How Local Health Districts can prepare for the effects of climate change: an adaptation model applied to metropolitan Sydney

Additional keywords: health services, health systems, population health, risk management.

There is an inextricable relationship between climate change and human health.^1,2 In many parts of the world, the changing climate is already having major health and social effects due to weather extremes, reduced food and water security and the spread of infectious disease.^3,4 As a result, leading international agencies and Australian health organisations have prioritised action on climate change, including the growing need and importance of adaptation by local health services.^5–8 In Australia, the Climate and Health Alliance (CAHA) has led the development of a framework for a national strategy on climate, health and well-being that outlined seven areas requiring government policy action, including emergency and disaster preparedness and building a climate-resilient health sector.⁸ The national framework has also been referenced in a recent Senate Select Committee report on the implications of climate change on Australia’s national security.⁹

Thus, climate change adaptation can be defined as a form of risk management (i.e. assessing climate change-related risks and responding appropriately so that they can be managed as they arise).^10,11 The UKCIP (formerly known as the UK Climate Impacts Program) at the University of Oxford offers online risk-based adaptation resources to assist organisations with local climate change adaptation planning.¹⁰ Steps include assessment of current and future climate vulnerabilities and development and evaluation of agency-appropriate adaptation measures.¹⁰ The US Centres for Disease Control have developed a similar framework for Building Resilience against Climate Effects (BRACE) by public health agencies.¹¹ Adapting to climate change by hospital and community health services would entail identifying effects on a population’s health and its use of health services, as well as preparing for the effects of climate change on health service resources, workforce and infrastructure. In this paper we illustrate how the existing models and available data can be used by local health services to predict the local risks and prepare for the effects. To do this, we outline the climate change predictions for the Sydney metropolitan area, present the health service problems and vulnerabilities for the Local Health Districts (LHDs) and consider the potential of LHDs to respond. As recommended by existing frameworks,^10,11 subsequent steps would entail the New South Wales (NSW) health service and its LHDs developing and implementing their own climate and health adaptation plans, possibly within the existing disaster management frameworks.

Although average Sydney temperatures fluctuate from year to year, overall over the past two decades the winter warm spells have been generally lasting longer, occurring more often and becoming more intense.¹² Sydney summers are also getting hotter, with more frequent and intense extremes. For example, during the summer of 2016–17, Sydney had a record total numbers of days at 35°C or above, and January 2017 was the warmest month on record. Since the late 1950s, Sydney has also experienced progressively longer heatwaves (Fig. 1; see also Box 1). In the summer of 2016–17, Sydney had the second highest total number of ‘3-day heatwave’ days, and its highest number of heatwave days in the extreme category. Even between heatwaves, the summer of 2016–17 was notable for its almost continuously above-average temperatures.¹²

Fig. 1.  Number of days in which Sydney has been in a 3-day heatwave during summer, within each heatwave severity category. Used with permission from the Bureau of Meteorology.¹²

Sydney’s current climate is summarised in Box 2.

Future climate change projections for different Australian regions have been prepared by the CSIRO and Bureau of Meteorology.¹³ The relevant projections for the East Coast Cluster – South (including the Sydney region) are compiled in Table 1.

Table 1.  Projected climate change for the Sydney region
Table compiled from data in Dowdy et al.¹³ Representative concentration pathways (RCPs) represent future scenarios for greenhouse gas (GHG) emissions, with GHG concentrations and associated global warming modelled to Year 2100. For RCP4.5, global warming is projected as likely to be 1.1–2.6 °C by 2100. For RCP8.5, global warming is projected to be 2.6–4.8°C²⁷

In summary, Sydney’s average temperatures will continue to increase in all seasons. There will be more very hot days, more frequent and longer warm spells and progressively harsher fire weather. The intensity of extreme rainfall will increase, and there will be some longer-term decreases in winter rain. Mean sea levels and the height of extreme sea levels will continue to rise. However, natural variabilities may mask or enhance longer-term anthropogenic changes over the next 20 years, particularly for rainfall.¹³

A projected increase in the average number of days above 35°C and 40°C is summarised in Table 2 (2030 and 2090 compared with the average for 1981–2010).¹³ It is of note that the projected increase in the frequency and severity of extreme heat outlined in Table 2 appears conservative relative to the observed more recent heatwaves reported in Fig. 1. Indeed, other modelling from the NSW and Australian Capital Territory (ACT) Regional Climate Modelling (NARCliM) project, which provides data specific to the Sydney metropolitan area, suggests a greater increase in heat extremes.¹⁴ The current annual number of hot days (above 35°C) of less than 10 days per year near the coast and 10–20 days per year in the western suburbs is projected to increase by approximately 4 days by 2030 and by approximately 11 days by 2070. This is summarised in Fig. 2. Recent modelling by researchers at the Australian National University also suggests that Sydney may experience summer extremes as high as 50°C as early as 2040, even under scenarios where global average temperature increases are contained to 2°C.¹⁷

Table 2.  Current average number of days (1981–2010) in Sydney above 35°C and 40°C and below 2°C compared with projections for 2030 and 2090
Table compiled from data in Dowdy et al.¹³ Representative concentration pathways (RCPs) represent future scenarios for greenhouse gas (GHG) emissions, with GHG concentrations and associated global warming modelled to Year 2100. For RCP4.5, global warming is projected as likely to be 1.1–2.6 °C by 2100. For RCP8.5, global warming is projected to be 2.6–4.8°C²⁷

Fig. 2.  Projected changes in the number of hot days (daily maximum temperature >35°C) for the Sydney metropolitan region, annually and by season, for 2030 (yellow) and 2070 (red). The length of the coloured bars shows the spread of model values for the region in each period; horizontal thin lines are values from individual models, whereas darker lines are the average of all models. Currently Sydney experiences <10 days per year with temperatures >35°C near coast and 10–20 days per year in western suburbs. Used with permission from the Office of Environment and Heritage.¹⁴

The direct and indirect health effects of climate change have been well described, both globally and for Australia^1,8,18–20 (Appendix 1). The measurement and quantification of health effects will enable us to monitor the effectiveness of adaptation and mitigation strategies.^3,4,21,22 In Australia, the single most dangerous climate-related hazard is extreme heat, which has been responsible for 4555 fatalities nationwide (since 1900), more than from all other natural hazards combined.²³ Heat stress and heat exhaustion also affect morbidity (with children, elderly people, pregnant women and people with pre-existing conditions and disabilities most at risk) and severely affect work capacity.^24,25

As demonstrated in Fig. 1, heatwaves are a significant concern for metropolitan Sydney, and thus its LHDs. For planning climate change adaptation, it can be useful to consider former climate- and/or weather extreme-related vulnerabilities, which, combined with climate change projections, can inform vulnerability predictions.¹⁰ Some of the important former climate-related vulnerabilities for Sydney’s LHDs are summarised in Box 3. These include increased heat-related ambulance call outs and hospital admissions from exacerbations of respiratory and cardiovascular conditions, mental diseases, diabetes, dehydration and heat stress. Health services have also been affected by other extreme weather events, particularly when these have caused spikes in demand while at the same time disrupting transport and power supplies.

Key vulnerabilities for the Sydney region identified by government service providers in 2015 are also included in Fig. 3.²⁶ We have added highlights to suggest which may be particularly relevant for LHDs.

Fig. 3.  Systems map of climate effects and their pathways from an integrated regional vulnerability assessment of Metropolitan Sydney. Reproduced, with some modifications, from Dunford et al.²⁶ (Our highlights indicate issues highly relevant to Local Health Districts.) GPs, general practitioners; LGAs, local government areas; R&D, research and development.

In NSW, LHDs and Speciality Networks (e.g. Sydney Children’s Hospitals) report regularly on service agreements with the Ministry of Health and, via the Secretary of NSW Health, to the NSW Government. Ideally, climate risk assessment and adaptation by public health services would also be coordinated by the state (and national) governments to support and reinforce local implementation. Western Australia, for example, detailed in 2008 a whole-of-government adaptation strategy for the health effects of extreme events and climate change.¹⁹ The Queensland Government recently developed a human health and well-being climate change adaptation plan, and work is underway for a climate change adaptation plan for Victoria.^28–30 The NSW Government supports climate change risk assessment and adaptation planning by local councils.³¹ However, although NSW Health offers advice to the public on extreme heat,³² there is no current government-endorsed health sector vulnerability assessment process or adaptation advice for the LHDs. The Australian Federal government only briefly describes the health risks of climate change.³³

Some LHDs in NSW have environmental sustainability plans³⁴ aimed at improving efficiency in the use of resources and reducing greenhouse gas emissions.³⁵ However, as yet no LHDs have developed plans for the assessment of and adaptation to climate change effects. LHDs will need to consider the exposure and risk of climate change to their own substantial workforce and facilities, as well as their capacity to respond to the changing needs of the populations they serve. Health sector adaptation to climate change requires clear governance arrangements, flexibility (of location, scale and type of services across administrative boundaries), strategic allocation of resources (to adapt existing services, prioritise vulnerable groups, ensure equitable access) and robustness (resilient infrastructure, consistent services, sustainable workforce).²⁰ It also requires a systems approach.⁴³

The United Nations identifies climate change as a core consideration in disaster risk management.⁴⁴ One existing and robust mechanism that could incorporate NSW LHDs’ climate change adaptation planning is the NSW disaster management network, which consists of a central Health Emergency Management Unit (HEMU) and LHD-based disaster management units, headed by a senior manager appointed as the Health Services Functional Area Coordinator (HSFAC). The NSW Health Services Functional Area Supporting Plan details the role of LHDs in disaster planning and response.⁴⁵ The plan adopts an ‘all hazards, all incidents’ approach, and a framework for planning and response that covers four core components: prevention, preparedness, response and recovery. This network and the work that it undertakes offer a robust mechanism that should incorporate climate change adaptation preparedness. The network has already begun such work (R. Hegner, pers. comm.), and this now needs to be continued and enhanced through the development and implementation of climate and health adaptation plans.

For the purpose of discussion and to inform health service planning, we have applied the climate change vulnerabilities identified in the sections above to compile some of the factors that may be considered by Sydney metropolitan LHDs in climate change adaptation (Table 3). We have cross-referenced the predicted effects of climate change in the Sydney metropolitan area (first column) with considerations of the resulting vulnerabilities (second column) and potential LHD adaptations (third column), a model adapted from the UK Climate Impacts Program.¹⁰ The considerations are examined across the three ‘core business’ categories of: (1) ambulance, emergency and acute health care; (2) routine health care; and (3) population and preventative health services. In Table 3 we also consider the key climate change risks and vulnerabilities of the LHDs’ workforce, facilities and finances, as well some of the important transboundary issues.

Table 3.  Factors to be considered by Sydney metropolitan Local Health Districts (LHDs) in climate change adaptation
CC, climate change; CKD, chronic kidney disease; GGHH, Global Green and Health Hospitals (see http://www.caha.org.au/globalgreen_healthyhospitals, accessed 5 November 2018); GPs, general practitioners; SLHD, Sydney LHD

Australian health services need to increase their preparedness to respond to the unavoidable effects of climate change, including spikes in local health service demands, as well as the direct effects on a service’s capacity to respond. In this paper we illustrate how local health services can use available data and existing models of climate change impact assessment and adaptation, as applied to the example of Sydney’s LHDs. The steps in climate change adaptation planning include drawing on available climate change projections and past exposures to identify local health service risks and vulnerabilities and using systems thinking to consider current preparedness and to forecast whether and what health service adaptations will be required. Health services are mandated to prepare for and respond to health emergencies and disasters on an ongoing basis. The adverse effects of climate change should be a key factor in such planning and response. Ideally, health service adaptation should also draw on existing planning for climate change adaptation by other government departments, incorporate other existing health service quality improvement structures and processes and be integrated across local, state and national levels. We believe that timely and effective climate change adaptation planning and implementation are essential and urgent, and can offer health services longer-term financial savings, as well as a safer environment, better health care and better health.

The authors declare no conflicts of interest.