Adaptation and Health System Resilience

An online survey of the status of Canadian health authorities’ actions to prevent, respond to, and adapt to the impacts of climate change and the adaptive capacity and vulnerability of health systems in Canada was conducted in both official languages. The survey examined which climate risks health authorities addressed most frequently, populations considered to be at highest risk, and current adaptation activities. In total, 219 participants representing local to national health authorities across Canada were invited to complete the online survey. Online survey data collection took place from January 17 to March 13, 2019 (eight weeks). A total of 80 surveys were completed with the following breakdown: Atlantic provinces 7; Quebec 11; Ontario 34; Prairie provinces 13; British Columbia and the territories 15.

Given that the province of Quebec has developed the earliest and most extensive climate change and health program in Canada, this study examined the level of adaptation to climate change in the Quebec health sector to understand factors that can influence the integration of the climate change dimension, mainly adaptation, in these organizations. To determine the factors that may have influenced climate change adaptation in Quebec’s health sector, a literature review and interviews with representatives of the health community were conducted. The literature review, conducted in May 2019, identified the factors that facilitate or hinder the implementation of climate change adaptation actions by public institutions, and the results were used as the basis for the interview questions. This was an exploratory review of the literature, since the quality assessment and methodological rigour of the selected studies were not in sufficient depth to qualify as systematic. The EBSCOhost by Web of Science and Google Scholar search engines were used for the research.

Interviews were conducted between July 2019 and November 2019. Participants in the study represented regions across the province and a variety of health-sector functions related to climate change. In total, 49 people were interviewed, including 25 officials from 16 of Quebec’s 18 health regions. The majority of individuals work in environmental health, but others working in occupational health, infectious diseases, health promotion, monitoring, construction, and civil safety were also interviewed. Seven officials from the Institut national de santé publique du Québec (INSPQ) and seven from the Ministère de la Santé et des Services sociaux (MSSS) were also interviewed, as were two people from Ministère de l’Environnement et de la Lutte aux changements climatiques. A total of eight officials from Centres intégrés de santé et des services sociaux (CISSS) and Centres intégrés universitaires de santé et des services sociaux (CIUSSS) also participated in the study.

This study examined evidence of health co-benefits or risks from GHG mitigation technologies, with a focus on Canada. Background information on the current knowledge of health co-benefits or risks was obtained through a literature review. Articles identified were then reviewed by title and abstract, based on established inclusion criteria. Papers had to discuss known climate change mitigation technologies or policies; how they reduce or mitigate GHGs, short-lived climate pollutants, or air pollution; and at least one corresponding human health co-benefit and/or associated co-risk. Peer-reviewed journal articles, reports, and books were included. Review articles were excluded from the analysis but were used for background information for the literature review. The structured review of literature was done from July to October 2018 and was conducted using the electronic databases EMBASE, MEDLINE, and Global Health.

Measures to help people prepare for the impacts of climate change can significantly reduce health risks as the climate continues to change (Smith et al., 2014; Campbell-Lendrum et al., 2015; Ebi et al., 2018a; WHO, 2018c; Haines & Ebi, 2019). By and large, the risks to health presented by climate change are not new; public health authorities have years of experience and evidence-based learnings about measures to address the health effects of air and water pollution, contaminated food, vector-borne diseases, ozone depletion, and extreme weather events (e.g., extreme heat events, floods, droughts, wildfires, ice storms, hurricanes) (Frumkin et al., 2008; Séguin, 2008; WHO, 2013; Ebi & del Barrio, 2017).

Preparing for the health impacts of climate change requires a wide range of actors in society to adapt at multiple temporal and geographic scales that take into account complex drivers and feedback mechanisms of the human–environment system (Crump et al., 2019). Adaptation actors include individual Canadians (all Canadians, but particularly people at highest risk of impacts) (see Chapter 9: Climate Change and Health Equity and Chapter 2: Climate Change and Indigenous Peoples’ Health in Canada), health sector decision makers in and outside of government, health care and social services professionals (e.g., doctors, nurses, home care providers, social workers, pharmacists), officials in other health-related sectors (e.g., water systems), and researchers. Health sector adaptation includes health officials, in collaboration with those in other fields, taking action to understand, assess, prepare for, and help prevent the health impacts of climate change, particularly on the highest-risk populations. It includes designing, implementing, monitoring, and evaluating specific measures to reduce health risks (Ebi & Semenza, 2008) and includes broader efforts to increase the climate resilience of health systems. Programs, policies, and measures are most effective in the shorter and longer term if they concomitantly address inequities and boost general population health, which is the foundation of climate-resilient individuals and communities.

Adaptation planning by health authorities will often focus on efforts to reduce priority risks from specific climate hazards already affecting population health (e.g., development of heat alert and response systems [HARS]), surveillance of emerging or new vector-borne diseases, interventions to reduce health risks of wildfire smoke), or hazards that threaten health in the future. Health adaptation and resilience-building should move society beyond simple coping, which is reactive and concerned primarily with minimizing the immediate damage from a particular climate-related impact. Reactive coping responses often lead to greater vulnerability in the face of increasingly severe climate change threats. By contrast, health adaptation and resilience-building provide a way for health authorities to seize the opportunity climate change presents (Watts et al., 2018) to build more equitable and effective health systems. This may be accomplished, for example, by developing and implementing systems-level changes and by refining targeted actions, such as early warning systems, including HARS. Such actions build social capital and networks (e.g., buddy system to check on neighbours requiring assistance) and remove barriers to treatment and recovery during and after climate events for disadvantaged populations.

Health adaptation is most effective when it is anticipatory and proactive given that the climate continues to change in Canada at an increasing rate creating greater risks to health, some of which may surprise, disrupt, and challenge health authority activities. It is also evidence-informed and future-facing, to include measures that protect populations from more severe projected health risks, which may occur earlier than expected. Iterative processes for adaptation risk management (e.g., regular climate change and health vulnerability and adaptation assessments, evaluation of adaptation effectiveness, Indigenous partnerships, stakeholder engagement) help to ensure that adaptation actions address uncertainty of timing, severity, and geographical extent of future climate change impacts, including the potential for non-linear risks to health (Ebi et al., 2016a; Hess & Ebi, 2016; Ebi & del Barrio, 2017). Non-linear risks to health arise from much more severe climate impacts that are low probability but potentially high consequence events. The extreme heat event that affected northwestern United States and British Columbia in July 2021 and that is likely to have contributed to over 700 deaths in that province (Roffel, 2021) was estimated to be a 1 in 1000 year event (Philip et al., 2021).

Knowledge of how health authorities undertake adaptation has increased (Lesnikowski, 2011; Paterson et al., 2012; Ebi & del Barrio, 2017). Effective health adaptation plans and measures are grounded in the following considerations:

• The adaptation process is instigated and energized by increased awareness and knowledge of climate change risks to health in a jurisdiction (Lesnikowski, 2011; Eyzaguirre & Warren, 2014).
• National and international health authorities and research institutions identify climate change as a priority and provide adequate funding to enable understanding of complex drivers of health outcomes across environmental, social, and human systems (Ebi et al., 2016b).
• Groundwork activities (e.g., capacity building, monitoring and surveillance, research) often precede and support concrete adaptation actions (e.g., information-sharing, infrastructure development, technology and innovation, management and planning, policy development, resource transfers and funding support) (Lesnikowski, 2011; Shah et al., 2018).
• Health adaptation measures are informed by scientific and/or Indigenous knowledge² gained through a climate change and health vulnerability and adaptation assessment or other knowledge-development activities (Shin & Ha, 2012; WHO, 2013; Berry et al., 2018; Watts et al., 2018).
• Health adaptation activities are developed and implemented with knowledge and consideration of linkages to complementary GHG mitigation measures (ACT, 2018), as there are significant opportunities to increase health co-benefits of actions and to reduce possible health risks (Haines et al., 2009; Martinez et al., 2018; Haines & Ebi, 2019).
• Adaptations to protect health are mainstreamed into existing policies, plans, programs, and budgets and are iterative and subject to regular monitoring for effectiveness and enhancement opportunities through adaptive management (Ebi, 2011a; WHO, 2013; Wheeler & Watts, 2018). The climate and other important drivers of health outcomes (e.g., health systems, demographics) will continue to change, resulting in uncertain futures (Sellers & Ebi, 2017).
• Health adaptation actions are most effective when they are undertaken to advance health system resilience and root causes of vulnerability, and when they consider maximizing public health and health equity co-benefits. They are identified through community consultations with a range of partners that are either highly exposed to climate hazards and/or may lack capacity to adapt. These populations can include First Nations, Inuit, and Métis peoples, women, people living with disability, seniors, immigrants, low-income residents, minority language communities, outdoor workers, people exposed to environmental pollution, people with preexisting illnesses, people without access to insurance, public housing residents, refugees, lone-parent households, students, those experiencing homelessness, and young children (Gould & Rudolph, 2015; Deas et al., 2017; Dodd et al., 2018; NASEM, 2018).
• Adaptations to protect health are intentionally and specifically focused on climate change impacts (Dupuis & Biesbroek, 2013) and strive to reduce risks from current climate hazards as well as future more severe and frequent impacts, including the possibility of compounding and cascading events (Sellers & Ebi, 2017; Glasser, 2019).
• Health authorities take a broad health systems approach to adaptation, to identify and address vulnerabilities existing in any and all components of health systems to make them climate-resilient to withstand possible impacts on health facilities (WHO, 2015; Balbus et al., 2016; Ebi et al., 2018b).
• Collaboration among a multitude of sectors that support and maintain the determinants of health (e.g., social housing, water systems managers) is required to prepare successfully for climate change impacts on health.

Figure 10.1 presents a framework that highlights the stages health decision makers go through when adapting to climate change risks, informed and initiated by a vulnerability and adaptation assessment for climate change and health. Table 10.1 proposes indicators of climate-resilient health system adaptation for Canada based on this framework.

Health decision makers can find adapting to climate change challenging if they do not have the required technologies (e.g., new vaccines, communications, data sharing), information and skills (e.g., projections of health risks, training of health authorities), infrastructure (e.g., climate-resilient health facilities), resources, and institutional arrangements (e.g., a climate change and health focal point) (Frumkin, 2011). Barriers can also include a lack of authority and leadership for action, a narrow framing for public health interventions that omits action on root causes of vulnerability, legal obstacles, and failures in collective decision making (Ford & King, 2015; Gould & Rudolph, 2015). Some health systems in rural, remote, and/or Indigenous communities are already affected by existing vulnerabilities that increase risks from climate change impacts, for example, higher rates of all-cause mortality, less surge capacity during emergencies, reduced access to health facilities, and difficulty in retaining health professionals and accessing specialized health care (DesMeules & Pong, 2006; Vodden & Cunsolo, 2021) (see Chapter 2: Climate Change and Indigenous Peoples’ Health in Canada). Health systems and communities with fewer resources have greater difficulties responding to impacts and recovering in ways that protect the health of populations. In Canada, federal and provincial/territorial levels of government have a key role to play in supporting preparedness activities for local health authorities by building capacity through information-sharing, coordination, developing and disseminating scientific information, and financial contributions (Austin et al., 2019). Adaptation to the effects of climate change will be much greater and ability to protect health will be much more limited without strong measures to reduce GHGs (IPCC, 2014; Wheeler & Watts, 2018).

No population group or Canadian region should bear an unreasonable portion of the costs associated with the health and social impacts of climate change. Existing social inequities within a community (e.g., income, water insecurity, food insecurity, chronic health disparities) and/or higher rates of disease burdens can reduce the adaptive capacity of specific subpopulations (UNEP, 2018; Friel, 2019). Populations and communities that lack the capacity to plan for, respond to, and recover from climate change impacts will remain disproportionately affected by climate hazards (Berry et al., 2014a; Crump et al., 2019). In Canada, this may include rural and remote communities, Indigenous Peoples and communities, racialized populations, low-income populations, people with mobility challenges, people who are socially isolated, immigrants, renters, outdoor workers, minority language communities, seniors, and people with chronic diseases. In some cases, individuals may be subject to multiple, possibly intersecting, vulnerability factors. For instance, rural and remote residents, in addition to being more geographically exposed to some climatic hazards (e.g., wildfires), are more likely to be elderly, to work outdoors, to have lower average incomes, to have less internet access, and to have higher rates of chronic health conditions. Policies and programs to address existing social inequities and the root causes of vulnerability are needed to plan for climate change impacts on health (CICC, 2021) (see Chapter 2: Climate Change and Indigenous Peoples’ Health in Canada and Chapter 9: Climate Change and Health Equity).

Other challenges to adaptation can arise when efforts to address climate change impacts by decision makers, in or outside of the health sector, are not coordinated and well planned, leading to maladaptation — unintentionally increasing risks to other sectors, social groups, or systems (Austin et al., 2016) (Table 10.2). Insufficient information and/or limited awareness of risk trade-offs can also lead to maladaptation or to insufficient adaptation among individuals to protect themselves and/or their families from the health effects of multiple climate hazards. For example, exercising during cooler parts of the day (e.g., night) or staying in shady areas to reduce risks from heat may lead to greater exposure to mosquitos and ticks that carry vector-borne diseases (Hill, 2012). Actions to plant vegetation like trees on the south side of a home to cool the building may be maladaptive if the trees produce pollen and are located near the intake of the furnace or air conditioner. They may also be maladaptive if vegetation, including leaves and fallen branches, is not maintained and serves to increase the presence of combustible materials near a home or structure that connects to a home, such as a fence. In some contexts vegetation may also harbour disease vectors. Efforts to conserve energy by opening blinds to take advantage of natural light whenever possible may increase risks of heat illness. As well, the use of cooling facilities (e.g., community centres, pools, libraries, malls) and public spaces during extreme heat events to protect health may increase risks from COVID-19 if necessary physical distancing, hand hygiene, and related measures are not taken (Shumake-Guillemot et al., 2020).

Maladaptation to climate change increases the risk that health decision makers will become trapped in a cycle of responding to and treating ever-increasing negative health outcomes in the population. Poorly designed or maladaptive measures may also exacerbate existing inequities, for example, if public information campaigns and funding are lacking (Paavola, 2017). Table 10.2 provides examples of maladaptive actions that can affect health.

There are opportunities for robust adaptation through collaboration among officials in a range of sectors (e.g., health, water, agriculture, energy, housing, environment, conservation, planning, transport, disaster management, and infrastructure) on monitoring and surveillance of climate change impacts on health; identifying higher-risk populations; addressing barriers that limit preparedness (e.g., poverty, inadequate housing and infrastructure, ineffective communications); reducing uncertainty through increased research on impacts; educating the public and decision makers about potential impacts and the benefits of preparedness; and funding needed actions (Séguin, 2008; WHO, 2010; Ebi, 2011b; Frumkin, 2011; Ebi & del Barrio, 2017). For example, technical and operational synergies can be achieved when health authorities and disaster management officials collaborate to improve disaster preparedness and response, communicate risks to the public, and undertake risk and vulnerability assessments and health system resilience-building (Banwell et al., 2018). The Emergency Management Framework for Canada recognizes the linkages between climate change and emergency management and the benefits of multisectoral approaches to resilience-building (PSC, 2017). At the individual level, preparing for climate hazards and taking action to avert impending threats requires information about risks and effective personal protective measures, resources to take action, and a supportive social network, particularly for people who require assistance.

Given increasing risks and potentially severe impacts on health, adaptation activities need to be rapidly scaled up outside of normal health ministry activities (Ebi, 2016). Box 10.1 provides an example of collaboration on adaptation among public health and infrastructure decision makers to reduce risks from climate change affecting children. A major benefit of collaboration among sectors on the design, implementation, and monitoring of adaptation and of GHG mitigation measures is that co-benefits to health from such actions can be maximized (e.g., improved mental health from increased social capital, reduced obesity from active infrastructure), while potential risks to health of the measures can be reduced (Cheng & Berry, 2013; WHO, 2018c) (see section 10.6 Health Co-benefit of Adaptation and GHG Mitigation Measures).

Partnerships with Indigenous Peoples and use of Indigenous knowledge, local context, and values — and incorporating sex, gender, and equity considerations into decision-making — support more effective measures through a respectful and meaningful adaptation process. Such collaboration can increase the relevance of the resulting measures, build capacity, and strengthen resilience through more inclusive and dynamic climate change networks within communities. Community-based adaptation research in Indigenous communities can be conducted through team-building approaches that identify common goals, support the meaningful engagement of knowledge users, and continuously monitor and evaluate progress (Ford et al., 2018) (see Chapter 2: Climate Change and Indigenous Peoples’ Health in Canada).

In recent years, the understanding of adaptation options that modify public health interventions for existing climate-related health hazards or address new and emerging risks, thereby building resilience to climate change impacts on health, has increased (Paterson et al., 2012; WHO, 2015; UNEP, 2018; ISC, 2019). Each chapter of this assessment provides information about adaptation measures to address specific climate change health concerns facing Canadians. Several tools to assess adaptation can be used to examine options for reducing risks, such as forecasting by analogy, screening, multi-criteria decision analysis, comparative risk assessment, benefit–cost analysis, cost-effective analysis, and implementation analysis (WHO, 2013). However, using such tools and prioritizing measures to reduce health risks from climate change can be difficult if there is insufficient information about current and/or projected impacts on health and of the possibility of surprise or unanticipated impacts (Wardekker et al., 2012).

Over the last several decades, the success of public health measures in reducing the health impacts of environmental hazards suggests that adaptations to address climate-related health risks can be effective in protecting populations. Adaptation can delay the increase in health risks from climate hazards at higher levels of warming (CCA, 2019; Ebi et al., 2021). Greater actions to prepare populations and health systems for climate change, and to reduce GHGs, would reduce the future burden of disease (Haines & Ebi, 2019). However, there is a paucity of information on the effectiveness of specific health adaptation measures in and outside of Canada, presenting a significant challenge to decision makers (Bouzid et al., 2013; Anderson et al., 2017). One study that reviewed the effectiveness of 56 specific interventions spanning 14 health issues of concern related to climate change revealed wide divergence among adaptations in terms of evidence (Anderson et al., 2017). Box 10.2 describes how the Texas Medical Centre undertook effective measures to increase its resilience to severe storms.

More investigation has been conducted on the effectiveness of measures to reduce health risks from extreme heat than on health risks from other climate hazards. The scope of discussion in this chapter does not permit review of the effectiveness of all health adaptation measures. Information on the current state of knowledge on the effectiveness of measures to reduce heat-health risks is presented to highlight the importance of regularly evaluating actions to protect health and of integrating uncertainty into the decision-making process.

Several studies suggest that, even with a warming climate, population susceptibility to extreme heat events has not been increasing, or has even been decreasing, in a number of countries (Fouillet et al., 2008; Kyselý & Plavcová, 2012; Schifano et al., 2012; Heudorf & Schade, 2014; Hondula et al., 2015; Arbuthnott et al., 2016; Barreca et al., 2016; Sheridan & Dixon, 2016). Research in regionally and economically diverse countries also indicates that HARS, components of which can include heat-health warning systems (McGregor et al., 2015) and heatwave action plans (HAPs) (Casanueva, et.al., 2019; Jay et al., 2021) can reduce poor health outcomes associated with extreme heat events (Hess & Ebi, 2016; Anderson et al., 2017; Lee, et al., 2019). In 2017, an estimated 47 countries had national or subnational HAPs in place (GHHIN, 2018), including Canada, which has HAPs in many communities and regions.

Sheridan and Allen (2018) suggest that implementation of HARS, greater awareness of heat-health risks, and improved quality of life have helped reduce the health impacts of heat in the developed world. These systems have been shown to be protective in Europe (Matthies et al., 2008; Martinez et al., 2019), France (Fouillet et al., 2008), Italy (Michelozzi et al., 2006; Baccini et al., 2011; Morabito et al., 2012), India (Das & Smith, 2012; Hess et al., 2018), Shanghai (Tan et al., 2007), Hong Kong (Chau et la., 2009), and Milwaukee (Weisskopf et al., 2002). It was estimated that implementing a heat action plan in Ahmedabad, India, in 2010 avoided an estimated 1190 average annualized deaths in 2014–2015 (Hess et al., 2018). However, some studies argue that robust evidence showing that such systems have a discernable influence on health outcomes is lacking (Boeckmann & Rohn, 2014; de’ Donato et al., 2015; Hondula et al., 2015; Weinberger et al., 2018). Well-designed HARS can result in significant economic savings when the costs of systems are compared with their economic benefits. For example, Hunt et al. (2017) calculated the benefit-to-cost ratios of alert systems to be 913 for Madrid, 308 for Prague, and 11 for London.

Many existing health sector policies, programs, and measures aimed at protecting people from extreme heat and other climate hazards and health outcomes (e.g., air pollution, infectious diseases, water-borne diseases, food-borne diseases, extreme weather events) were not designed incorporating information about increasing risks from climate change and so will have limited effectiveness in the future, unless they are modified (Haines & Ebi, 2019). In fact, many HARS are not designed to address increased risks posed by a changing climate, such as alterations in the onset, duration, and intensity of extreme temperatures and resulting health outcomes (Lee et al., 2019). HARS need to be regularly reviewed and evaluated through an iterative process to ensure they are fully protective under new climate conditions and hazards (Health Canada, 2012; Hess & Ebi, 2016; Lee et al., 2019).

In Canada, researchers in Quebec reported that heat alert systems can be effective (Poitras, 2018) and that local and provincial HAPs reduced mortality associated with a severe heat event in 2010 (Bustinza et al., 2013) and in 2018 (Lebel et al., 2019). Benmarhnia et al. (2016) reported that improvements to the Montréal HAP have decreased the number of daily deaths five-fold (see Chapter 3: Natural Hazards). In addition, efforts to warn the public about hazardous heat conditions and poor air quality have been found to be effective in getting people to take protective measures and in reducing costs to the health system (Gosselin et al., 2018; Mehiriz et al., 2018; Mehiriz & Gosselin, 2019). Health authorities in Toronto and Montréal reported that alert systems led to an increased awareness of risks to health from heat and to the uptake of health protective behaviours, such as drinking water, checking for alerts, wearing looser clothing, and seeking cooler locations (Health Canada, 2012; City of Toronto, 2019).

Additionally, preventive adaptation measures to reduce urban heat islands in Quebec (e.g., reduction of concrete/asphalt surfaces, increasing vegetation) were found to be effective in cooling communities and reducing health risks (Beaudoin & Gosselin, 2016; Health Canada, 2020d). From an economic perspective, the benefits of actions to reduce risks to health from extreme heat can justify implementation (Hunt et al., 2017) and may reap large cost savings. Tröltzsch et al. (2012) estimated that, between 2071 and 2100, implementation of a heat alert system in Germany would result in a value of EUR 2.36 billion in avoided deaths and EUR 165 million in hospital savings annually.

More research is required to better understand the effectiveness of adaptations to extreme heat events and to other climate hazards projected to increase in the future (Bouzid et al., 2013; Berry et al., 2014a). National estimates of heat-related morbidity and mortality would benefit from greater standardization of surveillance definitions and practices to enable comparisons among provinces. This evidence base would benefit the design, evaluation, and reporting of future climate change and health adaptation interventions (Hess & Ebi, 2016). For example, Valois et al. (2017) developed a behavioural index composed of 12 adaptations to gauge whether individuals in urban areas are adapting well to high summer temperatures. Studies of effectiveness are important because current health adaptations may not reflect important changes in exposure due to climate change, such as the longer heat season in many regions (Ebi et al., 2016c), including Canada (Zhang et al., 2019).

At the global level, some adaptation progress has been made; for example, at least 92 countries have completed vulnerability and adaptation assessments for climate change and health (Berry et al., 2018). However, a health adaptation gap exists that increases the vulnerability of people to climate change impacts (Watts et al., 2015; Martinez et al., 2018; Watts et al., 2018). The World Health Organization (WHO) collects global data every two years on a number of indicators to gauge progress toward preparing for climate change impacts on health. The data are reported through the WHO/United Nations Framework Convention on Climate Change (UNFCCC) Climate and Health Country Profiles (WHO, 2018a). The most recent survey, undertaken in 2017/2018, indicated that there has been progress on climate change and health adaptation internationally, but that adaptation plans and strategies vary widely in terms of their scope and that implementation of specific actions remains a key challenge (WHO, 2019). In addition, the results of vulnerability and adaptation assessments for climate change and health are influencing policy decisions in health ministries in various countries, and many health authorities are increasing collaboration with decision makers on adaptation in other sectors (WHO, 2019).

Analysis of Canada’s progress in addressing climate change risks to health, based on the WHO indicators, suggests that further actions are needed in some areas (Table 10.3).

Similarly, the Lancet Countdown on Health and Climate Change regularly tracks 41 indicators in five areas to gauge efforts to address climate change impacts on health globally. They include (1) climate change impacts, exposures, and vulnerability; (2) adaptation, planning, and resilience for health; (3) mitigation actions and health co-benefits; (4) finance and economics; and (5) public and political engagement (Watts et al., 2018). Following the methods and indicators of the Lancet Countdown, major medical organizations in Canada, including the Canadian Medical Association, Canadian Public Health Association, and the Canadian Association of Physicians for the Environment began in 2017 to report annually on actions undertaken in Canada (Howard et al., 2017; Howard et al., 2018). To improve Canada’s ability to tackle climate change specific to the health sector, recommendations include support for tele-commuting and telehealth options; creating curricula for all medical and health science faculties related to climate change; communicating the links between climate change and human health to the public; funding research on mental health impacts of climate change; and enhancing efforts to protect Canadians from extreme heat (Howard et al., 2017; Howard et al., 2018).

Two stakeholder workshops were hosted by Health Canada, including one in 2018 to discuss development of a pan-Canadian climate change and health surveillance system, and another in 2016, that brought together provincial and territorial health and environment officials, municipal health units, researchers, non-governmental organizations, and Indigenous partners from across Canada, to explore priority health issues, research gaps, and adaptation needs to prepare Canadians and health systems for climate change. Recommendations and needed actions from the meetings are presented below (Brettle et al., 2016; Knowledge Management, 2018).

Knowledge and data 

• Develop a pan-Canadian monitoring and surveillance system that is specific for climate change health outcomes and serves the needs of health authorities.
• Key climate change and health indicators adopted across Canada and at specific locations that are consistent and standardized with procedures to identify data quality issues.
• Increased data on indicators of climate change and health vulnerability, resilience benchmarks, and support for understanding regional vulnerabilities and risk.
• Climate change and health vulnerability and adaptation assessments by each province and territory to identify opportunities to decrease risks to health.
• Increased surveillance and monitoring of climate-related diseases, and evaluation of the efficacy of adaptation and GHG mitigation interventions.
• Provide data that can alert stakeholders in real or near-real time to emergencies as well as provide data for understanding long-term trends.

Program and policy development

• A national “Trees for Health” campaign (e.g., trees planted for patients and caregivers at health care facilities).
• Funding for sustainable health sector infrastructure.
• Guidance on standards for building codes and zoning regulations for the health sector.
• Actions to increase health co-benefits of GHG mitigation and adaptation efforts to address climate change.

Northern and Indigenous community considerations

• Increased actions to address the health challenges and capacity issues Northern and Indigenous communities face from climate change.
• Increased collaboration with Indigenous communities to support education efforts, communicate research findings, and support resilience-building.

Communication and information-sharing

• Collaborate on climate change and health communications with the health care community and non-governmental organizations.
• Increased public health education using evidence-based advice and targeted messaging.
• Incorporate information on climate change and health into educational curricula (e.g., health professionals).
• Develop a single window to provide easy access to climate change and health communication materials and messages.

Mechanisms for coordination and collaboration

Increase efforts by federal departments and agencies to support:

• Improved preparation of communities for emergency response/disaster recovery.
• Improved coordination on climate change and health activities among all federal health departments and agencies, provincial/territorial/local health authorities, and Indigenous partners with needed mechanisms (e.g., climate change and health committee, regional working groups, monthly webinars, collaborative research projects).
• Establish a platform to share best practices across provinces and territories (e.g., tool for open-sourcing plans and policies, guidance on developing adaptation options, checklists to assess vulnerability, economic analysis of actions).
• Map initiatives on climate change and health and provide funding to support needed actions.
• Work more closely with U.S. agencies on climate change and health, taking into consideration important cross-border agreements (e.g., air quality, water quality).

Progress has been made in some of these areas. For example, since 2007, Health Canada has led a heat-health program that is providing support and guidance to local, provincial, and territorial health authorities to develop HARS to protect Canadians from extreme heat events. The program provides public health authorities with guidance on assessing heat-health vulnerabilities at the community level, and on developing heat alert protocols, community response plans, and communications plans. To communicate heat-health risks to Canadians, including to those most vulnerable to the impacts, Health Canada has developed information brochures, infographics, and videos (Health Canada, 2020a; Health Canada, 2020b; Health Canada, 2020c; Health Canada, 2021). Health Canada has also collaborated with a number of communities in Ontario (Windsor, Ottawa, London, and the Regions of Peel and York) and British Columbia (Vancouver) on innovative projects to reduce the urban heat island effect, thereby reducing people’s exposure to higher temperatures in urban areas. The projects helped inform development of a guide for public health officials in Canada on how to engage with partners to address effects of urban health islands on health (Health Canada, 2020d).

Through the HealthADAPT program, launched in 2019, Health Canada is providing funding, information, and expertise to 10 local and regional health authorities across Canada to help build their capacity to understand climate change impacts on populations, develop needed adaptation actions, and communicate with the public and stakeholders on these issues. Many of the projects are examining current and future projected climate change impacts associated with extreme weather events, including on mental health (Health Canada, 2019). Project results and learnings are being shared through a pan-Canadian community of practice that includes public health officials from all levels of government.

Previous climate change and health assessments documented adaptation options for protecting health, roles and responsibilities for health adaptation, and measures being undertaken by health authorities in Canada (Séguin, 2008; Berry et al., 2014a). The following sections provide more detailed information on the current state of adaptation in Canada and describe the range of measures being taken at the regional and local level.

10.3.5.1 Adaptation by Regional and Local Canadian Health Authorities

Efforts are underway by a number of Canadian health authorities and partners in other sectors to prepare for climate change impacts on health, including, for example, risks related to extreme heat (Guilbault et al., 2016), extreme weather (Kovacs et al., 2018), and wildfires (Kovacs et al., 2020). A survey of 80 health sector officials from all regions of Canada conducted in 2018–2019 included respondents from Ontario (34), Quebec (11), the Atlantic provinces (7), the Prairie provinces (13), British Columbia (13), and the territories (2). It revealed that large majorities (80% or higher) reported taking some kind of action on health risks of concern due to climate change that were identified in previous assessment reports. These risks of concern included infectious diseases, air quality, extreme heat, other extreme events, and water safety and security, water quality and quantity, and food safety and security. Fewer, but still about four in 10 respondents, indicated they are taking action on climate-related mental health risks (see Figure 10.2) (Survey Research Centre, 2019).

Many of the activities health authorities have engaged in are awareness-building or groundwork. Just over half of respondents (56.3%) indicated they undertake surveillance and monitoring of the health impacts from hazards related to climate change. In addition, 53.8% reported undertaking climate change and health education and outreach with stakeholders, while just under half (47.5%) have done so with the public. In addition, 35% have undertaken a vulnerability and adaptation assessment for climate change and health, while fewer have undertaken an assessment of the vulnerability of their organization to climate change impacts (25%). Only 21.3% report that they have a climate change and health adaptation strategy, and 10% have a climate change and health research plan (Survey Research Centre, 2019).

Generally, health authorities are undertaking fewer concrete climate change and health actions in response to growing risks to Canadians, and there is a need to quickly scale up effective measures. Only one in four health authorities surveyed reported having a climate change and health program or dedicated resource, and this dropped to one in five for those reporting increasing resources (e.g., funding, human resources) to support adaptation measures (Survey Research Centre, 2019). This suggests that the health programs responsible for protecting the health of Canadians could themselves be vulnerable to climate change impacts and that many health authorities still do not see this issue as a priority, or do not have the resources to address climate issues due to competing priorities. Just over one in three (31.3%) indicated they have integrated climate change requirements into organizational or corporate health standards. Interestingly, 86% of health authorities indicated that they consider the needs of populations at higher risk when developing adaptation strategies. Far fewer consider implications for Indigenous Peoples (37.3%) or the use of Indigenous knowledge and perspectives in such activities (25.4%). Less than one in five (17.9%) consider sex and gender implications when developing measures to reduce climate change risks to health (Survey Research Centre, 2019).

Broader adaptation actions for health system readiness to prepare for climate change are not yet common among Canadian health authorities. For example, only 31% indicated enhancing emergency plans and programs to increase the resilience of the health system and associated health services to climate change impacts (Survey Research Centre, 2019). In addition, just under a quarter (23.8%) reported providing climate-informed training for public health professionals, and just less than one in five (18.8%) shared information among health service providers to raise awareness of possible climate change impacts on staff and/or infrastructure, and to share examples of adaptation options being undertaken. Current levels of education and training activities among Canadian health officials are insufficient to provide them with information needed to proactively prepare for climate change impacts on health (Hacket et al., 2020). New information is available for health authorities and health professionals to use to protect high-risk populations from climate change impacts (see Box 10.4), for example, preparing people with spinal cord injuries for more extreme weather events (Shapiro et al., 2020).

Important limitations of the survey study include the much higher response by health officials in certain regions (Ontario versus the territories and Atlantic provinces) and challenges in accurately identifying officials responsible for climate change and health activities in health authorities.

Another study of public health unit officials in Ontario in 2016 revealed similar results. In particular, 61% of respondents (representing 26 of 36 health units that participated) indicated that they are undertaking activities to raise awareness of climate change impacts on health or of the need to reduce GHGs. As well, 42% reported monitoring climate hazards such as extreme weather, but only 19% indicated they are monitoring climate change impacts on health. One-half of respondents confirmed being involved in research on climate change and health, with 38% indicating their health units have undertaken a climate change and health assessment. Similar to the national survey, but with somewhat higher proportions, 42% of health units reported using a health equity lens to identify, prioritize, and address climate change health risks (Doyle et al., 2017).

Researchers in Quebec have also examined the level of climate change and health adaptation in that province through the Quebec Observatory for Adaptation to Climate Change. For a number of concrete adaptations that help prepare for climate change impacts, health officials in that province are taking more action. For example, 64% (nine of 14) public health departments offer training to staff on climate change and health. In addition, 67% have developed prevention plans to reduce risks from extreme heat and 56% have done so for floods. However, many public health departments are still in the stages of early adaptation, as they are just beginning to allocate budget specifically to adaptation and to develop collaborations with partners in and outside of the health sector (e.g., school boards, community organizations, Hydro Québec) (Valois et al., 2018).

Many health authorities in Canada have not sufficiently scaled up climate change and health adaptation efforts to protect Canadians from current climate variability and from more severe impacts. Significantly ramped-up efforts are needed to train health care professionals, monitor climate change impacts and the effectiveness of adaptation measures, prioritize adaptation with sufficient resources, educate the public and stakeholders, and integrate considerations and information about higher-risk populations into activities.

10.3.5.2  Health in Climate Change Plans and Strategies

Many jurisdictions, from local to national levels, in Canada have climate change plans or strategies that include adaptation, and a greater number now include actions to protect human health and well-being (Kuchmij et al., 2020). Table 10.4 highlights that most provincial or territorial plans now include some reference to human health impacts. However, there is wide variation in the climate change and health activities by health authorities at all levels. Most Canadian provinces and territories are still in the early stages of adapting to the health impacts of climate change, with responses still being fragmented (Austin et al., 2016).

Currently, few provinces and territories have comprehensive or substantive (e.g., covering a wide range of likely risks to health) actions to address climate change and health adaptation as part of their broader climate change strategies. Few jurisdictions have a separate action plan or strategy that focuses exclusively on climate change and health. Given that analysis in other chapters of this assessment suggest wide-ranging health risks and vulnerabilities in communities across Canada, the lack of comprehensive strategies, and the wide diversity and inconsistency of health adaptation planning among many health authorities, increase the vulnerability of Canadians to current and future projected impacts on health.

10.3.5.3 Learning from the Quebec Experience

As a leader on health adaptation, the province of Quebec and its health authorities have been preparing for climate change impacts for almost 20 years (Demers-Bouffard, 2021). A formal requirement to prevent and mitigate the impacts of climate change on public health and safety was included in the Plan d’action sur les changements climatiques (PACC 2006-2012), led by the Quebec Ministère de l’environnement.

In 2012, the Government of Quebec adopted its Plan d’action 2013-2020 sur les changements climatiques (PACC 2013-2020) and the accompanying Stratégie d’adaptation aux changements climatiques 2013-2020, spending $200 million on adaptation (Government of Québec, 2012a; Government of Québec, 2012b). These include several adaptation objectives related to human health, including:

• considering climate change adaptation in land-use planning and other planning decisions;
• reducing risks and mitigating the consequences of disasters related to climate change;
• preventing excess diseases, injuries, and mortality associated with climate change;
• maintaining continuity of health and emergency services during disasters related to climate change; and
• limiting the psychosocial impacts of climate change.

Through this plan, $22 million was allocated to prevent and limit diseases, injuries, mortality, and psychosocial impacts (Demers-Bouffard, 2021). Led by the INSPQ and with the participation of many partners, a range of adaptation and knowledge development measures have been implemented by the existing Quebec health network. These include an observatory assessing the population’s level of adaptation to climate change; a multi-stakeholder zoonotic observatory; a weather and health warning and monitoring system; emergency response plans; an allergen-pollens reduction strategy; comprehensive research programs on climate change impacts and adaptations; several dozen urban greening pilot projects; and several knowledge transfer tools (websites, online courses, manuals, toolkits for surveys and evaluations, etc.). For example, the INSPQ, along with other partners, launched a Massive Open Online Course on climate change and health for health and social service professionals and for the general public. Other more targeted training is available for doctors, nurses, park workers, and other professions. The Mon climat, ma santé and MSSS websites provide information on the effects of climate change on health, populations at increased risk, and adaptation measures. Detailed clinical guidance is available to physicians for treating illnesses and diseases related to climate change and health in their daily practice (Gosselin et al., 2021).

An evaluation of efforts in Quebec to address climate change impacts on health identified important factors that facilitate such efforts and those that can act as barriers. Factors that supported climate change and health adaptation progress included (Demers-Bouffard, 2021):

• major extreme weather events;
• prioritization of climate change in government planning;
• funding for targeted actions;
• clarity of the roles and responsibilities of each of the stakeholders;
• availability of local climate and population data; and
• identification of external resources to support actions.

Important barriers to protecting health effectively included:

• public health resources being monopolized for other priorities;
• competition with other public health issues;
• organizational focus on the health protection role;
• lack of reliable and consistent funding;
• ambiguity of roles and responsibilities; and
• lack of guidance on the various adaptation measures to be implemented.

Ultimately, political, legal, social, regional, and organizational contexts matter for ensuring that government and regional health authorities can act to adapt to climate change. The political and legal contexts empower the health sector to respond to climate change by providing objectives and resources, while the social and regional contexts influence the development of partnerships and the effectiveness of implementing adaptation measures. The organizational context makes it possible to take advantage of the opportunities provided (Demers-Bouffard, 2021).

10.3.5.4 Individual-Level Health Adaptation

Individual Canadians have a primary responsibility for adapting to the health impacts of climate change by adopting protective behaviours. Educating the public and health professionals about climate change impacts on health is a key function of public health officials, and greater efforts are required to reduce risks (Hathaway & Maibach, 2018). Efforts in and outside of Canada to communicate climate change risks and get people to take protective behaviours have had mixed success and have faced significant challenges (MacIntyre et al., 2019; Maibach, 2019). Many Canadians are aware of climate change impacts on health and concerned about these impacts. In 2017, a survey of Canadians found that 79% of people reported being convinced that climate change is happening, and, of these, 53% indicated that it is a current health risk and 40% believe it will be a health risk in the future (Environics Research Group, 2017). However, concern about impacts is not translating into the adoption of protective behaviours; large numbers of Canadians are not taking actions to protect themselves, or their family members, from climate change impacts on health, putting themselves at higher risk. For example, the survey in 2017 revealed that (Environics Research Group, 2017):

• 43% of Canadians reported that they had taken steps in the past year to protect themselves and family members against the bite of an infected mosquito or tick (e.g., using insect repellent, wearing long pants and long sleeves, checking for ticks on skin after being outdoors);
• 37% reported that they had an emergency household plan for what to do during a natural disaster or emergency, down from 42% that reported having one in 2008;
• 77% reported that they regularly (51%) or occasionally (26%) check for extreme weather alerts, which is down from 2008 when 81% reported doing so;
• 53% reported that they either regularly (21%) or occasionally (32%) change daily routines as a result of an extreme weather alert; and
• 51% reported ever having taken action or changed plans as a result of hearing a heat warning.

Interestingly, when respondents were also asked a separate, more general question about whether they had taken steps in the past year to protect themselves or family members from the potential health risks or impacts of climate change, only 37% indicated that they had done so. There were very low rates of reported actions for some possible health adaptations, such as watching the weather more closely (5%), installing air conditioning (2%), having an emergency kit/plan (1%), preparing for storms (1%), and being vigilant for ticks on person/pets (1%) (Environics Research Group, 2017). The difference in responses suggests that many Canadians do not associate these measures with interventions that can protect them from climate change health impacts. In addition, some of the responses to this more general question included “better eating habits/gardening,” “recycling,” “increasing a home’s energy efficiency,” and “driving less,” which are actions to reduce GHGs. Although better home insulation and driving less can help reduce urban heat islands and attendant health risks, there is likely significant confusion among the public of the difference between some GHG mitigation and health adaptation measures.

The media plays an important role in influencing public perception of climate change risks and in influencing behaviours to address climate change (Watts et al., 2018; King et al., 2019). Callison and Tindall (2017) suggested that media coverage of climate change in Canada has tended to focus on national policy making and energy and economic issues, but has often omitted climate justice considerations, including those related to Indigenous Peoples and impacts in the Arctic. A review of climate change impacts on health covered by Canadian newspapers between 2005 and 2015 suggested that coverage over this time period has actually decreased, with greater information being provided to the public on negative climate change impacts on health and significantly less on climate change and health adaptation solutions. In fact, only 26% of the articles reviewed included information on actions that can be taken to protect health (King et al., 2019). The authors suggest that recent trends in media coverage of climate change in Canada may be partly responsible for a lack of public support and actions to address climate change, including preparing for the impacts (King et al., 2019). Adaptation by individual Canadians may also be significantly influenced by constraints on their ability to take protective actions due to existing inequities in society (see Chapter 9: Climate Change and Health Equity).

A range of impacts from extreme weather events and public health emergencies related to climate change can affect health facilities and systems (WHO, 2015; Balbus et al., 2016; Curtis et al., 2017; Ribesse & Varangu, 2019). The ability of these systems to mitigate climate change impacts on populations will be increasingly challenged in the future (Ebi & del Barrio, 2017). For example, cancer care can be disrupted by climate-related disasters that affect infrastructure, communications systems, availability of medications, and medical records (Man et al., 2018). The Lancet Countdown on Health and Climate Change suggested that health systems are unprepared to manage the impacts of climate change. Specifically, it reported that “A lack of progress in reducing emissions and building adaptive capacity threatens both human lives and the viability of national health systems they depend on, with the potential to disrupt core public health infrastructure and overwhelm health services” (Watts et al., 2018, p. 2479). Globally, between 2005 and 2019, an average of 412 health facilities were damaged or destroyed by climate-related disasters annually, and such impacts are increasing (UNDRR, 2019). Many decision makers expect climate change to worsen these risks; a survey of 814 global cities in 2019 indicted that 67% of respondents believed that climate change would seriously affect their public health assets and infrastructure (Watts et al., 2021).

Health care officials, including first responders, can be affected physically and suffer mental health impacts from extreme weather and disaster events. Health infrastructure, such as building envelopes, can be damaged or destroyed by wind storms, floods, wildfires, and extreme heat events. Reduced access to critical support services, including transportation, power, water supply, and telecommunications, can affect the normal operations of a health care facility (Scott et al., 2020; WHO, 2020). Medical and non-medical supplies and services (e.g., medications and medical products, blood services, food, linen and site cleaning, waste disposal storage and services, data management and patient record systems, and sterilization services) can be disrupted by severe weather events in or even outside of Canada. Patient safety can be compromised when access to critical health and clinical services, such as surgery or radiation therapy (Xiu-Gee Man et al., 2018), are reduced or when outpatient services, such as dialysis, are affected.

During disasters, increased hospital admissions and emergency services in health facilities can create stress on operations, particularly where surge capacity is lacking, where there are ongoing requirements for medication or treatment, and when patients are transferred from other affected facilities (Ebi et al., 2017; WHO, 2020). The activation of the emergency plan within the health care facility is a significant undertaking, and health care facilities experiencing climate change-related impacts will incur increased costs (Ribesse & Varangu, 2019).

Climate change is expected to increase future risks to health facility and health system staff, operations, and infrastructure in Canada from a range of hazards (Ribesse & Varangu, 2019). Some hazards, such as flooding, could affect critical health infrastructure, leading to severe health and socio-economic impacts on Canadians (Scott et al., 2020). Scott et al., (2020) examined the risks to health and emergency facilities (e.g., hospitals, long-term care centres, outpatient clinics, community health centres, police, fire) from floods due to river overflow, extreme rain events, and storm surge. Across Canada, 15.2% (17,177) of all health and emergency facilities (112,910) have some exposure to flood hazards, increasing their vulnerability to the impacts of this type of extreme event. Health care services constituted 94% or 16,240 of the health and emergency facilities that are at risk (Scott et al., 2020). In addition, a study of the climate resilience of facilities at Fraser Canyon Hospital in Hope, British Columbia, found that elevated temperatures are already being observed in the buildings. The projected quadrupling of hot days (>30°C) between 2016 and 2050 due to climate change will exceed the capacity of the heating, ventilation, and air conditioning (HVAC) systems to maintain thermal comfort, necessitating retrofits, such as building envelope upgrades and horizontal shading elements above windows (Bartko & Macdonald, 2017).

Discernable effects of climate change on health and on health systems are already evident and will increase in the absence of efforts to address existing vulnerabilities and close the “health adaptation gap” (Martinez et al., 2018; Haines & Ebi, 2019). In the United States, Superstorm Sandy, which struck in November 2012, severely affected health services in New York, with 3.1 billion USD in recovery costs (Health Care Climate Council, 2018). Health facilities in Canada are already being affected by climate hazards (Waddington et al., 2013; Canadian Coalition for Green Health Care, 2019b). Health authorities have reported impacts of climate-related events on the following health facility functions: damage to infrastructure, reduced access to medical supplies and products, reduced access to critical support services (including transportation, power, water supply, and telecommunications), and activation of emergency services (Canadian Coalition for Green Health Care, 2019b).

Table 10.5 provides information on Canadian health facility vulnerabilities to specific climate change hazards. It includes examples of climate-related impacts on health facilities. As there is no comprehensive and centralized surveillance system for monitoring such impacts, these types of impacts are likely significantly under-reported.

Climate impacts are not all acute events. Impacts can be less drastic and longer-term, but such cumulative impacts can also be significant. More frequent rainfall or gradual increase of day- and night-time temperatures and humidity levels can strain the physical plant (i.e., air conditioning and ventilation systems) while increasing the need for health services (i.e., more patients with heat stress). As another example, permafrost melt in Canada’s Far North is damaging the foundations of some medical clinics, and continued warming will require remediation to prevent further damage to these structures (Holubec, 2008). Permafrost maps were developed for health authorities in Nunavik to guide future decisions about planning new buildings and renovating those at structural risk by thawing (L’Hérault et al., 2013).

Climate hazards can also combine, or cascade, as happened in Dunrobin, Ontario, which was affected by record flooding in 2017, devastating tornadoes in 2018, and further severe flooding in 2019. Similarly, flooding in Japan in 2018 killed more than 200 people and was followed during the clean-up efforts less than a month later by record-breaking extreme heat that resulted in at least 30 deaths and 10,000 hospital admissions (ABC News, 2018). Whether acute climate shocks or chronic stresses, climate impacts will require health systems to respond and adapt (Ebi et al., 2018b).

Impacts on health systems in Canada can be very severe, as was the case with the 2013 Southern Alberta floods, when some hospitals were forced to close, patients were evacuated, and significant infrastructure damage occurred (MNP LLP, 2013; Roles, 2013). The catastrophic wildfires in British Columbia in 2017 and 2018 also resulted in facility closures, patient transfers, and major disruptions to care (Legassic, 2018). Climate events can have disproportionate impacts on Indigenous communities. For example, almost 2000 people displaced from four First Nations communities in Manitoba after extensive flooding in 2011 were still unable to return to their homes in 2017 (Lambert, 2018).

A major challenge facing health systems in Canada from climate change are possible surprises or unexpected hazards, events, or developments; these present new or much more severe threats to the health of Canadians or to health systems. For example, significant uncertainty exists about the impacts of climate change on human migration, and very little research has been conducted in the Canadian context. However, some evidence suggests that climate change could lead to large movements of populations seeking respite from climate-related disasters and other impacts. A U.S. National Intelligence Council study warned that climate change will continue to threaten the stability of many countries through climate-induced disruptions that can overwhelm response capacity (NIC, 2016). Missirian and Schlenker (2017) suggest that, under a high emissions scenario, the European Union could see annually an additional 660,000 asylum applications by the end of the century, a 175% increase from the present day.

Evidence suggests that many health facilities — a critical component of health systems in efforts to reduce climate change impacts — are not taking needed actions to prepare for current risks and future warming. A survey of health care facility staff, such as facility directors or managers, sustainability coordinators, and energy managers, representing 102 facilities, was undertaken by the Canadian Coalition for Green Health Care in 2019 through the Green Hospitals Scorecard questionnaire (Canadian Coalition for Green Health Care, 2019b). The respondents were primarily located in Ontario but also at some facilities in British Columbia, Manitoba, and Nova Scotia. The survey revealed that health authorities are recognizing climate change as an issue of concern, and some are taking adaptation measures. For example, 55% reported that senior leadership had assigned at least one person with some climate change responsibility in their health authority. However, only a small percentage of health care facilities (8%) had acknowledged climate change in their strategic plan or had identified climate risks in specific policies. A smaller number of facilities (4%) reported that the impacts of climate-related events, such as flooding and severe weather events, had been recognized in other ways. In addition, almost one-third (27%) of facilities had not recognized climate change as an issue of concern, and 10% responded that they did not know whether it was an issue of concern (Canadian Coalition for Green Health Care, 2019b).

Awareness of the need to examine the possible impacts of climate change on health facilities is relatively new. Therefore, few health facilities in Canada have undertaken assessments of vulnerability or have a good understanding of what vulnerability assessments would entail. Of the health care facility staff respondents (99 respondents), 9% reported having completed resilience assessments, while only 4% had completed vulnerability assessments (Canadian Coalition for Green Health Care, 2019b).

Use of on-site renewable energy systems can improve the resilience of the health care facility during grid-based power outages and reduce the generation of GHGs from the use of fossil fuels. Just over a quarter (27%) of health care facilities reported that they currently had some form of renewable energy in place, with many reporting multiple types of systems (100 participants provided multiple responses for a total of 245) (Canadian Coalition for Green Health Care, 2019b). Of the renewable energy systems currently in place, photovoltaic systems are currently the most popular (9%), followed by deep lake cooling (4%), with other numerous renewable energy system types at much smaller numbers. The potential growth of renewable energy systems in the future is significant, with 46% hoping to implement some renewable energy options in the future (Canadian Coalition for Green Health Care, 2019b). The renewable energy types of highest future interest are photovoltaic systems (45%), geothermal systems (14%), deep lake cooling (13%), and solar hot water (12%) (Canadian Coalition for Green Health Care, 2019b).

Given that the health system and health facilities are the first and last defence from climate change impacts on the health of Canadians, the limited number of existing efforts to build health facility resilience across Canada and educate and train health officials suggests ample opportunity to reduce existing vulnerability to health impacts.

When climate change increases mortality or morbidity, there is a loss of welfare to society and forgone income and/or wealth creation. Climate change may also disrupt labour productivity, educational attainment and other determinants of health, eroding economic output and future potential. Although limited evidence is available, climate change-driven impacts to various economic sectors (e.g., resource extraction) may disrupt future government revenues, including those that fund health and social services. In addition, more illnesses, injuries, and disease may increase stresses and costs to health systems and result in general impacts on economic productivity, with more sick leave and absenteeism (Campbell-Lendrum et al., n.d.; Martinez et al., 2018). To manage growing health risks effectively, decision makers need to know the following information about adaptation options: (1) the economic costs of climate change impacts on health in the absence of interventions; (2) the costs of implementing adaptation actions to protect health, including measures in and outside of the health sector; and (3) the costs of health impacts that are residual or that still occur after actions are taken (Campbell-Lendrum et al., n.d.).

There is a paucity of information about the economic costs of current climate variability and projected climate change on the health of individuals and on health systems internationally (Hutton & Menne, 2014; Martinez et al., 2018) and in Canada (Berry et al., 2014a). However, climate change is expected to result in tangible and significant economic costs to health systems and broader society (Kovats et al., 2011; Watkiss, 2015; Ebi et al., 2017).

Projections of future economic costs of climate change on health are uncertain and vary widely, depending on availability of data and methods used. The WHO has projected that a narrow range of direct climate change impacts on health would result in economic costs of 2 billion to 4 billion USD by 2030 (WHO, 2018b). Another study, with a broader set of health outcomes and including indirect costs, suggested that European Union countries alone might expect health costs between EUR 9 billion and 106 billion for the period 2041–2070 (Ciscar et al., 2014). In the United States, one study estimated the health costs of 10 climate-sensitive events that struck in 2012, including heat waves, hurricanes, wildfires, flooding, outbreaks of infectious diseases, and ozone pollution. The total cost was at least 10 billion USD, related to 900 deaths, 21,000 hospitalizations, 18,000 emergency room visits, and 37,000 outpatient visits (Limaye et al., 2019). The very severe wildfires in Washington and Colorado in that year resulted in 419 deaths and 627 hospital admissions, for a total cost of 3.9 billion USD (Limaye et al., 2019).

Recent research in Quebec suggested that, from 2015 to 2065, the projected costs of the increase in health effects of ragweed allergies due to climate change are $360 million for governments in that province and $475 million for society as a whole. For extreme heat, the study estimated costs of $370 million for governments and over $33 billion for society. In addition, increases in Lyme disease due to climate change are projected to cost governments $60 million to $95 million, depending on the level of public health preparation (Larrivée et al., 2015).

The health care costs will not be borne evenly among the population. For example, evidence suggests that the most vulnerable in society bear disproportionate health care costs from the impacts from extreme heat (Wondmagegn et al., 2019). Box 10.5 describes the health system impacts and economic costs of recent severe wildfire seasons in British Columbia.

Some of the costs to health and health care systems from climate change are avoidable through adaptation, but these actions often require upfront development and subsequent maintenance costs. Greater research is needed on the costs and benefits of various adaptations to reduce risks to Canadians from extreme heat and other climate change hazards.

Rapidly scaling up health adaptation measures is needed to help protect Canadians from current health hazards and to reduce risks from climate change impacts in the future, such as extreme weather events that exceed adaptive thresholds. Health authorities should build upon past and current efforts to prepare for a warmer world, such as undertaking vulnerability and adaptation assessments for climate change and health, examining risks to health facilities from climate change, and implementing targeted adaptations such as early warning systems. This may require going outside of normal approaches used by ministries of health, such as expanding integrated monitoring and surveillance activities, mainstreaming information about climate risk into new programs and policies, as well as training clinicians, health researchers, and public health professionals about how to protect health in a changing climate.

Progress in efforts to protect Canadians from climate change requires a commitment to upholding Indigenous leadership and partnership in research development and adaptation, including recognizing and using Indigenous knowledge in a respectful way. Inherent in these efforts is an openness to diverse ways of knowing and of learning from complementary and/or contrasting perspectives for adaptation decision-making. Respectful collaboration will ensure that actions to protect health are based on meaningful engagement informed by the unique circumstances and opportunities of Indigenous Peoples and Northern, remote, and rural communities, thereby respecting, upholding, and advancing the rights of Indigenous peoples.

Adaptation progress will also require working more closely with decision makers outside of the health sector (e.g., water, agriculture, insurance, housing, energy, environment, emergency management, urban planning, transport, and infrastructure) to implement preventive and equitable measures to protect Canadians including by more vigorously addressing the social and environmental determinants of health. These activities should focus on opportunities to address barriers that limit preparedness (e.g., poverty, inadequate housing and infrastructure, ineffective communications), and to reduce uncertainty through increased collaborative research on impacts and effectiveness of adaptation.

Strong measures to reduce GHGs are needed to protect health and ensure that the ability of Canadians to adapt is not limited due to the severity of impacts. Very large health co-benefits can be achieved through multi-sectoral climate change adaptation to build resilience and through well-designed GHG mitigation efforts. Health decision makers have an important leadership role to play in raising awareness of these benefits and providing needed information to support robust efforts to address climate change through GHG mitigation (PHAC, 2017), including reducing the carbon footprint of the health sector, which is a major emitter of GHGs.

National adaptation strategies for climate change and health must provide a comprehensive framework identifying key actors, accountabilities, priority areas of action, and clear goals and objectives. Such strategies can reduce future costs of preparedness through greater sharing of information and through more robust collaboration and coordination of efforts (WHO, 2021). The Government of Canada is developing its first ever national adaptation strategy that is expected to be released in 2023 (Government of Canada, 2021). A strong health component of a national strategy would include efforts to provide assistance to people and communities at highest risk through equitable adaptation measures. Actions would address the physical and operational risks of climate change to health systems and their infrastructure by supporting facility assessments, preparedness, and resilience-building, considering the special challenges faced by rural, remote and Indigenous health services and through efforts to update relevant codes and standards. It would enhance capacity for climate change and health modelling, forecasting, and state of the art early warning systems informed by surveillance of climate change and health indicators. A core component of a health adaptation strategy would be to work with other sectors to incorporate the perspectives, needs, and voices of equity-seeking groups and the general public. Considerations of social justice and integration of a gendered perspective into future climate change and health activities are needed to support resilience-building efforts; these considerations include empowering people disproportionately affected by climate change (e.g., Indigenous Peoples, women, people of low socio-economic status, immigrants) as educators, caregivers, holders of knowledge and agents of social change (Sorensen et al., 2018).

Greater efforts are needed to educate the public and decision makers about potential impacts and the benefits of preparedness to support scaled-up actions. This can include collaborating on climate change and health communications with the health care community and non-governmental organizations; increasing public health education using evidence-based advice and social marketing approaches; and developing a single window to provide easy access to climate change and health communication materials and messages (Brettle et al., 2016). Such activities would help Canadians, communities and their health systems move beyond responsive and more costly adaptation toward transformational adaptation that builds resilience to future climate change.

A national strategy could address many existing barriers to health adaptation, including limited social capital and ability to engage health relevant sectors, cognitive limits to behavioural change (Huang et al., 2011), a narrow framing of public health interventions that omits action on root causes of vulnerability (Gould & Rudolph, 2015) and the absence of coordinated planning among health sector partners at all levels of government. Through close collaboration, health decision makers, civil society partners, researchers, and members of the public can meet the challenge of climate change head-on, building more resilient health systems and communities to better protect health, now and in the future.