A well-resourced health workforce is at the core of health systems strengthening and healthcare professionals (HCPs) are critical to building strong and resilient healthcare systems that can mitigate the impact of climate change. A climate health crisis response requires HCPs who are well informed, able to anticipate, prevent and manage challenges placed on themselves, their patients, the community and on overall health systems due to climate change. The reality however, is that most HCPs are ill-equipped to manage the escalating climate health crisis. Healthcare professionals in public sectors are more vulnerable due to diminished capacity and support to sufficiently respond to the crisis. Lack of information and awareness on the extent of the climate health crisis, the urgency with which a response is needed, and lack of clear climate and health policy directives and resources is a barrier towards an effective health systems response.
Climate change poses the greatest threat to humanity and is rapidly becoming a public health emergency. The world is getting warmer at an unprecedented rate, with global warming likely to reach 1.5 degrees C between 2030 and 2052.(1) Most low- middle-income countries (LMIC) in Africa, including South Africa, are disproportionally affected by climate change despite emitting less greenhouse gases compared to developed countries.(1,2) According to the World Health Organization (WHO), climate health emergencies are on the rise in Africa and account for more than half of the public health events recorded in the past two decades, with 56% of climate health emergency events recorded in the African region in 2021 directly linked to climate change.(3) Climate variability due to excessive heat and precipitation events pose a threat to population health and have increased the demand on health systems due to a rise in human morbidity and mortality.(1,4,5)
There is emerging evidence linking excessive heat to poor health outcomes especially in vulnerable populations. Pregnant women and children are disproportionally affected by climate change, with studies showing an association between excessive heat and poor pregnancy outcomes that include preterm birth, low birth weight and stillbirth.(6–8) Heat stress, defined as the amount of heat that exceeds the level wherein the body can adapt prior physiological impairment,(9) has been shown to increase the prevalence of non-communicable diseases (NCDs).(10,11) Existing cardiovascular diseases and diabetes are worsening, respiratory diseases are also on the rise as a result of air pollution.(11) Although there is a scarcity of literature, climate change has been linked to mental health disorders including post-traumatic stress disorder, depression and extreme emotional distress.(12)
Climate change is also associated with a rise in infectious diseases including malaria and dengue.(13) Rising temperatures are changing vector breeding patterns and humans are exposed to increasing vector infectivity rates.(13) Water contamination due to floods are exacerbating the prevalence of diarrhoeal diseases such as cholera, particularly in the African region.(3) Food insecurity and malnutrition are on the rise due to loss of crops and diminishing biodiversity.(1) It is estimated that between 40 and 300 million people are at the risk of starvation globally as the climate crisis worsens.(1,13) Injuries and displacement of communities due to floods, wildfires and other natural disasters are contributing to the public health crisis. Migration from coastal and rural areas to safer urban areas is on the rise, with informal settlements, overcrowding and unhygienic living conditions further increasing the risk of infectious diseases and the emergence of zoonosis.(1,4,13) Health systems are also bearing the impact of climate change directly as a result of infrastructural damage, interruptions to information and supply chain systems etc.(3) All this adds to the burden on HCPs in already fragile healthcare systems.
The climate health crisis threatens to undermine the achievement of United Nations (UN) sustainable development goals (SDGs), especially SDG 1: ending poverty; SDG 2: ending hunger and SDG 3: achieving good health and wellbeing by 2030, with the latter most reliant on intact and responsive health systems. More than ever before, there is a need to strengthen and establish resilient healthcare systems, led by well-resourced HCPs. These health systems should have increased capacity to absorb and withstand the impact of a worsening climate crisis and at the same time support routine service delivery.
There is an urgent need to develop so called climate and environmental change and health competent HCPs to manage the impact of climate change on health.(14) Climate and environmental change and health competent HCPs should also be able to contribute to the body of knowledge on the impact of climate change on health, particularly in LMICs where there are knowledge gaps.(15) Research studies should include the pathophysiology of climate change and disease, prevention and management thereof as well as evidence to support the effectiveness and efficacy of proposed adaptation – mitigation interventions.(10,15,16)
An adequate response to the impact of climate change on health requires a non-traditional approach that embraces broader, transdisciplinary collaborations and multi-stakeholder engagement outside of health. This includes the establishment of knowledge sharing platforms with experts and key opinion leaders outside of the healthcare industry, e.g. environmentalists, climatologists and engineers. This approach is key to developing a better understanding of the problem and to jointly design and implement comprehensive climate change adaptation-mitigation health interventions.
Finally, although there is a global proliferation of climate health advocacy groups led by HCPs in developed countries, networks such as Doctors for extinction rebellion (17) are mostly based in developed countries, with under-representation in LMICs. Strides in climate and health policy development have been made albeit at a slow pace in sub Saharan Africa. South Africa has led the way through the development and dissemination of the 2020 National Heat Health Action Guidelines.(18) These guidelines will however, need to be translated into actionable activities and this requires an active HCP role and multisector collaboration.
Climate Change and the direct impact on Healthcare Professionals
Evidence is mounting on the direct impact of climate change on the physical and mental wellbeing of individuals including HCPs.(11) HCPs are often exposed to hazardous climate related working conditions, for example, exposure to excessive heat in labour and neonatal units or while delivering community-based health services. Furthermore, the infrastructure of most public health facilities has not been designed to withstand rising temperatures and may in fact worsen the problem, such as the presence of steel rods that absorb heat, lack of proper airflow design resulting in poor airflow, humidity and inadequate clearance of airborne infectious diseases. The result is increased risk of dehydration, heat exhaustion, the emergence of acute respiratory illnesses and worsening of pre-existing NCDs in healthcare workers.(5,10)
Excessive heat is also associated with loss of productivity in workers and HCPs are not exempt from this.(9) The 2019 International Labour Office report states that 2% of the total working hours are projected to be lost every year due to heat.(9) Loss of productivity is often associated with absenteeism, presenteeism and poor staff attitude as HCPs become overwhelmed and are unable to cope. This has direct impact on the quality of care provided and further weakens health systems as demand becomes greater than supply. Therefore, to strengthen health systems, HCPs need to be prepared to protect themselves against the impact of climate change on their immediate health to preserve health service delivery.
Healthcare Professional Response: The Interventions Framework
Healthcare professionals can significantly contribute towards an effective response to the climate and health crisis in various ways. Our unit has proposed an Interventions Framework (Figure 1) designed to outline an approach to interventions that mitigate the impact of climate change on health. This framework can be used to describe the HCP response to climate change heath systems strengthening and includes the following sub-components at various levels of intervention: 1) Promotion of Self-Care; 2) Patient and Community Awareness as part of behavioural change and awareness; 3) Health System Preparedness as part of health systems and new health services; nature-based solutions and the built environment; 4) Climate and Health Advocacy and Policy Advancement as part of policy action, and 5) Capacity Building and Research.
Promotion of Self-Care
The need to protect healthcare professionals from the direct impact of climate change on their health is critical and urgent. Interventions include raising HCP awareness on the impact of climate change on their physical and mental well-being. Examples of prevention- protection measures include adequate hydration, rest between shifts, prevention of NCDs through good nutrition and exercise, and the management of existing medical conditions. Mental screening, referral and management should be offered to HCPs working in adverse working environments. Early Warning Systems (EWS) and messaging, targeted at vulnerable HCPs could be beneficial when temperature thresholds exceed the norm and may assist in the anticipation and adoption of the above measures.(5)
Furthermore, there is a need to minimise HCP work related exposure to excessive weather elements through rigorous occupational health policies that protect HCPs from the effects of climate change. Examples include cool roofing of healthcare establishments where feasible, instalment of indoor temperature monitors, use of cooling devices within facilities, placement of water tanks within the vicinity of working areas. Nature based solution such as planting of trees around facilities will also help mitigate exposure. Other adaptation interventions include use of protective workwear such as encouraging community health workers to wear hats and sunscreen during hot outreach days, provision of light clothing for staff based in excessively hot working environments e.g. neonatal units.
Patient and Community Awareness
Healthcare professionals are at the centre of service delivery and are a trusted resource for patients and the community. HCPs are therefore well positioned to raise awareness on climate change and the impact thereof on population health. This can be done at various touch points: in facilities before and during clinic consultation, at households and within communities. Patient targeted climate related health education materials should be developed and displayed in facilities, and health promotion talks held in waiting areas within facilities. Patients most vulnerable to adverse climate conditions should be identified and adaptation interventions such as hydration, rest and management of existing health conditions advised. Care-packages should include the establishment of referral pathways within and outside of the healthcare industry for vulnerable patients.
Health Systems Preparedness
Key to mitigating the impact of climate change on health systems is preparation for anticipated events. Healthcare professionals are well positioned to support health systems to play an active role in this area. This can be done through vulnerability assessments, disaster management and support for climate related adaptation and mitigation innovations, as described above.
Healthcare professionals can support facility-based vulnerability assessments to determine if facilities are able to withstand the impact of a climate health disaster. To do this, HCPs and other health authorities need to be aware and align themselves with organizations and tools that build technical capacity for vulnerability assessments. For example, WHO Afro ClimHealth is a key resource to building in-country capacity to conduct facility-based vulnerability assessments.(3)
Climate related disasters are becoming more frequent and can either directly impact health systems because of infrastructural damage or indirectly due to referral of acute casualties for emergency assistance. Disaster management requires anticipation, planning and coordination of resources, execution, post-event evaluation and staff debriefing. Planning includes the development of disaster management policies, procedures, treatment protocols, and the allocation of resources. Execution involves triage during climate related events and appropriate referrals. Post event evaluation seeks to strengthen future responses while debriefing aims to build staff resilience to cope with climate crisis events.
Health Systems Adaptation-Mitigation Innovations
Healthcare professionals sensitised to climate change can play a key role towards supporting innovative adaptation-mitigation interventions such as indoor temperature monitoring, roll out and implementation of climate and health indicators as part of routine monitoring and evaluation, roll out of patient targeted EWS and messaging. Patient targeted adaptation interventions include use of fans and promotion of hydration during care. To support mitigation activities, HCPs should be familiarised with tools that quantify carbon emissions and encouraged to contribute to activities that reduce carbon footprints within facilities and in surrounding communities.
Climate Advocacy, Justice and Policy Advancement
Climate Advocacy and Justice
Across the world, HCPs are organizing themselves and are lobbying action to mitigate the climate health crisis. HCPs are using their unique voice to lobby policymakers, multinational corporates and others to prioritise interventions that mitigate the impact of climate change on the health. Advocacy groups led by healthcare professional networks are on the increase, mainly in developed countries. There is an urgent need for similar advocacy groups in LMICs to also promote climate justice for those disproportionately affected by the climate crisis. Healthcare professionals in LMICs should advocate for 1) Policymakers to heed the call for an urgent action to halt or reverse the impact of climate on health; 2) Protection of the most vulnerable populations through evidenced based interventions; 3) Climate funding for investments to strengthen health systems.
Healthcare professionals historically play a critical role in the development and implementation of national health policies and the same should extend to climate and health policy advancement. Contributions to policy should include i) Generation of evidenced based climate and health scientific data and knowledge to inform policy; ii) Technical support to policymakers and other health officials for the translation of science to policy; iii) Policy awareness campaigns for the benefit of the broader community; iv) Policy implementation at sub-national levels; and v) Evaluation of the impact, reach and effectiveness of interventions to further refine policy. This is illustrated in Figure 1 :
Capacity Building and Research
To adequately respond to climate change, HCPs need to develop competency in the field of climate change and health.(14) A comprehensive competency framework that enables transition from novice to expert, can guide the development of such expertise. In this framework (Figure 3), competency is developed through 1) Obtaining factual knowledge on climate change and health; 2) applying meaning and decision making based on factual knowledge; and 3) acting on that knowledge – the ultimate level of competency.(14)
Factual knowledge on climate change and health can be achieved formally through pre, post graduate training at learning institutes and informally through self-learning.(14) Training should accommodate HCPs at different levels of expertise from community health workers to nurses, doctors and specialists, and delivered in different mediums and methodologies. Curriculum for training should adopt non-traditional approaches and include transdisciplinary data science linking climate and environmental data to health data. HCP training curriculum should include rotation to climatology and environmental health departments and vice-versa, to promote transdisciplinary learning and foster joint collaborations on adaptation-mitigation interventions.
There is also a need for HCPs to develop practical skills through the application of theory in real life settings. This can be achieved through placement of HCPs in clinics for the application of theory in a real-life clinic and other environmental settings. Climate and health educational toolkits should be developed and distributed in healthcare facilities to reinforce learning. There should be continuing medical education for new and established HCPs to ensure they remain acquainted with rapidly evolving climate change literature to remain relevant. There is also scope for the introduction of new climate health cadres, i.e. environmental health officers who could be based in communities to augment or complement community health workers.(14)
A clear, well-articulated climate and health research agenda should be incorporated as part of pre and post graduate curriculum in learning and other institutes. This will help generate much needed contextual knowledge on climate change and health, particularly in LMICs. Funding investments for climate change and health research should prioritise pre- and post-graduate students and early career research scientists based in LMICs. There should therefore be a coordinated effort, led by researchers, policymakers, learning institutes and others to lobby for climate funding that prioritises investments in the healthcare industry.
Healthcare professionals are at the centre of health systems strengthening and there is a need for them to be better equipped to effectively respond to the impact of climate change on health. A comprehensive response should be targeted at various intervention components and levels, prioritising the promotion of self-care through to supporting climate advocacy, justice and policy advancement. Capacity building and research build a foundation for this response. This HCP centred intervention approach, if implemented effectively, has the potential to bolster HCPs and strengthen healthcare systems so they will help withstand the impact of climate change.