studies will increase; support by state and federal agencies would enhance linking social capital across levels. With a project design and an understanding of the available assets, the fourth step is to engage with a broader range of stakeholders to identify possible in- terventions for enhancing the management of climate change–related health risks. Engaging multiple sectors will advance the bridging and linking social capital of the community, and help ensure that the project addresses community concerns, thus facilitating stake- holder engagement. One approach is to invite neigh- borhood residents to open meetings to discuss the storylines and seek their ideas on possible solutions. Community members are likely to identify options that reflect their observations and concerns. One important outcome of this step is facilitating social networks and personal connections between individuals and organi- zations within the neighborhood, with the aim of advancing structural social capital. T h e c a t a l o g o f p o s s i b l e i n t e r v e n t i o n s t h e n n e e d s t o b e p r i o r i t i z e d u s i n g c r i t e r i a a g r e e d u p o n b y t h e s t a k e h o l d e r s . A t a m i n i m u m , t h e b e n e fi t s o f t h e i n t e r v e n t i o n s s h o u l d e x c e e d t h e i r c o s t , w i t h t h e s t a k e h o l d e r s a g r e e i n g o n t h e m e t r i c s f o r m e a s u r i n g b e n e fi t . I t w o u l d b e h e l p f u l a t t h i s p o i n t i f e x p e r t s w i t h k n o w l e d g e o f c l i m a t e c h a n g e p r o j e c t i o n s r e - v i e w e d t h e p r i o r i t y o p t i o n s , t o e n s u r e t h o s e l i k e l y t o b e i m p l e m e n t e d w i l l a l s o b e w i s e c h o i c e s u n d e r p r o j e c t e d f u t u r e c l i m a t e s ( e . g . , t h a t i n t e r v e n t i o n s w o n ’ t i n c r e a s e f u t u r e v u l n e r a b i l i t y ) . 2 8 T h e p r i o r i t i z a - t i o n p r o c e s s n e e d s t o b e t r a n s p a r e n t , s o t h a t a l l c o m m u n i t y m e m b e r s c a n u n d e r s t a n d t h e c r i t e r i a u s e d f o r t h e r a n k i n g a n d c a n u n d e r s t a n d w h i c h i n t e r v e n t i o n s a r e t h e h i g h e s t p r i o r i t i e s , e v e n i f t h e y d o n ’ t a l l a g r e e w i t h t h e fi n a l d e c i s i o n s . H a v i n g i d e n t i fi e d t h e h i g h e s t p r i o r i t y i n t e r v e n - t i o n s , a d e t a i l e d p l a n f o r i m p l e m e n t a t i o n c a n t h e n b e c r e a t e d a n d w i d e l y p u b l i s h e d . I n p r e p a r a t i o n f o r i m p l e m e n t a t i o n , r e s o u r c e s ( h u m a n a n d fi n a n c i a l ) w i l l n e e d t o b e m o b i l i z e d . T h e p r o j e c t t e a m m a y t a k e a c t i o n s , s u c h a s a p p l y i n g f o r f u n d i n g , w o r k i n g w i t h

p

r i v a t e i n d u s t r y t o o b t a i n d o n a t i o n s o f m a t e r i a l s a n d

o

t h e r r e s o u r c e s , a n d e n g a g i n g w i t h a c t o r s i n o t h e r

o m m u n i t i e s . The fifth step is to implement the intervention. By this point in the process, the community will have built

c

considerable social capital to ensure effective imple- mentation by using a wide range of stakeholders, with each contributing on the basis of specific talents and interests. Community involvement in the implementa-

tion will further increase social capital, as illustrated by the two examples below. T h e fi n a l s t e p i s t o e s t a b l i s h m o n i t o r i n g a n d e v a l -

u

a t i o n p r o c e s s e s t h a t a l l o w f o r e a r l y i d e n t i fi c a t i o n o f

p

r o b l e m s , t o e n a b l e m i d c o u r s e c o r r e c t i o n s w h e n

n

e e d e d .

Examples of Community-Based Adaptation An Urban Intervention

A community-based strategy to expand social capital was developed by a nonprofit organization (The City Repair Project) in Portland OR, field-tested in several settings, and evaluated. 29,30 The intervention was not designed to address climate change, but was a primary prevention effort to retrofit the urban environment to reduce urban heat islands. Metropolitan areas tend to be at higher risk during heatwaves because urban climates are often warmer than the unbuilt surround- ings. 31,32 Characteristics of the urban environment can have a significant effect on concentrations of air pol- lutants, urban energy consumption, human comfort, and incidence of heat- and air pollution–related mor- tality and morbidity. 33 The City Repair Project reached out to community members and mobilized neighbor- hood stakeholders in a discussion of potential interven-

tions. 31 Plans were developed and implemented with the participation of residents and volunteers, aided by experts. A c t i v i t i e s i n c l u d e d i n s t a l l i n g g r e e n r o o f s , i n c r e a s i n g u r b a n v e g e t a t i o n , p l a n t i n g t r e e s i n p a r k - i n g s t r i p s o r a b a n d o n e d l o t s , a n d c o n s t r u c t i n g t r e l - l i s e s f o r h a n g i n g g a r d e n s . A p r e – p o s t p a n e l s t u d y ,

u s i n g a v a l i d a t e d i n s t r u m e n t , e v a l u a t e d t h r e e i n t e r -

v e n t i o n s i t e s w h e r e c o m m u n i t i e s b u i l t h a n g i n g g a r -

d e n s , f o u n t a i n s , g r e e n r o o f s , p l a n t e r b o x e s o n t h e

s t r e e t c o r n e r s , a n d m a d e o t h e r c h a n g e s . 3 0 R e s i d e n t s

( n 2 6 5 ) w i t h i n a 2 - b l o c k r a d i u s o f t h e i n t e r v e n t i o n s i t e s w e r e i n t e r v i e w e d b e f o r e a n d a f t e r p r o j e c t c o m -

p l e t i o n . M u l t i v a r i a t e a n a l y s i s d o c u m e n t e d i m p r o v e -

m e n t s i n m e n t a l h e a l t h ( p 0 . 0 3 ) ; i n c r e a s e d s e n s e o f

c o m m u n i t y ( p 0 . 0 1 ) ; e x p a n s i o n o f s o c i a l i n t e r a c -

t i o n s ( p 0 . 0 6 ) ; a n d a n o v e r a l l e x p a n s i o n o f s o c i a l

c a p i t a l ( p 0 . 0 4 ) . T h i s g r a s s r o o t s e f f o r t a l s o t r i g g e r e d

a s t r o n g s e n s e o f o w n e r s h i p a n d c o m m u n i t y e m p o w -

e r m e n t t h a t w a s d o c u m e n t e d t h r o u g h o p e n - e n d e d i n t e r v i e w s . 3 4

Top-down approaches also can be effective; for ex- ample, empirical data from Sweden indicate that mem- bership in associations, interpersonal trust, informal interactions, and other social capital indicators are associated with higher cooperation and participation in the democratic process. 35

A Rural Intervention

In response to growing concern in the Canadian North about observed environmental changes, the national Inuit organization initiated a project in cooperation with regional Inuit organizations and Canadian re- search institutions to document changes and impacts experienced in communities and begin discussing integrated and comprehensive adaptation policies and measures. 36 Aboriginal communities throughout the Canadian Arctic have been very articulate about the climate and other environmental changes they have observed, the challenges they face as a result, and the possible solutions. 37 Participants at a workshop dealing with climate change and health in Northern Canada reviewed current health issues, including those that may be exacerbated by climate change, identified new concerns, and discussed the public health interventions and community support needed. 38 Issues included challenges related to Northern home design and a lack of ventilation causing heat stress among elderly on increasingly warmer days; impacts on food security because of changes in sea ice access routes to hunting areas, and the consequences of ice road stability on reliable transport of food stuffs; and mental health impacts due to the reduced ability of individuals to practice aspects of traditional activities, and to disrup- tion or relocation caused by damage to infrastructure. In the Inuvialuit Settlement Region, residents noticed an increasing number of biting flies and insects, includ- ing bees, whose arrival was believed to be related to the warmer summer weather. 36 Many residents were con - cerned because of the potential for spread of disease by airborne vectors and allergic reactions to bee stings, never seen before in this region. One recommendation was that public education programs be designed to inform people about actions to minimize the risks.

Storylines As a Tool to Facilitate Adaptation to Climate Change

Storylines of possible local health risks that are due to climate change can be compelling narratives that foster community-based adaptation. They can communicate the breadth of possible vulnerabilities in a form that helps stakeholders visualize the dimensions of the potential risks, and identify adaptive responses to en- hance current and future adaptive capacity. Storylines can be more effective than, for example, informing a community that the number of heatwave days could

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increase by some amount; such statements of likely increases in risks may not clearly communicate the breadth of possible impacts on human and animal health, water availability, power generation, infrastruc- ture, organized outdoor activities, and other aspects of community life. Community leaders, experts from sec- toral agencies and organizations, researchers, and oth- ers can jointly develop the storylines based on likely consequences of projected changes in weather variables and patterns in a particular place and time. Engaging all potentially affected sectors will provide a more realistic and nuanced description of possible futures. Disaster preparedness training exercises often use sim- ple storylines. Two examples are provided, one a national-level assessment that used storylines to estimate the impacts of climate change on the spread of vectorborne dis- eases, and the other a hypothetical storyline to illustrate compound local risks. Qualitative storylines were used during the assess- ment of health risks and responses in the first Portu- guese national assessment. 39 Included was an assess - ment of the possible impacts of climate change on vectorborne diseases, including malaria, West Nile vi- rus, schistosomiasis, Mediterranean spotted fever, and leishmaniasis; the last two are endemic to Portugal. 40 Although human cases of vectorborne diseases have generally decreased over recent decades, many compe- tent vectors are still present. Disease transmission risk was categorized qualitatively on the basis of vector distribution and abundance and pathogen prevalence. Four brief storylines were constructed using current climate and projected climate change, and assuming either the current distribution and prevalence of vec- tors and parasites, or the introduction of focal popula- tions of parasite-infected vectors. These storylines were discussed with experts to estimate transmission risk levels. For Mediterranean spotted fever, the risk of transmission was high under all storylines, suggesting a limited impact of climate change. For the other dis- eases, the risk level varied across the storylines. For example, the risk of leishmaniasis varied from medium under current climate to high under both climate change storylines. The risk of schistosomiasis varied from very low (current climate and current vector distributions) to medium (climate change and focal introduction). An example of a storyline developed to illustrate issues that a community may face in a changing climate is a hypothetical city in the midwestern U.S., that has a river running through downtown and a hospital com- plex located along the river’s edge. The city is located in a region where heatwaves are rarely a problem. Projections for the Midwest suggest that heatwaves could increase approximately 36% in frequency and 27% in duration; the combined effect is an overall increase of about 70% in the annual number of heat-

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wave days by the late twenty-first century. 41 There has been a 20% increase in heavy precipitation events over the past half century, with further increases expected. 42 In addition, the population is ageing, putting more people at risk during heatwaves and flooding events. This information can be used to create several story- lines. For example, spring rains in 2020 result in major flooding along the river for the first time in more than 50 years. Key hospital equipment located in the base- ment and on the first floor is under water, affecting hospital services. People in some of the poorer areas of the city are displaced by the floodwaters. Early in the summer, the city experiences an intense 2-week heat- wave, with hundreds of excess deaths, many among the people still repairing houses damaged by the flood. The aging electric grid limits availability of air condi- tioning; combined with high nighttime temperatures, this increases the risk of heat-related illnesses for many residents. The city heatwave early warning system is implemented, but it has not had adequate testing, resulting in operational difficulties. The hospital strug- gles with additional admissions and reduced availability of critical equipment. Select shopping malls provide places for people to cool down during the heat of the day, but few at-risk people are willing or able to travel there. The mayor and other city officials are blamed for the increasing number of deaths. More complex storylines can be created through discussions with public health professionals, hospital administrators, building managers, and others. These storylines then can be used to develop better emer- gency response plans, as well as plans on how to begin moving critical equipment and information to less vulnerable locations as opportunities arise (such as during hospital repairs).

Conclusion

Although public health programs designed to reduce the current burdens of climate-sensitive health out- comes are largely successful, recent events highlight an adaptation deficit to current climate variability, suggest- ing that climate change is likely to challenge the ability of programs and activities to control climate-sensitive h e a l t h d e t e r m i n a n t s a n d o u t c o m e s i n s o m e r e g i o n s a n d p o p u l a t i o n s . 4 3 , 4 4 O n e s o l u t i o n m a y b e t o i n c o r - p o r a t e t h e r i s k s o f c l i m a t e c h a n g e i n t o a l l h a z a r d s a p p r o a c h e s . T h e f e d e r a l P a n d e m i c a n d A l l - H a z a r d s P r e p a r e d n e s s A c t ( P A H P A ) w a s s i g n e d i n t o l a w ( N o . 1 0 9 - 4 1 7 ) i n D e c e m b e r 2 0 0 6 , with the goal of improv- ing emergency preparedness efforts by centralizing government responsibilities. The purpose of PAHPA is “to improve the Nation’s public health and medical preparedness and response capabilities for emergencies, whether deliberate, accidental, or natural” (www.hhs.gov/ aspr/opsp/pahpa/index.html). Although there is cer- tainly room for improving central emergency plans, in

light of the suboptimal government response to Hurri- cane Katrina, these efforts should also aim to increase community capacity. A key constraint is that funding for community development is needed to strengthen grassroots adaptation capacity. Adaptation activities must involve the full range of stakeholders, including businesses, community leaders, organizations, the public, and governments. 12 Survey data indicate that the American public is willing to engage in climate change issues 45 47 ; thus, stakeholder input is needed to make the difficult choices facing public health programs, in terms of how much of their scarce resources to spend to increase monitoring and surveillance for climate-sensitive health outcomes. 48 Investing human and financial resources in these pre- vention activities could mean fewer resources to ad- dress other problems. 49 Advancing community adaptation capacity to climate change is challenging but achievable. Cooperation and participation among different groups advances com- mon goals, and the benefits of public participation extend beyond the individual to the society at large. The framework for community-based adaptation pre- sented here can increase local adaptive and social capacity, and, as a result, help communities better prepare for and respond to the health risks of climate change.

No financial disclosures were reported by the authors of this paper.

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