Recent assessments have concluded that climate change presents real risks to human health and that the U.S. population will not be exempt \ue004rom health impacts o\ue004 recent and projected climate change (Con\ue004alonieri et al. 2007; Ebi et al. 2008). Given the observed and projected changes in climate and weather patterns and the signi\ue002cant degree o\ue004 regula- tory discussion under way in the U.S. govern- ment, it is reasonable to determine the extent o\ue004 direct \ue004ederal investment in research to understand and anticipate the human health impacts o\ue004 climate change in the United States and worldwide. Te need \ue004or this research has become more urgent given the signi\ue004icant degree o\ue004 climate change to which the world is already committed. In addition, there is a need to assess the potential bene\ue002t and harm to human health \ue004rom proposed policies to reduce greenhouse gas emissions. We were the authors o\ue004 the chapter on human health \ue004or Synthesis and Assessment Product (SAP) 4.6, in Analyses o\ue000 the Efects o\ue000 Global Change

ing the process o\ue004 researching and writing SAP 4.6 that \ue004ederal investment in research on the health impacts o\ue004 climate change has been extremely limited, leaving the United

We \ue004irst review the key research needs related to climate change and health, using peer-reviewed publications to show that these research needs are not being met to a signi\ue002- cant degree, then discuss steps that should be taken by the \ue004ederal government to meet the research needs.

Summary o\ue000 Key Research Needs
Related to Climate Change and
Health in the United States

SAP 4.6 reviewed the scienti\ue004ic literature published since the \ue002rst U.S. national assess- ment published in Potential Health Impacts o\ue000

climate change poses a risk \ue004or U.S. popula- tions, with uncertainties limiting the ability to quanti\ue004y the projected number o\ue004 increased injuries, illnesses, and deaths attributable to climate change (Ebi et al. 2008). Future cli- mate change could exacerbate a number o\ue004 current health problems, including heat-re- lated mortality, diarrheal diseases, and dis- eases associated with exposure to ozone and aeroallergens. Demographic trends, such as a larger and older U.S. population, will increase

overall vulnerability to these health risks; local geophysical and socioeconomic \ue004actors will in\ue004luence vulnerability at the local level. In addition, the U.S. population may be at risk \ue004rom climate-related diseases and disasters that occur outside U.S. borders, with travelers and re\ue004ugees importing diseases not currently present. Te unprecedented nature o\ue004 climate change also may bring unanticipated conse- quences \ue004or public health.

Research on the health impacts o\ue004 climate variability and changea) characterizes asso- ciations between weather/climate and health based on observed data;b) identi\ue002es observed e\ue004\ue004ects o\ue004 climate change on health;c) proj- ects health impacts using models; ord) iden- ti\ue002es, prioritizes, evaluates, implements, and monitors e\ue000ective and timely response options (including adaptation and mitigation). Overall, the research base \ue004or understanding the health risks o\ue004 climate change in the United States is limited, with most research exploring the asso- ciations between weather/climate and health (\ue003able 1). \ue003he literature base on observed impacts o\ue004 climate change contains only stud- ies conducted outside the United States.

Given the range o\ue004 impacts o\ue004 climate change on health and the state o\ue004 current research, SAP 4.6 recommended the \ue004ollowing (Ebi et al. 2008):

Address correspondence to K.L. Ebi, ESS, LLC, 5249 \ue000ancreti Lane, Alexandria, VA 22034 USA. \ue000elephone: (703) 304-6126. E-mail: krisebi@essllc.org

All authors, either directly or indirectly, received partial \ue001unding \ue001rom the U.S. Environmental Protection Agency (EPA) \ue001or their research on Synthesis and Assessment Product 4.6. Te authors received no \ue001unding support \ue001or their work on this manuscript.

K.L.E. and D.M. are consultants working under contract with the Centers \ue001or Disease Control and Prevention (CDC), the U.S. EPA, and others. J.B. works \ue001or a nongovernmental organization repre- senting > 500,000 members. P.L.K., E.L., M.S.O., and M.L.W. are employed in universities, three with \ue001unding support \ue001rom the CDC, National Institute o\ue001 Environmental Health Sciences, National Oceanic and Atmospheric Administration, U.S. Department o\ue001 Agriculture, and/or U.S. EPA.

ha\ue004 \ue003i\ue004en t\ue002 the \ue001\ue002\ue003e\ue001\ue003\ue002nt \ue002\ue001 climate change p\ue002licy \ue000ebate\ue004 an\ue000 bec\ue002me a t\ue002p p\ue003i\ue002\ue003ity \ue002\ue001 the public health c\ue002mmunity. Given the \ue002b\ue004e\ue003ve\ue000 an\ue000 p\ue003\ue002jecte\ue000 change\ue004 in climate an\ue000 \ue005eathe\ue003 patte\ue003n\ue004, thei\ue003 cu\ue003\ue003ent an\ue000 anticipate\ue000 health impact\ue004, an\ue000 the \ue004ignifcant \ue000eg\ue003ee \ue002\ue001 \ue003egulat\ue002\ue003y \ue000i\ue004cu\ue004\ue004i\ue002n un\ue000e\ue003\ue005ay in the U.S. g\ue002ve\ue003nment, it i\ue004 \ue003ea\ue004\ue002nable t\ue002 \ue000ete\ue003mine the extent \ue002\ue001 \ue001e\ue000e\ue003al inve\ue004tment in \ue003e\ue004ea\ue003ch t\ue002 un\ue000e\ue003\ue004tan\ue000, av\ue002i\ue000, p\ue003epa\ue003e \ue001\ue002\ue003, an\ue000 \ue003e\ue004p\ue002n\ue000 t\ue002 the human health impact\ue004 \ue002\ue001 climate change in the Unite\ue000 State\ue004.

inclu\ue000ing heat-\ue003elate\ue000 m\ue002\ue003tality, \ue000ia\ue003\ue003heal \ue000i\ue004ea\ue004e\ue004, an\ue000 \ue000i\ue004ea\ue004e\ue004 a\ue004\ue004\ue002ciate\ue000 \ue005ith exp\ue002\ue004u\ue003e t\ue002 \ue002z\ue002ne an\ue000 ae\ue003\ue002alle\ue003gen\ue004. Dem\ue002g\ue003aphic t\ue003en\ue000\ue004 an\ue000 ge\ue002phy\ue004ical an\ue000 \ue004\ue002ci\ue002ec\ue002n\ue002mic \ue001act\ue002\ue003\ue004 c\ue002ul\ue000 inc\ue003ea\ue004e \ue002ve\ue003all vulne\ue003ability. De\ue004pite the\ue004e \ue003i\ue004k\ue004, ext\ue003amu\ue003al \ue001e\ue000e\ue003al \ue001un\ue000ing \ue002\ue001 climate change an\ue000 health \ue003e\ue004ea\ue003ch i\ue004 e\ue004timate\ue000 t\ue002 be < $3 milli\ue002n pe\ue003 yea\ue003.

In\ue004titute\ue004 \ue002\ue001 Health, Cente\ue003\ue004 \ue001\ue002\ue003 Di\ue004ea\ue004e C\ue002nt\ue003\ue002l an\ue000 P\ue003eventi\ue002n, U.S. Envi\ue003\ue002nmental P\ue003\ue002tecti\ue002n Agency, an\ue000 \ue002the\ue003 agencie\ue004 nee\ue000 t\ue002 have \ue003\ue002bu\ue004t int\ue003amu\ue003al an\ue000 ext\ue003amu\ue003al p\ue003\ue002g\ue003am\ue004, \ue005ith \ue001un\ue000ing \ue002\ue001 > $200 milli\ue002n annually. Ove\ue003\ue004ight \ue002\ue001 the \ue004ize an\ue000 p\ue003i\ue002\ue003itie\ue004 \ue002\ue001 the\ue004e p\ue003\ue002g\ue003am\ue004 c\ue002ul\ue000 be p\ue003\ue002vi\ue000e\ue000 by a \ue004tan\ue000ing c\ue002mmittee \ue005ithin the Nati\ue002nal Aca\ue000emy \ue002\ue001 Science\ue004.

data on health issues o\ue004 potential concern, including vectorborne and zoonotic diseases, air quality, pollen and mold counts, reporting o\ue004 \ue004oodborne and waterborne diseases, morbid- ity due to temperature extremes, and mental health impacts \ue004rom extreme weather events.

health impacts o\ue004 climate change that can be used to explore the \ue004uture consequences o\ue004 a range o\ue004 socioeconomic and climate scenar- ios. Such models will be essential \ue004or mid- to long-term planning.

adaptation, including social and behavioral dimensions, as well as the costs and bene\ue002ts o\ue004 interventions.

tion measures. For example, evaluation o\ue004 heat wave warning systems, especially as they become implemented on a wider scale, is needed to understand how to motivate appropriate behavior.

ability and adaptive capacity to characterize the potential risks and the time horizon over which climate risks might arise. Tese assess- ments should include stakeholders to ensure that their needs are identi\ue002ed and addressed in subsequent research and adaptation activities.

agencies and organizations with responsibil- ity and research related to climate change- related health impacts, such as weather \ue004orecasting, air and water quality regulations, vector control programs, and disaster prepa- ration and response.

needed to protect against extreme events such as heat waves and \ue004oodborne and waterborne diseases; to alter urban design to decrease heat islands; and to maintain drinking and

the local and regional scale to conduct the types o\ue004 impact, vulnerability, and adapta- tion assessments that will enable adequate projections o\ue004 and responses to climate change and to determine the potential \ue004or interactions between climate and other risk \ue004actors, including societal, environmental, and economic \ue004actors. Te growing concern over impacts \ue004rom extreme events demon- strates the importance o\ue004 climate models that allow \ue004or stochastic generation o\ue004 pos- sible \ue004uture events, to assess not only how disease and pathogen population dynamics might respond, but also whether levels o\ue004 preparedness are likely to be adequate.

Realistically assessing the potential health e\ue000ects o\ue004 climate change must include consid- eration o\ue004 the capacity to manage the impacts o\ue004 new and changing climatic conditions. Individuals, communities, governments, and other organizations currently engage in a wide range o\ue004 actions to identi\ue004y and pre- vent adverse health outcomes associated with weather and climate such as heat waves, wild- \ue002res, hurricanes. Although these actions are generally viewed as having been largely suc- cess\ue004ul historically, two recent surveys suggest that climate change will challenge the ability o\ue004 current programs and activities to con- trol climate-sensitive health determinants and outcomes (Balbus et al. 2008; Maibach et al. 2008; Wells Bedsworth 2008). Although some level o\ue004 preparedness exists, there is a long way to go be\ue004ore the country\u2019s adaptive capacity is at a su\ue001cient level. Te prepared- ness gap includes not just in\ue004rastructure and capacity, but also \ue004undamental knowledge and the availability o\ue004 reliable decision sup- port tools. Preventing additional morbid- ity and mortality will require modi\ue004ication o\ue004 current and implementation o\ue004 new pro- grams and activities to increase resilience to climate change, taking into consideration the local context, including socioeconomic, geographic, and other \ue004actors. Research is needed to identi\ue004y e\ue004\ue004ective and e\ue004\ue004icient programs and activities, as well as how to

trans\ue004er lessons learned to other communities to assure broad protection o\ue004 public health (Ebi et al. 2008).

An issue not speci\ue004ically highlighted in the research recommendations is the increas- ing need \ue004or multidisciplinary research that addresses the interactions o\ue004 impacts across sectors (\ue004or example, decreasing precipitation leading to reduced \ue004reshwater availability, thus increasing the potential \ue004or \ue004oodborne and waterborne diseases, or how changes in temperature and precipitation a\ue004\ue004ect land use, which could a\ue000ect the geographic spread and intensity o\ue004 transmission o\ue004 a range o\ue004 vectorborne diseases). \ue003he possible mental health impacts o\ue004 climate change, nutritional issues related to \ue004ood scarcity, and population displacement are other issues requiring \ue004ur- ther research. Also not included in the list o\ue004 research needs is the importance o\ue004 identi\ue004y- ing how to communicate most e\ue000ectively the health risks o\ue004 climate change, and the pos- sible health harms and bene\ue002ts o\ue004 adaptation and mitigation options to address these risks, to motivate appropriate responses across all sectors o\ue004 society. Te possible health harms and bene\ue004its \ue004rom mitigation technologies and policies were explicitly excluded \ue004rom consideration in SAP 4.6 and are critically important to understand and better in\ue004orm policy development.

and other international assessments identi\ue002ed similar research needs, primarily \ue004ocused on needs outside the United States (Con\ue004alonieri et al. 2007). Several areas o\ue004 concern, such as the geographic spread o\ue004 human vectors and pathogens, can represent new and emerging risks to U.S. populations.

Progress in Addressing Key
Research Needs Related to
Climate Change and Health in
the United States

Quanti\ue004ying the current level o\ue004 U.S. \ue004und- ing o\ue004 climate and health research raises the issue o\ue004 which programs and projects should be included in the tally. Because the in\ue004orma- tion on the research conducted by intramu- ral programs is o\ue004ten not publicly available, the budgetary costs o\ue004 the valuable research conducted intramurally by scientists at U.S. agencies are not included in the calculations, which \ue004ocus only on extramural \ue004unding.

\ue003wo general approaches to estimating research investments are to count all programs sponsoring research that is in some way related to health and climate, or to count only pro- grams sponsoring research that is speci\ue002cally directed at climate change impacts on health. Estimates o\ue004 \ue004ederal \ue004unding o\ue004 the health impacts o\ue004 climate change have generally taken the \ue002rst approach.

0
nutritional issues related to food security,
and population displacement

When the U.S. Global Change Research Program [U.S. GCRP; since renamed the Climate Change Science Program (CCSP)] started in 1989, human health was included in the topic area o\ue004 human interactions. Health studies were mentioned as a high pri- ority need in the U.S. GCRP 1990 annual report, Our Changing Planet, but the health problem identi\ue002ed was ultraviolet (UV) radia- tion exposure, which is related to stratospheric ozone depletion and not climate change (U.S. GCRP 1990). Tere was no mention o\ue004 \ue004und- ing \ue004or speci\ue002c health studies. By 1996,Our

as \u201chuman dimensions\u201d and again listed cli- mate change and health studies as a priority (U.S. GCRP 1996). Roughly $28 million was reported \ue002nanced by the National Institutes o\ue004 Health (NIH) \ue004or the study o\ue004 UV radia- tion. \ue003he National Oceanographic and Atmospheric Administration (NOAA) and the U.S. Environmental Protection Agency (EPA) \ue004unded modest research on human dimen- sions and regional vulnerabilities, respectively, but there was no explicit mention o\ue004 support- ing human health research.

Beginning in \ue004iscal year (FY) 1999, the U.S. EPA began to explicitly study interac- tions between climate change and human health as part o\ue004 a new initiative on the con- sequences o\ue004 climate change. In FY 2000, the U.S. EPA, NOAA, National Science Foundation, National Aeronautics and Space Administration, and Electric Power Research Institute established a Joint Announcement on Climate Variability and Human Health to develop and demonstrate the \ue004easibility o\ue004 new approaches to investigate and develop tools to integrate use\ue004ul climate in\ue004ormation into public health policy and decision mak- ing. Tis Joint Announcement had a \ue004unding level o\ue004 approximately $1.5 million per year. Te program ended in 2005.

\ue003his inquiry showed that \ue004ew agency programs are aimed explicitly at human contributions and responses research, so detailed estimates o\ue004 expen- ditures could not be generated. Relevant research may or may not be counted as CCSP, and some research that is clearly peripheral to research element objectives is included in the program accounts. For example, the National Institutes o\ue004 Health (NIH) program on health e\ue004\ue004ects o\ue004 stratospheric ozone constitutes more than two-thirds o\ue004 the reported human contributions and responses budget, yet it is only tangentially concerned with climate change or social science research. Another large \ue004raction o\ue004 the \ue004unding goes to decision support activities, most o\ue004 which lack a human dimensions research com- ponent (see Chapter 5). Including such programs

paints a distorted picture o\ue004 CCSP human contri- butions and responses research. Funding \ue004or human dimensions research is likely on the order o\ue004 $25 million to $30 million per year, excluding NIH research on the health e\ue000ects o\ue004 ozone and National Aeronautics and Space Administration (NASA) decision support activities (Appendix B).

Further, in response to the question \u201cWhat are the potential human health e\ue000ects o\ue004 global environmental change, and what climate, socioeconomic, and environmental in\ue004ormation is needed to assess the cumulative risk to health \ue004rom these e\ue000ects?\u201d the NRC (2007) review concluded that

\ue003he vast bulk o\ue004 this research program involves either health e\ue000ects o\ue004 ultraviolet radiation or sat- ellite measurement o\ue004 particulate matter concen- trations \ue004or health-related analysis.

Te report concluded that the CCSP lags in understanding the human health impacts o\ue004 climate change. Further, e\ue000orts to under- stand climate change impacts on society, to analyze mitigation and adaptation strategies, and to study regional impacts are \u201crelatively immature.\u201d It recommended that the CCSP adjust the balance between climate science and application. Tat rebalancing has yet to take place.

Few research and data gaps have been \ue002lled since the First National Assessment. An important shi\ue004t in perspective that occurred since the First National Assessment is a greater appreciation o\ue004 the complex pathways and relationships through which weather and climate a\ue000ect health, and the understanding that many social and behavioral \ue004ac- tors will infuence disease risks and patterns (NRC 2001). Several research gaps identi\ue002ed in the First National Assessment have been partially \ue002lled by studies that address the di\ue000erential e\ue000ects o\ue004 tem- perature extremes by community, demographic, and biological characteristics; that improve our understanding o\ue004 exposure-response relationships \ue004or extreme heat; and that project the public health burden posed by climate-related changes in heat- waves and air quality. Despite these advances, the body o\ue004 literature remains small, limiting quantita- tive projections o\ue004 \ue004uture impacts.

Recent Levels o\ue000 U.S. Funding
o\ue000 Research on the Health
Impacts o\ue000 and Public Health
Responses to Climate
Variability and Change

\ue003wo authors o\ue004 the present commentary (K.L.E. and J.B.) testi\ue002ed on 10 April 2008 be\ue004ore the Senate Committee on Health, Education, Labor and Pensions on the poten- tial health impacts o\ue004 climate change. On the basis o\ue004 SAP 4.6, Ebi testi\ue002ed that \u201cA severe limitation to understanding current and pro- jecting \ue004uture health impacts o\ue004 climate change in the U.S. is the very low level o\ue004 research

aimed at providing quantitative projections o\ue004 the number o\ue004 increased injuries, illnesses, and deaths that could be attributable to cli- mate change.\u201d In \ue004ollow-up questions \ue004or the record, Ebi and Balbus were asked: \u201cAccording to their own estimates, NIH spends $164 mil- lion each year on the health e\ue000ects o\ue004 climate change, signi\ue002cantly more than they spend on autism, a disorder that a\ue000ects millions o\ue004 chil- dren today. CDC [Centers \ue004or Disease Control and Prevention] spends additional money on climate change through their National Center on Environmental Health. It seems to me that there is a pretty good \ue004ederal \ue004unding e\ue004\ue004ort going on. However, you indicated in your testimony that more \ue004unding \ue004or research was needed. Could you estimate how much more would be needed?\u201d

\ue003o be considered as research to address the health risks o\ue004 climate change, such research should, at a minimum, analyze associations between weather/climate variables and climate- sensitive health outcomes using empirical data; identi\ue004y observable health impacts o\ue004 climate change; project impacts under a range o\ue004 cli- mate and socioeconomic scenarios; or identi\ue004y and evaluate response options (including bar- riers to implementation).

Sponsoring research on associations between asthma and air pollutants, \ue004or exam- ple, does not provide speci\ue002c in\ue004ormation on how, i\ue004 at all, climate change could a\ue000ect the incidence and severity o\ue004 asthma (including where and when, and who is most at risk), the best options \ue004or reducing projected increases, and the associated health care and other costs. Similar examples could be provided \ue004or the other health outcomes o\ue004 concern. When West Nile virus was introduced into the United States, agencies did not increase their gen- eral \ue004unding o\ue004 vectorborne disease research (or highlight that research as the appropriate response to the problem), but rather estab- lished directed programs intended to answer speci\ue004ic questions relevant to the threat o\ue004 West Nile virus. Without programs directed speci\ue002cally at the unique challenges posed by changes in climate-related \ue004actors, identi\ue004i-

With regard to the estimated NIH annual \ue004unding o\ue004 $164 million, none o\ue004 the stud- ies projecting the health impacts o\ue004 climate change cited in SAP 4.6 acknowledged NIH \ue004unding, a requirement \ue004or research con- ducted with NIH support. Only one study o\ue004 the associations between weather/climate and health acknowledged partial NIH \ue004und- ing (Naumova et al. 2006). Tis indicates that NIH is not directing a total o\ue004 $164 million in \ue004unding to climate change and health research.

According to the in\ue004ormation provided by the Department o\ue004 Health and Human Services to the CCSP on the appropriations