Editing IPCC:AR6/WGII/Chapter-7 (section)

== 7.4 Adaptation to Key Risks and Climate Resilient Development Pathways ==

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''With proactive, timely and effective adaptation, many observed and projected risks for human health and well-being, health systems and those associated with migration and conflict can be reduced or potentially avoided'' ( ''high confidence'' ) ''.'' Given the key health risks identified in this chapter, adaptation that increases resilience and sustainability will require moving beyond incremental adaptation to sustained, adaptive management ( [[#Ebi--2011|Ebi, 2011]] ; [[#Hess--2012|Hess et al., 2012]] ) with the goal of transformative change for integrated protection of human, animal and ecosystem health. This includes differentiating adaptation to climate variability from adaptation to climate change ( [[#Ebi--2020|Ebi and Hess, 2020]] ). Health adaptation efforts are increasingly aiming to transition to building climate-resilient and environmentally sustainable health systems ( [[#WHO--2015b|WHO, 2015b]] ; [[#WHO--2020a|WHO, 2020a]] ) and healthcare facilities, emphasising service delivery including climate-informed health policies and programmes; management of the environmental determinants of health; emergency preparedness and management; health information systems such as health and climate research, integrated risk monitoring and early warning systems; and vulnerability, capacity and adaptation assessments ( [[#Marinucci--2014|Marinucci et al., 2014]] ; [[#Mousavi--2020|Mousavi et al., 2020]] ; WHO 2015a; Centres for Disease Control , 2019; [[#WHO--2020a|WHO, 2020a]] ).

Migration can contribute to or work against adaptation goals and progress, depending on the circumstances under which it occurs. Policies that support safe and orderly movements of people, protect migrant rights, and facilitate flows of financial and other resources between sending and receiving communities are consistent with adaptive capacity-building and building sustainability and are part of CRDPs (section 7.4.4).

Adaptation to prevent climate change from exacerbating conflict risk involves meeting development objectives encapsulated in the SDGs. Conflict-sensitive adaptation and climate-sensitive peacebuilding offer promising avenues to addressing conflict risk, but their efficacy is yet to be demonstrated through effective monitoring and evaluation ( [[#Gilmore--2018|Gilmore et al., 2018]] ). Associations between environmental factors and conflict are weak in comparison to socioeconomic and political drivers. Therefore, meeting the SDGs, including Goal 16 on peace, justice and strong institutions represent unambiguous pathways to reducing conflict risk under climate change ( [[#Singh--2021|Singh and Chudasama, 2021]] ). Actively pursuing peace rather than taking conflict for granted ( [[#Barnett--2019|Barnett, 2019]] ), improving focus on gender within peacebuilding ( [[#Dunn--2015|Dunn and Matthew, 2015]] ; [[#UNEP--2021|UNEP, 2021]] ) and understanding how natural resources and their governance interact with peacebuilding ( [[#Krampe--2021|Krampe et al., 2021]] ) present key elements of CRDPs for sustainable peace.

''As documented across this chapter, there is a large adaptation deficit for health and well-being, with climate change causing avoidable injuries, illnesses, disabilities, diseases and deaths'' ( ''high confidence'' ) ''.'' Implementation of health adaptation has been incremental because of significant constraints, primarily relating to financial and human resources and because of limited research funding on adaptation ( [[#Berrang-Ford--2021|Berrang-Ford et al., 2021]] ). Current global investments in health adaptation are insufficient to protect the health of populations and communities ''(high confidence)'' from most climate-sensitive risks, with large variability across and within countries and regions ( [[#UNEP--2018|UNEP, 2018]] ). Climate change adaptation in health is &lt; 1% of international climate finance despite health being a priority sector in 54% of NDCs featuring adaptation ( [[#UNEP--2018|UNEP, 2018]] ).

As climate change progresses and the likelihood of dangerous risks to human health continue to increase, there will be greater pressure for more transformational changes to health systems to reduce future vulnerabilities and limit further dangerous climate change ( [[#Ebi--2021a|Ebi et al., 2021a]] ). Transformational resilience would need parallel investments in social and health protections, including achieving the SDGs, coupled with investments in mitigation ( [[#Ebi--2020|Ebi and Hess, 2020]] ). Further, investments in mitigating GHG emissions will not only reduce risks associated with dangerous climate change but will improve population health and well-being through several salutary pathways.

This chapter section identifies and assesses specific elements in adapting to the risks identified in 7.2 and 7.3 and the opportunities for fostering sustainability and pursuing CRDPs.

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=== 7.4.1 Adaptation Solution Space for Health and Well-Being ===

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The solution space is the space within which opportunities and constraints determine why, how, when and who adapts to climate change (Chapter 1). ''There is increased understanding of exposure and vulnerabilities to climate variability and change, the capacities to manage the health risks, the effectiveness of adaptation (including a growing number of lessons learned and best practices), and the co-benefits of mitigation policies and technologies'' ( ''high confidence'' ) ''.''

''Effectively preparing for and managing the health risks of climate change requires considering the multiple interacting sectors that affect population health and the effective functioning of health systems'' ( ''high confidence'' ) ''. Given the wide range of causal pathways through which climate change affects environmental and social systems resulting in health impacts, a systems-based approach can promote identifying, implementing and evaluating solutions that support population health and health systems in the short and longer term'' ( ''high agreement, medium evidence'' ) ''.'' Such an approach provides insights into policies and programmes that promote health and well-being via multiple sectors (e.g., water and food safety and security) and can ensure that health policies do not have adverse consequences in other sectors ( [[#WHO--2015b|WHO, 2015b]] ; [[#Ebi--2017|Ebi and Otmani del Barrio, 2017]] ; [[#Wright--2021|Wright et al., 2021]] ) ''.''

Figure 7.11 illustrates the context within which risks to health outcomes and health systems emerge because of climate change. The figure presents the emergence of risk from interactions between specific types of climatic hazards, the exposure and vulnerability to those hazards, and the responses taken within the health sector. The figure also illustrates how health risks are situated within larger interactions between the health system and other sectors and systems, with underlying enabling conditions making adaptation and transformation possible. Within this context, response options can decrease the impacts of climate change on human health, well-being and health systems by (a) reducing exposure to climate-related hazards; (b) reducing vulnerability to such hazards and (c) strengthening health system responses to future risks. Such approaches are described as ‘Lateral Public Health’ and emphasise the importance of involving community members and stakeholders in the planning and coordination of activities ( [[#Semenza--2021|Semenza, 2021]] ; [[#Semenza--2011|Semenza, 2011]] ). Lateral public health strives for community engagement (e.g., through access to technology in decision-making, such as low-cost air sensors for wildfire smoke) in preparedness and response.

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[[File:0b61d61ab213e6d6009111bc1619e679 IPCC_AR6_WGII_Figure_7_011.png]]

'''Figure 7.11 |''' '''Context within which adaptation responses to climatic risks to health are implemented in the frame of interactions between health and multiple other sectors.'''

''Effective health risk management incorporates the magnitude and pattern of future climate risks as well as potential changes in factors that determine vulnerability and exposure to climate hazards, such as determinants of healthcare access, demographic shifts, urbanisation patterns and changes in ecosystems'' ( ''very high confidence'' ) ''.'' Climate change is associated with shocks and stresses that can affect the capacity and resilience of health systems and healthcare facilities ( [[#WHO--2020a|WHO, 2020a]] ). Figure 7.12 illustrates some possible extents to which the capacity of health systems could be reduced when exposed to a stress or shock, and possible pathways forward, from collapse to transformation. The subsequent sections of this chapter assess adaptation and mitigation options to facilitate building the resilience of health systems and healthcare facilities to recover better than before or to transform.

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[[File:2950f7c734f213aa1f4f8a360292ba77 IPCC_AR6_WGII_Figure_7_012.png]]

'''Figure 7.12 |''' '''Health systems capacity and resilience to climate change-related shocks and stresses.''' From WHO (2020).

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=== 7.4.2 Adaptation Strategies, Policies and Interventions ===

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==== 7.4.2.1 Current State of Health Adaptation ====

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Analysis of the NDCs to the Paris Agreement to determine how health was incorporated, including impacts, adaptation and co-benefits, concluded that most low- and middle-income countries referred to health in their NDC ( [[#Dasandi--2021|Dasandi et al., 2021]] ). Figure 7.13 shows the degree of health engagement; this engagement is based on indicators measuring the specificity and detail of health references within a country’s NDC. Many vulnerable countries had high engagement of the health sector in the country NDC. However, this analysis did not determine whether the ambition expressed was sufficient to address the health adaptation needs.

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[[File:865a3982833f789fd40a2b150648ebf6 IPCC_AR6_WGII_Figure_7_013.png]]

'''Figure 7.13 |''' '''Health engagement score in NDCs by country.''' Figure adapted from [[#Dasandi--2021|Dasandi et al. (2021)]] .

The 2018 WHO Health and Climate Change Survey, a voluntary national survey sent to all 194 WHO member states, to which 101 responded, found that national planning on health and climate change is advancing, but the comprehensiveness of strategies and plans need to be strengthened. Implementing action on key health and climate change priorities remains challenging and multi-sectoral collaboration on health and climate change policy is evident, with uneven progress ( [[#Watts--2021|Watts et al., 2021]] ). Approximately 50% of respondent countries had developed national health and climate strategies, with over two-thirds doing so within the preceding five years, and 48 of 101 countries had conducted a health vulnerability and adaptation assessment ( [[#Watts--2019|Watts et al., 2019]] ). However, most countries reported only moderate or low levels of implementation, with financing cited as the most common barrier due to a lack of information on opportunities, in turn linked to a lack of connection by health actors to climate change policy processes and a lack of capacity to participate in national planning. A review of public health systems in 34 countries found that only slightly more than half considered climate change impacts and adaptation needs ( [[#Berry--2018|Berry et al., 2018]] ). Because the health risks of climate change often vary within a country, sub-national assessments and plans are needed to help local authorities protect and promote population health in a changing climate ( [[#Aracena--2021|Aracena et al., 2021]] ; [[#Basel--2020|Basel et al., 2020]] ; [[#Schramm--2020a|Schramm et al., 2020a]] ).

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==== 7.4.2.2 Adaptation in Health Policies and Programmes ====

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''Health policies were historically not designed or implemented taking into consideration the risks of climate change and as currently structured are'' likely ''insufficient to manage the changing health burdens in coming decades'' ( ''very high confidence'' ) ''.'' The magnitude and pattern of future health burdens attributable to climate change, at least until mid-century, will be determined primarily by adaptation and development choices. Current and future emissions will play an increasing role in determining attributable burdens after mid-century. Increased investment in strengthening general health systems, along with targeted investments to enhance protection against specific climate-sensitive exposures (e.g., hazard early warning and response systems and integrated vector control programmes for VBDs) will increase resilience if implemented to at least keep pace with climate change ( ''high confidence'' ). Investments to address the social determinants of health can reduce inequities and increase resilience ( ''high confidence)'' ( [[#Thornton--2016|Thornton et al., 2016]] ; [[#Marmot--2020|Marmot et al., 2020]] ; [[#Wallace--2015|Wallace et al., 2015]] ; [[#Semenza--2021|Semenza and Paz, 2021]] ).

Peer-reviewed publications of health adaptation to climate change in low- and middle-income countries have typically focused on flooding, rainfall, drought and extreme heat through improving community resilience, DRR and policy, governance and finance ( [[#Berrang-Ford--2021|Berrang-Ford et al., 2021]] ; [[#Scheelbeek--2021|Scheelbeek et al., 2021]] ). Health outcomes of successful adaptation have included reductions in infectious disease incidence, improved access to water and sanitation and improved food security. Figure 7.14 shows a Sankey diagram of climate hazards, adaptation responses and health outcomes. The figure highlights the range of health adaptation responses that are discussed in more detail earlier in this chapter and demonstrates the potential health benefit of adaptation efforts that affect a broad range of health determinants.

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[[File:74b48a7ebfb82b48ec221f62634d76b3 IPCC_AR6_WGII_Figure_7_014.png]]

'''Figure 7.14 |''' '''Sankey diagram of climate hazards, adaptation responses and health outcomes.''' CSA is climate-smart agriculture. Source: [[#Scheelbeek--2021|Scheelbeek et al. (2021)]] .

Questions of the feasibility and effectiveness of health adaptation options differ from those in other sectors because public health is a societal enterprise that cuts across many different spheres of society. Consequently, there are dependencies that lie outside the jurisdiction of the health sector. All the health risks of a changing climate currently cause adverse outcomes, with policies and programmes implemented in at least some health programmes in some places. Policies and programmes are continuously modified to increase effectiveness; this will need to accelerate in a changing climate. Improvements are needed as more is understood about disease aetiology, changing socioeconomic and environmental conditions, obstacles to uptake and other factors.

Policies and programmes for climate-sensitive health outcomes are only beginning to incorporate the challenges and opportunities of climate change, although this is critical for increasing resilience. The fundamentals of many policies and programmes in a changing climate will remain the same: implementing infectious disease control programmes, preventing heat-related mortality and morbidity and reducing the burden of other climate-related health endpoints, but activities will need to explicitly account for climate change to continue to protect health. Even with such attention to climate change, there are limits to the feasibility and effectiveness of health adaptation options for extreme heat, controlling emerging infectious diseases and controlling cascading risk pathways.

As discussed in Sections 1.4.2 and 1.5, an adaptation option is feasible when it is capable of being implemented by one or more relevant actors. In the health sector, WHO, the United Nations Children’s Fund (UNICEF) and other organisations provide technical expertise to ministries of health, who then provide national to local healthcare and public health services. Generally, the question is less of overall feasibility, given the range of potential adaptation options that have yet to be fully explored and implemented, but more of readiness to buy into the adaptation efforts required from health and other sectors. In specific contexts, feasibility also depends on governance capacity, financial capacity, public opinion and the distribution of political and economic power (Chapter 17). In other words, adaptation to climate change is broadly feasible with adequate investment and engagement, although this has yet to materialise, and in specific contexts feasibility is contingent and time-varying, and needs to be assessed at national to sub-national scales. For example, a scoping review in the Pacific region noted the following areas where further and significant investment and support are needed to increase feasibility of climate and health action: (a) health workforce capacity development, (b) enhanced surveillance and monitoring systems and (c) research to address priorities and their subsequent translation into practice and policy ( [[#Bowen--2021|Bowen et al., 2021]] ). Vulnerability, adaptation and capacity assessments include consideration of the feasibility and effectiveness of priority health adaptation options and can help decision makers identify strategies for enhancing adaptation feasibility in specific contexts.

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==== 7.4.2.3 Adaptation Options for Vector-borne, Water-borne and Food-Borne Diseases ====

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''Integrated vector control approaches are crucial to effectively manage the geographic spread, distribution and transmission of VBDs associated with climate change'' ( ''high confidence'' ) ''.'' Some of the projected risks of climate change on VBDs can be offset through enhanced commitment to existing approaches to integrated case management and integrated vector control management ( [[#Cissé--2018|Cissé et al., 2018]] ; [[#Confalonieri--2017|Confalonieri et al., 2017]] ; [[#Semenza--2021|Semenza and Paz, 2021]] ). Important components include enhanced disease surveillance and early warning and response systems that can identify potential outbreaks at sub-seasonal to decadal time scales ( [[#Rocklöv--2020|Rocklöv and Dubrow, 2020]] ; [[#Semenza--2014|Semenza and Zeller, 2014]] ; Table 7.3). In many cases, the exposure dynamics of VBDs are strongly influenced by socioeconomic dynamics that should be considered when developing and deploying adaptation options ( [[#UNEP--2018|UNEP, 2018]] ). This is especially the case in low-income countries. For example, insufficient access to sanitation and the presence of standing water are important determinants of the presence of ''Aedes aegypti'' populations and the pathogens that cause visceral leishmaniasis ( ''L. donovani'' and ''L. infantum'' ) in urban and peri-urban areas. Low housing quality and lack of refuse management are associated with higher rodent infestation. Strategies expected to have important health co-benefits include those that support health systems strengthening and ecosystem health, improve access to health coverage, increase awareness and education and address the underlying conditions of uneven development and a lack of adequate housing and access to water and sanitation systems in areas endemic to mosquito-borne diseases ( [[#Semenza--2021|Semenza and Paz, 2021]] ; Cross-Chapter Box ILLNESS in Chapter 2).

'''Table 7.3 |''' Summary of adaptation options for key risks associated with climate-sensitive vector-, water- and food-borne diseases (VBDs, WBDs, FBDs).

{| class="wikitable"
|-
! '''Key risk'''

! '''Geographic region(s) at higher risk'''

! '''Consequence that would be considered severe and to whom'''

! '''Hazard conditions that would contribute to this risk being severe'''

! '''Exposure conditions that would contribute to this risk being severe'''

! '''Vulnerability conditions that would contribute to this risk being severe'''

! '''Adaptation options with high potential for reducing risk'''

! '''Selected key references'''

|-
| '''VBDs'''

| Global

| Increase in the incidence of some VBDs, such as malaria, dengue and other mosquito-borne diseases, in endemic areas and in new risk areas (e.g., cities, mountains and Northern Hemisphere)

| Increased climatic suitability for transmission (e.g., enhanced vectorial capacity through a temperature shift)

| Large increases in human exposure to vectors driven by growth in human and vector populations, globalisation, population mobility and urbanisation

| Few effective vaccines, weak health systems, ineffective personal and household protections, susceptibility to disease, poverty, poor hygiene conditions, insecticide resistance and behavioural factors

| Improved housing, better sanitation conditions and self-protection awareness; insecticide-treated bed nets and indoor spraying of insecticide; broader access to healthcare for the most vulnerable; establishment of disease surveillance and early warning systems for VBDs; cross-border joint control of outbreaks; effective vector control; targeted efforts to develop vaccines

| Cissé et al. (2018); [[#Semenza--2021|Semenza (2021)]] ; Rocklöv and Dubrow. (2020)

|-
| '''WBDs'''

| Mostly low- and middle-income countries (Africa and Asia); small islands; global for ''Vibrios''

| Increase in the occurrence and intensity of WBDs such as ''Vibrios'' (particularly ''V. cholerae'' ), diarrhoeal diseases and other waterborne GI illnesses

| Substantial changes in temperature and precipitation patterns, increased frequency and intensity of extreme weather events (e.g., droughts, storms and floods), ocean warming and acidification

| Large increases in exposure, particularly in flood-prone areas with poor sanitation and favourable ecological environments for WBD pathogens

| Poor hygiene conditions, lack of clean drinking water and safe food, flood- and drought-prone areas and vulnerable water and sanitation systems

| Improved WASH conditions and surveillance systems; improved personal drinking and eating habits; behaviour change

| [[#Brubacher--2020|Brubacher et al. (2020)]] ; [[#Ford--2018|Ford and Hamner (2018)]] ; [[#Lake--2018|Lake (2018)]] ; Levy et al. (2018); Nichols et al. (2018); [[#Rocklöv--2021|Rocklöv et al. (2021)]]

|-
| '''FBDs'''

| Global

| Increase in the occurrence and intensity of FBDs such as ''Salmonella'' and ''Campylobacter,'' including in high-income countries

| Substantial changes in temperature and precipitation patterns, increased frequency and intensity of extreme weather events (e.g., droughts, storms and floods), ocean warming and acidification

| Large increases in exposure, particularly in flood-prone areas with poor sanitation and favourable ecological environments for FBD pathogens

| Poor hygiene conditions; lack of clean drinking water and safe food; flood- and drought-prone areas; vulnerable water and sanitation systems, food storage systems, food processes, food preservation and cold chain/storage

| Improved WASH conditions and surveillance systems; improved personal drinking and eating habits; behaviour change; improved food storage, food processing, food preservation and cold chain/storage

| [[#Brubacher--2020|Brubacher et al. (2020)]] ; [[#Ford--2018|Ford and Hamner (2018)]] ; [[#Lake--2018|Lake (2018)]] ; Levy et al. (2018); Nichols et al. (2018); [[#Rocklöv--2021|Rocklöv et al. (2021)]]

|}

''Adaptation options for climate-related risks for WBDs and FBDs are strongly associated with wider, multi-sectoral initiatives to improve sustainable development in low-income communities'' ( ''high confidence'' ) ''.'' Effective measures include improving access to potable water and reducing exposure of water and sanitation systems to flooding and extreme weather events ( [[#Brubacher--2020|Brubacher et al., 2020]] ; [[#Cisse--2019|Cisse, 2019]] ; Table 7.3). This requires focusing on farm-level interventions that limit the spread of pathogens into adjacent waterways, preventing the ongoing contamination of water and sanitation systems and the promotion of food-safe human behaviours ( [[#Levy--2018|Levy et al., 2018]] ; [[#Nichols--2018|Nichols et al., 2018]] ). It is also important to implement well-targeted and integrated WASH interventions, including at schools and ensuring proper disposal of excreta and wastewater. Cities can integrate regional climate projections into their engineering models to produce lower-risk source waters and increase the resilience of water and sanitation technologies and management systems under a range of climate scenarios. Technologies can help abstract source waters from depth, introduce or increase secondary booster disinfection, design or modify systems to reduce residence times within pipes and/or coat exposed pipes ( [[#Levy--2018|Levy et al., 2018]] ). Other efficient interventions include source water protection, promoting water filtration, testing the presence of waterborne pathogens in shellfish, imposing trade restrictions where necessary and improving hygiene at all levels ( [[#Semenza--2021|Semenza and Paz, 2021]] ). Needed actions include early warning and response systems, strengthening the resilience of communities and health systems and promoting ecosystem health, water safety plans and sanitation safety plans ( [[#Brubacher--2020|Brubacher et al., 2020]] ; [[#Cisse--2019|Cisse, 2019]] ; [[#Ford--2018|Ford and Hamner, 2018]] ; [[#Lake--2018|Lake and Barker, 2018]] ; [[#Levy--2018|Levy et al., 2018]] ; [[#Nichols--2018|Nichols et al., 2018]] ; WHO and International Water Association, 2009; WHO, 2016a; [[#WHO--2018b|WHO, 2018b]] ; [[#Semenza--2021|Semenza, 2021]] ; [[#Rocklöv--2021|Rocklöv et al., 2021]] ).

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==== 7.4.2.4 Adaptation Options for Heat-Related Morbidity and Mortality ====

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Adaptations options for heat refer to strategies implemented at short time scales such as air conditioning and HAPs, including heat warning systems and longer-term solutions such as urban design and planning and NbS (Table 7.4).

'''Table 7.4 |''' Summary of adaptation options for key health risks associated with heat.

{| class="wikitable"
|-
! '''Key risk'''

! '''Geographic region'''

! '''Consequence that would be considered severe, and to whom'''

! '''Hazard conditions that would contribute to this risk being severe'''

! '''Exposure conditions that would contribute to this risk being severe'''

! '''Vulnerability conditions that would contribute to this risk being severe'''

! '''Adaptation options with high potential for reducing risk'''

! '''Selected key references'''

|-
| Heat-related mortality, morbidity and mental illness

| * Global but especially where temperature extremes beyond physical and mental health and thermal comfort threshold levels are expected to increase

| * Substantial increase in heat-related mortality and morbidity rates, especially in urban centres (heat island effect) and rural areas (outside workers), outdoors in general (sports and related activities) and for people suffering from obesity, weak cardiovascular capacity /physical fitness
* Increased risk of respiratory disease and CVD mortality
* Loss of economic productivity
* Substantial increase in mental illness compared to base rate

| * Substantial increase in frequency and duration of extreme heat events, especially in cities where heat will be exacerbated by UHI effects
* Unintended increases in urban temperatures from anthropogenic heat (vehicles, air conditioning, urban metabolism)
* Increased number of days with high temperatures in non-urban settings such as agricultural areas

| * Large increases in urban heat and population heat exposure driven by demographic change (e.g., aging) and increasing urbanisation
* Exposure will increase amongst agricultural and construction workers

| * Mortality/morbidity: Increases in the number of very young and elderly and of those with other health conditions such as lack of physical fitness, obesity, diabetes and associated comorbidities; lack of adaptation capacity
* Mental illness: Lack of air conditioning; lack of access to healthcare systems and services

| * Heat warning systems.
* Improved building and urban design (including green and blue infrastructure) and passive cooling systems, acknowledging that not all will have access to air conditioning
* Broader understanding of heat hazard and better access to public health systems for the most vulnerable
* Application where possible of renewable energy sources
* Communication around drinking water; availability of clean water via simple effective water purification systems in low water quality settings; water spray cooling
* Mental health support

| [[#Benmarhnia--2016|Benmarhnia et al. (2016)]] ; [[#Chen--2019|Chen et al. (2019)]] ; [[#Jay--2021|Jay et al. (2021)]] ; [[#Heo--2019b|Heo et al. (2019b)]] ; [[#Martinez-Solanas--2019|Martinez-Solanas and Basagana (2019)]] ; [[#Morabito--2021|Morabito et al. (2021)]] ; [[#Schwingshackl--2021|Schwingshackl et al. (2021)]]

|}

To date, air conditioning is the main adaptation approach for mitigating the health effects of high temperatures, especially in relation to cardiorespiratory health ( [[#Madureira--2021|Madureira et al., 2021]] ). However, air conditioning may constitute a maladaptation because of its high demands on energy and associated heat emissions, especially in high-density cities ( [[#Eriksen--2021|Eriksen et al., 2021]] ; [[#Magnan--2016|Magnan et al., 2016]] ; [[#Schipper--2020|Schipper, 2020]] ), and also lead to ‘heat inequities’ as this is not an affordable or practical option for many ( [[#Jay--2021|Jay et al., 2021]] ; [[#Turek-Hankins--2021|Turek-Hankins et al., 2021]] ). HAPs link weather forecasts with alert and communication systems and response activities, including public cooling centres, enhanced heat-related disease surveillance and a range of individual actions designed to reduce the health effects of extreme heat events such as seeking shade and altering the pattern of work ( [[#McGregor--2015|McGregor et al., 2015]] ). While well-designed and operationalisable HAPs possess the potential to reduce the likelihood of mortality from extreme heat events ( ''medium confidence'' ) ( [[#Benmarhnia--2016|Benmarhnia et al., 2016]] ; [[#Heo--2019b|Heo et al., 2019b]] ; [[#Martinez-Solanas--2019|Martinez-Solanas and Basagana, 2019]] ; [[#Martinez--2019|Martinez et al., 2019]] ; [[#De’Donato--2018|De’Donato et al., 2018]] ), full process and outcome-based evaluations of HAPs and their constituent components are lacking ( [[#Boeckmann--2014|Boeckmann and Rohn, 2014]] ; [[#Chiabai--2018b|Chiabai et al., 2018b]] ; [[#Boeckmann--2014|Boeckmann and Rohn, 2014]] ; [[#Nitschke--2016|Nitschke et al., 2016]] ; [[#Diaz--2019|Diaz et al., 2019]] ; [[#Benmarhnia--2016|Benmarhnia et al., 2016]] ; [[#Heo--2019a|Heo et al., 2019a]] ; [[#Heo--2019b|Heo et al., 2019b]] ; [[#Ragettli--2019|Ragettli and Roosli, 2019]] ). Evaluations of heatwave early warning systems as a component within HAPs show inconsistent results in terms of their impact on predicting mortality rates ( [[#Nitschke--2016|Nitschke et al., 2016]] ; [[#Benmarhnia--2016|Benmarhnia et al., 2016]] ; [[#Heo--2019a|Heo et al., 2019a]] ; [[#Heo--2019b|Heo et al., 2019b]] ; [[#Ragettli--2019|Ragettli and Roosli, 2019]] ; [[#Martinez--2019|Martinez et al., 2019]] ; [[#De’Donato--2018|De’Donato et al., 2018]] ; [[#Weinberger--2018b|Weinberger et al., 2018b]] ), indicating climate-based heat warning systems, which use a range of heat stress metrics ( [[#Schwingshackl--2021|Schwingshackl et al., 2021]] ), are not sufficient as a stand-alone approach to heat risk management ( ''high confidence'' ). To support HAP and heat risk-related policy development, identification and mapping of heat vulnerability ‘hot spots’ within urban areas have been proposed ( [[#Chen--2019|Chen et al., 2019]] ; [[#Hatvani-Kovacs--2018|Hatvani-Kovacs et al., 2018]] )

''A multi-sectoral approach, including the engagement of a range of stakeholders will'' likely ''benefit the response to longer-term heat risks through the implementation of measures such as climate-sensitive urban design and planning that mitigates UHI effects'' ( ''high confidence'' ) ''( [[#Ebi--2019|Ebi, 2019]] ; [[#Jay--2021|Jay et al., 2021]] ; [[#Alexander--2016|Alexander et al., 2016]] ; [[#Levy--2016|Levy, 2016]] ; [[#Masson--2018|Masson et al., 2018]] ; [[#McEvoy--2019|McEvoy, 2019]] ; [[#Pisello--2018|Pisello et al., 2018]] )'' . In the shorter-term, potentially localised solutions can include awnings, louvers, directional reflective materials, altering roof albedo, mist sprays, evaporative materials, green roofs and building facades and cooling centres ( [[#Jay--2021|Jay et al., 2021]] ; [[#Macintyre--2019|Macintyre and Heaviside, 2019]] ; [[#Spentzou--2021|Spentzou et al., 2021]] ; [[#Takebayashi--2018|Takebayashi, 2018]] ). NbS to reduce heat that offer co-benefits for ecological systems include green and blue infrastructure (e.g., urban greening/forestry and the creation of water bodies) ( [[#Koc--2018|Koc et al., 2018]] ; [[#Lai--2019|Lai et al., 2019]] ; [[#Shooshtarian--2018|Shooshtarian et al., 2018]] ; [[#Ulpiani--2019|Ulpiani, 2019]] ; [[#Zuvela-Aloise--2016|Zuvela-Aloise et al., 2016]] ; [[#Hobbie--2020|Hobbie and Grimm, 2020]] ). The implementation of climate-sensitive design and planning can be constrained by governance issues ( [[#Jim--2018|Jim et al., 2018]] ) and the benefits are not always evenly distributed among residents. Implementation of climate-sensitive design and NbS does, however, need to be carried out within the context of wider public health planning because water bodies and moist vegetated surfaces provide suitable habitats for a range of disease vectors ( [[#Nasir--2017|Nasir et al., 2017]] ; [[#Tian--2016|Tian et al., 2016]] ; [[#Trewin--2020|Trewin et al., 2020]] ). Solutions recommended for managing exposure to heat in outdoor workers include improved basic protection (including shade and planned rest breaks), heat-appropriate personal protective equipment, work scheduling for cooler times of the day, heat acclimation, improved aerobic fitness, access to sufficient cold drinking water and on-site cooling facilities and mechanisation of work ( [[#Morabito--2021|Morabito et al., 2021]] ; [[#Morris--2020|Morris et al., 2020]] ; [[#Varghese--2020|Varghese et al., 2020]] ; [[#Williams--2020|Williams et al., 2020]] ).

Most adaptation options were developed in high- and middle-income countries and typically require significant financial resources for their planning and implementation. Studies are needed of the benefits of indigenous and non-Western approaches to managing and adapting to extreme heat risk. Recently published reviews of approaches to heat adaptation outline the nature and limitations of a range of cooling strategies with optimal solutions for a number of settings recommended ( [[#Jay--2021|Jay et al., 2021]] ; [[#Turek-Hankins--2021|Turek-Hankins et al., 2021]] ).

<div id="7.4.2.5" class="h3-container"></div>

<span id="adaptation-options-for-air-pollution-related-health-effects"></span>
==== 7.4.2.5 Adaptation Options for Air Pollution-related Health Effects ====

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As noted in [[#7.3.1.6|Section 7.3.1.6]] , air pollution projections indicate ambitious emission reduction scenarios or stabilisation of global temperature change at 2°C or below would yield substantial co-benefits for air quality-related health outcomes. Improvements in air quality could be achieved by the deliberate adoption of a range of adaptation options to complement mitigation measures such as decarbonisation (e.g., renewable energy, fuel switching, energy efficiency gains and carbon capture storage and utilisation) and negative emissions technologies (e.g., bioenergy carbon capture and storage, soil carbon sequestration, afforestation and reforestation and wetland construction and restoration).

Adaptation options for air pollution include implementing ozone precursor emission control programmes; developing mass transit/efficient public transport systems in large cities; encouraging car-pooling, cycling and walking (active transport); traffic congestion charges; low emission zones in cities; integrated urban planning implementing NbS such as green infrastructure for pollutant interception and removal; managing wildfire risk regionally and across jurisdictional boundaries; developing air quality warning systems; altering activity on high pollution days; effective air pollution risk communication and education; wearing protective equipment such as face masks; avoiding solid fuels for cooking and indoor heating; ventilating and isolating cooking areas; and using portable air cleaners fitted with high-efficiency particulate air filters ( [[#Abhijith--2017|Abhijith et al., 2017]] ; [[#Carlsten--2020|Carlsten et al., 2020]] ; [[#Cromar--2020|Cromar et al., 2020]] ; [[#Ding--2021|Ding et al., 2021]] ; [[#Holman--2015|Holman et al., 2015]] ; [[#Jennings--2021|Jennings et al., 2021]] ; [[#Kelly--2021|Kelly et al., 2021]] ; [[#Kumar--2019|Kumar et al., 2019]] ; [[#Masselot--2019|Masselot et al., 2019]] ; [[#Ng--2021|Ng et al., 2021]] ; [[#Riley--2021|Riley, 2021]] ; [[#Voordeckers--2021|Voordeckers et al., 2021]] ; [[#Xu--2017|Xu et al., 2017]] ; Table 7.5). While the range of air pollution adaptation options is potentially extensive, barriers may need to be overcome to achieve successful implementation, including financial, institutional, political (i.e. inter- and intra-governmental) and social barriers ( [[#Barnes--2014|Barnes et al., 2014]] ; [[#Ekstrom--2018|Ekstrom and Bedsworth, 2018]] ; [[#Fogg-Rogers--2021|Fogg-Rogers et al., 2021]] ; [[#Schumacher--2019|Schumacher and Shandas, 2019]] ).

'''Table 7.5 |''' Summary of adaptation options for key health risks associated with air pollution.

{| class="wikitable"
|-
! '''Key risk'''

! '''Geographic region'''

! '''Consequence that would be considered severe and to whom'''

! '''Hazard conditions that would contribute to this risk being severe'''

! '''Exposure conditions that would contribute to this risk being severe'''

! '''Vulnerability conditions that would contribute to this risk being severe'''

! '''Adaptation options with high potential for reducing risk'''

! '''Selected key references'''

|-
| Air pollution-related health effects

| * Global, but especially in regions with existing poor air quality, particularly in relation to PM and ozone
* Greatest climate change driven ozone-related mortality is expected for East Asia and North America
* For PM the highest climate and air quality-related mortalities are projected for India, the Middle East, Former Soviet Union and East Asia

| * Substantial increase in air pollution-related mortality and morbidity rates, especially in urban centres, related to both severe pollution episodes and longer-term deterioration of air quality
* People particularly vulnerable include those with RTIs and CVD
* Increase in mental illness (depression) as a result of poor air quality and visibility

| * Non-achievement of emission reduction targets
* Substantial increase in frequency and duration of meteorological conditions conducive to the buildup of both primary and secondary air pollutants (e.g., greater frequency of calm atmospheric ‘blocking’ conditions) and no long-term improvement in air quality at a range of geographical scales (global to local)
* Increase in frequency and intensity of wildfires and dust storms
* Increase in the intensity of UHIs, especially in the summer, and the occurrence of ozone episodes due to anomalously high urban temperatures

| * Large increases in exposure to air pollutants driven by demographic change (e.g., aging) and increasing urbanisation
* For arid regions increases in exposure to dust storms
* Areas adjacent/downwind of major wildfires
* For urban populations intensifying UHIs and enhanced formation of secondary pollutants

| * Increases in the number of very young and elderly and those with respiratory or cardiovascular conditions, and lack of adaptation capacity (e.g., reduced reliance on solid fuel for cooking/heating)
* Mental illness: Lack of access to healthcare systems and services

| * Air quality management policies, air quality warning systems, efficient and cheap mass transit systems, integrated urban planning (including NbS and green infrastructure)
* Broader understanding of air pollution hazard and better access to public health systems for the most vulnerable
* Application where possible of renewable energy sources to reduce emissions

| [[#Carlsten--2020|Carlsten et al. (2020)]] ; Doherty et al. (2017); Jennings et al. (2021); [[#Kumar--2019|Kumar et al. (2019)]] ; Orru et al. (2017); [[#Orru--2019|Orru et al. (2019)]] ; [[#Schumacher--2019|Schumacher and Shandas (2019)]] ; [[#Silva--2017|Silva et al. (2017)]] ; [[#Voordeckers--2021|Voordeckers et al. (2021)]]

|}

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<span id="multi-sectoral-adaptation-for-risks-of-malnutrition"></span>
==== 7.4.2.6 Multi-sectoral Adaptation for Risks of Malnutrition ====

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''Adaptation to reduce the risk of malnutrition requires multi-sectoral, integrated approaches'' ( ''very high confidence'' ) ''.'' Adaptation actions include access to healthy, affordable diverse diets from sustainable food systems ''(high confidence)'' ; a combination of access to health—including maternal, child and reproductive health— and nutrition services, water and sanitation ( ''high confidence'' ); access to nutrition-sensitive and shock-responsive social protection ( ''high confidence'' ); and early warning systems ( ''high agreement'' ), risk sharing, transfer, and risk reduction schemes such as index-based weather insurance ''(medium confidence)'' ( [[#Mbow--2019|Mbow et al., 2019]] ; [[#Swinburn--2019|Swinburn et al., 2019]] ; UNICEF/WHO/WBG, 2019; [[#FAO--2021|FAO et al., 2021]] ; [[#Macdiarmid--2019|Macdiarmid and Whybrow, 2019]] ; [[#Liverpool-Tasie--2021|Liverpool-Tasie et al., 2021]] ). Common enablers across adaptation actions that enhance the effectiveness and feasibility of the adaptation include: education, women’s and girls’ empowerment ( ''high confidence'' ), rights-based governance and peacebuilding social cohesion initiatives such as the framework of the Humanitarian Development and Peace Nexus ''(medium confidence).''

''Nutrition-sensitive and integrated agroecological farming systems offer opportunities to increase dietary diversity at household levels while building local resilience to climate-related food insecurity'' ( ''high confidence'' ) ''( [[#Bezner%20Kerr--2021|Bezner Kerr et al., 2021]] ; [[#IPES-Food--2020|IPES-Food, 2020]] ; [[#Altieri--2015|Altieri et al., 2015]] )'' especially when gender equity, racial equity and social justice are integrated ( [[#Bezner%20Kerr--2021|Bezner Kerr et al., 2021]] ). Adaptation responses include a combination of healthy, culturally appropriate and sustainable food systems and diets; soil and water conservation; social protection schemes and safety nets; access to health services; nutrition-sensitive risk reduction; community-based development; women’s empowerment; nutrition-smart investments; increased policy coherence; and institutional and cross-sectoral collaboration ''(high agreement, medium evidence)'' ( [[#FAO--2018|FAO et al., 2018]] ; [[#Mbow--2019|Mbow et al., 2019]] ; [[#Pozza--2020|Pozza and Field, 2020]] ; [[#FAO--2021|FAO et al., 2021]] ; Table 7.7). Nutrition security can be enhanced through consideration of nutrient flows in food systems ( [[#Harder--2021|Harder et al., 2021]] ).This ‘circular nutrient economy’ perspective highlights the potential for adaptations throughout the food supply chain, including sustainable production practices that promote nutrient diversity and density, processing, storage, and distribution that conserves nutrition; equitable access and consumption of available, affordable, appropriate, and healthy foods; and waste management that supports nutrient recovery ( [[#Harder--2021|Harder et al., 2021]] ; [[#Boon--2020|Boon and Anuga, 2020]] ; [[#FAO--2021|FAO et al., 2021]] ; [[#Pozza--2020|Pozza and Field, 2020]] ; [[#Ritchie--2018|Ritchie et al., 2018]] ). Traditional, indigenous and small-scale agroecology and regional food systems provide context-specific adaptations that promote food and nutrition security as well as principles of food sovereignty and food systems resilience ( [[#HLPE--2020|HLPE, 2020]] ; [[#Bezner%20Kerr--2021|Bezner Kerr et al., 2021]] ; [[#IPES-Food--2020|IPES-Food, 2020]] ; [[#IPES-Food--2018|IPES-Food, 2018]] ).

A feasibility and effectiveness assessment was conducted for six adaptation strategies often used and recommended by the UN to respond to malnutrition risks that combined a literature review and expert judgment assessment of 80 peer-reviewed studies (UNSCN, 2010; Tirado et al. 2013; methods adapted from de Coninck et al. (2018) and Singh et al. (2020)). Nineteen indicators of six dimensions of feasibility (economic, technical, social, institutional, environmental and geophysical) were considered. The lead time to initiate and the expected longevity of each option were examined. Feasibility was defined as how significant the reported barriers were to implement a particular adaptation option. Highly feasible options were those where no or very few barriers were reported. Moderately feasible were those where barriers existed but did not have a strong negative effect on the adaptation option (or evidence was mixed). Low feasibility options had multiple barriers reported that could block implementation. Effectiveness ratings were based on expert consultation and reflected the potential of the adaptation option to reduce risk. The final effectiveness and feasibility scores were categorised as high, medium or low and reflect the combined results of all studies for a given adaptation option (Table 7.6).

'''Table 7.6 |''' Feasibility and effectiveness assessments of multi-sectoral adaptation for food security and nutrition.

[[File:67e7bd220e017716d8b76889691a94a7 IPCC_AR6_WGII_Chapter7_Table_7_6.png]]

Adaptive social protection programmes and mechanisms that can support food insecure households and individuals include cash transfers or public work programmes, land reforms, and extension of credit and insurance services that reduce food insecurity and malnutrition during times of environmental stress ( [[#Carter--2018|Carter and Janzen, 2018]] ; [[#Johnson--2013|Johnson et al., 2013]] ; [[#Alderman--2016|Alderman, 2016]] ). For example, children from families participating in Ethiopia’s Productive Safety Net Program experienced improved nutritional outcomes, partly due to better household food consumption patterns and reduced child labour ( [[#Porter--2016|Porter and Goyal, 2016]] ). School feeding programmes improve nutritional outcomes, especially among girls, by promoting education, and by reducing child pregnancy and fertility rates ( [[#Bukvic--2017|Bukvic and Owen, 2017]] ). Adaptive social protection is most effective when it combines climate risk assessment with DRR and wider socioeconomic development objectives ( [[#Davies--2013|Davies et al., 2013]] ).

Transformative approaches towards healthier, more sustainable, plant-based diets require integrated strategies, policies and measures, including economic incentives for the agroecological production and equitable access to and consumption of more fruits, vegetables and pulses; inclusion of sustainability criteria in dietary guidelines, labelling and public education programmes; and promoting collaboration, good governance and policy coherence (Glover, 2019).

'''Table 7.7 |''' Summary of adaptation options for key risks associated with malnutrition.

{| class="wikitable"
|-
! '''Key risk'''

! '''Geographic region'''

! '''Consequence that would be considered severe and to whom'''

! '''Hazard conditions that would contribute to this risk being severe'''

! '''Exposure conditions that would contribute to this risk being severe'''

! '''Vulnerability conditions that would contribute to this risk being severe'''

! '''Adaptation options with high potential for reducing risk'''

! '''Selected key references'''

|-
| Malnutrition due to decline in food availability and increased cost of healthy food

| * Global, with greater risks in Africa, south Asia, Southeast Asia, Latin America, the Caribbean and Oceania

| * Substantial number of additional people at risk of hunger, stunting, and diet-related morbidity and mortality, including decreased mental health and cognitive function
* Micro- and macronutrient deficiencies
* Severe impacts on low-income populations from LIMICs
* Risks especially high for groups that suffer greater inequality and marginalisation

| * Climate changes leading to reductions in crop, livestock or fisheries yields, including temperature and precipitation changes and extremes, drought, and ocean warming and acidification

| * Large numbers of people in areas and markets particularly affected by climate impacts on food security and nutrition

| * High levels of inequality (including gender inequality) and substantial numbers of people subject to poverty or violent conflict, in marginalised groups or with low education levels
* Slow economic development.
* Ineffective social protection systems, nutrition services, and health services

| * Multi-sectoral approach to nutrition-sensitive adaptation and disaster risk reduction/management, including food, health and social protection systems
* Inclusive governance involving marginalised groups
* Improved education for girls and women
* Maternal and child health, water and sanitation, gender equality, climate services and social protection mechanisms

| [[#Glover--2019|Glover and Poole (2019)]] ; [[#Mbow--2019|Mbow et al. (2019)]] ; [[#Swinburn--2019|Swinburn et al. (2019)]]

|}

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<span id="adaptation-options-for-risks-to-mental-health"></span>
==== 7.4.2.7 Adaptation Options for Risks to Mental Health ====

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''Adaptation options for reducing mental health risks associated with extreme weather include preventive and post-event responses'' ( ''high confidence'' ) ''( [[#Brown--2017|Brown et al., 2017]] ; Cohen, 2019; [[#James--2020|James et al., 2020]] ; Table 7.8)'' . Responses include improving funding and access to mental healthcare, which is under-resourced (WHO, 2019a); surveillance and monitoring of psychosocial impacts of extreme weather events; community-level planning for mental health as part of climate-resilience planning ( [[#Clayton--2017|Clayton et al., 2017]] ); and mental health and psychological first aid training for care providers and first responders ( [[#Hayes--2018|Hayes et al., 2018]] ; [[#O’Donnell--2021|O’Donnell et al., 2021]] ; [[#Hayes--2018|Hayes et al., 2018]] ; [[#Taylor--2020|Taylor, 2020]] ; [[#Morgan--2018|Morgan et al., 2018]] ; [[#Sijbrandij--2020|Sijbrandij et al., 2020]] ). Legislation can ensure access to services as well as establish a regulatory framework ( [[#Ayano--2018|Ayano, 2018]] ). Advanced disaster risk planning reduces post-event mental health challenges. One example is from China, where pre-planning of temporary shelters resulted in significantly lower rates of anxiety, depression and PTSD in the aftermath of flooding among displaced people who accessed them ( [[#Zhong--2020|Zhong et al., 2020]] ). Key elements of successful initiatives include coordinated planning and action between key regional agencies and governments with a focus on improving accountability and removing barriers to implementation and subsequent access to programmes ( [[#Ali--2020|Ali et al., 2020]] ). As an example, following the 2019/2020 Australian bushfires, the federal government allocated funds to support mental health through free counselling for those affected, increased access to telehealth, extended hours for mental health services and programmes designed specifically for youth ( [[#Newnham--2020|Newnham et al., 2020]] ).

'''Table 7.8 |''' Summary of adaptation options for key risks associated with mental health.

{| class="wikitable"
|-
! '''Key Risk'''

! '''Geographic region'''

! '''Consequence that would be considered severe and to whom'''

! '''Hazard conditions that would contribute to this risk being severe'''

! '''Exposure conditions that would contribute to this risk being severe'''

! '''Vulnerability conditions that would contribute to this risk being severe'''

! '''Adaptation options with high potential for reducing risk'''

! '''Selected key references'''

|-
| Mental health impacts in response to floods, storms, and wildfires

| * Global; some areas at greater risk for storms, flooding, or wildfires

| * Substantial increase in mental illness compared to base rate

| * Increased frequency of major storms, weather-related flooding or wildfires

| * Low-lying areas, dry areas, urban areas

| * Physical infrastructure that is vulnerable to extreme weather, inadequate emergency response and mental health services, social inequality

| * Improved urban infrastructure, warning systems, and post-disaster social support
* Improved funding and access to mental healthcare
* Improved surveillance and monitoring of mental health impacts of extreme weather events
* Climate change resilience planning in the mental health system (including at a community level
* Mental health first aid training for care providers and first responders

| [[#Ali--2020|Ali et al. (2020)]] ; [[#Ayano--2018|Ayano (2018)]] ; [[#Buckley--2019|Buckley et al. (2019)]] ; [[#Clayton--2017|Clayton et al. (2017)]] ; Hayes et al. (2019); [[#James--2020|James et al. (2020)]] ; [[#Sijbrandij--2020|Sijbrandij et al. (2020)]]

|}

''Because mental health is fundamentally inter-twined with social and economic well-being, adaptation for climate-related mental health risks benefits from wider multi-sectoral initiatives to enhance well-being, with the potential for co-benefits to emerge'' ( ''high confidence'' ) ''.'' Improvements in education, quality of housing, safety and social protection support enhance general well-being and make individuals more resilient to climate risks ( [[#Lund--2018|Lund et al., 2018]] ; Hayes et al., 2019). Among Indigenous Peoples, connections to traditional culture and to place are associated with health and well-being ( [[#Bourke--2018|Bourke et al., 2018]] ) as well as with resilience to environmental change ( [[#Ford--2020|Ford et al., 2020]] ). As an example of the connection between infrastructure improvements and mental health, a study of domestic rainwater harvesting initiatives to promote household water security also improved mental health in participating households ( [[#Mercer--2017|Mercer and Hanrahan, 2017]] ). Adaptive urban design that provides access to healthy natural spaces—an option for reducing risks associated with heat stress—also promotes social cohesion and mitigates mental health challenges ''(high confidence)'' ( [[#Buckley--2019|Buckley et al., 2019]] ; [[#Clayton--2017|Clayton et al., 2017]] ; [[#Jennings--2019|Jennings and Bamkole, 2019]] ; [[#Liu--2020b|Liu et al., 2020b]] ; [[#Mygind--2019|Mygind et al., 2019]] ; [[#Marselle--2020|Marselle et al., 2020]] ).

<div id="7.4.2.8" class="h3-container"></div>

<span id="adaptation-options-to-facilitate-early-warning-and-response-systems"></span>
==== 7.4.2.8 Adaptation Options to Facilitate Early-Warning and Response Systems ====

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''Early warning systems are a potentially valuable tool in adapting to climate-related risks associated with infectious diseases when based on forecasts with high skill and when there are effective responses within the time frame of the forecast'' ( ''high confidence'' ) ''.'' Through advanced seasonal weather forecasting that draws upon established associations between weather/climate and infection/transmission conditions, conditions conducive to disease outbreaks can be identified months in advance, providing time to implement effective population health responses ( [[#Morin--2018|Morin et al., 2018]] ). Most current early warning systems are focused on malaria and dengue but there are examples for other diseases, such as an early warning system developed for ''Vibrios'' monitoring in the Baltic Sea ( [[#Semenza--2017|Semenza et al., 2017]] ). An early warning system for dengue outbreaks in Colombia based on temperature, precipitation and humidity successfully detected 75% of all outbreaks between one and five months in advance, detecting 12.5% in the same month ( [[#Lee--2017b|Lee et al., 2017b]] ). Dengue warning systems in Brazil, Malaysia and Mexico have generated satisfactory results ( [[#Hussain-Alkhateeb--2018|Hussain-Alkhateeb et al., 2018]] ). An effective early warning system for malaria was implemented in the Amhara region of Ethiopia ( [[#Merkord--2017|Merkord et al., 2017]] ).

''Early warning systems are effective at detecting and potentially reducing food security and nutrition risks'' ( ''high confidence'' ) ''.'' Examples of proven systems include the United States Agency for International Development (USAID) Famine Early Warning System, the Food and Agricultural Organization’s Global Information and Early Warning System and the World Food Programme’s Corporate Alert System. Such systems are fundamental for anticipating when a crisis might occur and setting priorities for interventions ( [[#Funk--2019|Funk et al., 2019]] ). Financial investments to develop early warning systems are cost-effective and reduce human suffering ( [[#Choularton--2019|Choularton and Krishnamurthy, 2019]] ) ( ''high confidence'' ). For instance, during the 2017 drought-induced food crisis in Kenya, 500,000 fewer people required humanitarian assistance than would have been expected based on past experiences; this was largely due to timely and effective interventions triggered by the early warning ( [[#Funk--2018|Funk et al., 2018]] ).

Early warning systems have been established for other climate-sensitive health outcomes, such as respiratory diseases associated with air pollution ( [[#Shih--2019|Shih et al., 2019]] ; [[#Li--2018|Li and Zhu, 2018]] ; [[#Yang--2017|Yang and Wang, 2017]] ). Early warning systems for non-heat extreme weather and climate events, such as storms and floods, are designed to protect human health and well-being; disaster risk management organisations and institutions typically communicate these warnings through their networks. Research is ongoing to extend the time period for warnings.

<div id="7.4.2.9" class="h3-container"></div>

<span id="incorporating-disaster-risk-reduction-into-health-adaptation"></span>
==== 7.4.2.9 Incorporating Disaster Risk Reduction into Health Adaptation ====

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''Integrating health into national disaster risk management plans has wider benefits for resilience and adaptation to climate change risks'' ( ''high confidence'' ) ''( [[#UNFCCC--2017a|UNFCCC, 2017a]] ; [[#Watts--2019|Watts et al., 2019]] )'' . DRR, including disaster preparedness, management and response, is widely recognised as important for reducing health consequences of climate-related hazards and extreme weather events ( [[#Keim--2008|Keim, 2008]] ; [[#Phalkey--2016|Phalkey and Louis, 2016]] ). A systematic review by [[#Islam--2020|Islam et al. (2020)]] identified multiple, ongoing challenges to integrating climate adaptation and DRR at global and national levels, including a lack of capacity among key actors and institutions, a lack of coordination and collaboration across scales of government and general lack of funding—challenges that are particularly relevant for the health sector. Global events, including climate-related extreme events and public health emergencies of international concern (for example, Ebola, Middle East respiratory syndrome (MERS) and COVID-19) have influenced the development of national public health preparedness and response systems and attracted significant investment over the last two decades ( [[#Khan--2015|Khan et al., 2015]] ; [[#Murthy--2017|Murthy et al., 2017]] ; [[#Watson--2017|Watson et al., 2017]] ). The Sendai Framework for Disaster Risk Reduction and the International Health Regulations establish important global and regional goals for increasing health system resilience and reducing health impacts from biological hazards and extreme climate events ( [[#Aitsi-Selmi--2015|Aitsi-Selmi et al., 2015]] ; [[#Maini--2017|Maini et al., 2017]] ; [[#UNFCCC--2017b|UNFCCC, 2017b]] ; [[#Wright--2020|Wright et al., 2020]] ). There are explicit links between the health aspect of the Sendai Framework and UN SDGs 1, 2, 3, 4, 6, 9, 11, 13, 14, 15 and 17 ( [[#Wright--2020|Wright et al., 2020]] ). More specifically, reducing the number of disaster-related deaths, illnesses and injuries, as well as damage to health facilities are key indicators for achieving the goals set out in the Sendai Framework ( [[#UNFCCC--2017b|UNFCCC, 2017b]] ).

The intersection of health and multi-sectoral DRR and management, generally described as health emergency and disaster risk management (health-EDRM), encompasses multi-sectoral approaches from epidemic preparedness and response including the capacities for implementing the International Health Regulations (IHR, 2005), health systems strengthening and health systems resilience ( [[#Lo%20Iacono--2017|Lo Iacono et al., 2017]] ; WHO 2019; [[#Wright--2020|Wright et al., 2020]] ). Health-EDRM costs to governments are notably lower than the cost of inaction ( [[#Peters--2019|Peters et al., 2019]] ). Additional per capita costs in low-income countries have been estimated to range from USD 4.33 (capital) and USD 4.16 (annual recurrent costs), and in upper middle-income countries to an additional USD 1.35 in capital costs and USD 1.41 in extra annual recurrent costs ( [[#Peters--2019|Peters et al., 2019]] ). Adopting a health-EDRM approach supports the systematic integration of health and multi-sectoral EDRM to ensure a holistic approach to health risks and assists in the alignment of action in health security, climate change and sustainable development ( [[#Chan--2017|Chan and Peijun, 2017]] ; [[#Dar--2014|Dar et al., 2014]] ; WHO, 2019; [[#Wright--2020|Wright et al., 2020]] ).

Climate-informed health-EDRM is crucial for the climate resilience of health systems ( [[#WHO--2015a|WHO, 2015a]] ), particularly to account for additional risks and uncertainties associated with climate change and allow for well-planned, effective and appropriate EDRM and adaptation ( [[#Watts--2018a|Watts et al., 2018a]] ; [[#WHO--2013|WHO, 2013]] ; [[#WHO--2015a|WHO, 2015a]] ). Potential coherent approaches to addressing climate change and disaster risks to health include: strengthening health systems; vulnerability and risk assessments that incorporate disaster and climate change risk; building resilience of health systems and health infrastructure; and climate-informed EWSs ( [[#Banwell--2018|Banwell et al., 2018]] ; [[#Phalkey--2016|Phalkey and Louis, 2016]] ). However, a review of DRR projects including climate change in south Asia found that the health sector was the least represented with only 2% of 371 projects relating to health ( [[#Mall--2019|Mall et al., 2019]] ), indicating a need to strengthen the incorporation of climate change in health-EDRM. Current tracking under the Sendai Framework of Disaster Risk Reduction 2015–2030 shows that most countries (particularly low-income countries and lower middle-income countries) still lack robust systems for integrated risk monitoring and early warning ( [[#UNEP--2018|UNEP, 2018]] ). The incorporation of DRR and management strategies into climate adaptation for health and health systems at local scales is particularly important, given that it is at local scales where health services are most often delivered and where knowledge of specific needs and challenges is often greatest ( [[#Amaratunga--2018|Amaratunga et al., 2018]] ; [[#Schramm--2020a|Schramm et al., 2020a]] ). Indigenous knowledge has been shown to be valuable in DRR, with particularly strong evidence existing for drought risk reduction in sub-Saharan Africa ( [[#Fummi--2017|Fummi et al., 2017]] ; [[#Muyambo--2017|Muyambo et al., 2017]] ; [[#Dube--2018|Dube and Munsaka, 2018]] ; [[#Macnight%20Ngwese--2018|Macnight Ngwese et al., 2018]] ). In the USA, DRR strategies that draw upon traditional knowledge and local expertise are being incorporated into climate adaptation planning for health in a number of indigenous communities under the ‘Climate-ready Tribes Initiative’ ( [[#Schramm--2020b|Schramm et al., 2020b]] ).

<div id="7.4.2.10" class="h3-container"></div>

<span id="monitoring-evaluation-and-learning"></span>
==== 7.4.2.10 Monitoring, Evaluation and Learning ====

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''Monitoring, evaluation and learning (MEL) can assess the ability of nations and communities to prepare for and adequately respond to the health risks of climate change over time'' ( ''high confidence'' ) ''( [[#Boyer--2020|Boyer et al., 2020]] ).'' MEL describes a process that includes baseline assessment, prioritising actions and activities, identifying key indicators to track, ongoing data collection and periodically considering new information (Kruk et al., 2015). MEL determines whether adaptation options achieved their goals and whether resources were used effectively and efficiently ( [[#Boyer--2020|Boyer et al., 2020]] ). One of the challenges for MEL in the context of adaptation is that climate risks vary as a function of time, location, socioeconomic development, demographics and activities in other sectors ( [[#Ebi--2018a|Ebi et al., 2018a]] ). MEL indicators in the health sector need to account for factors related to governance, implementation and learning as well as for exposures, impacts and programmatic activities, all of which are context dependent and are often outside the health sector ( [[#Boyer--2020|Boyer et al., 2020]] ; [[#Ebi--2018a|Ebi et al., 2018a]] ; [[#Fox--2019|Fox et al., 2019]] ).

''No universal standardised approach exists for monitoring or evaluating adaptation activities in the health sector'' ( ''high confidence'' ) ''.'' Candidate indicators of climate change health impacts and adaptation activity, typically at the national level, are available ( [[#Bowen--2017|Bowen and Ebi, 2017]] ; [[#Cheng--2013|Cheng and Berry, 2013]] ; [[#Kenney--2016|Kenney et al., 2016]] ; [[#Navi--2017|Navi et al., 2017]] ; [[#WHO--2015b|WHO, 2015b]] ). Indicators are best grouped by category of activity, that is, vulnerability, risk and exposure; impacts; and adaptation and resilience ( [[#Ebi--2018a|Ebi et al., 2018a]] ). As health adaptation expands, enhanced monitoring will be needed to ensure that scientific advances are translated into policy and practice. A promising initiative that emerged since the AR5 is the ''Lancet Countdown'' , which represents a global effort at tracking various indicators of exposures, impacts, adaptation activities, finance and media activity related to climate change and health ( [[#Watts--2018a|Watts et al., 2018a]] ), although this effort is principally focused on monitoring and does not explicitly focus on evaluation adaptation efforts or learning from adaptation efforts.

Community-based monitoring of adaptation responses to health impacts, especially by Indigenous Peoples, has not been widely undertaken, despite its potential to improve monitoring of and local adaptation to environmental change ( [[#Kipp--2019|Kipp et al., 2019]] ). The health sector has been particularly weak at recognising the climate impacts on and the adaptation needs of Indigenous Peoples and in engaging Indigenous Peoples in monitoring progress ( [[#Ford--2018|Ford et al., 2018]] ; [[#David-Chavez--2018|David-Chavez and Gavin, 2018]] ; [[#Ramos-Castillo--2017|Ramos-Castillo et al., 2017]] ). Successful adaptation to the health impacts of climate change in Indigenous Peoples requires recognition of their rights to self-determination, focusing on indigenous conceptualisations of well-being, prioritising Indigenous knowledge and understanding the broader agenda of decolonisation, health and human rights ( ''high confidence)'' ( [[#Ford--2015|Ford and King, 2015]] ; [[#Green--2014|Green and Minchin, 2014]] ; [[#Hoy--2014|Hoy et al., 2014]] ; [[#Jones--2019|Jones, 2019]] ; [[#Jones--2014|Jones et al., 2014]] ; [[#Mugambiwa--2018|Mugambiwa, 2018]] ; [[#Nursey-Bray--2018|Nursey-Bray and Palmer, 2018]] ).

Indicators should capture measures of processes that drive adaptation readiness, including leadership, institutional learning and inter-sectoral collaboration ( [[#Boyer--2020|Boyer et al., 2020]] ; [[#Ford--2015|Ford and King, 2015]] ) as well as outcome measures such as the presence of programming known to reduce risks ( [[#Ebi--2018a|Ebi et al., 2018a]] ). Additionally, indicators related to scaling up of effective interventions and relying on the implementation of science frameworks are important ( [[#Damschroder--2009|Damschroder et al., 2009]] ; [[#Theobald--2018|Theobald et al., 2018]] , 2020; [[#Ebi--2018a|Ebi et al., 2018a]] ; [[#Fox--2019|Fox et al., 2019]] ). Measuring impacts attributable to climate change could be addressed with a combination of indicators related to overall health system performance and population vulnerability ( [[#Ebi--2017|Ebi et al., 2017]] ; [[#Ebi--2018a|Ebi et al., 2018a]] ).

<div id="7.4.3" class="h2-container"></div>

<span id="enabling-conditions-and-constraints-for-health-adaptation"></span>
=== 7.4.3 Enabling Conditions and Constraints for Health Adaptation ===

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<div id="7.4.3.1" class="h3-container"></div>

<span id="governance-collaboration-and-coordination"></span>
==== 7.4.3.1 Governance, Collaboration and Coordination ====

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''Effective governance institutions, arrangements, funding and mandates are key for adaptation to climate-related health risks'' ( ''high confidence'' ) ''.'' Without integration and collaboration across sectors, health adaptation can become siloed, leading to less effective adaptation or even maladaptation ( [[#Magnan--2016|Magnan et al., 2016]] ; [[#Fox--2019|Fox et al., 2019]] ). Integration and collaboration include working laterally across national government departments and agencies, as well as vertically from national agencies to local governments and with the private sector, academia, NGOs and civil society. In this context, top-down policy design and implementation are complemented by bottom-up approaches that engage community actors in programme design and draw upon their local practices, perspectives, opinions and experiences. Opportunities exist to better integrate public health into climate change discourse and policymaking processes, and to strengthen public health partnerships and collaborations ( [[#Awuor--2020|Awuor et al., 2020]] ). Creating networks, integration across organisations and jointly developed policies can facilitate cross-sectoral collaboration ( [[#Bowen--2017|Bowen and Ebi, 2017]] ).

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<span id="multi-sectoral-collaborations"></span>
==== 7.4.3.2 Multi-sectoral Collaborations ====

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''Multi-sectoral collaborations aimed at strengthening the health sector can generate multiple co-benefits in other sectors'' ( ''high agreement, medium evidence'' ). Solutions for the health and well-being risks described in 7.2 and 7.3 often have their origins in sectors that include water, sanitation, agriculture, food systems, social protection systems, energy and key components of urban systems such as housing and employment ( [[#WHO--2015a|WHO, 2015a]] ; [[#Bowen--2014b|Bowen et al., 2014b]] ; [[#Machalaba--2015|Machalaba et al., 2015]] ; [[#Confalonieri--2015|Confalonieri et al., 2015]] ; [[#Bowen--2014a|Bowen et al., 2014a]] ; [[#Semenza--2021|Semenza, 2021]] ). Climate resilient development pursued in these other sectors, and in cooperation with the health sector, simultaneously increases the potential for adaptation and climate resilience in terms of health and well-being ''(high confidence)'' ( [[#Ahmad--2017|Ahmad et al., 2017]] ; [[#Watts--2018b|Watts et al., 2018b]] ; [[#Levy--2015|Levy and Patz, 2015]] ; WHO, 2018a; [[#Chiabai--2018a|Chiabai et al., 2018a]] ; [[#Dudley--2015|Dudley et al., 2015]] ; [[#Zinsstag--2018|Zinsstag et al., 2018]] ; [[#Sherpa--2014|Sherpa et al., 2014]] ).

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<span id="financial-constraints"></span>
==== 7.4.3.3 Financial Constraints ====

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''Financial constraints are the most referenced barrier to health adaptation and so scaling up financial investments remains a key international priority'' ( ''very high confidence'' ) ''( [[#Wheeler--2018|Wheeler and Watts, 2018]] ; [[#UNFCCC--2017a|UNFCCC, 2017a]] )'' . AR5 estimated the costs of adaptation in developing countries at between USD 70 billion and USD 100 billion annually in the year 2050, but these are ''likely'' to be a significant underestimate, particularly in the years 2030 and beyond (UNEP, 2014). National surveys conducted by WHO identified financial constraints as a major barrier to the implementation of health adaptation priorities ( [[#WHO--2019b|WHO, 2019b]] ; [[#Watts--2021|Watts et al., 2021]] ). Novel research drawing on global financial transaction data suggests that in 2019, global financial transactions with the potential to deliver adaptation in the health and healthcare sector reached USD 18.4 billion, driven by transactions in high- and upper middle-income countries, with investment in Africa, Southeast Asia and the eastern Mediterranean mostly stagnant ( [[#Watts--2021|Watts et al., 2021]] ).

There has been limited participation of the health sector in international climate financing mechanisms ( [[#Martinez--2018|Martinez and Berry, 2018]] ). Of 149 projects listed in the Adaptation Fund database in October 2020, a large number were broad-based initiatives that may have considerable indirect benefits for health systems, such as enhanced disaster preparedness and food security, but none were explicitly aimed at strengthening health systems or had directed funds through ministries of health. A review of projects funded by the major multi-lateral climate funds showed that less than 1.5% of dispersed adaptation funding and less than 0.5% of overall funding have been allocated to projects aimed at protecting health ( [[#WHO--2015a|WHO, 2015a]] ). A survey of national public health organisation representatives from a mix of low-, middle- and high-income countries found that a lack of political commitment, insufficient coordination across sectors and inadequate funding for public health-specific adaptation initiatives were common barriers to building climate resilience ( [[#Marcus--2020|Marcus and Hanna, 2020]] ). Under-investment in climate-specific initiatives in health systems coincides with persistent under-investment in healthcare more generally, especially in low- and middle-income countries ( [[#Schaferhoff--2019|Schaferhoff et al., 2019]] ).

Adaptation financing does not often reach places where the climate-sensitivity of the health sector is greatest ( [[#Weiler--2019|Weiler, 2019]] ). Financial constraints in Africa are one of the key reasons for slow implementation of health adaptation measures ( [[#Nhamo--2019|Nhamo and Muchuru, 2019]] ). Strengthening health systems in vulnerable countries has the potential to reduce current and future economic costs related to environmental health risks, thus enabling reinvestment in the health system and sustainable development ( [[#WHO--2020a|WHO, 2020a]] ; [[#WHO--2015a|WHO, 2015a]] ). Robust and comprehensive climate and health financing builds first on core health sector investments ( [[#WHO--2015a|WHO, 2015a]] ). Other potential opportunities for resource mobilisation include health-specific funding mechanisms, climate change funding streams and investments from multi-sectoral actions and actions in health-determining sectors ( [[#WHO--2015a|WHO, 2015a]] ). Incorporating climate change and health considerations into disaster reduction and management strategies could improve funding opportunities and increase potential funding streams ( [[#Aitsi-Selmi--2015|Aitsi-Selmi et al., 2015]] ). Reinforcing cross-sectoral governance mechanisms maximises health co-benefits and economic savings by allowing for multi-sectoral costs and benefits to be comprehensively considered in decision-making ( [[#Belesova--2016|Belesova et al., 2016]] ; [[#WHO--2020a|WHO, 2020a]] ; [[#WHO--2015b|WHO, 2015b]] ). An additional financial need concerns health research, the existing funding for which does not match what is needed to support the implementation of the combined objectives of the UN 2030 Agenda for Sustainable Development, the Sendai Framework for Disaster Risk Reduction and the Paris Agreement ( [[#Green--2014|Green and Minchin, 2014]] ; [[#Ebi--2016|Ebi, 2016]] ; [[#Green--2017|Green et al., 2017]] ).

<div id="7.4.3.4" class="h3-container"></div>

<span id="perceptions-of-climate-change-risks-and-links-to-adaptation"></span>
==== 7.4.3.4 Perceptions of Climate Change Risks and Links to Adaptation ====

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''Adaptation decisions and responses to climate change can be influenced by perceptions of risks, which are shaped by individuals’ characteristics, knowledge and experience'' ( ''medium agreement, medium evidence'' ) ''.'' Institutional and governmental responses are critical for adapting to climate-related risks in health and other sectors, but individual responses also are relevant, such as choosing to implement adaptation measures. Individual responses are in turn affected not only by capabilities but also by perceptions that climate change is real and requires a response ( [[#Ogunbode--2019|Ogunbode et al., 2019]] ). Perceptions of climate risks are formed by experiences of changes in local weather and extreme weather events ( [[#Sattler--2018|Sattler et al., 2018]] ; [[#Sattler--2020|Sattler et al., 2020]] ; [[#van%20der%20Linden--2015|van der Linden, 2015]] ), observations of environmental changes ( [[#Hornsey--2016|Hornsey et al., 2016]] ), experiences of and knowledge about climate change impacts ( [[#Ngo--2020|Ngo et al., 2020]] ; [[#van%20der%20Linden--2015|van der Linden, 2015]] ) and individual characteristics such as values and worldviews ( [[#Poortinga--2019|Poortinga et al., 2019]] ) ( ''high agreement, medium evidence'' ). Risk perceptions include both logical assessments about the likelihood and severity of climate change impacts and affective feelings about those impacts. On average, affective measures of risk perception are more strongly associated with disaster preparation than cognitive measures ( [[#Bamberg--2017|Bamberg et al., 2017]] ; [[#van%20Valkengoed--2019|van Valkengoed and Steg, 2019]] ).

In addition to perceptions of risk, the likelihood that an individual will implement behavioural adaptations or support relevant public policy is affected by subjective assessments of the response options ( [[#Bamberg--2017|Bamberg et al., 2017]] ; [[#van%20Valkengoed--2019|van Valkengoed and Steg, 2019]] ; [[#Akompab--2013|Akompab et al., 2013]] ; [[#Carman--2020|Carman and Zint, 2020]] ; [[#Hornsey--2016|Hornsey et al., 2016]] ; [[#Brenkert-Smith--2015|Brenkert-Smith et al., 2015]] ).

''Efficacy beliefs, social norms and subjective resilience also affect adaptation behaviour'' ( ''medium confidence'' ) '', which has implications for communication about the need for climate adaptation.'' Efficacy beliefs represent the belief in one’s ability to carry out particular action(s) and the belief that the action(s) will have the desired outcome. Belief that one is personally able to complete a behaviour is moderately associated with engaging in disaster preparations ( [[#Navarro--2021|Navarro et al., 2021]] ; [[#van%20Valkengoed--2019|van Valkengoed and Steg, 2019]] ) and with adaptation intentions ( [[#Burnham--2017|Burnham and Ma, 2017]] ). ''Collective efficacy'' , the belief that a group of people working together can achieve a desired outcome, is important for participating in community adaptation behaviours ( [[#Bandura--1982|Bandura, 1982]] ; [[#Chen--2015|Chen, 2015]] ; [[#Thaker--2015|Thaker et al., 2015]] ). Related to this is ''response efficacy'' , a belief that a behaviour will achieve its desired outcome, which is also moderately associated with engaging in disaster preparations ( [[#van%20Valkengoed--2019|van Valkengoed and Steg, 2019]] ). Collective efficacy can potentially be developed by strengthening communication networks and social ties within a community ( [[#Haas--2021|Haas et al., 2021]] ; [[#Jugert--2016|Jugert et al., 2016]] ). Norms describing the adaptation strategies of others in a community, particularly those with high social status, can either facilitate or inhibit individual adaptation decisions ( [[#Neef--2018|Neef et al., 2018]] ; [[#Smith--2021|Smith et al., 2021]] ).

Distinct from efficacy beliefs, subjective resilience is a more general optimism or belief about one’s ability ( [[#Jones--2019|Jones, 2019]] ; [[#Khanian--2019|Khanian et al., 2019]] ). Subjective resilience ( [[#Clare--2017|Clare et al., 2017]] ) can influence preferred responses to climate change via assessment of one’s ability to engage in specific response options. Identities can influence assessment of subjective resilience. Place attachment, having a strong emotional connection to a particular location, is weakly associated with disaster preparation ( [[#Brügger--2015|Brügger et al., 2015]] ). In some cases, place attachment may inhibit adaptive responses, either by reducing perceptions of risk or by making people reluctant to leave an area that is threatened ( [[#De%20Dominicis--2015|De Dominicis et al., 2015]] ; [[#van%20Valkengoed--2019|van Valkengoed and Steg, 2019]] ). Place attachment can also contribute to enhanced community resilience ( [[#Khanian--2019|Khanian et al., 2019]] ; [[#Jones--2019|Jones, 2019]] ; [[#Wang--2021|Wang et al., 2021]] ).

<div id="7.4.4" class="h2-container"></div>

<span id="migration-and-adaptation-in-the-context-of-climate-change"></span>
=== 7.4.4 Migration and Adaptation in the Context of Climate Change ===

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<div id="7.4.4.1" class="h3-container"></div>

<span id="linkages-between-migration-adaptation-and-household-resilience"></span>
==== 7.4.4.1 Linkages between Migration, Adaptation and Household Resilience ====

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AR5 (Chapter 17) concluded that migration is often, though not in all situations, a potential form of adaptation initiated by households. ''Subsequent research indicates that the circumstances under which migration occurs and the degree of agency under which household migration decisions are made are important determinants of whether migration outcomes are successful in terms of advancing the well-being of the household and providing benefits to sending and receiving communities'' ( ''high confidence'' ) ''( [[#Adger--2015|Adger et al., 2015]] ; [[#Cattaneo--2019|Cattaneo et al., 2019]] ; Cross-Chapter Box MIGRATE in Chapter 7)'' . Evidence from refugee studies and general migration research indicates that higher agency migration, in which migrants have mobility options, allows migrants greater opportunities for integrating into labour markets at the destination, makes it easier to remit money home and generally creates conditions for potential benefits for migrant households and for sending and receiving communities ( [[#International%20Organization%20for%20Migration--2019|International Organization for Migration, 2019]] ). Bilateral agreements that facilitate labour migration have been identified as being especially urgently needed for Pacific small island states ( [[#Weber--2017|Weber, 2017]] ).

''Adaptive migration and the implied assumption that people can or should simply move out of harm’s way is not a substitute for investment in adaptive capacity-building'' ( ''high agreement'' ) ''( [[#Bettini--2016|Bettini and Gioli, 2016]] )'' . Climate-related migration, and especially involuntary displacement, often occurs only after ''in situ'' adaptation options have been exhausted and/or where government actions are inadequate ( [[#Adger--2015|Adger et al., 2015]] ; [[#Ocello--2015|Ocello et al., 2015]] ; Cross-Chapter Box MIGRATE in Chapter 7). The threshold at which household adaptation transitions from ''in situ'' measures to migration is highly context specific and reflects the degree of exposure to specific climate risks, mobility options and the socioeconomic circumstances of the household and local community ( [[#McLeman--2017|McLeman, 2017]] ; [[#Adams--2019|Adams and Kay, 2019]] ; Semenza and [[#Ebi--2019|Ebi, 2019]] ; Cross-Chapter Box MIGRATE in Chapter 7). A consistent theme in the research literature reviewed for all sections of this chapter is that proactive investments in health, social and physical infrastructure, including those not aimed specifically at climate risks, build societal adaptive capacity and household resilience. In turn, expanding the range of adaptation options available to households increases the likelihood that, when migration does occur, it does so under conditions of high agency that lead to greater chances of success. In communities where climate-related migration and/or relocation is occurring or may occur, policymaking and planning benefits from understanding the cultural, social and economic needs of exposed populations and helps in the identification of responses and policies that build resilience (Hino et al. 2017)

<div id="7.4.4.2" class="h3-container"></div>

<span id="climate-migration-and-linkages-to-labour-markets-and-social-networks"></span>
==== 7.4.4.2 Climate, Migration and Linkages to Labour Markets and Social Networks ====

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''Adaptive climate-related migration is often closely related to wage-seeking labour migration'' ( ''medium confidence'' ) ''.'' Due to the circumstances under which they move, climate-related migrants’ destinations, labour market choices and returns from migration may be more heavily constrained than those of other labour migrants ( [[#Jessoe--2018|Jessoe et al., 2018]] ; [[#Wrathall--2016|Wrathall and Suckall, 2016]] ).Within low- and middle-income countries, rural–urban migrant networks are important channels for remittances that may help build socioeconomic resilience to climate hazards in sending areas ( [[#Porst--2020|Porst and Sakdapolrak, 2020]] ), with higher levels of wage-seeking labour participation observed in climate-sensitive locales in south Asia ( [[#Maharjan--2020|Maharjan et al., 2020]] ). Local-level research in China and south Asia shows, however, that the potential for remittances to generate improvements in household level adaptive capacity is highly context specific, has significant gender dimensions and depends on such factors as the nature of the hazard, the distance migrated and the length of time over which remittances are received ( [[#Banerjee--2019a|Banerjee et al., 2019a]] ; [[#Banerjee--2019b|Banerjee et al., 2019b]] ). Social networks are a key asset in helping climate migrants overcome financial and structural impediments to their mobility, but these have their limits, particularly with respect to international migration (Semenza and [[#Ebi--2019|Ebi, 2019]] ). Since AR5, greater restrictions have emerged on movement between many low- and high-income countries (not including those necessitated by public health measures during the COVID-19 pandemic), a trend that, if it continues, would generate additional constraints on destination choices for future climate migrants ( [[#McLeman--2019|McLeman, 2019]] ). Transnational diasporic connections are a potential asset for building resilience in migrant-sending communities highly exposed to climatic risks, with migrants’ remittances potentially providing resources for long-term resilience building, recovery from extreme events and reducing income inequality ( [[#Bragg--2018|Bragg et al., 2018]] ; [[#Mosuela--2015|Mosuela et al., 2015]] ; [[#Obokata--2018|Obokata and Veronis, 2018]] ; [[#Shayegh--2017|Shayegh, 2017]] ; Semenza and [[#Ebi--2019|Ebi, 2019]] ). Safe and orderly labour migration is consequently a potentially beneficial component of wider cross-sectoral approaches to building adaptive capacity and supporting sustainable development in regions highly exposed to climate risks ( [[#McLeman--2019|McLeman, 2019]] ).

<div id="7.4.4.3" class="h3-container"></div>

<span id="attitudes-towards-climate-migration"></span>
==== 7.4.4.3 Attitudes Towards Climate Migration ====

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''The success of climate-related migration as an adaptive response is shaped by how migrants are perceived and how policy discussions are framed'' ( ''high agreement, medium evidence'' ) ''.'' The possibility that climate change may enlarge international migrant flows has in some policy discussions been interpreted as a potential threat to the security of destination countries ( [[#Sow--2016|Sow et al., 2016]] ; [[#Telford--2018|Telford, 2018]] ), but there is little empirical evidence in peer-reviewed literature assessed for this chapter of climate migrants posing significant threats to security at state or international levels. There is also an inconsistency between framing in some policy discussions of undocumented migration (climate-related and other forms) as being ‘illegal’ and the objectives of the Global Compact on Safe, Orderly and Regular Migration and the Global Compact on Refugees ( [[#McLeman--2019|McLeman, 2019]] ). Although climate-related migrants are not officially recognised as refugees under the 1951 Convention relating to the Status of Refugees, terms such as ‘climate refugees’ are common in popular media and some policy discussions ( [[#Høeg--2018|Høeg and Tulloch, 2018]] ; [[#Wiegel--2019|Wiegel et al., 2019]] ). The framing of migration policy discussions is relevant, for example, in discussing climate adaptation options for Pacific Island Countries, where there is considerable disagreement over policies that range from a ‘migration with dignity’ approach that would liberalise labour migration in the Pacific region to those that see migration as a last resort option to be avoided as much as possible ( [[#McNamara--2015|McNamara, 2015]] ; [[#Farbotko--2019|Farbotko and McMichael, 2019]] ; [[#Oakes--2019|Oakes, 2019]] ; [[#Remling--2020|Remling, 2020]] ). A more beneficial policy framing in terms of ensuring that future migration contributes to climate resilience and sustainable development has been established since AR5 within the framework of the Global Compact for Safe, Orderly and Regular Migration (see [[#7.4|Section 7.4.7.7]] ).

''Attitudes of residents in migrant-receiving areas with respect to climate-related migration warrant consideration when formulating adaptation policy'' ( ''medium confidence'' ) ''.'' Existing research is modest and difficult to generalise with respect to the impacts of climate-related migration and displacement on social dynamics and stability in receiving destinations, with outcomes being tied to the attitudes and social acceptance of receiving communities and efforts to integrate migrant arrivals into the community (Koubi and Nguyen, 2020). Research from Kenya and Vietnam shows that residents of receiving communities view environmental drivers as being legitimate reasons for people to move and consequently tend not to stigmatise such migrants ( [[#Spilker--2020|Spilker et al., 2020]] ). In these examples, urban residents viewed environmental motivations as being comparable to economic reasons for migrating and did not see climate-related migrants as posing any particular risks for receiving communities. However, case studies from India suggest that a lack of recognition by local authorities of climatic factors being legitimate drivers of rural–urban migration may lead to discrimination against migrants in terms of access to housing and other social protections, thereby undermining household resilience ( [[#Chu--2018|Chu and Michael, 2018]] ).

<div id="7.4.4.4" class="h3-container"></div>

<span id="planned-relocation-and-managed-retreats"></span>
==== 7.4.4.4 Planned Relocation and Managed Retreats ====

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''There is high agreement among existing studies that immobile populations often have high vulnerability and/or high long-term exposure to climate hazards, and that non-climatic political, economic and social factors within countries may strongly constrain mobility ( [[#Zickgraf--2019|Zickgraf, 2019]] ; [[#Ayeb-Karlsson--2020|Ayeb-Karlsson et al., 2020]] ; [[#Cundill--2021|Cundill et al., 2021]] ).'' Section 7.2.6.2 highlighted the particular vulnerability of immobile populations in the face of growing climatic risks. However, research suggests governments should be slow to label such populations as being ‘trapped’ or to actively promote relocations in the absence of local agreement that ''in situ'' adaptation options have been exhausted ( [[#Adams--2016|Adams, 2016]] ; [[#Farbotko--2019|Farbotko and McMichael, 2019]] ). In the case of indigenous settlements, efforts made to incorporate traditional knowledge in decision-making and planning increase the potential for longer-term success (Manrique, 2018). Considerable health implications can emerge within populations that are relocated as part of a planned retreat, and represent an important consideration for planners that requires greater research ( [[#Dannenberg--2019|Dannenberg et al., 2019]] ). Organised relocations are not inherently transformative in their outcomes but, depending on the circumstances under which they occur and on how issues of equity and respect for the rights of those affected are implemented, relocation could potentially represent a positive transformation ( [[#Siders--2021|Siders et al., 2021]] ).

''Disruptive and expensive relocations of low-lying coastal settlements in many regions would become increasingly necessary in coming decades under high levels of warming'' ( ''high confidence'' ) ''.'' Organised relocations require long-term innovation, planning and cooperation on the part of governments, institutions, affected populations and civil society ( [[#Hauer--2017|Hauer, 2017]] ; [[#Hino--2017|Hino et al., 2017]] ; [[#Haasnoot--2021|Haasnoot et al., 2021]] ; [[#Moss--2021|Moss et al., 2021]] ). Recent examples illustrate the substantial financial costs of organised relocations, ranging from USD 10,000 per person in examples from Fiji to USD 100,000 per person in coastal Louisiana, USA ( [[#Hino--2017|Hino et al., 2017]] ). Organised relocations are politically and emotionally charged, may not necessarily be seen as desirable by exposed populations and are most successful when approached proactive and strategically to avoid increasing the socioeconomic vulnerability of those who are relocated ( [[#Jamero--2017|Jamero et al., 2017]] ; [[#Wilmsen--2015|Wilmsen and Webber, 2015]] ; [[#Chapin--2016|Chapin et al., 2016]] ; [[#McNamara--2018|McNamara et al., 2018]] ; [[#Hauer--2019|Hauer et al., 2019]] ; [[#Bertana--2020|Bertana, 2020]] ). Key considerations for protecting the rights and well-being of people who might need to be resettled include proactive communication with and participation of the affected communities, availability of compensation, livelihood protection and ensuring there is permanence and security of tenure at the relocation destination ( [[#Tadgell--2018|Tadgell et al., 2018]] ). Availability of funds for resettlement, how to manage relocation from communally owned lands, how to value privately owned land to be abandoned and the potential for loss and damage claims are just some of the many potential complications ( [[#Marino--2018|Marino, 2018]] ; [[#McNamara--2018|McNamara et al., 2018]] ). As a proactive option, researchers in Bangladesh have suggested the creation of ‘migrant-friendly towns’ to provide options for autonomous relocation from hazardous areas (Khan and Huq, 2021).

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<span id="adaptation-solutions-for-reducing-conflict-risks"></span>
=== 7.4.5 Adaptation Solutions for Reducing Conflict Risks ===

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There has been increased activity within the international community to understand and address climate–conflict linkages since AR5, with high level actions including the UN Climate Security Mechanism, launched in 2018 and tasked with providing integrated climate risk assessments to the United Nations Security Council and other UN bodies in partnership with UN and external actors (DPPA et al., 2020). G7 governments initiated an integrated agenda for resilience ( [[#Rüttinger--2015|Rüttinger et al., 2015]] ) and the Berlin Call for Action in 2019 sought a foreign policy platform to address climate security concerns, focusing on risk-informed planning, enhanced capacity for action within the UN and improvements to operational response to climate security risks (Federal Foreign Office, 2019). The non-peer-reviewed literature that currently addresses these policy dimensions is often generated by a small number of consultancies funded by governments from the Global North and can lack diverse perspectives and priorities.

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==== 7.4.5.1 Environmental Cooperation and Peacebuilding ====

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''The environment can form the basis for active peacebuilding, and a sustainable natural environment is important for ongoing peace'' ( ''high agreement, medium evidence'' ) ''.'' EP is a framework increasingly utilised to understand the diverse ways in which the natural environment supports peace and can be utilised in peacebuilding; key tenets include preserving the natural environment such that degradation does not contribute to violence, protecting natural resources during conflict and using natural resources to support post-conflict economic recovery ( [[#Kron--2019|Kron, 2019]] ). EP frames natural resources as facilitating peace rather than driving conflict ( [[#Dresse--2019|Dresse et al., 2019]] ) with emerging literature analysing what this means in practice ( [[#Kovach--2016|Kovach and Conca, 2016]] ; [[#Krampe--2017|Krampe, 2017]] ; [[#Ide--2019|Ide, 2019]] ; [[#Ide--2021|Ide et al., 2021]] ; [[#Johnson--2021|Johnson, 2021]] ; [[#Kalilou--2021|Kalilou, 2021]] ). There is emergent evidence for the success of EP pathways. For example, a natural resource sharing agreement on the Kenya–Uganda border was able to reconcile spatial, logistical and conceptual barriers to addressing climate risks in development contexts ( [[#Abrahams--2020|Abrahams, 2020]] ). However, the long-term impacts of EP approaches on sustaining peace are yet to be monitored and evaluated ( [[#Ide--2020|Ide and Tubi, 2020]] ). EP may be successful depending on the context and the element of peace being built ( [[#Johnson--2021|Johnson, 2021]] ) or undermine processes when environmental arguments are co-opted for geopolitical purposes ( [[#Barquet--2015|Barquet, 2015]] ) or to depoliticise conflict ( [[#Ide--2020|Ide, 2020]] ).

''Formal institutional arrangements for natural resource management can contribute to transnational cooperation'' ( ''high confidence'' ) ''(see also Chapter 4)'' . Evidence from transboundary water sharing agreements provides evidence for cooperation rather than conflict over resources ( [[#Timmerman--2017|Timmerman et al., 2017]] ; [[#Timmerman--2020|Timmerman, 2020]] ; [[#Dinar--2015|Dinar et al., 2015]] ). Transboundary water agreements and river basin organisations help build robust institutions that facilitate trust and relationship building that have benefits in other domains ( ''strong agreement, medium evidence'' ) ( [[#Dombrowsky--2010|Dombrowsky, 2010]] ; [[#Krampe--2018|Krampe and Gignoux, 2018]] ; [[#Barquet--2014|Barquet et al., 2014]] ; Ide and Detges 2018). However, outcomes can be mixed, and the international and top down nature of these approaches may limit their transferability to intra-state conflicts at local levels ( [[#Rigi--2020|Rigi and Warner, 2020]] ; [[#Ide--2021|Ide et al., 2021]] ; [[#Krampe--2021|Krampe et al., 2021]] ).

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<span id="adaptation-in-fragile-settings"></span>
==== 7.4.5.2 Adaptation in Fragile Settings ====

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''Climate-resilient peacebuilding has the potential to limit the impact of future climate change on peace efforts'' ( ''medium confidence'' ) ''.'' Practical guidance has been developed, driven by policy concerns on climate–conflict links. The United Nations Environment Programme (UNEP), the European Union and Adelphi have developed a toolkit for addressing climate fragility risks in peacebuilding, adaptation and livelihoods support (UNEP et al., 2019). [[#Crawford--2015|Crawford et al. (2015)]] provide recommendations for climate-resilient peacebuilding consistent with the UN Secretary General’s five peacebuilding principles, including integrating ex-combatants through the construction of climate-resilient infrastructure, using climate impacts as a platform to engage previously conflicting groups, developing national DRR and management strategies, and climate-proofing economic development activities. The USAID, in a report prepared for the Adaptation Thought Leadership and Assessments (ATLAS) programme (Adelphi &amp; Chemonics International, 2020) that drew upon resilience and peacebuilding programmes in the Horn of Africa, recommend two critical conditions to ensure activities address compound climate fragility risks. Firstly, conducting local analyses of the links between climate, conflict and fragility to identify specific risks to target and, secondly, ensuring long-term commitment with a focus on participation and flexibility.

''Conflict-sensitive adaptation that focuses on institutional frameworks, conflict management and governance mechanisms has the potential to address complex interacting risks and emergencies over the long term'' ( ''medium agreement, limited evidence'' ) ''( [[#Scheffran--2012|Scheffran et al., 2012]] ; [[#Matthew--2018|Matthew, 2018]] ; [[#Okpara--2018|Okpara et al., 2018]] )'' . However, most adaptation activities are planned and implemented under development or climate finance funds without systematic integration of conflict sensitivity, and National Adaptation strategies rarely and only implicitly address conflict and potential changes to power relations ( [[#Tänzler--2019|Tänzler et al., 2019]] ). Practitioners and policy researchers have attempted to address this gap by developing guidance and delivering training (e.g., Tänzler et al. (2019); [[#Bob--2014|Bob and Bronkhorst (2014)]] ). However, there are real challenges relating to discounting indirect impacts on conflict and maladaptation ( [[#Asplund--2020|Asplund and Hjerpe, 2020]] ) and risks of unintended outcomes ( [[#Mirumachi--2020|Mirumachi et al., 2020]] ). [[#Crawford--2020|Crawford and Church (2020)]] highlight the synergies between adaptation planning under the UNFCCC’s National Adaptation Plan process and conflict reduction. Discussing development more broadly, [[#Abrahams--2020|Abrahams (2020)]] suggests three barriers to development that incorporate conflict–climate risks: geographically disconnected impacts and outcomes, the discourse of climate as a threat multiplier (rather than underlying peace) and teleconnected risks occurring at different scales. Effective approaches rely on understanding local power dynamics and social relations (Sovacool 2018; Roth et al. 2019; Sapiains et al. 2021) ( ''high agreement, medium evidence'' ).

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==== 7.4.5.3 Gender-Based Approaches to Peacebuilding ====

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''Gender-based approaches provide novel under-utilised pathways to achieving sustainable peace'' ( ''high confidence'' ) ''.'' Security council resolutions have encouraged the incorporation of gender analysis into peacebuilding and research has shown that taking into account the gendered nature of networks and dialogues opens new avenues for cooperation that are conflict sensitive ( [[#Dunn--2015|Dunn and Matthew, 2015]] ), creating potential for women’s rights and advocacy groups to be drivers of peace (Céspedes-Báez, 2018). For example, women are working to reduce climate vulnerability security risks in urban settings by entering local politics and joining community-based organised and civil society networks ( [[#Kellog--2020|Kellog, 2020]] ). The gendered nature of vulnerability and access to natural resources (Sections 4.6.4, 4.7.5.3, 5.4.2.3, 5.5.2.6, 5.8.2.2; Cross-Chapter Box GENDER in Chapter 18) will influence the efficacy of interventions to prevent conflict or to build durable peace ( [[#Pearse--2017|Pearse, 2017]] ; [[#Chandra--2017|Chandra et al., 2017]] ; [[#Fröhlich--2018|Fröhlich et al., 2018]] ). However, this understanding has not so far resulted in widespread employment of gender-led analyses ( [[#Fröhlich--2015|Fröhlich and Gioli, 2015]] ). This represents a key opportunity for expansion of the solution space for climate-related conflict. Analysis of peace processes more generally demonstrates the benefits of women’s participation in peace processes for devising strategies for building peace ( [[#Paffenholz--2018|Paffenholz, 2018]] ; [[#Cárdenas--2021|Cárdenas and Olivius, 2021]] ) and for the durability of that peace ( [[#Shair-Rosenfield--2017|Shair-Rosenfield and Wood, 2017]] ; [[#Krause--2018|Krause et al., 2018]] ).

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<span id="climate-resilient-development-pathways"></span>
=== 7.4.6 Climate Resilient Development Pathways ===

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Climate resilient development is a set of trajectories that strengthens sustainable development and efforts to eradicate poverty and reduce inequalities while promoting fair and equitable reductions of GHG emissions. Climate resilient development also serves to steer societies towards low-carbon, prosperous and ecologically safer futures (Chapter 1). ''All pathways to pursue climate resilient development will involve balancing complex synergies and trade-offs (very high confidence; Chapter 18).'' Pathways to climate resilient development can be pursued simultaneously with recovering from the COVID-19 pandemic (Cross-Chapter Box COVID in Chapter 7; Ebi et al., 2021).

Meeting commitments against the following seven existing global priorities would facilitate CRDPs and transformational futures for health, well-being, conflict and migration ( ''high agreement, medium evidence'' ):

# Fully implementing the WHO Operational Framework for building climate-resilient health systems ( [[#WHO--2015b|WHO, 2015b]] )
# Achieving Universal Health Coverage (UHC) under SDG 3 (good health and well-being)
# Achieving net zero GHG emissions from healthcare systems and services
# Achieving the SDGs more generally
# Adopting mitigation policies and technologies that have significant health co-benefits (see Cross-Chapter Box HEALTH)
# Meeting the objectives of the Global Compact for Safe, Orderly and Regular Migration
# Inclusive and integrative approaches to climate-resilient peace

These transformations map across all five of the system transitions identified in Chapter 18: energy systems; land, ocean, and ecosystems; urban and infrastructural systems; industrial systems; and societal systems.

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<span id="fully-implementing-the-world-health-organization-operational-framework"></span>
==== 7.4.7.1 Fully Implementing the World Health Organization Operational Framework ====

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The WHO Operational Framework for building climate-resilient health systems was designed to increase the capacity of health systems and public health programming to protect health in an unstable and changing climate ( [[#WHO--2015b|WHO, 2015b]] ). The guidance defines a climate-resilient health system as ''one that is capable to anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stress, so as to bring sustained improvements in population health despite an unstable climate'' . Full implementation of this framework has the potential to achieve transformational adaptation; the fundamental attributes of health systems would change to anticipate and effectively manage the population health and healthcare risks of climate change. This includes having the knowledge, capacity, tools and human and financial resources for health systems to extend beyond soft limits to adaptation.

The WHO framework outlines 10 key components (Figure 7.15) that, when achieved, will:

* Guide professionals working in health systems and in health determining sectors (e.g., water and sanitation, food and agriculture, energy, and urban planning) to understand and effectively prepare for the additional health risks posed by climate variability and change
* Identify the main health functions that need to be strengthened to build climate resilience, and to use these to develop comprehensive and practical plans (e.g., the health component of National Adaptation Plans (H-NAP))
* Support health decision makers to identify roles and responsibilities to implement this plan for actors within and outside the formal health sector

[[File:41456f250ec9aaf0cf80c4ba91cab066 IPCC_AR6_WGII_Figure_7_015.png]]

'''Figure 7.15 |''' '''Ten components of the WHO operational framework for building climate-resilient health systems with links to the building blocks of health systems.''' Source: [[#WHO--2015b|WHO (2015b)]] .

Achieving full implementation of the WHO Operational Framework requires determination and commitment—with associated funding—from the health community specifically and health-determining sectors more generally. Identifying priority areas is an immediate step required to commence this implementation process, which will vary across different contexts. Active engagement with Communities of Practice to share lessons and experiences would be a useful approach to support national and sub-national efforts; examples of this already exist (e.g., the Climate Change Community of Practice in Canada and the ‘weADAPT’ initiative under the auspices of the Stockholm Environment Institute).

Table 7.9 summarises selected characteristics of health systems as they might be under SSP1 (a world aiming to sustainable development), SSP2 (a world continuing current trends) and SSP3 (a world with high challenges to adaptation and mitigation), with systems under SSP1 being most consistent with climate resilient development. The table highlights the importance of investments that promote sustainable and resilient development to decrease vulnerability, no matter the magnitude and pattern of climate change. Adapting under SSP3 would be challenging even under pathways of limited additional climate change.

'''Table 7.9 |''' Characteristics of future health systems under three SSPs; modified from [[#Sellers--2017|Sellers and Ebi (2017)]] .

{| class="wikitable"
|-
!
! SSP3

! SSP2

! SSP1

|-
| Basic characteristics

| Reactive; failure to adapt; siloed information channels and national governance; limited partnerships

| Incomplete planning; new information incorporated as convenient; occasional partnerships

| Proactive; adaptively managed; frequent partnerships; inter-disciplinary

|-
| Leadership and governance

| Little focus at national and international levels on climate change and health; minimal planning conducted

| Planning for climate change and health, but not comprehensive and often side-tracked by other issues

| Strong climate change and health planning apparatus, including health components of national adaptation plans; regional/international partnerships

|-
| Health workforce

| Climate change and health not often incorporated into training; few provisions for new training programmes or funding for increase health worker positions in climate change-relevant specialties; health disparities not addressed

| Climate change and health not systematically incorporated into training; new training programmes insufficient to fill gaps in demand; limited attention to addressing health disparities

| Systematic inclusion of climate change and health in worker training; expansion of funding and training; financing and incentive mechanisms to address health disparities

|-
| Health information systems

| Assessments of vulnerability and adaptation rarely conducted, if ever; information not useful for planning; minimal risk monitoring or research

| Vulnerability and adaptation assessments occasionally conducted, but generally of poor quality; early warnings incomplete; fiscal and political constraints on research

| Vulnerability and adaptation assessments regularly conducted and used in planning; robust early warning networks; research agenda focused on vulnerable communities

|-
| Climate-resilient and sustainable technologies and infrastructure

| Facilities sited and constructed without climate consideration incorporated; medical supply chains not modified

| Capital cost serves as a key factor in siting and construction; increasing vulnerability of facilities to shocks

| Health infrastructure designed to be robust to storms/floods, with redundant systems added to ensure continuity of care

|-
| Service delivery

| Policies to manage environmental health hazards generally not followed; care practices not modified to accommodate climate information; few changes to emergency management procedures; health inequities worsen

| Environmental health policies are not robust; marginal improvements in care practices; risk assessments and communication inadequate; no shift in health inequities

| Policies to manage environmental health hazards regularly reviewed; practitioners review care practices and adjust as appropriate based on local climate and health conditions; robust communication tools developed; health service improvements reduce health inequities

|-
| Climate and health financing

| Few funds devoted to climate change and health activities, particularly in low- and middle-income countries; few if any financing partnerships between high-, low- and middle-income countries; very weak regional and international coordinating bodies due to funding constraints

| High-income countries generally form robust financing mechanisms; fiscal pressures in low- and middle-income countries constrain their financing abilities; financial partnerships formed across countries, but financing often not robust; regional and international coordinating bodies receive inadequate funds

| Robust funding streams for climate change and health; climate change and health activities receive continuing financial support; effective financing partnerships; regional and international coordinating bodies effectively funded

|}

Stress testing is an approach for evaluating the extent to which health systems are prepared for a future different from today ( [[#Ebi--2018a|Ebi et al., 2018a]] ). These desk-based exercises identify a desirable future outcome, such as successfully managing an extreme heatwave, flood or storm with characteristics outside the range of recent experiences. The exercises move beyond identifying ''likely'' challenges from hazardous exposures to specifying policies and measures that could be successful under a different climate and development pathway. The exercises consider socioeconomic and political factors that can influence the extent of health system vulnerability and other factors that can affect health system demands by impacting population health. Stress testing is designed to identify conditions under which it would be difficult for the health system to maintain its essential functions and to identify interventions that could maintain essential system functions despite climate-related shocks and stresses.

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<span id="achieving-universal-health-coverage-under-sdg-3-good-health-and-well-being"></span>
==== 7.4.6.2 Achieving Universal Health Coverage Under SDG 3 (good health and well-being) ====

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UHC is when all people have access to the health services they need, when and where they need them, without financial hardship ( [[#WHO--2021b|WHO, 2021b]] ). Achieving UHC is one of the targets in the SDGs. However, climate change is threatening to undermine the achievement of UHC through negative health outcomes and healthcare system disruptions ( [[#Salas--2019|Salas and Jha, 2019]] ; [[#Phillips--2020|Phillips et al., 2020]] ; [[#Kadandale--2020|Kadandale et al., 2020]] ; [[#Roa--2020|Roa et al., 2020]] ). Climate change adaptation and UHC progress are closely linked to one another, as both may improve health and achieve health equity ( [[#Salas--2019|Salas and Jha, 2019]] ). Supporting UHC is key to securing population health under a changing climate as well as addressing structural inequalities ( [[#Roos--2021|Roos et al., 2021]] ; [[#Aleksandrova--2020|Aleksandrova, 2020]] ; [[#Phillips--2020|Phillips et al., 2020]] ). Many regions of the world with the highest levels of vulnerability to the health impacts of climate change also have low levels of UHC; an integrated approach to UHC planning that incorporates climate change will have great benefits particularly in improving health equity ( [[#Salas--2019|Salas and Jha, 2019]] ).

The COVID-19 pandemic has shown some countries taking positive steps to achieving UHC. For example, Ireland nationalised healthcare for the duration of the pandemic and many countries, including Australia, have enhanced their telehealth services, which has enabled specific groups to access health services, particularly those in rural and remote settings, and has allowed continuous care to the community ( [[#Monaghesh--2020|Monaghesh and Hajizadeh, 2020]] ; Cross-Chapter Box COVID in Chapter 7).

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<span id="achieving-net-zero-ghg-emissions-from-healthcare-systems-and-services"></span>
==== 7.4.6.3 Achieving Net Zero GHG Emissions from Healthcare Systems and Services ====

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The healthcare system is a core component of UHC, supporting climate-resilient and environmentally sustainable healthcare facilities ( [[#Corvalan--2020|Corvalan et al., 2020]] ). Health systems are large carbon polluters and have the potential to look beyond traditional ‘green’ initiatives towards a more fundamental, longer-term redesign of current service models, with health practitioners participating actively in this process ( [[#Charlesworth--2018|Charlesworth and Jamieson, 2018]] ). In the largest and most comprehensive accounting of national healthcare service emissions, the UK’s National Health Service (NHS) quantified its health services’ emissions and identified that 62% came from the supply chain, 24% from the direct delivery of care, 10% from staff commute and patient and visitor travel, and 4% from private health and care services commissioned by the NHS ( [[#Tennison--2021|Tennison et al., 2021]] ).

The health sector has considerable opportunity to reduce its own carbon footprint and by doing so would contribute to mitigation efforts and help reduce health burdens associated with GHG emissions ( [[#Vidal--2014|Vidal et al., 2014]] ; [[#Duane--2019|Duane et al., 2019]] ; [[#Charlesworth--2019|Charlesworth and Jamieson, 2019]] ; [[#Charlesworth--2018|Charlesworth et al., 2018]] ; [[#Guetter--2018|Guetter et al., 2018]] ; [[#Bharara--2018|Bharara et al., 2018]] ; [[#Frumkin--2018|Frumkin, 2018]] ) ( ''high confidence'' ). The UK’s NHS has committed to becoming the world’s first net zero national healthcare system. Other examples of recent and ongoing initiatives include those undertaken by the Kaiser Permanente and the Gundersen Clinics in the USA, Health Care without Harm in the Asia Pacific region, and the Green Hospital Initiative in New Delhi ( [[#Frumkin--2018|Frumkin, 2018]] ; [[#Bharara--2018|Bharara et al., 2018]] ).

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==== 7.4.6.4 Achieving the SDGs Would Increase Resilience in Health-Determining Sectors and Contribute to Reducing the Risks of Involuntary Displacement and Conflict ====

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The SDGs are globally agreed objectives that integrate the economic, environmental and social aspects of sustainable development to end poverty, protect nature and ensure that all people enjoy peace and prosperity. The SDGs were developed under the principle that the goals are integrated and indivisible, such that progress in one goal depends on progress in others ( [[#WHO--2016b|WHO, 2016b]] ). Promoting health and well-being is not the sole responsibility of the health sector; it is also partially determined by strategies, policies and options such as poverty reduction, promoting gender equality, ensuring all people enjoy peace and prosperity, eliminating nutritional insecurity and ensuring availability and sustainable management of water and sanitation ( [[#Morton--2019|Morton et al., 2019]] ; [[#Bennett--2020|Bennett et al., 2020]] ). Unique themes in the SDGs for health policy and systems research include social protection, access to health services, stronger and more effective multi-sectoral collaborations beyond the health sector to address the upstream drivers of health and well-being, and participatory and accountable institutions to strengthen civic engagement and local accountability within health systems ( [[#Bennett--2020|Bennett et al., 2020]] ).

For example, clean water, sanitation and hygiene are essential to human health and well-being. Unsafe water and sanitation and a lack of hygiene caused an estimated 870,000 associated deaths in 2016 ( [[#WHO--2021c|WHO, 2021c]] ). Only 71% of the global population has access to safely managed drinking water services; only 45% of the global population has access to safely managed sanitation services; and 60% has basic handwashing facilities in their home. About 25% of healthcare facilities lack basic water services, exposing workers and patients to higher infection risks. More than 80% of countries reported in 2018 that they lacked sufficient funding to meet national WASH targets. As detailed in [[#7.2.2.2|Section 7.2.2.2]] , Box 7.3, [[#7.3.1.4|Section 7.3.1.4]] and [[#7.4.2.3|Section 7.4.2.3]] , the burden of climate-sensitive WBDs would be reduced if WASH targets were met.

WHO developed a Global Action Plan for Healthy Lives and Well-Being for All that brings together multi-lateral health, development and humanitarian agencies to support countries in accelerating progress towards the health-related SDGs ( [[#WHO--2021c|WHO, 2021c]] ). Themes include sustainable financing to reduce unmet needs for services, community and civil society engagement to generate knowledge to inform policymaking and health responses, addressing the socioenvironmental determinants of health, ensuring health and humanitarian services are available in fragile and vulnerable settings, research and development, and greater implementation of digital health delivery. In 2020, enhanced collaboration through the Global Action Plan provided support for an equitable recovery from the COVID-19 pandemic in, for example, Lao People’s Democratic Republic, Pakistan, Tajikistan, Somalia, South Sudan, Malawi, Nepal and Columbia, highlighting the potential for multi-sectoral integration of economic, environmental and social aspects of sustainable development to maintain essential health services and core public health functions during shocks and stresses ( [[#WHO--2021a|WHO, 2021a]] ).

Meeting the SDGs also contributes towards reducing involuntary displacement and conflict, as assessed in Sections 7.4.6.6 and 7.4.6.7.

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<span id="adopting-mitigation-policies-and-technologies-that-have-significant-health-co-benefits"></span>
==== 7.4.6.5 Adopting Mitigation Policies and Technologies that Have Significant Health Co-benefits ====

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Substantial co-benefits from climate action can result from investing in health systems, infrastructure, water and sanitation, clean energy, affordable healthy diets, low-carbon housing, public transport, improved air quality, and social protection. These benefits are in addition to the avoided health impacts associated with climate change (see Cross-Chapter Box HEALTH in Chapter 7).

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==== 7.4.6.6 International Policy Frameworks for Migration that Contribute to Climate Resilient Development ====

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Climate-related migration, displacement and immobility in coming decades will coincide with global and regional demographic changes that will produce a widening distinction between high-income countries that have aging, slow-growing (or in some countries, shrinking) population numbers and low-income countries that have rapidly growing, youthful populations. Given this dynamic, coordinated national and international strategies that integrate migration and displacement considerations with wider adaptation and sustainable development policies may contribute to climate resilient development. Since AR5, the international community has established a number of agreements and initiatives that, with continued pursuit and implementation, would create potential for climate-related migration to be a positive contribution towards adaptive capacity-building and sustainable development more broadly ( [[#Warner--2018|Warner, 2018]] ).

The 2018 Global Compact for Safe, Orderly and Regular Migration provides an important opportunity for planning for and responding to future climate-related migration and displacement ( [[#Kälin--2018|Kälin, 2018]] ). Among its 23 objectives, the Compact explicitly encourages the international community to implement migration policies that facilitate voluntary migration and actively prepare for involuntary displacements due to climate change, especially in low- and middle-income countries. The Compact’s objectives include reducing barriers to legal and safe migration, and facilitating the freer flow of remittances between sending and receiving communities. By doing so the Compact aims to increase the potential for migration to make positive contributions to sustainable development and to adaptive capacity-building. It also contains specific provisions pertaining to climate- and disaster-related migration and displacement. Objective 2 of the Compact aims at reducing drivers of involuntary or low-agency migration and recommends that states establish systems for sharing information on environmental migration, develop climate adaptation and resilience strategies harmonised at sub-regional and regional levels, and cooperate on disaster risk prevention and response. Other objectives in the Compact relevant to climate-related migration include Objective 5 (increasing pathways for regular migration) and Objective 19 (facilitating migrants’ ability to contribute to sustainable development). Objective 18, which links migration with skills development, is consistent with the ‘migration with dignity’ approach to displacement risks ( [[#McNamara--2015|McNamara, 2015]] ; [[#Kupferberg--2021|Kupferberg, 2021]] ). The 2018 Global Compact on Refugees observes that climate hazards increasingly interact with the drivers of refugee movements. The guidelines this Compact provides to governments regarding actions for addressing the causes of refugee movements and considerations for assisting and supporting refugees are useful for governments seeking guidance for all forms of displacement more generally, including displacement linked to climate change.

Pursuant to the Paris Agreement, a task force was struck by the Warsaw International Mechanism to make recommendations to the Conference of the Parties to the UNFCCC on how to reduce the risks of climate-related displacement. Its 2018 report recommended that parties work towards development of national legislation, cooperate on research, strengthen preparedness, integrate mobility into wider adaptation plans, work towards safe and orderly migration, and provide assistance to people internally displaced for climate-related reasons. Such recommendations dovetail strongly with the objectives of the Compacts on Migration and Refugees as well as the Sendai Framework for DRR and the 2030 SDGs. The SDGs, which include multiple goals and targets in which migration plays an explicit role in fostering development ( [[#Nurse--2019|Nurse, 2019]] ), may be seen as completing the international policy arrangements necessary for addressing future climate-related migration and displacement.

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==== 7.4.6.7 Inclusive and Integrative Approaches to Climate-Resilient Peace ====

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CRDPs to reduce conflict risk rely on a shift in perspective from framings around resource scarcity and security to sustainable natural resource governance and peace (Brauch et al., 2016; Barnett, 2018; Dresse et al., 2018; [[#Day--2020|Day and Caus, 2020]] ). Recognising that conflict results from underlying vulnerabilities, development that reduces vulnerability offers the best win-win option for building sustainable, climate-resilient peace rather than specific security-focused interventions ''(high confidenc'' ''e'' ). To this end, meeting the SDGs represents an unambiguous path to reducing conflict risk in a climate-changed world ( [[#Singh--2021|Singh and Chudasama, 2021]] ). There is growing acceptance in the development community, despite reservations about the securitisation of climate, that instability and conflict exacerbated by climate change has the potential to undermine development gains ( [[#Casado-Asensio--2020|Casado-Asensio et al., 2020]] ; [[#Day--2020|Day and Caus, 2020]] ).

Core to achieving climate-resilient peace are new ways of working that involve cross-issue and cross-sectoral collaboration and integration as a default to policy and programming. The Security Council Resolution 1325 Women and peace and security (S/RES/1325 (2000)) and the Sustaining Peace Agenda (A/RES/70/262 (2016)) are notable examples of this. The 2020 UNEP report on gender and security recommends integrated policy frameworks, better financing to strengthen women’s roles in peacebuilding, integrated programme design, and further research on gender, climate and security linkages. Inclusive approaches recognise that much of the vulnerability that drives conflict risk is generated by existing inequality and marginalisation of large proportions of the population—for example women and youth—and that peace cannot be achieved without their needs being taken into account and without their participation in peace processes ( [[#Mosello--2021|Mosello et al., 2021]] ). Diverse and inclusive partnerships also require ways to better engage local-level participation, and improve understanding of how to build consensus through human rights-based approaches that recognize non-violent conflict and protest to be potentially positive and constructive elements of transformational approaches to building resilience ( [[#Nursey-Bray--2017|Nursey-Bray, 2017]] ; [[#Ensor--2018|Ensor et al., 2018]] ; [[#Schipper--2021|Schipper et al., 2021]] ). Addressing the lack of participation of researchers and experts from countries most at risk of conflict in many climate-related conflict and peacebuilding assessments and initiatives could also support this objective. There is an increasing focus on the role of environmental defenders in highlighting violations and gaps in state obligations through non-violent protest ( [[#Butt--2019|Butt et al., 2019]] ; [[#Scheidel--2020|Scheidel et al., 2020]] ).

CRDPs for sustainable peace also require different ways of gathering intelligence and informing conflict risk. Dynamics that affect such risks exist across scales from the local to the regional, and require response in a transboundary manner. There is increasing emphasis on engaging local stakeholders and diverse partnerships to inform context appropriate measures and better policy coordination ( [[#Bremberg--2019|Bremberg et al., 2019]] ; [[#Tshimanga--2021|Tshimanga et al., 2021]] ; [[#Abrahams--2020|Abrahams, 2020]] ). The UN’s Climate Security Mechanism, working across three UN departments, takes an integrated approach to analyse and support timely and appropriate responses to conflict risk, focusing on risk assessments and early warning systems to aid conflict prevention, climate-informed peace and security activities and conflict-sensitive development, and to promote inter-sectoral cooperation, partnership and information sharing (DPPA et al., 2020). There is already acknowledgement that adaptation needs to be effectively monitored so that maladaptation can be avoided ( [[#Eriksen--2021|Eriksen et al., 2021]] ). Here, academic research, which until now has predominantly focused on understanding the causal relationship between conflict and climate, could contribute to advancing the monitoring and evaluation of climate-resilient peacebuilding initiatives ( [[#Mach--2020|Mach et al., 2020]] ; [[#Gilmore--2018|Gilmore et al., 2018]] ).

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'''Cross-Chapter Box HEALTH | Co-benefits of Climate Actions for Human Health, Well-Being and Equity'''
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Authors: Cristina Tirado (USA/Spain, Chapter 7); Robbert Biesbroek (Netherlands, Chapter 13); Mark Pelling (United Kingdom, Chapter 6); Jeremy Hess (USA, Chapter 7); Felix Creutzig (Germany, WGIII); Rachel Bezner Kerr (Canada/USA, Chapter 5); Siri Eriksen (Norway, Chapter 18); Diarmid Campbell-Lendrum (United Kingdom, Chapter 7); Elisabeth Gilmore (USA/Canada, Chapter 14); Maria Figueroa (Denmark/Venezuela, WGIII); Nathalie Hilmi (Monaco, Chapter 18); Peter Newman (Australia, WGIII); Sebastian Mirasgedis (Greece, WGIII); Sharma Rohit (India); Yamina Saheb (France/Algeria, WGIII); Gerardo Sanchez Martinez (Spain); Peter Smith (United Kingdom, WGIII); Adrian Leip (Italy, WGIII); Dhar Subash (Denmark/India, WGIII); Chris Trisos (South Africa, Chapter 9); Mercedes Bustamante (Brazil, WGIII); Luisa Cabeza (Spain, WGIII); Diana Urge-Vorsatz (Hungary, WGIII)

''Achieving the Paris Agreement and SDGs can result in low-carbon, healthy, resilient and equitable societies with high well-being for all (very high confidence) ( [[#Alfredsson--2018|Alfredsson et al., 2018]] ; [[#O’Neill--2018|O’Neill et al., 2018]] )'' . Given the overlap in sources of greenhouse gases (GHGs) and co-pollutants in energy systems, strategies that pursue GHG emission reductions and improvements in energy efficiency hold significant potential health co-benefits through air pollution emission reductions ( ''high confidence'' ) ( [[#Gao--2018|Gao et al., 2018]] ). Air quality improvements alone can substantially offset, or most likely exceed, mitigation costs at the societal level ( [[#Schucht--2015|Schucht et al., 2015]] ; [[#Chang--2017|Chang et al., 2017]] ; [[#Markandya--2018|Markandya et al., 2018]] ; [[#Vandyck--2018|Vandyck et al., 2018]] ; [[#Peng--2017|Peng et al., 2017]] ; [[#Woodward--2019|Woodward et al., 2019]] ; [[#Sampedro--2020|Sampedro et al., 2020]] ; [[#Xie--2018|Xie et al., 2018]] ). Pursuit of a mitigation pathway compatible with warming of +1.5°C with associated cleaner air, avoided extreme events and improved food security and nutrition could result in 152 ± 43 million fewer premature deaths worldwide between 2020 and 2100 compared with a business-as-usual scenario ( [[#Shindell--2018|Shindell et al., 2018]] ). Reaching the Paris Agreement could result in an annual reduction of 1.18 million air pollution-related deaths, 5.86 million diet-related deaths and 1.15 million deaths due to physical inactivity across nine major economies by 2040 ( [[#Hamilton--2021|Hamilton et al., 2021]] ). In Europe, a mitigation scenario compatible with RCP2.6 could reduce total pollution costs, mostly from PM2.5, by 84%, with human health benefits equal to more than Euro 1 trillion over five years ( [[#Scasny--2015|Scasny et al., 2015]] ). In the EU, ambitious climate mitigation policies could reduce years of lost life due to fine particulate matter (PM) from over 4.6 million in 2005 to 1 million in 2050, reduce ozone-related premature deaths from 48,000 to 7,000 and generate health benefits of Euro 62 billion yr –1 in 2050 ( [[#Schucht--2015|Schucht et al., 2015]] ).

However, there may be significant trade-offs between mitigation and other societal goals ( [[#Dong--2019|Dong et al., 2019]] ; [[#Gao--2018|Gao et al., 2018]] ). In some scenarios, mitigation policies consistent with the NDCs may slow poverty reduction efforts ( [[#Campagnolo--2019|Campagnolo and Davide, 2019]] ) with implications for health. A framework of ‘co-impacts’ that assumes neither a general beneficial nature of all implications from mitigation policy nor a hierarchy between climate and other types of benefits, may be more appropriate ( [[#Ürge-Vorsatz--2014|Ürge-Vorsatz et al., 2014]] ; [[#Cohen--2017|Cohen et al., 2017]] ).

''Transitioning to affordable clean energy sources for all presents opportunities for substantial well-being, health, and equity co-benefits (high confidence) ( [[#Gibon--2017|Gibon et al., 2017]] ; [[#Lacey--2017|Lacey et al., 2017]] ; [[#Peng--2018|Peng et al., 2018]] ; [[#Vandyck--2018|Vandyck et al., 2018]] ; [[#Williams--2018|Williams et al., 2018]] )'' . Residential solid fuel use affects health and degrades indoor air quality for up to 3.1 billion people in low- and middle-income countries ( [[#WHO--2016b|WHO, 2016b]] ; [[#Wang--2017a|]] [[#Wang--2017|Wang et al., 2017]] a ). Adherence to planned emission reductions from the Paris Agreement related to renewables could subsequently improve air quality and prevent 71,000–99,000 premature deaths annually by 2030 ( [[#Vandyck--2018|Vandyck et al., 2018]] ). This effect increases with a 2°C pathway, with 0.7–1.5 million premature deaths avoided annually by 2050 ( [[#Vandyck--2018|Vandyck et al., 2018]] ). Co-benefits are also observed at national and regional levels. For instance, China could expect 55,000–69,000 averted deaths in 2030 if it transitioned to a half-decarbonised power supply for its residential and vehicle sectors ( [[#Peng--2018|Peng et al., 2018]] ).

''Investing in universal basic infrastructure, including sanitation, clean drinking water, drainage, electricity, and land-rights, can transform development opportunities, increase adaptive capacity, and reduce vulnerability to climate-related risks (high agreement, high evidence)'' .Transformative approaches that reduce climate-related risks and deliver enhanced social inclusion and development opportunities for the urban poor are most likely where local governments act in partnership with local communities and other civil society actors ( ''high confidence'' ) (Chapter 6, sections 6.1, 6.3, 6.4).

''Rapid urbanisation offers a time-limited opportunity to work at scale towards transformational adaptation and climate resilient development ('' ''medium evidence, high agreement).'' Multi-level leadership, institutional capacity and financial resources to support inclusive adaptation in the context of multiple pressures and inter-connected risks can help ensure that the additional 2.5 billion people projected to live in urban areas by 2050 are less exposed to climate-related hazards and contribute less to global warming ( ''high confidence'' ) (Chapter 6, sections 6.1, 6.3, 6.4). Integrating low-carbon, inclusive adaptation into infrastructure investment driven by rapid urban population growth and COVID-19 recovery can accelerate co-benefits (Chapter 6).

''Urban planning that combines clean, affordable public transportation, shared clean vehicles and accessible active transportation modes can improve air quality and contribute to healthy, equitable societies and higher well-being for all.'' Stimulating active mobility (walking and bicycling) can bring physical and mental health benefits ( ''high confidence'' ) (Chapter 6; [[#Rojas-Rueda--2016|Rojas-Rueda et al., 2016]] ; [[#Avila-Palencia--2018|Avila-Palencia et al., 2018]] ; [[#Gascon--2019|Gascon et al., 2019]] ; [[#Hamilton--2021|Hamilton et al., 2021]] ). The health gains from active mobility outweigh traffic-related injuries due to a decreased incidence of chronic diseases ( [[#Ahmad--2017|Ahmad et al., 2017]] ; [[#Maizlish--2017|Maizlish et al., 2017]] ; [[#Tainio--2017|Tainio et al., 2017]] ; [[#Woodcock--2018|Woodcock et al., 2018]] ).

''Urban green and blue spaces contribute to climate change adaptation and mitigation and improve physical and mental health and well-being (high confidence) (Hansen 2017; EC, 2018; WHO, 2018a; Rojas-Rueda et al. 2019;'' 13.7.3, WGII; 6. WGII; 8.4 WGIII). Urban green infrastructure including urban gardens, can bring benefits to social cohesion, mental health and well-being and reduce the health impacts of heatwaves by decreasing temperatures, thus reducing inequities in exposure to heat stress for low income, marginalised groups ( [[#Hoffman--2020|Hoffman et al., 2020]] ; [[#Hoffmann--2020|Hoffmann et al., 2020]] ; [[IPCC:Wg2:Chapter:Chapter-5|Chapter 5]] section 5.12.5; Chapter 6; [https://www.ipcc.ch/report/ar6/wg2/chapter/chapter-7 Chapter 7] section 7.4; [[IPCC:Wg2:Chapter:Chapter-13|Chapter 13]] section 13.7). The trade-offs of increasing urban green and blue spaces include potential public health risks related to increased vectors or hosts for infectious diseases, toxic algal blooms, drowning and aeroallergens ( [[#Choi--2021|Choi et al., 2021]] ; [[#Stewart-Sinclair--2020|Stewart-Sinclair et al., 2020]] ; Chapter 6).

''Climate adaptation and mitigation policies in the building sector offer multiple well-being and health co-benefits (high confidence)'' ( [[#Diaz-Mendez--2018|Diaz-Mendez et al., 2018]] ; [[#Macnaughton--2018|Macnaughton et al., 2018]] ; Chpater 3 section 3.6.2). Leadership in Energy and Environmental Design (LEED) certified buildings in the USA, Brazil, China, India, Germany and Turkey saved an estimated USD 7.5 billion in energy costs and averted 33 Mt of CO 2 from 2000–2016 ( [[#Macnaughton--2018|Macnaughton et al., 2018]] ). These measures can increase health benefits through better indoor air quality, reduction of the heat island effect, improved social well-being through energy poverty alleviation, creation of new jobs, increased productive time and income, increased thermal comfort and lighting indoors and reduced noise impact ( [[#Smith--2016|Smith et al., 2016]] ; [[#McCollum--2018|McCollum et al., 2018]] ; [[#Thema--2017|Thema et al., 2017]] ; [[#Mirasgedis--2014|Mirasgedis et al., 2014]] ; [[#Alawneh--2019|Alawneh et al., 2019]] ; [[#Diaz-Mendez--2018|Diaz-Mendez et al., 2018]] ). The value of these multiple co-benefits associated with climate actions in buildings is equal to or greater than the costs of energy savings ( [[#Ürge-Vorsatz--2016|Ürge-Vorsatz et al., 2016]] ; [[#Payne--2015|Payne et al., 2015]] ; [[IPCC:Wg2:Chapter:Chapter-14|Chapter 14]] section 14.4.5).

''Shifting to sustainable food systems that provide affordable, diverse and plant-rich diets with moderate quantities of GHG-intensive animal protein can bring health co-benefits and substantially reduce GHG emissions, especially in high income countries and where ill health related to overconsumption of animal-based products is prevalent (very high confidence) ( [[IPCC:Wg2:Chapter:Chapter-5|Chapter 5]] section 5.12.6; [https://www.ipcc.ch/report/ar6/wg2/chapter/chapter-7 Chapter 7] section 7.4, [[IPCC:Wg2:Chapter:Chapter-13|Chapter 13]] section 13.5; [[#Springmann--2018c|Springmann et al., 2018c]] ; [[#IPCC--2019b|IPCC, 2019b]] ; [[#Clark--2017|Clark and Tilman, 2017]] ; [[#Poore--2018|Poore and Nemecek, 2018]] ; [[#Hayek--2021|Hayek et al., 2021]] )'' . Transforming the food system by limiting the demand for GHG-intensive animal foods, reducing food over-consumption and transitioning to nutritious, plant-rich diets can have significant co-benefits to health ( ''high confidence'' ) ( [[#Hedenus--2014|Hedenus et al., 2014]] ; [[#Ripple--2014|Ripple et al., 2014]] ; [[#Tirado--2017|Tirado, 2017]] ; [[#Springmann--2018c|Springmann et al., 2018c]] ; IPCC, 2018; [[#IPCC--2019a|IPCC, 2019a]] ; [[#IPCC--2019b|IPCC, 2019b]] ; [[#Nelson--2016|Nelson et al., 2016]] ; [[#Willett--2019|Willett et al., 2019]] ; [[#Tilman--2014|Tilman and Clark, 2014]] ; [[#Green--2015|Green et al., 2015]] ; [[#Springmann--2016b|Springmann et al., 2016b]] ; [[#Springmann--2018b|Springmann et al., 2018b]] ; [[#Springmann--2018a|Springmann et al., 2018a]] ; [[#Springmann--2018c|Springmann et al., 2018c]] ; [[#Milner--2015|Milner et al., 2015]] ; [[#Milner--2017|Milner et al., 2017]] ; [[#Farchi--2017|Farchi et al., 2017]] ; [[#Song--2017|Song et al., 2017]] ; [[#Willett--2019|Willett et al., 2019]] ). Reduction of red meat consumption reduces the risk of cardiovascular disease (CVD) and colorectal cancer; the consumption of more fruits and vegetables can reduce the risk of CVD, type II diabetes, cancer and all causes of mortality ( [[#Tilman--2014|Tilman and Clark, 2014]] ; [[#Sabate--2014|Sabate and Soret, 2014]] ; [[#Willett--2019|Willett et al., 2019]] ; [https://www.ipcc.ch/report/ar6/wg2/chapter/chapter-7 Chapter 7] section 7.4; [[IPCC:Wg2:Chapter:Chapter-5|Chapter 5]] section 5.12.5). Globally, it is estimated that transitioning to more plant-based diets—in line with World Health Organization (WHO) recommendations on healthy eating—could reduce global mortality by 6 ‒ 10% and food-related GHG emissions by 29 ‒ 70% by 2050 ( [[#Springmann--2016b|Springmann et al., 2016b]] ). There are limitations in accessibility of affordable of healthy and diverse diets for all ( [[#Springmann--2020|Springmann et al., 2020]] ) and trade-offs such as the potential increase of GHG emissions from producing healthy and diverse diets in low- and medium-income countries (Semba et al., 2020). Agroecological approaches have mitigation and adaptation potential and deliver ecosystem services, biodiversity, livelihoods and benefits to nutrition, health and equity ( [[#Rosenstock--2019|Rosenstock et al., 2019]] ; [[#Bezner%20Kerr--2021|Bezner Kerr et al., 2021]] ; [[IPCC:Wg2:Chapter:Chapter-5|Chapter 5]] sections 5.4.4, 5.14.1; [[IPCC:Wg2:Chapter:Chapter-13|Chapter 13]] section 13.5; [[IPCC:Wg2:Chapter:Chapter-14|Chapter 14]] section 14.4.4).

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