PERSPECTIVE

From advocacy to action: Projecting the health

impacts of climate change
Hannah Nissan1*, Declan Conway2
1 International Research Institute for Climate and Society, Columbia University, New York, New York, United
States of America, 2 Grantham Research Institute on Climate Change and the Environment, London School
of Economics and Political Science, London, United Kingdom

* [email protected]

Mitigating climate change by reducing greenhouse gas emissions has many health co-benefits
and is a top public health priority. Policies to limit emissions are associated with improvements
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across a wide range of public health outcomes, including, among other impacts, obesity, acute
a1111111111
a1111111111 respiratory infections among children, and ischaemic heart disease in adults [1]. However, rec-
a1111111111 ognition that climate change is already underway has led to an increasing focus on adaptation.
a1111111111 Studies projecting the impacts of future climate change on health date back to the late 1980s,
and their number has grown substantially in recent years. Climate change impact assessments
generally use the output of global climate models (GCMs). Here, we profile, and suggest
means for addressing, the challenges associated with the use of GCM projections for impact
studies to inform adaptation.
OPEN ACCESS
GCMs provide projections of the climate at a typical resolution of about 100 km2. Such low
Citation: Nissan H, Conway D (2018) From precision is of limited use to decision-makers trying to determine how climate change might
advocacy to action: Projecting the health impacts
affect their particular district, town, or even country. Often, a regional climate model is
of climate change. PLoS Med 15(7): e1002624.
https://doi.org/10.1371/journal.pmed.1002624
employed to ‘downscale’ the output of the global model to a resolution considered more useful
for practical applications. Climate model output can then be used to drive disease models or to
Published: July 31, 2018
investigate the risks of surpassing health-relevant climate thresholds in the future.
Copyright: © 2018 Nissan, Conway. This is an open The outputs of these analyses are often explicitly intended to inform the development of
access article distributed under the terms of the adaptation strategies and plans. However, there is little evidence that climate change projections
Creative Commons Attribution License, which
are used to inform practical adaptation decisions [2–4]. Climate change projections typically
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
target the future several decades ahead, or even at the end of the century. Yet the most pressing
author and source are credited. issues faced by people and institutions often necessitate a focus on the present and near-term
future, particularly in developing countries where there is less capacity to act [3]. Heat waves,
Funding: DC acknowledges support from the UK
Economic and Social Research Council (ES/
for example, are an increasing risk to human health in a warming climate, but many of the most
K006576/1) for the Centre for Climate Change effective strategies to reduce this risk concern the development of seasonal adaptation plans and
Economics and Policy (CCCEP). HN acknowledged early warning systems [5]. These programs allow a range of preparedness measures to reduce
funding support from the Earth Institute at vulnerability and exposure, from training and awareness-raising activities at the start of the
Columbia University and from the UK Fulbright summer season to emergency interventions that could include public alerts, opening cooling
Commission. The funders had no role in study
centres, and distributing drinking water. In India, for example, moving the neonatal ward from
design, data collection and analysis, decision to
publish, or preparation of the manuscript. the top to the bottom floor of a hospital had a significant protective effect and required no fore-
cast information at all [6]. Even when the long term is relevant, as, for example, in the case of
Competing interests: The authors have declared
large infrastructure developments, the uncertainties involved in climate prediction on local
that no competing interests exist.
scales are so large that they can exceed the magnitude of the projected change [7]. Moreover,
Abbreviations: GCM, global climate model. with many relevant non-climate factors, it is difficult to disentangle the role that climate change
Provenance: Commissioned; not externally peer- projections may have played in the development of an adaptation plan.
reviewed.

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002624 July 31, 2018 1/5

 What we can and cannot say about the future climate
Uncertainty in climate change prediction arises from multiple sources: (1) an imperfect ability
to measure and initialize simulations with the current state of the climate system, atmospheric
greenhouse gas, and aerosol concentrations (‘initial conditions’); (2) uncertainty about the
anticipated future trajectory of greenhouse gas and aerosol emissions; (3) climate model errors
leading to uncertainty about how the climate system will respond to this external forcing; and
(4) natural climate variability. To quantify the likelihood of different climate futures, multiple
model simulations are run, which attempt to sample the range of prediction uncertainty aris-
ing from these different sources. These simulations assume different emissions trajectories, use
a range of climate models, and are initialized using slightly perturbed initial conditions to see
how each of these factors contributes to the total uncertainty. The spread of projected out-
comes is taken as an indication of the uncertainty, and probabilities are assigned to outcomes
according to how frequently they occur within the ensemble. The problem is that it is impossi-
ble to sample the full range of uncertainty within such an ensemble of projections [8,9]. Differ-
ences in projections among models are examined closely, but the ensemble of available models
is ad hoc and cannot be expected to provide a reliable estimate of the range of futures that
might plausibly occur. Moreover, without past test cases over which to calibrate the ensemble
projections, it is impossible to know whether probabilistic climate change projections are reli-
able [8].
These limitations pertain to projections of future climate change at any scale. Obtaining
information at local scales and at specific points in the future gives rise to a number of addi-
tional issues, which are often overlooked in studies projecting future health impacts. Scientists
have high confidence in several aspects of large-scale climate change, including, for example,
global warming and large-scale temperature trends and sea level rise. However, the models
have many documented limitations, particularly regarding their ability to capture extremes,
which are often of most interest for impacts [10]. Projections among models can differ dramat-
ically, especially on scales smaller than continents and even for the direction of change in rain-
fall in many parts of the world [11]. Downscaled climate information may appear to be a
solution, as the output of this process delivers information that appears more realistic because
of its higher resolution. However, regional downscaling cannot rectify many of the problems
with global models and can give a false impression of confidence [12].
Of all the challenges associated with predicting climate change impacts, the natural variabil-
ity of the climate system is perhaps the most overlooked. Unlike weather or seasonal forecasts,
which are initialized with current weather and climate observations, climate change projec-
tions are uninitialized. The models are able to reproduce key modes of natural climate variabil-
ity on interannual and decadal timescales, but without initialization, the timing of these cycles
does not coincide with the real world. Initialised decadal predictions offer promise, but they
are currently experimental and do not perform well enough to inform decision-making
directly, particularly on local scales and for precipitation [13]. Interannual fluctuations are,
overwhelmingly, the largest contributor to total climate variability for both rainfall and tem-
perature. Decadal variability can be significant as well. For example, East Africa has experi-
enced a decline in rainfall since the late 1990s despite long-term projections suggesting that
the region is heading for wetter conditions by the end of the century [14]. The ‘global warming
hiatus’, when upward temperature trends stalled at the beginning this century, is another
example [15]. The science behind global warming is unequivocal, but the expectation that the
temperature will be hotter at the end of the century says nothing about the trajectory between
now and the long-term future. Failure to consider these fluctuations could have major conse-
quences for adaptation planning, particularly when looking at the next 10 to 30 years [16].

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 Presentations of future impacts require explicit communication of uncertainties, which
includes realistic levels of precision [17] and clear guidance on the relevance of the informa-
tion (or not) for planning and decision-making. The process of delineating their limitations
may, in itself, be enough to deter decision-makers from direct use. Climate model outputs can-
not be used to infer local conditions, and they perform especially poorly at the level of an indi-
vidual model grid. Nor can we use climate projections to infer anything about the future
climate over periods shorter than 30 years. Because projections do not capture the timing of
interannual and decadal variations, statistics should always be calculated over at least three
decades. Extracting model output over shorter windows of time could result in a substantial
over- or underestimation of the trend, particularly over the next 10 to 30 years. Alternatively,
the output from several models can be averaged to cancel out the different phases of variability
in each model. However, only the trend remains after this multi-model averaging is per-
formed; interannual to decadal variability is an additional source of uncertainty in the projec-
tions that should be factored into future scenarios, for example, by taking past variability as an
indicator of variability in the future [18,19]. Finally, we cannot set too much store by probabi-
listic projections because the ensemble of models used in the projections is not an accurate
representation of the full range of possible futures [9]. The complexities of these considerations
point to the importance of close collaboration between climate and health experts when con-
ducting research on future impacts. Failure to capture the full range of uncertainty in decisions
could lead to maladaptation [20].

Long-term impacts, short-term actions

If long-term climate prediction is so uncertain, where is the value in modelling the health
impacts of future climate change? Long-term projections are one of many lines of evidence
that help to shape climate and health policy by their gradual influence on the culture and prior-
ities of people and institutions. Research on the health impacts of future climate change thus
plays an important role in the climate change discourse, but its value is primarily in shaping
policy by providing material that can be used to advocate for both mitigation and adaptation
programming rather than triggering practical actions. Much of the published information on
climate change health impacts serves this advocacy agenda (e.g., WHO’s Climate and Health
Country Profile Project [21]). The language used to promote such materials, however, often
suggests that they are intended to guide practical adaptation decisions. The high precision of
the information that is generally provided gives the misleading impression of high confidence
in very specific outcomes.
Practical adaptation measures need to focus on what can be accomplished today with avail-
able and reliable climate information while keeping the long term in mind. For example,
warming in Ethiopia is raising the maximum elevation for malaria transmission in mountain-
ous areas, exposing new highland populations to malaria risk, but projected temperature
trends are uncertain [22]. A suitable adaptation response might use seasonal forecasts to advo-
cate for new surveillance and clinics in marginal transmission zones, with higher vigilance dur-
ing El Niño years when climate anomalies are more predictable [23] and highland warming is
often strongest [22]. Such windows of enhanced predictability can be used to push for malaria
eradication, a priority of the WHO Strategic Advisory Group on Malaria Eradication, by put-
ting additional resources into control programs like bednet distribution, indoor residual spray-
ing, and vector control at these times [24]. Approaches to decision-making under uncertainty
are attracting attention and provide some promise for planners to incorporate uncertain future
climate projections into planning decisions. Rather than a “predict then act” approach, they
assess risks to policies [25]. These methods require deep consultation with stakeholders,

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 considerable technical capacity, financial resources, and experience of facilitation. As yet, there
are few practical examples in high-income countries and even fewer in low-income countries
[26] although examples are now emerging, such as the implementation of a long-term water
resources master plan in Lima, Peru [27]. Whilst flexibility can sometimes be built into long-
term decisions—even in the case of sunk infrastructure projects [28]—more gradual adapta-
tion options are also available, such as decisions to invest in monitoring and surveillance,
reducing vulnerabilities, research, and capacity building [24,29,30].
The modelling of future health impacts has an important role to play in motivating these
types of adaptation decisions so that the systems and expertise needed to manage changing cli-
mate-related health risks are in place. Studies that project the health impacts of climate change
should avoid overselling the utility of this information for practical adaptation by clearly pre-
senting uncertainties and being realistic about the value of projections for shaping policy,
rather than triggering actions.

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