[Senate Hearing 110-888]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 110-888
                    CLIMATE CHANGE: A CHALLENGE FOR 
                             PUBLIC HEALTH



                                 OF THE

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION


                           FOR PUBLIC HEALTH


                             APRIL 10, 2008


 Printed for the use of the Committee on Health, Education, Labor, and 

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               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
BARACK OBAMA, Illinois               PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont         WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio                  TOM COBURN, M.D., Oklahoma

           J. Michael Myers, Staff Director and Chief Counsel

                 Ilyse Schuman, Minority Staff Director



                            C O N T E N T S



                        THURSDAY, APRIL 10, 2008

Kennedy, Hon. Edward M., Chairman, Committee on Health, 
  Education, Labor, and Pensions, opening statement..............     1
Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming, 
  opening statement..............................................     2
Patz, Jonathan, M.D., Ph.D., Professor of Environmental Studies 
  and Population Health Sciences, University of Wisconsin-
  Madison, Madison, WI...........................................     5
    Prepared statement...........................................     6
Ebi, Kristie, Ph.D., M.P.H., President, ESS LLC, Alexandria, VA..    11
    Prepared statement...........................................    12
Balbus, John, M.D., M.P.H., Chief Scientist and Program Director, 
  Environmental Defense Fund, Washington, DC.....................    19
    Prepared statement...........................................    20
McDonald, Ambassador John W., Chairman and CEO, Institute for 
  Multi-Track Diplomacy, Arlington, VA...........................    26
    Prepared statement...........................................    28
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont, 
  prepared statement.............................................    36

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Obama................................................    40
    Senator Coburn, M.D..........................................    40
    Senator Inhofe...............................................    43
    Dunn, John Dale, Board Certified Emergency Physician.........    45
    Kuepper, T.A., Executive Director, Global Water..............    47
    Maccabee, Howard, Ph.D., M.D.,...............................    48
    Reiter, Professor Paul, Director of the Insects and 
      Infectious Diseases Unit of the Institut Pasteur, Paris; 
      and Roger Bate, Resident Fellow, American Enterprise 
      Institute..................................................    54





                        THURSDAY, APRIL 10, 2008

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:03 a.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Edward M. 
Kennedy, chairman of the committee, presiding.
    Present: Senators Kennedy, Sanders, and Enzi.

                  Opening Statement of Senator Kennedy

    The Chairman. I welcome our committee members to today's 
hearing on the health effects of climate change, and I welcome, 
too, our distinguished witnesses. I look forward to hearing 
from them on this important topic.
    Over the past few years, the American public's awareness 
and concern about climate change has reached unprecedented 
levels, and we have heard about what climate change means for 
the Earth, about the melting ice caps, and about the rising sea 
levels. The issue of climate change is not just about polar 
bears or melting distant glaciers. It is about our communities 
and our health and the health effect on our children.
    History is full of examples of health problems ignored 
until it was too late. We must see that climate change does not 
join that list. People across America and around the globe will 
be affected by changes in the Earth's climate. Those changes 
will have a profound impact on our health, and it is time that 
our committee turned our attention to this problem.
    Leading scientists from across the globe have studied 
climate change and know that our health is at risk. Extreme 
weather events will become more common, more severe in the 
future. Climate change will cause heat waves, which we know 
result in heat stroke, heat stress, and even death in 
vulnerable populations like the elderly, and we have seen in 
the past the loss of life that can occur. The heat wave that 
hit Europe in 2003 was responsible for 30,000 deaths.
    Extreme heat will also raise ozone levels in places that 
already have high pollution, causing problems for people with 
allergies, asthma, and chronic lung diseases. Illnesses spread 
by mosquitoes, such as malaria, and other diseases previously 
confined to the tropics will spread to areas of the country 
that have never experienced these problems before. We can 
expect that hurricanes become more frequent, and we know only 
too well the destruction these storms bring.
    Public health must be a central part of the discussion 
about climate change. Sadly, vulnerable populations like the 
elderly, children, the poor, and the chronically ill are likely 
to experience these health effects disproportionately. They are 
also the least likely to have the resources to prepare for and 
respond to these events. That is why we need the public health 
community involved in discussions about climate change.
    This week is National Public Health Week, and across the 
Nation, public health officials in communities are holding 
events to draw attention to climate change as a major public 
health challenge. We are holding this hearing today to draw 
attention and awareness to this issue to find out how prepared 
we are and where we need to focus our efforts in the future.
    We are at an important moment in time. The decisions we 
make now can improve our health and our climate for years to 
    Today, we will hear from our expert panel about how 
prepared public health departments are to respond to these 
challenges, about the innovative and practical solutions that 
are already being adopted, and about the role the Federal 
Government should play in assisting them in responding to the 
threat. I look forward to their comments.
    I welcome, Ranking Member Senator Enzi for his comments.

                   Opening Statement of Senator Enzi

    Senator Enzi. Thank you, Mr. Chairman.
    I am a little concerned about us holding this hearing. This 
is one of the polarized issues, and we are adding to the 
polarization. Whenever you polarize something--and I understand 
that we need to get ready for the debate that is going to 
happen, I guess, around June 4, which will be on climate 
change. My prediction is that the Senate will work for about 3 
weeks discussing climate change and will do nothing--not a 
thing--because we have already polarized this issue.
    On the other hand, there are a whole bunch of solutions out 
there waiting for our work that can be taken one step at a 
time, done in relatively short periods of time. In fact, on 
bills that Senator Kennedy and I work on, we usually get them 
done by unanimous consent in both houses in a matter of 
minutes. That is because we didn't polarize them. When you 
polarize them, you encourage debate. Of course, you get news 
coverage, and we thrive on news coverage around here, but it 
doesn't get anything done.
    We already have a whole bunch of issues on our plate. Some 
are related to global climate change, but they are not being 
called that. Consequently, we can get them done without the 
same polarization that is likely to take place when we get into 
climate change.
    I am from Wyoming, and I was doing a radio interview 
recently. I always try to avoid talking about the weather 
because out here, you know, we have the cherry blossoms and the 
apple blossoms, and we have got things coming up. In Wyoming, 
it is snowing. In fact, what the announcer said was, ``How is 
it out there? We are getting 6 more inches of global warming 
out here.''
    We get most of our snow in April, and we are very pleased 
with that because it is a nice, wet snow, and we are a dry part 
of the country.
    I am afraid that taking this approach will stop some 
solutions. These will be stopped because of the time it will 
take us to debate climate change, and that will stop us from 
solving health problems regardless of their direct or indirect 
causes. So I think it would make more sense to focus on 
challenges that may deal with the same thing but are directed 
toward specific goals that we have.
    We have a need to provide clean water to prevent disease. 
That hasn't been polarized. That is internationally recognized. 
In the United States and in Wyoming, we are very blessed. We 
have abundant resources of natural, human, intellectual, and 
financial capabilities. It isn't that way everywhere, and we 
have a moral obligation to solve some of those problems for 
people less fortunate than us, even outside the United States.
    Whatever the health effects of climate change may be, 
Americans are resilient, and we have the resources to adapt. 
The witnesses today, I appreciate their testimony and having 
the opportunity to look at it in advance. We will learn about 
how climate change may cause disease, air pollution, and 
extreme weather events. Some of those assertions will come to 
pass. Some of them won't.
    I am not sure that the devastating impacts that are 
described will dramatically affect the people of Wyoming or 
even the United States as a whole. Passing health legislation 
that we already have in the works would make an immediate 
difference and can blend into future problems. We will develop 
drugs and vaccines to deal with new diseases. We will come 
together as communities in the Nation to get new prediction 
tools to better understand weather risks. We will invent new 
technologies such as sea water desalting techniques to adapt to 
a changing world.
    Take another industrialized Nation, Australia, for example. 
That country desalts at night with wind power. I agree that the 
decades ahead of us hold challenges, but we have to face and 
meet the challenges.
    I am going to do an inventors conference this weekend, and 
we will be concentrating not on climate change, but on having a 
better environment and ways that people can get into the mix of 
the economy by inventing something that will improve our way of 
life and the way of life around the globe. We get past that 
discussion about whether there is or whether there isn't and 
get solutions for problems that are happening and will happen, 
and we can avoid them.
    For me, the health effects of climate change are 
inextricably intertwined with poverty. What we do today to 
provide clean water, clean energy, and public health 
infrastructure in the developing world will not only reduce 
poverty but will mitigate the health problems that many face 
today and lessen any potential future health effects that may 
come about because of climate change. I believe access to clean 
water is the keystone to those efforts. Water is a bridge to 
health, and health is a bridge to peace and prosperity for all 
of the people on this planet.
    This is something that kind of sticks in my mind since I 
visited Mozambique. That country's goal is to get everybody 
within 5 miles of water. In this country, we can't even imagine 
being 5 miles from water. If we saw the water, we would be 
appalled. A pond that animals drink out of and bathe in, that 
people do their laundry in and bathe in, if it is within 5 
miles of your house, that is your drinking water, regardless of 
climate change.
    In Sub-Saharan Africa, climate change could make access to 
water even more difficult and survival more precarious. Before 
we get ahead of ourselves on solving a problem that may come 
about because of climate change, we have to remember that more 
than a billion people in the world today don't have access to 
safe drinking water. That is a sixth of the world's population.
    We can wring our hands and say the problem is too big and 
turn our backs to focus only on ourselves. The technology 
exists to put clean water into the hands of all people and not 
5 miles away. Simple interventions are available. I can name 
two--the Safe Water System and LifeStraw. The Safe Water System 
is a suite of approaches suitable for the developing world. 
LifeStraw is a portable personal instant purification device 
that requires no power or spare parts, but can filter at least 
700 liters of water.
    We can improve on that. By helping other nations become 
more prosperous in the cleanest, most efficient way possible, 
we mitigate the effects of climate change. As a member of the 
Senate, I have long opposed any measures to deal with climate 
change by shutting down the economy, and I oppose trying to 
deal with climate change by shutting down someone else's 
    I think it is the height of arrogance to tell impoverished 
people that they must remain impoverished because we developed 
in an inefficient way. Instead, there is an obligation to take 
what we have learned and help others out of poverty, and water 
is just one example.
    Yes, climate change could be a challenge for public health 
in the future, but we face challenges with malaria, air 
pollution, and HIV-AIDS today. We need to do more in many areas 
of public health, but we can't be so narrow-minded as to focus 
only on ourselves. We need to shine the light on the global 
public health challenges we face to see our way forward.
    I have a number of statements from outside groups, and I 
ask unanimous consent that they be entered into the record. I 
won't be here for the testimony this morning. I am going to a 
meeting on genetic nondiscrimination.

    [The information referred to may be found in additional 

    The Chairman. There you go. We wish you the best of luck 
with that meeting.
    Senator Enzi. Another problem that we need to solve, and we 
have been working on, and we can.
    The Chairman. Thank you.
    We will hear from Dr. Jonathan Patz, who is Professor and 
Director of Global Environmental Health, University of 
Wisconsin-Madison. He has written 75 peer-reviewed papers as 
well as a textbook on the health effects of climate change. Co-
author for the Health Expert Panel on the U.S. National 
Assessment on Climate Change. He was the convening lead author 
for a similar United Nations assessment.
    For the past 4 years, Dr. Patz has been the lead author for 
the United Nations Intergovernmental Panel on Climate Change 
and the organization that shared the 2007 Nobel Peace Prize 
with Al Gore.
    Dr. Kristie Ebi--correct?
    Dr. Ebi. Ebi [Ee-bi].
    The Chairman. Ebi, thank you. Dr. Ebi is an independent 
consultant based in Alexandria, VA. She has worked in the field 
of global climate change for more than a decade. She has a 
master's degree in toxicology from MIT, and Ph.D. and M.P.H. 
degrees in epidemiology from the University of Wisconsin.
    Dr. Ebi has worked at the World Health Organization's 
Center for Environmental Health, Electric Power Research 
Institute. She recently conducted an analysis for the 
Environmental Protection Agency on the effects of climate 
change on the human health.
    Dr. John Balbus is the Chief Health Scientist, Program 
Director, Environmental Defense Fund. As a physician and public 
health professional, he consults on a broad range of 
environmental health issues. A member of the Advisory Committee 
for the National Academy of Science, Institute of Medicine, 
Environmental Protection Agency.
    Ambassador John McDonald, currently Chairman and Co-Founder 
of the Institute for Multi-Track Diplomacy in Washington, which 
focuses on national and international ethnic conflicts. Served 
for 40 years as a diplomat of the Foreign Service, spending 20 
years in Western Europe and the Middle East, working for 16 
years on the United Nations Economic and Social Affairs.
    You all are very welcome here.
    Dr. Patz.


    Dr. Patz. Thank you very much, Mr. Chairman. Senator 
Kennedy--is this on?
    The Chairman. Yes.
    Dr. Patz. Senator Enzi, as you have mentioned, yes, I have 
been quite engaged with this issue. Co-chaired the U.S. 
National Assessment on Climate Change and Climate Variability, 
Health Expert Panel, and have been on the IPCC, and I have 
studied this for over 15 years, the issue of climate change and 
    One thing that I would like to really start with is the 
uniqueness of this health hazard. Climate change will affect 
our health through multiple direct and indirect pathways, be it 
from heat waves and air pollution, as you have mentioned, to 
threats to our water quality as well, and other issues. And so, 
the multiple pathways through which climate change can affect 
our health are very important to recognize. It is not just a 
single toxic, a single agent of disease. It is a multifactorial 
    And for the record, I would like to submit this recent 
revision from the World Health Organization that summarizes the 
health effects.

    [Editor's Note: Due to the high cost of printing, 
previously published materials are not reprinted. The World 
Health Organization's summary can be found at www.who.int/

    The Chairman. Fine.
    Dr. Patz. Because there are so many pathways through which 
climate change can affect our health, in addition to 
confronting these specific hazards--be it water quality, air 
pollution, heat waves, or other infectious diseases--it is 
important to also go upstream and consider targeting policy 
toward the root of the problem. That is greenhouse gas 
emissions and climate change.
    Following Senator Enzi's good advice, I do think that it is 
extremely important not to view climate change in isolation 
from other environmental problems because there are potentially 
dangerous synergies that may occur as climate happens across 
our landscape, be it an extreme heat wave that happens over a 
sprawling urban city that intensifies the heat, and you get 
this urban heat island, or an extreme hurricane like Hurricane 
Katrina that hit New Orleans, and part of the destruction and 
what made that city so vulnerable was the destruction in the 
coastal wetlands. What we do on our landscape actually can play 
into the risks from climate change.
    Regarding solutions, public health concerns of climate 
change should absolutely be included as the Congress considers 
the transportation bill, for example, or the energy bill 
because these issues are very linked. Some of the testimony 
that will follow will also point out how energy and 
transportation policy really are one and the same--as public 
health policy--as we approach this problem.
    I think that I also agree that the polarization of this 
issue is not at all healthy. I think that when you look at many 
of the effects of climate change, they are across many issues 
that we already are grappling with, like water quality, air 
pollution, and when you think about issues that are in crisis 
today, like HIV-AIDS, malaria, diarrheal disease, climate 
change can exacerbate all of those.
    Mosquito-borne diseases are extremely sensitive to climate 
fluctuations because they are cold-blooded animals, and just a 
fraction of a degree in temperature can affect the transmission 
of these diseases. Places that already have water stress could 
be further exacerbated from climate change.
    I would say that my background is that I am a physician and 
a public health scientist. If you have an emergency coming into 
the ER, that is someone who is bleeding to death versus someone 
with high blood pressure, you need to treat that acute problem 
first. You also have to recognize that more people die from 
high blood pressure, and you need to look at the long-term 
issues at the same time.
    Thank you.
    [The prepared statement of Dr. Patz follows:]

            Prepared Statement of Jonathan Patz, M.D., Ph.D.

    Good morning Mr. Chairman, Senator Kennedy, and other distinguished 
members of the committee. Thank you for the opportunity to appear 
before your committee for this hearing, ``Climate Change: A Challenge 
for Public Health,'' a topic that I have studied for over 14 years. I 
served as Co-chair for the Health Expert Panel of the U.S. National 
Assessment on Climate Variability and Change and have been a Principle 
Lead Author on five reports of the UN Intergovernmental Panel on 
Climate Change (IPCC) since 1995. I am a Full Professor at the 
University of Wisconsin at Madison, and have active research and 
teaching in the field of environmental public health, specifically 
addressing global climate change.

                       THE NATURE OF THE PROBLEM

    Global warming is unlike many other health threats with which we 
have confronted because unlike ``single agent'' toxins or microbes, 
climate change affects multiple pathways of harmful exposures to our 
health. Climate change can affect human health either from direct heat 
waves and severe storms to ground level smog/ozone pollution and 
airborne allergens, as well as many climate-sensitive infectious 
    Disease risks originating outside the United States must also be 
considered because we live in a very globalized world. Many poor 
nations of the world are expected to suffer even more health 
consequences due to climate change compared to the United States. With 
global trade and transport, however, disease flare-ups in any part of 
the world can potentially reach the United States. Additionally, 
climate extremes, e.g. droughts and storms, can further stress 
environmental resources by destabilizing economies and potentially 
creating security risks both internally and to other nations.
    Finally, while climate change is a long-term environmental threat, 
health ramifications are already occurring. The World Health 
Organization finds that warming in just the past 30 years may already 
be adversely affecting the global burden of disease. And while single 
climate events can not be attributed to climate change, 70,000 deaths 
in the 2003 European heat wave remind us of the risk of extreme weather 
events (a study in Nature concluded that global warming over the recent 
decades doubled the ``probability'' of the occurrence of such an 
extreme heat wave).
What Are Some of the Potential Impacts of Climate Change on Health in 
        the United States?
    Climate-related disease risks occur throughout the United States, 
and many are expected to be exacerbated by climate change. Some health 
benefits could result, including reduced cold-related mortality and 
Rocky Mountain Spotted Fever in the southeastern United States. 
However, the net health effects have been assessed to be adverse. Our 
country has experienced deadly heat waves (e.g, the 1995 heat wave 
killed > 700 persons in Chicago alone), and according to climate 
models, heat waves will become more frequent and intense. For example, 
a study of Los Angeles projected a 3-fold increase in heat waves by the 
end of this century. Major portions of the United States are expected 
to have a higher number of extremely hot days (the figure below shows 
the changing probability for days >100F in Minneapolis).

    Preliminary analysis from our own research finds that the frequency 
of extreme heat waves in Wisconsin will increase disproportionately 
compared to a smaller decline in the frequency of extremely cold 
temperatures. Poor and elderly populations are especially at risk of 
dying in heat waves.
    Air pollution accompanies heat waves, due in part to the 
temperature sensitivity of the chemical reaction that forms ozone smog 
pollution. A recent study of the 50 largest cities in the eastern 
United States finds that by mid-century, ``Red Ozone Alert Days'' could 
increase by 68 percent due to projected regional warming alone. The 
projected increase in stagnant air masses for the Midwest and 
Northeast, according to the IPCC, may exacerbate this problem further. 
Ozone is especially dangerous to children with asthma. Recall the 
findings during the 1996 Atlanta Olympics when traffic restrictions 
resulted in a 28 percent decrease in ground-level ozone, and subsequent 
42 percent decline in asthma admissions to emergency rooms.
    Pollen, another air contaminant, may increase with elevated 
temperature and CO2. For instance, a doubling of the 
atmospheric CO2 concentration stimulated ragweed-pollen 
production by over 50 percent.

    Many infectious diseases are sensitive to climate fluctuations. For 
example, 67 percent of reported water-borne disease outbreaks in the 
United States (between 1948-94) were preceded by very heavy rainfall; 
projections are for increases in extreme rainfall and runoff, placing 
more risk on already deteriorating water systems in many cities. 
Combined sewage overflows (CSOs) will likely become a more frequent 
problem. West Nile virus (WNV) emerged for the first time in North 
America during the record hot July 1999. While international transport 
likely explained its entry, this particular strain of WNV requires 
warmer temperatures than other strains around the globe. The greatest 
WNV transmissions during the epidemic summers of 2002-04 in the United 
States were linked to above-average temperatures.
Can't We Adapt to Climate Change Risks?
    Relying on adaptation alone is a dangerous strategy. Building 
adaptive capacity takes time and it is unlikely to be reliable for 
climatic changes that might be more rapid or more extreme than 
expected. In addition, according to an energy policy expert at SAGE 
(Dr. Greg Nemet) a majority of greenhouse gas emissions in the future 
will come from developing countries. Therefore, by relying on 
adaptation to deal with climate change, the United States provides no 
basis for leadership or persuasion to enlist developing countries in 
reducing their emissions--in the end, we may have to adapt even more. 
Dr. Nemet further notes that global greenhouse gas emissions have been 
accelerating over the past decade and outside the upper end of 
scenarios predicted a decade ago.
Are There Co-benefits to Reducing Greenhouse Gas Emissions That Also 
        Improve Public Health Simultaneously?
    Considering the multiple health outcomes and potential for adverse 
synergies between global warming, urban sprawl, and land degradation, 
climate change poses a major threat to the health of the U.S. 
population. The policy changes needed to address this problem are going 
to be very large if we are serious about protecting the public from the 
adverse health effects of climate change. Adopting a modest emissions 
reductions policy, which may be riddled with loopholes, in the interest 
of pushing the United States to finally adopt a climate policy seems 
like a risky approach. With such large ramifications at stake and so 
many potential health co-benefits to be gained by reducing greenhouse 
gas emissions, major policy measures to mitigate climate change seem 
like an obvious component to protecting our health.
    Scientific assessments caution that climate change will have 
dangerous synergies with other environmental public health risks and so 
must not be viewed as an isolated health risk. Dangerous synergies will 
include, for example: the ``urban heat island'' effect over sprawling 
cities with asphalt highways; destruction of storm-buffering coastal 
wetland, e.g., near New Orleans; and increased allergens in the air 
along with a lengthening ozone pollution season.
    Yet, these dangerous synergies also point to potential co-benefits 
of mitigating greenhouse warming. There are potentially large 
opportunities and co-benefits in addressing the health risks of global 
warming. Certainly, our public health infrastructure must be 
strengthened, e.g., fortify water supply systems, heat and storm early 
warning and response programs, and enhance disease modeling and 
surveillance. However, energy policy now becomes one and the same as 
public health policy. Reducing fossil fuel burning will: (a) further 
reduce air pollution--all reductions of fossil fuel burning will reduce 
NOx and CO emissions, as well as SO2, 
PM2.5, Hg, VOC and/or air toxic emissions as well (depending 
on the sectors, fuels, and technologies affected); (b) improve our 
fitness--only 40 percent of the U.S. population meets the minimum daily 
recommended level of exercise (60 percent of Americans are overweight), 
and if urban transportation planning allows for more Americans to 
travel by foot or bike and public transportation rather than by car, 
these percentages would inevitably improve); and (c) lessen potential 
greenhouse gas emissions and subsequent global warming. Note from the 
figure below that most of the 10 leading causes of death in the United 
States are linked either to sedentary lifestyles, air pollution, or 
motor vehicle crashes.
    In short, the challenges posed by climate change urgently demand 
improving public health infrastructure AND energy conservation/urban 
planning policies--as such, climate change can present both enormous 
health risks and opportunities quite directly via improved fitness, 
reduced obesity (with its multitude of associated diseases), and 
improved air quality.

    The scientific rationale for regulating CO2 is 
absolutely clear when considering the health risks described above. The 
legal nuances, however, are beyond my expertise. My colleague and 
energy policy expert, Dr. Greg Nemet, shared with me his concern that 
if CO2 is regulated by the EPA, then CO2 
regulation will be subject to a cost/benefit risk assessment analysis. 
The dilemma is that since many of the impacts of climate change will be 
only weakly captured in that type of analysis: (1) most impacts of U.S. 
emissions will be outside the United States; (2) impact assessments are 
focused on likely ranges, and ignore tails (or extremes) of 
distributions; and (3) impacts will be mostly in the future, so will be 
discounted heavily. Thus, a worrisome outcome is that EPA could end up 
regulating CO2, but set only modest reduction targets which 
do not adequately protect the health of Americans. From my standpoint 
as a public health scientist, I view the health threats of climate 
change as extremely large in magnitude, and therefore requiring 
equivalently significant policy change--both in areas of public health 
preparedness and in greenhouse gas mitigation to avert this threat by 
whatever best policy interventions are required.
    Dr. Tracey Holloway, a climate-air pollution expert at SAGE, 
pointed out to me that policy analyses for Europe have quantified the 
economic and physical interactions between climate change and air 
quality, and they find that integrated policies to address both issues 
simultaneously could reduce total costs by well over 1 billion Euro/yr 
by 2020 (vs. the cost of considering air quality and climate 
separately). http://www.iiasa.ac.at/rains/gains-


    The broad and interconnected exposures stemming from climate change 
will require a well-coordinated, cross-sector and comprehensive disease 
prevention strategy. In addition to enhancing disease preparedness, 
this would include proactive energy conservation and transportation 
policies, and in so doing, will provide substantial health co-benefits.
    The Department of Health and Human Services, that includes CDC and 
NIH, are responsible for protecting the health of the American public. 
To the extent that extremes of climate can have broad population-wide 
impacts, neither the CDC nor NIH have directed adequate resources to 
address climate change, and to date, funding has been minimal compared 
to the size of the health threat. Coordinated efforts on climate change 
& health also will need to cut across agencies--EPA, NASA, NSF, and 
NOAA have already been engaged on the issue, though funding 
historically has been insufficient in the health impacts area.
    Strategic planning should take place across Federal, State, and 
local government, academia, and the private sector to look for co-
benefits of solutions in combating climate change. The multimodal 
transportation scenario (reducing obesity and associated diseases while 
also reducing greenhouse gas emissions and improving local air quality) 
is a clear example. Such cases of co-benefits bring me to the 
conclusion that policies towards sustained mitigation of the threat of 
global warming could, in the end, represent one of the largest public 
health opportunities that we've had in over a century.

    The Chairman. Doctor.

                    ESS LLC, ALEXANDRIA, VA

    Ms. Ebi. Mr. Chairman, Senators, thank you very much for 
the opportunity to speak with you today. I have a few short 
points I would like to make.
    In talking about how we handle the health risks of climate 
change, it is useful to put it into a risk management 
framework. This is one more risk. As Dr. Patz mentioned, there 
is a range of risks that are affecting health here in the 
United States and throughout the world. And looking at how 
public health can address those risks, I think there are four 
issues that would be useful to bring forward to the committee.
    The first is there is, as you mentioned, very keen interest 
across the United States in understanding what the risks might 
be within the United States to our health and the health of our 
communities. There has been very little research conducted in 
the United States. The amount of funding going to this issue 
means that we cannot tell you at local and regional scales what 
kinds of impacts people might experience.
    Without understanding at the local and regional level what 
those impacts might be, we are then constrained in how well we 
can inform public health on the kinds of activities they have 
to undertake.
    The second issue is we do have a very strong public health 
system in the United States, and we do know it is under stress 
for a lot of different reasons. We do not have enough capacity 
to deal with large-scale issues. Climate change is providing 
the opportunity to have more large-scale issues. We saw 
Hurricane Katrina and we saw how difficult it has been for our 
public health system to respond to those kinds of issues.
    A second part of this is as we go forward, one of the 
things that the climate scientists are telling us is the future 
will not be like the past. We have to change the way we plan. 
We do not have sufficient information within our public health 
system for people to look at the programs and activities that 
are in place to see if they need to be modified, how they need 
to be modified, and do they have the human and financial 
resources to do so?
    A third issue, as highlighted very clearly by Senator Enzi, 
is what happens around the world affects us here. Disease is 
spread from one country to another. Problems in other countries 
affect us. I personally am working with about 15 different low-
income countries in developing adaptation to climate change. I 
can tell you what people are seeing on the ground is things 
changing much faster than what is listed in the literature.
    People in Kenya and Bhutan are reporting vector-borne 
diseases changing their range. Their public health systems are 
straining to try and adapt to those changes. As we see those 
changes, again, they will affect us. If we ignore what is going 
on internationally, there will be impacts here.
    Finally, there is a whole range of policies that are being 
discussed here in Congress. There are technologies that are 
being developed across the various agencies from energy 
efficiency policies to carbon capture and storage. All of those 
have potential consequences for health. Public health has not 
been a player in the development of those policies, in the 
assessment of those policies, and the evaluation of those 
    As you noted in your opening statement, if public health is 
not at the table, then typically at some point when something 
goes wrong and it affects the health of a community, we have to 
come and help solve the problem. It would be better to get out 
in front of these and make sure that we make effective and 
efficient choices today.
    Thank you.
    [The prepared statement of Ms. Ebi follows:]

          Prepared Statement of Kristie L. Ebi, Ph.D., M.P.H.


    Climate change poses a risk for U.S. populations. Climate change is 
projected to increase heat-related mortality, increase the number of 
cases of diarrheal diseases, and increase mortality from diseases 
exacerbated by high concentrations of ozone and by aeroallergens. 
Extreme weather events (floods, droughts, and windstorms) also could 
affect human health and safety. A very limited research base means 
there are few quantitative projections of health risks at the local and 
regional scales needed to implement programs to prepare for and 
effectively respond to these risks. The groups most vulnerable to the 
health impacts of climate change depend on the region of interest, the 
health outcome, and population characteristics, including human, 
institutional, social, and economic capacity. Trends in factors that 
affect susceptibility, such as a larger and older U.S. population, will 
increase overall vulnerability to climate-related health risks. In 
addition, the U.S. population may be at risk from climate-related 
diseases and disasters that occur outside her borders, with travelers 
and refugees importing diseases not currently present.
    Adaptation and mitigation are the primary approaches for addressing 
the risks of climate change. Neither is sufficient in itself; focusing 
only on mitigation would leave communities ill-prepared for changes 
expected in the short term, and focusing only on adaptation would 
increase the amount of future climate change.
    Climate change will make more difficult the control of climate-
sensitive health determinants and outcomes. Therefore, health policies 
need to explicitly incorporate climate-related risks in order to 
maintain current levels of control. Examples of adaptation measures 
range from developing and deploying early warning systems and emergency 
response plans that specifically incorporate projections of climate 
change-related health risks to establishing surveillance programs in 
regions where projections suggest disease vectors may change their 
geographic range. Proactive policies and measures should be identified 
that improve the context for adaptation, reduce exposures related to 
climate variability and change, prevent the onset of climate-sensitive 
health outcomes, and increase treatment options. However, the ability 
to incorporate the risks of climate change into public health programs 
and activities is constrained by limited awareness and data, few 
decision-support tools, and very limited human and financial resources.
    In addition to increasing the public health capacity to prepare for 
and effectively respond to climate change, there is a need to evaluate 
the possible health consequences of policies and technologies being 
developed to reduce emissions of greenhouse gases, from energy 
efficiency policies to carbon capture and storage.
    Adaptation to climate change across all sectors would be 
facilitated if there were a central (or regional) responsible agency. 
The elements needed, from weather forecasting to air and water quality 
regulations to vector control programs to disaster response, are spread 
across multiple agencies and organizations, with lack of consistent 
collaboration and coordination. Identifying and supporting a lead 
agency that can provide access to the information and tools, and that 
can support the adaptation process, will advance preparation for the 
risks of climate change.

                            1.0 INTRODUCTION

    Over the past decade, the fact that the world's climate is changing 
has become clear. In 2007, the Intergovernmental Panel on Climate 
Change (IPCC 2007a) concluded: warming of the climate system is 
unequivocal, as is now evident from observations of increases in global 
average air and ocean temperatures, widespread melting of snow and ice, 
and rising global average sea level. In addition: most of the observed 
increase in globally averaged temperatures since the mid-20th century 
is very likely due to the observed increase in anthropogenic greenhouse 
gas concentrations. Ambient temperatures increased 0.74C worldwide 
over the period 1906-2005. The rate of warming averaged over the past 
50 years (0.13C + 0.03C per decade) is nearly twice that for the last 
100 years. Changes in extreme temperatures (such as the 2003 European 
heat wave) are consistent with warming over recent decades.
    Climate change is increasing the frequency and intensity of heat 
waves, droughts, floods, and storms; altering agricultural productivity 
and food security; reducing water quantity and quality; and increasing 
the geographic range and incidence of climate-sensitive infectious 
diseases, particularly certain vector-, rodent-, tick-, water-, and 
foodborne diseases (IPCC 2007b). Impacts are projected to increase with 
increasing climate change, and will be greatest in developing countries 
in tropical regions because of their geographic location, low incomes, 
and low institutional capacity, as well as their greater reliance on 
agriculture and other climate-sensitive sectors. The extent to which 
impacts are experienced will depend, in the short term, on the speed 
with which effective and timely adaptation measures can be developed 
and deployed, and will depend, in the longer term, on rapid reduction 
of greenhouse gas emissions.

                          IN THE UNITED STATES

    The observation that major causes of ill health exhibit distinct 
seasonal patterns suggests a priori that weather and/or climate 
influence their distribution and incidence. Weather, climate 
variability, and climate change affect a wide range of health outcomes 
directly and indirectly. Directly, heat waves, floods, droughts, 
windstorms, and fires annually affect millions of people and cause 
billions of dollars of damage. In 2003 in Europe, Canada, and the 
United States, floods and storms resulted in 101 people dead or missing 
and caused $9.73 billion in insured damages (Swiss Re 2004). More than 
35,000 excess deaths were attributed to the extended heat wave in 
Europe the same year (Kostasky 2005). The frequency and intensity of 
extreme weather events are expected to increase over the coming decades 
as a consequence of climate change, suggesting that the associated 
health impacts also could increase.
    Indirectly, climate can affect health through alterations in the 
geographic range and intensity of transmission of vector-, tick-, and 
rodent-borne diseases, and food- and waterborne diseases, as well as 
through changes in the prevalence of diseases associated with air 
pollutants and aeroallergens. Climate change could alter or disrupt 
natural systems, making it possible for diseases to spread or emerge in 
areas where they had been limited or had not existed, or for diseases 
to disappear by making areas less hospitable to the vector or the 
pathogen (NRC 2001). Climate-induced economic dislocation and 
environmental decline also can affect population health.
    The cause-and-effect chain from climate change to changing patterns 
of health determinants and outcomes is often complex and includes 
factors such as wealth, distribution of income, status of the public 
health infrastructure, provision of medical care, and access to 
adequate nutrition. Therefore, the severity of future impacts will be 
determined by changes in climate as well as by concurrent changes in 
non-climatic factors and by policies implemented to reduce negative 
impacts. It is important to note that even if total burdens of some 
climate-sensitive health outcomes decrease in the future, the 
attributable burden due to climate change is projected to increase.
    The Climate Change Science Program is coordinating the development 
of 21 synthesis and assessment products to enhance scientific 
understanding of the potential impacts of climate change. The U.S. 
Environmental Protection Agency is the lead agency for the development 
of Synthesis and Assessment Product 4.6 ``Analyses of the effects of 
global change on human health and welfare and human systems.'' The 
third draft will be posted in April 2008 (www.climatescience.gov). 
Included in this assessment is a chapter on the potential health 
impacts of global change.
    An assessment of the potential impacts of climate variability and 
change on human health was published in 2000 as part of the First 
National Assessment of the Potential Impacts of Climate Variability and 
Change undertaken by the U.S. Global Change Research Program. This 
Health Sector Assessment examined potential impacts and identified 
research and data gaps to be addressed in future research; results 
appeared in a special issue of Environmental Health Perspectives (May 
    Ebi, et al. (2006a) updated this assessment and concluded that 
climate change poses a risk for U.S. populations, with uncertainties 
limiting quantitative projections of the number of increased injuries, 
illnesses, and deaths attributable to climate change. Future climate 
change could increase heat-related mortality, increase the number of 
cases of diarrheal diseases, and increase mortality from diseases 
exacerbated by high concentrations of ozone and by aeroallergens. 
Trends in factors that affect vulnerability, such as a larger and older 
U.S. population, will increase overall vulnerability to these health 
risks, which currently cause injuries, illnesses, and deaths in the 
United States. In addition, the U.S. population may be at risk from 
climate-related diseases and disasters that occur outside her borders, 
with travelers and refugees importing diseases not currently present. 
The unprecedented nature of climate change also may bring surprises for 
public health.
    The capacity of the United States to develop and deploy effective 
and timely policies to address climate change is assumed to remain high 
throughout this century, thus reducing the likelihood of severe health 
impacts if appropriate programs and activities are implemented. 
However, the nature of the risks posed by climate change means that 
some adverse health outcomes may not be avoidable.
Extreme Weather Events
    Heatwaves affect human health via heat stress, heatstroke, and 
death, as well as exacerbations of underlying conditions that can lead 
to an increase in mortality from all causes of death (not just 
heatstroke). Older adults, children, city-dwellers, the poor, and 
people taking certain medications are at the highest risk during a heat 
wave. The number of heat-related deaths are projected to increase with 
climate change (Confalonieri et al. 2007).
    Recent projections of the impacts of climate change on heat waves 
in the Midwest, using two definitions of a heat wave (the warmest 
average minimum temperatures over 3 consecutive nights in a given year, 
and exceedance of particular thresholds, suggested an increase in the 
average heat wave frequency of about 24 percent for Chicago (from 1.7 
to 2.1 heat waves per year); 50 percent for Cincinnati (from 1.4 to 2.1 
heat waves per year); and 36 percent for St. Louis (from 1.4 to 1.9 
heat waves per year) (Ebi and Meehl 2007). The average duration of heat 
waves was projected to increase by 21 percent for Chicago (from 7.3 to 
8.8 days); by 22 percent for Cincinnati (from 8.8 to 10.7 days); and by 
38 percent for St. Louis (from 10.3 to 14.2 days). Combining changes in 
duration and intensity of heat waves implies an overall increase of 
about 70 percent in the annual number of heat wave days for the Midwest 
by the late 21st century. Moreover, these extreme days will be hotter 
on average than at present. The projections also suggested that areas 
such as the Northwest, where heat waves are not severe at present and 
where use of air conditioning is less common, future increases in heat 
wave intensity could result in more heat-related illnesses and deaths.
    Hayhoe et al. (2004), the most recent study focused on the United 
States, projected the impacts of extreme heat on heat-related mortality 
in California. Taking some acclimatization into account (but no change 
in the prevalence of air conditioning), assuming a linear increase in 
heat-related mortality with increasing temperature, and assuming no 
change in the population, expected heat-related deaths in Los Angles 
were projected to increase (from a baseline of about 165 excess deaths 
annually) two- to three-fold under a low emission scenario and five- to 
seven-fold under a high emission scenario by 2070-99.
    Climate change is projected to increase the intensity and frequency 
of floods, droughts, and windstorms in many regions (IPCC 2007a). The 
impacts of an extreme event, including loss of life and livelihood, are 
determined by the physical characteristics of the event, attributes of 
the location affected, and interactions of these with human actions and 
social, economic, institutional, and other systems. The adverse health 
consequences of flooding and windstorms often are complex and far-
reaching, and include the physical health effects experienced during 
the event or clean-up process, or from effects brought about by damage 
to infrastructure, including population displacement. The physical 
effects largely manifest themselves within weeks or months following 
the event, and may be direct (such as injuries) and indirect (such as 
water and food shortages and increased rates of vector-borne and other 
diseases). Extreme weather events are also associated with mental 
health effects, such as post-traumatic stress disorder, resulting from 
the experience of the event or from the recovery process. These 
psychological effects tend to be much longer lasting and may be worse 
than the direct physical effects.
Infectious Diseases
    Climate change will likely have mixed effects on the health burdens 
of infectious diseases. Climate is a primary determinant of whether a 
particular location has environmental conditions suitable for the 
transmission of several vector-, rodent-, and tick-borne diseases, 
including West Nile virus, St. Louis encephalitis, Lyme disease, and 
dengue. A change in temperature may hinder or enhance vector and 
parasite development and survival, thus lengthening or shortening the 
season during which vectors and parasites survive. Small changes in 
temperature or precipitation may cause previously inhospitable 
altitudes or ecosystems to become conducive to disease transmission (or 
cause currently hospitable conditions to become inhospitable). The many 
determinants of infectious diseases often form an interconnected web 
with positive feedbacks between transmission dynamics and other 
factors, making modeling of the impacts of climate change challenging.
    Several food- and waterborne diseases are climate sensitive, 
suggesting that climate change may affect their incidence and 
distribution. For example, studies report an approximately linear 
association between temperature and common forms of foodborne diseases 
such as salmonellosis (Confalonieri et al. 2007).
Air Pollutants
    Climate change may increase concentrations of selected air 
pollutants, particularly ozone in some regions, and decrease 
concentration of other pollutants, such as particulate matter. Air 
pollution concentrations are the result of interactions among local 
weather patterns, atmospheric circulation features, wind, topography, 
and other factors. Climate change might affect local to regional air 
quality directly through changes in chemical reaction rates, boundary 
layer heights that affect vertical mixing of pollutants, and changes in 
synoptic airflow patterns that govern pollutant transport. Indirect 
effects may result from increasing or decreasing anthropogenic 
emissions via changes in human behavior, or from altering the levels of 
biogenic emissions because of higher temperatures and land cover 
change. Establishing the scale (local, regional, global) and direction 
of change (improvements or deterioration) of air quality is 
    There is extensive literature documenting the adverse health 
impacts of exposure to elevated concentrations of air pollution, 
especially particulates with aerodynamic diameters under 10 and 2.5 
micrometers, ozone,\1\ sulphur dioxide, nitrogen dioxide, carbon 
monoxide, and lead. More is known about the potential impact of climate 
change on ground-level ozone than on other air pollutants. Changes in 
concentrations of ground-level ozone driven by scenarios of future 
emissions and/or weather patterns have been projected for Europe and 
North America (Confalonieri et al. 2007). Increases in ozone 
concentrations will likely increase respiratory problems in susceptible 
individuals. Based on projections of county-level pollutant 
concentrations, summer ozone-related mortality was projected to 
increase by 4 percent in the New York area by the 2050s based on 
climatic changes alone (Knowlton et al. 2004).
    \1\ The aerodynamic diameter of a particle determines the depth to 
which it will be inhaled into the lungs, and, therefore, the degree of 
damage that may be caused to various parts of the lung.
Global Assessments of the Health Impacts of Climate Change
    Two studies have estimated the aggregated global health burdens 
attributed to climate change. Hitz and Smith (2004) reviewed the 
literature on the projected health impacts of climate change and 
concluded that health risks are more likely to increase than decrease 
with increasing global mean surface temperature, particularly in low 
latitude countries. In addition to greater vulnerability to climate, 
these countries have some of the highest populations, tend to be less 
developed, and generally have poorer public health infrastructure, 
suggesting greater damages.
    In the most comprehensive evaluation of the health burden due to 
climate change, McMichael et al. (2004) used a comparative risk 
assessment approach as part of the Global Burden of Disease study to 
project total health burdens between 2000 and 2030 and to project how 
much of this burden might be avoided by stabilizing greenhouse gas 
(GHG) emissions. The health outcomes included were chosen based on 
sensitivity to climate variation, predicted future importance, and 
availability of quantitative global models (or feasibility of 
constructing them). Specific health outcomes included were episodes of 
diarrheal disease, cases of Plasmodium falciparum malaria, fatal 
unintentional injuries in coastal floods and inland floods/landslides, 
and non-availability of recommended daily calorie intake (as an 
indicator for the prevalence of malnutrition). Inclusion of a limited 
number of health outcomes suggests that the estimated impacts are 
likely to be underestimates. In the year 2000, climate change-related 
changes in temperature, precipitation, and other weather variables were 
estimated to have caused the loss of more than 150,000 lives (0.3 
percent of worldwide deaths) and 5,500,000 Disability Adjusted Life 
Years (DALYs) \2\ (0.4 percent worldwide), with malnutrition accounting 
for approximately 50 percent of these deaths and DALYs. These estimates 
are for a period when limited climate change occurred, suggesting 
larger health burdens in the near future.
    \2\ DALYs are a metric used to express how a healthy life is 
affected by disease; it combines the years lost because of premature 
death and disability.
    The projected relative risks attributable to climate change in 2030 
vary by health outcome and region, and are largely negative, with the 
majority of the projected health burden due to increases in diarrheal 
disease and malnutrition, primarily in low-income populations already 
experiencing a large burden of disease. Absolute health burdens depend 
on assumptions of population growth, future baseline disease incidence, 
and the extent of adaptation.
Particularly Vulnerable Populations and Regions
    Vulnerability to climate change will vary between and within 
populations. Sub-populations that are most vulnerable to the health 
impacts of climate change depend on the region of interest, the health 
outcome, and population characteristics, including human, 
institutional, social, and economic capacity, distribution of income, 
provision of medical care, and access to adequate nutrition. In 
general, children, older adults, those with chronic disease, and the 
poor and disadvantaged are most at risk.


    Adaptation and mitigation are the primary approaches for addressing 
the risks of climate change, with mitigation focusing on reducing 
greenhouse gas emissions to limit longer-term climate change and 
adaptation typically focusing on measures to reduce impacts in the 
shorter term due to the climate change to which Earth is already 
committed. Mitigation and adaptation are not mutually exclusive; co-
benefits to human health can result concurrently with implementation of 
mitigation actions. Neither is sufficient in itself; focusing only on 
mitigation would leave communities ill-prepared for changes expected in 
the short term; and focusing only on adaptation would increase the 
amount of climate change to which future societies would need to cope.
    Viewing adaptation within a risk management framework highlights 
some of the key differences between climate change and other 
environmental risk factors, including that the exposure cannot be 
prevented (i.e. increases in the frequency, intensity, and length of 
many extreme weather events); the rate of change is likely to increase 
over the next several decades; and the risks will vary over temporal 
and spatial scales, with the extent of impacts dependent on local and 
national factors. Therefore, adaptation will be a continual process of 
attempting to prevent adverse impacts from changing exposures and 
    Climate change will make more difficult the control of climate-
sensitive health determinants and outcomes. Therefore, health policies 
need to explicitly incorporate climate-related risks in order to 
maintain current levels of control. In most cases, the primary response 
will be to enhance current health risk management activities. The 
health determinants and outcomes that are projected to increase with 
climate change are problems today. In some cases, programs will need to 
be implemented in new regions; in others, climate change may reduce 
current infectious disease burdens. The degree to which programs and 
measures will need to be augmented to address the additional pressures 
due to climate change will depend on factors such as the current burden 
of climate-sensitive health outcomes, the effectiveness of current 
interventions, projections of where, when, and how the health burden 
may change with changes in climate and climate variability, the 
feasibility of implementing additional cost-effective interventions, 
other stressors that might increase or decrease resilience to impacts, 
and the social, economic, and political context within which 
interventions are implemented (Ebi et al. 2006b). Examples of 
adaptation measures range from developing and deploying early warning 
systems and emergency response plans that specifically incorporate 
projections of climate change-related health risks to establishing 
surveillance programs in regions where projections suggest disease 
vectors may change their geographic range. Adaptation policies and 
measures need to consider how to effectively and efficiently reduce 
climate-related health risks in the context of sustainable development, 
considering projected demographic, economic, institutional, 
technologic, and other changes.
    Because fossil fuel combustion is a source of urban air pollutants 
and greenhouse gases, policies to reduce greenhouse gas emissions may 
have health benefits in the near- and long-term. There are potential 
synergies in reducing greenhouse gas emissions and improving population 
health via sustainable transport systems that make more use of public 
transport, walking, and cycling.

                          IN THE UNITED STATES

    A severe limitation to understanding current and projecting future 
health impacts of climate change in the United States is the very low 
level of research aimed at providing quantitative projections of the 
number of increased injuries, illnesses, and deaths that could be 
attributable to climate change. There is increasing interest by local 
and State public health agencies in understanding their climate change 
risks. However, the National Research Council, in its report 
``Evaluating Progress of the U.S. Climate Change Science Program: 
Methods and Preliminary Results'' (2007), concluded that the U.S. 
Climate Change Science Program lags in understanding the human health 
impacts of climate change. Further, efforts to understand climate 
change impacts on society, to analyze mitigation and adaptation 
strategies, and to study regional impacts are ``relatively immature.'' 
It was recommended that the Climate Change Science Program adjust the 
balance between climate science and application. That re-balancing has 
not yet taken place.
    Citing urgent threats including climate change, Centers for Disease 
Control and Prevention (CDC) Director Julie Gerberding advocated in 
March 2008 for an increase in CDC funding. Instead, the President's 
fiscal year 2008 budget cut CDC funding by 2.8 percent of what would 
maintain 2007 funding levels adjusted for inflation. The proposed 
fiscal year 2009 budget will cut CDC funding further. Dr. Frumkin, the 
Director of the Division of Environmental Hazards and Health Effects at 
CDC, stated in March 2007 that the ``public health effects of climate 
change remain largely unaddressed.''
    Significantly greater funding on climate change issues by the 
European Commission has resulted in greater understanding of the health 
risks of and public health responses to climate change in the European 
Union, including projections of health impacts at local and regional 
levels, as well as implementation of public health policies and 
measures to address these projected risks.


    Realistically assessing the potential health effects of climate 
change must include consideration of the capacity to manage new and 
changing climatic conditions. Individuals, communities, governments, 
and other organizations currently engage in a wide range of actions to 
identify and prevent adverse health outcomes associated with weather 
and climate. Although these actions have been largely successful, 
recent extreme events and outbreaks of vector-borne diseases highlight 
areas for improvement. Further, climate change is projected to 
challenge the ability of current programs and activities to control 
climate-sensitive health determinants and outcomes (Confalonieri, et 
al. 2007). Preventing additional morbidity and mortality requires 
evaluation of programs and activities in light of climate change 
projections to identify modifications that will increase resilience to 
the full range of health risks that may arise with climate change, and 
to ensure that these modifications reduce the sensitivity of those 
populations and regions most at risk. The effectiveness of these 
programs and measures will depend on the local context, including 
socio-economic, geographic, and other factors.
    The risks of climate change are likely to place extraordinary 
demands on public health programs and activities designed to protect 
the health and safety of U.S. residents and visitors. Increases in 
illnesses, injuries, and deaths would be expected 
unless policies and measures are developed to ensure effective 
functioning of these programs and activities. National, State, and 
local plans are needed to ensure sufficient public health capacity 
during and following extreme events such as flooding, storms and storm 
surges, and to address outbreaks of climate-related outbreaks of 
vector-, food-, and waterborne diseases. This capacity must be present, 
consistent, and effective in analyzing the safety of drinking water, 
monitoring for the appearance of vector-borne diseases, and providing 
acute and chronic care for persons suffering from the effects of 
climate-related events. Constraints include the financial, human, and 
institutional capacity at all levels of government and institutional 
service providers.
    In his testimony, Dr. Balbus will discuss the results of a survey 
of the level of awareness of climate change risks by local public 
health departments and the extent to which they have begun to address 
those risks. The results suggest that there remains limited knowledge 
of the potential health impacts of climate change. Local public health 
officials are only beginning to recognize the risks and to implement 
policies to reduce current impacts and those projected to occur over 
the short and long term.


    Health security in the United States is influenced by risks outside 
her borders, as illustrated by the introduction and spread of West Nile 
virus and the concerns over the possible spread of SARS in the United 
States. Globalization, increased travel and trade, immigration, and 
other factors can introduce new health risks, and disasters can 
increase the flow of refugees. Plasmodium vivax malaria, dengue fever, 
and other vector-borne diseases were once prevalent in the United 
States, and the mosquitoes that can carry these diseases remain common 
in the United States. Climate change is providing an opportunity for 
these mosquitoes to increase their geographic range; this could put 
more people at risk for introduced diseases if vector control programs 
are insufficient or not prepared. Better understanding of how climate 
change could alter the current distribution and incidence of climate-
sensitive health outcomes throughout the world is needed to ensure 
U.S.-based programs and activities have adequate knowledge and 
resources to protect the health of our citizens.


    The policies and technologies being developed to reduce the risks 
of climate change, from energy efficiency policies to carbon capture 
and storage, may have considerable health consequences. Therefore, a 
mechanism is required to assess the consequences of proposed mitigation 
and adaptation policies and measures prior to their adoption. Health 
Impact Assessments (HIAs) are a proven approach to ensuring that 
potential public health concerns are identified and addressed before 
they become a problem. According to the World Health Organization, 
``HIA provides decisionmakers with information about how any policy, 
programme or project may affect the health of people. HIA seeks to 
influence decisionmakers to improve the proposal.'' (http://
www.who.int/hia/en) HIAs includes consideration of potential 
alternatives to reduce or mitigate potential health consequences of a 
proposed policy, as well as monitoring and evaluation of the adopted 
policy's implementation, to make corrections as needed to ensure the 
policy's effectiveness and its protection of human health. HIAs also 
can be used to identify the co-benefits of smart growth and development 


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    Lopez, A. Rodgers and C. Mathers. Geneva, WHO: 1543-1649.
National Research Council (2001). Under the Weather: Climate, 
    Ecosystems, and Infectious Disease. Washington, DC., National 
    Academy Press.
National Research Council (2007). Evaluating Progress of the U.S. 
    Climate Change Science Program: Methods and Preliminary Results. 
    Washington, DC, National Academy Press.
Swiss, Re (2004). Natural Catastrophes and Man-Made Disasters in 2003. 
    Sigma 1/2004.

    The Chairman. Good. Dr. Balbus.


    Dr. Balbus. Good morning, Chairman Kennedy and Ranking 
Member Enzi, and thank you very much for having this hearing 
today during National Public Health Week. I chair a small 
climate change task force for the American Public Health 
Association, and we are very delighted to be able to air these 
issues and have this discussion this week.
    I am the Chief Health Scientist for the Environmental 
Defense Fund, which is an environmental nonprofit organization 
that has been working for over two decades on the issue of 
climate change. We could not agree more, that polarization is a 
damaging thing for making progress on the issues that we face, 
and we focus on economically sound and nonpartisan science-
based solutions to environmental problems.
    My goals in testifying today are really two-fold. First, to 
convince you that increased attention and resources are needed 
in order to increase and ensure public health preparedness for 
the problems that climate change will be bringing. Second, that 
public health professionals need to be more engaged in the 
monumental challenge ahead of us of reducing greenhouse gas 
emissions, both as communication and behavior change experts 
and also as health-risk assessors to help steer our energy, 
transportation, and land use policies toward a state of healthy 
sustainability. I have specific recommendations toward those 
    I just want to mention two other pieces of work. In order 
to better understand the current state of preparedness, the 
Environmental Defense Fund collaborated with the National 
Association of City and County Health Officials and also with 
the George Mason University to conduct a survey of a 
representative sample of local public health departments around 
the country.
    Most of the health department directors were aware of 
climate change as an issue and felt that it was going to affect 
their jurisdiction, but relatively few reported that climate 
change was either a top priority or an area in which they felt 
that they had adequate resources or expertise. There is a gap 
there between the recognition and their ability to respond to 
    Second is an example of health-risk assessment supporting 
this kind of policy decisionmaking. We have also conducted a 
preliminary analysis of the ancillary health benefits that 
would come from just the particulate matter reduction 
associated with specific greenhouse gas emission reduction 
measures, which are on the table now.
    We only have very preliminary results, but they suggest the 
ancillary benefits are on the order of $10 billion to $30 
billion per year by the year 2020, looking at just the health 
effects of the particulate matter reductions.
    The health threat of climate change is emerging in a 
context of declining support for public health preparedness in 
general. This isn't just about climate change. It is about 
public health preparedness for the country in general. Of 
course, many of the measures that we need to improve the health 
resilience for climate change effects are the same ones that we 
need for preparedness for bioterrorism, pandemic influenza, and 
the natural disasters we know we are going to be facing.
    In addition to us using an adaptation to changes in climate 
to which the planet is already committed, public health has 
crucial roles to play in preventing the more severe impacts of 
climate change and helping us to optimize the policy measures 
implemented to reduce greenhouse gases. The work we are doing 
indicates that the readiness of the public health community to 
take on this challenge is there if given the needed resources.
    Thank you very much.
    [The prepared statement of Dr. Balbus follows:]

           Prepared Statement of John M. Balbus, M.D., M.P.H.


    While it is essential that we strengthen the resilience of 
communities and individuals against the health threats that will be 
associated with climate change, public health also has critical roles 
to play in reducing greenhouse gas emissions and thereby preventing the 
more severe impacts of unchecked climate change, and also in enhancing 
public health by identifying those climate change policies that provide 
the greatest ancillary benefits for health.
    Global climate change currently contributes to disease and 
premature deaths across the planet, and these impacts are likely to 
increase with progressive warming and other changes in climate. 
Although the health impacts of climate change will be less severe in 
the United States than in poorer countries, the U.S. public health 
infrastructure may not be adequately prepared to address the health 
effects of climate change.
    In order to better understand the current state of preparedness for 
health effects of climate change, Environmental Defense Fund (EDF) 
collaborated with the National Association of City and County Health 
Officials and George Mason University to conduct a survey of a 
representative sample of local health departments from around the 
country. Most health department directors believed that climate change 
was an important threat, yet relatively few reported that climate 
change was a top priority for their health department. Most directors 
also perceived a lack of required expertise to prepare for climate 
change impacts.
    Because public health can not protect the population from all 
anticipated climate-related health threats, prevention of the more 
severe impacts through reduction of greenhouse gas emissions is a 
health imperative. The public health community has expertise in social 
marketing and behavioral change that should be called upon to assist 
the Nation in meeting greenhouse gas reduction goals.
    Climate change policies can provide immediate and short-term health 
and economic benefits. Measures that reduce fossil fuel combustion can 
reduce both carbon dioxide and criteria air pollutant generation at the 
same time. In addition to air pollution effects, there are other types 
of health effects associated with options for greenhouse gas reduction 
policies. Preliminary results of an EDF study of specific greenhouse 
gas reduction measures suggest the ancillary benefits resulting from 
just the associated particulate matter reductions could be substantial.
    In addition to assisting in adaptation to changes in climate to 
which the planet is already committed, public health has crucial roles 
to play in preventing the more severe impacts of climate change and 
optimizing the policy measures implemented to reduce greenhouse gas 
emissions. Our work indicates the readiness of the public health 
community to take on these challenges if given the needed resources.


    Protect, Prevent and Enhance. This is the bottom line of our 
report, discussed below, that will be released later this month on 
climate change and public health. I start with these three words to 
emphasize that public health has more than one critical role to play 
with respect to climate change. While it is essential that we 
strengthen the resilience of communities and individuals against the 
health threats that will be associated with climate change, public 
health also has critical roles to play in reducing greenhouse gas 
emissions and thereby preventing the more severe impacts of unchecked 
climate change, and also in enhancing public health by identifying 
those climate change policies that provide the greatest ancillary 
benefits for health.


    Global climate change currently contributes to disease and 
premature deaths across the planet, and these impacts are likely to 
increase with progressive warming and other changes in climate.\1\ The 
World Health Organization estimates that climatic changes are already 
causing more than 150,000 deaths and about 5 million disability 
adjusted life years lost per year due to diarrheal disease, malaria, 
malnutrition, and flooding. This burden is borne mostly by poor 
countries in Asia and Africa.\2\
    Health impacts are usually divided into those that result directly 
from warmer temperatures and extreme weather, like heat stress, and 
those that result indirectly through climate and weather impacts on 
atmospheric chemistry (like increased ozone air pollution) or other 
forms of life (like bacterial or insect-borne infectious diseases).
    More frequent and severe heat waves,\3\ \4\ hurricanes, wildfires, 
and floods will cause deaths and injury \5\ while simultaneously 
damaging health infrastructure.\6\ Behavioral \7\ and emotional \8\ 
responses to these disasters, contact with contaminated floodwater,\9\ 
and displacement contribute to additional morbidity and mortality.
    Warmer temperatures will favor formation of ozone air pollution; 
higher CO2 and other climate changes may increase allergenic 
pollen formation.\10\ \11\ \12\ These effects are likely to worsen 
asthma and allergic diseases. Ozone air pollution also has been 
associated with premature mortality from cardiovascular causes.
    Climate-related increases in disasters and warmer ambient 
temperatures could increase the burden of food- and water-borne 
diseases (for example infections from Salmonella,\13\ Campylobacter 
\14\ Vibrio species,\15\ \16\ Leptospira,\17\ Giardia,\18\ and 
Cryptosporidium \19\).
    Some health effects of climate change will be unpredictable. For 
example, climate change could contribute to the emergence of novel or 
foreign diseases like the pathogenic fungus Cryptococcus gattii that 
recently emerged in British Columbia.\20\ In this instance, a lethal 
fungus that had been confined to Australia killed several people in 
British Columbia and Washington State after emerging during an unusual 
period of wetter and then drier weather.
    And although the health impacts of climate change will be less 
severe in the United States than in poorer countries, the U.S. public 
health infrastructure may not be adequately prepared to address the 
health effects of climate change. The increasing burden of chronic and 
emerging diseases has added new responsibilities to already-
overburdened public health systems,\21\ but spending and hiring has not 
kept pace.\22\ The public health infrastructure that will respond to 
climate-related health threats remains seriously underfunded.\23\
 how well prepared for climate change is the u.s. public health system?
    The inadequate public health response to Hurricane Katrina,\24\ for 
example, raises concerns about our ability to address climate-related 
increases in the frequency and severity of disasters.\25\ A 2007 survey 
of local health departments on preparedness for public health disasters 
found that over three-quarters of the departments were not highly 
prepared, and over half reported that Centers for Disease Control and 
Prevention (CDC) funding was insufficient to meet the preparedness 
deliverables required of them.\26\ Between fiscal year 2002 and fiscal 
year 2007, CDC funding for all-hazards preparedness declined by nearly 
28 percent from $918 million to $665 million.\27\ Many cities at risk 
of heat waves have inadequate response plans or lack written planning 
entirely.\28\ Current disease surveillance and response capabilities 
are likely inadequate to effectively address novel and emerging spread 
of disease as may occur with climate change.\29\
    An updated nationwide climate change health sector assessment in 
2006 noted that while the United States has a high capacity to respond 
to climate change, little implementation of adaptive measures has been 
documented.\30\ The Director of the Division of Environmental Hazards 
and Health Effects at CDC asserted in March 2007 that the ``public 
health effects of climate change remain largely unad-
dressed.'' \31\

                           FOR CLIMATE CHANGE

    In order to better understand the current state of preparedness for 
health effects of climate change, EDF collaborated with the National 
Association of City and County Health Officials and George Mason 
University to conduct a survey of a representative sample of local 
health departments from around the country. Directors of local health 
departments were asked to discuss their perceptions of climate-
related health risks and the status and adequacy of their departments' 
programmatic activities in response to these risks.
    These public health professionals generally recognized the reality 
of climate change impacts. Nearly 70 percent believed that signs of 
climate change had already affected health problems in their 
jurisdiction, and 78 percent believed that climate change would have 
impacts on their jurisdiction over the next 20 years. Roughly 60 
percent believed that climate change would affect health in their 
jurisdiction over the next 20 years, and slightly over half of the 
directors felt the climate change was an ``important priority,'' yet 
relatively few health department directors surveyed reported that 
climate change was a top priority for their health department. Only 19 
percent of respondents indicated that climate change was among their 
department's top 10 current priorities, and only 6 percent indicated 
climate change was one of their health department's current top five 
    This lack of high prioritization of climate change health impacts 
was accompanied by a lack of perceived expertise to prepare for them. 
Seventy-seven percent of local health directors felt they lacked the 
expertise to assess local health impacts of climate change in their 
region, and 82 percent felt they lacked the expertise to craft 
adaptation plans. Local health directors did not perceive that much 
help would come from the State or Federal public health agencies. Only 
26 percent felt their State had the needed expertise to assist with 
adaptation plans, while only 34 percent believed the CDC had such 
expertise. In addition to lacking expertise, 77 percent of the 
directors felt they lack necessary resources to address climate-related 
health threats, with additional funding and staff most frequently cited 
as being needed. The report concludes that additional funding is 
necessary to increase public health resiliency for climate change, and 
that the programs needed for climate change effects have synergy and 
overlap with those needed for other preparedness needs, including 
bioterrorism, emerging infectious diseases, and existing weather 
    Our findings were very similar to those from a survey of local 
public health officers from the State of California that was released 
in February 2008 by the Public Policy Institute. In this survey, 94 
percent of local health officers perceived climate change to be a 
serious threat to public health, with extreme weather events, wild 
fires, air pollution, vector-borne illnesses, and heat stress 
identified as the climate-related health problems of greatest concern. 
And yet in California, only 24 percent of respondents were aware of 
programs in their departments that were developed with climate change 
in mind.
Public Health has a Role in Reducing Greenhouse Gas Emissions as Well
    The American Public Health Association, in its newly revised policy 
on global climate change, states,

          ``The public health community must communicate the critical 
        importance of primary prevention, namely the mitigation of 
        climate change, in addition to preparing to provide secondary 
        and tertiary prevention of climate change health effects.''

    This is out of recognition that there are likely to be a number of 
``tipping points'' for climate-related health effects in different 
parts of the world, beyond which protecting populations will be 
extremely challenging. The most imminent appears to be triggering and 
initiating irreversible melting of the Greenland ice sheet, which would 
ultimately lead to inundation of low-lying coastal areas and massive 
population displacement with attendant health problems of refugees. 
Similar tipping points may exist for severe droughts and consequent 
crop failure, or ecosystem disruption and infectious diseases. 
Identifying such climate thresholds for public health is extremely 
challenging, and I was unable to identify any publications in this 
area. However, the Intergovernmental Panel on Climate Change (IPCC) in 
its Summary for Policy Makers from Working Group II notes a number of 
health drivers that either greatly increase in risk with increasing 
temperature rise, such as species extinctions and significant ecosystem 
disruption. \32\ In the case of food production, the direction of 
change is anticipated to go from an increase to a global decrease with 
temperature increases above 1.5-2.5 C.\33\ Given the enormous 
difficulty accommodating coastal flooding and declines in food supply, 
preventing temperature increases above these thresholds is imperative 
from a global public health standpoint.
    Identifying the need to reduce greenhouse gas emissions to avoid 
the most dangerous outcomes is one thing; achieving the necessary 
modifications in personal behaviors is another. This is one area in 
which the expertise of public health professionals can assist in 
preventing more severe climate change. Public health has to tackle 
complex personal behavior problems as a matter of course. Examples 
include early efforts at smoking cessation, use of condoms and other 
changes in sexual practice, and discouraging drug use. This expertise 
in social marketing and behavioral change should be called upon to 
assist the Nation in meeting greenhouse gas reduction goals.

                      HEALTH AND ECONOMIC BENEFITS

    The recognition that policies that reduce greenhouse gas emissions 
will have both positive and negative ancillary effects on public health 
is not new. Because carbon dioxide and criteria air pollutants such as 
particulate matter, ozone (and its precursors nitrogen oxides and 
volatile organic compounds) and sulfur dioxide are all produced by 
fossil fuel combustion, measures that reduce fossil fuel combustion can 
reduce both carbon dioxide and criteria air pollutant generation at the 
same time. In addition, technologies designed to separate and capture 
carbon dioxide will facilitate the separation and removal of toxic air 
pollutants as well. Several studies estimating ancillary health 
benefits of climate change policies were released at the beginning of 
this decade, but there has been relatively little development of this 
literature since, and this important point has been more or less absent 
from recent debates regarding greenhouse gas reduction policies. 
Especially with an ongoing discussion of the economic costs of meeting 
greenhouse gas reduction goals, it is all the more important that the 
public health community seize the opportunity to identify and assess 
the ancillary benefits and costs of different greenhouse gas reduction 
    While most analyses have focused on the ancillary benefits related 
to reductions in toxic air pollution, there are a range of other types 
of health effects associated with options for greenhouse gas reduction 
policies. For example, transportation policies that augment the use of 
public transportation or provide safer and more convenient means for 
individuals to walk or bicycle provide co-benefits not just related to 
any reductions in toxic air pollution that may result from reduced 
personal automobile use, but also co-benefits resulting from the 
increases in physical activity. With the ongoing epidemic of obesity 
and diabetes in this country, greater understanding of the potential 
for such synergies between climate and public health goals is 
critically needed.
    EDF has conducted a preliminary analysis of ancillary health 
benefits accruing from just the particulate matter reductions 
associated with greenhouse gas reduction policies. We have looked at 
specific categories of greenhouse gas reductions, using a ``wedge-
based'' approach similar to that developed by Professors Pacala and 
Sokolow in their seminal 2004 Science Paper.\34\ We updated our 
baseline emissions scenarios to reflect major air pollution reduction 
rules such as the Clean Air Interstate Rule. Assuming full 
implementation of these air pollution reductions means that ancillary 
benefits from further reductions related to climate change policies are 
far smaller than they would be were air pollution emissions to remain 
constant into the future. Nonetheless, our preliminary results suggest 
the ancillary benefits could still be substantial. The total economic 
benefits in the year 2020 associated with improved fuel efficiency and 
reductions in projected miles driven for heavy duty vehicles, for 
example, were estimated at $8.7 billion. For a cluster of electric 
utility substitutions for coal-fired power plants, the total economic 
benefits were estimated to be over $32 billion. These results are 
preliminary, and a good deal of additional modeling studies are needed 
to gain confidence in such numbers, but these health benefits must not 
be forgotten in the debates over how we go about reducing greenhouse 
gas emissions. And it must be emphasized that the health benefits 
associated just with reduced particulate air pollution are not the only 
significant positive health and economic outcomes associated with 
greenhouse gas reductions. Health benefits from reductions in other air 
pollutants and from policy measures that improve physical activity 
profiles will also be substantial.


    The growing threat to public health from climate change is emerging 
in the context of declining support for public health preparedness in 
general. Many of the measures needed to improve health resilience for 
climate change effects are the same as those needed for preparedness 
for bioterrorism, pandemic influenza and other viral infections, and 
natural disasters. These include improved modeling and assessment 
capacity, enhanced and integrated monitoring and surveillance networks, 
and development of rapid response units. But in addition to assisting 
in adaptation to changes in climate to which the planet is already 
committed, public health has crucial roles to play in preventing the 
more severe impacts of climate change and optimizing the policy 
measures implemented to reduce greenhouse gas emissions. Our work 
indicates the readiness of the public health community to take on these 
challenges if given the needed resources.


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Science. 2004 Aug 13;305

    The Chairman. Thank you.
    Ambassador McDonald.


    Ambassador McDonald. Thank you, Mr. Chairman. It is an 
honor and a privilege to be with you today. I totally agree 
with my three fellow panelists on the points that they have 
been making.
    From my perspective and since we are the world's greatest 
polluters, the best way to reduce the impact on individuals in 
this country is to develop a policy on climate change and make 
it happen. I would urge that we take a look at the U.N. 
Conference in Bali last November and see if we can join the 
rest of the world and sign up and start acting.
    My own involvement in this basic issue of water and 
sanitation, which is certainly a part of climate change today, 
started way back in 1978. I tell people when I talk about this, 
that this glass of water, which is clear and clean and 
beautiful, is a miracle to well over a billion people in the 
developing world. And as the Senator stated, there are ways and 
means that we can do something about this.
    In 1978, I came back to Washington, DC, from Geneva, and 
this committee will be pleased to know that I was Deputy 
Director General of the International Labor Organization, one 
of your concerns on this committee, for 4 years. I read a 
document from the U.N. water conference in 1977, and there was 
one paragraph in about 100 recommendations for an action which 
said there should be a 10-year period, a decade, focused on 
drinking water sanitation.
    While I was at the State Department, I plucked out this one 
paragraph and then, in the next year and a half, was able to 
present my resolution to carry that out to the United Nations 
General Assembly and the first U.N. decade on water and 
sanitation was adopted and started in 1981.
    At the end of that decade, according to WHO figures, 1.1 
billion people in the world got access to safe water. Seven 
hundred and sixty-nine million people got access to sanitation. 
These are massive figures, major steps forward was taken by 
putting our focus on that particular issue. Then it dropped off 
the radar screen for a dozen years or more.
    In 2002, now I, as a private citizen, thought maybe we 
should have a second water decade. And so, I picked up on 
recommendations and said the world shall reduce by half by 2015 
the number of people in the world without access to water and 
sanitation. I had to get a government, of course, to introduce 
that resolution at the General Assembly. I went to my friends 
at the State Department, who patted me on the head and said, 
``no, thank you'', with no interest. I went to eight other 
countries during that time, no success. They were all from the 
    Finally, in August 2003, I went to the government of 
Tajikistan, who had set up a year on fresh water and knew the 
subject and knew the issues. With their help and the help of 
many other people, the General Assembly adopted the second 
water decade called Water for Life on December 23, 2003. It was 
launched on Water Day 2005.
    The world was recognizing this issue. Now what is exciting 
is that this Congress and this committee and many others began 
to recognize that something had to be done on a global scale, 
and at the end of 2005, the House passed a bill called the Paul 
Simon Water for the Poor Act. Then this esteemed body adopted 
it unanimously, and it was signed into law on December 1, 2005 
by Mr. Bush.
    Unfortunately, there was not one word in the press, TV, 
radio, anywhere. Not a single word about this momentous event, 
which was a major bipartisan act on the previous Congress.
    The idea was to focus on the rural poor, where the real 
problems lay. The State Department was responsible for carrying 
out this act. Last December, Congress and the President signed 
into law a bill allocating $300 million to carry out the Paul 
Simon Water for the Poor Act. Again, State Department level.
    Well, I have written three times to the State Department--
to Secretary Rice and never received a reply--urging that the 
State Department carry out this mandate, this law, now that 
they have money and appoint an ambassador-at-large, as I was 
appointed in the first decade, to focus on these issues and 
then to set up an ad hoc committee to advise that person how to 
    We are in a position for world leadership on this issue, 
which ties in directly with health issues, directly with the 
climate change because the worse the climate gets, the more 
difficult drinking water and sanitation will be for the entire 
world. I hope that this committee will push the State 
Department to take the action that has been mandated by law.
    Thank you very much.
    [The prepared statement of Ambassador McDonald follows:]

                 Prepared Statement of John W. McDonald


    All of the Nations of the world have agreed three times, at UN 
world conferences in 2000, 2002, and 2003 to reduce by half the number 
of people in the world without access to safe water and sanitation by 
the year 2015. The U.S. Congress has risen to this challenge by passing 
the Paul Simon Water for the Poor Act in December 2005 and December 
2007, allocating $300 million in order for the State Department to 
begin implementation of the Paul Simon Water for the Poor Act. The 
State Department's response has been inadequate.


    In 1977 the United Nations hosted a World Conference on Water. One 
of the many recommendations made by the Conference was to recommend a 
Decade focused on drinking water and sanitation. In 1978, as a career 
Foreign Service Officer working on U.N. economic and social affairs, I 
lifted that paragraph out of the larger World Conference document and 
decided to make that recommendation a reality. On November 10, 1980 the 
United Nations General Assembly adopted my resolution unanimously and 
the Decade was launched (1981-1990). I was named the U.S. Coordinator 
for the Decade by the State Department in 1979.
    Dr. Peter Bourne, a former White House Special Assistant to 
President Carter, was named United Nations Coordinator for the Decade 
in 1982, with the rank of Assistant Secretary General and was based in 
New York. The goal of the Decade was for all people in the world to 
have access to safe drinking water and sanitation. The Decade was very 
successful as it provided 1.1 billion people with access to safe water 
and 769 million people with access to improved sanitation.
    During this period, I traveled extensively to developing nations 
and saw first hand the problems that unclean water causes people to 
endure. Nothing I had ever seen in my life prepared me for the day I 
landed in Africa. I saw villages where people trekked miles in the hot 
sun just to get clean water for the day. Even more tragic were the 
children I saw suffering from the lack of clean water. Many seemed to 
be just hours from death, and others had lost their vision to trachoma, 
an easily preventable disease caused by contaminated water.

                              GLOBAL WATER

    In 1982, Dr. Peter Bourne and I founded GLOBAL WATER to help save 
the lives of people in developing countries that are lost due to 
unclean water.
    Global Water is based upon the belief that the lack of access to 
safe drinking water is the primary cause of hunger, disease and poverty 
throughout the world. Our program is designed to provide safe water 
supplies in rural villages to enable the rural poor to help themselves.
    To achieve this goal, Global Water's strategy is to provide 
permanent solutions to a region's water needs by providing appropriate 
equipment (to include state-of-the-art technology) to:

     Secure, purify, store and distribute new sources of water 
for domestic uses and agricultural purposes; and
     Drill new water wells to allow access to groundwater.

    Rather than providing short-term supplies like food and bottled 
water that are quickly consumed, GLOBAL WATER focuses on permanent 
solutions to a region's water needs. A handout fills a stomach for a 
few hours. Global Water enables entire villages to have clean, healthy 
water forever in order to change their lives--forever.
    Global Water is also a volunteer-based organization and therefore 
none of us receive a salary for what we do. All the money that is 
donated to Global Water goes right into water projects implemented by 
non-profit organizations in the developing countries, themselves (often 
referred to as nongovernmental organizations or NGOs). Working directly 
with NGOs, Global Water provides funding for specific projects (either 
partial or total), program management assistance, and technical support 
with water treatment technologies and equipment.
    Over the past 25 years, Global Water has developed a model called 
the ``Rural Outreach Water Supply (ROWS) Program.'' This model 
identifies local NGOs in developing countries that are already working 
with rural water supply projects to help complete Global Water 
projects. The ROWS model has worked well for implementing projects in 
remote villages in many challenging developing countries.
    To date, Global Water has carried out projects in Brazil, 
Guatemala, Honduras, Kenya, Laos, Liberia, Nicaragua, Romania, Somalia, 
South Africa, Sudan, Togo, Zaire, and Zimbabwe.
    And yet, over 1 billion men, women, and children (more than four 
times the population of the United States and Canada combined) do not 
have safe water to drink and therefore cannot live a healthy life. Who 
are these people?
    They are the innocent children and desperate families living in 
overcrowded urban ghettos, in refugee encampments, and in towns and 
villages too numerous to count in rural areas of developing countries.
    They are unfortunate victims of drought and ever-changing 
environmental conditions. When drought occurs, their countryside is 
transformed into an arid wasteland where every living thing seems to 
cry out for lack of water.
    They do not have enough water to grow and harvest food, enough 
water to keep their livestock alive, enough clean water to protect 
themselves and their children from hunger and disease.
    Worldwide hunger problems are really water problems.
    Without water, crops and livestock wither and die. People go hungry 
and become weak. Weakness allows disease to run its course and finally 
the ``Quiet Killer''--hunger, takes its toll.
    At this moment, many communities in over 50 countries throughout 
the world are suffering needlessly because water is either insufficient 
or polluted or may not exist at all. A sad irony is that many times 
there is life saving water just 100 feet away! Directly underground. So 
near, yet too far for people lacking the tools and knowledge to reach 
    With technologies ranging from simple and inexpensive to state-of-
the-art, Global Water is helping poor communities in developing 
countries find new supplies of clean, life-sustaining water. And when 
clean, fresh water begins to flow in a community--a whole new life 
begins--free from the threat of food shortages and a myriad of health-
related problems that are associated with hunger.
    Daily, tens of thousands of men, women, and children die from 
diseases directly related to drinking polluted water.
    Even if there is enough food to eat, families may still be slowly 
dying from another form of hunger called ``invisible hunger'' and it 
comes from drinking unsafe water. Waterborne parasites, received from 
drinking contaminated water, multiply continuously in already weakened 
bodies--robbing their hosts of the nourishment and energy they need to 
grow and develop normally.
    A full 80 percent of fatal childhood diseases that kill children 
and destroy families worldwide are caused--not by shortages of food and 
medicine--but by drinking contaminated water. When you think of 
fighting hunger, you may think only of emergency relief efforts 
bringing shipments of food. When you think of healing disease, you may 
think only of doctors, nurses and medicine.
    You can actually stop hunger, heal disease and save many thousands 
of precious lives with the simple gift of water. And long after a 
humanitarian relief effort has ended and temporary medical teams have 
gone--the gift of water continues to heal.
    Water can overcome poverty. Water is the lifeblood of a community. 
When water is unsafe to drink, the entire community suffers.
    Sick children lack the energy to learn and weak young men lack the 
drive to work hard--and so poverty continues. In many rural 
communities, it is the women and children who are responsible for 
locating and transporting water. Fulfilling this daily responsibility 
often leaves little or no time for women to pursue developmental 
opportunities and for the young to get an education--and so poverty 
    Nothing can change a community like providing a source of clean 
water for the first time. It creates a complete transformation. It has 
the power to actually stop the cycle of poverty. The entire community 
becomes healthier. For the first time, children become eager to learn 
while young men and women are able to work harder to produce an income 
and more food.
    Everyone can envision better futures and begin working towards 
them. Giving clean water to a poverty-stricken community is like giving 
a blood transfusion to a dying man. Water means new potential, new hope 
for a better tomorrow, and a new life.


    In 2002, now as a private citizen, because water and sanitation for 
health had fallen off the map as a critical issue, I decided it was 
time to launch a Second U.N. Water Decade. I drafted a U.N. Resolution 
which was designed to carry out the Millennium Development Goals, 
proclaimed at a U.N. World Conference in New York in 2000 focusing on 
water and sanitation for health. I focused on Millennium Development 
Goal #7 dealing with the environment which called on the world to 
reduce by half by 2015 the number of people in the world without access 
to safe water.
    In September 2002, the United Nations held its Third World 
Conference on the Environment in Johannesburg, South Africa and 
repeated the above goal, adding the word sanitation.
    I took my draft resolution to the State Department and asked if 
they would support this resolution in the U.N. General Assembly because 
a government has to introduce such a resolution. They refused. Over the 
course of the next year, I contacted seven other Western countries and 
asked the same question. They all refused.
    On August 1, 2003, I had a great idea. Because the Government of 
Tajikistan had launched a U.N. Year of Fresh Water in 2003, I 
approached the Ambassador of Tajikistan with my idea and he agreed, 
with the approval of his president, to introduce my resolution to the 
U.N. General Assembly. The Second U.N. Water Decade, ``Water for Life'' 
(2005-2015), was adopted on December 23, 2003 by the U.N. General 
Assembly and began on World Water Day, March 22, 2005.
    The United Nations has opened branch offices in Bonn, Germany and 
Zaragoza, Spain whose primary goal is to push the Second U.N. Water 
Decade to a successful completion of its mandate.

                        CONGRESSIONAL LEADERSHIP

    Congressman Blumenauer (D-Portland, OR) in 2002 returned from the 
Johannesburg Conference determined to focus U.S. Government attention 
on the drinking water and sanitation issue. Senator Frist (R-TN) 
returned from Mozambique in 2004 with the same determination. In 2005, 
many people, including myself and David Douglas, Chairman of an NGO in 
Washington, DC called Water Advocates, helped to push the Blumenauer 
bill through Congress. On November 10, 2005 the House passed the 
Blumenauer bill 319-34 and renamed it the ``Paul Simon Water for the 
Poor Act'' and passed the bill to the Senate. Senator Frist, in an act 
of statesmanship, withdrew his proposal and introduced the Blumenauer 
bill which was adopted unanimously by the Senate 1 week later.
    On December 1, 2005 President Bush signed into law the Senator Paul 
Simon Water for the Poor Act (H.R. 1973). For the first time in our 
history, the Department of State has made drinking water and sanitation 
a major foreign policy goal of the United States. I believe that to be 
properly implemented, H.R. 1973 requires an individual, with the rank 
of ambassador, to be appointed to the Office of the Under Secretary for 
Global Affairs in the State Department. This ambassador would 
coordinate development of strategy and oversee implementation of the 
new law. An Ad Hoc NGO Advisory Committee would also be put in place to 
advise the Ambassador on the development and implementation of 

                       STATE DEPARTMENT INACTION

    Because there was zero publicity about the Paul Simon Water for the 
Poor Act, I wrote Secretary Rice on December 30, 2005 and informed her 
of the act and my two recommendations for action, the Ambassadorial 
Post and the Advisory Committee. I did not receive a reply.
    In August 2006, I wrote Secretary Rice, again proposing my two 
ideas and saying that the State Department's June 1 report to Congress 
on the Water for the Poor Act was inadequate because it did not propose 
a future strategy as the law required. I did not receive a reply.
    In December 2007, the Congress allocated $300 million to implement 
the Paul Simon Water for the Poor Act. I wrote Secretary Rice a third 
time congratulating her and asking her to appoint an ambassador to 
manage these funds and to appoint an Ad Hoc Advisory Committee to 
advise the ambassador. I have not yet received a reply.


    I urge this distinguished committee to push the State Department 
for immediate implementation of the Paul Simon Water for the Poor Act.

    The Chairman. Thank you very much. That is an enormously 
interesting historical pathway that you have described. Very 
helpful in terms of the issues on safe water and I think very 
helpful to have that as part of our record.
    Dr. Patz, perhaps you could describe to us a little bit 
about what we are really talking about, the health 
implications? I want to get your assessment eventually about 
how prepared the public health community is in dealing with 
these issues. At some time, we will come to that. I think it is 
important to try and sort of get a little flesh on this body in 
terms of understanding what the real potential dangers are for 
Americans, for children, for elderly, for vulnerable people 
with these changes that are coming.
    There are a lot of committees that are considering what is 
causing these changes. Let us just assume that these changes 
are on their way, and public health is going to be presented 
with these challenges. As I understand, mosquitoes and dengue 
fever is moving up in Texas, for example, a place where it has 
never been sort of thought about or even kind of considered. 
What are some of these kinds of things that are on the horizon 
that you think are real?
    We are not trying to alarm the American people unduly, 
although this committee did take steps in bioterrorism before 
9/11, and we also want to be able to try and recognize that 
there are very, very important public health implications in 
terms of climate change. That hasn't been sort of a focus of 
the institution of the Senate just generally, and we want to 
try and relate it in real terms that families can sort of 
    Dr. Patz. Sure, thank you. I appreciate the question.
    I would like to caveat my answer by saying this is a global 
problem, and we do need to recognize that the risks do not just 
lay within our boundaries and that we are in a globalized world 
with international trade and transportation. Disease increase 
anywhere in the world can affect the United States.
    Let me focus now on some immediate risks in the United 
States, though. Certainly, we know about heat waves, and we had 
over 700 people die in the Chicago heat wave of 1995. I will 
actually quickly update your figure from the European heat wave 
of 2003. A new paper this year actually puts that figure at 
70,000 deaths in less than 2 weeks.
    But back to the United States. Heat waves are important--
air pollution, especially ground-level ozone. A study targeting 
the United States looking at the eastern United States found 
that just from warmer temperatures alone projected for the 
middle of this century--just from warmer temperatures, ground-
level ozone smog pollution will increase such that we could 
have an increase of 68 percent more ozone red alert days, which 
are very dangerous for asthmatics, especially children with 
asthma. That is a real issue.
    The projections are for increased frequency and intensity 
of heat waves in the United States, increased stagnant air 
masses, which would then, of course, exacerbate this air 
pollution issue. These are projections for the United States.
    Regarding water-borne diseases, our group asked the 
question how many reported water-borne disease outbreaks in the 
United States--and this was from 1948 to 1994, how many 
outbreaks were preceded by heavy rainfall events? And we found 
67 percent. Two thirds of water-borne disease outbreaks are 
preceded by heavy rainfall.
    What does that have to do with climate change? Well, the 
climatologists remind us that it is not just global warming, it 
is extremes of the water cycle, the hydrologic cycle. More 
floods, more droughts.
    Our research group at Wisconsin is modeling this work--this 
effect in the Great Lakes region, and the projections are for 
more intense heavy rainfall events. This can threaten our water 
safety. Already we have problems with these combined sewage 
overflow events. When it rains too hard, sewage and storm water 
overflow into surface water. It is a problem today. 
Climatologists are showing us that the projections are for more 
extreme precipitation events that can put further stress on our 
water quality.
    That, in conjunction with some of our municipalities that 
have failed water systems, they are rusting away. This is an 
infrastructure problem that is going to demand a lot of 
resources. This is where in the United States we do have some 
real threats that can affect us here, and at the same time, not 
to forget the nature that this is an international problem. If 
we truly want to do an adequate assessment, we have to look 
both nationally and internationally.
    Internationally, of course, climate change will exacerbate 
many of the major health challenges that Senator Enzi 
mentioned--issues of diarrheal disease, malaria, and 
    The Chairman. Dr. Ebi, the climate change expect to affect 
the incidence and distribution of malaria, West Nile fever, 
other diseases spread by mosquitoes. Can you tell us about some 
of the concerns in this area and what we ought to be thinking 
    Dr. Ebi. Yes, I would be happy to.
    I would like to go back to something that Jonathan Patz 
said at the beginning. That when we look at climate change 
issues, human health is just one of them. When we look across 
the spectrum of events that are changing--and I should say that 
climate change is not only for the future, climate change has 
already occurred. We are seeing impacts today in many parts of 
the world. It is a problem for the here and now.
    The kinds of problems we are seeing with diseases 
spreading, such as malaria, dengue fever, chikungunya in 
Southeast Asia, is similar to the kinds of changes we are 
seeing in ecosystems. If we look within the United States, if 
you look at the pine bark beetle, which is chewing its way 
across the United States and Canada and has destroyed millions 
of acres of forest, and it is doing so because it used to be 
contained by cold nights during the winter. It no longer is as 
cold as it used to be. It is not killing off the beetles, and 
it doesn't look like we can stop it from moving across the 
United States.
    It is not different for the pathogens that we are concerned 
about for human health. We are providing opportunities for 
mosquitoes to live places that are currently too cold. I have 
been on the ground in Bhutan. It is more or less a vertical 
country, and they are seeing dengue fever and malaria move up 
the highlands in ways that they have never seen, and they are 
having to deal with it.
    Will it happen here? Of course. We are providing an 
opportunity for these diseases to live places they have never 
been. Lyme disease is moving into places in Canada it has never 
been. We are seeing it happen. The question is how effective we 
in public health can be in designing our surveillance and 
response systems to make sure that we identify disease 
outbreaks before they occur and put in the kind of prevention 
activities that we do know need to be established.
    Thank you.
    The Chairman. I will ask Dr. Balbus--we are delighted to 
welcome my friend and colleague from Vermont, Bernie Sanders, 
    Dr. Balbus, perhaps you will tell us a little bit about our 
public health systems. I was asking my staff before coming over 
here, when we were looking through the testimony thinking about 
the hearing, about these public health systems. How are they 
going to be able to tell? They are generally more contained 
systems. How are they going to be able to tell about the 
projections that we just heard from our last two witnesses?
    We are reminded that there is a lot of information, 
worldwide information from various studies about what we are 
going to be facing in terms of drought and range and climate 
change, temperature change is out there. I mean, you can look 
at various charts. They may be accurate. They may not be. There 
are very, very substantial amounts of scientific information.
    What is your kind of sense about how do you evaluate our 
systems? We know that we are going to deal with these issues. 
We need systems to be able to deal with these things. What is 
your sense? And maybe from others, Ambassador McDonald, anyone 
can comment about it. Your evaluation of our existing systems, 
and how alert are they to these dangers in terms of climate 
    Dr. Balbus. That is a very good and a somewhat complex 
    The Nation's public health system is a bit of a complex 
web. Right on the ground, we have the local public health 
departments, over 2,300 of them. Then there is a hierarchy of 
State health departments and, of course, the Federal CDC. The 
money tends to flow downhill from the Feds and the States down 
to the local public health departments. The action is really 
primarily on the ground at the local public health department 
level, and that is where the integration of all of this 
information really has to occur.
    The public health departments are not going to see these 
problems as climate change problems. They are going to see them 
as disease outbreaks, as heat waves. There are kind of two 
pieces to it. One, is the climate change aspect of this really 
comes in in the preparedness and in the planning and the 
predictive capability.
    Right now, we have a lot of systems around to address 
climate-sensitive health problems. The most well-developed for 
the climate aspect are the heat wave early warning systems, and 
these exist in a number of different localities, and Kris and 
John may be able to speak more to them.
    We also have monitoring and surveillance around the country 
for viral diseases and for other kinds of infectious agents and 
infectious disease vectors. In many cases, these monitoring and 
surveillance systems are not well integrated. We don't have 
great integration, for example, between monitoring and 
surveillance that goes on in animals and the monitoring and 
surveillance that goes on in people. A lot of the diseases we 
are concerned about cross between animals and people. We need 
better integration there.
    In terms of the current state, I would characterize it just 
very briefly as being somewhat fragmented and not as well 
integrated as it should be and severely hampered for the task 
of addressing the planning and the responsiveness to climate 
change by the fact that we just don't have either the research 
or the modeling tools to be able to make predictions down at 
the scale where it all happens, down at the local public health 
departments. They don't have either the tools and, in many 
cases, lack--and I am sure they feel they lack the expertise 
and the resources to be able to do this down at the local 
    The Chairman. I yield at this time to my friend and 
colleague, Senator Sanders.
    Senator Sanders. Thank you, Mr. Chairman, and thanks for 
holding this important hearing, and thank you for our panelists 
being here. I apologize for being late. I may well have missed 
some of what I am going to ask, and if so, I will get the 
information later.
    It seems to me that in addition to everything else we are 
talking about, that if we are talking about global warming and 
we are talking about drought and we are talking about problems 
like even in California where they are wondering in 20 or 30 
years where they are going to get their water from, and if you 
are talking about that problem all over the world, you are 
talking about the likelihood of more conflict as nations fight 
for scarce resources and agricultural land and so forth and so 
    I know that it is not--a little bit--an immediate health 
issue, but war is a health issue. People get killed and 
wounded. We think that is a health issue. I don't know, have 
you discussed that, Mr. Chairman, yet, or does anyone want to 
say a word about that? What does it mean if there are countries 
in the world that lack potable drinking water from a health 
point of view?
    Ambassador McDonald. If I could start by focusing on that 
question? I totally recognize the concern that you have 
expressed. As a matter of fact, next month, I am co-hosting a 
colloquium at Columbia University on water and peace. I do 
believe that with care and preparation and skill, it is 
possible to ensure that we will not have water wars, as so many 
people have been talking about.
    I think the heart of that is doing something that we 
haven't been doing very well recently, and that is bypassing 
corrupt governments in the Third World, who receive a lot of 
our international aid and aid from other countries, and then 
many of them pocket that money.
    There is a group out of Houston called the Millennium Water 
Alliance, which is made up of a dozen nongovernmental 
organizations focusing on water and sanitation of which my NGO 
called Global Water, which I started in 1982, is a part of. We 
focus, as the Paul Simon Water for the Poor Act does, on the 
rural poor. If we can bypass governments and go directly to the 
village leaders and the village elders, I think we can have 
much more of a powerful impact.
    Thank you.
    Senator Sanders. Lack of water and health.
    Dr. Ebi. I would like to add that this certainly is an area 
that is very important. The State Department and the Department 
of Defense are both looking at this because it does affect U.S. 
security. Water will be a major issue. By and large, areas that 
are drier are going to get drier. Areas that are wet are going 
to get wetter.
    I, a year or so ago, did a project with USAID working with 
farmers in Mali, and the farmers told me that they have, over 
the course of their lifetime, seen the rainy season go from 120 
days to less than 100. The traditional rice takes 120 days to 
reach maturity. USAID had a very small project working with 
these farmers to plant different cultivars.
    There are some possible solutions. We have to start looking 
at the complexity of these problems and start looking at the 
kinds of solutions that we can implement to help these farmers 
so that as they do have less water, they are still able to feed 
their families. They still can do the kinds of things that they 
want to do. We have a problem.
    Senator Sanders. Are we looking at the possibility of mass 
migration of people leaving areas where they have traditionally 
lived to go elsewhere for water?
    Dr. Ebi. It certainly is a distinct possibility. The fourth 
assessment report of the Intergovernmental Panel on Climate 
Change said that their projections for rain-fed agriculture in 
parts of Sub-Saharan Africa, is that within a decade, the crop 
yields could fall by 30 percent, which is an enormous impact. 
So, yes, I have been talking with organizations such as the 
International Federation of the Red Cross/Red Crescent 
Societies, and they are looking at how they can be prepared if 
there is mass migration on a scale that we haven't seen before.
    People are starting to say that there are these 
possibilities. We would all be very happy if they never came 
about, but they are real possibilities. We need to get ahead of 
them and really start planning and doing the kinds of 
activities this committee is talking about.
    Dr. Balbus. If I could just add to that one more point? 
There is obviously a problem of too little water, but we have a 
very certain problem of too much water in the oceans. We have 
seen a surprising rate of the melting of the Greenland ice 
shield and the other Arctic and Antarctic ice shields. There 
are hundreds of millions of people in low-lying coastal areas 
around the world, a lesser problem probably in terms of 
refugeeism and the health threats of refugeeism in the United 
States, but certainly worldwide this is something that needs 
immediate attention.
    Senator Sanders. The bottom line is that global warming 
could lead to drought, water conditions--either flooding or 
lack of ability to grow food, which could lead to migrations, 
which could lead to international conflict, among other things, 
or mass dislocation, which causes all kinds of other problems.
    OK, Mr. Chairman, I would ask unanimous consent, if I 
could, that my opening remarks be----
    The Chairman. Yes. Yes, those will be included.
    [The prepared statement of Senator Sanders follows:]

                 Prepared Statement of Senator Sanders

    Good morning. As a member of the Environment and Public 
Works Committee, I spend a significant amount of my time 
thinking about how we appropriately respond to the tremendous 
challenge of global warming--we talk about allowances, auction, 
solar power, and safety valves. We have heard, however, only a 
little about the public health threats that global warming 
    That is why I am glad that this committee is holding this 
hearing today.
    I am also glad that the American Public Health Association 
decided to focus its National Public Health Week on global 
warming this year.
    And, just yesterday, I introduced a resolution to 
correspond with the APHA's efforts in this area. The 
resolution, which lays out in plain English just some of the 
ways our health is going to be affected if we don't 
significantly reduce global warming, was cosponsored by many of 
my colleagues, including Senators Snowe, Kerry, Clinton, 
Menendez, Whitehouse, Bingaman, Boxer, Leahy, and Bill Nelson. 
I ask that a copy of the resolution be included in the 
committee record.
    Let's quickly consider some of what we already know about 
the public health threat associated with global warming:

     The World Health Organization estimates that 
human-induced climate change lead to at least 5 million cases 
of illness and more than 150,000 deaths each year.
     The Intergovernmental Panel on Climate Change 
suggests that global warming contributes to the global burden 
of disease, premature death, and other adverse health impacts 
due to changes in infectious disease patterns, air quality, and 
water quality.
     And, we know, based on the work of the World 
Health Organization, that the negative health impacts of global 
warming are likely to disproportionately affect communities 
that are already vulnerable, including developing countries, 
young children, the elderly, and people with chronic illnesses 
or otherwise compromised health.

    Basically, we know that global warming is a real threat to 
our collective public health, that we must do much more to get 
our public health infrastructure prepared to deal with the 
crisis, and dare I say we know that we must act aggressively to 
reduce our greenhouse gas emissions and help to set the world 
on a path to reduce global warming.
    Let me say it a different way: we have a moral 
responsibility to enact policies to address the global warming 
    While we work to pass such policies, I must also suggest 
that the Administration is long overdue in its leadership on 
the issue. Last year the Supreme Court basically rebuked the 
Administration's position on regulation of carbon dioxide and 
ever since, we have been waiting for the Administration to make 
the obvious determination that CO2 is an 
endangerment to public health. But, it is pretty clear that 
they are sidestepping their national--and international--
responsibility on what is the largest environmental crisis the 
planet has ever faced.
    But, today, we aren't focusing on this lack of leadership 
or how to get the needed reductions in CO2 
emissions. Instead, we focus our attention to experts as they 
detail some of the concrete public health challenges that will 
confront us as our climate warms.
    Mr. Chairman, I look forward to hearing from today's 
witnesses, who are clearly some of the most knowledgeable 
individuals on how public health is at risk from global 
warming, and again, I appreciate the committee holding today's 
    The Chairman. Senator Sanders is here and I am here, and we 
are interested in the Northeast and interested in the problems 
of the ozone and the pollution. We have seen--for example, I am 
the father of a chronic asthmatic, who happens to be in the 
House of Representatives, but he has been a chronic asthmatic 
since he was a child.
    We have seen the problems, the deaths from asthma grow in 
our part of the country and the region, just gradually been 
growing. These lung-congested kinds of complications have 
increased significantly that we have seen over a period of 
time. If you are talking about the increasing pressure that is 
going to be on populations, I mean, he is obviously fortunate 
that he is able to get treatment for it. It is very costly. 
That comes back to another issue on health insurance. It is 
very, very costly. Many families obviously can't afford this.
    I'd like to talk about the kinds of pressure that is going 
to be on populations from this ozone and from what you see just 
generally in terms of the heat population and these other kinds 
of environmental challenges that we face. What do you see down 
the line in terms of--let us just take the Northeast, for 
example, Dr. Patz.
    Dr. Patz. Well, there is, of course, concern about ground-
level ozone because ozone is the most temperature-sensitive air 
pollutant. These models have shown that just a small amount of 
temperature increase in the eastern United States can 
significantly increase the amount of ozone. Put on top of that 
the projections for more stagnant air masses, it could be even 
    I hope that we would adjust and have reduced emissions of 
ozone precursors, and so the scenario may not be so bad. The 
potential is that global warming in the eastern United States 
can increase ozone. As far as asthma is concerned, there is 
another issue that climate change can affect, and that is 
    There have been studies that show that with increased 
temperatures and increased CO2 in the air, ragweed 
pollen can increase. In fact, doubled CO2 increased 
ragweed production by 50 percent in one study.
    One concern I have is that your summer ozone season 
lengthens in calendar time and overlaps with the pollen season, 
you may have a dangerous synergy between more ozone and pollen 
in the air. That is one area in this, as far as respiratory 
health, that is concerning.
    The Chairman. Good.
    Dr. Balbus. If I could just add, but as John pointed out in 
the beginning, it doesn't necessarily have to be a bad news 
story. What was going to play out in terms of climate change is 
also going to play out in terms of what we are doing in 
transportation and energy. We have to do it right. As we go to 
alternative fuels, it looks like there may be paths that may be 
beneficial for ozone and paths that may not be so beneficial 
for ozone.
    Some recent studies, for example, show that corn ethanol 
may actually have a negative effect on ozone concentrations, at 
least in the West. This is where the public health community, I 
think, has an important role to play to help look at these 
problems, look at the potential risks ahead of us, but also 
steer us away from them by moving toward energy solutions, 
transportation solutions that, as John says, reduce the 
emissions, reduce the precursors so that we actually can have a 
world of cleaner air despite the fact that the temperatures are 
warmer and the setting for making more ozone is there.
    The Chairman. Thank you.
    Ambassador McDonald. If I could add a point in support of 
your concern, Senator? The coal-belching plants in Ohio impact, 
harm the Northeast by destroying trees and bringing pollution 
to your part of the world. I think strong action by this 
committee and the Congress itself could avoid that from taking 
place in the future.
    The Chairman. That is good.
    Dr. Patz.
    Dr. Patz. If I can just follow up that comment? Again, I 
think it is very important to not look at climate change in 
isolation, and this point about fossil fuel burning, the coal-
fired power plants is very important to recognize that there 
could be co-benefits. Dr. Balbus mentioned this in his 
introduction. That fossil fuel burning creates greenhouse gases 
and global warming, but fossil fuel burning creates all of the 
other criteria air pollutants. So that by reducing greenhouse 
gases and targeting mitigating climate change, there are co-
benefits--you know, reduced air pollution.
    The other issue is transportation that, in fact, 60 percent 
of the U.S. population does not meet the minimum recommended 
daily levels of exercise, and we have that problem on our hand. 
If we were to modernize our transportation system so that we 
had multimodal mass transit, more bikeable, walkable cities, we 
could have multiple co-benefits--reduced air pollution, better 
fitness, and reduced greenhouse gases.
    The Chairman. Dr. Ebi.
    Dr. Ebi. I would like to go back to one of the points I 
raised at the beginning that to look at what we need to do in 
the Northeast, we really don't have research focused on the 
Northeast. We have very little research that has been done in 
any particular region. We can tell you on a general basis what 
we know from research done primarily in other countries, other 
developed countries.
    To focus now on--I know Maryland is not really part of the 
Northeast, but I had the opportunity over the past several 
months. Maryland is one of the very few States in the Nation 
that is looking at what they need to do in public health to 
adapt to climate change. As part of the Maryland Climate Change 
Commission that will be finished sometime in June, I have been 
working with the Maryland Department of Health and Mental 
Hygiene, and several issues that have come out to support the 
survey that Dr. Balbus talked about.
    They can deal with the day-to-day issues that they are 
faced with, but if they are faced with more sea-level rise, 
they are worrying not only about human health. They are worried 
about human well-being and livelihoods. There is an awful lot 
of industry in Maryland that relies on well water. And if you 
have problems with storm surges, you have drought, you are 
going to have contamination of wells that will affect 
livelihoods. They are trying to figure out how they could 
handle that.
    They have looked at a whole range of issues and have 
basically said if we are presented with additional pressures 
because of climate change, we do not have the human and 
financial resources to be able to deal with them.
    The Chairman. I think this is very interesting that 
Maryland--are the public health systems about as good as they 
get? Pretty good.
    Well, I think that is very important. I think what we are 
hearing, too, is the importance of keeping in mind public 
health in each and every one of these judgments and decisions 
that is going on because it has broad implications. I am not 
sure that we have done that quite as much and as effectively as 
we should.
    We might try and see if we--with the experience of the 
public health, maybe we could communicate with these other 
States about mentioning this hearing here and about what has 
happened up in Maryland is something that has caught our 
attention that they may want to take a look at for themselves, 
may want to take a look at reviewing and studying similarly 
their own States. I think that is what we are going to have to 
    Systems are going to be the answer down the line. If we 
have got a good example and a good model for it, it ought to be 
shared and replicated where necessary.
    Well, I want to----
    Senator Sanders. Well, I just wanted to pick up on the 
point that Senator Kennedy made. I could tell you I go to a lot 
of schools in Vermont. Asthma is a huge problem. I think the 
point here is that we have problems today, health problems 
today, and how are they going to be exacerbated as a result of 
global warming and what can we do to pay attention to that and 
prepare for that is something that is very important.
    The Chairman. We have heard a number of thoughtful 
comments, recommendations, and the health effects of climate 
change. We know that this isn't a challenge we need to confront 
in the distant future. It is something we need to deal with 
    Our hearing today is sort of a first step in addressing 
these important matters, and we look forward to working with 
our colleagues on the committee, as well as colleagues 
throughout the Senate who view some recommendations on the 
issue. We can develop proposals to see that addressing the 
health concerns are a central part of our response to the 
climate change. We are very grateful for our panel this 
    We will stand in recess. Thank you very much.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                  Prepared Statement of Senator Obama

    Mr. Chairman, I commend you for holding this hearing on an 
issue that rarely receives the attention that it deserves--the 
effect of climate change on the health of the American people.
    Over the past decade, our knowledge about the impact of 
climate change on the physical health and well-being of the 
world's population has grown considerably. According to the 
World Health Organization (WHO), climate change is a 
substantial and escalating menace to the world's overall 
health. The WHO estimates that alterations in the Earth's 
climate, generated by human behaviors, have led to at least 
5,000,000 cases of illness and more than 150,000 deaths each 
year. The Intergovernmental Panel on Climate Change (IPCC) has 
reported that changes in the earth's climate have contributed 
to the global burden of disease, premature death, and other 
adverse health effects. Because of extreme weather events, we 
are experiencing adverse changes in infectious disease 
patterns, air quality, quality and quantity of water and food, 
ecosystem equilibrium. Collectively, these changes have led to 
elevated risks for a number of debilitating health problems 
such as asthma, allergies, and chronic obstructive pulmonary 
    Unfortunately, the harmful health consequences of climate 
change disproportionately affect our most vulnerable 
populations, particularly young children, the elderly, patients 
with chronic illnesses, and individuals from underserved 
communities, including communities of color, traditional 
societies, and coastal populations. Sadly, more than 
900,000,000 of the world's people live in impoverished 
conditions and are especially susceptible to the possible 
health impacts of climate change because of lack of access to 
health care, poor sanitation, and vulnerability to 
    We, as individuals and as a nation, must change our 
behaviors in order to reduce the negative impacts of climate 
change on our health. This will not be easy. As first steps we 
must establish and strengthen collaborations between health and 
environmental stake- holder groups and foster interdisciplinary 
partnerships that can help us better tackle this issue. 
Research efforts must be increased in order to identify 
creative solutions to mitigate the human impact of global 
warming. Public education and awareness initiatives should be 
expanded. It is important that each and every American 
understand climate change and its effects on health, and more 
importantly, what actions can be taken to protect and promote 
their health. Thank you.

             Prepared Statement of Senator Tom Coburn, M.D.


    I want to start off by noting misguided priorities of this 
committee. This hearing is on the potential public health 
threats of climate change, and yet the committee has done very 
few oversight hearings on the $29 billion at the National 
Institutes of Health (NIH) and $9 billion at the Centers for 
Disease Control and Prevention (CDC) being used to fight real 
and current public health threats.
    This committee should be more aggressive in protecting the 
public's dollars as we work to protect their health. Time after 
time we see calls for funding, subsequent increases in funding, 
and then a failure to follow-through on whether or not our 
investments are working. This is mismanagement of taxpayer 
money and a failure to make sure we are really protecting the 
public's health. We should be holding regular hearings on how 
the NIH and the CDC are using their money to protect the public 
    Forty-seven million dollars is being spent by the NIH today 
on climate change research, mainly through the National 
Institute of Environmental Health Sciences. And yet, at this 
hearing on climate change, we haven't invited someone from the 
NIH to share the results of that research.
    Few people doubt that the Earth has recently warmed. By 
scientific estimates, it has slowly and erratically warmed 
approximately 0.8 Celsius since 1850. However, there isn't 
scientific consensus on an imminent climate disaster as global 
warming alarmists contend. In fact, history tells us that 
warming trends happen periodically: the Medieval Warming (950-
1300 A.D.) and the Roman Warming (200 B.C. to 600 A.D.). There 
are hundreds of scientific peer-reviewed papers that support 
the fact that global warming--and subsequent cooling--is a 
natural and moderate pattern throughout history.
    According to the Journal of Geophysical Research,

          ``Research in 2006 found that Greenland has been 
        warming since the 1880's, but since 1955, temperature 
        averages at Greenland stations have been colder than 
        the period between 1881-1955. Another 2006 peer-
        reviewed study concluded the rate of warming in 
        Greenland from 1920-1930 was about 50 percent higher 
        than the warming from 1995-2005. One 2005 study found 
        Greenland gaining ice in the interior higher elevations 
        and thinning ice at the lower elevations. In addition, 
        the often media-promoted fears of Greenland's ice 
        completely melting and a subsequent catastrophic sea 
        level rise are directly at odds with the latest 
        scientific studies.''

    There is not yet scientific consensus proving that humans 
have caused recent warming and climate change. A recent news 
article stated,

          ``Few scientists agree with the idea that the recent 
        spate of potent hurricanes, European heat waves, 
        African drought and other weather extremes are, in 
        essence, our fault [a result of manmade emissions]. 
        There is more than enough natural variability in nature 
        to mask a direct connection, [scientists] say.'' \1\
    \1\ April 23, 2006, the New York Times by Andrew Revkin.

    Let me be clear, while I don't doubt some climate change 
has happened in recent years, it is a part of a long-term 
pattern. Scientists are divided on the extent to which it is 
happening today. Even the U.N. Intergovernmental Panel on 
Climate Change changes its story from time to time.\2\ This 
committee should be wary of considering and passing knee-jerk 
legislation based on fear instead of sound science. As my 
colleague from Oklahoma, Senator Inhofe, has stated, ``We can 
approach climate policy in a more methodical way that 
recognizes the long-term nature of the issue that requires a 
long-term solution.'' Senator Inhofe's complete statement has 
been entered into the committee record.
    \2\ http://epw.senate.gov/public/
    This committee should be cautious about legislating based 
on the weak premise that humans contributed to climate change. 
Furthermore, it is important to remember that human life 
unfortunately suffers during periods of extreme cold as well as 
extreme heat. This committee needs to carefully consider the 
issues related to climate change and the most effective way to 
mitigate potential risk to human life in the long term.
    The American Public Health Association has sponsored 
``National Public Health Week'' and asked Congress to examine 
``Climate Change: Our Health in the Balance.'' It is a good 
opportunity to look closely at health risks potentially related 
to climate change and other varied factors.
    For example, the American Public Health Association's Web 
site lists potential geographic impact of climate change in the 
United States on its Web site: http://www.nphw.org/nphw08/
facts.htm. In the Southeast Atlantic and Gulf Coast Region, the 
Web site lists,

          ``Hurricanes and other weather events are expected to 
        be more intense, meaning bigger storm surges, more 
        damage to buildings and roads, and contaminated food 
        and water.''

    While we've all seen those results from hurricanes, it is 
scientifically untenable to contend that hurricanes are 
directly related to recent global warming. The 
Intergovernmental Panel on Climate Change admitted in a 2001 
report that ``No systemic changes in the frequency of 
tornadoes, thunder days or hail events are evident in the 
limited areas analyzed'' and that ``changes globally in 
tropical and extratropical storm intensity and frequency are 
dominated by inter-decadal and multi-decadal variations, with 
no significant trends evident over the 20th century.'' \3\ 
Scientists at the NOAA have cited evidence of natural swings 
between hurricane highs and lows over 25-40 year periods.
    \3\ IPCC, Climate Change 2001, Summary for Policymakers.
    A New York Times bestseller cites fascinating historical 
records from the British Navy about hurricanes in the Caribbean 
over the last several centuries.

          ``Historic records tell us the region had nearly 
        three times as many major hurricanes per year during 
        the Little Ice Age from 1701 to 1850 as during the 
        `warming' years from 1950 to 1998.'' \4\
    \4\ Unstoppable Global Warming Every 1,500 Years, by S. Fred Singer 
and Dennis T. Avery.

    The American Public Health Association Web site also lists 
climate change as a factor for diseases carried by insects and 
mosquitoes--like Lyme Disease and West Nile Virus--``extending 
their reach'' up to the Northeast United States. While I wish 
that the solution to mosquito-borne illnesses was simply moving 
farther north, science indicates differently. ``. . . Malaria 
epidemics have occurred as far north as the Arctic Circle, and 
the worst outbreak was in Russia during the 1920s, with 16 
million sick and 600,000 deaths.'' \5\
    \5\ Unstoppable Global Warming Every 1,500 Years, by S. Fred Singer 
and Dennis T. Avery.
    I could go on with other examples, but I will end this 
topic with a final thought about the effects of extreme 
temperatures on human life. No one can doubt heat stroke, heart 
attacks, and asthma attacks are related to heat waves. Yet it's 
important to remember the devastating effects of extremely cold 
weather--elderly dying in poorly-heated homes, skull fractures 
from falls on ice, car accidents from black ice, men dying of 
heart attacks while shoveling snow, etc. According to the U.S. 
Department of the Interior's Indur Goklany, from 1979 to 1997, 
``extreme cold killed roughly twice as many Americans as heat 
waves did.'' \6\ It's important to note that cardiovascular 
disease is a leading killer in the United States, and cold 
weather exacerbates that condition far more than warm weather.
    \6\ Unstoppable Global Warming Every 1,500 Years, by S. Fred Singer 
and Dennis T. Avery.
    As this committee examines mitigating the potential effects 
of climate change and other public health risks, we must act 
responsibly and effectively. For too long the mode of operation 
on this committee has been to pass new spending authorizations 
and programs before we ensure the ones we have are working to 
mitigate risk and protect the public health. I hope that we act 
more responsibly than to continue that status quo of creating 
new programs and spending that propel our country deeper and 
deeper into debt.
    This country is more than $9 trillion in debt. Paying for 
the Medicare program alone means every American household 
shares a $320,000 IOU.\7\ Long-term economic solutions and debt 
control--that will enable individuals to afford air 
conditioning in their homes, for example--must be part of the 
solution in mitigating the potential risks from climate 
    \7\ http://www.heritage.org/Research/HealthCare/wm1869.cfm.
    I look forward to reviewing the testimony of today's 
witnesses and effective strategies they may have to mitigate 
real, long-term risks. Should this committee take specific 
legislative action on this issue, it should be a balanced 
approach based on sound peer-
reviewed science--not on hyped up fear from a politically 
charged agenda.

                  Prepared Statement of Senator Inhofe

    Once again it appears that the issue of health and climate 
change, like so many areas, has fallen prey to politics. With 
all of the dire consequences that many advocates are rushing to 
predict as a result of global warming, I believe it is 
important to remind ourselves of one simple truth. It is 
economic development that is the key factor in saving lives. 
Bringing people out of poverty has done more to advance health 
and well-being than any other indicator in history. As the 
debate on climate policy progresses, I believe it will be 
important to continue to remind ourselves of this truth, and 
that the policy choices that we make in the near term will have 
real effects, and with them unintended consequences.
    Consider current ethanol policy as an example, which was 
greatly expanded upon in last year's energy bill and originally 
touted for its climate benefits. As a result of the mandate, 
corn prices have skyrocketed in the past year, making food more 
expensive and exports less available to supply World Food Aid 
Groups and the effects are only just beginning to take place. 
Clearly, the global demand for food places a severe limit on 
the feasibility of using grain supplies for producing a large 
percentage of U.S. motor fuel, yet the scale implications as it 
relates to food aid were never considered during the energy 
policy debate.
    One issue that does currently receive a lot of attention 
for its supposed link to climate change is malaria. Reducing 
issues such as malaria to a simple and naive view that higher 
temperatures equal higher malaria rates is not only simple, but 
simply wrong. Temperatures are a factor, but it is also true 
that malaria can spread when and where it is relatively colder. 
According to Paul Reiter of the Pasteur Institute in testimony 
before the Senate Commerce Committee last year:

          ``The most catastrophic epidemic on record anywhere 
        in the world occurred in the Soviet Union in the 1920s, 
        with a peak incidence of 13 million cases per year, and 
        600,000 deaths.''

    More important than temperatures are preventative measures 
and economic standards of living, which--make no mistake--will 
be worsened by rash action to pass costly symbolic measures. As 
the record will point out, when you look beyond the rhetoric at 
the facts, malaria is very much a disease that we can greatly 
diminish or help flourish, depending on how we live and what 
policies we put into place.
    The facts are this: malaria was nearly wiped out a few 
decades ago by the use of DDT. This is not disputed. The 
disease now claims 1 million lives or more every year--again, 
not disputed. Regardless of the science of DDT--and it appears 
it did not support a ban--selective spraying can greatly 
diminish cases of malaria. But it was only recently, after 
millions of deaths, that policies began to shift away from 
alarmism and toward a genuine concern for the people who were 
paying for that alarmism with their lives. Let us not repeat 
history here.
    Even if temperatures do rise, natural environmental forces 
might save more lives due to a warmer climate. Professor Bjorn 
Lomborg has stated recently, that while global warming might 
result in 400,000 more heat-related deaths a year, there will 
be a decrease in 1.8 million cold-related deaths. This is a net 
of 1.4 million lives saved due to higher global temperatures.
    It all comes down to how do we want to be remembered? We 
can rush to leap before we look and spend hundreds of billions 
of dollars on carbon controls and a market-based trading system 
that may or may not prevent some of these extreme scenarios. 
For much less money, there are many other problems where we can 
do much greater good. The United Nations estimates that for $75 
billion per year, we can solve all major basic problems 
plaguing the developing and developed world, including clean 
drinking water, sanitation, basic healthcare, and primary 
    At the same time we can approach climate policy in a more 
methodical way that recognizes the long-term nature of the 
issue that requires a long-term solution. A good starting point 
is heavy investment in R&D of non-carbon emitting energy 
technologies, while simultaneously working on the international 
front on country specific measures through a sector by sector, 
approach. In this manner, the developing world is engaged at 
the outset and clean energy trade barriers are broken, while 
the focus can remain on the pressing public health issues that 
demand our attention.

         Prepared Statement of John Dale Dunn, Board Certified 
                          Emergency Physician

    Members of the committee, Senator Enzi's staff asked me to testify 
and because of short notice, and time pressures, I was subsequently 
asked to submit my testimony in writing.
    Thank you for this opportunity to address the issues.
    My name is John Dale Dunn and I am a 36-year physician, a Board 
Certified Emergency Physician, member of the civilian faculty in 
emergency medicine at Carl R. Darnall Army Medical Center, Fort Hood, 
TX where we see 75,000 emergency patients a year in a Department that 
trains physicians, physician assistants, and other Army personnel in 
emergency care. I was the Public Health Authority for 10 years and 
Emergency Department Director in Brownwood, Brown County, TX. I have 
studied environmental regulation and science for more than 10 years and 
taught college level environmental regulation and law. My abbreviated 
curriculum vitae is attached to this written submission. I reference 
supportive materials in the appendix.
    I assume the committee is concerned about the human health effects 
in America from projected global warming. Climate change is not 
pertinent. Weather and climate are always changing.


    The World Health Organization (WHO) has claimed that global warming 
killed 150,000 people in 2000 and that warmer temperatures will put 65 
percent of the world's population at risk for insect borne tropical 
diseases. Paul Reiter of the Pasteur Institute, an expert in vector 
disease studies says that the WHO is not providing reliable 
information. I refer staff to his work and focus here on the health 
effects of warming.
    I assert that people suffer more from cold than from hot around the 
globe and in the United States and the evidence is unequivocal.
    Daily change in temperature in any location on the planet is more 
than even the most exaggerated warming projection changes of the IPCC: 
Any discussion of human health effect should start first with the 
concept that the human species has a wonderful ability to adapt to 
temperature change. In a year the adaptation in temperate climes is 
100 F. or more.
    More important for human health are the basics--clean water, good 
nutrition, effective sewage and quality clothing and housing (including 
heat and air conditioning as needed). Modern medicine works around the 
edges, but the life expectancy of Americans is effected more by basic 
quality of life and infrastructure than modern medicine. Read the 
reports of cholera, typhus, dysentery, malaria and yellow fever 
epidemics, all seen in America and all eliminated by basic housing and 
infrastructure improvements. Vaccines are important, but adequate 
quality of living is essential.


    People die more often during the cold winter months. People of all 
ages, infants to the elderly get sick in the winter more than summer. 
The World Health Organization, claims that global warming will kill 
150,000 or twice that number and fails to comment on the well-known 
observation that twice or more of that number die from cold waves and 
cold exposure. Warm is good for circulation, arthritis, respiratory 
health, and well-being. It reduces strokes and heart attacks. Cold 
weather brings on viruses, asthma and pneumonia because of temperature 
change, bugs in the air and close living.
    A study by Keatinge published September 16, 2000 in the British 
Medical Journal showed a ten-fold increase in deaths in the elderly 
(age 65-74) from cold waves versus heat waves (2,000 deaths per million 
attributed to cold stress, 200 deaths per million attributed to heat 
stress.) Cold wave death effects are not only more severe, but last 
longer than heat wave effects, probably because of prolonged illness 
tail due to physiological and infection exposure.
    The rates of stroke and other cardiovascular events like myocardial 
infarction are higher in cold weather, explained by the effects of cold 
on blood vessels.
    In 1st world cultures, climate has no significant effect on the 
general health of the population because only the vulnerable and poor 
live at risk of heat and cold stress.
    Global warming will moderate, not exaggerate temperature extremes. 
It's a physical principle related to air circulation and the way the 
planet warms up. This more moderate and pleasant weather without cold 
snaps blows a hole in the theory of catastrophe proposed by the WHO. 
Warmer climate will not kill more people, it will reduce the nasty 
effects of winter and cold without causing any dramatic warming or 
increase in heat waves.

                              HEAT ILLNESS

    So the scaremongers point to heat illness. The evidence is the 
Chicago deaths of elderly living in non-air-conditioned old buildings 
in summer of 1995 and the European heat wave of 2003 that was 
associated with about 35,000 deaths. That's the WHO case for panic in a 
    The human organism operates in a controlled, very small range of 
internal temperature, regardless of ambient temperature. Humans in good 
health not exposed to extremes have no problem keeping body temperature 
in the right range. That's what mammals do. People are about 99.6 F 
rectally, dogs 102 F, horses at 100.5 F. Ambient temperature is not a 
    Heat stress and illness is caused by lack of adaptation and loss of 
thermoregulation. 100 F is an emergency for the isolated, ill and 
disabled if air conditioning, ventilation and fluids are inadequate. 
That's the answer to Chicago and European deaths.
    People who are at risk of heat illness or effects can avoid the 
risk by being quiet, drinking fluids and staying in a well-ventilated 
place, even if they don't have air conditioning.
    Improvements in heat wave survival in Germany and United States 
since 1995 and 2003 are due to awareness, prevention, and most 
important, air conditioning. The typical high risk range for the 
healthy human is temperature and heat index factors in excess of 100 
with the margin at 105 F, humidity 10 percent or more.
    Dry desert produces the extremes of heat. The 130 degree desert 
summer temperatures of Iraq and military training conditions in the 
Southern United States, are an excellent laboratory for heat illness. 
At Fort Hood the last 2 years, intense training of thousands of 
soldiers of varying degrees of fitness, has produced less than 50 cases 
of heat illness per year.
    The WHO has not been a responsible source of information on heat 
death numbers or analysis of deaths allegedly due to heat. Death during 
hot weather is not always death from heat. The same is true of deaths 
attributed to cold. However net deaths favor warm over cold for all age 


    The current environmental movement actions to increase the cost of 
energy will definitely result in the poor and disabled living less 
safely and with less access to air conditioning and heat. I think 
current environmental proposals will be very damaging to the people of 
3rd or 2nd world economies and societies.
    I ask the committee to be skeptical about the claims of 
authoritarian global warming advocates. The poorly clothed and housed 
will suffer and die from environmentalist experiments.
    The Copenhagen Consensus group of international economists 
(including 4 Nobel Prize winners) has reviewed the moral and economic 
choices available to the advanced countries of the world.
    They placed basic public health as high priority and global warming 
as low priority for addressing the problems of the human race on planet 
Earth. I hope the committee shares my outrage at the attitude of 
comfortable and arrogant European and American snobs who insist that 
global warming be first on any list of policy priorities while ignore 
the desperate conditions of the poor and deprived of the third world.
    There is nothing charming and quaint about open sewage and bad 
water, children dying of diarrhea and malaria, people suffering when we 
have the ability to spend a small percentage of the billions proposed 
for environmental anxieties for people who just need a little help to 
get clean water, sewage, better clothes and shoes and a decent place to 
    Mr. Gore is right, there is a moral imperative, the imperative is 
humans, not his anxiety or his ambition about carbon dioxide controls. 
More about humans and less about warming should be the committee 
priority. In emergency medicine we find out a lot about what kills 
people--I assure the committee it is not global warming.
    I hope the committee was assisted by my comments and I thank you 
for your attention.


    1. The work of Dr. Paul Reiter of the Pasteur Institute of Paris 
will set the committee right on the WHO junk science claiming the 
plague of vector-borne diseases that is alleged to be the consequence 
of warming.
    2. For studies that show the benefit of warming on human health, I 
reference the work of Lawrence Kalkstein in Environmental Health 
Perspectives, vol. 96 pages 145-50 1991, Laschewski in Climate Research 
vol. 21 pages 91-203 2002, Hong in Epidemiology vol. 14 pages 473-78 
2003, Gouveia in International J. of Epidemiology vol. 32 pages 390-97 
2003, Davis in Environmental Health Perspectives vol. 111 pages 1712-
18. All of these studies show the benefits of warmer climate, reducing 
strokes, promoting general health and reducing death rates.
    3. Keetinge in British Medical Journal vol. 321 pages 670-73, as 
mentioned in the text, shows dramatically the ten-fold death benefits 
of warm versus cold.
    4. Finally, I reference Roy Innis, who speaks for the impoverished 
and neglected of the world, of any ethnic or national identity, when he 
speaks from the podium and writes in his book. Energy Keepers Energy 
Killers--The New Civil Rights Battle

    ``Your anti-energy, anti-insecticide, anti-biotechnology ideologies 
and policies have killed millions of African and other Third World 
babies, children and parents.''

    I agree with Mr. Innis. I hope the committee and the Senate wake up 
before they kill more innocents with bad energy policy pandering to 
neurotic greenies like Al Gore.

 Prepared Statement of T. A. Kuepper, Executive Director, Global Water


    Most people knowledgeable of the developing world and climate 
change agree that health effects felt by rural populations in 
developing countries will be more severe than that felt by the 
developed world. The simple reason is water, or more precisely, a lack 
of it.
    Rural populations in the developing world, now numbering over 2 
billion people, must fend for themselves when it comes to the basics of 
life, such as water, food and shelter. The reality is rural populations 
in the developing world live basically as humans lived thousands of 
years ago. Although their life could be made much easier if a safe 
water supply was provided by the governments of the developing world 
(as is done today in the developed world) the simple truth is leaders 
of countries in the developing world often do not feel responsible to 
take care of their own people.
    Most climate experts agree that one of the primary effects of 
climate change will be that droughts will occur in ever-expanding areas 
of the world. In today's drought-prone areas of the world, especially 
on the African continent, the search for water is a true life and death 
situation that is played out everyday of people's lives. Even in areas 
without drought, such as Central America, microbiologically-unsafe 
water is the primary reason why infant mortality is some of the highest 
in the world as rural populations must fend for themselves to find 
water for their everyday needs.
    The bottom line is the fact that water is the major factor causing 
hunger, disease and poverty throughout the developing world and it is 
not going away. From all indications, it is going to get worse and its 
going to get worse relatively soon as already the effects of climate 
change are being felt in water-short areas of the world that are 
expanding as we speak.
    So that is why the developed world should consider the rural 
populations of the developing world when it comes to climate change.
    The solution to the coming water crises in the developing world is 
far from hopeless, but it requires political will. What is necessary is 
for the developed world to ``encourage'' the leaders of the developing 
world to help their own people. This can be done by doing just two 

    1. Adding humanitarian clauses to business transactions between the 
developed world and the developing world, especially those which 
include the extraction of natural resources; when the U.S. government 
and U.S.-based international businesses create business dealings in the 
developing world that include natural resources, it should be stated 
that a percentage of gross revenues be set aside to provide the 
necessities of life, such as water and food production, for rural 
populations of that country (a suitable percentage would not be less 
than 20 percent). This type of clause is justifiable since the rural 
populations of a developing country ``own'' its natural resources as 
much as anyone in that country and the leaders of the country should 
have a moral obligation to share its rewards.
    2. Mandate international lending institutions (such as the World 
Bank) to provide funding to local non-governmental organizations (NGOs) 
in the developing world instead of only funding governments. This 
practice of only funding governments has allowed the developed world to 
say that they show their concern for the people of the developing world 
by providing money to developing countries earmarked for humanitarian 
projects. But the reality is little, if any, of that money actually 
goes towards humanitarian projects to actually help people. Most of 
that money goes to pay salaries of supporters of the current regime and 
in the bank accounts of the countries leaders. As such, often money 
earmarked for humanitarian purposes has encouraged corruption and 
little else.
    Global Water has worked with many local NGOs in the developing 
world and has found them to be the most cost-effective way to initiate 
and manage humanitarian projects. But there is very little funding for 
local NGOs since major humanitarian funding ignores them and gives 
directly to governments of developing countries.
    Lastly, the United States continues to ignore the greatest 
opportunity in the world to increase its own security through winning 
the hearts and minds of people outside the United States by not 
combining its water technology expertise (which happens to be the 
finest in the world) and foreign aid in a way that is effective. My 
experience in working in developing countries is that people are most 
appreciative when receiving the basics for life, especially safe water.
    U.S. foreign policy spends billions per year in the category of 
foreign aid but little of this money actually goes towards helping 
ordinary people of the world which is the best way to raise the 
prestige and popularity of the United States and this is directly 
connected to its worldwide security. Unfortunately, endemic forms of 
corruption have been created by international business and misdirected 
foreign aid. Throughout this process, a developing country's population 
knows very well what is going on and the fact that they are being 
exploited under the guise of international trade.
    I was in Guatemala last year when President Bush visited that 
country. The headlines in the newspapers read ``President Bush Brings 
Millions of Dollars to Guatemala for Education.'' The NGOs I was 
visiting told me none of that money will go to education and the people 
know that. It's only purpose is to make sure Guatemalan politics 
continue as usual and politicians are friendly to U.S. businesses.
    I then visited a hospital in a rural area of Guatemala that was 
staffed by doctors from Cuba. Cuba has initiated a program in Central 
America that has brought Cuban doctors to help a Guatemalan medical 
system which has historically been dysfunctional and dangerous. It is 
currently training Guatemalan students to become doctors and to bring 
that knowledge back to Guatemala. In the meantime, Cuban doctors help 
in Guatemala directly.
    The people of Guatemala understand what foreign governments are 
actually doing in their country, whether the residents of the developed 
world are aware or not. I was told by ordinary Guatemalan citizens, the 
United States is helping the current batch of national politicians 
while the Cuban government is helping our people.
    This lost opportunity is being played out all over the developing 
world and is a major contributing factor why U.S. security around the 
world continues to deteriorate.

           Prepared Statement of Howard Maccabee, Ph.D., M.D.


    We note that moderate climate warming is already occurring, due to 
anthropogenic causes and more powerful natural causes, especially 
increased solar activity.


    There have been prior threats of health disaster due to ``nearly 
global warming.'' Remember that the Antarctic, which contains 90 
percent of the world's ice, is cooling. Recent measurements show one-
third more ice than prior decades. Increases in malaria, infections and 
other vector-borne diseases have been considered by McMichael, et al. 
(Lancet, 2006). Malaria claims have been refuted by Dr. Paul Reiter 
(Int'l. Conf. on Climate Change, NYC, 2008).
    Direct threats to health from warming were predicted by McMichael, 
et al. from his model (see Slide A). Thomas G. Moore, however, 
published skeptical analysis in The Public Interest (1995), and there 
is increasing data consistent with increasing human health and 
decreasing death rates with moderate temperature increase.
    As a clinical physician with a background in engineering and 
biophysics, I have also become skeptical about threats of direct harm 
to health from climate change. As a member of hospital ``house-staff '' 
in several urban hospitals, I observed that many more people are 
admitted to hospital on cold winter days and nights than in the summer, 
and many more die in the following weeks. Reliable public health data 
show that mortality in winter due to cardiac, vascular and respiratory 
disease is seven times greater than summer (Moore, 1998) in the United 
States. The ratio is 9 to 10 in Europe.
    Death rates in the developing world have been decreasing because of 
better nutrition, as agricultural yields improve with the ``Green 
Revolution.'' As the CO2 concentration in the atmosphere increases, 
photosynthesis becomes more efficient, leading to more food production. 
Climate-related death rates have been decreasing globally for the past 
70 years (Goklany, 2007).
    My conclusion is that the world is already adapting to the 0.7 C 
temperature warming so far, with no direct health disaster.

                      WHAT DOES THE DATA INDICATE?

    The mechanisms of serious illness from cold are dominated by 
hemoconcentration (like sludging of the blood), causing death from 
ischemic heart disease and cerebrovascular disease, which together 
account for half of all excess cold-related mortality (The Eurowinter 
Group, Keatinge, et al. 1997). Thus mortality in Europe in winter is 
much greater than summer. (See Slide C, Keatinge, et al., 2000.)
    Mortality in the United States in winter is also much greater than 
summer. (See Slide D, Deschenes & Moretti, 2007.)
    I have revised the model proposed by McMichael, et al., to account 
for the shape of the actual data from the United States and Europe. 
This shows the mechanism of the significant reduction of overall 
mortality expected from moderate warming. (See Slide E.)
    These explanations and expectations are consistent with existing 
data showing long-term environmental trends of decreasing death rates 
from tornadoes, hurricanes and extreme temperatures (the dominant 
factor). (See Slide F. Goklany, 2007.)

                        CALCULATIONS OF BENEFIT

    I have evaluated the slopes of the straight lines drawn by The 
Eurowinter Group through their data. These are consistent with a 
reduction estimate of 1 to 2 percent for each  C warming. This would 
lead to an estimated decrease of 30,000 to 60,000 U.S. deaths per year. 
This is very significant by comparison with 30 thousand deaths per year 
from breast cancer in the United States, a similar number from prostate 
cancer and about 40,000 from motor vehicle accidents. Bjorn Lomborg, 
the distinguished Danish environmental economist, has estimated 1.7 
million fewer deaths in the world per year, or 170 million fewer by 
year 2100. (He also notes that deaths from cold are nine times greater 
than deaths from warmth.)
    Consider that heat deaths often represent ``displacement'' i.e., 
weakened people die a few days or weeks before prior expectation, but 
deaths due to cold usually result in months to years of life lost. Thus 
the benefits in lifespan from warming in cold periods may be much more 
than 10 times greater than lifespan lost in warm periods.
    Note also that deaths from warmth are preventable with improvements 
in air conditioning, architectural shades, public health measures, 
etc., and already are falling in European and American cities.


    Cities have already warmed by 2-4 C, much more than the climate 
average, due to the ``urban heat island'' effect. Mortality has not 
increased, because of better buildings, air conditioning, health care, 
etc. Adaptation to climate change is not only possible, but already 
    Large populations have already migrated south in the United States 
(and Europe) with average temperatures increased by more than 5 C, 
resulting in improved health and life expectancy.
                conclusions on effects of climate change
    I expect better health and better health statistics, with moderate 
warming, in both the developing and the industrialized world. We still 
need more research on health effects of climate change, and more effort 
in adaptation, given the excessive costs of greenhouse gas reduction 
and the impossibility of preventing natural events.
      2008 update on nearly-global warming . . . or is it cooling?

    The Antarctic Continent, containing 90 percent of the world's ice, 
has been cooling such that its ice and snow are now one-third greater 
than in the recent past. Most of the melted ice in the Arctic has 
frozen again. It snowed in Baghdad for the first time ever. Average 
temperatures for the last year appear to be cooler by 0.7 C, equal to 
the entire average warming for the prior century! There has been no 
increase in average temperatures since 1998. Solar activity is at a 
dramatic slowdown. World class solar scientists from Russia, China and 
Germany are predicting that this could be the beginning of a major 
cooling cycle. These are news items of early 2008.
    They are a dramatic counterpoint to earlier events of 2007, 
including the IPCC summary for policymakers, which backed off on its 
estimate of anthropogenic climate forcing, down to 1.6 watts/meter\2\, 
and reduced its estimate of ocean level rise to 17 inches (worst case), 
leaving Al Gore's estimate of 20 feet very high, but not dry. What 
happened to his ``consensus? '' Oh, yes, Al Gore shared the Nobel Prize 
with the U.N. Intergovernmental Panel on climate change (IPCC), but it 
was the very political ``Peace'' Prize, not an award for science. In 
the realm of physical science, however, Svensmark and Calder published 
``The Chilling Stars,'' a new theory of climate change that correlates 
solar magnetic activity with earth's climate much more accurately than 
anthropogenic CO2 production. Also, in the realm of economic science, 
Bjorn Lomborg published ``Cool It,'' in which he shows that Kyoto 
protocols, carbon taxes, and ``cap and trade'' schemes are the most 
wasteful and lowest priority use of scarce resources for the purpose of 
fighting poverty and disease.
    Finally, the claims of direct risks to human health from moderate 
warming have been refuted by scientists such as Thomas G. Moore and 
physicians such as W.R. Keatinge of the UK and Howard Maccabee of 
California. They have shown that warming of 1-2 C is likely to reduce 
deaths from cardiac, vascular and respiratory disease by 1-2 percent.
    For more on these subjects, contact: Howard Maccabee, Ph.D., M.D., 
Speaker, 2008 International Conference on Climate Change. E-mail: 
[email protected]; fax: (925) 820-2567.
 Prepared Statement of Professor Paul Reiter, Director of the Insects 
and Infectious Diseases Unit of the Institut Pasteur, Paris; and Roger 
          Bate, Resident Fellow, American Enterprise Institute

    Mr. Chairman, Senator Enzi, distinguished members of the committee, 
we are pleased to be able to share with you this morning what we 
believe are our well-considered views, grounded in considerable 
experience with issues of public health, development, and resource 
access in Africa and elsewhere in the developing world, as well as 
intensive research into the incidence and mechanisms of vector-borne 
diseases. For the record, please note that while Dr. Bate is testifying 
in his capacity as Resident Fellow at AEI, he also serves as Director 
of Africa Fighting Malaria, a nonprofit organization dedicated to the 
pursuit of ``best practices'' in preventing and treating malaria and 
reducing its incidence among affected populations.
    Mr. Chairman, many of today's witnesses will speak of the specific 
implications of climate change that they perceive as most important for 
human health. Doubtless malaria will top the menu, but we fear 
ignorance and disinformation may as well.
    Dr. Jonathan Patz, of the University of Wisconsin-Madison the lead 
witness listed for today, has suggested that U.S. energy policy may be 
``indirectly exporting diseases to other parts of the world.'' Dr Patz, 
and even official bodies such as the World Health Organisation (WHO), 
claim that global warming is already causing increases in disease 
(160,000 deaths per year), particularly those, such as malaria 
transmitted by insects.
    In 2007, for example, WHO implicated rising temperatures as the 
``cause'' of an outbreak of a mosquito-borne virus, Chikungunya, in an 
Italian town. Yet WHO totally missed the point: it was modern 
transportation systems, not climate change that caused the outbreak.
    The vector of the disease in that case, the Asian Tiger mosquito, 
is native to Asia, but exported worldwide in shipments of used tires. 
It is now abundant in the United States as far north as Chicago and in 
at least 12 countries in Europe. It breeds in man-made containers of 
water in the urban environment (saucers under flour-pots, buckets, 
water barrels, blocked gutters etc.). The virus was introduced to Italy 
by an infected Indian who flew from Delhi, where an epidemic was 
    In short, human activities, not fossil fuel emissions, carried the 
exotic species of mosquito across the Pacific Ocean, soon followed by 
an exotic virus transported by a new and effective ``disease vector,'' 
the jet aircraft. Absurd, then, that WHO stated ``although it is not 
possible to say whether the outbreak was caused by climate change . . . 
conditions in Italy are now suitable for the Tiger mosquito.'' 
Environmental alarmists took WHO's statement as fact and chimed in with 
their apocalyptic pronouncements.
    The globalization of vectors and pathogens is indeed a serious 
problem, and one that will not go away. It is not new. The yellow fever 
mosquito, and the yellow fever virus, were imported into North America 
from Africa during the slave trade. The dengue virus is distributed 
throughout the tropics, and regularly jumps continents when infected 
passengers travel by air. West Nile virus undoubtedly arrived in the 
New World in shipments of wild birds. Historically quarantines have 
prevented the transmission of disease by passengers, but quarantine 
regulations do not give us any protection from mosquitoes.
    It may come as a surprise that malaria was once common in most of 
Europe and North America. In parts of England, mortality from ``the 
ague'' was comparable to that in sub-Saharan Africa today. Indeed, 
William Shakespeare, born at the start of the especially cold period 
that climatologists call the ``Little Ice Age,'' was aware of the 
disease, as he mentions in eight of his plays. Malaria disappeared from 
much of western Europe during the second half of the 19th century, 
mainly because of changes in agriculture, living conditions, and a drop 
in the price of quinine, a cure for malaria still used today. However, 
in some regions it persisted until the era of the insecticide DDT. 
Indeed, temperate Holland was not certified malaria-free by the WHO 
until 1970.
    Clearly, the concept of malaria as a ``tropical'' infection is 
nonsense--it is a disease of the poor. And it is obscene that for more 
than a decade, environmental alarmists in the richest countries have 
peddled the notion that the increase in malaria in poorer countries is 
due to ``global warming,'' claiming that this will eventually cause 
mosquitoes and malaria to ``spread'' to areas that were ``previously 
malaria free,'' including the United States. At the same time they 
oppose the use of the cheapest and best insecticide to combat the 
disease, DDT.
    It is true that malaria has been increasing at an alarming rate in 
many regions of Africa and other parts of the world. Scientists ascribe 
this increase to a whole multitude of factors including population 
growth, deforestation, settlement in de-
forested highlands, rice cultivation in previously un-cultivated upland 
marshes, clustering of populations around these marshes, construction 
of dams for irrigation, population displacement due to war and civil 
strife, the evolution of drug-resistant parasites and insecticide-
resistant mosquitoes, and the cessation of mosquito-control operations.
    Of course, temperature is one factor in the transmission of 
mosquito-borne diseases and future incidence may perhaps be affected if 
the world's climate continues to warm. But throughout the world and 
throughout history, human behavior, human ecology, vector behavior, and 
vector ecology, and above all, living standards--poverty--have always 
been the critical factors that affect transmission.
    To the lay person, it may be difficult to understand that 
scientists permit such abuse of the facts. But because public quarrels 
are intellectually tiresome, and rarely achieve the desired goal, 
people often opt for what alarmists offer: simplicity in place of 
complexity, ideology in place of scientific dialogue, and emotion in 
place of dry perspective. The alarmists always seem to win.
    Those worried about malaria in impoverished countries should focus 
on improving interventions on the ground, rather than worrying about 
the weather.
    In the following sections, we attempt to summarize for the 
committee the factors that based on the best research, sound science, 
and practical experience, should be taken into consideration when 
evaluating climate policy and its interrelations with aspects of public 

      Human Ecology and Human Behavior: Climate Change and Health 
                             in Perspective

                            1. INTRODUCTION

    There is a remarkable constancy in many of the articles published 
on the impacts of climate change on infectious diseases. They name a 
disease, describe where it occurs and how it is transmitted, and make a 
succession of statements on the action of temperature, rainfall and 
other climate variables on specific components of the transmission 
cycle. These statements--often valid in themselves--are persuasive 
because they are intuitive, and their logic leads to obvious 
conclusions: tropical diseases will claim ever more victims in the 
(poorer) tropical countries and will move into temperate regions. Those 
of temperate regions will move towards the poles. All will move to 
higher altitudes, and so on. Many such articles focus on the 
vulnerability of people in poorer countries, placing the blame squarely 
on the activities of the industrial nations.
    This analytical template, as it were, is not restricted to the 
popular media and several professional scientific journals which carry 
similar articles, but in many cases it is clear that these articles 
have been written by persons with little or no background in the 
relevant field. A deplorable trend is the inclusion of a political 
message, much as in the popular media.

                           2. MAN AND DISEASE

    Human ecology and human behavior are the two factors which are key 
to the transmission of infectious diseases of humans. When the cycle of 
transmission includes mosquitoes, ticks, rodents or other 
intermediaries, their ecology and behavior are also critical. Lastly, 
the virulence \1\ of the pathogen, the susceptibility of its hosts \2\ 
and the immunity of the host populations can be critical at all levels 
to transmission of disease.
    \1\ Strains of many pathogens show distinct differences in their 
infectivity towards a particular host. Here, this degree of infectivity 
is defined as virulence.
    \2\ In this context, host refers to any organism that is infected 
by the pathogen. In the case of arthropod-borne pathogens, the 
arthropod is generally referred to as the vector, and the organism that 
it infects as its host.
    Climate and weather \3\ are often invoked as the dominant 
parameters in transmission, but their true significance can only be 
assessed in the perspective of complex interactions of humans and 
ecology. Moreover, the key climatic parameters--temperature, rainfall 
and humidity--cannot be viewed independently. The effects of 
temperature are modified by humidity. The daily range of each may be 
more significant than the daily mean. Brief periods of atypical heat or 
cold can be more significant than long-term averages. Heavy storms can 
have a different impact than light prolonged rainfall. Events in 1 year 
may have critical impact on incidence in subsequent years.
    \3\ Climate is always varying, so climatologists define it as the 
mean of a set of climate variables over a specific period, usually not 
less than 30 years. Weather is short-term variation of climate.
    The diseases most commonly cited at risk of re-emerging with a 
warmer climate--malaria, dengue, cholera, West Nile virus, among 
others--are not affected by climate to the extent commonly believed. 
Malaria epidemics raged in Russia until the 1950s, when man's ingenuity 
and resourcefulness finally controlled it. During that final crisis, 
people died of malaria in Archangel, a port inside the Arctic Circle. 
Cholera can flourish wherever faecal-contaminated water remains in 
contact with humans. Epidemics were common in England until the 1850s 
when the cause was discovered and public hygiene facilities were built 
on a massive scale. Sub-Saharan Africa remains prey to so-called 
tropical diseases primarily because they lack the resources which have 
allowed developed countries to free themselves from such diseases.
Enteric Diseases
    Enteric infections kill nearly 2 million people per year. Among 
infectious diseases, only HIV/AIDS causes more deaths. Transmission is 
from person to person, either directly or through contaminated food and 
water. They are an outstanding illustration of the dominant role of 
human ecology and human behavior in the dynamics of transmission.
    In much of the developing world, particularly in the crowded 
conditions of rapidly urbanizing populations, pervasive faecal 
contamination of food and water present ideal conditions for 
transmission of a host of bacterial, protozoal, parasitic and viral 
diseases. Even in the industrialized regions of the world, distinct 
patterns of diarrhoeal disease are occurring with increasing frequency, 
despite piped water, flush toilets, wastewater treatment, 
microbiologically monitored drinking water, adequate housing and 
widespread awareness of the importance of faecal-oral hygiene.
        Enteric Diseases in Developing Countries--Urban Ecology
    In most economically advanced countries, public sanitation, 
enforced by strict legislation, is so much a part of the urban 
infrastructure that many inhabitants are hardly aware of its existence. 
Such measures are non-existent, or at best inadequate, in much of the 
rest of the world. Rapid urbanization and high birth rates are dominant 
factors in the ever-increasing toll of viral, bacterial and protozoal 
diseases. In much of the world, it is not uncommon for children less 
then 2 years old to suffer severe diahrroeal illness for 4 to 6 months 
in the first 2 years of life, with more than one-third of all deaths in 
this age group attributable to such infections.
                    Changing Patterns of Agriculture
    Human and animal faeces are used as fertilizer to boost food 
production in many countries, with obvious dangers. In addition, in 
many countries, the cultivation of cash crops for export has led to 
malnutrition, which in turn renders children prey to infection. In some 
countries rural people from relatively isolated hamlets and villages 
have moved to larger agricultural communities, with attendant problems 
of sanitation and disease transmission.
                          War and Civil Strife
    Throughout history, war has been a major, often dominant human 
behavioral factor in public health. Today, as never before, conflicts 
in dozens of countries are responsible for mass displacement of 
populations, with accompanying malnutrition and disease. The ecology of 
enormous refugee camps provides an optimum environment for enteric 
disease and many other types of infection. Death rates are frequently 
measured in days, rather than years. This scenario is not restricted to 
the developing world. For example, disruption of public health 
infrastructure resulted in high incidence of diahrroeal disease in 
Europe during the Balkan wars in the 1980s.
                           Maternal Behavior
    In many developing countries, the incorporation of women into the 
workforce has led to a major decline in breast-feeding as mothers 
return to work. Breast milk is bacteriologically sterile, and contains 
antibodies and non-immunological anti-bacterial systems that are highly 
effective against enteric infections. Infants deprived of this 
protective nutrition are particularly prone to intestinal infection.
    Early weaning of infants is encouraged by availability of 
manufactured substitutes, often backed by persuasive advertising. Apart 
from the absence of anti-bacterial components, the dilution of such 
formulae with contaminated water is a dangerous route to severe 
 Enteric Disease in Wealthy Industrialized Countries--Imports of Food 
                       From Developing Countries
    The advent of cheap transport by air and sea has provided poor 
countries with a valuable source of foreign currency through exports of 
agricultural products. In a number of instances, unexpected outbreaks 
of bacterial and protozoal disease have been traced to these exports, 
such as an outbreak of cholera in Maryland, USA, which was traced to 
contaminated frozen coconut milk imported from Thailand.
                Mass Production and Consumption of Food
    Economies of scale have led to a revolution in food production and 
food consumption, particularly in industrialized countries. Intensive 
farming of chickens and eggs in densely packed, indoor colonies 
numbering hundreds of thousands of birds provide ideal environment for 
enteric pathogens, particularly Salmonella and Campylobacter. 
Consumption of uncooked or partly cooked products of such ``farms'' has 
resulted in several major epidemics in northern Europe and North 
    Fast food chains are a major component in food consumption in 
wealthy countries, and, to an increasing extent, in those with emerging 
economies. These chains rely on a brand identity that requires strict 
standardization of the end product on a national and even international 
scale. Here again, economies of scale require centralized, mass-
production and mass-preparation of the basic ingredients, followed by 
dissemination over long distances. Unsanitary preparation and cooking 
practices can lead to huge, and widely disseminated outbreaks of 
enteric infection. A classic example was the entero-haemorrhagic strain 
of E. coli that emerged in Europe and the United States in the 1980s, 
infecting tens of thousands of people, with a significant proportion of 
severe, sometimes fatal illness. These epidemics were traced to 
intensive cattle rearing and insufficient cooking of meat processed as 
hamburgers. Interestingly, this pathogen is uncommon in poorer 
countries, where intensive livestock rearing and fast-food chains are 
relatively rare.
                            Day-care Centres
    Just as in poorer countries, the children of working women in 
industrialized countries are weaned early in order for their mothers to 
return to work. Problems of infected food are lessened by sterile 
prepared foods, availability of clean water, and attention to personal 
hygiene, but the crowded conditions of nursery schools, particularly in 
low-income neighborhoods, have led to a high prevalence of enteric 
pathogens such as Giardia and Shigella.
    Hospitals are closely packed communities of people under the care 
of staff who are in close contact with multiple patients, many of whom 
arrive with low defense against infection. For this and other reasons, 
diahrroeal disease among hospital patients is an increasingly serious 
problem in many technically advanced countries. In the UK, for example, 
hospital deaths as a result of infection by the spore-forming bacillus 
Clostridium difficile account for nearly as many deaths as those from 
road accidents. Control of C difficile is difficult because of rapidly 
increasing resistance to a wide range of antibiotics, and because 
normal alcohol scrubs and other sanitary measures are ineffective. 
Other pathogens, including viruses and protozoans, readily proliferate 
in the environment of large numbers of patients with suppressed 
               Geriatric Wards and Homes for the Elderly
    A similar ecological niche exists in colonies of elderly persons. 
In many cases, low stomach acidity allows living pathogens to pass 
easily through the stomach. Other factors include chronic disease and 
poor personal hygiene. Breakdowns in food-
hygiene in such institutions can result in outbreaks of enteric disease 
with high fatality.
                          International Travel
    Traveler's diarrhoea is a familiar term for a condition that 
affects persons from affluent countries when they visit countries with 
relatively unhygienic conditions and a higher incidence of enteric 
disease. Cheap air-travel allows millions of people to experience such 
infections during holidays abroad, and to import them when they return 
home. Outbreaks of similar infections on cruise ships are another 
example of recreational exposure.
    The dominant theme of the examples above, and of those that follow, 
is that human health is determined by a constellation of events and 
circumstances. In the developing world, the main defects are in the 
social matrix--a scarcity of basic needs: shelter; food; clothing; 
electricity; clean water; a safe living environment; education and 
access to healthcare. In the richer countries, new and challenging 
problems have arisen as a direct result of economic success. In both 
cases, straightforward strategies are available to correct the 
problems, given suitable economic circumstances. New technologies, such 
as the development of genetically modified-food crops and novel methods 
for control of pathogens, will also become available. In nearly all 
cases, climate is at most a minor, often irrelevant parameter. A 
continued, obsessive emphasis on climate change is unwarranted, and 
will misdirect efforts to implement these strategies.

                       3. MOSQUITO-BORNE DISEASES

    Speculations on the potential impact of global warming on human 
health often focus on the mosquito-borne diseases. Predictions are 
common that malaria will move into Europe, that dengue is increasing 
its range in the tropics, that mild winters enabled West Nile virus to 
become enzootic in the United States, and so on. A search of the 
electronic catalogue of the National Library of Medicine (PubMED) 
listed more than 200 articles on climate change and health, the 
majority citing vector-borne diseases, particularly malaria. Many are 
simply speculative reviews with liberal quotations from other reviews, 
frequently written by the same authors.\4\ These authors, their deluge 
of publications, and the enormous media attention that they generate, 
have had a major impact on public perceptions of climate and malaria.
    \4\ These articles all refer to malaria, and all propose that 
incidence and prevalence will increase as a direct result of climate 
    Many people are unaware that there are more than 3,500 species of 
mosquitoes, that they are found throughout the world in all climates, 
and that colossal numbers breed in snow-melt pools that overlie the 
permafrost in the Artic tundra.
    There is a widespread misconception that mosquito-borne diseases 
require tropical temperatures, or at least the warmer temperatures of 
the temperate regions. But if tropical mosquito-borne pathogens are 
introduced to temperate regions in the right season, they can be 
transmitted if suitable vectors are present.
    There is also a misconception that mosquitoes die in winter, and 
that more die in colder winters, but mosquitoes have evolved strategies 
to survive low temperatures. In the tropics, comparable adaptations are 
necessary for surviving unfavorable dry periods, which may last for 
several years. In both cases, such adaptations merely impose a 
seasonality on transmission. Before eradication, for example, the 
transmission season for Plasmodium falciparum (the most dangerous 
species of malarial pathogen) in Italy was July to September. The same 
3 months constitute the malaria season in Mali, where the disease is 
still endemic today.\5\
    \5\ Diseases that occur commonly in a population at a constant but 
relatively high rate are said to be endemic. An epidemic appears as new 
cases in a given human population, during a given period, at a rate 
that substantially exceeds what is expected, based on recent 
    The physical environment is an important modifier of local climate. 
Anopheles arabiensis, an important vector of malaria in Africa,\6\ can 
survive in Sudan when outdoor temperatures are above 55 C by hiding in 
the thatch of buildings in the daytime, feeding after mid-night, and 
ovipositing at dawn or dusk. In Lapland, Anopheles can survive the 
winter in houses and stables, feeding occasionally, and even (in the 
past) transmitting malaria when outdoor temperatures were below -40 C. 
Culex pipiens, a vector of West Nile virus in the northern hemisphere, 
is common as far north as Nova Scotia and Finland. It over-winters in 
the adult stage; Dr. Reiter has collected live specimens in Tennessee 
that were sheltering at -20 C. Aedes aegypti, the principal urban 
vector of dengue and yellow fever, is a tropical species for which 
temperatures below 0 C are fatal, but its range extends from Texas to 
South Carolina, surviving the sub-zero winter temperatures in niches 
protected from the cold. Thus, meteorological variables alone are of 
limited value as a guide to the development times, behavior and 
geographic range of vector species, and the same is true for the 
pathogens they transmit.
    \6\ In all parts of the world, malaria is transmitted by a group 
(genus) of mosquito species called Anopheles.
Malaria in Temperate Climates
    Malaria is the most important of all mosquito-borne diseases. Each 
year between 350 and 500 million cases of malaria occur worldwide, and 
over a million people die, most of them young children in sub-Saharan 
Africa. This appalling toll is mainly restricted to the tropics, but 
less than 40 years have passed since the final eradication of the 
disease from Europe. It is instructive to review the history of the 
disease in Europe in the context of the continuous natural variation of 
    More than 60 species of Anopheles mosquitoes are capable of 
transmitting human malaria. Those that exist in Europe probably began 
colonizing the region as the ice caps retreated, at the end of the 
Pleistocene. Hippocrates (460-377 B.C.) described the symptoms and 
treatment of ``intermittent fevers'' in ancient Greece and Rome and 
their association with wetlands. He even noted that splenomegaly 
(enlarged spleen, often a symptom of chronic malaria infection) was 
particularly prevalent in the Pontine Marshes, close to Rome. Today, it 
is clear from historic descriptions that three species of parasite--P. 
falciparum, P. ovale and P. vivax--were common.
    During the ``Medieval Warm Period,'' which reached its peak around 
the year 1200 ``agues,'' ``intermittent fevers,'' ``tertians,'' and 
``quartans'' were described from caliphate Spain to Christian Russia. 
In the first decades of the 15th century, a rapid cooling trend caused 
many years of famine, and a large-scale abandonment of farms, but 
malaria persisted, even in northern regions.
    The first half of the 16th century was warm again, but the period 
from the 1550s to the early 18th century--dubbed the Little Ice Age--
was probably the coldest of any time since the end of the last major 
ice age. Despite this spectacular cooling, malaria persisted throughout 
Europe. Data from burial records around the Thames estuary reveal 
mortality in ``marsh parishes'' comparable to that in areas of 
transmission in sub-Saharan Africa today. Temperatures were probably at 
their lowest from 1670 to 1700, yet during that period Robert Talbor 
(c.1642-1681) became an exceedingly wealthy man by selling an effective 
prescription for curing malaria to the European aristocracy. His 
concoction was based on cinchona bark (the origin on quinine), and he 
had developed it by experimenting on malarious patients in the malarial 
marshlands of Essex.
    In the 18th and 19th centuries, malaria was common in most of 
England and in many parts of Scotland. It was endemic throughout 
Denmark, coastal areas of southern Norway, and much of southern Siden 
and Finland. In Russia it was common in the Baltic provinces and 
eastward at similar latitudes throughout Siberia. The northern limit of 
transmission was roughly defined by the present 15 C July isotherm 
(not the 15 C winter isotherm cited by the Intergovernmental Panel on 
Climate Change).
                          Spontaneous Decline
    In the second half of the 19th century, malaria began to decline in 
much of northern Europe. Denmark suffered devastating epidemics until 
the 1860s, particularly in the countryside around Copenhagen, but 
thereafter transmission diminished and had essentially disappeared by 
the turn of the century.
    The decline of malaria in northern European countries cannot be 
attributed to climate change, for it occurred during a warming phase, 
when temperatures were already much higher than in the Little Ice Age. 
Nor can it be attributed to deliberate mosquito control, for it came 
before recognition of the role played by the vector. A number of other 
factors, however, can be identified, all attributable to the ecology 
and behavior of both the vectors and its hosts.
                        Ecology of the Landscape
    Improved drainage, reclamation of swampy land for cultivation and 
the adoption of new farming methods (there is an old Italian saying: 
``malaria flees before the plough'' ) all served to eliminate mosquito 
                             New Farm Crops
    New root crops, such as turnips and mangel-wurzels were adopted as 
winter fodder. These enabled farmers to maintain larger numbers of 
animals throughout the year, thus diverting mosquitoes from feeding on 
                         New Rearing Practices
    Selective breeding of cattle, and new introductions (e.g. the 
Chinese domestic pig), in combination with the new fodder crops, 
enabled farmers to keep large populations of stock in farm buildings 
rather than in open fields and woodland. These buildings provided 
attractive sites for adult mosquitoes to rest and feed, diverting them 
from human habitation.
    Rural populations declined as manual labor was replaced by 
machinery. This further reduced the availability of humans vs. animals 
as hosts for the mosquitoes, and of humans as hosts for the parasite.
                        Human Living Conditions
    New building materials and improvements in construction methods 
made houses more mosquito proof, especially in winter, another factor 
that reduced contact with the vector.
                              Medical Care
    Greater access to medical care, and wider use of quinine (in part 
due to a major reduction in price) reduced the survival rate of the 
malaria parasite in its human host.
                           Control Campaigns
    In countries where profound changes in crop production and stock 
rearing were absent, malaria did not decline ``spontaneously.'' In 
Russia, for example, from the Black Sea to Siberia, major epidemics 
occurred into the 20th century. In the 1920s, in the wake of massive 
social and economic disruption, a pandemic swept through the entire 
Soviet Union. Official figures for 1923-1925 listed 16.5 million cases, 
of which not less than 600,000 were fatal. Tens of thousands of 
infections, many caused by P. falciparum, occurred as far north as the 
Arctic seaport of Archangel (61 30 N). A huge, multi-faceted anti-
malaria campaign was initiated in 1951. It involved widespread use of 
DDT and other residual insecticides, antimalarial therapy, land 
reclamation, water management, public health education and other 
approaches. This mammoth effort finally brought about a dramatic 
reduction of transmission; by the mid-1950s the national annual 
incidence was below 1 per 10,000.
    The contrast between the devastation caused by malaria in the 
Soviet Union until the 1950s, and its quiet withdrawal from other 
European countries in the previous century is a vivid illustration of 
the importance of non-climatic factors in transmission. Until the 
collectivization of farmland that began in the winter of 1929-1930, the 
Soviet Union had been largely unaffected by the agricultural 
revolution. By 1936, all farming was essentially in government hands, 
but in protest, many peasants had slaughtered their horses and 
livestock, and destroyed their equipment. These events ran counter to 
many of the changes that had reduced transmission in much of Europe.
    The advent of DDT revolutionized malaria control. Cheap, safe, 
effective treatments could be targeted at the site where most 
infections occur--in the home. Initial efforts in Italy, Cyprus and 
Greece were so successful that a decision was made to eradicate the 
disease from all of Europe. The entire continent was finally declared 
free of endemic malaria in 1975. One of the last countries affected was 
    The history of the decline of malaria in North America is similar 
to that of Europe. In the 1880s, the disease was widespread in nearly 
all States east of the Rocky Mountains, particularly where rainfall is 
abundant, from the semitropical Gulf Coast States to the northern 
border and into Canada. As living conditions improved, and antimalarial 
drugs became more widely available, the incidence of the disease 
declined. In 1946 the United States Congress established a new agency, 
the Communicable Disease Center. This was the forerunner of the U.S. 
Centers for Disease Control and Prevention (CDC), and its principal 
mission was to eradicate malaria from the entire country. Its 
headquarters were in Atlanta, GA, because the southern States were the 
main region still affected by the disease; malaria was finally 
eradicated in the late 1950s. Today, as in Europe, there are many parts 
of the country where anopheline vectors are abundant, but disease 
transmission cycles have been disrupted and the pathogens are absent.
Malaria in the Tropics
    Increases in the global incidence of malaria are frequently 
attributed to climate change but this ignores several fundamental 
concepts in the dynamics of transmission, including stability. Broadly, 
a disease is stable when it is endemic (occurs commonly at a fairly 
high rate) and is fairly constant from year to year. A disease is 
unstable when transmission can vary greatly from year to year, and the 
potential for epidemics is high. These terms are, of course, a 
simplification; there is a wide range of degrees of stability, 
depending on complex factors in local circumstances, illustrated in the 
examples below. These refer to sub-Saharan Africa, because it is the 
focus of much of the scientific and public debate, but the principles 
involved apply to many other parts of the world.
                         Stable Endemic Malaria
    In regions where the anophelines are anthropophilic (prefer to feed 
on humans) and have a high survival rate, transmission is usually 
stable. Temperature and humidity are generally high, and there is 
relatively little seasonal variation. The disease is hard to control 
because transmission is efficient and transmission rates are so high 
that most people experience many infective bites per year. Severe 
illness and mortality is mainly among ``new arrivals,'' i.e. children 
and non-immune immigrants. Older inhabitants have survived multiple 
infections and maintain a degree of immunity by repeated re-infection. 
They can have bouts of illness that may be life threatening, but are 
usually relatively mild, if debilitating.
                        Unstable Endemic Malaria
    This generally occurs in regions where the anophelines are 
zoophilic (bite animals as well as humans), or their survival rates are 
low, or where both conditions apply. Transmission can vary greatly from 
year to year, with epidemics separated by many years of relatively low 
Behavioral and Ecological Factors That Affect Transmission
    As in temperate regions, the behavior and ecology of vector and 
host are the dominant factors in transmission, and as with enteric 
diseases, many can be attributed to explosive population increase and 
                               Birth Rate
    The world's population has grown from 2.5 billion in 1950 to 6.2 
billion in 2007. In sub-Saharan Africa, there are now nearly five times 
as many people (ca. 750 million) as there were in 1955. In some 
countries, more than half the population is under 15 years of age. A 
high birth rate invokes a high incidence of ``new arrivals,'' and thus 
of new infections. Clinical studies in parts of Africa quote 998 
infections per 1,000 infants.
                            Forest Clearance
    Many important malaria vectors breed in open sunlit pools. Forest 
clearance provides abundant new habitat for these species, a classic 
cause of the emergence of malaria problems.
    Irrigation creates an ideal habitat for mass-production of 
mosquitoes, as can construction of dams for hydroelectric power. Rice 
cultivation provides an environment for many of the most efficient 
malaria vectors. Conversely, the cultivation of low-lying water-logged 
land can suppress such vectors and thereby reduce transmission.
                           Movement of People
    Infected people in pursuit of work can introduce malaria to areas 
where it is rare. Non-immune people are at high risk if they move to 
areas of transmission. Extensive road building and modern 
transportation have greatly exacerbated this factor.
    Water storage and inadequate waste water disposal can provide 
habitat for mosquitoes, particularly in rapidly expanding urban areas. 
The absence of cattle can promote stable transmission by forcing 
zoophilic species to feed on people. Moreover, many tropical cities are 
surrounded by densely populated satellite settlements that are 
essentially rural in nature.
                         Insecticide Resistance
    Physiological resistance to insecticides is common in many regions. 
Behavioral resistance can also be a major problem: species that prefer 
to feed and rest indoors (endophilic) can switch to outdoor (exophilic) 
activity in response to treatment of indoor surfaces.
                            Drug Resistance
    In many parts of the world, the malaria parasite has evolved 
resistance to commonly used anti-malarial drugs. Substitutes are 
available, but are much more expensive.
                Degradation of the Health Infrastructure
    Lack of funding, institutional difficulties, rapid urbanization and 
other problems associated with rapid development have eroded the public 
health sector of many countries. In addition, the AIDS pandemic has 
overwhelmed the ability of authorities to deal with other diseases.
                          War and Civil Strife
    In times of conflict, mass movements of people, e.g. soldiers and 
refugees, often promote malaria transmission. The breakdown of public 
health services, damage to water distribution and drainage systems, and 
the destruction of homes often exacerbate the situation. High 
concentrations of people in camps for displaced persons can also be 
Climatic Factors That Affect Transmission
    The distribution of climates suitable for endemic malaria 
transmission in sub-
Saharan Africa is shown in Figure 1.\7\ It is clear that the vast 
majority of people in Africa live in regions of stable endemic 
transmission. In other words, throughout their lives, people living in 
the red areas of the map are regularly exposed to multiple bites from 
infective mosquitoes; studies in some regions have shown that people 
experience up to 300 infective bites per year. Under such 
circumstances, just as it is impossible to pour more water into a glass 
that is already full, it is illogical to suggest that increased 
temperatures will result in an increased incidence of infections.
    \7\ Published by the MARA/ARMA (Mapping Malaria Risk in Africa / 
Atlas du Risque de la Malaria en Afrique) project, a major 
international project supported by International Development Research 
Centre (IDRC), the South African Medical Research Council (SAMRC) and 
The Wellcome Trust, UK. http://www.mara.org.za/.
    In regions of unstable, epidemic transmission (roughly from parts 
of the yellow areas to those in pale blue), incidence may be affected 
by variations in climatic factors, but the relationships are often 
complex and counterintuitive, and in many cases the factors that 
precipitate transmission are unclear.
    High temperatures should increase the likelihood of transmission 
because they reduce the extrinsic incubation period, but the frequency 
of biting, egg-laying and other behaviors are also likely to be 
accelerated. These are high-risk activities, so survival rate--and thus 
transmission rate--may also be affected.
    Survival rate may be reduced when hot weather is accompanied by low 
humidity, but in areas where such conditions are normal, local species 
are adapted to cope with them. For example, in the severe drought and 
extreme heat of the dry season in semi-arid parts of the Sudan, female 
An. gambiae survive for up to 11 months of the year by resting in 
dwelling huts, wells and other sheltered places. Blood feeding 
continues, so transmission is not interrupted, but eggs do not develop 
until the rains return. This gonotrophic dissociation is remarkably 
similar to the winter survival of An. atroparvus in Holland and other 
parts of Europe in the past. In both cases, inactivity leads to a high 
vector survival rate and continued transmission of malaria, even under 
adverse climatic conditions.
    Rainfall can promote transmission by creating ground pools and 
other breeding sites, but heavy rains can have a flushing effect, 
cleansing such sites of their mosquitoes. Drought may eliminate 
standing water, but cause flowing water to stagnate. Thus, in arid 
areas, prolonged drought may cause malaria to decline, whereas in areas 
where rainfall is normally abundant, vast numbers of mosquitoes can be 
produced and ``drought malaria'' may follow. The same applies to 
artificial streams in irrigated regions and storm drains and sewers in 
urban areas. Drought may also stimulate people to store water in 
cisterns, drums and other man-made containers that serve as breeding 
Highland Malaria
    A topic that is repeatedly cited in the climate change debate, both 
in the scientific and the popular press, is that warmer temperatures 
will drive malaria transmission to higher altitudes in the Highlands of 
Africa, particularly East Africa. Indeed, environmental alarmists often 
state that this is already happening.
    It is certainly true that, just as in lowland regions, the 
incidence of malaria has increased in highland areas, and it is 
perfectly acceptable to cite the lower temperatures found at higher 
altitudes as a limiting factor in transmission; vectors such as An. 
gambiae are commonly found as high as 3,000 m above sea level, but 
endemic malaria disappears above 1,800-2,000 m. What is rarely 
mentioned is that less than 2 percent of the African continent 
(including North Africa) is above 2,000 m, and that much of this is so 
arid that it offers little opportunity for cultivation.
    The fundamental cause of the spread of malaria to high altitudes in 
Kenya, East Africa, was widespread deforestation and development, as 
the areas were opened up for large farming ventures. The construction 
of roads and railways generated innumerable flooded ``borrow pits,'' 
depressions left by excavation for materials, and also contributed to 
the dispersal of the mosquito. The introduction of the ox wagon caused 
a proliferation of rough cart roads; water in the wheel ruts provided a 
prolific breeding site for vectors. Milldams on rivers interfered with 
natural drainage. These and many other factors were components of a 
drastic ecological change, and it was this change that brought 
transmission to the Highlands. The disease continued to be a serious 
public health problem until the 1950s, when the colonial government 
organized an extensive control program, mainly based on DDT, after 
which the area was essentially malaria free until the 1970s, when 
control efforts were reduced and malaria returned.
    Simplistic reasoning on future prevalence of malaria is close to 
irrelevant. Malaria is not limited by climate in most temperate 
regions,\8\ nor in the tropics. In nearly all cases, ``new'' malaria at 
high altitude is well below the maximum altitudinal limits for 
transmission, and in sub-Saharan Africa the altitudes above the present 
limits are so small as to be insignificant. Moreover, there is no 
evidence that climate has played any role in the burgeoning tragedy of 
this disease at any altitude; as with the enteric diseases, most of the 
other significant variables are attributable to defects in the social 
matrix. Future changes in climate may result in minor changes in 
prevalence and incidence, but obsessive emphasis on climate change as 
the dominant parameter is unwarranted. There is a desperate need for 
cheap effective control campaigns, as were implemented during the DDT 
era. The development of new strategies, such as the release of 
transgenic mosquitoes carrying lethal genes, should be a priority.
    \8\ Effective vector species are still present, sometimes common, 
in many of the regions that were previously malarious, and transmission 
can occur if the parasite is introduced by the arrival of infected 
people. Such local cases, however, are easily eliminated by treatment 
with antimalarial drugs. Unfortunately, these incidents are exploited 
by environmental alarmists as evidence of the impact of climate change.
                       4. MOSQUITO-BORNE ZOONOSES

    Nearly six hundred viruses (arboviruses) transmitted by 
arthropods--principally mosquitoes, sandflies, biting midges and 
ticks--have been described. Of these, about a hundred are known to 
produce clinical infection in humans, though infection is often 
asymptomatic. All are zoonoses; they circulate in nature without 
involving humans. In most cases, infections in humans are incidental, 
acquired by an arthropod that has been infected by feeding on a bird or 
mammal. Thus, unlike malaria, infection of humans involves a third 
level of complexity.
Yellow Fever, Dengue and Chikungunya
    These three viruses originated, and still exist, in forest cycles, 
transmitted between primates. They are among the few zoonoses that are 
regularly transmitted between humans. The majority are termed ``dead 
end'' because the level of virus in the blood during infection 
(viraemia) is insufficient to infect an arthropod and thus continue the 
chain of infection.
    Humans are infected when they enter the forest to hunt, gather food 
(fruit, honey, etc.), harvest timber, make charcoal, and other 
activities. In recent years, a number of unvaccinated tourists from 
developed countries have died from these diseases.
    For dengue, yellow fever, chikungunya and indeed many other 
viruses,\9\ illness begins with a sudden onset of high fever and ``flu-
like'' symptoms. The disease is usually self-limiting--fever rarely 
lasts more than a week--but a small percent of cases require 
hospitalization, up to 5 percent of which can die of haemorrhage and 
other complications. Unlike parasitic diseases such as malaria, 
viraemia for all three viruses--and indeed for most viral diseases--is 
short-lived, a matter of days, but a viraemic person entering a village 
or town can relay the virus to the community via mosquitoes living in 
the peridomestic environment. Chief among these is the Yellow Fever 
mosquito, Aedes aegypti, a highly effective vector of all three viruses 
because it feeds almost exclusively on humans. A safe, cheap and 
effective vaccine is available against Yellow Fever, but, apart from 
Brazil, very few countries routinely vaccinate populations at risk.
    \9\ Many non-viral diseases also start with these symptoms. The 
author has had typhus, malaria and dengue. In the first days of 
illness, he diagnosed his typhus infection as malaria, his malaria as 
dengue, and his dengue as malaria. Apart from other considerations, it 
is not a good idea to consult a medical entomologist to diagnose a 
    A second species, the Asian Tiger mosquito, Aedes albopictus, has 
generally been regarded as less effective because it does not 
discriminate between hosts; blood meals taken from animals and birds 
that are not susceptible to the viruses do not contribute to the 
transmission cycle. Nevertheless, in recent years, the species has 
proved highly effective in urban transmission of chikungunya, possibly 
because the blood titres of this virus are very high, and because it 
has a high rate of infection and replication in the mosquito; all would 
contribute to a high vectorial capacity. Both species live in close 
contact with humans because they have adopted man-made containers such 
as water storage vessels, abandoned tires, buckets and blocked gutters 
as a substitute for tree-holes and other natural containers in their 
original habitat.
    Aedes aegypti, Ae. albopictus, and the three viruses share an 
important feature: all have been disseminated worldwide by human 
activities. Aedes aegypti, yellow fever and dengue were introduced to 
the New World from Africa, transported in slave ships. Yellow Fever 
(and possibly dengue) is now enzootic in the forests of Latin America, 
and occasionally gives rise to urban transmission. In the past 30 
years, Ae. albopictus has become widely established from Chicago to 
Buenos Aires in the Americas, in 12 countries in Europe, and at least 3 
countries in Africa. Nearly all infestations are attributable to an 
international trade in used tires. Dengue and chikungunya viruses 
circulate freely around the world in aircraft, transported by infected 
    The global prevalence of dengue has grown dramatically in recent 
decades, and it is now endemic in more than 100 countries throughout 
the tropics, with some 2,500,000 people--two fifths of the world's 
population--at risk. The only effective approach to control is to 
eliminate the breeding sites of the mosquito.
    Symptoms of chikungunya are similar to dengue, but also involve 
arthritic complications that may last for many months. Pandemics of 
chikungunya have been known in Africa and Asia for many decades, but 
only claimed world attention in 2005 when the disease appeared on the 
island of La Reunion, a departement (county) of France in the Indian 
Ocean. Modern transportation has enabled the vector, Ae. albopictus to 
extend its range worldwide. A small outbreak occurred in the autumn of 
2007 in northern Italy, in the delta region of the River Po. The area 
was once notoriously malarious, but the disease disappeared when the 
marshes were drained at the beginning of the 20th century. The 
outbreak, which began in two small villages, was traced to a traveler 
from India.
West Nile Encephalitis
    West Nile virus is transmitted between birds by ornithophilic 
mosquitoes, many of which rarely bite mammals. It is an Old World virus 
with a huge range from southern Europe, to South Africa, the Indian 
subcontinent, Southeast Asia and even Australia. For the most part, the 
virus goes unnoticed though it is clear that incidence is high in many 
parts of the world. Humans are incidental to transmission--dead end 
hosts. Infections are usually asymptomatic or mildly febrile, but a 
small portion involves inflammation of the brain and can be fatal, 
particularly in older people.
    Human clinical cases are rare and sporadic; in many years, less 
than five are confirmed on the whole continent. Two exceptions stand 
out: a major epidemic involving at least a thousand cases in Bucharest, 
Romania, in 1996, and a similar outbreak in Volgograd (formerly 
Stalingrad), Russia, in 1999. In both cases, leaking water, heating and 
sewage pipes in the basements of Soviet-style ``functionalist'' 
apartment buildings created perfect breeding site for Cx. pipiens, an 
effective vector that breeds in organically polluted water. Inadequate 
refuse disposal encouraged high populations of House Sparrows to 
complete the zoonotic cycle. The problem is widespread in ex-Soviet 
bloc countries, and will undoubtedly get worse in coming years.
    In 1999, the virus was identified in a sudden outbreak of 
encephalitis in the Queens district of New York. It had probably been 
imported in infected live birds; protection from local mosquitoes is 
not required by quarantine regulations. Once established, the speed of 
transcontinental spread was spectacular and totally unexpected. By 2003 
it had reached the Pacific seaboard, and had been detected in every 
State except Washington and Oregon. It is now enzootic from Canada to 
Venezuela, including Mexico, Central America and the Caribbean Islands.
    Dispersal is clearly by birds, both migrant and resident. Some 
25,000 human cases--about 1 percent of the total number of infections--
and just over 1,000 deaths have been reported in the United States. 
Viraemia in New World birds is very high, and lethal to at least 250 
species of birds. For this reason, the introduction of the virus has 
had a catastrophic impact on wildlife, a phenomenon typical of the 
introduction of an exotic virus into a new environment.
    Environmental alarmists have ascribed the conquest of the Americas 
by West Nile virus to unusually warm winters and other climatic 
phenomena, and have predicted future changes in range in many parts of 
the world. As with so many such claims, there is no scientific basis 
for this; temperatures can drop below ^300 C in the provinces of 
Canada where transmission is now an annual event.

                             FINAL COMMENT

    The ecology and natural history of disease transmission involves 
the interplay of a multitude of interacting factors that defy 
simplistic analysis. The rapid increase in the incidence of many 
diseases worldwide is a major cause for concern, but the principal 
determinants are politics, economics, human ecology and human 
behaviour. A creative and organized application of resources to reverse 
this increase is urgently required, irrespective of any changes of 
    Figure 1.--Theoretical suitability of local climatic conditions for 
malaria transmission in sub-Saharan Africa. Published by the MARA/ARMA 
(Mapping Malaria Risk in Africa/Atlas du Risque de la Malaria en 
Afrique) project, http://www.mara.

    [Whereupon, at 11:00 a.m., the hearing was adjourned.]