Introduction
Climate change is now an irrefutable reality. Since the beginning of the industrial age, human activity has led to an unprecedented rise in greenhouse gases, chiefly carbon dioxide released through the burning of fossil fuels. The accumulation of these gases in the atmosphere traps solar energy, warming the planet at an increasing rate. The result of a warming planet, albeit by only around 1°C thus far (1) has had a major effect on weather patterns around the globe. Much of these changes have been seen as increasing temperatures and unprecedented heat waves, but the effect on rainfall variability has also become apparent, with a noticeable increase in floods and droughts worldwide.
The case for the world to act now within a narrowing window of time is set out unequivocally by the Intergovernmental Panel on Climate Change (IPCC) who draws together evidence from across the globe with hundreds of authors from different countries. According to a recently released report in August 2021,(1) scientists have detected changes in the Earth's climate in every region and across the whole climate system. Much of these changes are unprecedented in thousands, if not hundreds of thousands of years. Limiting climate warming is, nonetheless, possible through decisive mitigation actions worldwide such as strong and sustained reductions in emissions of carbon dioxide (CO2) and other greenhouse gases (GHGs). Whilst we could see reductions in GHG emissions in a short period of time, it could take 20-30 years to see global temperatures stabilize.(1) It is therefore critical to start building adaptive capacity within the most vulnerable population groups as a matter of urgency.
Exposure, hazards and impacts in South Africa
In the past four decades, South Africa has seen 99 devastating weather-related disasters which has affected nearly 34 million people and have caused direct economic losses in excess of R150 billion.(2) Of particular concern is the uptick in events noticed in the past two decades, with 70% of all events recorded since the turn of the century.(2) Current global mitigation efforts are falling short of what is needed to achieve the temperature threshold set by the Paris Agreement of a 1.5°C increase, and rapid rises in annual-average near surface temperatures are projected over Southern Africa, at rates 1.5 to 2 times the global rate of increase.(3) By mid-century temperature increases over the northern interior of South Africa are projected to increase by as much as 3°C.(4) Increases in very hot days and heatwaves,(5) and more frequent high-fire danger days are also projected over South Africa. The intensity of storms is likely to become more severe in KwaZulu-Natal, the Eastern Cape and the Free State provinces, while a reduction in precipitation is anticipated over large parts of the Western and Northern Cape.(4) The number of days during which indoor ambient temperatures will be categorized as potentially harmful may increase in the future, including in rural settings in South Africa.(6)
Alongside a shifting climate, we need to be aware of growing vulnerabilities within communities. Rapid population increase, urbanization, poor land use practices and surging informal settlements has exposed more people to these devastating climate hazards, significantly increasing the risk of loss of lives and livelihoods.(7,8)
Human health and well-being are impacted by climate change in multiple ways through both direct and indirect effects. Whilst these impacts are occurring worldwide, Southern Africa is among the worst affected regions globally.(9) The indirect impacts that climate change is having on health are less visible and ranges from changing ecosystems and disease patterns to air quality deterioration and its impact on respiratory conditions, to changing socioeconomic conditions and increasing malnutrition. Chersich (10) has previously reported on the impact of climate change on the health and well-being in South Africa.
Whilst climate change affects all population groups, children are disproportionately vulnerable. Children are dependent on adult care and on the available resources in a household. Children are also physiologically at higher risk of the impact of both higher temperatures, infectious diseases, as well as catastrophic weather events. Children have unique pathways of exposure and sensitivity to climate hazards, given their immature physiology and metabolism, and high intake of air, food, and water relative to their body weight, as compared with adults.(11) Climate change is also contributing to forced migration and displacement (12) that places children at even greater risks of poor health outcomes. It is helpful to look at the impact of climate change on children by unpacking several direct and indirect impacts.(13)
Observed Impacts on Maternal, Foetal and Child Health
Climate change is threatening neonatal health in the Africa region.(14) A study in Johannesburg showed that high temperatures in early pregnancy increased the risk of severe hypertensive disorders (15) and evidence indicates that there is an association between heat and increased rates of pre-term birth, low birthweight and stillbirths.(10) Extreme weather events are also associated with reduced access to prenatal care and unattended deliveries (16) while links have been postulated between high environmental temperatures and congenital anomalies.(17) Among children, higher temperatures are associated with increased risk of infant mortality and hospital admissions.(18) Modelling indicates that if carbon emissions are not curtailed then heat-related child mortality in Africa may reach over 38 000 per year in 2049.(19)
Food insecurity and Malnutrition
Climate change can lead to dietary changes and malnutrition through its contribution to reduced agricultural productivity, crop failures and food insecurity. Malnutrition includes undernutrition as well as overweight and obesity and with their associated vulnerabilities to non-communicable diseases (NCDs).(20) A study from different regions, including Africa, showed that diet diversity reduces significantly at higher temperatures.(21)
Projections for 2030 suggest that malnutrition will be exacerbated by climate change. Stunting amongst children under five years of age across 44 countries could increase by an additional 570,000 cases to one million cases depending on a low or high emission scenario coupled with the model of economic growth in the country.(22)
Due to the large subsistence farming dependency in sub-Saharan Africa, children in this region are particularly at risk of undernutrition from increasing temperatures (23) and rainfall variability. Risk is high for increased food insecurity, especially in rural communities, as extended drought, floods or storms interrupt crop production, distribution of medicine, aid and food supply chains.
Water-borne and Diarrhoeal disease
A 1°C increase in mean average temperature is expected to increase diarrhoeal incidences in all age categories by 7%.(24) E. coli is expected to rise by 8% (25) with an increase in deaths attributable to diarrhoea climbing between 3% and 11%.(26)
Water-borne diseases are set to increase in Africa due to rising temperatures and drought through vectors such as protozoan parasites including Cryptosporidium spp. and Giardia duodenalis (intestinalis).(27,28) The risk of further listeriosis outbreaks in South Africa have also been attributed to climate change.(29)
Vector-borne disease
Malaria is a climate sensitive outcome. As rainfall variability sets in and temperatures rise, risks of vector-borne diseases become more severe and infections extend into new areas, with major implications for children. Malaria mortality among children under the age of one year could increase significantly in Africa and there is a shift expected in geographical risk of transmission with more recent climate model projections.(30,31)
Mental health
Climate change has major negative impacts on well-being and mental health. Post-traumatic stress is experienced particularly by children and adolescents following extreme weather events. Some of these effects are long lasting and may persist into adulthood.(32,33) In sub-Saharan Africa, children and adolescents, particularly females, are extremely vulnerable to mental health impacts of climate change both through direct and indirect pathways.(34,35) An important pathway that has an indirect impact on well-being is migration and displacement.(36) Levels of aggression rise with temperature, with one global study suggesting a 6% increase in homicides per a 1°C rise in temperature, albeit with significant variation across countries.(37) Locally, in South Africa the question of the impact of heat on levels of violence have also been considered.(38) A study in South Africa showed that homicide was about 22% more likely when temperatures were above 35°C, compared to when temperatures were below 20°C.(39)
Action to reduce the impacts of climate change
It is an understatement to point out that the enormity and urgency of the climate crisis we are all facing demands action from all, at an individual level, as well as organized groups and nations. Health systems need to be strengthened and made resilient to acute shocks and long-term changes resulting from climate change. Toward this end, WHO has developed an operational framework for building climate resilient health systems.(40)
On 6 September 2021, an editorial “Call for emergency action to limit global temperature increases, restore biodiversity, and protect health” was published simultaneously in 233 international titles including the British Medical Journal, the Lancet, the New England Journal of Medicine, the East African Medical Journal, the Chinese Science Bulletin, the National Medical Journal of India, and the Medical Journal of Australia.(41) This editorial sets out the response of the medical community to this global problem, and is one example of powerful action taken by the profession. It includes both committing to healthcare without harm, i.e., reducing the carbon footprint of the sector, while also advocating and preparing for the impacts of climate change on public health and well-being.
Aside from concerted global mitigation efforts, prudent investment in adaptation is needed in South Africa. Each municipality in South Africa requires robust disaster management plans, as mandated by the Disaster Management Act, 2005. It is vital that heat risk assessments are included and that heatwave contingency plans are put in place for at-risk settlements across the country.(7) Systemic vulnerabilities within communities and high-risk population groups must be reduced. People need to be aware of the risks they face from weather-related hazards and must be fully capacitated on how to respond and adapt to these risks.(8,42)
What is our role as healthcare workers looking after children?
Aside from all the actions described above, healthcare workers looking after children have an import role to play. Whilst there is a role for the entire healthcare sector in South Africa to look at its response to the health threats posed by climate change locally,(43) there are specific actions focused on the care of mothers, new-borns and children to be made. It starts with a recognition of the current and future expected impact climate change is having on the health of children. An appreciation of the urgency of the action is required given that all efforts to mitigate and adapt against the impact of climate change work over a prolonged period.
Importantly, we need to consider how healthcare professionals adapt to the changing landscape of ill-health brought about by climate change. There is a need to upskill all healthcare workers on what these impacts are and how to be prepared to deal with these now, as well as mainstreaming training on such skills within the curricula. Our voices as health advocates are an important instrument and need to be harnessed to drive government and society to take seriously the immense challenges we are facing.
Healthcare providers can assist caregivers to adapt to the effects of climate change by providing pro-active guidance and preparedness for extreme heat, infectious diseases, reduced air quality and extreme weather events. Professional bodies such as the American Academy of Paediatrics have long presented a list of recommendations and further health advocacy strategies that need to be more widely practiced now.(44) Child healthcare associations in the Southern African region need to develop local position statements and issue anticipatory guidance along the same lines considering prevailing conditions affecting children.
Perhaps the most challenging aspect of getting healthcare providers to begin to act on this problem is the lack of a clearly defined programme of action and a void of advocacy in this area. What is needed is an urgent recognition of the harm that is already occurring and the threats that exist for the foreseeable future. Quantification of the impact of climate change on the health of children in Southern Africa is urgently required. We call for the establishment of a dedicated a unit within the South African National Department of Health that would be solely focused on this work. Such a unit would be supported by counterpart experts within the Schools of public and environmental health in the various academic institutions in the region. The time for us to dedicate learning and advocacy to climate change impacts, adaptation and mitigation in the healthcare system, especially focussing on children, is now.
We propose a number of strategies to secure the future of child health in Southern Africa and they are highlighted in Figure 1.
