Editing IPCC:AR6/WGII/Chapter-13 (section)

== 13.7 Health, Well-Being and the Changing Structure of Communities ==

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=== 13.7.1 Observed Impacts and Projected Risks ===

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==== 13.7.1.1 Mortality Due to Heat and Other Extreme Events ====

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Attribution studies show that human-induced climate change is increasing the frequency and intensity of heatwaves and has already impacted human health in Europe ( [[#13.10.1|Section 13.10.1]] ; [[#Vicedo-Cabrera--2021|Vicedo-Cabrera et al., 2021]] ); for example, the 2010 heatwave in EEU resulted in 55,000 heat-related deaths ( [[#Barriopedro--2011|Barriopedro et al., 2011]] ; [[#Russo--2015|Russo et al., 2015]] ); also, the 2018 heatwave in NEU ( [[#Ebi--2021|Ebi et al., 2021]] ) and the 2019 heatwave in WCE and NEU both had significant health impacts (Cross-Chapter Box DISASTER in Chapter 4; [[#Vautard--2020|Vautard et al., 2020]] ; [[#Watts--2021|Watts et al., 2021]] ). Elderly, children, (pregnant) women, socially isolated people and those with low physical fitness are particularly exposed and vulnerable to heat-related risks, as are those people suffering from pre-existing medical conditions, including cardiovascular disease, kidney disorders, diabetes and respiratory diseases ( [[#de’Donato--2015|de’Donato et al., 2015]] ; [[#Sheridan--2018|Sheridan and Allen, 2018]] ; [[#Szopa--2021|Szopa et al., 2021]] ). An ageing population in Europe is increasing the pool of vulnerable individuals, resulting in higher risk of heat-related mortality ( [[#Montero--2012|Montero et al., 2012]] ; [[#Carmona--2016b|Carmona et al., 2016b]] ; [[#WHO--2018b|WHO, 2018b]] ; [[#Watts--2021|Watts et al., 2021]] ).

A GWL of 1.5°C could result in 30,000 annual deaths due to extreme heat, with up to threefold the number under 3°C GWL ( ''high confidence'' ) ( [[#Roldán--2015|Roldán et al., 2015]] ; [[#Forzieri--2017|Forzieri et al., 2017]] ; [[#Kendrovski--2017|Kendrovski et al., 2017]] ; [[#Naumann--2020|Naumann et al., 2020]] ). The risk of heat stress, including mortality and discomfort, is dependent on socioeconomic development (Figure 13.22; [[#Rohat--2019|Rohat et al., 2019]] ; [[#Ebi--2021|Ebi et al., 2021]] ). Heat stress risks will be lower under SSP1 than the SSP3 or SSP4 scenarios ( ''high confidence'' ) ( [[#Hunt--2017|Hunt et al., 2017]] ; [[#Rohat--2019|Rohat et al., 2019]] ; [[#Wang--2020|Wang et al., 2020]] ; [[#Ebi--2021|Ebi et al., 2021]] ). The incidence of heat-related mortality and morbidity will be highest in SEU, where their magnitude is also expected to increase more rapidly ( [[#Forzieri--2017|Forzieri et al., 2017]] ; [[#Gasparrini--2017|Gasparrini et al., 2017]] ; [[#Guo--2018|Guo et al., 2018]] ; [[#Díaz--2019|Díaz et al., 2019]] ; [[#Vicedo-Cabrera--2021|Vicedo-Cabrera et al., 2021]] ). WCE, NEU and SEU will experience accelerating negative consequences beyond 1.5°C GWL, particularly under SSP3 and SSP4 due to higher vulnerability compared with SSP1 (Figure 13.22; [[#Rohat--2019|Rohat et al., 2019]] ). The number of heat-related respiratory hospital admissions is projected to increase from 11,000 (1981–2010) to 26,000 annually (2021–2050), particularly in SEU mainly due to a relative increase in the number of extremely hot days ( [[#Åström--2013|Åström et al., 2013]] ). Cold spells are projected to decrease across Europe, particularly in Southern Europe, but do not compensate for the additional heat-related deaths projected ( [[#Lhotka--2015|Lhotka and Kysely, 2015]] ; [[#Carmona--2016a|Carmona et al., 2016a]] ; [[#Martinez--2018|Martinez et al., 2018]] ).

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[[File:9fa5f00368abe4c2f8af9125c7f7ea6d IPCC_AR6_WGII_Figure_13_022.png]]

'''Figure 13.22 |''' '''Scenario matrix for multi-model median heat stress risks for the baseline 1986–2005, and different SSP–RCP combinations for the period 2040–2060.''' The SSPs are extended for Europe (EU28+). Heat stress risk is calculated by geometrical aggregation of the hazard (heatwave days), population vulnerability and exposure. Risk values are normalised using a z-score rescaling with a factor-10 shift. Details of the methodology are provided by [[#Rohat--2019|Rohat et al. (2019)]] .

Among Europeans, 74% live in urban areas ( [[#13.6|Section 13.6]] ), where the effect of heatwaves on human health is exacerbated by microclimates due to buildings and infrastructure, UHI effects and air pollution ( [[#WHO--2018a|WHO, 2018a]] ; [[#Smid--2019|Smid et al., 2019]] ). In large European cities, stabilising climate warming at 1.5°C GWL would decrease premature deaths by 15–22% in summer compared with stabilisation at 2°C GWL ( ''high confidence'' ) ( [[#Mitchell--2018|Mitchell et al., 2018]] ).

Although there is ''very high confidence'' that risk consequences will inevitably be more pervasive and widespread in a warmer Europe, evidence of higher heat tolerance is also emerging across most European regions ( [[#Todd--2015|Todd and Valleron, 2015]] ; Åström et al., 2016; [[#Follos--2020|Follos et al., 2020]] ). Future projections of mortality rates in Europe under the assumption of complete acclimatisation suggest constant or even decreasing rates of mortality in spite of global warming ( [[#Åström--2017|Åström et al., 2017]] ; [[#Guo--2018|Guo et al., 2018]] ; [[#Díaz--2019|Díaz et al., 2019]] ); however, there are large uncertainties in the ability to adapt to future heat extremes which might fall outside of historical ranges ( [[#Vanos--2020|Vanos et al., 2020]] ).

Other extreme events already result in major health risks across Europe. Between 2000 and 2014, for example, floods in Russia killed approximately 420 people, mainly older women ( [[#Belyakova--2018|Belyakova et al., 2018]] ). Fatalities associated with coastal and riverine flooding ( [[#13.2.2|Section 13.2.2]] ), wildfires ( [[#13.3|Section 13.3.4]] ) and windstorms could rise substantially by 2100 ( [[#Forzieri--2017|Forzieri et al., 2017]] ; [[#Feyen--2020|Feyen et al., 2020]] ). Lifetime exposure to extreme weather events for children born in 2020 will be about 50% greater at 3.5°C compared with 1.5°C GWL ( [[#Thiery--2021|Thiery et al., 2021]] ).

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==== 13.7.1.2 Air Quality ====

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Air pollution is already one of the biggest public health concerns in Europe: in 2016, roughly 412,000 people died prematurely due to long-term exposure to ambient PM2.5, 71,000 due to NO 2 and more than 15,000 premature mortalities occurred due to near-surface ozone ( [[#EEA--2019b|EEA, 2019b]] ; [[#Lelieveld--2019|Lelieveld et al., 2019]] ). The impacts of air pollution are determined by air-quality policies, changes to temperature, humidity and precipitation ( [[#Szopa--2021|Szopa et al., 2021]] ). Climate change could increase air pollution health effects, with the size of the effect differing across European regions and pollutants ( ''medium confidence'' ) ( [[#Jacob--2009|Jacob and Winner, 2009]] ; [[#Orru--2017|Orru et al., 2017]] ; [[#Tarin-Carrasco--2021|Tarin-Carrasco et al., 2021]] ). Increases in temperature and changes in precipitation will impact future air quality due to increased risk of wildfires and related air pollution episodes. Data on the health impacts of wildfires in Europe is currently limited ( [[#13.3.1.4|Section 13.3.1.4]] ), but examples, such as the 2017 fires, suggest that more than 100 people died prematurely in Portugal alone as a result of poor air quality ( [[#Oliveira--2020|Oliveira et al., 2020]] ).

At 2.5°C GWL, mortalities due to exposure to PM2.5 are projected to increase by up to 73% in Europe ( ''medium confidence'' ) ( [[#Silva--2017|Silva et al., 2017]] ; [[#Lelieveld--2019|Lelieveld et al., 2019]] ; [[#Tarin-Carrasco--2021|Tarin-Carrasco et al., 2021]] ). At 2°C GWL, annual premature mortalities due to exposure to near-surface ozone are projected to increase up to 11% in WCE and SEU and to decrease up to 9% in NEU (under RCP4.5) ( ''medium confidence'' ) ( [[#Orru--2019|Orru et al., 2019]] ). A projected increase in wildfires and reduced air quality is expected to increase respiratory morbidity and mortality, especially in SEU ( [[#Slezakova--2013|Slezakova et al., 2013]] ; [[#de%20Rigo--2017|de Rigo et al., 2017]] ). Constant or lower emissions, combined with stricter regulations and new policy initiatives, might improve air quality in the coming decades ( ''medium agreement, low evidence'' ). The ageing population in Europe will augment the air-quality mortality burden 3–13% by 2050 ( [[#Geels--2015|Geels et al., 2015]] ; [[#Orru--2019|Orru et al., 2019]] ). Besides ambient air quality, projected increases in flood risk and heavy rainfall could decrease indoor air quality ( [[#13.6.1.5.2|Section 13.6.1.5.2]] ) due to dampness and mould, leading to increased negative health impacts, including allergies, asthma and rhinitis ( [[#EASAC--2019|EASAC, 2019]] ; [[#EEA--2019b|EEA, 2019b]] ).

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==== 13.7.1.3 Climate-Sensitive Infectious Diseases ====

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Figure 13.23 summarises the observed and projected changes in climatic suitability and assesses the risk for selected climate-sensitive infectious diseases in Europe.

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[[File:a90b43f80eb36cefd30a7846613d5648 IPCC_AR6_WGII_Figure_13_023.png]]

'''Figure 13.23 |''' '''Assessment of climate-sensitive infectious diseases.''' The assessment considers the main drivers of hazard (climate-impact drivers, pathogens and vectors), vulnerability (lack of safeguards and a predisposition to these hazards) and exposure (humans to be affected by these pathogens and vectors), the direction of change in climatic suitability (i.e., temperature, precipitation, relative humidity, extreme weather events) of observed changes and at 1.5°C and 3°C GWL, and the overall infectious disease risks across Europe (Chapters 7.3, 7.4; [[#Lindgren--2012|Lindgren et al., 2012]] ; [[#Semenza--2021|Semenza and Paz, 2021]] ). The assessment does not consider incidence of disease infections through autochthonous transmission (Table SM13.18).

Among the tick-borne diseases, Lyme disease is the most prevalent disease in Europe. There has been a temperature-dependent range expansion of ticks that is projected to expand further north in Sweden, Norway and the Russian Arctic ( [[#Jaenson--2012|Jaenson et al., 2012]] ; [[#Jore--2014|Jore et al., 2014]] ; [[#Tokarevich--2017|Tokarevich et al., 2017]] ; [[#Waits--2018|Waits et al., 2018]] ), and to higher elevations in Austria and the Czech Republic ( ''medium confidence'' ) ( [[#Daniel--2003|Daniel et al., 2003]] ; [[#Heinz--2015|Heinz et al., 2015]] ). A potential habitat expansion of these ticks of 3.8% across Europe, relative to 1990–2010, is projected for 2°C GWL ( [[#Porretta--2013|Porretta et al., 2013]] ; [[#Boeckmann--2014|Boeckmann and Joyner, 2014]] ). In contrast, there are projected habitat contractions for these ticks in SEU due to unfavourable climatic conditions ( [[#Semenza--2018|Semenza and Suk, 2018]] ).

The Asian tiger mosquito ( ''Aedes albopictus'' ) is present in many European countries and can transmit dengue, chikungunya and zika ( [[#Liu-Helmersson--2016|Liu-Helmersson et al., 2016]] ; [[#Tjaden--2017|Tjaden et al., 2017]] ; [[#Messina--2019|Messina et al., 2019]] ). There is a moderate climatic suitability projected for chikungunya transmission, notably across France, Spain and Germany, but also contractions particularly in Italy. Europe experienced an exceptionally early and intense transmission season of the West Nile virus in 2018, with elevated spring temperature abnormalities ( [[#Haussig--2018|Haussig et al., 2018]] ; [[#Marini--2020|Marini et al., 2020]] ). Projections for Europe show the West Nile virus risk to expand: by 2025, the risk is projected to increase in SEU and southern and eastern parts of WCE ( ''medium confidence'' ) ( [[#Semenza--2016|Semenza et al., 2016]] ). Although climatic suitability for malaria transmission in Europe is increasing and will lead to a northward spread of the occurrences of ''Anopheles'' vectors, the risk from malaria to human health in Europe remains low due to economic and social development as well as access to health care ( ''medium confidence'' ) ( [[#Sudre--2013|Sudre et al., 2013]] ; [[#Hertig--2019|Hertig, 2019]] ).

Water-borne diseases are also associated with changes in climate such as heavy precipitation events ( [[#Semenza--2020|Semenza, 2020]] ). Warming has been linked with elevated incidence of campylobacteriosis outbreaks in various European countries ( [[#Yun--2016|Yun et al., 2016]] ; [[#Lake--2019|Lake et al., 2019]] ). Marine bacteria, such as ''Vibrio'' , thrive under elevated sea surface temperature and low salinity such as that of the Baltic Sea. Under further warming, the number of months with risk of ''Vibrio'' transmission increases and the seasonal transmission window expands, thereby increasing the risk to human health in the future ( ''high confidence'' ) ( [[#Baker-Austin--2017|Baker-Austin et al., 2017]] ; [[#Semenza--2017|Semenza et al., 2017]] ).

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==== 13.7.1.4. Allergies and Pollen ====

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The main drivers of allergies are predominantly non-climatic (e.g., increased urbanisation, adoption of westernised lifestyles, social and genetic factors), but climate change strongly contributes to the spread of some allergenic plants, thus exacerbating existing allergies and causing new ones in people across Europe ( ''high confidence'' ) ( [[#D’Amato--2016|D’Amato et al., 2016]] ; [[#EASAC--2019|EASAC, 2019]] ). The prevalence of hay fever (allergic rhinitis), for example, is between 4 and 30% among European adults ( [[#Pawankar--2013|Pawankar et al., 2013]] ). The invasive common ragweed ( ''Ambrosia asteraceae'' ) is a key species already causing major allergy in late summers (including hay fever and asthma), particularly in Hungary, Romania and parts of Russia ( [[#Ambelas%20Skjøth--2019|Ambelas Skjøth et al., 2019]] ). Across Europe, sensitisation to ragweed is expected to increase from 33 million people in 1986–2005 to 77 million people at 2°C GWL ( [[#Lake--2017|Lake et al., 2017]] ).

Warming will result in an earlier start of the pollen season and extending it, but this differs across regions, species, traits and flowering periods ( [[#Ziello--2012|Ziello et al., 2012]] ; [[#Bock--2014|Bock et al., 2014]] ; [[#EASAC--2019|EASAC, 2019]] ; [[#Revich--2019|Revich et al., 2019]] ). For instance, in different parts of WCE and NEU, the start of birch-season flowering has been shifted and extended up to 2 weeks earlier during recent decades ( [[#Biedermann--2019|Biedermann et al., 2019]] ). Airborne pollen concentrations are projected to increase across Europe ( [[#Ziello--2012|Ziello et al., 2012]] ). In south-eastern Europe, where pollen already has a substantive impact, the pollen count could increase more than 3 to 3.5 times at 2.5°C GWL and can become a more widespread health problem across Europe, particularly where it is currently uncommon ( ''medium agreement, low evidence'' ) ( [[#Lake--2017|Lake et al., 2017]] ).

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==== 13.7.1.5. Labour Productivity and Occupational Health ====

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Extreme heat and cold waves have been linked to an increased risk of occupational injuries ( [[#Martinez-Solanas--2018|Martinez-Solanas et al., 2018]] ) and changes in labour productivity ( [[#Orlov--2019|Orlov et al., 2019]] ; [[#García-León--2021|García-León et al., 2021]] ), while evidence on the consequences of other extreme events is lacking. The sectors with a high percentage of high-intensity outdoor work in Europe, mainly agriculture and construction, have the highest risk of increased injury and labour productivity losses, but also manufacturing and service sectors can be affected when air conditioning is not available ( [[#13.6.1.3|Section 13.6.1.3]] ; [[#Gosling--2018|Gosling et al., 2018]] ; [[#Szewczyk--2018|Szewczyk et al., 2018]] ; [[#Dellink--2019|Dellink et al., 2019]] ; [[#Orlov--2019|Orlov et al., 2019]] ). The heatwaves of August 2003, July 2010 and July 2015 were concentrated in SEU and led to reductions in monthly worker productivity of on average 3–3.5% in SEU, ranging up to 8–9% in Cyprus (2003, 2010) and Italy (2015) ( [[#Orlov--2019|Orlov et al., 2019]] ); in contrast, the heatwave of 2018 centred on NEU but also led to pronounced productivity reductions in WCE and SEU ( [[#García-León--2021|García-León et al., 2021]] ). Each of these major European heatwaves led to considerable economic losses in agriculture and construction ( ''high confidence'' ) and reduced GDP in Europe (except EEU) by 0.3–0.5% ( [[#García-León--2021|García-León et al., 2021]] ). At 2.5°C GWL and beyond, GDP losses are projected to increase fivefold compared with 1981–2010, ranging from 2–3.5% in SEU to 0.5–1.5% in WCE, and below 0.5% in NEU and EEU ( [[#13.10.3|Section 13.10.3]] ; [[#Roson--2016|Roson and Sartori, 2016]] ; [[#Takakura--2017|Takakura et al., 2017]] ; [[#Szewczyk--2018|Szewczyk et al., 2018]] ; [[#Dellink--2019|Dellink et al., 2019]] ; [[#García-León--2021|García-León et al., 2021]] ).

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==== 13.7.1.6. Food Quality and Nutrition ====

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There is growing evidence that climate change will negatively affect food quality (diversity of food, nutrient density and food safety) and food access, although the risks for European citizens are significantly lower compared with other regions ( [[#Fanzo--2018|Fanzo et al., 2018]] ; [[#IFPRI--2018|IFPRI, 2018]] ). Projected changes in crop and livestock production ( [[#13.5.1|Section 13.5.1]] ), particularly reduced access to fruits and vegetables and foods with lower nutritional quality, will impact already vulnerable groups ( [[#Swinburn--2019|Swinburn et al., 2019]] ). The effects of climate change on food quality and access varies by income, livelihood and nutrient requirements, with low-income and more vulnerable groups in Europe most affected ( [[#IFPRI--2018|IFPRI, 2018]] ). Spikes in food prices due to changing growing conditions in Europe ( [[#13.5.1|Section 13.5.1]] ), increased competition for land (e.g., land-based climate-change mitigation) and feedbacks from international markets are expected to decrease access to affordable and nutritious food ( [[#13.9.1|Section 13.9.1]] ; [[#EASAC--2019|EASAC, 2019]] ; [[#Loopstra--2020|Loopstra, 2020]] ). Reduced access to healthy and varied food could contribute to being overweight or obese, which is a growing health concern across Europe ( [[#Springmann--2016|Springmann et al., 2016]] ). Increased rates of obesity and diabetes further exacerbate risks from heat-related events ( [[#EASAC--2019|EASAC, 2019]] ).

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==== 13.7.1.7. Mental Health and Well-Being ====

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Extreme weather events can trigger post-traumatic stress disorder (PTSD), anxiety and depression; this is well-documented for flooding in Europe ( ''high confidence'' ) but less for other extreme weather events. For example, in the UK, flooded residents suffered stress and identity loss from the flood event itself, but also from subsequent disputes with insurance and construction companies ( [[#Carroll--2009|Carroll et al., 2009]] ; [[#Greene--2015|Greene et al., 2015]] ). Residents displaced from their homes for at least 1 year due to 2013–2014 floods in England were significantly more ''likely'' to experience PTSD, depression and anxiety, with stronger effects in the absence of advance warning ( [[#Munro--2017|Munro et al., 2017]] ; [[#Waite--2017|Waite et al., 2017]] ). There is emerging evidence across Europe that young people may be experiencing anxiety about climate change, although it is unclear how widespread or severe this is ( [[#Hickman--2019|Hickman, 2019]] ). In northern Italy, the number of daily emergency psychiatric visits and mean daily air temperature has been linked ( [[#Cervellin--2014|Cervellin et al., 2014]] ).

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=== 13.7.2 Solution Space and Adaptation Options ===

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Adaptation to health impacts has generally received less attention compared with other climate impacts across Europe ( [[#EASAC--2019|EASAC, 2019]] ). Progress on health adaptation can be observed. Between 2012 and 2017, at least 20 European countries instituted new governance mechanisms, such as interdepartmental coordinating bodies for health adaptation and adopted health adaptation plans ( [[#Kendrovski--2019|Kendrovski and Schmoll, 2019]] ). Progress on city-level health adaptation is generally limited ( [[#Araos--2015|Araos et al., 2015]] ), with most activities occurring in SEU ( ''high agreement, medium evidence'' ) ( [[#Paz--2016|Paz et al., 2016]] ).

Figure 13.24 presents the assessment of the feasibility and effectiveness of key heat-related health adaptation actions. It shows that substantial social–cultural and institutional barriers complicate widespread implementation of measures; studies on the implementation of new blue–green spaces in existing urban structures in, for example, Sweden ( [[#Wihlborg--2019|Wihlborg et al., 2019]] ), the UK ( [[#Carter--2018|Carter et al., 2018]] ) and the Netherlands ( [[#Aalbers--2019|Aalbers et al., 2019]] ), point to important feasibility challenges (e.g., access to financial resources, societal opposition, competition for space) ( ''high confidence'' ). Lower perception of health risks has been observed among vulnerable groups which, in conjunction with perceived high costs of protective measures, act as barriers to implementing health adaptation plans ( [[#van%20Loenhout--2016|van Loenhout et al., 2016]] ; [[#Macintyre--2018|Macintyre et al., 2018]] ; [[#Martinez--2019|Martinez et al., 2019]] ). Key barriers to mental health adaptation actions include lack of funding, coordination, monitoring and training (e.g., psychological first aid) ( [[#Hayes--2018|Hayes and Poland, 2018]] ). Existing health measures, such as monitoring and early warning systems, play an important role in detecting and communicating emerging climate risks and weather extremes ( ''high confidence'' ) ( [[#Confalonieri--2015|Confalonieri et al., 2015]] ; [[#Casanueva--2019|Casanueva et al., 2019]] ; [[#Linares--2020|Linares et al., 2020]] ). Stricter enforcement of existing health regulations and policies can have a positive effect in reducing risks ( [[#Berry--2018|Berry et al., 2018]] ).

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[[File:4d08dd38d4fa8cdf114c5eef90b863f0 IPCC_AR6_WGII_Figure_13_024.png]]

'''Figure 13.24 |''' '''Effectiveness and feasibility of the main adaptation options to reduce heat-related impacts and health risks in Europe''' (Section SM13.9, Table SM 13.19)

The effectiveness of most options in reducing climate-induced health risks is determined by many co-founding factors, including the extent of the risk, existing sociopolitical structure and culture, and other adaptation options in place ( ''high agreement, medium evidence'' ). Successful examples include the implementation of heatwave plans ( [[#Schifano--2012|Schifano et al., 2012]] ; [[#van%20Loenhout--2016|]] [[#van%20Loenhout--2016|van Loenhout and Guha-Sapir, 2016]] ; de’Donato et al., 2018), improvements in health services and infrastructure of homes ( [[#13.10.2.1|Section 13.10.2.1]] ; [[#Vandentorren--2006|Vandentorren et al., 2006]] ). A study of nine European cities, for example, showed lower numbers of heat-related deaths in SEU and attributed this to the implementation of heat prevention plans, a greater level of individual and household adaptation, and growing awareness about exposure to heat ( [[#de’Donato--2015|de’Donato et al., 2015]] ). Long-term national prevention programmes in NEU have been shown to reduce temperature-related suicide ( [[#Helama--2013|Helama et al., 2013]] ). The physical fitness of individuals may increase resilience to extreme heat ( [[#Schuster--2017|Schuster et al., 2017]] ). Combining multiple types of adaptation options into a consistent policy portfolio may have an amplifying effect in reducing risks, particularly at higher GWL ( ''medium confidence'' ) (Chapter 7; [[#Lesnikowski--2019|Lesnikowski et al., 2019]] ).

Health adaptation actions have demonstrable synergies and trade-offs (Cross-Chapter Box HEALTH in Chapter 7). For example, increasing green–blue spaces in Europe’s densely populated areas can be effective in improving microclimates, reducing the impact of heatwaves, improving air quality and improving mental health by increasing access to fresh air and green (restorative) environments ( [[#Gascon--2015|Gascon et al., 2015]] ; [[#Kondo--2018|Kondo et al., 2018]] ; [[#Kumar--2019|Kumar et al., 2019]] ). Health adaptations can also have negative trade-offs, be inconsistent with mitigation ambitions and could lead to maladaptation. Green–blue spaces, for example, may create new nesting grounds for carriers of vector-borne diseases, increase pollen and allergies ( [[#Kabisch--2016|Kabisch et al., 2016]] ), enlarge freshwater use for irrigation ( [[#Reyes-Paecke--2019|Reyes-Paecke et al., 2019]] ) and could raise climate equity and justice issues such as green gentrification ( [[#Yazar--2019|Yazar et al., 2019]] ). Similarly, air conditioning and cooling devices are considered highly effective but have low economic and social feasibility as well as negative trade-offs due to increasing energy consumption, raising energy costs which is particularly challenging for the poor ( [[#13.8.1.1|Section 13.8.1.1]] ), enhancing the UHI effect and increasing noise pollution ( [[#Fernandez%20Milan--2015|Fernandez Milan and Creutzig, 2015]] ; [[#Hunt--2017|Hunt et al., 2017]] ; [[#Macintyre--2018|Macintyre et al., 2018]] ).

The solution space for implementing health adaptation options is slowly expanding in Europe. Health adaptation can build on, and integrate into, established health system infrastructures, but these differ significantly across Europe, as do existing capacities to deal with climate-related extreme events ( [[#Austin--2016|Austin et al., 2016]] ; [[#Austin--2018|Austin et al., 2018]] ; [[#Orru--2018|Orru et al., 2018]] ; [[#Watts--2018|Watts et al., 2018]] ; [[#Austin--2019|Austin et al., 2019]] ; [[#Martinez--2019|Martinez et al., 2019]] ). Despite some progress, limited mainstreaming of climate change has been observed, particularly due to low societal pressure to change, confidence in existing health systems and lack of awareness of links between human health and climate change ( ''medium confidence'' ) ( [[#Austin--2016|Austin et al., 2016]] ; [[#WHO--2018b|WHO, 2018b]] ; [[#Watts--2021|Watts et al., 2021]] ). Coordination of health adaptation actions across scales and between public sectors is needed to ensure timely and effective responses for a diversity of health impacts ( ''high confidence'' ) ( [[#Austin--2018|Austin et al., 2018]] ; [[#Ebi--2018|Ebi et al., 2018]] ). Key enabling conditions to extend the solution space include increasing the role for national and regional governments in facilitating knowledge sharing across scales, allocating dedicated financial resources, and creating dedicated knowledge and policy programmes on climate and health ( [[#Wolf--2014|Wolf et al., 2014]] ; [[#Akin--2015|Akin et al., 2015]] ; [[#Curtis--2017|Curtis et al., 2017]] ). Investing in public healthcare systems more broadly increases their capacity to respond to climate-related extreme events and will ensure wider societal benefits as the COVID-19 pandemic has demonstrated (Cross-Chapter Box COVID in Chapter 7).

Despite a range of options available, there are limits to how much adaptation can take place, and residual risks remain. These risks are predominantly discussed in the context of excess mortality and morbidity due to heat extremes ( [[#Hanna--2015|Hanna and Tait, 2015]] ; [[#Martinez--2019|Martinez et al., 2019]] ). Future heatwaves are expected to stretch existing adaptation interventions well beyond levels observed in response to the observed events of 2003 and 2010 ( [[#13.10.2.1|Section 13.10.2.1]] ; [[#Hanna--2015|Hanna and Tait, 2015]] ).

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=== 13.7.3 Knowledge Gaps ===

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Literature on the link between public health, climate impacts, vulnerability and adaptation is skewed across Europe, with most studies focusing on region-specific impacts (e.g., flood injuries in WCE, heatwaves in SEU). In general, attributing health impacts to climate change remains challenging, particularly for mental health and well-being, (mal)nutrition and food quality and climate-sensitive infectious diseases, where other socioeconomic determinants play an important role. The connection between climate change and health risks under different socioeconomic development pathways is hardly studied comprehensively for Europe, with some exceptions for extreme events; however, these interactions seem to play an important role in better understanding projected risks and inform choices on adaptation planning.

Some climate-related health issues are emerging, but evidence is too limited for a robust assessment, for example, the links between climate change and violence in Europe ( [[#Fountoulakis--2016|Fountoulakis et al., 2016]] ; [[#Mares--2016|Mares and Moffett, 2016]] ; [[#Sanz-Barbero--2018|Sanz-Barbero et al., 2018]] ; [[#Koubi--2019|Koubi, 2019]] ).

The solution space for public health adaptation in Europe, and the effectiveness of levers for interventions, are hardly assessed. Although health adaptations are documented, these are particularly around mortality and injuries due to extreme events, predominantly floods ( [[#13.2.1|Section 13.2.1]] ) and heatwaves ( [[#13.7.1.1|Section 13.7.1.1]] ). There are very few studies assessing the barriers and enablers of health adaptations, nor systematic assessment of the effectiveness of (the portfolio of) options. Limited insights into what works, and where, hamper upscaling these insights across Europe and constrains the ability to evaluate whether investments in health adaptation have actually reduced risks.

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