The Lancet Commissions

Health and climate change: policy responses to protect

public health
Nick Watts, W Neil Adger, Paolo Agnolucci, Jason Blackstock, Peter Byass, Wenjia Cai, Sarah Chaytor, Tim Colbourn, Mat Collins, Adam Cooper,
Peter M Cox, Joanna Depledge, Paul Drummond, Paul Ekins, Victor Galaz, Delia Grace, Hilary Graham, Michael Grubb, Andy Haines, Ian Hamilton,
Alasdair Hunter, Xujia Jiang, Moxuan Li, Ilan Kelman, Lu Liang, Melissa Lott, Robert Lowe, Yong Luo, Georgina Mace, Mark Maslin, Maria Nilsson,
Tadj Oreszczyn, Steve Pye, Tara Quinn, My Svensdotter, Sergey Venevsky, Koko Warner, Bing Xu, Jun Yang, Yongyuan Yin, Chaoqing Yu,
Qiang Zhang, Peng Gong*, Hugh Montgomery*, Anthony Costello*

Executive summary global health opportunity of this century. Many Lancet 2015; 386: 1861–914
The 2015 Lancet Commission on Health and Climate mitigation and adaptation responses to climate change Published Online
Change has been formed to map out the impacts of are “no-regret” options, which lead to direct reductions June 23, 2015
http://dx.doi.org/10.1016/
climate change, and the necessary policy responses, in in the burden of ill-health, enhance community
S0140-6736(15)60854-6
order to ensure the highest attainable standards of health resilience, alleviate poverty, and address global inequity.
See Editorial page 1795
for populations worldwide. This Commission is multi- Benefits are realised by ensuring that countries are
See Comment pages 1798,
disciplinary and international in nature, with strong unconstrained by climate change, enabling them to e27, and e28
collaboration between academic centres in Europe and achieve better health and wellbeing for their populations.
See Online for video
China. These strategies will also reduce pressures on national
*Co-chairs
The central finding from the Commission’s work is health budgets, delivering potentially large cost savings,
Institute for Global Health
that tackling climate change could be the greatest global and enable investments in stronger, more resilient health (N Watts MA, T Colbourn PhD,
health opportunity of the 21st century. The key messages systems. I Kelman PhD,
from the Commission are summarised below, Prof A Costello FMedSc) and
accompanied by ten underlying recommendations to The Commission recommends that over the next 5 years, Institute for Sustainable
Resources (P Agnolucci PhD,
accelerate action in the next 5 years. governments: P Drummond MSc,
1 Invest in climate change and public health research, Prof P Ekins PhD,
The effects of climate change are being felt today, and monitoring, and surveillance to ensure a better Prof M Grubb PhD,
M Lott MSEng), and
future projections represent an unacceptably high and understanding of the adaptation needs and the
Department of Science,
potentially catastrophic risk to human health potential health co-benefits of climate mitigation at Technology, Engineering and
The implications of climate change for a global the local and national level. Public Policy (J Blackstock PhD,
population of 9 billion people threatens to undermine 2 Scale-up financing for climate resilient health systems A Cooper PhD) and Public Policy
(S Chaytor MA) and Energy
the last half century of gains in development and global world-wide. Donor countries have a responsibility to
Institute (I Hamilton PhD,
health. The direct effects of climate change include support measures which reduce the impacts of Prof R Lowe PhD,
increased heat stress, floods, drought, and increased climate change on human wellbeing and support Prof T Oreszczyn PhD, S Pye MSc)
frequency of intense storms, with the indirect adaptation. This must enable the strengthening of and Centre for Biodiversity and
Environment Research
threatening population health through adverse changes health systems in low-income and middle-income
(Prof G Mace DPhil),
in air pollution, the spread of disease vectors, food countries, and reduce the environmental impact of Department of Geography
insecurity and under-nutrition, displacement, and health care. (Prof M Maslin PhD) and
mental ill health. 3 Protect cardiovascular and respiratory health by Institute for Human Health
and Performance
Keeping the global average temperature rise to less ensuring a rapid phase out of coal from the global
(Prof H Montgomery MD),
than 2°C to avoid the risk of potentially catastrophic energy mix. Many of the 2200 coal-fired plants University College London,
climate change impacts requires total anthropogenic currently proposed for construction globally will London, UK; Geography,
carbon dioxide (CO2) emissions to be kept below 2900 damage health unless replaced with cleaner energy College of Life and
Environmental Sciences
billion tonnes (GtCO2) by the end of the century. As of alternatives. As part of the transition to renewable (Prof W N Adger PhD) and
2011, total emissions since 1870 were a little over half of energy, there will be a cautious transitional role for College of Engineering,
this, with current trends expected to exceed 2900 GtCO2 natural gas. The phase out of coal is proposed as part Mathematics and Physical
in the next 15–30 years. High-end emissions projection of an early and decisive policy package which targets Sciences (Prof M Collins PhD,
Prof P M Cox PhD, A Hunter PhD)
scenarios show global average warming of 2·6–4·8°C by air pollution from the transport, agriculture, and and Environment and
the end of the century, with all their regional energy sectors, and aims to reduce the health burden Sustainability Institute
amplification and attendant impacts. of particulate matter (especially PM2.5) and short- (T Quinn PhD), University of
lived climate pollutants, thus yielding immediate Exeter, Exeter, UK; Centre for
Global Health Research, Umea
Tackling climate change could be the greatest global gains for society. University, Umea, Sweden
health opportunity of the 21st century 4 Encourage a transition to cities that support and (Prof P Byass PhD;
Given the potential of climate change to reverse the promote lifestyles that are healthy for the individual M Nilsson PhD); Centre for
health gains from economic development, and the health and for the planet. Steps to achieve this include Earth System Science, Tsinghua
University, Haidian, Beijing,
co-benefits that accrue from actions for a sustainable development of a highly energy efficient building China (W Cai PhD,
economy, tackling climate change could be the greatest stock; ease of low-cost active transportation; and

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 The Lancet Commissions

Prof P Gong PhD, X Jiang PhD, increased access to green spaces. Such measures key health determinants: access to safe water and clean
M Li PhD, L Liang PhD, improve adaptive capacity, whilst also reducing urban air, food security, strong and accessible health systems,
Prof Y Luo PhD, S Venevsky PhD,
Prof B Xu PhD, J Yang PhD,
pollution, greenhouse gas emissions, and rates of and reductions in social and economic inequity. Any
Y Yin PhD, C Yu PhD, cardiovascular disease, cancer, obesity, diabetes, prioritisation in global health must therefore place
Prof Q Zhang PhD); Department mental illness, and respiratory disease. sustainable development and climate change front and
of Politics and International
centre.
Studies, University of
Cambridge, Cambridge, UK Achieving a decarbonised global economy and securing
(J Depledge PhD); Stockholm the public health benefits it offers is no longer primarily The Commission recommends that over the next 5 years,
Resilience Centre, Stockholm a technical or economic question—it is now a political governments:
University, Stockholm, Sweden
one 8 Adopt mechanisms to facilitate collaboration
(V Galaz PhD,
M Svensdotter MSc); Major technical advances have made buildings and between Ministries of Health and other government
International Livestock vehicles more efficient and renewable energy sources far departments, empowering health professionals and
Research Institute, Nairobi, more cost effective. Globally, there is plentiful financial ensuring that health and climate considerations are
Kenya (D Grace PhD);
resource available, however much of it is still being thoroughly integrated in government-wide
Department of Health Sciences,
University of York, York, UK directed towards the fossil-fuel industry. Bold political strategies. A siloed approach to protecting human
(Prof H Graham PhD); London commitment can ensure that the technical expertise, health from climate change will not work. This must
School of Hygiene and Tropical technology, and finance to prevent further significant acknowledge and seek to address the extent to which
Medicine, London, UK
climate change is readily available, and is not a barrier to additional global environmental changes, such as
(Prof A Haines FMedSci); and UN
University Institute for action. deforestation, biodiversity loss, and ocean
Environment and Human acidification, will impact on human health and
Security, Bonn, Germany The Commission recommends that over the next 5 years, decrease resilience to climate change.
(K Warner PhD)
governments: 9 Agree and implement an international agreement
Correspondence to:
5 Establish the framework for a strong, predictable, and that supports countries in transitioning to a low-
Mr Nick Watts, Institute for
Global Health, University College international carbon pricing mechanism. carbon economy. Whilst the negotiations are very
London WC1E 6BT, London 6 Rapidly expand access to renewable energy in low- complex, their goals are very simple: agree on
[email protected] income and middle-income countries, thus providing ambitious and enforceable global mitigation targets,
reliable electricity for communities and health on adaptation of finance to protect countries’ rights to
facilities; unlocking substantial economic gains; and sustainable development, and on the policies and
promoting health equity. Indeed, a global development mechanisms that enable these measures. To this end,
pathway that fails to achieve this expansion will come international responsibility for reducing greenhouse
at a detriment to public health, and will not achieve gas emissions is shared: interventions that reduce
long-term economic growth. emissions and promote global public health must be
7 Support accurate quantification of the avoided burden prioritised irrespective of national boundaries.
of disease, reduced health-care costs, and enhanced
economic productivity associated with climate change Responding to climate change could be the greatest
mitigation. These will be most effective when global health opportunity of the 21st century.
combined with adequate local capacity and political
support to develop low-carbon healthy energy choices. To help drive this transition, the 2015 Lancet
Commission on Health and Climate Change will:
The health community has a vital part to play in 10 Develop a new, independent Countdown to 2030:
accelerating progress to tackle climate change Global Health and Climate Action, to provide expertise
Health professionals have worked to protect against in implementing policies that mitigate climate change
health threats, such as tobacco, HIV/AIDS, and polio, and promote public health, and to monitor progress
and have often confronted powerful entrenched interests over the next 15 years. The Collaboration will be led
in doing so. Likewise, they must be leaders in responding by this Commission, reporting in The Lancet every
to the health threat of climate change. A public health 2 years, tracking, supporting, and communicating
perspective has the potential to unite all actors behind a progress and success along a range of indicators in
common cause—the health and wellbeing of our global health and climate change
families, communities, and countries. These concepts
are far more tangible and visceral than tonnes of Introduction
atmospheric CO2, and are understood and prioritised In 2009, the UCL–Lancet Commission on Managing the
across all populations irrespective of culture or Health Effects of Climate Change called climate change
development status. “the biggest global health threat of the 21st century”.1
Reducing inequities within and between countries is 6 years on, a new multidisciplinary, international
crucial to promoting climate change resilience and Commission reaches the same conclusion, whilst adding
improving global health. Neither can be delivered without that tackling climate change could be the greatest global
accompanying sustainable development that addresses opportunity of the 21st century.

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 The Lancet Commissions

The Commission represents a collaboration between use and human agricultural practice. GHG emissions
European and Chinese climate scientists and geographers, have steadily climbed since the industrial revolution.4
social and environmental scientists, biodiversity experts, CO2 remains in the atmosphere for a long time, with a
engineers and energy policy experts, economists, political part remaining for thousands of years or longer.5 As a
scientists and public policy experts, and health result, atmospheric GHG concentrations have risen
professionals—all seeking a response to climate change steeply in the industrial age, those of CO2 reaching more
that is designed to protect and promote human health. than 400 parts per million (ppm) in 2014, for the first
time since humans walked the planet. Every additional
The physical basis ppm is equivalent to about 7·5 billion tonnes of
The Intergovernmental Panel on Climate Change (IPCC) atmospheric CO2.6,7
has described the physical basis for, the impacts of, and In view of their proven physical properties, such rising
the response options to climate change.2 In brief, short- concentrations must drive a net positive energy balance,
wave solar radiation passes through the Earth’s the additional heat distributing between gaseous
atmosphere to warm its surface, which emits longer atmosphere, land surface, and ocean. The IPCC’s 2014
wavelength (infrared) radiation. Greenhouse gases report confirms that such global warming, and the role of
(GHGs) in the atmosphere absorb this radiation and re- human activity in driving it, are unequivocal. The oceans
emit it, sharing it with other atmospheric elements, and have absorbed the bulk (90% or more) of this energy in
with the Earth below. Without this effect, surface recent years and ocean surface temperatures have risen.8
temperatures would be more than 30°C lower than they However, temperatures at the Earth’s surface have also
are today.3 One such GHG is carbon dioxide (CO2), risen, with each of the last three decades being successively
primarily released when fossil fuels (ie, oil, coal, and warmer than any preceding decade since 1850. Indeed,
natural gas) are burned. Others, such as methane (CH4) 2014 was the hottest year on record. Overall, the Earth
and nitrous oxide (N2O), are generated through fossil-fuel (global average land and ocean temperature) has warmed

Greenhouse
gas emissions

Climate change

Ocean acidification Raised average, and extreme temperatures Other air pollutants
Altered rainfall patterns Sea-level rise Extreme weather (eg, particulates)

Flood Heatwaves Drought Fire Social mediating

factors

Loss of habitation
Reduced fishery Reduced
and aquaculture physical work
productivity capacity
Poverty

Mass migration
Reduced Biodiversity Ozone Particulate Pollen
agricultural loss, ecosystem increase pollution allergenicity
productivity collapse, pests Violent conflict
burden
Bacterial
diarrhoea Other social
determinants of
Undernutrition Impact on Cardiovascular Respiratory Harmful Vector-borne health
mental health disease disease algal blooms disease

Figure 1: An overview of the links between greenhouse gas emissions, climate change, and health
The causal links are explained in greater detail in the section about climate change and exposure to health risks.

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 The Lancet Commissions

by some 0·85°C between 1880 and 2012.8 Arctic sea ice is The health impacts of climate change
disappearing at a rate of up to 50 000 km² per year, the The resultant climate change poses a range of threats to
Antarctic ice sheet is now losing 159 billion tonnes of ice human health and survival in multiple, interacting ways
each year, and sea levels are rising inexorably.9 (figure 1). Impacts can be direct (eg, heatwaves and
Much of past emissions remain in the atmosphere and extreme weather events such as a storm, forest fire,
will drive continued warming in the future. GHG flood, or drought) or indirectly mediated through the
concentrations in the atmosphere are continuing to rise effects of climate change on ecosystems (eg, agricultural
at a rate that is incompatible with limiting warming to losses and changing patterns of disease), economies,
2°C in the coming 35 years (by 2050), and which exceeds and social structure (eg, migration and conflict). After
the IPCC’s “worst case scenario”.10 We are on track for a only 0·85°C warming, many anticipated threats have
global average temperature rise of more than 4°C above already become real-world impacts. Table 1 summarises
pre-industrial temperatures in the next 85 years, at the evidence attributing climate change to specific
which point global temperature will still be increasing extreme weather events, outlining the role that climate
by roughly 0·7°C per decade (due to the lag in reaching change is playing in the present day (2013). It
equilibrium). This distribution will not be even: the so- demonstrates increasing certainty that climate change
called polar amplification phenomena might cause significantly alters the probability of extreme weather,
temperatures in parts of the Arctic to increase by 11°C in most often in directions that have dangerous health
this timeframe.8 consequences.

Summary statement Anthropogenic influence increased event Anthropogenic influence Anthropogenic influence not found or Number
likelihood or strength decreased event uncertain of papers
likelihood or strength
Heat Long-duration heatwaves during Europe heat, 2003 (Stott et al, 200411); Russia heat, ·· ·· 14
the summer and prevailing 2010 (Rahmstorf and Couman, 2011;12 Otto et al,
warmth for annual conditions 201213); USA heat, 2012 (Diffenbaugh and Scherer,
are becoming increasingly likely 2013;14 Knutson et al, 2013);14 Australia heat, 2013
because of a warming planet (Arblaster et al, 2014; King et al, 2014; Knutson
et al, 2014; Lewis et al, 2014; Perkins et al, 2014);15
Europe heat, 2013 (Dong et al, 2014);15 China heat,
2013 (Zhou et al, 2014);15 Japan heat, 2013 (Imada
et al, 2014);15 Korea heat, 2013 (Min et al, 2014)15
Cold Prolonged cold waves have ·· UK cold spring, 2013 UK extreme cold, 2010–11 (Christidis and Stott, 2
become much less likely than they (Christidis et al, 2014)15 2012)16
were previously, such that the
probability of reoccurrence of the
2013 severely cold winter in the
UK might have fallen by 30 times
because of global warming
Heavy Extreme precipitation events UK floods, 2011 (Pall et al, 2011);17 USA seasonal USA Great Plains drought, Thailand floods, 2011 (Van Oldenborgh et al, 14
precipitation were found to have been much precipitation, 2013 (Knutson et al, 2014);15 India 2013 (Hoerling et al, 2012);16 UK summer floods, 2012 (Sparrow et al,
and flood less influenced by human- precipitation, 2013 (Singh et al, 2014)15 2014)15 2013);14 north China floods, 2012 (Tett et al,
induced climate change than 2013);14 southwest Japan floods, 2012 (Imada
extreme temperature events et al, 2013);14 southeast Australia floods (2012);
(King et al, 2013,14 Christidis et al, 2013);14
southern Europe Precipitation, 2013 (Yiou and
Cattiaux, 2014);15 central Europe precipitation,
2013 (Schaller et al, 2014)15
Drought Droughts are highly complex East African drought, 2011 (Funk et al, 2012);16 ·· Central USA drought, 2012 (Rupp et al, 2013);14 9
meteorological events and research Texas drought, 2011 (Rupp et al, 2012);16 Iberian USA California drought, 2013 (Funk et al,
groups have analysed different Peninsula drought, 2011 (Trigo et al, 2012);16 east 2014);16 (Wang and Schubert, 2014)15
factors that affect droughts, such African drought 2012, (Funk et al, 2012);16 New
as sea surface temperature, heat, or Zealand drought, 2013 (Harrington et al, 2014);15
precipitation USA California drought, 2013 (Swain et al, 2014)15
Storms No clear evidence of human ·· ·· USA hurricane Sandy, 2012 (Sweet et al, 4
influence was shown for any of 2013);14 cyclone Christian, 2013 (von Storch
the four very intense storms et al, 2014);15 Pyrenees snow, 2013 (Anel et al,
examined 2014);15 USA south Dakota blizzard, 2013
(Edwards et al, 2014)15
Number of ·· 23 2 18 43
papers

References are in Peterson et al, 2012;16 Peterson et al, 2013;14 Herring et al, 2014;15 or listed separately. Adapted from the Bulletin of the American Meteorological Society.

Table 1: Detection and attribution studies linking recent extreme weather events to climate change

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 The Lancet Commissions

Some population groups are particularly vulnerable to

the health effects of climate change, whether because of Panel 1: Teeth in the tails
existing socioeconomic inequalities, cultural norms, or Tail risks are those whose probability of occurring is low (ie, >2 or 3 SDs from the mean).
intrinsic physiological factors. These groups include The size of the tail and the combination of tails will decide the chance of extreme or
women, young children and older people, people with catastrophic outcomes. Interactions between tail risks greatly affect the risk of several
existing health problems or disabilities, and poor and happening at once—eg, interactions between crop decline and population migration, or
marginalised communities. Such inequalities are often between heatwaves, water insecurity and crop yields. The 2008 global financial crisis is an
also present in relation to the causes of climate change: example. Here, rating agencies catastrophically mispriced the risks of pooled
women and children both suffer the majority of the health mortgage-related securities. For example, Nate Silver showed that if five mortgages, each
impacts of indoor air pollution from inefficient cookstoves with a 5% risk of defaulting, are pooled, the risks of a default of all five is 0·00003% as
and kerosene lighting, and so mitigation measures can long as the default is perfectly uncorrelated.19 If they are perfectly correlated (as almost
help to reduce existing health inequities such as these. happened with the housing crash) the risk is 5%. In other words, if rating agencies
assumed no interaction, their risk would be miscalculated by a factor of 160 000.19
Non-linearities, interactions, and unknown
We must not assume that individual climate tail risks will be uncorrelated. In complex
unknowns
systems, individual events might become more highly correlated when events place the
The magnitude and nature of health impacts are hard to
whole system under stress. For example, in the UK in 2007, flooding threatened electricity
predict with precision; however, it is clear that they are
substations in Gloucestershire. The authorities requested the delivery of pumps and other
pervasive and reflect effects on key determinants of
equipment to keep one of these substations, Walham, from flooding. Loss of the substation
health, including food availability. There are real risks
would have left the whole county, and part of Wales and Herefordshire without power, and
that the effects will become non-linear as emissions and
many people without drinking water. Equipment had to be delivered by road. Parts of the
global temperatures increase. First, large-scale
road system in the region of the substation flooded, which almost prevented the delivery of
disruptions to the climate system are not included in
equipment. Under normal conditions, disturbances to the three subsystems—roads,
climate modelling and impact assessments.18 As we
electricity, and the public water supply—are uncorrelated and simultaneous failure of all
proceed rapidly towards 4°C warming by the end of the
three very unlikely. With extreme flooding they became correlated under the influence of a
century, the likelihood of crossing thresholds and tipping
fourth variable, resulting in a higher than expected probability of all three failing
points rises, threatening further warming and accelerated
together.20,21 Indeed, these extremes of weather, which will occur more frequently with
sea-level rise. Second, small risks can interact to produce
unmitigated climate change, are the ones that are often most important for human health.
larger-than-expected chances of catastrophic outcomes,
especially if they are correlated (panel 1).22,23
Such impacts (and their interactions) are unlikely to be countries, 26% of health facilities had no energy at all and
trivial and could be sufficient to trigger a discontinuity in only 33% of hospitals had what could be called “reliable
the long-term progression of humanity.24 Whilst the electricity provision”, defined as no outages of more than
poorest and most vulnerable communities might suffer 2 h in the past week.28 Solar power is proposed as an ideal
first, the interconnected nature of climate systems, alternative energy solution, providing reliable energy that
ecosystems, and global society means that none will be does not harm cardiovascular or respiratory health in the
immune. Indeed, on the basis of current emission same way that diesel generators do. Clean cookstoves and
trajectories, temperature rises in the next 85 years may fuels will not only protect the climate from black carbon (a
be incompatible with an organised global community.25 very short-lived climate pollutant), but also cut deaths from
household air pollution—a major killer in low-income
The health co-benefits of emissions reduction countries. Buildings and houses designed to provide better
Acting to reduce GHG emissions evidently protects insulation, heating efficiency, and protection from extreme
human health from the direct and indirect impacts of weather events will reduce heat and cold exposure, disease
climate change. However, it also benefits human health risks from mould and allergy, and from infectious and
through mechanisms quite independent of those relating vector-borne diseases.29
to modifying climate risk: so-called health co-benefits of Many other co-benefits exist across different sectors,
mitigation.26 from agriculture to the formal health system. The cost
Reductions in emissions (eg, from burning fossil fuels) savings of the health co-benefits achieved by policies to
reduce air pollution and respiratory disease, whilst safer cut GHG emissions are potentially large. This is
active transport cuts road traffic accidents and reduces particularly important in a context where health-care
rates of obesity, diabetes, coronary heart disease, and expenditure is growing relative to total government
stroke. These are just some of the many health co-benefits expenditure globally. The health dividend on savings
of mitigation, which often work through several causal must be factored into any economic assessment of the
pathways via the social and environmental determinants costs of mitigation and adaptation. The poorest people
of health. Protecting our ecosystems will create the are also most vulnerable to climate change, meaning that
wellbeing we gain from nature and its diversity.27 the costs of global development will rise if we do nothing,
Affordable renewable energy will also have huge benefits and poverty alleviation and sustainable development
for the poorest. WHO found that in 11 sub-Saharan African goals will not be achieved.

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 The Lancet Commissions

This Commission opportunity for evolutionary and revolutionary new

6 years ago, the first Lancet Commission called climate technologies to develop, commercialise, and deploy is
change “the biggest global health threat of the 21st also held open for longer.
century”.1 Since then, climate threats continue to become In section 5, we examine the political processes and
a reality, GHG emissions have risen beyond worst-case mechanisms that might play a part in delivering a low-
projections, and no international agreement on effective carbon economy. Multiple levels are considered,
action has been reached. The uncertainty around including the global response (the UN Framework
thresholds, interactions and tipping points in climate Convention on Climate Change), national and
change and its health impacts are serious enough to subnational (cities, states, and provinces) policy, and the
mandate an immediate, sustained, and globally role of individuals. The interaction between these
meaningful response. different levels, and the lessons learnt from public health
This report further examines the evidence of threat, are given particular attention.
before tabling a prescription for both prevention and Finally, in section 6 we propose the formation of an
symptom management. We begin in section 1 by re- international Countdown to 2030: Global Health and
examining the causal pathways between climate change Climate Action. We outline how an international,
and human health, before offering new estimates of multidisciplinary coalition of experts should monitor and
exposure to climate health risks in the coming decades. report on: the health impacts of climate change; progress
The changes in the spatial distribution of populations, in policy to reduce GHG emissions, and synergies used
and their demographic structure over the coming to promote and protect health; and progress in health
century, will put more people in harm’s way. adaptation action to reduce population vulnerability to
Given that the world is already locked in to a significant build climate resilience and to implement climate-ready
rise in global temperatures (even with meaningful action low-carbon health systems. A Countdown process would
to reduce GHG emissions), section 2 considers measures complement rather than replace existing IPCC reports,
that must be put in place to help lessen their unavoidable and would bring the full weight and voice of the health
health impacts. Adaptation strategies are those that and scientific communities to this critical population
reduce vulnerability and enhance resilience—ie, the health challenge.
capacity of a system to absorb disturbance and re-
organise—so as to retain function, structure, identity, Section 1: climate change and exposure to
and feedbacks.30 We identify institutional and decision- health risks
making challenges related to uncertainty, multicausal No region is immune from the negative impacts of climate
pathways, and complex interactions between social, change, which will affect the natural world, economic
ecological, and economic factors. We also show tangible activities, and human health and wellbeing in every part of
ways ahead with adaptations that provide clear no-regret the world.31 There are already observed impacts of climate
options and co-benefits for food security, human change on health, directly through extreme weather and
migration and displacement, and dynamic infectious hazards and indirectly through changes in land use and
disease risks. nutrition. Lags in the response of the climate system to
Symptomatic intervention and palliation must, historical emissions means the world is committed to
however, be accompanied by immediate action to address significant warming over coming decades.
the cause of those symptoms: the epidemiology and All plausible futures resulting from realistic anticipated
options for scaling up low-carbon technologies and emissions trajectories expose the global population to
technical responses are discussed in section 3, in addition worsening health consequences. In 2014, WHO estimated
to the necessary measures required to facilitate their an additional 250 000 potential deaths annually between
deployment. This section also explores the health 2030 and 2050 for well understood impacts of climate
implications of various mitigation options, with change. WHO suggest their estimates represent lower
particular attention to those which both promote public bound figures because they omit important causal
health and mitigate climate change. pathways. The effects of economic damage, major
Transformation to a global low-carbon economy heatwave events, river flooding, water scarcity, or the
requires political will, a feasible plan, and the requisite impacts of climate change on human security and
finance. Section 4 examines the financial, economic, and conflict, for example, are not accounted for in their global
policy options for decarbonisation. The goal of mitigation burden estimates.32 Without action to address continued
policy should be to reduce cumulative and annual GHG and rising emissions, the risks, and the number of people
emissions. Early emissions reduction will delay climate exposed to those risks, will likely increase significantly.
disruption and reduce the overall cost of abatement by WHO emphasises that the importance of the interactions
avoiding drastic and expensive last-minute action. between climate change and many other trends affecting
Immediate action offers a wider range of technological public health, stressing the need for interventions
options, allows economies of scale and prospects for designed to address climate change and poverty—two key
learning, and will reduce costs over time. The window of drivers of ill health.32 Similarly, the authors of the IPCC

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 The Lancet Commissions

assessment of climate change on health emphasise that dynamics to produce health outcomes. All these risks
the health impacts become amplified over time.21 have social and geographical dimensions, are unevenly
This report provides new insights into the potential distributed across the world, and are influenced by social
exposure of populations, showing that when demographic and economic development, technology, and health
trends are accounted for, such as ageing, migration, and service provision. The IPCC report documents in
aggregate population growth, the populations exposed to expansive detail the scientific knowledge on many
climate change that negatively affect health risk are more individual risks.31 Here, we discuss how these risks could
seriously affected than suggested in many global change globally as a result of a changing climate and of
assessments. It involves new analysis on specific and evolving societal and demographic factors.
direct climate risks of heat, drought and heavy Changes in extreme weather and resultant storm, flood,
precipitation that directly link climate change and drought, or heatwave are direct risks. Indirect risks are
wellbeing. The number of people exposed to such risk is mediated through changes in the biosphere (eg, in the
amplified by social factors: the distribution of population burden of disease and distribution of disease vectors, or
density resulting from urbanisation, and changes in food availability), and others through social processes
population demographics relating to ageing. (leading, for instance, to migration and conflict). These
Thus, human populations are likely to be growing, three pillars, shown in figure 2, interact with one another,
ageing, and migrating towards greater vulnerability to and with changes in land use, crop yield, and ecosystems
climate risks. Such data emphasise the need for action to that are being driven by global development and
avoid scenarios where thresholds in climate greatly demographic processes. Climate change will limit
increase exposure, as well as adaptation to protect development aspirations, including the provision of
populations from consequent impacts. health and other services through impacts on national
economies and infrastructure. It will affect wellbeing in
How climate affects human health material and other ways. Climate change will, for example,
Mechanisms linking climate and health exacerbate perceptions of insecurity and influence aspects
The principal pathways linking climate change with of cultural identity in places directly affected.33
health outcomes are shown in figure 2, categorised as Thus, in figure 2, climate risks might be both amplified
direct and indirect mechanisms that interact with social and modified by social factors. The links between food

Direct effects Indirect effects Social dynamics Health impact

Age and gender Mental illness Undernutrition Allergies

Storms Water quality

Cardiovascular diseases Infectious diseases

Health status

Injuries Respiratory diseases Poisoning

Climate change

Drought Air pollution

Socioeconomic
status

Social capital
Flood Land use change

Public health
infrastructure

Heatwave Ecological change Mobility and

conflict status

Figure 2: The direct and indirect effects of climate change on health and wellbeing
There are complex interactions between both causes and effects. Ecological processes, such as impacts on biodiversity and changes in disease vectors, and social
dynamics, can amplify these risks. Social responses also ameliorate some risks through adaptive actions.

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production and food security in any country, for instance, extreme heat are projected under all scenarios of climate
are strongly determined by policies, regulations and change.38 On an individual basis, tolerance to any change
subsidies to ensure adequate food availability and is diminished in those whose capacity for temperature
affordable prices.34 Vulnerabilities thus arise from the homoeostasis is limited by, for example, extremes of age
interaction of climatic and social processes. The or dehydration. There is a well-established relationship
underpinning science shows that impacts are unevenly between extreme high temperatures and human
distributed, with greater risks in less developed countries, morbidity and mortality.39 There is also now strong
and with specific subpopulations such as poor and evidence that such heat-related mortality is rising as a
marginalised groups, people with disabilities, the elderly, result of climate change impacts across a range of
women, and young children bearing the greatest burden localities.31
of risk in all regions.31 Evidence from previous heatwave events suggests that
In many regions, the consequences of lower socio- the key parameters of mortality risk include the
economic status and cultural gender roles combine to magnitude and duration of the temperature anomaly and
increase the health risks that women and girls face as a the speed of temperature rise. The risks are culturally
result of climate change relative to men and boys in the defined, even temperate cities experience such mortality
same places, although the converse might apply in some as it is deviation from expectations that drives weather-
instances. Whilst in developed countries, males comprise related risks. This is especially true when hot periods
approximately 70% of flood disaster fatalities (across occur at the beginning of summer, before people have
studies in which sex was reported), the converse is acclimatised to hotter weather.38 The incidence of
generally true for disaster-related health risks in heatwaves has increased in the past few decades, as has
developing country settings, in which the overall impacts the area affected by them.40,41
are much greater.35,36 For example, in some cultures The most severe heatwave, measured with the Heat
women may be forbidden from leaving home Wave Magnitude Index, was the summer 2010 heatwave
unaccompanied, are less likely to have learnt how to in Russia.40 More than 25 000 fires over an area of
swim, and may have less political representation and 1·1 million hectares42 raised concentrations of carbon
access to public services. Additionally, women’s and girls’ monoxide, nitrogen oxides, aerosols, and particulates
nutrition tends to suffer more during periods of climate- (PM10) in European Russia. The concentration of
related food scarcity than that of their male counterparts, particulate matter doubled from its normal level in the
as well as starting from a lower baseline, because they are Moscow region in August, 2010, when a large smoke
often last in household food hierarchies.37 plume covered the entire capital.43 In combination with
the heat wave, the air pollution increased mortality
Direct mechanisms and risks: exposure to warming and between July and August, 2010, in Moscow, resulting in
heatwaves more than 11 000 additional deaths compared with July to
While societies are adapted to local climates across the August, 2009.44 Projections under climate scenarios show
world, heatwaves represent a real risk to vulnerable that events with the magnitude of the Russian heatwave
populations and significant increases in the risks of of 2010 could have become much more common and

A B
6 SSP3 plus RCP8·5
2010 population plus RCP8·5
SSP1 plus RCP2·6
50 5 2010 population plus RCP2·6
Mean warming experienced (K)

4
0
3

–50 2

−150 −100 −50 0 –5 100 150

K 0
2020 2040 2060 2080 2100
1 2 3 4 5 6 7 Year

Figure 3: Exposure to warming resulting from projections of 21st century climate and population change
Changes in summertime temperatures (June–July–August for the northern hemisphere, and December–January–February for the southern hemisphere) between
1995 and 2090, for the RCP8.5 scenario, using the mean of the projections produced by the CMIP5 climate models (A). Change in the mean warming experienced by
a person under RCP8.5 (red lines) and RCP2.6 (blue lines), calculated using the 2010 population (dashed lines), and time-varying future population scenarios
(continuous lines; B). To encompass the range of possible exposures, we have paired the high-growth SSP3 population scenario with RCP8.5 and the low-growth
SSP1 population scenario with RCP2.6. RCP=Representative Concentration Pathway.

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with high-end climate scenarios could become almost relative to an area’s average temperature does more
the summer norm for many regions.40,45 clearly correlate with mortality rates.46,47 There may be
Rising mean temperatures mean that the incidence of modest reductions in cold-related deaths; however, these
cold events is likely to diminish. The analysis here reductions will be largely outweighed at the global scale
focuses on the heat-related element because the health by heat-related mortality.46 Whilst climate change will
benefits of reductions in cold are not established. Whilst have an impact on cold-related deaths, particularly in
there is an increase in deaths during winter periods in some countries with milder climates, the overall impact
many climates, the mechanisms responsible for this is uncertain.48,49
increase are not easily delineated. Most winter-related Population growth, urbanisation trends, and migration
deaths are cardiovascular, yet the link between patterns mean that the numbers exposed to hot
temperature and cardiovascular mortality rates is weak. temperature extremes, in particular, will increase, with
There is a stronger link between respiratory deaths and major implications for public health planning. Urban
colder temperatures but these account for a smaller areas will expand: urban land cover is projected to triple
percentage of winter deaths.46 by 2030 from year 2000 levels.50 Many assessments of
The impact of cold temperatures can be measured climate risks, including those for heat, do not consider
considering seasonal means, extreme cold spells, and the detail of demographic shifts, in effect, overlooking
relative temperature changes. Seasonal means and the location of vulnerable populations as a part of the
extreme cold spells (or absolute temperature) have calculus. We have produced models that consider both
relatively small or ambiguous relationships with climate and population projections. We use Shared
numbers of winter deaths, however temperature cooling Socioeconomic Pathway (SSP) population projections to

A B

50 50

0
0

–50
–50

−150 −100 −50 0 50 100 150

Ratio −150 −100 −50 0 50 100 150
0·1 0·5 0·9 1·3 1·7 2·1 2·5 2·9 Exposure events per km2 per year

25 50 75 100 150 200 275 500

C D
Change with population and demographic change
Change without population and demographic change
Change in exposure events (billions per year)

50 3

0
2

–50
1

−150 −100 −50 0 50 100 150

Exposure events per km2 per year 0
2020 2030 2040 2050 2060 2070 2080 2090
25 50 75 100 150 200 275 500 Year

Figure 4: Changing exposure to heatwave resulting from projections of 21st century climate and population and demographic change
Change in heatwave frequency between 1995 and 2090 for the RCP8.5 scenario, in which a heatwave is defined as more than 5 consecutive days for which the daily
minimum temperature exceeds the summer mean daily minimum temperature in the historical period (1986–2005) by more than 5°C (A). Change in the mean
number of heatwave exposure events annually per km2 for people older than 65 years as a result of the climate change in panel A and assuming the 2010 population
and demography (B). The same scenario as for panel B, but for the 2090 population and demography under the SSP2 population scenario (C). Time series of the change
in the number of annual heatwave exposure events for people older than 65 years with (red line) and without (blue line) population and demographic change (D).

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A B

50 50

0
0

–50
–50

−150 −100 −50 0 50 100 150

−150 −100 −50 0 50 100 150 Person-years per km2 per year
K
1 2·5 5 10 25 50
1 2 3 4 5 6 7

C D
SSP2
2010

50
Labour lost (million person-years)
250

150

–50

−150 −100 −50 0 50 100 150

50
Person-years per km2 per year

1 2·5 5 10 25 50 2020 2040 2060 2080 2100

Year

Figure 5: Change in outdoor labour productivity resulting from projections of 21st century climate and rural population change
Change in summer mean (June–July–August for the northern hemisphere, and December–January–February for the southern hemisphere) wet-bulb globe
temperature65 for the RCP8.5 scenario (A). Annual loss of outdoor labour productivity due to the climate change in panel A and assuming the 2010 rural population
(B). The same scenario as for panel B, but for the 2090 rural population under the SSP2 population scenario (C). Time series of the annual loss of outdoor labour with
(red line) and without (blue line) rural population change (D).

calculate future demographic trends alongside Coupled person) might also be extensively driven by demographics,
Model Intercomparison Project Phase 5 (CMIP5) climate shown as the divergence between red and blue lines
models (as used in the IPCC 5th Assessment report) and driven by different warming and population scenarios
projected emission pathways (so-called Representative across the incoming decades. In other words, population
See Online for appendix 1 Concentration Pathways [RCPs]).51–54 Appendix 1 outlines change in areas of the world where population growth is
assumptions, together with the data and the climate and significant, fundamentally affects the increase in numbers
population scenarios used to estimate the scale of various of people exposed to the impacts of climate change.
health risks for the 21st century, shown in figures 3–7. Whilst hotter summers increase vulnerability to heat-
The projected global distribution of changes in heat in related morbidity, heatwaves in particular have a negative
the coming decades is shown in figure 3A using the high- impact on health. Figure 4 re-analyses projections from
emission projections of RCP8.5, as explained in the latest climate models (the CMIP5 models as used in
appendix 1. This focuses on summer temperatures, hence the IPCC 5th Assessment report) in terms of the number
the graph represents the summer months for both the of exposure events per year for heatwaves. Heatwaves here
northern (June to August) and southern (December to are defined as 5 consecutive days of daily minimum night-
February) hemispheres. Climatic impact will not be time temperatures more than 5°C greater than the
experienced uniformly across the globe. At such levels of presently observed patterns of daily minimums. Although
warming, the return period of extreme heat events, such heatwaves have different characteristics, this definition
as those experienced in 2003 in western Europe, is focuses on health impacts based on deviation from normal
significantly shortened. Figure 3B makes clear that future temperature, duration, and extent.
health risks arising from exposure to warming (measured Elderly populations are especially vulnerable to
as the mean temperature increase experienced by a heatwaves, and demographic and climatic changes will

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A B

50 50

0
0

–50
–50

−150 −100 −50 0 50 100 150 −150 −100 −50 0 50 100 150
Ratio Exposure events per km2 per year

0·3 0·7 0·9 1·1 1·3 1·5 2 25 50 75 100 150 200

C D
SSP2
1·4
2010
Change in exposure events (billions per year)

50

1·0
0

–50 0·6

−150 −100 −50 0 50 100 150

Exposure events per km2 per year 0·2
2020 2030 2040 2050 2060 2070 2080 2090
25 50 75 100 150 200 Year

Figure 6: Changing exposure to drought resulting from projections of 21st century climate and population change
Change in drought intensity between 1995 and 2090 for the RCP8.5 scenario, defined as the ratio of the mean annual maximum number of consecutive dry days
(2080–99, 1986–2005), in which a dry day is any day with less than 1 cm of precipitation (A). Change in the mean number of drought exposure events annually per
km² as a result of the climate change in panel A and assuming the 2010 population (B). The same scenario as for panel B, but for the 2090 population under the SSP2
population scenario (C). Time series of the change in the number of annual drought exposure events with (red line) and without (blue line) population change (D).

combine to shape population heatwave vulnerability in hot humid environments is a particular health and
coming decades (figure 4).55 We use populations economic risk to millions of working people and their
projected over 65 years of age rather than a frailty index, families in hot tropical and sub-tropical parts of the
recognising the underlying health of elderly populations world.59 These have been documented in young and
and the cultural context of ageing are both likely to middle-aged men in France 2003,60 agricultural workers
change over time.56 Educational levels and other in the USA,61 and sugar-cane harvesters in Central
demographic factors are also important in the ability of America.62 The Climate Vulnerability Monitor 2012
societies to cope with extreme events.57 Allowing for estimated the annual costs in China and India at
these caveats, figure 4D shows growing exposure in US$450 billion in 2030.63 The percentage of GDP losses
global projections of the number of people older than due to increasing workplace heat is greater than the
65 years exposed to heatwave risks. The numbers of current spending on health systems in many low-income
events of elderly people experiencing high temperatures and middle-income countries.64
reaches more than 3 billion towards the end of the Impacts of heat on labour productivity will be
century. A key message is that demographic change compounded in cities by increased urbanisation and the
added to climate changes will expose increasing corresponding heat island effect, but will also be offset by
numbers of elderly people to increasing numbers of reductions in populations working outdoors in sectors
heat waves, especially in the developed and transition (eg, construction and agriculture).38 Tolerance to any
economies. given temperature will be influenced by humidity, which
Heat also poses significant risks to occupational health alters the capacity for thermoregulation through the
and labour productivity in areas where people work evaporation of sweat. These measures are combined in
outdoors for long hours in hot regions.58 Heavy labour in an index known as wet-bulb globe temperature (WBGT),

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 The Lancet Commissions

used to determine how long an individual can work growth.74 Cholera is transmitted through infected water
before a break, with work capacity falling substantially sources and often occurs in association with seasonal
after WBGT 26–30°C.58 algal blooms with outbreaks sometimes experienced
Using projections from RCP8.5 and SSP2, figure 5 following extreme weather events such as hurricanes
estimates the extent of lost labour productivity (on the that result in the mixing of wastewater and drinking
basis of the response function between temperature and water, and in association with El Niño events.72 Such
productivity used by Dunne et al, 201265) across the coming extreme weather events are likely to increase in frequency
decades, focusing on proportion of the labour force in in the coming decades and waterborne epidemics need
rural and urban areas. Again the impact of climate change to be planned for and monitored carefully.
is greater in regions such as sub-Saharan Africa and India. In effect, all health outcomes linked to climate variables
But some trends offset the potential impact, including the are shaped by economic, technological, demographic, and
trend towards employment in service and other sectors governance structures. Institutions and social norms of
where exposure is reduced (assumed in the SSP2 used behaviour and expectation will play a significant part in
here; figure 5C, D). As demographic trends towards urban how new weather patterns impact health.38,71 Changes in
settlement and secondary and tertiary sector employment temperature, precipitation frequency, and air stagnation
progress, increasing urbanisation may reduce the negative also affect air pollution levels with significant risks to
impacts of warming on total outdoor labour productivity, health. Climate affects pollution levels through pollutant
depending on the population scenario (SSP2 in figure 5D). formation, transport, dispersion, and deposition. In total,
Loss of agricultural productivity through impaired fine particulate air pollution is estimated to be responsible
labour will be amplified by direct climate change impacts for 7 million additional deaths globally in 2012, mainly due
on crop and livestock production.66 The impact of to respiratory and cardiovascular disease.75 Its effect is
increasing temperatures on labour productivity can be amplified by changes in ambient temperature, precipitation
mitigated—eg, by use of air conditioning or by altering frequency, and air stagnation—all crucial for air pollutant
working hours. However, these actions are predicated on formation, transport, dispersion and deposition.
affordability, infrastructure, the suitability of a job to Ground-level ozone (GLO) and particulate air pollutants
night labour, and energy availability.67 are elements that will be most affected by climate change.
Whilst the net global effect is unclear, regional variation
Indirect and complex mechanisms linking climate will see significant differences in local exposure.31,76 GLO is
change and health more readily created and sustained in an environment
Most climate-related health impacts are mediated through with reduced cloudiness and decreased precipitation
complex ecological and social processes. For risks frequency, but especially by rising temperatures.77 Thus,
associated with transmission vectors and water, for ozone levels were substantially elevated during the
example, rising temperatures and changes in precipitation European heatwave of summer 2003.76,78 Climate change is
pattern alter the viable distribution of disease vectors predicted to elevate GLO levels over large areas in the
such as mosquitoes carrying dengue or malaria. Climate USA and Europe, especially in the summer, although the
conditions affect the range and reproductive rates of background of GLO in the remote areas shows a decreased
malarial mosquitoes and also affect the lifecycle of the trend.77,79–82 In the USA, the main impact of future climate
parasitic protozoa responsible for malaria. The links change on GLO is centred over the northeast and mid-
between climate change, vector populations and hence west where the future GLO are expected to increase by
malarial range and incidence may become significant in 2–5 ppbv (about 3–7%) in the next 50–90 years under the
areas where the temperature is currently the limiting IPCC A1 scenario.79,81 Knowlton and colleagues estimated
factor, possibly increasing the incidence of a disease that that ozone-related acute mortality in the USA would rise
causes 660 000 deaths per year.68 In some highland by 4·5% from 1990 to 2050, through climate change
regions, malaria incidence has already been linked to alone.83 Likewise, climate change is predicted to increase
warmer air temperatures although successful control concentrations of fine particulate matter (2·5 micron
measures in Africa have cut the incidence of malaria in particles [PM2.5]) in some areas.80,84
recent decades, and there are long established successes The interactions between air pollution and climate are
of managing malaria risk in temperate countries highly differentiated by region. In China, for example, the
including in southern USA and in Europe.69,70 There are interactions between climate and a range of pollutants is
equally complex relationships and important climate- especially acute. While action on carbon emissions
related risks associated with dengue fever, cholera and dominate energy policy in China, climatic changes will
food safety.54,71,72 Dengue fever for example has 390 million have a significant impact on air pollutants in all regions
recorded infections each year, and the number is rising.54,73 of the country.84,85 Chinese ozone concentrations in 2050
Changing weather patterns are also likely to affect the have been projected to likely increase beyond present
incidence of diseases transmitted through infected water levels under many climate scenarios through the
sources, either through contamination of drinking water combined effects of emissions and climate change. The
or by providing the conditions needed for bacterial greatest rises will be in eastern and northern China.85

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Compared with ozone, PM2.5 levels rely more on changes Increased frequency of floods, storm surges, and
in emissions than temperature. The concentrations of hurricanes will have a substantial effect on health.
SO4²−, black carbon and organic carbon are projected to Extreme events have immediate risks, exemplified by
fall, but those of NO3− to rise, across China under many more than 6000 fatalities as a result of typhoon Haiyan in
possible climate futures.84 Levels of aerosols (especially the Philippines in late 2013. Floods also have long-term
NO3−) in the eastern Chinese spring will be especially and short-term effects on wellbeing through disease
affected by 2030. Falling emissions would reduce overall outbreaks, mental health burdens, and dislocation.93
PM2.5 concentrations by 1–8 μg/m³ in 2050 compared with Risks related to water shortages, flood, and other
those in 2000 despite a small increase (10–20%) driven by mechanisms involve large populations. Projections
climate change alone.84 Although emission changes play a suggest, for example, that an additional 50 million people
key part in projections, climate-driven change should not and 30 000 km² of land could be affected by coastal storm
be ignored if warming exceeds 2°C. PM2.5 is sensitive to surges in 2100, with attendant risks of direct deaths and
precipitation and monsoon changes and global warming of infectious diseases.94,95 Involuntary displacement of
will alter Chinese precipitation seasonally and regionally, populations as a result of extreme events has major
thereby changing the regional concentration of PM2.5.76,86 public health and policy consequences. In the longer
Independent of climate change, China’s air pollution has term, flooding affects perceptions of security and safety,
already come at great cost, with an annual pollution- and can cause depression, anxiety, and post-traumatic
related mortality of 1·21 million in 2010.87 stress disorder.93,96
Climate change has important implications for Figure 7 shows estimates of extreme precipitation
livelihoods, food security, and poverty levels, and on the events (events exceeding 10 year return period) under
capacity of governments and health systems to manage the RCP8.5 (high-emission) scenario. We estimate that
emerging health risks. Crops and livestock have there would be around 2 billion additional extreme
physiological limits to their health, productivity, and rainfall exposure events annually (individuals exposed
survival, which include those related to temperature. For once or multiple times during any year), partly due to
every degree greater than 30°C, the productivity of maize population growth in exposed areas and partly due to
production in Africa might be reduced by 1% in optimum the changing incidence of extreme events associated
conditions and 1·7% in drought, with a 95% chance of with climate change. Whilst not all extreme rainfall
climate change-related harm to the production of South events translate into floods, such extreme precipitation
African maize and wheat in the absence of adaptation.88,89 will inevitably increase flood risk. Regions of large
Sensitivity of crops and livestock to weather variation population growth dominate changes in the number
has a substantial impact on food security in regions that exposed to flood risk (especially in sub-Saharan Africa
are already food insecure, pushing up food prices and and South Asia).97
ultimately affecting food availability and affordability to All these climate-related impacts are detrimental to the
poor populations and contributing to malnutrition.90 security and wellbeing of populations around the world.
This effect is amplified by polices on food stocks, Whilst there is, as yet, no definitive evidence that climate
reactions to food prices by producer countries, and by the change has increased the risk of violent civil conflict or
global demand for land to hedge against climate shifts. war between states, there are reasons for concern. The
The increased volatility of the global food system under IPCC concludes that climate change will directly affect
climate change has impacts on labour, on farmer poverty, resource uncertainty and volatility, and the ability
livelihoods and on consumers of food, with attendant of governments to fulfil their obligations to protect
health outcomes for all these groups.66 settlements and people from weather extremes.33,98 These
Within this complex relationship between climate and factors are important correlates of violent conflict within
food security, the availability of water for agricultural states, suggesting that climate change is detrimental to
production is a key parameter. Figure 6 shows very peaceful and secure development, even if they do not
significant changes in exposure to drought-like directly enhance conflict risks.99 Similarly, migration has
meteorological conditions over the coming decades. The significant complex consequences for human security.
analysis shows that the population changes (from SSP2) The continued movement of migrant populations into
alongside climate change could lead to 1·4 billion cities, the potential for climate hazards in high-density
additional person drought exposure events per year by the coastal mega-cities, and impaired air quality create
end of the century. Importantly, the geographical significant public health challenges, not least for
distribution of this exposure is highly localised and migrants themselves.100,101
variable (eg, across Asia and Europe), acutely degrading The direct and indirect effects of climate change
water supply and potentially quality. But all such estimates outlined here represent significant risks for human
focus on availability of surface water, whereby both long- health. The precautionary case for action is amplified
term water availability and supply for specific regions are with three additional dimensions: (1) interventions to
also affected by groundwater resources, which have been adapt to evolving climate risks as discussed in section 2
shown to be in a critical state in many regions.91,92 might not be as effective as required; (2) unforeseen

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A B

50 50

0 0

–50 –50

−150 −100 −50 0 50 100 150 −150 −100 −50 0 50 100 150
Ratio Exposure events per km2 per year

0·3 0·7 0·9 1·1 1·3 1·5 2 25 50 75 100 150 200 275

C D
SSP2
2010

Change in exposure events (billions per year)

50 2·0

1·5
0

1·0
–50

0·5
−150 −100 −50 0 50 100 150
Exposure events per km2 per year
2020 2030 2040 2050 2060 2070 2080 2090
25 50 75 100 150 200 275 Year

Figure 7: Changing exposure to flood resulting from projections of 21st century climate and population change
Change in flood frequency between 1995 and 2090 for the Representative Concentration Pathway (RCP) 8.5 scenario, in which a flood event is defined as a 5 day
precipitation total exceeding the 10 year return level in the historical period (1986–2005; A). Change in the mean number of flood exposure events annually per km²
due to the climate change in panel A and assuming the 2010 population (B). The same scenario as for panel B, but for the 2090 population under the SSP2
population scenario (C). Time series of the change in the number of flood exposure events with (red line) and without (blue line) population change (D).

interactions and amplifications of climate risks are the formal health system. Responses aim to reduce the
possible (eg, emerging zoonotic and other diseases being underlying vulnerability of populations; empower actors
affected through complex ecological changes, covered in to cope or adapt to the impacts; and whenever possible
more detail in the Lancet Commission on Planetary support longer-term development. The health sector has
Health); (3) the risk that tipping elements in the climate a central part to play in leading climate change adaptation
system could rapidly accelerate climate change at and resilience efforts.102,103 However, effective adaptation
regional or global scale. Lags in warming and climate measures must cross multiple societal sectors, identify
impacts mean that irrespective of the mitigation pathway ways to overcome barriers to achieve co-benefits, and
taken, many impacts and risks will increase in the target vulnerable groups and regions.
coming decades. Early action to address vulnerability allows for more
options and flexibility before we face indispensable and
Section 2: action for resilience and adaptation involuntary adaptation.104,105 Panel 2 provides definitions
Adaptation measures are already required to adapt to the of vulnerability, adaptation, and resilience.
effects of climate change being experienced today. As
shown in section 1, these risks will increase as worsening Adaptation to the direct health impacts of climate
climate change affects more people, especially in highly change
exposed geographical regions and for the most vulnerable The direct health impacts result from extreme weather
members of society. events such as storms, floods, droughts, and heatwaves.
This section outlines possible and necessary actions to Many responses centre on the importance of health
limit the negative impacts and burden on human health, system strengthening; however, actions in other sectors
including direct and indirect impacts within and beyond are also needed.

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Early warning systems for extreme events

Approaches to the health management of extreme Panel 2: Vulnerability, adaptation, and resilience
weather events involve improved early warning systems Vulnerability is here defined as the degree to which a system
(EWS), effective contingency planning, and identification is susceptible to, or unable to cope with, the adverse effects of
of the most vulnerable and exposed communities.111 climate change.106 This definition considers demographics,
They include forecasting, predicting possible health geographical circumstances, effectiveness, and coverage of
outcomes, triggering effective and timely response the health-care system, pre-existing conditions, and
plans, targeting vulnerable populations, and socioeconomic factors such as inequity.107
communicating prevention responses. Public health
Adaptation to climate change is here defined as “the process
authorities need to upgrade existing emergency
of adjustment to actual or expected climate and its effects, in
programmes and conduct exercises to enhance
human systems in order to moderate harm or exploit
preparedness for anticipated health risks due to new
beneficial opportunities, and in natural systems human
extreme events such as sea level rise, saline water
intervention may facilitate adjustment to expected
intrusion into drinking water courses, and severe
climate”.108
flooding from storm surges. These efforts to improve
disaster preparedness must also run in parallel with Resilience is here defined as the capacity of a system to
efforts to strengthen local community resilience. absorb disturbance and reorganise while undergoing change,
so as to still retain essentially the same function, structure,
Actions to reduce burdens of heatwaves identity and feedbacks.30 Resilience has also been referred to
The frequency, intensity, and duration of extreme heat the ability of human communities to withstand external
days and heatwaves will increase with climate change, shocks to their social infrastructure.109 Resilience includes the
leading to heat stress and increased death rates (see capacity of a system to not only absorb a disturbance, but to
section 1). The effects are worsened by the so-called innovate and transform.110
urban heat island effect, which results from greater heat
retention of buildings and paved surfaces, compared
with reflective, transpiring, shading, and air-flow- Panel 3: Adaptation to floods and storms in Bangladesh
promoting vegetation-covered surfaces. Evidence
In a mid-range climate-sensitivity projection, the number
suggests that effective adaptation measures would reduce
of people flooded per year globally is expected to increase
the death rates associated with these heat waves. The
by 10–25 million per year by 2050.117 Bangladesh is one of
2003 European heatwave, which killed up to 70 000 people
the most vulnerable countries to climate change in south
led France to introduce a heatwave warning system and a
Asia, regularly suffering from events such as flooding,
national action plan.111 Health worker training was
cyclones, or coastal erosion, which cause inundation of
modified, urban planning altered, and new public health
farmlands, affect migration, and lead to displacement.118
infrastructure developed. The 2006 heatwave suggested
More than 5 million Bangladeshis live in areas highly
that these measures had been effective, with 4400 fewer
vulnerable to cyclones and storm surges, and more than
anticipated deaths.112
half the population lives within 100 km of the coast.119 In
Adaptation options within health care include training
2007, cyclone Sidr killed roughly 4000 people in
of health-care workers and integrated heatwave early
Bangladesh. By comparison, an equivalent storm in 1970
warning systems (HEWS), especially for the most
killed 300 000 people.120 Bangladesh achieved this
vulnerable populations.111,113 Adaptation measures also
reduction in mortality via collaborations between
include increasing green infrastructures and urban
governmental and non-governmental organisations and
green spaces, improving the design of social care
local communities. Together, these groups improved
facilities, schools, other public spaces, and public
general disaster reduction, deployed early warning systems,
transport to be more climate-responsive.113,114 This also
and built a network of cyclone shelters.31
entails mitigating effort to reduce air pollutants, which in
turn reduces air quality related morbidity and mortality.115
of funds for efforts to control floods. However, the
Floods and storms construction of flood control works may have a
In general, adaptive measures to floods can be classified maladaptive effect, encouraging more rapid economic
as structural or non-structural. Infrastructure such as development of the flood plains, and hence ultimately
reservoirs, dams, dykes, and floodways can be used to increasing flood losses.116
keep flooding away from people and property. In some Adaptation to flood risk requires comprehensive
areas there is also the possibility to incorporate floodable approaches (panel 3). Non-structural measures include
low-lying areas into the urban design that can be flood insurance, development policies, zoning laws,
temporarily under water during an extreme event. flood-plain regulations, building codes, flood proofing,
Structural programmes are considered by many flood tax incentives, emergency preparedness, flood fore-
managers as a priority and are also the principal source casting, and post-flood recovery.116,121 Non-structural flood

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 The Lancet Commissions

adaptation options aim to reduce flood damages and Important adaptation options for food security action include:
enhance the ecological functions of flood plains. Many • Enhancement of food security through improved
opportunities to increase resilience to extreme weather ecosystem based management and ecosystem
events are found in improved planning, zoning, and the restoration. Case studies show the benefits of
management of land use. These have the additional implementing strategies to improve ecosystem
advantage of providing multiple co-benefits (see management as a means to increase not only food
ecosystem-based adaptation below). security, but also to achieve other social goals. Examples
include collaborative management of mangrove forests
Action for resilience to indirect impacts to promote conservation, mitigation of climate change
Adaptation to indirect effects poses difficult challenges to and alleviation of poverty among people dependent on
policy making due to complex causal chains and limited the mangroves and adjacent marine ecosystems.125
predictibility.122 These complex interactions can result in Such strategies require supportive institutions,
“surprises”—situations in which the behaviour in a partnerships, collaboration with farmers’ innovation
system, or across systems, differs qualitatively from networks, and connections from sustainable farms to
expectations or previous experiences. These indirect markets.129,131 Similar strategies have recently been
impacts pose serious obstacles for climate adaptation, explored for fisheries and aquaculture.134
especially where health responses require integrated and • Increased investments in agricultural research and
cross-sectoral interventions.123 human capital are often raised as an important strategy
to improve yields and long-term food security.131
Food insecurity Agricultural research and development (R&D) has
Food insecurity and its health impacts play out at the local proven to have high economic rates of return.135
level, but have clear links to drivers and changes at the Innovative crop insurance mechanisms, new uses of
national and international level. The compounded information technology, and improved weather data
impacts of climate change and ocean acidification will also hold promise for increased agricultural
affect both agricultural production and fisheries, production.136 Education in agricultural areas is critical
including food availability and prices.124 –126 Adaptation to enhance the diffusion of technologies and crop
policies should consider agro-food systems and fisheries management, and as a means to increase household
and aquaculture alike. incomes and promote gender equality.131,137
Resilience to increased food insecurity and price • Increased investments in rural and water
volatility is of great importance to human health. Food infrastructure. Investment is essential for situations in
security could be enhanced while simultaneously which underdeveloped infrastructure results in poor
ensuring the long-term ability of ecosystems to produce supply chains and large food losses. Investments
multiple benefits for human wellbeing (panel 4). Issues could boost agricultural production, reduce price
such as improved local ecosystem stewardship (see volatilities, and enhance food security in the long
section on ecosystem-based adaptation), good term. The investments required in developing
governance, and international mechanisms to enhance countries to support this expansion in agricultural
food security in vulnerable regions are of essence.130,131 output have been estimated to be an average annual
Even though the drivers of increased food prices and net investment of US$83 billion (not including public
price volatilities are contested, investment in improved goods such as roads, large scale irrigation projects,
food security could provide multiple co-benefits and no- and electrification).131
regret options.132,133 • Enhanced international collaboration. International
collaboration is critical for food security in food
insecure regions. Early warning systems, financial
Panel 4: Food security, climate change, and human health support, emergency food and grain reserves, the
Today, agriculture uses 38% of all ice-free land areas and ability to scale up safety nets such as child nutrition
accounts for 70% of freshwater withdrawals and roughly a schemes, and capacity building play a key part in
third of global greenhouse gas emissions.127 The provision for emergency responses to food crises, and can be
global food demand by 2050 cannot assume improved crop supported by international organisations.131,138
yields through sustainable agricultural intensification because
of the negative effects on crop growth from an increased Environmental migration
frequency of weather extremes. Multifunctional food Changes in human mobility patterns have multiple
production systems will prove important in a warmer world. drivers,139 and range from large-scale displacement (often
These systems are managed for benefits beyond yield, and in emergency situations), to slow-onset migration (in
provide multiple ecosystem services, support biodiversity, which people seek new homes and livelihoods over a
improve nutrition, and can enhance resilience to shocks such lengthy period of time as conditions in their home
as crop failure or pest outbreaks. 128,129 communities worsen).140 The efficacy of national and
international policies, institutions, and humanitarian

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 The Lancet Commissions

responses also influence whether people are able to cope

Panel 5: Mental health impacts and interventions
with the after-effects of natural hazard in a manner that
allows them to recover their homes and livelihoods.141 Climate change affects mental health through various
Displacement occurs when choices are limited and pathways by inflicting natural disasters on human
movement is more or less forced by land loss, for example settlements and by causing anxiety-related responses, and
due to extreme events.142 Population displacement can later chronic and severe mental health disorders, and
further affect health through increased spread of implications for mental health systems.147,148 These effects will
communicable diseases and malnutrition, resulting from fall disproportionately on individuals who are already
overcrowding and lack of safe water, food, and shelter.143 vulnerable, especially for indigenous people and those living
Additional impacts on economic development and political in low-resource settings.147 Additionally, individuals might
instability could develop, generating poverty and civil feel a distressing sense of loss, known as solastalgia, that
unrest that will exacerbate the population burden of people experience when their land is damaged and they lose
disease.1,143 amenity and opportunity.149
Existing vulnerabilities will determine the degree to Elevated levels of anxiety, depression, and post-traumatic
which people are forced to migrate.144 The availability of stress disorders have been reported in populations who have
alternative livelihoods or other coping capacities in the experienced flooding and during slow-developing events
affected area generally determines the scale and form of such as prolonged droughts;93,96 impacts include chronic
migration that may take place. Conflict undermines the distress and increased incidence of suicide.150,151 Even in high-
capacity of populations to cope with climate change, income regions where the humanitarian crisis might be less,
leading to greater displacement than might have been the impact on the local economy, damaged homes, and
the case in a more stable environment. Conflicts have economic losses can persist for years after natural disasters.152
also been shown to reduce mobility and trap populations Government and agencies now emphasise psychological and
in vulnerable areas, exposing politically marginalised psychosocial interventions within disaster response and
populations to greater environmental risks.145 emergency management. Social adaptation processes can
Migration from both slow and rapid-onset crises is mediate public risk perceptions and understanding,
likely to be immediately across borders from one poor psychological and social impacts, coping responses, and
country into another. Receiving countries could have few behavioural adaptation.153
resources and poor legal structures or institutional
capacity to respond to the needs of the migrants.
Destination areas may face similar environmental 2 Reducing the impact of environmental change through
challenges (eg, drought or desertification) and may offer early warning systems, integrated water management,
little respite. In rural areas, drought particularly affects rehabilitation of degraded coastal and terrestrial
rural to urban migration.143 Urbanisation can be beneficial ecosystems, and robust building standards.154,155
for health and livelihood, but also entails many risks.121,142 3 Promoting long-term resilience through enhanced
The social disruption provoked by migration can lead to a livelihoods, increased social protection, and provision
breakdown in traditional institutions and associated of services. These include ecosystem-based invest-
coping mechanisms.146 Furthermore, the lack of mobility ments, and processes that decrease marginalisation of
and risks entailed by those migrating into areas of direct vulnerable groups—eg, by increased access to health
climate-related risk, such as low-lying coastal deltas, services.
presents a further hazard.121 The mental health
implications of involuntary migration are often down- Limitations of migration as a means of adaptation
stream effects, seen as a result of multiple interacting Migration has been proposed as a transformational
social factors (panel 5). adaptive strategy or response to climate change. The policy
response is often referred to as “managed retreat”.121,156
No or low-regret policies to reduce environmental migration With changes in climate, resource productivity, population
Effective public health and adaptation strategies to growth, and risks various governments have now, as part
reduce environmental migration or reduce the negative of their adaptation strategies, engaged in planning to move
impact of environmental migration should entail the settlement.33 As an example, five indigenous communities
coordinated efforts of local institutions, national and in Alaska have planned for relocation with government
international governments and agencies.100 There are funding support. Research on experience of migration
several no or low-regret practices that generate both policy concludes that a greater emphasis on mobility
short-term and long-term benefits if integrated with within adaptation policies could be effective.100,156
existing national development, public health and poverty Using migration as a strategy to cope with environmental
reduction strategies. stress might however create conditions of increased (rather
1 Slowing down the rate of environmental change, than reduced) vulnerability.100,144,156 Even though migration is
including mitigation policies and reducing land used as a strategy to deal with imminent risks to livelihoods
degradation.121,154 and food security, many vulnerable low-income groups do

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not have the resources to migrate in order to avoid floods, Zoonosis outbreaks are costly: the economic losses
storms, and droughts.157 In addition, studies of resettlement from six major outbreaks of highly fatal zoonoses
programmes demonstrate negative social outcomes, often between 1997 and 2009 cost at least US$80 billion.173
analysed as breaches in individual human rights.154 There Implementing a one-health approach is, by contrast,
are significant perceptions of cultural loss and the economically sensible: the World Bank values its global
legitimacy, and success depends on incorporating cultural benefits at $6·7 billion per year.173 It provides no-regret
and psychological factors in the planning processes.158 options because investments will contribute to reduced
vulnerability applicable across climate futures, and it
Dynamic infectious disease risks enhances resilience by linking government and civil
Interactions and changes in demographics, human society partners, facilitating early warning and building
connectivity, climate, land use, and biodiversity will capacities to respond to multiple disease risks.
substantially alter disease risks at local, national and
international scales.159 For example, vector-borne 3 Surveillance and monitoring
infectious disease risks are affected by not only changing Strengthening the capacity of countries to monitor and
temperatures, but also sea level rise.160 The geographical respond to disease outbreaks is vital, as shown by the
distribution of African trypanosomiasis is predicted to ongoing Ebola epidemic in West Africa. Climate-change
shift due to temperature changes induced by climate adaptation for human health requires a range of data,
change.161 Biodiversity loss may to lead to an increase in including on health climate risks or vulnerabilities, and
the transmission of infectious diseases such as Lyme specific diseases related to climate change impacts.
disease, schistosomiasis, Hantavirus and West Nile Information and data collected from public health
virus.162 Infectious disease risks are dynamic and subject surveillance or monitoring systems can be used to
to multiple and complex drivers. Adaptation responses determine disease burdens and trends, identify vulnerable
therefore must consider multiple uncertainties people and communities, understand disease patterns, and
associated with dynamic disease risks, which include a prepare response plans and public health interventions.174,175
focus on co-benefits, no regrets and resilience.113,163–165
Health co-benefits from climate adaptation
Adaptation policy options for infectious disease risks Even though many climate-related health effects are
1 Investing in public health beset by uncertainties, policy makers and communities
Determinants of health, such as education, health care, can prepare if they focus on measures that: 1) create
public health prevention efforts, and infrastructure play a multiple societal and environmental benefits; 2) are
major part in vulnerability and resilience.166 Adapting to robust to multiple alternative developments, and 3)
climate change will not only be beneficial in reducing enable social actors to respond, adapt and innovate as a
climate change impacts, but also have positive effects response to change. 164,165
on public health capacity.163 Furthermore, health
improvements account for 11% of economic growth in Ecosystem-based adaptation (EbA)–co-benefits for indirect effects
low-income and middle-income countries.167 The UN Ecosystem services contribute to human health in
Framework Convention on Climate Change (UNFCCC) multiple ways and can act as buffers, increasing the
estimates the costs of health-sector adaptation in resilience of natural and human systems to climate
developing countries to be US$4–12 billion in 2030. change impacts and disasters.155
However, the health consequences of not investing would Ecosystem-based Adaptation (EbA) utilises ecosystem
be more expensive, and it is clear that there are several services, biodiversity, and sustainable resource
health impacts that we will not be able to adapt to.168 management as an adaptation strategy to enhance natural
resilience and reduce vulnerability (covered in more detail
2 One-health approaches in a forthcoming Lancet Commission on Planetary
These approaches involve collaboration across multiple Health).176,177 Natural barriers can act as a defence against
disciplines and geographical territories to protect the climatic and non-climatic events—eg, restoration of
health for people, animals and the environment. 70% of mangroves for protecting coastal settlements and
emerging infectious diseases are zoonotic169 and have conservation of forests to regulate water flow for vulnerable
multiple well-established links to poverty.170 They also communities.178,179 EbA is considered to be more cost
pose considerable global risks (eg, avian influenza, effective than many hard-engineered solutions, and
Ebola). Effective responses to emerging infectious thought to minimise the scope for maladaptation.155,180 It
diseases require well-functioning national animal and can be combined with engineered infrastructure or other
public health systems, reliable diagnostic capacities, and technological approaches. EbA interventions can be
robust long-term funding. Critical gaps are present in effective in reducing certain climate change vulnerability
existing health systems, including poor reporting, severe as it provides both disaster risk reduction functions, and
institutional fragmentation, and deficient early response enables improvements in livelihoods and food security,
capacities.171,172 especially in poor and vulnerable settings.181 However, the

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scientific evidence about their role in reducing institutional capacity needs-assessment and collaboration
vulnerabilities to disasters is developing, and the limits are critical for health adaptation to climate change.188 The
and timescales of EbA interventions need further support of bridging organisations, as well as partnerships
evaluation. Drawbacks can include the amount of land through networks, are critical as a means to overcome
they require, uncertainty regarding costs, the long time fragmentation and improve collaboration, information
needed before they become effective, and the cooperation flows, and learning.189
required across institutions and sectors.180
Finance
Ecosystem-based adaptation in urban areas Lack of finance is commonly cited as a major obstacle to
EbA also has the potential to yield benefits for highly adaptation, especially in the poorest regions and
urban areas, through the development of green communities. This might result in economic incentives
infrastructure.180 The evidence comes mainly from the for investment in adaptation appearing small, individuals
northern hemisphere, in high-income settings with a or firms lowering initial costs by avoiding expensive
dense city core. In many cases enhancement of urban adaptation technologies or options, and the fact that the
ecosystems provides multiple co-benefits for health such long-term benefits of health risk reduction, health
as clean air and temperature regulation.182 EbA can improvements, and other societal benefits (reduced
further create synergies between adaptation and climate- public health care costs) are heavily discounted.
change mitigating measures by assisting in carbon Community and informal networks may provide
sequestration and storage, and enhancing various financial support, but regional, national, and
ecosystem services considered beneficial for human international funds as well as private sector funding will
health.176,183 Trees are particularly considered to be efficient be required for adaptation responses at a larger scale.190
in reducing concentrations of pollutants, although the To date, adaptation funding is inadequate compared to
capacity can vary by up to 15 times between species.184 the risks and hazards faced. This is covered in more
Green urban design can reduce obesity and improve detail, in section 4 of the Commission.
mental health through increased physical activity and
social connectivity.164 Increased neighbourhood green Communication
spaces reduces both morbidity and mortality from many Public awareness of the health risks of climate change,
cardiovascular and respiratory diseases and stress-related even from heatwaves and other extreme weather events,
illnesses.31 Tree canopies have a higher albedo effect than is currently low.191 Innovative media strategies are needed
other hard surfaces and can work to reduce the urban to enhance awareness of such risks and improve public
heat island effect, lowering heat mortality by 40–99%.185 adaptive skills and effectiveness.192 health professionals,
Whilst resulting in improved public health and being knowledgeable and trusted, are in a strong position
community resilience, many of these measures will also to communicate the risks posed by climate change and
act to mitigate climate change. the benefits of adaptation.102

Overcoming adaptation barriers Monitoring indicators for adaptation to indirect impacts

Globally, relatively few national strategies bring climate Several indicators can serve as proxies for investments in
change into public health decision-making processes. adaptation and resilience to the indirect health effects of
The health impacts of climate change are often poorly climate change.
communicated and poorly understood by the public and
policy makers. Barriers to health climate adaptation National adaptation programmes of action
include competing spending priorities, widespread National adaptation programmes of action (NAPAs) are
poverty, lack of data to inform adaptation policies, weak designed for low-resource countries to communicate
institutions, a lack of capital, distorted economic their most urgent adaptation needs to the UNFCCC for
incentives, and poor governance. Here, we elaborate funding.193 Health projects are more often included in the
these barriers and discuss some ways to overcome them. NAPAs and they typically address current disease (eg,
malaria) control issues.168 To this end, there is a need to
Institutional collaboration provide ongoing assessment of the number of countries
Health-adaptation policies and programmes require that integrate health aspects in their NAPA, as well as the
engagement of numerous agencies and organisations, extent to which health is integrated. This indicator should
including government agencies, non-governmental assess adaptation for both direct and indirect health
organisations (NGOs), informal associations, kinship impacts.
networks, and traditional institutions.186 At the same time,
institutional fragmentation, lack of coordination and Early warning systems
communication across levels of government, and conflicts This indicator should include the number of countries
of interest between ministries are overly common.186,187 that have upgraded early warning systems for extreme
Strengthening institutions at multiple levels is vital, and weather events, climate-change-sensitive diseases, food

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 The Lancet Commissions

security, and migration movements. Early warning surprise. Urgent mitigation efforts must accompany the
systems have proved to be a critical and co-beneficial recommendations provided in section 2, a subject
investment and, if matched with response capacities, covered in section 3 of this Commission.
could help societies adapt more promptly to changing
circumstances that affect human health. Section 3: transition to a low-carbon energy
infrastructure
Ecosystem-based adaptation It is technically feasible to transition to a low-carbon
Investments in ecosystem based adaptation for both infrastructure with new technologies, the use of alternate
direct (eg, flood risk) and indirect (eg, food security, materials, changing patterns of demand, and by creating
disease mitigation) health impacts could create multiple additional sinks for GHGs. This requires challenging the
co-benefits and provide no-regret options for several of deeply entrenched use of fossil fuels. Any significant
the indirect effects discussed above. deployment to meet demanding CO2 targets will require
the reduction of costs of mitigation options, carbon
Conclusion pricing, improvement in the research and development
This section has outlined interventions available to process and the implementation of policies and regulations
enhance community resilience and adapt to the health to act as enabling mechanisms, as well as recognition of
effects of climate change. Many of these are no-regret the strong near-term and long-term co-benefits to health.
options that could provide co-benefits across several The technologies for reducing GHG emissions related
dimensions including food security, disease prevention, to energy and many energy-related end-uses have been in
and sustainability in general. Adaptation will provide existence for at least 40 years (table 2), and several key
both short-term and long-term benefits beyond human technologies have their roots deep in the 19th century.
health. Effective adaptation requires institutional The technologies are available now. We have a reasonable
collaboration across levels, integrated approaches, grasp of their performance, economics and side-effects
appropriate long term funding, and institutions flexible (unintended impacts). They treat the causes of the
enough to cope with changing circumstances and problem (fossil fuel GHG emissions) rather than the
symptoms (climate change). Other technologies, such as
Potential mitigation effects
those described under geo-engineering have a high
degree of uncertainty as to their effectiveness and also
Energy efficiency
their side effects. We view these technologies as being
Supply-side efficiency Save 14% of primary energy supply (121 EJ by 2050)194
highly risky but also (at this time) unnecessary, as we
End-user efficiency 1·5 Gt of CO2-equivalent in 2020195
have the tools needed to achieve emission targets to avoid
Carbon sequestration
catastrophic climate change. Geo-engineering is
Land carbon sequestration analogous to using unlicensed drugs to treat Ebola when
Afforestation and reforestation 183 Gt of carbon by 2060196 public health and hygiene could have prevented the
Biochar 0·55 Gt of carbon per year196 problem in the first place. It is also important to recognise
Upstream oil and gas industry methane recovery 570 Mt of CO2-equivalent in 2020195 that for an energy source to be renewable, it must satisfy
Ocean carbon-sink enhancement a low-carbon requirement, and consider the use of scarce
Increase ocean alkalinity 0·27 Gt of carbon per year after 100 years196 resources such as copper, silicon, and rare earth metals.
Iron fertilisation 3·5 Gt of carbon per year for first 100 years196 Public health has much to gain from the mitigation of
Carbon capture and storage short lived climate pollutants (SLCPs) such as methane,
Carbon capture during energy generation Can reduce lifecycle CO2 emission from fossil-fuel black carbon, hydrofluorocarbons, and tropospheric
combustion at stationary sources by 65–85%195
ozone. The benefits for health, climate change, and crop
Direct air capture 3·6 Gt CO2 per year with 10 million units197 yields are covered in great detail in a report by WHO and
Carbon intensity reduction the Climate and Clean Air Coalition.200
Renewable energy*
Geothermal 0·2–5·6 Gt of CO2 per year by 2050198 Main sources of GHG emissions
Bioenergy 2·0–5·3 Gt of CO2 per year by 2050198 In 2010, annual global GHG emissions were estimated at
Ocean energy (thermal, wave, tidal) 0·0–1·4 Gt of CO2 per year by 2050198 49 GtCO2e.201 The majority (about 70%) of all GHG
Solar energy 0·4–15·0 Gt of CO2 per year by 2050198 emissions can be linked back to the burning of fossil fuel
Hydropower 0·6–4·5 Gt of CO2 per year by 2050198 for the production of energy services, goods or energy
Wind energy 1·2–9·8 Gt of CO2 per year by 2050198 extraction (figure 8).202 Global emissions from heat and
Nuclear energy 1·5–3·0 Gt of CO2 per year with current capacity199 electricity production and transport have tripled and
doubled respectively since 1970, whereas the contribution
*We obtained the values of CO2 emission mitigation for renewable energy from figure 10. 20 of the Intergovernmental
Panel on Climate Change (IPCC) special report on renewable sources and climate change mitigation.198 The ranges from agriculture and land-use change has slightly
represented the minimum and maximum values from four future energy scenarios. reduced from 1990 levels.203
When upstream and electricity sector emissions are
Table 2: List of high-impact technologies for climate mitigation
allocated on an end-use basis, most emissions (about 61%)

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are related to the built environment (ie, buildings, products feeds into the built environment system through
transport, and industry). These emissions are related to movement of goods, economic activity and employment.
providing services such as cooling and heat in buildings,
power for lights, appliances, electronics and computing, The global energy system
and motive power for moving to and within largely We know that the global energy system is heavily
urbanised places, while industrial manufacturing of dependent on the extraction, availability, movement, and

A B
AFOLU AFOLU Other Indirect
(23%) (0·87%) buildings buildings
Buildings other Energy (0·27%) (12%)
(0·27%) (1·4%) Commercial
(1·7%)
Commercial AFOLU
Industry Residential (24%)
(1·7%)
(10·6%) (4·4%)
Residential Indirect transport
(4·4%) (0·3%) Indirect
Transport Electricity Other AFOLU
other Electricity
and heat Transport transport (0·87%)
(3·9%) and heat
production (0·30%) (3·9%) Flaring and
(1·4%)
Road (25%) Road fugitive
(10·2%) (6·0%)
(10·2%)
Waste Buildings:
Other
(2·9%) residential Indirect energy
(7·1%) industry
Industry (3·6%)
(18%) (10·6%)
Industry
Energy other Buildings: (18%)
(3.6%) commercial Waste
(5·1%) (2·9%)
Flaring and fugitive
(6.0% )

Direct emissions Indirect emissions Direct +/– indirect emissions

C
60
+2·2% per year
2000–10

+0·6% per year 49 Gt

50
1990–2000 2·0%
+1·4% per year 6·2%
Greenhouse gas emissions (Gt of CO2-equivalent per year)

1980–90
+2·0% per year 40 Gt
1970–80 16%
40 38 Gt 1·3%
0·81% 6·9%

33 Gt 7·4%
11%
16%
0·67% 18%
30 27 Gt 7·9%

18% 13%
0·44%
7·9% 16%
19% 15% 62%
20
Gas
17% HFC plus PFC 65%
plus SF6
N2O
59% CH4
10 58%
55% CO2FOLU
CO2 fossil fuel
and industrial
processes
0
1970 1975 1980 1985 1990 1995 2000 2005 2010 2010
Year

Figure 8: Sources of greenhouse gas emissions (source: IPCC, 2014202)

Allocation of total greenhouse gas emissions in 2010 (49·5 Gt CO2 equivalent per year) across the five sectors examined in detail in this report (A). The enlarged
section of panel A allocates indirect CO2 emission shares from electricity and heat production in the sectors of final energy use. Panel B allocates total emissions
(49·5 Gt of CO2 equivalent per year) to show how the total from each sector increases or decreases when adjusted for indirect emissions. Total annual greenhouse gas
emissions by groups of gases 1970–2010, and estimated uncertainties for 2010 (whiskers; C). The uncertainty ranges are illustrative, given the limited literature in the
field.201 AFOLU=agriculture, forestry, and other land uses. FOLU=forestry, and other land uses.

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 The Lancet Commissions

consumption of fossil fuels, and this system shows The growth in energy demand
vulnerabilities when stressed. For example, the 1972 Global energy demand has grown by 27% from 2001–10,
Organization of the Petroleum Exporting Countries largely concentrated in Asia (79%), the Middle East and
(OPEC) oil embargo (which resulted in a cut of global Africa (32%), and Latin America (32%), but with near
production by 6·5% over 2 months) or the first Persian stable but high demand (on a territorial accounting basis)
Gulf War (which caused a doubling of global oil prices in the 1990 Organisation for Economic cooperation and
over 3–4 months) each caused major pressure on the Development (OECD) group of countries.203 China
access and security of global energy supplies.204 doubled its energy demand during this period and
Furthermore, many of the world’s largest actual and represented the single largest proportion of the global
potential conventional oil reserves are in areas of historic increase (44%).209 Most global growth in energy was in
volatility and civil unrest.205 coal (44%) for use in electricity production, a dangerous
Climate change poses a risk to the existing energy reality for human health.210
system. Under a changing climate, these vulnerabilities Economic productivity has risen alongside global
could result in disruption in both supply and production energy demand. Whilst fossil fuel-based energy demand
of power under extreme weather events, operations (eg, has grown slowly in OECD countries since 1970, gains
water availability for cooling towers), viability of were made in GDP terms that were largely a result of de-
infrastructure (eg, location of power lines or hydroelectric industrialisation of the economy (largely exported to
systems), impact on transmission (eg, high temperatures Asia). As a result, Asia has made a significant leap in
or wind damage), and higher demand for cooling and energy consumption, emissions and GDP. The energy
building system performance.206,207 intensity of large global economies (ie, the USA, China,
The usefulness of fossil fuels relates to their power and EU, India) have fallen progressively over the period of
energy density, portability, and relative cost compared industrialisation.211 Figure 9 shows that economic gains
with other forms of energy. These attributes have acted as need not be strongly coupled to CO2 emissions, though
challenges to the transition to low-carbon energy sources the association is partly obscured by the export of CO2
and vectors, such as renewable and nuclear electricity and emissions. Moving energy-intensive industries offshore
hydrogen. Maintaining power supply based on (most of which remain fossil-fuel powered) allows for
intermittent electricity sources such as wind power is a territorial emissions to fall, but at the cost of increased
complex system integration problem.208 Practical solutions emissions elsewhere.
will involve combinations of energy stores (hydroelectric, Growth in demand for energy will probably continue
thermochemical), demand-side management, and the over the coming 25 years, particularly in lower-middle
harnessing of geographical diversity with respect to and low-income economic regions, where most citizens
demand and supply. Cross-continental power grids can lack access to safe and affordable energy. The growth in
play a significant part in reducing low-carbon systems global per capita energy demand is linked to
costs because greater diversity of demand and supply improvements in the standard of living in developing
reduces the need for expensive energy storage. regions and directly supports development goals.
Expected energy demand in non-OECD countries may
double by 2035 (107%) from 2010, while OECD countries
25
may increase by 14% over the same period.209 However,
this growth in demand will continue to directly benefit
USA high-income regions through exported production of
20 goods.
Australia
CO2 emissions (tonnes per head)

Meeting our future energy needs

15 Canada
Access to energy is a key enabler of economic
development and social wellbeing. In recognition of
Germany
energy being a key determinant of economic and social
Poland
10
UK development, and of health and wellbeing, the UN has
Japan
declared that 2014–24 is the UN Decade of Sustainable
China South Korea Energy for All. The world’s population must be able to
France
5 access clean forms of energy that can provide these basic
needs, which can minimise the health burden from both
Brazil
direct exposure and indirect from future climate change
India
0 risks. The Sustainable Development Goals (SDGs) have
0 5000 10 000 15 000 20 000 25 000 30 000 35 000 40 000 45 000 50 000
emphasised the role that energy plays in securing a
GDP per head (US$ billion, 2005)
sustainable future for a global 9 billion population by
Figure 9: Per head CO2 emission trends in relation to income for a selection of countries (1990–2008)212,213 2050, and has outlined four targets to support, which
*Based on purchasing power parity. could act as progress metrics. The indicators measuring

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progress on the proposed SDGs for securing sustainable disease and lung cancer. The exposure to emissions can
energy for all by 2030 include: ensuring universal access result in immediate health effects for the local population,
to affordable, sustainable, reliable energy services; such as respiratory tract infections, or take many years or
doubling the share of renewable energy in the global decades to have an effect. A coal-fired station will produce
energy mix; doubling the global rate of improvement in immediate CO2 emissions, but these emissions do not
energy efficiency; phasing out fossil-fuel production and result in immediate health impact. Instead, GHG
consumption subsidies that encourage wasteful use, emissions that accumulate in the atmosphere over the
while ensuring secure affordable energy for the poor.214 long term will result in global climate change. The long-
term nature of climate change means that these
The health burden of the current energy system exposures build towards a more dangerous level. Another
Although linked to a historical transformation in health, dimension is locality of the emissions-exposure,
a fossil-fuel-based energy system also imposes significant exposure-health effect pathways. Locally generated
health burdens (figure 10). The direct burden occurs emissions will affect both the population surrounding
through emissions of particulates and solid wastes (coal, the point of discharge and in some cases more widely, as
oil, gas, biomass), risk of flooding (hydroelectricity), in burning coal in north Asia. Climate change, however,
accidents and injuries (all), and emission of radioactive will affect all areas to varying degrees.
materials (coal, nuclear). But as the main driver of The global increased use of energy per capita is highly
anthropogenic climate change, an energy system based related to considerable improvements in quality of life
on fossil fuels will also have indirect effects through across much of the world. The majority of this energy
climate change and the increase in temperatures, use is derived from fossil-fuel use, but mainly coal.
extreme weather, heatwaves, and variable precipitation Coal’s wide availability and economic attractiveness has
(see section 1). made it the fuel of choice for use in power generation.
The immediacy of this burden varies with the inertia The recent expansion of coal use, mainly in the newly
built into the emission to exposure pathways and industrialising countries, effectively reverses the global
exposure to health-effect pathways. Compared with pattern through most of the 20th century towards less
climate change, the locality and visibility of fossil fuel carbon intensive and less polluting fossil fuels–the
emissions are more apparent today as poor air quality progressive displacement of coal by oil, and of both by
and toxic discharges, such as smog in Beijing or Delhi. A natural gas. However, the time when fuel switching
coal-fired power plant will emit particulates that result in could decarbonise the global economy sufficiently
immediate exposure for the local population with quickly to avoid dangerous climate change has almost
consequent increased risk of developing respiratory certainly passed. It is increasingly difficult to justify

100 Health effects

HFC+
climate change

Exposures Temperature-related mortality

Temperature increase and morbidity
Global

90 N2O
Heatwaves Extreme weather-related health effects
CH4 Extreme weather Water and food-borne diseases
80 Precipitation variation Vector-borne and rodent-
CO2 borne diseases
70 Effects of food and water shortages
03 Mental health
Air
emissions PM10
60 PM2·5 Cardiorespiratory disease
Percentage (%)

air quality

Exposures Lung cancer

Local

SO2
Outdoor air quality Acute respiratory infection
50 NO2
Indoor air quality Cardiovascular disease and stroke
Benzene
Mental health
40

30 Ash or slag
FGD residue
Solid discharges

Sulphur Exposures
contamination

20 Acute radiation sickness

Air, soil, water
Cancer
Local

contamination
10 Drowning
Radioactive Mercury
Physical injury
materials Ionising radiation
Mental health
Water Flooding
0

Oil (32%) Traditional biomass (6%)

Coal (27%) Nuclear (6%)
Gas (22%) Hydro (2%)
Modern* biomass (4%) Other renewables (1%)

Figure 10: Connections between the global energy system and health impacts
Length of arrows denotes time to impact; width denotes inertia of impact. FDG=flue gas desulphurisation. *Does not include other renewables.

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 The Lancet Commissions

large-scale investment in unabated gas-fired switch fuels are not undertaken with care, there are
infrastructure. The dangerous impacts of coal on health risks of unintended consequences through, for
from exposure to air pollution in the form of noxious example, poor housing ventilation.219 Besides air quality,
particulates and heavy metals, the environmental several links between climate mitigation practices and
degradation (eg, contaminating water courses and technologies and potential health benefits have been
habitat loss) from the extraction and processing of coal, established (figure 11).220,221 Using active transport as an
and the major contribution that burning coal and the example, the shift from car driving to walking and
release of GHGs has in changing the long-term climate cycling not only reduces the air pollutant emissions,
almost certainly undermines the use of coal as a long- but also increases levels of exercise, which in turn can
term fuel. Although the use of coal as a fuel source for lead to reduced risks of several health outcomes,
power generation will be linked to economic growth and including cardiovascular diseases, diabetes, and some
(sometimes precarious) improvements in quality of life, cancers.218
the risk that coal has on our global health through The formal health sector itself also has a role to play in
climate change and habitat loss means that moving to reducing its emissions. Hospitals and health systems,
low-emission fuels in areas of high coal demand is a particularly in more industrialised settings, account for
major part of the global low-carbon energy transition. around 10% of GDP and have a significant carbon
Whilst the use of technologies such as carbon capture footprint. While the full extent of health care’s climate
and storage (CCS) are consistently cited in reducing the impacts is not known, emerging data confirms its
impact of coal-based power generation, at present, these significance and the need for mitigation strategies. For
technologies have many major unknowns and are instance, the NHS in England calculated its carbon
without substantial government investment or the use footprint at more than 18 million tonnes of CO2 each
of carbon pricing. year—25% of total public sector emissions.222 72% of the
One important strategy to protect against the health NHS’s carbon footprint is related to procurement and the
burdens of local and national energy choices, is to ensure remaining split between travel and energy use in
that health impact assessments are built in to the buildings.223 In the USA, the health-care sector is
planning, costing, and approval phases of a new project. responsible for 8% of the country’s total GHG
By developing the tools and capacity to enforce this, emissions.224 With among the largest sectoral purchasing
policy makers can better understand the broader power globally, the health sector could reduce its impact
consequences of their decisions. through the products it purchases and through
investment in its infrastructure (ie, hospitals, ambulatory
Actions, technologies, and health outcomes services, and clinics).
Actions that seek to mitigate climate change have the By moving toward low-carbon health systems, health
potential to be beneficial to health, both directly and care can mitigate its own climate impact, become more
indirectly.1,29 Across a number of sectors, the potential resilient to the impacts of climate change, save money,
health benefits of switching to low-carbon technologies and lead by example. For instance, in South Korea,
include a reduction in carbon emissions from power Yonsei University Health System is targeting reducing
generation,215,216 improved indoor air quality through GHG emissions by 30% by 2020. Energy efficiency
clean household cooking technologies in low-income measures saved the system $1·7 million and reduced
settings and housing thermal efficiency in high-income GHG emissions by 5316 tonnes of CO2 in 2011 alone.225 In
settings, and lowered particulate-matter exposure from the USA, Gunderson Health has increased efficiency by
low-emission transport.217,218 40%, saving $2 million annually, while deploying solar,
Decarbonising the power supply sector holds both wind, geothermal, and biomass to significantly reduce its
risks and benefits for health. The direct benefits centre carbon footprint and end its dependence on fossil fuels.226
on reducing exposure to air pollutants from fossil-fuel In England, the NHS Public Health and Social Care
burning.216 In the UK, the associated burden of air System has similarly committed to reducing their carbon
pollution from the power sector is estimated to account footprint by at least 34% by 2020.227
for 3800 respiratory related deaths per year.216 In China, Conversely, accounting for the health co-benefits of
air pollution is thought to result in 7·4 times more climate change mitigation, can help to bring down the
premature deaths from PM2.5 than in the EU.215 It has overall cost of greenhouse gas mitigation. Jensen and
been estimated that current ambient concentrations of colleagues have shown that the incorporation of health
particulate matter led to the loss of about 40 months co-benefits of cleaner vehicles and active travel can make
from the average life expectancy in China, but that this those mitigation practices cost effective.228 The health
loss could be cut by half by 2050 if climate mitigation benefits of reducing methane emission in industrialised
strategies were implemented. The risks to health from nations could exceed costs even under the least aggressive
decarbonisation are more likely to be indirect; if the mitigation scenario between 2005 and 2030.229 For
deployment and adoption of technologies that aim to example, in the UK, retrofits aimed at improving energy
reduce carbon emissions, reduce energy demand, or performance of English dwellings have the potential to

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 The Lancet Commissions

Figure 11: Frequently cited co-benefits of major mitigation techniques

Red arrows between a mitigation technology and an effect indicate that the technology will increase the effect; green arrows indicate an opposite trend.

offer substantial health benefit over the long-term, • Stage 1: typically low technology, relatively inefficient
providing ventilation to control indoor pollutants is and with little regard for damage due to pollution and
installed (see appendix 2). other externalities. See Online for appendix 2
• Stage 2: locally clean. As countries become wealthier,
Pathways to (GHG emissions reduction) they can afford to invest in the longer term and deal
pathways with the local health problems associated with
Over the last two centuries, the prevailing pattern of burning fossil fuels.
national development has involved dramatic increases in • Stage 3: regionally and globally clean. This involves
productive capacity, supporting transformations in the development of energy systems that address
nutrition and housing, underpinned by development of transboundary pollution problems including that of
fossil-fired energy supply, conversion, and distribution anthropogenic climate change. Stage 3 is generally
systems. Three overlapping stages of development can associated with high GDP and indices of public
be identified: health.

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 The Lancet Commissions

Importantly, improvements in technology and efficiency security of supply or reduced air pollution. This suggests
have historically accompanied and assisted, but have not that the transition to low-carbon energy will need to be
been primarily driven by the goal of pollution control. predicated on achieving multiple objectives, including
The patterns of development associated with stages 1 and climate change, health, equity, and economic prosperity.
2 are complex and multi-dimensional, and stage 3 is Many trajectories that are consistent with such a budget
unlikely to be different. Stages 1 and 2 have historically (panel 6 shows those of the UK and China) are in
been associated with increasing income and health. principle possible. Such trajectories necessarily involve
This pattern of development has resulted in emission of emissions in the second half of the century in the region
about 1600 GtCO2 since 1870, with a consequent rise in of 90% lower than emissions between 2011–50.232 All
global mean temperature anomaly of +0·85°C (1870–2010). would require an unprecedented global commitment to
To have a better than 66% probability of keeping the rise change, and none appears easy. To stabilise CO2−
in global temperatures to below 2°C, cumulative equivalent concentrations in the range 450–650 ppm
greenhouse gas emissions from 2011 on would need to be (consistent with 2–4°C of warming) will require the
limited to around 630–1180 GtCO2,eq.201,230,231 At the current global emission rate to fall by between 3–6% per year, a
global emission rate, this budget would be used up in rate that so far has only been associated with major social
between 13 and 24 years. upheaval and economic crisis.25 Postponing deep cuts in
The last 30 years of OECD data have shown that emissions may allow for new policies and technologies,
significant changes to global energy systems are possible. but at the cost of significant impacts (eg, for land use and
Indeed, the whole of the 20th century has been food production) in the second half of the century.
characterised by a succession of transitions in energy
technologies. However, this process has not been Achieving a 2°C warming target
inevitable and decisions on energy systems have been Many technologies exist or have been proposed to
aligned with other national objectives—eg, enhanced mitigate climate change. But they vary in their potential

Panel 6: Decarbonisation pathways for the UK and China230

The Deep Decarbonisation Pathways Project (DDPP) aims to sustained strategic vision and interdecadal coordination between
understand and show how major emitting countries can energy supply and demand sectors of the economy. Challenges to
transition to low-carbon economies and, in doing so, move delivery will probably include the scale of infrastructure
towards the internationally agreed 2°C target by 2050. The investment, and public acceptability across end-use sectors.
project comprises representatives of 15 countries contributing The challenge in China is to achieve decarbonisation alongside
to more than 70% of current global greenhouse gas emissions, continued rapid economic growth. The pathway shows GDP per
and is led by the UN Sustainable Development Solutions head increasing by six times from 2010 to 2050; this increase is
Network (SDSN), and the Institute for Sustainable offset by a 72% reduction in energy intensity of GDP—a
Development and International Relations (IDDRI), Paris.227 substantial decoupling. Emissions peak by 2030, and fall by
The project’s interim report describes pathways that achieve a 34% by 2050, driven by falling energy intensity and almost
45% decrease of total CO2-energy emissions over the period complete decarbonisation of power generation. Despite
(falling to 12·3 Gt by 2050, from 22·3 Gt in 2010). Although the electricity generation more than doubling by 2050, unabated
interim pathways do not reach a 50% probability of restricting coal is replaced by renewables, nuclear, and carbon capture and
climate change to 2°C, they provide important insights. Three key storage (figures 13A and B). In industry, carbon capture and
pillars of decarbonisation are crucial in all the countries studied: storage and higher efficiency could reduce emissions by 57% by
energy efficiency and conservation, a shift to low-carbon 2050. But growth will continue in the transport sector due to
electricity, and a switch to lower carbon fuels. However, the an increase of ten times in mobility, only partly offset by higher
balance between these pillars depends on national circumstances. efficiency and little penetration of low-carbon vehicles.
The UK pathway is characterised by early decarbonisation of the Key to the transition of the Chinese energy system is rapid
power generation sector, and increased electrification of end-use development and deployment of low-carbon technologies, and
sectors from 2030, leading to an 83% reduction in CO2-energy a shift away from unabated coal use, facilitated by energy
emissions by 2050 (see figures 12A and B). The cumulative market reform and carbon pricing.
investment requirements for such a large-scale decarbonisation The project shows the crucial need for large-scale global
are in the region of £200–300 billion, and require a strong policy technology research, development, demonstration, and
framework, including electricity market reform. After 2030, deployment, and transfer efforts. A common feature of most
radical changes in energy vectors are necessary, with heating pathways is the need to decarbonise freight transport and
switching from gas to heat pumps and district heating, and industry. The final DDPP report will review investment levels
transport increasingly electrified. Greater-than-marginal and policy frameworks to enable the transition.
reductions in emissions (eg, associated with heating) require

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 The Lancet Commissions

A B
500 489 503 500
450 28 –83%

(g of CO2 per kWh)

300

Carbon intensity
400 105
350
CO2 emissions (MT)

300 200
128
250
200 –10
70
0
150
22
100 85 45
158 600 Other renewables Natural gas with CCS
24 Biomass with CCS Natural gas
50
–6 Solar Coal
0 Wind
2010 2050 500
Year Hydro
Nuclear
Other
Electricity gereration (TWh)

Buildings 400
Transportation
Industry
Electricity generation
300

200

100

0
2010 2020 2030 2040 2050
Year

Figure 12: Energy-related CO2 emissions pathway for the UK in 2010 and 2050 (A), and energy supply pathway for electricity generation for the UK, 2010–50 (B)230
CCS=carbon capture and storage.

mitigation impacts, stages of development, costs, and difficult to achieve through persuasion. In practice,
potential risks. Table 2 summarises mitigation different societies favour divergent approaches to
technologies. Among them are climate engineering influencing behaviour, ranging from the economic,
approaches such as land and sea sequestration. Although through the physical to the psychological.236
these have significant potential, they carry significant Technologies that have the greatest decarbonisation
risks, including the possibility of damage to ecosystems. potential include nuclear power, offshore wind,
It is currently uncertain that the necessary international concentrated solar power (CSP), and CCS.237,238 Solar
consensus to allow the deployment of such technologies photovoltaic (PV) and wind systems have been growing
could be achieved. Energy efficiency improvement is exponentially for decades (wind about 12% per year, PV
considered as the least risky of the options, although on about 35%), with consequent reductions in costs due to
its own it is insufficient to achieve the necessary learning and increasing scale of production and
decarbonisation.233 deployment, while both CSP and CCS have not yet been
Individual behaviour is an important factor that affects deployed at any significant scale and so cannot capture
the end-user energy efficiency—eg, using high-efficiency significant learning effects. CCS suffers from similar
heating and cooling systems, adopting more efficient problems to nuclear—ie, large unit sizes, potential
driving practices, routine maintenance of vehicles and regulatory concerns, and long lead times, which means
building systems, managing temperatures for heating, weak and delayed learning once deployment has begun.
and hot water for washing.234,235 But behavioural changes But CCS’s additional disadvantage compared with
are not so easily achieved and pose considerable risk as a nuclear and renewables is that while the latter decouple
mitigation strategy. The medical professions have economies from the threat of future rising and volatile
decades of experience with attempts to induce mass fossil fuel costs, CCS magnifies these threats. Even in the
changes of behaviour through health promotion. The absence of carbon pricing, renewables and nuclear can
most prominent campaigns have been targeted at alcohol be justified as a hedge against future increases in fossil
consumption, smoking, diabetes, and obesity. The fuel prices, whereas CCS cannot.
overarching lesson is that even when behaviour change Attempts to understand the adaptation of the whole
yields direct personal benefits, amounting in some cases energy system in the context of rapid transitions to low-
to a decade or more of life expectancy, it is extraordinarily carbon emissions have been predominantly from the

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 The Lancet Commissions

A B
8000
7247 743 800
54
7000 633 –34%

(g of CO2 per kWh)

Carbon intensity
600
634
6000
CO2 emissions (MT)

5000 4766 400

66
2999
752
4000 200
1601 32
3000
0
2000
2927 2018 Other renewables Natural gas with CCS
12 500
1000 Biomass with CCS Natural gas
329 Solar Coal with CCS
0 Wind Coal
2010 2050
Year 10 000 Hydro
Nuclear
Other
Electricity generation (TWh)

Buildings
Transportation
7500
Industry
Electricity generation

5000

2500

0
2010 2020 2030 2040 2050
Year

Figure 13: Energy-related CO2 emissions pathway for China in 2010 and 2050 (A), and energy supply pathway for electricity generation for China, 2010–50 (B)230
CCS=carbon capture and storage.

discipline of economics. Among these is the Deep the actors and decision makers involved. The
Decarbonization Pathways Project (DDPP), which has application of low-carbon technologies, their impact,
developed pathways for 15 countries.230 Panel 6 provides deployment, and co-benefits must be maximised by
an example of these technology pathways for the UK and understanding what works, where it works, and why it
China. Transforming the global economy in anything works. This understanding is particularly important to
like the timescale implied by the above discussion support emerging technologies that are yet to reach
requires unprecedented action in both industrialised and market-scale deployment. Three key drivers are
developing countries. The former will need to embark required to support pathways to a low-carbon future:
more-or-less immediately on CO2 reduction programmes maximising the efficacy of low and zero carbon
with a high level of ambition. Developing countries will technologies, maximising the deployment of these
need to move directly from stage 1 to stage 3 (significantly technologies, and maximising and internalising the
reduced emissions with associated high GDP and indices potential health co-benefits of decarbonisation.
of public health) probably with both capital and technical
support from developed countries. Delayed emission Maximising efficacy
reduction would lower the possibility to control climate Although significant progress has been made in adopting
change, raise costs and force the uptake of riskier and clean technologies, the resulting impact on energy
unproven mitigation technologies with increased risk of intensities and carbon emissions has been lower than
unintended consequences for human wellbeing and expected. Barriers to adoption and deployment of mitigation
ecosystems.239 technology include a lack of awareness and access to
The range of unintended consequences when the technical knowledge, segmentation and fragmentation
technologies are administered to different systems is within and amongst sectors, and financial disincentives.
large, complicated, and in some areas poorly These barriers will be particularly acute in developing
understood. Ultimately, rapid mass deployment of low- countries where the benefits of energy efficiency are not
carbon technologies requires a better understanding of necessarily recognised and may be a lower priority
the drivers and barriers to delivery within different compared to many other urgent issues, such as poverty
economic sectors, the scale and opportunity of eradication, public health improvement, and crime
deployment, and the setting and its context including reduction; this may be further affected by a lack of means of

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communication. Furthermore, due to a lack of quantitative between developed countries who dominate the invention
and reliable measurements of energy performance, many of technologies for climate mitigation.242 This does
stakeholders are not aware of energy savings potential. We nothing to overcome the low availability of mitigation
propose three actions to improve efficacy: technologies in developing countries. Major barriers to
1 Understanding the direct and indirect impacts of technology transfer from developed to developing
technologies from an integrated technical, economic, countries include insufficient local human capital and
social, health and cultural, and political perspective; technology support capabilities, lack of capital, trade and
2 Gathering, evaluating, and reporting real-world policy barriers, lax intellectual property regimes in
evidence to support and guide development and developing countries, and the potential lack of commercial
implementation of mitigation strategy; viability of the technology itself.243 These barriers need to
3 Put in place policies and regulations (such as reporting be overcome to enable countries seeking to achieve a high
schemes, inspections, and benchmarks) to make quality of life to tunnel from stage 1 to stage 3.
performance visible within the market. Mechanisms to support low-carbon technology uptake
should include:
Maximising uptake • Enacting policy regulations to improve deployment of
Minimum deployment of low-carbon technologies poses technologies (such as incremental minimum
a significant risk to the transition to a low-carbon future. performance standards or delivery obligations)
The International Energy Agency (IEA) has stated that • Developing strong national-level commitments and
nine out of ten low-carbon technologies that are essential sources of funds for investment in low-carbon
for energy efficiency and decarbonisation are failing to infrastructure that is accessible to local delivery
meet their deployment objectives. Limited deployment, agents.
particularly early in the process, limits learning and • Targeting decision makers who can achieve maximum
constrains subsequent progress. on-the-ground change and uptake of technologies and
Inertia in the technology diffusion process within changes in practices (ie, sector heads, mayors, and
many sectors means that many off-the-shelf technologies councils).
today could take 20 years to achieve significant market
penetration without incentives to support their uptake. Maximising co-benefits and avoiding unintended consequences
Overcoming such inertia requires clear guidance on Many low-carbon technologies provide benefits other
technology potential; robust data on technology than reducing greenhouse gas emissions—eg, increased
performance, impact, and costs; detailed information on energy security, improved asset values, improved air
existing sectors and historic structures; removal of quality, greater disposable income, and improved health
disincentives and perverse incentives; and strong and comfort. Some low-carbon technologies are primarily
regulations. For certain technologies, regulation can play deployed because of their co-benefits.
a major part in accelerating deployment. Criteria for Low-carbon technologies inappropriately deployed can
regulations to be effective in this role may be summarised hurt the economic and social development of developing
as follows: that the goal of regulation should be countries. The increased use of expensive low-carbon
unambiguous; that the technical nature of measures energy sources could delay essential structural changes
which will achieve the goal should be clear, and they and slow down the construction of much needed
should be easy to apply; that the technical nature of these infrastructure. Higher energy prices can affect economic
measures should make it easy for the regulator to growth and exacerbate poverty and inequality. However,
confirm that they have been implemented; that the total abstaining from mitigation technologies in developing
benefits should outweigh costs; and that both benefits countries carries the risk of lock-in into a high-carbon-
and costs should be a small part of some larger economic intensity economy.244 In order to avoid such unintended
transaction.240 Cities offer opportunities and challenges consequences, a balanced strategy focusing on both
for technology deployment. For appropriate technologies, human development and climate mitigation in
economies of scale are quickly achieved with population developing countries is needed.
and economic densities supported by larger tax bases, Mechanisms to maximise co-benefits should include:
deployment through existing services and a history of • Developing compelling arguments for action that
operating large scale infrastructure. Density intensifies emphasise co-benefits (ie, health, quality of life, air
local environmental problems (particulates, noise, etc), quality, a creative and resilient economy).
which can in turn make it politically possible to introduce • Putting in place national and international level
local regulation favouring low-carbon technologies. mechanisms to support and encourage technology
Resulting niches and learning can then accelerate the adoption (ie, carbon pricing).
development and wider deployment of key mitigation • Putting in place policies and economic tools that can
technologies.241 facilitate the technology transfer from developed
Development status is another important driver of countries to developing countries (ie, the importance
deployment. The bulk of technology transfer occurs of the Green Climate Fund).

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 The Lancet Commissions

already reaching such levels, with concomitant

Panel 7: Total external costs of burning fossil fuels emissions; helping others to avoid doing so, or helping
The prices of fossil fuels routinely do not account for their global impacts related to those (like India) still with huge challenges to lift
climate change, or their local impacts on human health and ecosystems. These external hundreds of millions of people out of extreme poverty,
costs of fossil fuels can be expressed by the following formula: will require international assistance.
Through a multipronged approach that advocates co-
TECff = Ccc + Clap = (Ccd + Cad + Cmg) + (Cpd + Che + Cpc) benefits, targets decision makers and puts in effective
measures that are understood, it might be possible to
Where TECff are the total external economic costs of burning fossil fuels; Ccc are the costs
make real progress towards meeting our emission
related to climate change, which can in turn be regarded as the sum of Ccd (the damage
reduction goals. These mechanisms represent a public
costs of unmitigated climate change), Cad (the costs of adapting to climate change, either
health-style approach to developing and implementing
present or anticipated), and Cmg (the costs of mitigating climate change); and Ctap—the
mitigation strategies, with the end goal of many co-
costs of local air pollution—which can be regarded as the sum of Cpd (the pollution
benefits.
damages to buildings, crops and health of such pollution), Che (the health and other
expenditures to remedy this pollution damage) and Cpc (the costs of controlling this
Section 4: financial and economic action
pollution). There is symmetry in these cost terms relating to climate change and local air
The total economic cost of fossil-fuel use
pollution, between Ccd and Cpd (the estimated damage costs), Cad and Che (the actual
Past failures to reduce GHG emissions mean that
expenditures in response to the pollution), Cmg and Cpc and (the costs of reducing the
remaining within the required carbon budget is
extent of the pollution). The components of this formula are also dependent on each
becoming progressively challenging. We are increasingly
other, in conceptually simple if often practically complex ways, as follows:
committed to a certain level of climate disruption,
• Ccd is a function of Cmg, such that increased mitigation will reduce the costs of climate requiring adaptation measures to reduce the impact this
damage, with a similar relationship between Cpd and Cpc for local air pollution. is likely to have. Given that the world is already committed
• Cad is also a function of Cmg, such that increased mitigation will reduce the costs of to some degree of climate change, and given too that the
adaptation, with a similar relationship between Che and Cpc for local air pollution. combustion of fossil fuels also emits a variety of other
• Clap is also a function of Cmg, such that increased mitigation will reduce the costs of air pollutants, the total external costs of burning fossil fuels
pollution. (ie, those costs that are not included in the price of fossil
• Ccd is a function of Cad, such that increased adaptation will reduce the costs of climate fuels) may be expressed as shown in panel 7.
damage, with a similar association between Che and Cpd for local air pollution. The optimum outcome of this formula is that which
Notably, in each case, the effects of the different variables on each other might act over minimises TECff, computed over the time horizon of
widely differing timescales. Furthermore, whereas the above equation has been discussed interest. Unfortunately, the state of knowledge now, or at
in terms of the combustion of fossil fuels, which make the major contribution to any likely point in time in the future, does not permit
anthropogenic greenhouse gas emissions, for full cost-effectiveness of climate mitigation such a dynamic optimum to be computed. The purpose
the equation should be computed over the full range of greenhouse gas emissions to of this section is to explore the estimates of these
ensure that relatively cheap abatement measures are not overlooked. different cost categories that appear in the literature to
draw conclusions regarding the extent of climate change
adaptation and mitigation that should be attempted, and
Conclusions the policies that might be able to deliver it.
Energy systems comprise some of the largest, most The question of what is optimum in economic terms
complex and enduring capital structures in modern (GDP or welfare per head) for a given level of carbon
economies. Decarbonisation and reducing energy emissions and discount rate requires the computation
demand is not a simple challenge of cleaning up of an optimal time path. What is optimum today
pollutants or installing new equipment, it requires (without regard for the future) will not be optimal if the
systemic transformations of energy infrastructures and future is to be taken into account. And of course the
associated systems. We need to put in place mechanisms relation between low prevention costs now means very
that support the uptake of technologies in an effective high treatment costs later, compared with high
manner (ie, support pathways to impact pathways or prevention costs now means lower treatment costs later
pathways to pathways). Finally, it should be noted that will be subject to very great uncertainty. Higher
the full potential of mitigation technologies will only be uncertainty may mean that high prevention costs would
achieved if the social and political systems around these be wasted. On the other hand, with higher uncertainty
technologies co-evolve to deliver carbon targets. comes the increased probability that high prevention
There is a clear and compelling need for the costs are not high enough. However, whatever the
industrialised world to achieve faster and much deeper answers to these questions, models reviewed in the
emission reductions than anything delivered to date. At IPCC’s Working Group III Fifth Assessment Report
the same time, industrialisation historically has been (AR5) indicate with sufficient certainty that more needs
accompanied by rising greenhouse gas emissions to be spent earlier rather than later if even a moderate
(particularly CO2) up to income levels of $10–15 000 per value is given to the intermediate and long term
capita. Some of the major emerging economies are future.201

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The health and related economic benefits of adaptation ambient air pollution in terms of the value of lives lost
There are significant research gaps regarding the and ill health in OECD countries, plus India and China,
scientific evaluation of the health benefits of climate- to be more than $3·5 trillion annually (about 5% gross
change adaptation due to its highly diffuse and context- world product [GWP]), with India and China combined
specific nature, with only scattered quantitative or accounting for 54% of this total.251 Globally, and with the
semi-quantitative studies on the health costs and addition of indoor air pollution, this value is likely to be
benefits of adaptation options.245 Monetising these costs substantially higher (appendix 3) See Online for appendix 3
and benefits is an even more difficult task. However, the The European Commission has estimated that in the
studies that do exist present a strong message. Seven of EU alone, reduced air pollution from policies to
the eight studies on the effectiveness of heatwave early mitigate climate change could deliver benefits valued at
warning systems reported fewer deaths after the systems €38 billion a year by 2050 through reduced mortality.
were implemented. For example, in the summer of From a broader perspective, the European Commission
2006, a heatwave in France produced around 2000 excess estimates that moving to a low-carbon economy could
deaths—4000 less than anticipated based on previous reduce the control costs of non-CO2 air pollutants by
events.31 A national assessment attributed this to greater €50 billion by 2050.252 With an increase to 36%
public awareness of the health risks of heat, improved renewables in global final energy consumption by 2030
health-care facilities, and the introduction of a heatwave (from 18% in 2010), IRENA calculates up to $230 billion
early warning system in 2004.112 A Climate Forecast of avoided external health costs annually by 2030.253 In
Applications Network developed in the USA had addition, West and colleagues note that if RCP4.5 is
successfully forecast three major floods in 2007 and achieved, annual global premature deaths avoided
2008 in Bangladesh 10 days in advance, allowing farmers reach 500 000 by 2030, 1·3 million by 2050, and
to harvest crops, shelter animals, store clean water, and 2·2 million by 2100. Global average marginal benefits
secure food before the event.246 Webster also strongly of avoided mortality are $50–380 per tCO2, exceeding
advocates the establishment of a network between marginal abatement costs in 2030 and 2050. The
weather and climate forecasters in the developed world, greatest benefit is projected for east Asia, with
and research and governmental and non-governmental
organisations in the less-developed world.246 According
Panel 8: Global expenditure on health care
to his estimation, such a network could produce
10–15 day forecasts for south and east Asia for a wide Figure 14 shows the global range of total expenditure on
range of hydrometeorological hazards (including slow- health care as a proportion of GDP in 2011. Total expenditure is
rise monsoon floods, droughts, and tropical cyclones) at 9·1% gross world product (GWP)—about US$6·8 trillion—with
an annual cost of around $1 million, but with prevention geographical variation ranging from 1·65% GDP in South
of “billions of dollars of damage and protecting Sudan, to 17·7% in the USA. At a global level, 59% of
thousands of lives”. To support assessments such as expenditure is sourced from government budgets (of which
these, WHO Europe have prepared an economic analysis 60% is via social security mechanisms), accounting for more
tool to enable health systems to calculate the health and than 15% of total expenditure by governments worldwide. The
adaptation costs of climate change, which was in turn remaining 41% is sourced from the private sector (of which
tested in their study of seven European countries.247,248 38% is in the form of health insurance, with 50% out-of-
pocket expense). Total average global health expenditure per
The health and related economic benefits of mitigation capita was $1053, in purchasing power parity (PPP) terms.247
Unmitigated climate change presents serious health Figure 15 shows the variation between the economies of
risks that could reach potentially catastrophic different average income levels against these global totals.
proportions. Mitigating climate change not only Total expenditure per head varies between an average of
significantly reduces this risk, but can also yield $64 in low-income countries and $4319 in high-income
substantial health co-benefits against contemporary countries in PPP terms. This increase in expenditure
circumstances. proportional to income is accompanied by the increasing use
Panel 8 illustrates the proportion of national GDP of insurance mechanisms (either private or social security),
directed to health care increasing with wealth, along with and decreased reliance on external (international) resources
the proportion accounted for by government (principally development assistance and funding from non-
expenditures. This suggests that governments of high governmental-organisations), and private expenditure and
and increasing income countries should give significant out-of-pocket expenses (in proportional terms). Whereas
priority to mitigating climate change to prevent private expenditure and out-of-pocket expenses remain a
detrimental health impacts, which could result in the significant component in all groups, external resources
need for significant extra health expenditures, from both decrease rapidly, from 29% in low-income countries to 2·3%
governmental and personal finances. Indeed, the direct in lower middle-income countries, 0·4% in upper
and indirect cost of existing pollution-induced illnesses middle-income countries, and 0% in high-income countries.
alone is significant. The OECD estimates the cost of

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 The Lancet Commissions

Not applicable
1·3–4·7% GDP
4·8–6·5% GDP
6·6–8·7% GDP
8·8–19·7% GDP
Data not available

Figure 14: Total expenditure on health as proportion of GDP (2011)249

duration and severity of depressive episodes—all of

100 4500
which are linked to obesity and are costly to treat.218 For
Proportion of total health-care expenditure (%)

90 4000 example, increased levels of active travel coupled with

Total health-care expenditure per head

80 3500 increased fuel efficiency in the UK’s urban areas could

70 lead to a net saving to public funds cumulatively
(PPP international $)

3000
60 exceeding £15 billion by 2030, whilst achieving GHG
2500
50 reductions of over 15% in the private transport sector by
2000 2030.228 Patz and colleagues have comprehensively
40
1500 reviewed the health, environmental, and economic
30
1000
benefits of active travel.256
20
In many countries, climate-change mitigation through
10 500
increased energy efficiency will have the benefit of
0
Low income Lower middle Upper middle High income Global
0 reducing fuel poverty (a condition in which low-income
income income households have to spend a high proportion of their
Out-of-pocket expenses Private health insurance Total health-care income to keep warm or cool), and associated impacts on
External resources Other government expenditure expenditure excess winter mortality, respiratory health of children and
Other private expenditure Social security
infants, and the mental health of adults.257 Nicol and
Figure 15: Global health-care expenditure profile (2011)250 colleagues estimated that improved housing in England
PPP=purchasing power parity. alone could save the UK NHS more than €700 million per
year in treatment no longer required.258 In addition,
220 000–470 000 premature deaths avoided per annum Copenhagen Economics estimates that improvements in
by 2030, with marginal benefits of $70–840/tCO2—a housing energy efficiency in Europe would, alongside the
range 10–70 times that of the projected marginal cost254 production of direct energy and health-care savings,
(see appendix 3 for more about the cost of ambient air reduce public subsidies for energy consumption by
pollution in China). In the USA, Thompson and €9–12 billion per year.259 Various other health and ancillary
See Online for appendix 4 colleagues estimate that human health benefits benefits exist. Appendix 4 provides information about a
associated with air quality improvements driven by CO2 recently developed framework to quantity key co-benefits.
mitigation policies can offset the cost of the policies by It is apparent both that societies spend very large
up to ten times.255 sums on health care and that measures to mitigate
Mitigation actions have other health-related benefits. climate change would directly reduce existing and
Policies in the transport sector that encourage active projected damages to health from the combustion of
travel (eg, walking and cycling) produce significant fossil fuels, and associated costs. In fact, Markandya
reductions in cardiovascular disease, dementia, and colleagues estimated that in India, if the health
diabetes, and several cancers, in addition to reduced benefits of reduced PM2.5 emissions alone, resulting

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from a 50% reduction in CO2 emissions by 2050 (from Estimating existing expenditure on adaptation actions
1990 levels) from electricity generation, were valued is not much easier than estimating the possible future
similarly to the approach used in the EU for air costs of adaptation. Buchner and colleagues263 estimate
pollution, then they offset the cost of GHG emissions that in 2012, about $22 billion was invested in activities
reductions in full.215 As such, a significant proportion of with an explicit adaptation objective. However, the lack of
expenditures for climate-change mitigation (and common agreement on what constitutes an adaptation
adaptation) may legitimately be seen as offsetting health measure over other investment classifications and
expenditures, existing or anticipated, or even put objectives mean understanding of existing financial
forward itself as expenditure on the treatment and flows to adaptation measures is poor. Even so, whilst the
prevention of ill health. If a large part of the costs of magnitude is difficult to determine, it is reasonable to
climate-change mitigation and adaptation is offset by conclude that existing financial flows for climate change
improved health of the existing population, and if adaptation are not sufficient to match long-term
unabated climate change is itself a major health risk, requirements, even for impacts resulting from current
investment in such actions is clearly an attractive and and past emissions.
sensible proposition.
Macroeconomic implications of mitigation and
Investment required for mitigation and adaptation adaptation
In industrialised countries, large-scale investment in The macroeconomic impacts of climate change
energy systems is required simply to maintain existing Attempts to estimate the marginal social cost of CO2
services as infrastructures age and need to be replaced. emissions in the absence of mitigation or adaptation
Emerging and developing economies will require very measures have produced an extremely wide range of
large energy system investments to meet growing results, spanning at least three orders of magnitude.264
demand as they develop and to provide increasing Table 3 illustrates the multifaceted, diverse, and
proportions of their populations with access to modern potentially extreme nature of the impacts involved.
energy services. It is estimated that such business-as- The IPCC’s AR5 chapter on impacts, adaptation and
usual investments will total around $105 trillion between vulnerability estimates an aggregate loss of up to 2%
2010 and 2050, with average annual investment GDP if global mean temperatures reach 2·5°C above
requirements rising rapidly over time.260 However, this pre-industrial levels.266 A world of unabated GHG
value excludes the costs of climate damage to the energy emissions, what might be called a business-as-usual
system or resilience measures to reduce it. Such costs pathway (in which a global mean temperature increase
could be significant. is likely to far exceed 2·5°C, and in which many of the
The IEA estimates that to achieve a trajectory that kinds of impacts in the last row and column of table 3
produces an 80% chance of remaining on a 2°C are likely to be experienced) could produce costs
stabilisation pathway, additional cumulative investment equivalent to reducing annual GDP by 5–20% now, and
of $36 trillion in the energy system is required by 2050— forever, compared with a world with no climate change,
roughly $1 trillion per year (in the order of 1% GWP according to the Stern Review on the Economics of
under moderate growth assumptions or about 10% of Climate Change.267
existing expenditure on health care), although recent It may be noted that these costs are the result of a low
estimates from the New Climate Economy report suggest discount rate, the validity of which has been
that this value may be a much reduced $270 billion per questioned.268 However, the relevant point here is that
year.260,261 The insurance premium represented by this the physical impacts underlying the upper range of
additional investment is very modest in relation to the these costs represent a substantial risk to human
potential costs that are being avoided, even without the
offsetting health and other co-benefits such as those
described above. To achieve both the requisite level of Market Non-market Multiple stresses and
socially contingent
decarbonisation whilst meeting increasing global
demand for energy, the IEA estimates that investments Projection (trend) Coastal protection, dry- Heat stress, wet-land loss, Displacement from
land loss, energy (heating ocean acidification, ecosystem, coastal zones, regional
in low-carbon technologies and energy efficiency must and cooling) migration and termination systemic impacts
account for around 90% of energy system investment by Climate variability Agriculture, water, storms Loss of life, biodiversity, Cascading social effects,
2035.262 Currently, this value is around 23%.262 and (bounded) environmental services environmental migration
Estimates for the investment required for adaptation extremes
measures to protect against climate impacts to which the System changes So-called tipping-point High-order social effects, Regional collapse,
world is already committed are limited. The most and surprises effects on land and irreversible losses famine, war
resources
comprehensive global estimate thus far was produced by
the World Bank (2010), which estimates the annual Adapted from Grubb et al, 2014.265
global cost of adaptation even on a 2°C trajectory to be
Table 3: Social cost of CO2 emissions—assessment framework
$70–100 billion by 2050.171

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 The Lancet Commissions

societies—what Weitzmann269 has called the “fat tails” of resources or, in a situation of full employment, crowd
climate-risk distributions. The costs of mitigation may out more productive investment, and whether they can
be seen to represent a premium paid to reduce these build domestic supply chains and new competitive
risks and, hopefully, avoid the worst climate outcomes industries that can substitute for imports. Whilst
entirely. In any case, even these large costs derive from employment in fossil fuel-related and emission-
economic models built upon climate science and impact intensive industries would decline over time, low-
models, which themselves necessarily cannot fully carbon technology industries would expand and
characterise all processes and interactions known to be increase employment. IRENA estimate a net global
of importance.270 increase of 900 000 jobs in core activities alone (i.e. not
including supply chain activities), if the level of
The macroeconomic impacts of responding to climate change renewable energy in global final energy consumption
The theoretical microeconomics position on the doubles from 18% in 2010 to 36% of by 2030.253
balance to be struck between mitigation and adaptation Advantages may accrue to those countries or industries
is clear—there should be investment in mitigation up that begin investment in decarbonisation quickly, by
to the point where the marginal cost of further gaining technological leadership through experience
investment is higher than the marginal cost of and innovation, affording the first mover a competitive
adaptation plus that of remaining climate damages. In edge in a growing market.
practice, the robust identification of this point is For fossil-fuel importing countries, investment in
impossible, because of the uncertainty of the costs indigenous low-carbon energy sources will reduce the
concerned and how they will develop over time, the need to import fossil fuels. In the EU, the trade deficit in
difficulties of valuing non-market costs, and the lack of energy products in 2012 was €421 billion (3·3% EU
consensus over the appropriate discount rate for such GDP),273 and is projected to rise to €600 billion (in 2010
costs, when they are incurred over long and varied time euros) by 2050, as the EU’s dependence on foreign fossil
periods.271 Given that some climate impacts (such as the fuels increases.274 Low-carbon investments that reduce
phenomena in the bottom-right corner of table 3) the need to import fossil fuels are macroeconomically
cannot be adapted to at any computable cost, mitigation- beneficial, with the value of these trade effects in the
focused investment would seem to be the prudent future being uncertain and dependent on the price of oil
priority at a global level. In a globally interdependent and other fossil fuels. Such uncertainty is itself a cost,
world, even regions that might be less negatively which is amplified when allied with price volatility—a
affected by climate change itself, could expect common characteristic of fossil-fuel markets.
considerable economic and social disruption from
those regions that were thus affected. Possible sources of finance
The macroeconomic impacts of reducing CO2 In the public sector (aside from the extensive resources
emissions derive from several sources, all of which need to be found in local, regional, national, and supranational
to be taken into account if the overall impact is to be government budgets), sovereign wealth funds, as of
properly evaluated. First, there are the impacts of the August 2014, held over $6·7 trillion in assets.275 However,
various kinds of investments discussed above. in the private sector, institutional investors held a global
Investments in energy efficiency measures and total of $75·9 trillion in assets under management in
technologies are often cost effective at prevailing energy 2013 (this includes $22·8 trillion with pension funds,
prices, and there is substantial evidence that $24·6 trillion with insurance companies, and $1·5 trillion
opportunities for such investments are considerable.272 in foundations and endowments).276
Such investments will themselves tend to increase Institutional investors are likely to be critical sources
GDP. Investments in low-carbon energy that are of finance for mitigation and adaptation due to the scale
redirected from fossil fuel investments will, where the of resources available and the presence of long-term
low-carbon energy is more expensive than fossil fuels investment obligations. However, only 0·1% of
and leaving out considerations of avoided climate change institutional investor assets (excluding sovereign
and co-benefits, tend to reduce GDP. However, if fossil wealth funds) are currently invested in low-carbon
fuel prices increase from their currently relatively low energy infrastructure projects ($75 billion).277
levels and remain volatile, and the capital costs of Commercial banks are also a key source of finance and
renewables (especially solar and wind) continue to fall, are one of the main existing sources of renewable
then at some point renewable electricity may become investment capital. The resources held by non-financial
economically preferable to fossil-fuel derived power, companies are also extensive, with the largest 1000
irrespective of other factors. such companies estimated to hold $23 trillion in cash
Investments in low-carbon energy that are reserves.278
additional—such as the extra $1 trillion required International financial institutions (IFIs) such as the
annually as identified above—may increase or reduce Bretton Woods institutions and other multilateral
GDP depending on whether they employ unutilised development banks (MDBs), multilateral finance

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 The Lancet Commissions

institutions (MFIs), and regional investment banks to deliver cleaner products and processes. The final
(RIBs), whilst not holding collective assets to match domain, transformation, uses insights from evolutionary
those above, are also leaders in existing mitigation and and institutional economics to describe the ways in
adaptation finance, and are likely to be key in building a which complex systems develop over time under the
low-carbon economy in developing countries; their influence of strategic choices made by large entities,
mandates are explicitly focused on development and particularly governments, multinational corporations
poverty reduction promoted through low-interest, long- and institutional investors. The third pillar of policy
term loans—suitable for large infrastructure projects. arising from such analysis seeks to deliver
Existing dedicated funds for climate-change mitigation strategic investment in low-carbon innovation and
and adaptation under the UNFCCC, such as the Green infrastructure.265
Climate Fund (GCF), are also important resources. The Each of the three domains and policy pillars, whilst
GCF, established by the UNFCCC in 2010 and launched presented as conceptually distinct, interact through
in 2013, aims to raise $100 billion of new and additional numerous channels. For example, as figure 16 illustrates,
funding per annum from industrialised nations, by 2020 whilst the impact of each policy pillar is strongest in one
(from both public and private finance), to support domain, each of the pillars of policy have at least some
mitigation and adaptation pathways in developing influence on all three domains. All three pillars of policy
countries. In 2012, $125·9 billion of official development have an important role in producing a low-carbon global
assistance (ODA) was delivered by donor countries, energy system.265
equivalent to 0·29% of their combined gross national
income (GNI). Were states to meet their ODA Standards and engagement
commitments of 0·7% of GNI, another $174·7 billion Energy efficiency standards may take many forms.
would be mobilised.279 However, all act to push a market, product or process to
higher levels of efficiency (or lower levels of emission
Enabling architecture and policy instruments intensity), through regulation. Such regulations help to
The mobilisation of such financial resources requires overcome market failures such as split incentives, a
robust policy-generated incentive frameworks, under- prominent example of which is the landlord–tenant
pinned by credible political commitments. By the end of problem, when the interests of the landlord and tenants
2013, 66 countries had enacted 487 climate mitigation are misaligned. The problem arises because, whilst the
and adaptation-related laws (or policies of equivalent installation of energy efficiency measures would benefit
status), with a rich diversity of approaches.280 The Stern the energy bill-paying tenant, savings do not accrue to
Review considered that a policy framework for CO2 the landlord who therefore has no incentive to bear the
abatement should have three elements: carbon pricing, cost of installing such measures. Instead, standards can
technology policy, and the removal of barriers to require their installation, or other measures to induce
behaviour change.267 This three-part classification maps the same effect.
closely to three policy pillars, which in turn correspond to The main typologies of standards relating to
three different domains of change.265 Figure 16 illustrates mitigation are CO2 intensity standards, energy intensity
this framework, which can be applied to develop both standards and technology standards. The first two
mitigation and adaptation policy. specify a target limit for specific CO2 emissions or
Each of the three domains reflects three distinct energy consumption. Examples are a cap on CO2
spheres of economic decision making and development.
The first, satisficing, describes the tendency of Policy pillars
individuals and organisations to base decisions on habit, 1 2 3
Standards and Markets Strategic
assumptions, and rules of thumb, and, to some extent, Domain engagement and prices investment To deliver
the presence of psychological distancing (discussed in
section 5). Such occurrences are the subject matter of Smarter
Satisfice H L/M L
choices
behavioural and organisational economics, which can
explain the significant presence of unutilised Cleaner
opportunities for already cost-effective energy efficiency Optimise M H M products and
measures. The first pillar of policy, standards and processes
engagement, seeks to address these issues, resulting in
firms and individuals making smarter choices. The Innovation and
Transform L L/M H
infrastructure
second domain, optimising, describes the rational
approach that reflects traditional assumptions around Highest relevance
market behaviour and corresponding theories of Medium relevance
neoclassical and welfare economics. The second pillar of Lowest relevance

policy, markets and pricing, seeks to harness markets, Figure 16: Three pillars of policy
mainly acting through producers rather than consumers, Adapted from Grubb et al, 2014.265

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 The Lancet Commissions

emissions from passenger cars per kilometre driven existing and expected carbon price into short-term
(based on the average rating for all cars sold per operational and long-term investment decisions.
manufacturer), or on the annual energy consumption Figure 17 summarises the state of pricing mechanisms
of a new building per unit of floor area. Both such around the world. As of June 2014, around 40 national
policies (and variants) have been successfully and over 20 subnational jurisdictions were engaged in
implemented in the EU and around the world, and have carbon pricing of varied scope and instrument design,
proven effective. Technology standards may act in a covering about 12% of annual global GHG emissions
similar manner to CO2 or energy intensity standards, (the Australian ETS was discontinued in July 2014).281 The
but may also proscribe the use of certain components largest ETS is the European ETS, established in 2005,
in products, or prevent the sale of the least efficient and capping more than 40% of annual GHG emissions
models of a product type. Such standards may be from power generation and energy-intensive and
applied with a legal basis, or through the use of emission-intensive heavy industry across the EU-28 (plus
voluntary agreements. Standards may also be applied to Norway, Iceland, and Lichtenstein). This is followed in
produce adaptation actions, for example by amending scale by the aggregate of the seven ETS pilot schemes in
See Online for appendix 5 building codes to obligate developers to incorporate China, described in appendix 5. As of 2014, the total value
resilience measures in new construction. of all explicit pricing mechanisms was around
Processes and mechanisms for targeted $30 billion.281
communication and engagement between For sectors of the economy for which explicit carbon
governments, businesses, other organisations, pricing is infeasible or administratively burdensome,
communities and individuals help to overcome issues taxes on energy products (such as transport fuels) could
of psychological distancing, motivational issues, split be realigned to reflect their carbon content (producing
incentives and information asymmetry, and act to pull an implicit carbon price) By implementing
the market towards higher efficiency, lower emissions Environmental Tax Reform (ETR) principles, in which
and greater resilience. Such mechanisms can take the burden of taxation increases on environmentally
many forms and include training and education damaging activities and is reduced on desired inputs,
campaigns, but also labelling and certification, public such as labour, the increase in energy prices can be
reporting and other information disclosure and neutralised from a macroeconomic perspective. Parry
transparency measures. All these approaches act to and colleagues estimate that corrective taxation that
provide consumers and investors with information internalises CO2 emissions, local air pollution, and
surrounding environmental performance of a product, additional transport-related externalities (such as
service, process or organisation at the point of use, or congestion and accidental injury) arising from coal,
across the product lifecycle or organisational operations natural gas, gasoline, and diesel, could raise additional
and supply chain, in order to help them to make revenues of 2·6% GDP globally, whilst simultaneously
informed decisions regarding investments and reducing CO2 emissions by 23% and pollution-related
purchases. This encourages organisations to mitigate mortality by 63%.282 If this revenue was used to offset
risks by reducing organisational (and possibly supply labour taxation (eg, by a reduction in payroll or other
chain) emissions and to invest in adaptation measures corporate taxation), revenue neutrality is achieved
to improve resilience, ensuring they retain a strong whilst producing a double dividend effect of
customer base and remain a safe investment. The employment, as well as environmental improvement.283
introduction of these instruments may also reveal Alternatively, carbon pricing mechanisms can be used
opportunities for efficiency measures that have an to finance, subsidise, or otherwise incentivise
economic rationale independent of environmental investments into other mitigation and adaptation
considerations. measures, as discussed below.
In addition to pricing pollution, distorting subsidies for
Markets and prices the extraction and consumption of fossil fuels should be
The Stern Review called the market externality of GHG removed. For consumers, such subsidies (aimed at
emissions in the global economy “the greatest and providing energy at below market price, and principally
widest-ranging market failure ever seen”.267 Carbon applied in developing countries) total around $400 billion
pricing is the economist’s preferred means to address annually,284 whilst producer subsidies (aimed at
this externality. Such pricing may be achieved through sustaining otherwise uncompetitive production,
national or regional explicit carbon taxes or cap-and-trade principally applied in industrialised countries), are
emissions trading systems (ETS), which are increasingly around $100 billion annually.285
present around the world. A carbon tax sets the carbon Both fossil-fuel subsidies and the presence of
price directly, but not the level of abatement, whilst an externalities tend disproportionately to benefit the
ETS sets the level of abatement, but the price derives wealthiest in society (in both national and international
from the carbon market. Regardless of the pricing contexts), as energy consumption (and associated
mechanism, market actors may be expected to factor the emissions) increases with prosperity, both directly (eg,

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British Alberta Manitoba Sweden South Korea

Columbia Norway Finland
Denmark
Iceland EU
Quebec Ukraine Kazakhstan
UK and Turkey
Ireland
Washington Ontario
Oregon France
RGGI* Switzerland
California Japan

China
Mexico

Thailand

Brazil
Australia
Chile Rio de Janeiro
São Paulo
ETS implemented or South Africa
scheduled for implementation
Carbon tax implemented or Saitama
Beijing Kyoto
scheduled for implementation
ETS or carbon tax under Tianjin New Zealand
consideration Tokyo
Shanghai
Carbon tax implemented or Chong- Hubei
scheduled, ETS under consideration qing
ETS and carbon tax implemented Guangdong
or scheduled Shenzhen

Figure 17: Existing, emerging, and potential regional, national, and subnational carbon pricing instruments (ETS and tax)281
*The RGGI (Regional Greenhouse Gas Initiative) is a coordinated cap and trade programme, operating between nine Northeastern and Mid-Atlantic States in the USA
and Canada. ETS=emissions trading scheme.

via additional travel demand, domestic heating and technologies. To encourage deployment, improvement
cooling requirements) and indirectly through additional and cost-reduction of less mature technologies, direct
consumption of energy embodied in products and investment is also required. Although various options
services. Globally, an estimated 80% of such subsidies exist, Feed-in tariffs (FiTs), used in the electricity sector to
actually benefit the wealthiest 40% of the population.286 provide a guaranteed rate of return to low-carbon
However, the introduction of carbon pricing and the generators, have been the most effective policy
removal of fossil fuel subsidies may be regressive, as the instrument used for this purpose, and have been
poorest in society spend a greater proportion of their responsible for a significant majority of installed global
disposable income on energy. Reduced taxation of the renewable power capacity (appendix 6). A FiT-style See Online for appendix 6
low paid may partly offset this in industrialised instrument may also be used to encourage the
economies, although further targeted support, such as deployment of non-electric renewable technologies,
the provision of energy efficiency measures for low- including heating and cooling options.
income or vulnerable households (funded by carbon However, FiTs and comparable instruments only
price revenues and foregone subsidy), or the encourage diffusion and incremental improvements for
introduction of electricity tariffs differentiated by technologies around the end of the innovation chain
consumption level, is also likely to be required. In (market accumulation and diffusion). For technologies
developing countries where most consumer fossil-fuel in the earlier stages (applied research to demonstration
subsidies are provided, and where a greater proportion and commercialisation), concerted R&D efforts are
of the population is not employed in the formal economy required, comparable to public and private pharma-
or have no access to electricity, more targeted ceutical research that has been shown to produce
interventions to remove disproportionate effects on low- innovative new drugs.287 Such efforts may be analogous
income households, such as the expansion of social to the Manhattan Project for nuclear technology, or the
security, health care, and education provision, will be Apollo Program for space flight, but focused perhaps on
required. energy storage technologies, which are often seen as
crucial for the effective decarbonisation of the global
Strategic investment energy system.
Whilst a price on carbon is a key component for Public-led strategic investment is also required in
mitigation, it is technologically agnostic and mainly urban low-carbon travel infrastructure (eg, segregated
encourages the adoption of mature low-carbon cycle lanes), along with investment in electric-car

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 The Lancet Commissions

charging points. This also applies to the electricity humans to ignore or discount unpleasant facts or
transmission network, which is under state ownership in difficult choices (something familiar to doctors); the
most countries. Such investments may be financed in a nature of companies and countries to defend their own
number of ways, including directly by governments, rather than collective interests (something familiar to
multilateral organisations, or other public bodies, those working in global health); and the narrow, short-
through the use of carbon pricing revenues or by the term horizons of most human institutions, which feed
See Online for appendix 7 issuance of specialised climate bonds (appendix 7). into the difficulties of global negotiations.
Over the past century, the world has made enormous
Institutional reform and support strides in overcoming similar obstacles in the field of
Beyond the appropriate selection of policy instruments health, with international cooperation on health challenges
and timeframes for implementation, investments in as a shining example. The problem of anthropogenic
decarbonisation and adaptation measures will depend climate change is more recent, arguably more complex,
on the existence of effective and supportive governance and the efforts to tackle it more nascent. But there are
and well-functioning markets. Good governance some promising developments, and a great deal can be
requires the well-defined division of responsibilities learned by examining the history of efforts to date.
between government departments, agencies and One conclusion evident throughout our report is that
hierarchies, enforcement of standards and regulations, much of the technical expertise, technology, and finance
transparency at key stages of the regulatory process and required to turn climate change from a public health
subsequent monitoring and reporting, and effective threat into an opportunity is readily available, but
communication and stakeholder engagement. politically restricted. In essence, whether we respond to
Additionally, governments are often the largest “the biggest global health threat of the 21st century” is
consumer in the market, with public spending no longer a technical or economic question—it is
accounting for 15–30% of GDP in any given country.288 political. This section analyses the politics of climate
Sustainable public procurement (SPP) policies act to change and provides suggestions for action. We
provide a market for efficient, low-carbon goods and examine the international regime (under the UN
services. Framework Convention on Climate Change and its
Governments may promote well-functioning markets Kyoto Protocol); national policy responses; the role of
through the kinds of policies described above, and by sub-national governance processes, particularly in
reducing institutional barriers to low-carbon investment major cities; and the importance of individuals and
and innovation. For example, many pension funds public opinion. Importantly, we stress the need for
across the world are barred from investing in better synergy between top-down and bottom-up
infrastructure, including all in China (except the approaches. We seek to draw lessons from global health
National Social Security Fund) and many in the EU. governance mechanisms, and make suggestions for
Whilst these regulations aim to alleviate legitimate how health-related issues can inform the climate
concerns (such as preventing pension funds from change negotiation process.
becoming an extension of government budgets), they
are often excessive and increasingly irrelevant as funds Three phases of response—the international regime
gradually become independent of political It is almost 30 years since climate change emerged onto
interference.276 Reform of such rules is essential in political agendas, with three phases of response since
mobilising capital from institutional investors, then, of roughly a decade each.
irrespective of the policy and incentive mechanisms in
place to encourage investment in developing the low- First phase: understanding the evidence and establishing
carbon economy. institutions and broad goals
The first phase established the institutional basis for
Section 5: delivering a healthy low-carbon responding to climate change, including for scientific
future input into policy processes. Building on long-held
Central to this Commission’s work is the question of concerns of the scientific community, a series of
whether human societies can deliver a healthy, low- international workshops in the mid-1980s, hosted by the
carbon future. Sections 1 and 2 have explained the World Meteorological Organisation and the UN
scientific basis for concern, the potential health Environment Programme, led governments to establish
dimensions of impacts, and the adaptation responses the IPCC in 1988, as the official channel of scientific
required. Sections 3 and 4 have demonstrated the advice to the international community. In 1990, the
technological and economic feasibility of tackling the IPCC’s first report expressed enough concern for
problem. Yet over the past decade, global emissions have governments to formally launch international
still risen sharply. The evidence to date of humanity’s negotiations aimed at tackling the problem, and 2 years
ability to respond effectively is not encouraging. The later to agree on the UNFCCC. The UNFCCC now enjoys
difficulty, essentially, is ourselves: the tendency of almost universal membership.

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The UNFCCC established the “ultimate objective” of feasible, or even appropriate. Academics and
stabilising GHG concentrations at a level that would commentators increasingly argued that action happens
prevent dangerous human interference in the climate from the bottom up, not in response to binding top-down
system (UNFCCC, article 2). This objective has been commitments, and pointed to a wide range of initiatives,
recently interpreted as implying that global temperatures including at state level in the USA, to argue that a
should not rise more than 2°C above pre-industrial levels, fundamentally different approach was needed.
an aim reiterated in frequent statements under the These divergent views came to a head at a summit in
UNFCCC and other international fora, such as the G8. Copenhagen in 2009, which collapsed in acrimony save
The 2°C goal implies a need to roughly halve global for two pages of unofficial outline text hammered out as
emissions by 2050; stabilising the atmosphere at any a fallback compromise, initially between the USA and
level ultimately means bringing net emissions (emissions major emerging economies. The so-called Copenhagen
minus removals from forests, oceans, and other carbon Accord did register some landmark achievements,
sinks) to zero. notably confirming the 2°C goal, and a promise to raise
The UNFCCC established that industrialised countries $100 billion per year of international finance by 2020 to
would take the lead in curbing GHG emissions, setting help developing countries deal with climate change. In
them a non-binding goal of returning their emissions to terms of emission commitments, however, there were no
1990 levels by 2000. All parties, including developing binding targets; instead, the Copenhagen Accord called
countries, were given general commitments to address on countries to declare domestically-generated voluntary
climate change, as well as reporting obligations. The pledges of what they might deliver. Since then, almost all
UNFCCC also set up a raft of institutions to monitor major emitters have registered pledges, although based
implementation and pursue ongoing negotiations, under on varying indicators and with very different levels of
the auspices of the main decision-making body, the precision and ambition.
Conference of the Parties (COP). Negotiations in Durban in 2011 saw the launch of a
Health concerns feature, albeit in general terms, in the new round of talks aimed at agreeing a universal
UNFCCC, which lists impacts on human health and framework to deal with climate change from 2020.
wellbeing as part of the adverse effects of climate change According to the so-called Durban Platform, this new
(definitions, article 1). The only other reference requires agreement should be applicable to all parties, and “raise
parties to consider the broader implications of their the ambition” of the international community.
mitigation and adaptation actions on human health.289
Patchy progress in the negotiations
Second phase: leading through top-down international If global emission trends are the only indicator of
commitments progress, the results of the negotiations to date have been
In 1995, governments accepted the findings of the dismal. The 2014 IPCC report warned that global
IPCC’s second report and launched negotiations to emissions since 2000 have been rising ever faster at
strengthen the UNFCCC’s commitments. The working around 2% every year, powered largely by spectacular
assumption was that the international response would growth in China, and other emerging economies.201
be led by specific, binding emission targets for Viewed more closely, the picture is more nuanced. Taken
industrialised countries, which would then be together, the industrialised countries did meet the
implemented at a national level. This was the approach UNFCCC’s goal of returning their emissions to 1990
adopted in the Kyoto Protocol of 1997, which built levels by 2000 (helped by massive declines in the former
mainly on designs proposed by the USA under Soviet Union and Eastern Bloc). The industrialised
President Clinton. countries that accepted targets under the Kyoto Protocol
However, the fact that developing countries were not and remained parties to that agreement also all achieved
subject to any such specific commitments weakened the their official goals. There is no question that in the EU,
Protocol’s short-term impact and undermined its political the Protocol provided the legal framework and impetus
viability, particularly in the USA, where strong political for strengthening mitigation policies.
forces were opposed to any robust action on climate The international process has also had successes in
change. The subsequent US repudiation of the Kyoto other areas. Through the Kyoto Protocol’s Clean
Protocol made it clear that the Kyoto-type top-down Development Mechanism (CDM), many developing
model was unworkable in these circumstances as the countries came forward with new projects that generated
principal way forward. cheap emission reductions (that could then be sold on to
industrialised countries), and by most accounts
Third phase: bottom-up initiatives contributed to the establishment of renewable energy
Global negotiations continued, but with widely varying industries and other low-carbon technologies. Through a
objectives and perceptions. Whilst the EU and developing levy on CDM transactions, the Kyoto Protocol also
countries continued to support a Kyoto-style approach established a fund to help finance adaptation measures
with specific targets, few others believed that to be in developing countries.

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The UNFCCC also provides a crucial ingredient of regime’s coverage is expanding and deepening among
transparency. A major achievement has been in the developing countries parties. The voluntary
establishing a robust system of reporting and review, for approach of the Copenhagen Accord and Cancun
both national emissions data and broader policy actions. Agreements has engaged a much wider group of
In 1992, when the UNFCCC was adopted, many countries countries, including all major emitters, into national
had very little knowledge of their emissions profile—ie, target-setting. At the same time, the Durban Platform
what GHGs they were emitting and from what sources. mandate implies that all countries, not just the
The UNFCCC’s provisions, building on the IPCC’s industrialised ones, are expected to raise their ambition
methodological work, have been crucial in filling that in the new post-2020 regime. On the other hand, the
knowledge gap, which lays the foundation for an effective engagement of industrialised countries is weakening
response to climate change. compared with in the 1990s and early 2000s, with major
Despite patchy progress, the global negotiations emitters, such as Canada, Japan, Russia and, of course,
continue, and indeed are regaining momentum. It is the USA, now operating only under the Copenhagen
likely that the hybrid course set out in the Copenhagen Accord and Cancun Agreements, whose targets are
Accord, and ratified in 2010 by the Cancun Agreements, voluntary and not subject to common metrics.
of domestic aspirations, policies, and objectives will The outlook for future international negotiations is
define the primary ingredients of a future global therefore challenging, to say the least. The rest of this
agreement. Perhaps most importantly, it is also now clear section turns to consider reasons why progress on this
that international agreements must run concurrent with issue is so difficult (from both a top-down, and bottom-
(rather than precede) implementation efforts. The future up perspective), and what can be done to change this.
of the international negotiations will inevitably have to
combine elements of top-down and bottom-up policies The generic barriers
within the global framework. The technological, investment, and behavioural
One indication of both the opportunities and challenges changes needed to meet ambitious long-term goals, as
is found in a joint US–China agreement of 2014, in which illustrated in sections 3 and 4, are, in principle, entirely
the US Administration pledged to reduce its emissions feasible. But they need to be accomplished in the face
by 26–28% below 2005 levels by 2025, and China offered of highly diverse social, cultural, economic, and
to cap its emissions growth by 2030, or sooner if possible. political contexts. Opposing national (and vested)
On the positive side, this is the first time that any major interests, clashing views of what constitutes fair
emerging economy has stated it is willing to cap its distribution of effort, and a model of economic growth
emission growth in absolute terms, and interactions that is currently tied to fossil fuel use, can make
between the USA and China helped each to a new level of progress fraught. There are several key issues, as
commitment. outlined by Hulme, 2009:293
On the negative side, it illustrates the scale of the gap • Uncertainty and complexity. The climate is naturally
between science and action: if viewed in terms of per- variable and the science that has identified dangerous,
capita emissions, it means that the USA is planning to anthropogenic climate change to a very high level of
come down somewhat below 15 tCO2 per capita, whilst probability is complex. This leaves considerable room
China wants headroom to reach potentially 10 tCO2 per for public ignorance or misunderstanding of the
capita by 2030, before declining. This is a far cry from nature and severity of the issue. Moreover, climate
the scientific goals—a 2°C limit implies the need for a scientists can be ineffective at communicating the
global average close to 2 tCO2 per capita by mid-century. issue to the public.294
It emphasises that in isolation, such decentralised • Climate change is psychologically distant along four
policy action also seems unlikely in the aggregate to dimensions—temporal, social, geographical, and
deliver the necessary global mitigation effort effectively, degree of uncertainty—whereas people tend to connect
equitably, and efficiently, and points to the risks of more easily with issues that are close in time, space and
abandoning any collective, science-led direction to the social group, and about which there is little uncertainty.
global effort. These dimensions interact with each other, all tending
There are indeed reasons for concern regarding the to dampen concern and willingness to act.295
international regime’s ability to deliver on its promise.290 • There is enormous lock-in to current economic
The international relations literature has tended to patterns.296 Fossil-fuel use is at the heart of the
assume that regimes start off weak, but as scientific industrial economy, often operating through long-
evidence hardens and political will increases, parties lived infrastructure (eg, roads, buildings, and power
agree to ratchet up their commitments and the regime plants) and enabling valued dimensions of modern
strengthens; this was clearly the assumption of the lifestyles (eg, travel and temperature control in
early climate change negotiators.291,292 It is difficult to buildings). It is no exaggeration to say that human
say, however, whether the climate change regime is societies are addicted to fossil fuels, or at least the
now getting stronger or weaker. On the one hand, the services they provide. Providing these valued services

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through alternative, lower-carbon means requires using the networked reach of their municipal governments
systemic change over a long period. to address climate change in ways that are often more
• These three factors can all come together in a fourth: flexible and more directly applied than those of the
the active promotion of misinformation, motivated by national or international levels. Evermore city leaders have
either ideology or vested economic interests. Here, been leveraging their network power through international
parallels can be drawn between public health efforts networks such as the United Cities and Local Governments
to reduce tobacco consumption (appendix 8). It is (UCLG), ICLEI Local Governments for Sustainability, the See Online for appendix 8
estimated that US industry spent close to $500 million World Mayors Council on Climate Change and the
in its successful campaign against the 2010 House of Climate Leadership Group (or C40).299
Representatives proposal to cap US emissions. A These groups are now a well-established presence in
major study of the Climate Change Counter the international climate change arena,302 pointing to the
Movement in the USA identifies funding of around emerging imprint on global environmental governance
$900 million annually.297 by city leaders.303 Their most crucial contribution to
These obstacles are further compounded by the climate action is that of leveraging city diplomacy to
economic characteristics of responses. Low-carbon implement specific actions on the ground via municipal
technologies are generally more capital-intensive than management and multi-city initiatives. In practice, this
their fossil-fuel alternatives, albeit with much lower governance from the middle is about taking advantage of
running costs. Their implementation therefore requires the pooled networked connections of cities to implement
more upfront investment and a longer time horizon, a plethora of initiatives aimed at direct and quick
resulting initially either in higher energy prices or higher implementation, which then injects urban elements in
taxes, or some combination of the two. The same is true wider international processes.
of most adaptation measures; flood protection defences, Among the networks of larger cities, there is an
for example, are capital-intensive investments with emerging pattern of their local policy priorities becoming
uncertain returns. aggregated under a single strategic issue, as seen in
A large-scale shift to such technologies will require integrated planning, climate, and sustainability plans
very large investments over a prolonged period of time. such as Sustainable Sydney 2030. Concurrently, climate
This shift in financial flows will need to be incentivised, action has taken place on municipal purview areas such
in the early periods at least, by strong, consistent, and as energy regulation, transport and mobility, building
credible public policies, and a change in financial retrofit, or waste management. Major centres like New
structures. Such policies are far from easy to introduce York or Tokyo, for instance, have implemented building
and sustain, given other political priorities that may be energy retrofit schemes across their city infrastructures.
perceived as more pressing, and the political complexities Taken together, such a two-headed agency can enable
indicated above. cities to collectively attract and therefore release
investment capital to execute wide-ranging policy
Cities, states, and provinces: progress at the subnational programmes (such as C40’s Energy Efficiency Building
level Retrofit programme). This ability to leverage global
Despite all these obstacles, action does continue in varied capital by effectively generating a large single market can
ways, at many levels. Local issues have long been part of be highly influential insofar as the cities are able to act
the broader agenda of international environmental quickly, often within the space of a year, and increasingly
politics, and local governments have an increasingly represent a significant proportion of the world’s
well-documented track record in climate action. population and energy generation. This stands by
In the past two decades, cities have been pivotal in contrast with national governments, where climate policy
producing multiple policy-making frameworks and is often subsumed within other priorities rather than as
advocacy coalitions. This has fostered a thick texture of an organising aim across government.
para-diplomatic links and policy action around climate City-level governance may also provide the flexibility
change and environmental health.298,299 The rise and and scope to include health in actions on climate
cross-cutting international spread of cities as actors in change, with city leaders becoming key actors in
climate action also evidences a more refined pattern of recognising and responding to the health co-benefits of
transnational connections that are not solely bottom up, doing so. It is important that the UN-led international
but rather offer a level of governance from the middle negotiations process takes account of this dimension of
that cuts horizontally across international and national multi-level governance, which operates in both formal
frameworks, involving an expanding variety of public- and informal ways.
private structures and offering a distinct variation on civil
society models of climate action.300,301 Public opinion and behaviour
The leaders of cities around the world, from major Ultimately, effective actions by local and national
metropolitan hubs like New York and São Paulo, to governments, and by businesses, are unsustainable
smaller centres like Rabat or Medellin, are increasingly without supportive public opinion. Public support for

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stronger action on climate change is a necessary, albeit Public understandings of climate change are shaped
far from sufficient, factor, and is essential if behavioural by broader knowledge and belief systems, including
change is to contribute to solving the problem. In this religious convictions and political beliefs.294 There is
respect, the evidence is somewhat mixed. Cross-national evidence that the public recognises that climate change
studies, such as the 2013 survey presented in figure 18, is complex, and interconnected with other
suggest that most people view climate change as a environmental and social challenges.305 Effective
threat, although with some significant variation within communication about climate change requires trust.306
regions.304 The most trusted sources vary across time and place,

Nigeria
South Africa
Africa

Senegal
Ghana
Uganda
Kenya

Egypt
Mediterranean to

Palestine
southeast Asia

Turkey
Tunisia
Jordan
Israel
Lebanon

Russia
Poland
Czech Republic
Europe

UK
France
Spain
Italy
Germany
Greece

Pakistan
China
Asia Pacific

Malaysia
Indonesia
Australia
Philippines
Japan
South Korea

Venezuela
South America

Mexico
Bolivia
El Salvador
Argentina
Chile
Brazil
America
North

USA
Canada
0 10 20 30 40 50 60 70 80 90 100
Percentage (%)
Major threat Minor threat Not a threat Not known or refused

Figure 18: Perceptions of the threat of climate change, 2013304

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and can include family and friends, environmental organisations to take action. A recurrent finding is that
groups, scientists, and the media; local and city-level the public sees the main responsibility for action lying
authorities may provide an important conduit for with governments and other powerful institutions, not
communicating information from trusted sources. For least because the options open to individuals to take
scientists to engage effectively with the public, however, radical action to cut their own GHG emissions are
they need to seek a greater understanding of prior often sorely limited by cost or availability (eg, poor
knowledge and belief systems, and communication public transport provision). Public willingness to take
skills radically different from those of academia. They action is also contingent on those considered
must move beyond traditional scientific discourse to responsible for climate change taking action
convey a big picture of climate change with which themselves.316 The majority of the public in cross-
members of the public can engage; this can then provide national surveys believe that their country has a
a context and framing for the discussion of new responsibility to take action on climate change, and that
scientific results and their consequences.294 their government is not doing enough.317
Fourth, many climate-affecting behaviours are habitual
Public responses to climate change and resistant to change. Everyday domestic energy use
The causes of climate change lie ultimately in human (eg, cooking, heating the home), travel behaviour, and
behaviour, in particular in the economies and lifestyles of eating patterns are undertaken as part of a daily routine
rich societies.307 However, it has been science, rather than and without conscious thought. Such behaviours are
social science, that has underpinned climate change resistant to change, even if alternative options are
communication and policy development.308 There is as available, and interventions relying on increasing
yet little evidence on how to change behaviours that knowledge have limited effect.318
contribute to climate change,309 but taking broader
evidence on the determinants of behaviour and Conclusions
behavioural change, four themes stand out. It is clear that in isolation, a top-down approach
First, knowledge deficits are not the primary barrier to (international agreement followed by national legislation
action; knowing about the causes and consequences of with which individuals and business must comply) to
climate change does not, on its own, motivate people to managing climate change is no longer a sufficient
change their lifestyles.310 Instead, it is emotions—the response. Other actors are already taking steps
feelings that accompany thinking—that are central.311 independent of any agreement to reduce their emissions,
Negative emotions, including fear, pessimism, and guilt, and a voluntary transformation to a low-carbon economy
can produce passive and defensive responses, and do may already be underway. At the same time, as indicated
little to encourage individuals to change their behaviour throughout this report, these bottom-up initiatives have
and to press for wider social action. So-called fear appeals hardly, as yet, taken us any closer to the scale of global
only work if accompanied by equally strong messages action required to protect human health against the risks
about how to address the problem.312 Representations of of climate change, than has the decade of targets under
climate change as inexorably heading for catastrophe the Kyoto Protocol.
close off the possibility that individual and collective Section 1 has underlined the way in which the
action can make a difference.294 continued acceleration of GHG emissions and
Second, climate change is best represented in ways that atmospheric concentrations, mapped on to changing
anchor it in positive emotions,313 by framing action in global demographics, is making climate change an
ways that connect with people’s core values and identities. increasingly severe risk to global health. Despite the
Examples include framing climate change as: an ethical threat that climate change poses to human development,
and intergenerational issue; about safeguarding ancestral it remains but one of many factors influencing decision
lands and the sanctity of the natural world; or an makers, and rarely the most important one.
appreciation of the global injustice of anthropogenic Precautionary adaptation is clearly inadequate and
climate change driven by rich countries but paid for by prevailing patterns of energy production and
poorer ones.107,314 Aligning climate change to a range of consumption are still driving the world towards a
ethical positions and a core set of identities can offer a dangerous climatic future. Current economic drivers of
way of appealing to diverse social groups, and thus growth lock communities into patterns of energy use
securing a broad and inclusive platform of public support which no amount of reframing can change unless
for action. This could be facilitated by avoiding the coordinated realignment of these drivers takes place.
rhetoric of climate catastrophe, and emphasising, instead, And the argument that others should be doing more to
human capacity to steer a way to a sustainable future, tackle climate change, because they are more to blame,
including lifting the burdens that unmitigated climate remains one of the most politically potent excuses for
change would otherwise impose on future generations.313,315 inadequate action.
Third, integral to such an ethical framing of climate Thus the challenge, and the crucial test of the
change is the implied duty on national and international international process, will be finding a synthesis of

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top-down and bottom-up forces. An effective bottom-up action in many realms. A sophisticated
international agreement will be one that supports approach is needed, which draws on the universal
stronger efforts everywhere and at every level. The desire to tackle threats to health and wellbeing (without
diverse worlds of bottom-up initiatives in cities, any particular philosophical slant), in order to motivate
companies and many others should in turn help rapid action, and a policy framing that is more human
overcome the obstacles that impede the ability or than purely environment, technology, or economy
willingness of national governments to commit to focused. This requires making the impact of climate
stronger national actions. To be truly effective, any change on people explicit, rather than implicit. By
future agreement will thus need not only to agree goals considering directly how climate change will impact on
and aspirations, but also identify what is necessary at human health, we are naturally drawn to the human
the international and national levels to achieve them. component of climate impacts, rather than the
This may also require a mechanism, such as a feedback environmental (flooding, forest fires) or more abstract
loop, that will motivate increased national ambitions effects (the economy, the climate). This supports a
over time. A system of review will be a crucial human framing of climate change, putting it in terms
component, with regular assessments of the that may be more readily understood by the public.
effectiveness of national policies, actions, and targets. Fostering such public resonance can act as a powerful
policy driver: public pressure is, of course, a crucial
Section 6: bringing the health voice to climate factor motivating both national governments and their
change negotiators in the international arena.
Our studies point to multiple ways in which the health Fourth, local health benefits could in themselves help
agenda may help accelerate the response to climate to drive key adaptation and mitigation actions. The
change. First are the positive lessons for international numerous health co-benefits of many adaptation
cooperation. No-one would suggest that national action measures were emphasised in section 2, whilst
to protect health should depend on a global, section 3 noted substantial health co-benefits of many
all-encompassing treaty. Yet few would deny that WHO mitigation measures. Examples of the latter include the
and numerous other fora of international cooperation reduced health risks and costs when populations live in
are important in accelerating, coordinating, and well-insulated buildings, and the reduction in air
deepening responses to health challenges—particularly, pollution (and other health) damages associated with
but not exclusively, those with transboundary fossil fuel use, which, as noted, even in strictly
dimensions. The health experience neatly illustrates the economic terms typically amount to several percent of
falsity of the dichotomy between top-down and bottom- GDP, as well as adding directly to the strain on limited
up: one measure of success is how each can reinforce health-care resources. With the direct costs of deep cuts
the other. Learning from the health experience may in emissions estimated at around 10% of global
illuminate the most effective actions at a particular level expenditure on health, both the direct and indirect
or levels of governance, and how the multi-level health dimensions should be a major driver for
governance framework and international negotiation mitigation efforts. It is also commonly seen that
process can mutually reinforce actions at different levels. responding to climate change from a public health
Second, political lessons from health have particular, perspective brings together both mitigation and
and largely encouraging, resonance for a climate dialogue adaptation interventions, yielding powerful synergies.
increasingly characterised by pessimism about the ability Fifth, analogies in health responses can also help to
to control the problem. The denialism of HIV, responsible underline that there is rarely a single solution to complex
for perhaps a million deaths, did eventually give way to problems: different and complementary measures are
global acceptance of the science. 50 years of tobacco required to tackle different dimensions, and pursuing
industry resistance and obfuscation of the science on both prevention (mitigation) and treatment (adaptation)
lung cancer has to a large extent been overcome, is crucial:
including with recognition embodied in WHO’s With severely ill or vulnerable patients, the first step is to
Framework Convention on Tobacco Control, that stabilise the patient and tackle the immediate symptoms.
governments have a duty to resist such lobbying forces. Helping poor countries particularly to adapt to the impacts
Third, the health implications could and should be of climate change is similarly a priority. But as noted in
more effectively harnessed in efforts to build support section 2, adaptation cannot indefinitely protect human
for a stronger response to climate change. The health health in the face of continuing and accumulating degrees
impacts of climate change discussed in this of climate change, any more than tackling the symptoms
Commission are not well represented in global will cure a serious underlying disease.
negotiations, but they are a critical factor to be • For infectious diseases, antimicrobials and a
considered in mitigation and adaptation actions. A functioning health system to produce, distribute, and
better understanding of the health impacts of climate administer drugs effectively are essential components.
change can help to drive top-down negotiations and The obvious analogy here is with specific greenhouse

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gas mitigation policies, such as energy efficiency is obvious and focuses global attention on the need to
programmes and technology programmes that span stabilise atmospheric concentrations, which in climate
the full spectrum from R&D through to policies to terms, means getting net emissions (that is, emissions
support industrial scale deployment and related minus removals by forests, oceans, and other sinks) to
infrastructure. zero. On most scientific indicators, it means getting to
• Deeply-ingrained patterns of behaviour are best zero during the second half of this century. A unifying
addressed by comprehensive approaches and the use of goal, therefore may be a commitment to achieve zero
multiple policy levers. Evidence from studies of health emissions based on multiple partnerships involving
behaviour change suggests that, to be sustained, different actors. If any region can achieve net zero, there
changes in the individual’s everyday environments are is no fundamental reason why that should not become
required. Structural levers are also important for global. Getting to net zero also focuses us on a common
addressing social inequalities in harmful behaviours. task: how to get there, which is potentially harder for the
Such evidence could be harnessed to inform policies to societies that have become more dependent on fossil
address climate change—eg, the behaviour change fuels, whilst in developing countries, it sends a clear
checklists developed to guide policy to reduce tobacco signal that the sooner their emissions can peak, the
use and tackle harmful alcohol consumption may be better for their own path towards that common goal. If
particularly useful. Applying lessons from health the goal is net zero, all actors in all societies have a sense
behaviour change may help to accelerate policy of the direction of the international framework for action
development, building an evidence platform for in order to protect everyone’s health against the risks
interventions to promote mitigative and adaptive posed by continual increases in the global concentration
behaviours. of heat-trapping gases.
• As with the evolution of drug-resistant bacteria, the
challenges of drug addiction, or the rising health A Countdown to 2030: global health and climate action
problems of obesity, medical fixes cannot solve all If we are to minimise the health impacts of climate
health problems. Similarly, in our energy systems, change, we must monitor and hold governments
specific mitigation policies and projects are constantly accountable for progress and action on emissions
faced with the ingenuity of the fossil fuel industry in reduction and adaptation. One might argue that action
finding and driving down the costs of extracting new on climate change is already effectively addressed by the
fossil fuel resources and marketing them. The long- IPCC, World Bank, UNFCCC, WHO, and the G20. We
term antidote is more analogous to programmes of believe, however, that the health dimension of the climate
sustained immunisation, education, incentives, and change crisis has been neglected. There are four reasons
enforcement, all oriented towards supporting healthier why an independent accountability and review process is
lives. warranted:
The single most powerful strategic instrument to 1 The size of the health threat from climate change is
inoculate human health against the risks of climate on a scale quite different from localised epidemics or
change would be for governments to introduce strong specific diseases. On current emissions trajectories
and sustained carbon pricing, in ways pledged to there could be serious population health impacts in
strengthen over time until the problem is brought every region of the world within the next 50 years.
under control. Like tobacco taxation, it would send 2 There is a widespread lack of awareness of climate
powerful signals throughout the system, to producers change as a health issue.191
and users, that the time has come to wean our 3 Several independent accountability groups have
economies off fossil fuels, starting with the most carbon brought energy, new ideas and advocacy to other
intensive and damaging like coal. In addition to the global health issues. For example, the Institute of
direct incentives, the revenues could be directed to Health Metrics and Evaluation in Seattle have led
measures across the spectrum of adaptation, low-carbon analyses of the Global Burden of Disease, the
innovation, and the global diffusion of better Countdown to 2015 child survival group has
technologies and practices. As outlined in section 4, monitored global progress since 2003, and the Global
carbon pricing thus has immense potential, particularly Health 2035 group have stimulated new ideas about
when embedded in comprehensive policy packages. global health financing.
This most powerful antidote, however, still faces many 4 Perhaps the paramount reason for an independent
political obstacles. review is the authority of health professional voices
The crux of the matter is that stabilising the atmosphere with policy makers and communities. Doctors and
at any level ultimately requires reducing net emissions to nurses may be trusted more than environmentalists.
zero. A healthy patient cannot continue with indefinitely They also bring experience of collating evidence and
rising levels of a toxin in the blood; even nutrients conducting advocacy to cut deaths as a result of
essential to a healthy body (like salt) can become tobacco, road traffic accidents, infectious disease, and
damaging if not stabilised. The climate-change analogy lifestyle-related non-communicable diseases.

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and to implement low-carbon, sustainable health

Panel 9: Framework of indicators for monitoring progress systems.
in three critical areas A Countdown process would complement rather than
Health impacts replace existing IPCC and other UN reports. UN
An updated review of evidence on the health impacts of climate reports understandably seek cautious consensus. An
change: independent review of progress would add the full
• Heat stress and heatwaves weight and voice of the health community and valuable
• Climate-sensitive dynamic infectious diseases metrics to this critical population health challenge. A
• Air pollution and allergy Countdown to 2030: global health and climate action
• Climate-related migration coalition would independently decide the structure of
• Food insecurity and crop yields their reports and the sentinel indicators they would
• Extreme weather events choose to monitor progress towards key outcomes,
• Ecosystem service damage policies and practice. Panel 9 outlines one possible
framework for monitoring progress in three critical
Actions to reduce greenhouse gas emissions that improve areas: health impacts; progress with action to reduce
public health GHG emissions; and progress with actions to support
International progress and compliance with: adaptation, and the resilience of both populations and
• A strong and equitable international agreement health systems, to climate change.
• Low-carbon and climate-resilient technology innovation
and investment Optimism
• Climate governance (finance, decision making, We should draw considerable strength in the face of the
coordination, legislation) challenges of climate change from the way in which the
Regional and national progress and successes with: global community has addressed numerous other threats
• Phasing out of coal-fired power generation and removal to health in the recent past. Although the threats are
of fossil-fuel subsidies great and time is short, we have an opportunity for social
• Urban planning, spatial infrastructure, and liveable cities transformation that will link solutions to climate change
• Government incentives capital for low-carbon, resilient with a progressive green global economy, reductions in
buildings and infrastructure social inequalities, the end of poverty, and a reversal of
the pandemic of non-communicable disease.
Adaptation, resilience, and climate-smart health systems
There are huge opportunities for social and
Progress and successes with:
technological innovation. We have modern com-
• Poverty reduction and reductions in inequities
munications to share successful local learning. At the
• Vulnerability and exposure reduction in high-risk
highest levels of state, there are opportunities for political
populations
leaders to grasp the global challenge with transformative
• Food security in poor countries
climate initiatives of a scale and ambition to match the
• Communication of climate risks and community
Marshall plan, the Apollo and Soyuz space programmes,
engagement for local solutions
and the commercial success of mobile telephony.
• Development of climate resilient, low-carbon health
Scalable, low-carbon, and renewable energy technologies
systems; scale up of renewables and combined heat and
require billions of dollars of new investment and ideas.
power generation in health facilities; use of climate
In cities, municipal governments are already bringing
finance for health infrastructure; decentralisation of care
energy and innovation to create connected, compact
urban communities, better buildings, managed growth,
We propose the formation of an independent and more efficient transport systems. In local
international Countdown to 2030: global health and communities transformative action creates greater
climate action coalition, along the same lines as other environmental awareness and facilitates low-carbon
successful global health monitoring groups. We transition. And within local government, civil society,
recommend that a broad international coalition of and business, many people aim to bring about social and
experts across disciplines from health to the economic transformation. All of us can help cut GHG
environment, energy, economics, and policy, together emissions and reduce the threat of climate change to our
with lay observers, drawn from every region of the environment and health. At every level, health must find
world, should monitor and report every 2 years. The its voice. In health systems we can set an example with
report would provide a summary of evidence on the scale up of renewables, combined heat and power
health impacts of climate change; progress in generation in health facilities, decentralisation of care
mitigation policies and the extent to which they and promotion of active transport, and low-carbon
consider and take advantage of the health co-benefits; healthy lifestyles. But time is limited. Immediate action
and progress with broader adaptation action to reduce is needed. The Countdown to 2030 coalition must begin
population vulnerability and to build climate resilience its work immediately.

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Contributors Harm), and Duan Maosheng (Tsinsghua University). Olivia Stevenson

The 2015 Lancet Commission on Health and Climate Change is an (University College London) provided ongoing guidance and policy
international collaboration led by University College London, Tsinghua expertise to the Commission. Neil Morisetti (University College
University, the University of Exeter, the Stockholm Resilience Centre, London) provided ongoing guidance and strategic input throughout the
and Umeå University. The Commission undertook its work within five Commission’s process. Elaine Fletcher and Marina Maiero from
central working groups, which were responsible for the design, drafting, WHO’s Department of Public Health, Environmental and Social
and review of their individual sections. All commissioners contributed to Determinants of Health, and Bettina Menne from WHO’s Regional
the overall report structure and concepts, and provided input and Office for Europe provided both formal and informal advice and
expertise in facilitating integration between the five core sections. assistance to the Commission. The Commission also worked with
Members of Working Group 1 (climate change and exposure to health risks): various practitioner commissioners who reviewed its progress
W Neil Adger, Mat Collins, Peter M Cox, Andy Haines, Alasdair Hunter, independently, and provided policy insight and guidance on how the
Xujia Jiang, Mark Maslin, Tara Quinn, Sergey Venevsky, Qiang Zhang. final report could be most useful to decision makers. The practitioner
Members of Working Group 2 (action for resilience and adaptation): commissioners included Diarmid Campbell-Lendrum (WHO),
Victor Galaz, Delia Grace, Moxuan Li, Georgina Mace, My Svensdotter, Matthew Pencharz (Greater London Authority), Virginia Murray (PHE),
Koko Warner, Yongyuan Yin, Chaoqing Yu, Bing Xu. Members of Working and Martin Frick (German Federal Foreign Office). In particular, the
Group 3 (transition to a low-carbon energy infrastructure): Ian Hamilton, Commission would like to thank Diarmid Campbell-Lendrum, who
Lu Liang, Robert Lowe, Tadj Oreszczyn, Steve Pye, Jun Yang. leads WHO’s efforts on health and climate change, for his advice and
Members of Working Group 4 (financial and economic action): Wenjia Cai, ongoing work in understanding the health impacts and adaptation
Paul Drummond, Paul Ekins, Paolo Agnolucci, Melissa Lott. Members of responses to climate change, which provided a foundation for much of
Working Group 5 (delivering a healthy low-carbon future): Jason Blackstock, our report. Various experts in the fields of finance and economics
Sarah Chaytor, Adam Cooper, Joanna Depledge, Hilary Graham, provided invaluable guidance during the initial preparation stages for
Michael Grubb, Yong Luo. section 4, for which the authors are most grateful. These include
Michael Grubb acted as the integrating editor for mitigation (working Bernie Bulkin (Ludgate Investment), Mark Campanale (Carbon Tracker
across Working Groups 3, 4, and 5), and Maria Nilsson acted as the Initiative), Martin Rushton-Turner (Swiss Re), Michael Mainelli
integrating editor for health (working across all working groups). Peter (Z/Yen), Andrew Scott (Overseas Development Institute), Adrian Gault
Byass, Ilan Kelman, and Tim Colbourn provided global health expertise (Committee on Climate Change), Paul Dickinson (CDP, formerly
for a number of working groups, and contributed to the Commission’s Carbon Disclosure Project), Jim Watson (UK Energy Research Centre),
overall direction. Nick Watts, Anthony Costello, Hugh Montgomery, and and Simon Buckle (Organization for Economic Cooperation and
Peng Gong were responsible for the strategic direction, integration, and Development). Administrative, communications, and design support
editing of the Commission. was provided by Ron Finaly, and by Ayesha Ally, Anila Babla,
Faye Basset, Rosie Bartlett, Helen Hopkins, Kate Hoyland, and
Declaration of interests
Maxine Lenza at UCL.
Five commissioners (PD, MG, MLo, MS, and NW) were compensated for
their time whilst working on the Commission’s drafting and development. References
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