Social Science

HUMAN HEALTH THE IMPACTS OF CLIMATE CHANGE ON

IN THE UNITED STATES A Scientific Assessment

U.S. Global Change Research Program

THE IMPACTS OF CLIMATE CHANGE ON

HUMAN HEALTH THE IMPACTS OF CLIMATE CHANGE ON

IN THE UNITED STATES A Scientific Assessment

U.S. Global Change Research Program

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Recommended Citation: USGCRP, 2016: The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. Crimmins, A., J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen, N. Fann, M.D. Hawkins, S.C. Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds. U.S. Global Change Research Program, Washington, DC, 312 pp. http://dx.doi.org/10.7930/J0R49NQX

To read the full report, go to: health2016.globalchange.gov

This report was produced by the U.S Global Change Research Program. 1800 G Street, NW, Suite 9100 Washington, D.C. 20006 USA www.globalchange.gov

First Published April 2016

ISBN: 978-0-16-093241-0

This report is in the public domain. Some materials in the report are copyrighted and permission was granted for their publication in this report. For subsequent uses that include such copyrighted materials, permission for reproduction must be sought from the copyright holder. In all cases, credit must be given for copyrighted materials. All other materials are free to use with credit to this report.

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April 2016

Dear Colleagues:

On behalf of the National Science and Technology Council and the U.S. Global Change Research Program, I am pleased to share this report, The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. It advanc- es scientific understanding of the impacts of climate change on public health, highlights social and environmental dispar- ities that make some communities particularly vulnerable to climate change, and confirms that climate change is a signifi- cant threat to the health of all Americans.

This report was developed by over 100 experts from across the Nation representing eight Federal agencies. I want to thank in particular the efforts of the U.S. Environmental Protection Agency (EPA), the U.S. Department of Health and Human Services (HHS), and the National Oceanic and Atmospheric Administration (NOAA) for leading in the development of this report. It was called for under the President’s Climate Action Plan and is a major contribution to the sustained Nation- al Climate Assessment process. The report was informed by input gathered in listening sessions and scientific and technical information contributed through open solicitations. It underwent rigorous reviews by the public and by scientific experts inside and outside of the government, including a special committee of the National Academies of Sciences, Engineering, and Medicine.

I applaud the authors, reviewers, and staff who have developed this scientific assessment. Their dedication over the past three years has been remarkable and their work has advanced our knowledge of how human health is impacted by climate change now and in the future.

Combating the health threats from climate change is a top priority for President Obama and a key driver of his Climate Action Plan. I strongly and respectfully urge decision makers across the Nation to use the scientific information contained within to take action and protect the health of current and future generations.

Dr. John P. Holdren

Assistant to the President for Science and Technology

Director, Office of Science and Technology Policy Executive Office of the President

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About the USGCRP Climate and Health Assessment

The U.S. Global Change Research Program (USGCRP) Climate and Health Assessment has been developed to enhance understanding and inform decisions about the growing threat of climate change to the health and well-being of residents of the United States. This scientific assessment is part of the ongoing efforts of USGCRP’s sustained National Climate Assessment (NCA) process and was called for under the President’s Climate Action Plan.1 USGCRP agencies identified human health impacts as a high-priority topic for scientific assessment.

This assessment was developed by a team of more than 100 experts from 8 U.S. Federal agencies (including employees, contractors, and affiliates) to inform public health officials, urban and disaster response planners, decision makers, and other stakeholders within and outside of government who are interested in better understanding the risks climate change presents to human health.

The USGCRP Climate and Health Assessment draws from a large body of scientific peer-reviewed research and other publicly available sources; all sources meet the standards of the Information Quality Act (IQA). The report was extensively reviewed by the public and experts, including a committee of the National Academies of Sciences, Engineering, and Medicine,2 the 13 Federal agencies of the U.S. Global Change Research Program, and the Federal Committee on Environment, Natural Resources, and Sustainability (CENRS).

About the National Climate Assessment

The Third National Climate Assessment (2014 NCA)3 assessed the science of climate change and its impacts across the United States, now and throughout this century. The report documents climate change related impacts and responses for various sectors and regions, with the goal of better informing public and private decision making at all levels. The 2014 NCA included a chapter on human health impacts,4 which formed the foundation for the development of this assessment.

THE IMPACTS OF CLIMATE CHANGE ON HUMAN HEALTH IN THE UNITED STATES

A Scientific Assessment

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TABLE OF CONTENTS

About this Report ……………………………………………………………………………………………………………….vi

Guide to the Report …………………………………………………………………………………………………………… ix

List of Contributors ………………………………………………………………………………………………………….. xii

CHAPTERS

Executive Summary ………………………………………………………………………………………..1

1. Introduction: Climate Change and Human Health …………………………………………….25

2. Temperature-Related Death and Illness ………………………………………………………….43

3. Air Quality Impacts ………………………………………………………………………………………69

4. Impacts of Extreme Events on Human Health …………………………………………………..99

5. Vector-Borne Diseases ……………………………………………………………………………….129

6. Climate Impacts on Water-Related Illness …………………………………………………….157

7. Food Safety, Nutrition, and Distribution …………………………………………………………189

8. Mental Health and Well-Being ……………………………………………………………………..217

9. Populations of Concern ………………………………………………………………………………247

Appendix 1: Technical Support Document: Modeling Future Climate Impacts on Human Health ..287

Appendix 2: Process for Literature Review …………………………………………………………………………301

Appendix 3: Report Requirements, Development Process, Review, and Approval …………………….303

Appendix 4: Documenting Uncertainty: Confidence and Likelihood…………………………………………305

Appendix 5: Glossary and Acronyms ………………………………………………………………………………….307

U.S. Global Change Research Program Impacts of Climate Change on Human Health in the United Statesvi

ABOUT THIS REPORT

Climate change threatens human health and well-being in the United States. The U.S. Global Change Research Program (USGCRP) Climate and Health Assessment has been developed to enhance understanding and inform de- cisions about this growing threat. This scientific assessment, called for under the President’s Climate Action Plan,1 is a major report of the sustained National Climate Assessment (NCA) process. The report responds to the 1990 Congressional mandate5 to assist the Nation in understanding, assessing, predicting, and responding to human-in- duced and natural processes of global change. The agencies of the USGCRP identified human health impacts as a high-priority topic for scientific assessment.

The purpose of this assessment is to provide a comprehensive, evidence-based, and, where possible, quantitative estimation of observed and projected climate change related health impacts in the United States. The USGCRP Climate and Health Assessment has been developed to inform public health officials, urban and disaster response planners, decision makers, and other stakeholders within and outside of government who are interested in better understanding the risks climate change presents to human health.

The authors of this assessment have compiled and assessed current research on human health impacts of climate change and summarized the current state of the science for a number of key topics. This assessment provides a comprehensive update to the most recent detailed technical assessment for the health impacts of climate change, the 2008 Synthesis and Assessment Product 4.6 (SAP 4.6), Analyses of the Effects of Global Change on Human Health and Welfare and Human Systems.6 It also updates and builds upon the health chapter of the 2014 NCA.4 While Chapter 1: Introduction: Climate Change and Human Health includes a brief overview of observed and projected climate change impacts in the United States, a detailed assessment of climate science is outside the scope of this report. This report relies on the 2014 NCA3 and other peer-reviewed scientific assessments of climate change and climate scenarios as the basis for describing health impacts.

Each chapter of this assessment summarizes scientific literature on specific health outcomes or climate change re- lated exposures that are important to health. The chapters emphasize research published between 2007 and 2015 that quantifies either observed or future health impacts associated with climate change, identifies risk factors for health impacts, and recognizes populations that are at greater risk. In addition, four chapters (Temperature-Re- lated Death and Illness, Air Quality Impacts, Vector-Borne Disease, and Water-Related Illness) highlight recent modeling analyses that project national-scale impacts in these areas.

The geographic focus of this assessment is the United States. Studies at the regional level within the United States, analyses or observations in other countries where the findings have implications for potential U.S. impacts, and studies of global linkages and implications are also considered where relevant. For example, global studies are considered for certain topics where there is a lack of consistent, long-term historical monitoring in the United States. In some instances it is more appropriate to consider regional studies, such as where risk and impacts vary across the Nation.

While climate change is observed and measured on long-term time scales (30 years or more), decision frame- works for public health officials and regional planners are often based on much shorter time scales, determined by epidemiological, political, or budgeting factors. This assessment focuses on observed and current impacts as well as impacts projected in 2030, 2050, and 2100.

The focus of this assessment is on the health impacts of climate change. The assessment provides timely and relevant information, but makes no policy recommendations. It is beyond the scope of this report to assess the peer-reviewed literature on climate change mitigation, adaptation, or economic valuation or on health co-bene-

U.S. Global Change Research Program Impacts of Climate Change on Human Health in the United Statesvii

fits that may be associated with climate mitigation, adaptation, and resilience strategies. The report does assess scientific literature describing the role of adaptive capacity in creating, moderating, or exacerbating vulnerability to health impacts where appropriate. The report also cites analyses that include modeling parameters that make certain assumptions about emissions pathways or adaptive capacity in order to project climate impacts on human health. This scientific assessment of impacts helps build the integrated knowledge base needed to understand, predict, and respond to these changes, and it may help inform mitigation or adaptation decisions and other strate- gies in the public health arena.

Climate and health impacts do not occur in isolation, and an individual or community could face multiple threats at the same time, at different stages in one’s life, or accumulating over the course of one’s life. Though important to consider as part of a comprehensive assessment of changes in risks, many types of cumulative, compound- ing, or secondary impacts are beyond the scope of this report. Though this assessment does not focus on health research needs or gaps, brief insights gained on research needs while conducting this assessment can be found at the end of each chapter to help inform research decisions.

The first chapter of this assessment provides background information on observations and projections of climate change in the United States and the ways in which climate change, acting in combination with other factors and stressors, influences human health. It also provides an overview of the approaches and methods used in the quantitative projections of health impacts of climate change conducted for this assessment. The next seven chapters focus on specific climate-related health impacts and exposures: Temperature-Related Death and Illness; Air Quality Impacts; Extreme Events; Vector-Borne Diseases; Water-Related Illness; Food Safety, Nutrition, and Distribution; and Mental Health and Well-Being. A final chapter on Populations of Concern identifies factors that create or exacerbate the vulnerability of certain population groups to health impacts from climate change. That chapter also integrates information from the topical health impact chapters to identify specific groups of people in the United States who may face greater health risks associated with climate change.

The Sustained National Climate Assessment The Climate and Health Assessment has been developed as part of the U.S. Global Change Research Program’s (USGCRP’s) sustained National Climate Assessment (NCA) process. This process facilitates continuous and trans- parent participation of scientists and stakeholders across regions and sectors, enabling new information and insights to be synthesized as they emerge. The Climate and Health Assessment provides a more comprehensive assessment of the impacts of climate change on human health, a topic identified as a priority for assessment by USGCRP and its Interagency Crosscutting Group on Climate Change and Human Health (CCHHG) and featured in the President’s Climate Action Plan.1

Report Sources The assessment draws from a large body of scientific, peer-reviewed research and other publicly available resources. Author teams carefully reviewed these sources to ensure a reliable assessment of the state of scientific understanding. Each source of information was determined to meet the four parts of the Information Quality Act (IQA): utility, transparency and traceability, objectivity, and integ- rity and security (see Appendix 2: Process for Literature Review). More information on the process each chapter author team used to review, assess, and determine whether a literature source should be cited can be found in the Support- ing Evidence section of each chapter. Report authors made use of the findings of the 2014 NCA, peer-reviewed literature and scien- tific assessments, and government statistics (such as population census reports). Authors also updated the literature search7 conducted by the National Institute of Environmental Health Sciences (NIEHS) as technical input to the Human Health chapter of the 2014 NCA.

U.S. Global Change Research Program Impacts of Climate Change on Human Health in the United Statesviii

Overarching Perspectives Five overarching perspectives, derived from decades of observations, analysis, and experience, have helped to shape this report: 1) climate change is happening in the context of other ongoing changes across the United States and around the globe; 2) there are complex linkages and important non-climate stressors that affect individual and community health; 3) many of the health threats described in this report do not occur in isolation but may be cumula- tive, compounding, or secondary; 4) climate change impacts can either be amplified or reduced by individual, commu- nity, and societal decisions; and 5) climate change related impacts, vulnerabilities, and opportunities in the United States are linked to impacts and changes outside the United States, and vice versa. These overarching perspectives are briefly discussed below.

Global Change Context This assessment follows the model of the 2014 NCA, which recognized that climate change is one of a number of global changes affecting society, the environment, the economy, and public health.3 While changes in demographics, socio- economic factors, and trends in health status are discussed in Chapter 1: Introduction: Climate Change and Human Health, discussion of other global changes, such as land-use change, air and water pollution, and rising consumption of resources by a growing and wealthier global population, are limited in this assessment.

Complex Linkages and the Role of Non-Climate Stressors Many factors may exacerbate or moderate the impact of cli- mate change on human health. For example, a population’s vulnerability 1) may be affected by direct climate changes or by non-climate factors (such as changes in population, economic development, education, infrastructure, behavior, technology, and ecosystems); 2) may differ across regions and in urban, rural, coastal, and other communities; and 3) may be influenced by individual vulnerability factors such as age, socioeconomic status, and existing physical and/or mental illness or disability. These considerations are summa- rized in Chapter 1: Introduction: Climate Change and Human Health and Chapter 9: Populations of Concern. There are limited studies that quantify how climate impacts interact with the factors listed above or how these interactions can lead to many other compounding, secondary, or indirect health effects. However, where possible, this assessment identifies key environmental, institutional, social, and be- havioral influences on health impacts.

Cumulative, Compounding, or Secondary Impacts Climate and health impacts do not occur in isolation and an individual or community could face multiple threats at the same time, at different stages in one’s life, or accumulating over the course of one’s life. Some of these impacts, such as the combination of high ozone levels on hot days (see Ch. 3: Air Quality Impacts) or cascading effects during extreme events (see Ch. 4: Extreme Events), have clear links to one another. In other cases, people may be threatened simulta- neously by seemingly unconnected risks, such as increased exposure to Lyme disease and extreme heat. These impacts can also be compounded by secondary or tertiary impacts, such as climate change impacts on access to or disruption of healthcare services, damages to infrastructure, or effects on the economy.

Societal Choices and Adaptive Behavior Environmental, cultural, and socioeconomic systems are tightly coupled, and as a result, climate change impacts can either be amplified or reduced by cultural and socioeconom- ic decisions.3 Adaptive capacity ranges from an individual’s ability to acclimatize to different meteorological conditions to a community’s ability to prepare for and recover from damage, injuries, and lives lost due to extreme weather events. Awareness and communication of health threats to the public health community, practitioners, and the pub- lic is an important factor in the incidence, diagnosis, and treatment of climate-related health outcomes. Recognition of these interactions, together with recognition of multiple sources of vulnerability, helps identify what information decision makers need as they manage risks.

International Context Climate change is a global phenomenon; the causes and the impacts involve energy-use, economic, and risk-manage- ment decisions across the globe.3 Impacts, vulnerabilities, and opportunities in the United States are related in com- plex and interactive ways with changes outside the United States, and vice versa. The health of Americans is affected by climate changes and health impacts experienced in other parts of the world.

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The following describes the format of the report and the structure of each chapter.

Executive Summary The Executive Summary describes the impacts of climate change on the health of the American public. It summarizes the overall findings and represents each chapter with a brief overview, the Key Findings, and a figure from the chapter.

Chapters Key Findings and Traceable Accounts Topical chapters include Key Findings, which are based on the authors’ consensus expert judgment of the synthesis of the assessed literature. The Key Findings include confidence and likelihood language as appropriate (see “Documenting Uncertainty” below and Appendix 4: Documenting Uncertainty).

Each Key Finding is accompanied by a Traceable Account which documents the process and rationale the authors used in reaching these conclusions and provides addition- al information on sources of uncertainty. The Traceable Accounts can be found in the Supporting Evidence section of each chapter.

Chapter Text Each chapter assesses the state of the science in terms of observed and projected impacts of climate change on hu- man health in the United States, describes the link between climate change and health outcomes, and summarizes the authors’ assessment of risks to public health. Both positive and negative impacts on health are reported as supported by the scientific literature. Where appropriate and sup- ported by the literature, authors include descriptions of critical non-climate stressors and other environmental and institutional context; social, behavioral, and adaptive factors that could increase or moderate impacts; and underlying trends in health that affect vulnerability (see “Populations of Concern” below). While the report is designed to in- form decisions about climate change, it does not include an assessment of literature on climate change mitigation, adaptation, or economic valuation, nor does it include policy recommendations.

GUIDE TO THE REPORT

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