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Competing Interests: Declaration of interests 14 of the authors (MRo, MWa, LJ, MBO'H, CO, HW, CdN, HK, PL, DS, CG, ZA, MY-G, and KRvD) were compensated for their time while drafting and developing the Lancet Countdown's report. OG was supported by the EU Horizon Grant: Climate Action To Advance Healthy Societies in Europe (Project 101057131–CATALYSE), for which there is overlap of data collection and preprocessing with the materials submitted in this report. MSp was supported by the Wellcome Trust Livestock, Environment and People (grant number 205212/Z/16/Z) and Wellcome Trust (grant number 225318/Z/22/Z). JT was supported by the Academy of Finland grants for the T-Winning (grant number 353327). CD was supported by the UK Natural Environment Research Council Independent Research Fellowship (grant number NE/N01524X/1), which ended in 2021, and by the European Research Council starting grant FLORA (grant number 101039402). OJ was supported by the NHMRC Investigator Grant entitled Heat and Health: Building resilience to extreme heat in a warming world (GNT20009507), the Wellcome Trust grant Heat stress in ready-made garment factories in Bangladesh (216059/Z/19/Z), and the Resilience New South Wales grant A new heat stress scale for general public (PJ-0000850). YL was supported by funding from the National Aeronautics and Space Administration (grant number: 80NSSC21K0507) for the wildfire population exposure and fire danger indicators. TO and IH were supported by the UK Research and Innovation Engineering and Physical Sciences Research Council Centre for Research in Energy Demand Solutions (grant number EP/R035288/1). MRo was supported by funding from IDAlert project (UK Research and Innovation project reference number 10056533). KB was supported by funding from the National Institute for Health and Care Research (NIHR) Centre on Non-communicable Diseases and Environmental Change (NIHR203247). All other authors declare no competing interests. The authors alone are responsible for the views expressed in this Commission, and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Local public health authorities often lack the capacity to adapt to climate change, despite being on the 'front lines' of climate impacts. Upper-level governments are well positioned to create an enabling environment for adaptation and build local public health authorities' capacity, yet adaptation literature has not specified how upper-level governments can build local-level adaptive capacity. In this paper we examine how federal and regional governments can contribute to enabling and supporting public health adaptation to climate change at the local level in federal systems. We outline the local level's self-assessed adaptive capacity for public health adaptation in Canadian and German comparative case studies, in terms of funding, knowledge and skills, organizations, and prioritization, drawing upon 30 semi-structured interviews. Based on interviewees' recommendations and complemented by scientific literature, we develop a set of practical measures that could enable or support local-level public health adaptation. We find that adaptive capacity varies widely between local public health authorities, but most report having insufficient funding and staff for adaptation activities. We propose 10 specific measures upper-level governments can take to build local public health authorities' capacity for adaptation, under the interrelated target areas of: building financial capital; developing and disseminating usable knowledge; collaborating and coordinating for shared knowledge; and claiming leadership. Federal and regional governments have an important role to play in enabling local-level public health adaptation, and have many instruments available to them to fulfill that role. Selecting and implementing measures to enable local public health authorities' adaptive capacity will require tailoring to, and consideration, of the local context and needs., (Copyright © 2018. Published by Elsevier Ltd.)

Climate change is a major challenge facing public health. National governments play a key role in public health adaptation to climate change, but there are competing views on what responsibilities and obligations this will-or should-include in different nations. This study aims to: (1) examine how national-level public health adaptation is occurring in Organization for Economic Cooperation and Development (OECD) countries; (2) examine the roles national governments are taking in public health adaptation; and (3) critically appraise three key governance dimensions of national-level health adaptation-cross-sectoral collaboration, vertical coordination and national health adaptation planning-and identify practical examples suited to different contexts. We systematically reviewed publicly available public health adaptation to climate change documents and webpages by national governments in ten OECD countries using systematic web searches, assessment of self-reporting, and content analysis. Our findings suggest national governments are primarily addressing infectious disease and heat-related risks posed by climate change, typically emphasizing capacity building or information-based groundwork initiatives. We find national governments are taking a variety of approaches to public health adaptation to climate change that do not follow expected convergence and divergence by governance structure. We discuss practical options for incorporating cross-sectoral collaboration, vertical coordination and national health adaptation planning into a variety of contexts and identify leaders national governments can look to to inform their public health adaptation planning. Following the adoption of the Paris Agreement and subsequent increased momentum for adaptation, research tracking adaptation is needed to define what health adaptation looks like in practice, reveal insights that can be taken up across states and sectors, and ensure policy orientated learning., Competing Interests: This project was originally developed on a contract with the Public Health Agency of Canada.

In Canada, the emergence of vector-borne diseases may occur via international movement and subsequent establishment of vectors and pathogens, or via northward spread from endemic areas in the USA. Re-emergence of endemic vector-borne diseases may occur due to climate-driven changes to their geographic range and ecology. Lyme disease, West Nile virus (WNV), and other vector-borne diseases were identified as priority emerging non-enteric zoonoses in Canada in a prioritization exercise conducted by public health stakeholders in 2013. We review and present the state of knowledge on the public health importance of these high priority emerging vector-borne diseases in Canada. Lyme disease is emerging in Canada due to range expansion of the tick vector, which also signals concern for the emergence of human granulocytic anaplasmosis, babesiosis, and Powassan virus. WNV has been established in Canada since 2001, with epidemics of varying intensity in following years linked to climatic drivers. Eastern equine encephalitis virus, Jamestown Canyon virus, snowshoe hare virus, and Cache Valley virus are other mosquito-borne viruses endemic to Canada with the potential for human health impact. Increased surveillance for emerging pathogens and vectors and coordinated efforts among sectors and jurisdictions will aid in early detection and timely public health response.

Climate change poses numerous risks to the health of Canadians. Extreme weather events, poor air quality, and food insecurity in northern regions are likely to increase along with the increasing incidence and range of infectious diseases. In this study we identify and characterize Canadian federal, provincial, territorial and municipal adaptation to these health risks based on publically available information. Federal health adaptation initiatives emphasize capacity building and gathering information to address general health, infectious disease and heat-related risks. Provincial and territorial adaptation is varied. Quebec is a leader in climate change adaptation, having a notably higher number of adaptation initiatives reported, addressing almost all risks posed by climate change in the province, and having implemented various adaptation types. Meanwhile, all other Canadian provinces and territories are in the early stages of health adaptation. Based on publically available information, reported adaptation also varies greatly by municipality. The six sampled Canadian regional health authorities (or equivalent) are not reporting any adaptation initiatives. We also find little relationship between the number of initiatives reported in the six sampled municipalities and their provinces, suggesting that municipalities are adapting (or not adapting) autonomously.

Research on climate change media coverage is growing. Few studies, however, have investigated how the media portrays climate change impacts on human health. This review, therefore, presents a quantitative spatiotemporal analysis of Canadian newspaper coverage of climate change impacts on health between 2005 and 2015. Using the ProQuest® and Eureka® databases, a multiphase systematic review strategy was employed to identify relevant English and French articles from two national and six regional high-circulation newspapers. Quantitative and qualitative data were extracted from 145 articles and analyzed to characterize the range, extent, and nature of climate-health newspaper coverage in Canada and to compare these characteristics by region and over time. Coverage varied by region, with the highest proportion of climate-health coverage in Northern Territories (Yukon, Northwest Territories, Nunavut). Over time, there was a decreasing publication frequency trend. Almost all articles described negative climate change impacts on health, with a predominant focus on infectious and chronic noninfectious diseases; however, less than half of the articles discussed climate change solutions. These trends suggest that current media coverage might not drive widespread public support for policies and actions needed to protect against projected climate-health risks. Consequently, as climate change continues to challenge human health, increasing media emphasis on climate change impacts on human health, as well as a shift toward enabling and empowering climate change communication, in which viable mitigation and adaptation options are emphasized, could help to spur action to reduce climate change health risks. [ABSTRACT FROM AUTHOR]

Highlights • Canadian and German intergovernmental relations for health adaptation are studied. • Federal-regional relationships for adaptation follow federalism patterns. • Regional-local relationships for adaptation deviate from federalism patterns. • Examining other countries' approaches to health adaptation can promote learning. Abstract Climate change is a significant threat to public health, and governments at all scales will need to adapt to protect the health of their populations. The impacts of climate change are highly localized and thus federal systems theoretically have the inherent advantage of allowing for regional diversity and policy experimentation in adaptation. However, there are also higher levels of conflict and stalemates in federal systems than in unitary systems, complicating intergovernmental relations and coordination necessary for public health adaptation. We examine how intergovernmental dynamics are patterned across national, regional and local levels of government for public health adaptation to climate change, drawing upon semi-structured interviews (n = 28) in comparative embedded case studies of Canada and Germany. We find that coordination between levels of government specifically for climate change and health is rare, but climate change issues are occasionally discussed through working groups or through existing methods of public health coordination. These findings have implications for national and regional governments in federal systems seeking to enable sub-national public health adaptation to climate change and create synergies between levels of government. [ABSTRACT FROM AUTHOR]

Vulnerability to the health impacts of climate change will be shaped by the existing burden of ill- health and is expected to be highest in poor and socio-economically marginalized populations. Sub-Saharan Africa, in particular, is considered a highly vulnerable region. This paper analyses the vulnerability and adaptive capacity of rural Bakiga communities in southwestern Uganda to climate-sensitive health risks. The objectives were threefold: i) identify key climate-sensitive, community-identified health priorities; ii) describe and characterize determinants of sensitivity to these health priorities at the individual, community and regional levels; and iii) assess the adaptive capacity of Bakiga. Data collection employed a combination of individual and key informant interviews, biographies, future storylines, and Photovoice. Three key health risks were identified by the study communities (malaria, food insecurity, and gastrointestinal illnesses) - all affected by local climatic and environmental conditions, livelihoods, land use changes, and socio-economic conditions. Adaptation within these communities is dependent on their capacity to reduce sensitivities to identified health challenges among the potential of increasing exposures. Crop diversification, reducing deforestation, expanding of livestock rearing, transfer of traditional knowledge, and access to affordable health services are among potential strategies identified. We demonstrate significant existing vulnerabilities to present day climate-related health risks and highlight the importance of non-climatic processes and local conditions in creating sensitivity to health risks. Our place-based understanding is useful to inform interventions or policies aimed to reduce exposure and sensitivity and support adaptive capacity as the conditions these communities face are consistent with many other sub-Saharan African countries. [ABSTRACT FROM AUTHOR]

Climate change will have significant impacts on human health, and urban populations are expected to be highly sensitive. The health risks from climate change in cities are compounded by rapid urbanization, high population density, and climate-sensitive built environments. Local governments are positioned to protect populations from climate health risks, but it is unclear whether municipalities are producing climate-adaptive policies. In this article, we develop and apply systematic methods to assess the state of public health adaptation in 401 urban areas globally with more than 1 million people, creating the first global baseline for urban public health adaptation. We find that only 10% of the sampled urban areas report any public health adaptation initiatives. The initiatives identified most frequently address risks posed by extreme weather events and involve direct changes in management or behavior rather than capacity building, research, or long-term investments in infrastructure. Based on our characterization of the current urban health adaptation landscape, we identify several gaps: limited evidence of reporting of institutional adaptation at the municipal level in urban areas in the Global South; lack of information-based adaptation initiatives; limited focus on initiatives addressing infectious disease risks; and absence of monitoring, reporting, and evaluation. [ABSTRACT FROM AUTHOR]

Background: Climate change is among the major challenges for health this century, and adaptation to manage adverse health outcomes will be unavoidable. The risks in Ontario - Canada's most populous province - include increasing temperatures, more frequent and intense extreme weather events, and alterations to precipitation regimes. Socio-economic-demographic patterns could magnify the implications climate change has for Ontario, including the presence of rapidly growing vulnerable populations, exacerbation of warming trends by heat-islands in large urban areas, and connectedness to global transportation networks. This study examines climate change adaptation in the public health sector in Ontario using information from interviews with government officials. Methods: Fifty-three semi-structured interviews were conducted, four with provincial and federal health officials and 49 with actors in public health and health relevant sectors at the municipal level. We identify adaptation efforts, barriers and opportunities for current and future intervention. Results: Results indicate recognition that climate change will affect the health of Ontarians. Health officials are concerned about how a changing climate could exacerbate existing health issues or create new health burdens, specifically extreme heat (71%), severe weather (68%) and poor air-quality (57%). Adaptation is currently taking the form of mainstreaming climate change into existing public health programs. While adaptive progress has relied on local leadership, federal support, political will, and inter-agency efforts, a lack of resources constrains the sustainability of long-term adaptation programs and the acquisition of data necessary to support effective policies. Conclusions: This study provides a snapshot of climate change adaptation and needs in the public health sector in Ontario. Public health departments will need to capitalize on opportunities to integrate climate change into policies and programs, while higher levels of government must improve efforts to support local adaptation and provide the capacity through which local adaptation can succeed. [ABSTRACT FROM AUTHOR]

Abstract: Human African Trypanosomiasis (HAT) has reemerged in sub-Saharan Africa as a disease of major public health importance. The success of HAT elimination in sub-Saharan Africa is subject to the feasibility of controlling, eliminating, or mitigating the determinants of incidence in affected countries. Conflict has been widely recognized and cited as a contributing factor to the resurgence of HAT in many countries, as well as to continuing HAT incidence in politically unstable and resource-poor regions. Despite extensive anecdotal and qualitative recognition of the role of conflict, there has been no quantitative research of this topic at the population level in affected African countries. We characterize the qualitative and quantitative associations between HAT incidence and conflict-related processes in HAT-affected African countries over the past 30 years. HAT and conflict-related data were collected for 35 affected countries in sub-Saharan Africa for the years 1976–2004. Descriptive and univariate inferential statistics, as well as negative binomial regression modeling, are used to assess the associations between HAT and conflict. A space-time scan statistic is used to identify significant incidence clusters. Clusters of HAT incidence over the past 30 years have predominantly coincided with periods of conflict or socio-political instability. HAT cases occurred significantly more often in countries and during years with conflict, high political terror, and internationalized civil war. The results indicate a lag period between the start of conflict events and a peak in incidence of approximately 10 years. We recommend explicit consideration and quantification of socio-political measures such as conflict and terror indices in GIS (Geographic Information Systems)-based risk assessments for HAT policy and intervention. [Copyright &y& Elsevier]

Abstract: Climate change has been identified as potentially the biggest health threat of the 21st century. Canada in general has a well developed public health system and low burden of health which will moderate vulnerability. However, there is significant heterogeneity in health outcomes, and health inequality is particularly pronounced among Aboriginal Canadians. Intervention is needed to prevent, prepare for, and manage climate change effects on Aboriginal health but is constrained by a limited understanding of vulnerability and its determinants. Despite limited research on climate change and Aboriginal health, however, there is a well established literature on Aboriginal health outcomes, determinants, and trends in Canada; characteristics that will determine vulnerability to climate change. In this paper we systematically review this literature, using a vulnerability framework to identify the broad level factors constraining adaptive capacity and increasing sensitivity to climate change. Determinants identified include: poverty, technological capacity constraints, socio-political values and inequality, institutional capacity challenges, and information deficit. The magnitude and nature of these determinants will be distributed unevenly within and between Aboriginal populations necessitating place-based and regional level studies to examine how these broad factors will affect vulnerability at lower levels. The study also supports the need for collaboration across all sectors and levels of government, open and meaningful dialogue between policy makers, scientists, health professionals, and Aboriginal communities, and capacity building at a local level, to plan for climate change. Ultimately, however, efforts to reduce the vulnerability of Aboriginal Canadians to climate change and intervene to prevent, reduce, and manage climate-sensitive health outcomes, will fail unless the broader determinants of socio-economic and health inequality are addressed. [ABSTRACT FROM AUTHOR]

Identifying the nature of the association between climate, environmental, socio-economic and political context and disease remains a major challenge, yet a better comprehension of the linkages is imperative if predictive models to guide public health responses are to be devised. Our understanding of the relationships could be improved through investigations of historical epidemics. In this paper we draw on a range of published and unpublished documents to explore the complex relationship between climate, environmental change and epidemic disease (re)emergence in East Africa, and Uganda in particular. This is a region which has experienced climate variability at a range of temporal and spatial scales, but which also has a long history of episodic epidemic disease. We focus on the late nineteenth and early twentieth centuries – a time of social, economic and political reordering in East Africa associated with European colonial intervention, but also a period which witnessed a variety of climatic, ecological and disease events. It will be argued that these developments coalesced, creating a set of spatially distinctive social and environmental conditions which fostered the emergence and prolongation of one of the most deadly episodes of disease in East African history, the sleeping sickness epidemic of c.1900–20. [ABSTRACT FROM AUTHOR]

Sleeping sickness reemerged in southeastern Uganda in the 1970s and remains a public health problem. It has continued to spread north into new districts, and gaps remain in the understanding of the causes of its spread and distribution. We report the distribution and magnitude of sleeping sickness in southeastern Uganda from 1970 to 2003. Data were collected from records of the Ugandan Ministry of Health, individual sleeping sickness treatment centers, and interviews with public health officials. Data were used to develop incidence maps over time, conduct space-time cluster detection analyses, and develop a velocity vector map to visualize spread of sleeping sickness over time in southeastern Uganda. Results show rapid propagation of sleeping sickness from its epicenter in southern Iganga District and its spread north into new districts and foci. [ABSTRACT FROM AUTHOR]