• Climate Change and Environmental Health
    (Position Paper)

    Introduction

    Anthropogenic climate change — the accelerated warming of the planet driven by human activities that include burning of fossil fuels and deforestation — is harming human health. Exposure to excess heat and particulate matter 2.5, or PM2.5, from air pollution and wildfire smoke increases hospitalizations and death from cardiovascular and respiratory diseases.1 Sea level rise and more frequent, intense extreme weather increase flood risks, leading to injuries, displacement and psychological trauma.2 As global temperatures increase, the emergence of pathogens and the geographic distribution of infectious diseases are changing.3 Greater water insecurity threatens food production and can lead to increased malnutrition. These impacts worsen existing health inequities and will affect people throughout their lifespans.2 The effects of climate change on intergenerational inequity are profound, with children bearing disproportionate impacts in the near- and long-term.4,5 For example, the World Health Organization estimates that children under 5 years of age bear approximately 90% of the global burden of disease attributable to climate change.6 Climate change also threatens health care delivery and access in communities as they contend with increasing disruptions to transportation, utilities, facilities and supply chain systems.3

    Globally, the health care sector is responsible for 4.6% of total greenhouse gas emissions.7-9 If health care were a country, it would be the fifth-largest emitter on the planet.9 In the United States, this sector contributes 8.5% to greenhouse gas emissions.10 Reducing these emissions will help slow global temperature rise in the future and bring immediate and long-term health co-benefits by improving air quality. Poor air quality remains an underappreciated public health burden. Family physicians play a critical role in preventing and mitigating the health impacts of anthropogenic climate change on their patients and communities. 

    Call to Action

    The American Academy of Family Physicians calls for action in the following areas:

    Physician Level

    • Become informed about the impact of climate change on human health and take tangible steps to address these impacts while promoting health equity.
    • Address and manage each patient’s specific environmental health risks to help them achieve their health goals. 

    Practice Level

    • Understand the health care sector’s environmental footprint and how this contributes to adverse community and public health outcomes.
    • Understand how climate change will impact the health care sector’s ability to provide safe, effective, high-quality care.
    • Partner with sustainability experts to set greenhouse gas emissions reduction goals, and create practices for providing climate-smart, climate-ready and climate-resilient health care. 

    Community/Leadership Level

    Educational Level

    • Lead change in undergraduate, graduate and continuing medical education to prepare current and future physicians to prevent, mitigate and adapt to health and occupational impacts related to climate change.

    Advocacy Level

    • Leverage the voices of family physicians as stewards of public health to advocate for local, national and international policies that improve the environmental health determinants affecting communities, patients and health care workers.

    Health Impacts of Climate Change

    Heat

    Climate change is causing an unprecedented rise in ambient temperatures and extreme heat events. Heat waves are the deadliest weather event in the United States and are associated with increased morbidity and health care utilization across the lifespan.11,12 Extreme heat exposure is associated with preterm birth, low birth weight, cardiovascular and respiratory disease, ischemic stroke, renal failure, poor mental health and violence.

    Children are among the most vulnerable to heat-related illnesses. Leaving a child unsupervised in a parked vehicle is a leading and entirely preventable contributor to heat-related mortality in children 14 years of age and younger.13-15 Adolescents and young adults who play outdoor sports face escalating risks of exertional heat illness and even death.16 Compared with people born in 1960, people born after 2020 are estimated to experience up to a sevenfold increase in extreme events such as heat waves, which highlights the intergenerational inequity of climate change.17

    People with disabilities can have specific physiologic vulnerabilities to extreme heat and/or poor adaptive capacity when exposed to it.2 Older adults are also highly susceptible to heat-related illness due to impaired thermoregulation, chronic disease, medication use, social isolation and cognitive impairment.18 People over age 55 account for nearly 60% of heat-related deaths and the majority of cardiac deaths during heat waves.19,20 For workers of all ages, excess heat poses dangerous occupational health risks. Working in hot indoor and outdoor conditions can cause acute injuries and illnesses, including kidney disease.21

    People of color, people experiencing homelessness, historically redlined communities and low-income communities have disproportionate exposure to excess heat, which exacerbates existing health inequities.5,22 Heat-related mortality is a public health threat currently, and it is projected to increase by a factor of four to 10 by the end of this century. Community and public health strategies like early warning systems, equitable access to air conditioning, cooling stations, and climate-ready and climate-resilient built environments can effectively reduce heat-related mortality.23

    Extreme Precipitation and Flooding

    The increase in global average temperatures has an impact on health that goes beyond the effects of extreme heat events. With continued warming, every global region is projected to experience increased frequency and intensity of extreme weather including high-precipitation events, tropical cyclones, floods and winter storms.24 In 2023 alone, the United States experienced 28 climate-related, billion-dollar weather and climate disasters, of which 26 were due to severe storm events, flooding, precipitation and winter storms.25 Extreme precipitation and flooding events result in morbidity and mortality from traumatic injuries, drowning, transportation injuries, exacerbations of chronic disease, displacement, psychological stress, toxic exposures, water contamination, infectious disease outbreaks and malnutrition.26,27 Assessing the mortality rate following these events is complex, and their true impact is often underestimated. For example, the original official death toll of 64 lives lost in Puerto Rico from the massive devastation of Hurricane Maria In 2017 appeared to be a gross underestimate.28 A household survey study found an estimated 4,645 excess deaths in the same period and considerable disruption to medical services. Health care workers, facilities and services and critical supply chains for supplies including pharmaceuticals are particularly impacted by disruptions to power, transportation and water infrastructure.

    Communities affected by extreme weather events experience an inequitable degree and distribution of morbidity and mortality. A community’s vulnerability is determined by its relative risk for and exposure to extreme precipitation and flooding events and its capacity to withstand and respond to these events. People of color and low-income households reside disproportionately in floodplains, cope with higher flood insurance costs and have less access to health insurance and health care.22 Additionally, children, older adults, women, LGBTQ+ people, people with disabilities, people with medical comorbidities, first responders and other emergency workers all face disproportionate health risks from extreme precipitation and flooding events.5,27

    Water Security

    Climate change threatens access to clean, fresh water, which is essential for human health. Extreme variations in precipitation patterns, decreased fresh groundwater supply, diminishing snowpacks and rapid melting of glaciers are climatic trends that reduce clean water supply.28 Drought and accompanying heat waves cause the second-highest number of climate-related deaths annually in the United States.25 It also impacts health by decreasing the drinking water supply and concentrating contaminants in the remaining water sources, which can lead to increased rates of infectious diseases and greater exposure to toxic industrial pollutants.24,29,30 Drought also exacerbates food insecurity because it reduces the amount of water available for agricultural irrigation even as crops require more water due to warmer growing seasons.31

    In addition to reducing access to safe, clean water, climate change is worsening an international water security crisis that disproportionately impacts historically marginalized populations and low-income countries.24,30,32 In the United States, many historically marginalized communities already have an increased risk of adverse health impacts because they lack access to safe, clean drinking water.33 Native communities that have been systematically restricted from accessing natural resources vital to their traditional way of life are particularly vulnerable to water insecurity. One example of this is the Indigenous communities in the southwestern United States that have water rights to the Colorado River but must rely on costly water delivery services because they lack adequate infrastructure to procure water from the river.33,34

    Implementation of adaptive climate solutions is essential to limiting the impacts of water insecurity. Increasing investment in climate-resilient infrastructure enables access to clean, safe drinking water, protects vulnerable areas from flooding, and allows for continued operation of vital services (e.g., health care systems) during water-related disasters.24,32,33,35 Improving water conservation, particularly in drought-prone areas such as the western United States,36 and implementing early warning systems for storms and other water-related extreme weather events have been shown to reduce the damage from these events dramatically.35

    Air Quality

    Fossil-fuel combustion drives climate change and worsens air quality, causing multiple public health harms. Rising temperatures and changes in precipitation are expected to increase ground-level ozone and particulate matter, worsening air quality throughout regions of the United States.37 Climate change causes an increase in wildfire activity and smoke pollution, as well as longer, stronger pollen seasons that increase aeroallergens. The health effects of poor air quality are wide reaching and affect people across their lifespans. Specific impacts of poor air quality include premature death related to cardiovascular and pulmonary disease, increased hospital admissions for myocardial infarction, arrhythmia, exacerbation of respiratory disease (e.g., asthma), ischemic stroke, lost productivity from missed work and school days due to acute respiratory illness and severe allergies, and adverse pregnancy outcomes including preterm delivery and intrauterine growth restriction.37-42 These effects are caused by both chronic and acute exposure to poor air quality.40-42

    Globally, poor air quality is among the top five risk factors for premature mortality.43 Each year, more than 10 million excess deaths worldwide are attributable to air pollution created by fossil fuel use (specifically PM2.5).44 Coexposure to extreme heat and PM2.5 increases mortality risk more than heat or air pollution exposure alone,45 which escalates health alarms given the increasing severity and frequency of extreme heat resulting from climate change.

    Adverse health effects caused by poor air quality have a disproportionate impact on people of color and people of lower socioeconomic status because these populations tend to experience greater exposure to air pollution and have less access to health care services.22,46,47 One factor leading to inequitable air pollution exposure in communities of color is historical redlining policies.48 In the United States, the mortality burden of PM2.5 is disproportionately borne by Black people and socioeconomically disinvested communities.47 Occupational air quality risks also exist for groups who may have higher exposure to air pollutants, such as firefighters and outdoor workers. While scientific evidence is clear on the inequitable mortality risk associated with air pollution, evidence also points to opportunities to rapidly improve health equity through air quality improvement measures including creation of more green spaces and use of clean electricity (e.g., solar, wind) and transportation (e.g., electric vehicles, active transport like bicycling). Environmental modeling estimates that eliminating air pollutant emissions like PM2.5, sulfur dioxide and nitrogen oxides from energy-related sectors could prevent more than 50,000 deaths and provide over $600 billion in health benefits from avoided death and illness each year in the United States.49

    Infectious Diseases

    Rising global temperatures and shifts in precipitation patterns are altering the ecological suitability for numerous infectious diseases and pathogens of concern, as well as their geographic distribution. Climate change has already fueled an expanded range and increased burden of tick-borne diseases (e.g., Lyme disease) in the United States. The risk of increased distribution and transmission of tick-borne illness is projected to continue rising as summers become longer and warmer in North America.5,50 Risks for increased burden and geographic distribution of fungal diseases (e.g., Valley fever), waterborne illnesses (e.g., vibriosis) and mosquito-borne illnesses (e.g., malaria, dengue, West Nile virus, encephalitis) are also climate sensitive and threaten human health.5,51

    Infectious disease impacts of climate change can disproportionately impact people who live and work outdoors, as well as Indigenous people and communities that rely on subsistence hunting and gathering.2 Moreover, climate-sensitive vector-borne disease can be especially harmful for pregnant people, contributing to fetal anomalies and other adverse maternal-child health outcomes.52 Public health interventions and investment in climate adaptation measures can reduce the burden of climate-sensitive infectious diseases. It is essential to have a climate-informed health care workforce capable of diagnosing and managing climate-sensitive infectious diseases that can integrate effectively with public health systems that promote community health.

    Food Security

    Climate change disrupts land-based and marine food systems, threatening all dimensions of global food security including availability, access, utilization and stability. Flooding, increased temperatures, drought, hurricanes and wildfires affect agricultural land, crop yields, and food safety and delivery, amplifying domestic and global food security risks.53 Changes in ocean temperatures, acidity and oxygenation, along with invasive species proliferation, algal blooms and loss of coral reefs, significantly compromise ocean health and decrease marine harvests, impacting the food supply for millions of people.54 Increasing global conflict destroys valuable cropland, further increasing food vulnerability.55 Outdoor agriculture workers face occupational health risks (e.g., heat-related illness) associated with decreased productivity, which can also affect food security.56 In addition, increasing atmospheric carbon dioxide levels that result from burning fossil fuels can lower the nutritional value of many staple crops, thereby increasing the risk of malnutrition.2,57

    Existing inequities related to food insecurity are likely to worsen due to climate-related environmental stressors. Globally, people whose livelihoods rely on subsistence practices face the highest risks of food and economic insecurity related to climate change. In the United States, rural communities face unique risks related to food security in a changing climate. Low-income families and people of color in the United States are also disproportionately affected by food insecurity. Other disproportionately impacted groups include women, LGBTQ+ people, children, older adults, people with mental illness, people who are unemployed, people with a history of incarceration and people who do not have stable housing.58,59 While climate change threatens global and domestic food security and results in related health disparities, plant-rich food systems and dietary practices that are healthful, well balanced and nutritious are two of the most impactful individual and public health interventions to mitigate climate change.60,61

    Displacement and Migration

    Climate change contributes to environmental degradation in myriad ways and is projected to drive substantial increases in the movement of human populations.62 In the short term, climate-related disasters like extreme weather, floods and wildfires can displace families who must flee dangerous environmental conditions. Impacts of displacement in the aftermath of disasters can be long lasting (e.g., persistent post-traumatic stress disorder and other stress-related disorders). More insidious climate-related threats to food and water security (e.g., drought) can contribute to longer-term migration and displacement, particularly among agricultural communities.

    People over age 65, children, women, LGBTQ+ people, people of color, Indigenous people and communities, and people with low income are more likely to be displaced due to climate change and face more negative impacts of displacement.2 For example, women and children displaced by weather-related events face higher risks of premature mortality, malnutrition, poor mental health and violence.63,64 Family physicians play an important role in caring for people who are coping with climate-related displacement and migration, and they must be equipped with knowledge, skills and resources specific to these situations.

    Mental Health

    Climate change affects mental health through direct and indirect pathways across the lifespan.65-70 Climate-related disasters and displacement can cause cascading mental health issues including higher rates of depression, anxiety, PTSD and suicidality.67,71,72 Mental health can also be adversely affected by more incremental climate change impacts, such as rising temperatures, changes in precipitation, drought and changes in air quality due to wildfire smoke and air pollution.70,73-76 Even people who have not personally experienced climate-related events or emergencies can feel anxiety, grief, anger, helplessness and other negative emotions due to awareness of the climate crisis.77,78

    Prenatal exposure to air pollutants can impact cognitive abilities, and air pollution is a risk factor for mental health conditions in children.79 Children and adolescents can experience significant mental health problems in response to natural disasters and climate emergencies,  particularly if their parents’ mental health is impacted.80-82 Elevated temperatures are associated with more mental health-related emergency department and hospital visits involving children, adolescents and young adults.83 Children also experience significant “eco-anxiety.”84 A survey of children and young people around the world found widespread climate-related mental health impacts that negatively affected their functioning and included anxiety, grief, rage and feelings of betrayal by adults and governments.85

    The mental health impacts of climate change are not experienced equally, and groups that historically have been made vulnerable continue to be at disproportionate risk.68 How a person experiences and responds emotionally to climate change is determined, in part, by their experience of environmental stressors, social determinants of health, historical social injustices, power, privilege (including access to resources that facilitate adaptation) and other systemic factors.86-88 Thus, we can anticipate that people in the Global South, people with preexisting health or mental health conditions, people of low socioeconomic status, women, children, older people, some racial and ethnic minority groups (including Indigenous people), people with disabilities, outdoor workers and emergency responders will be particularly vulnerable to climate change’s mental health impacts.24,68,86,88-91

    The sixth assessment report of the Intergovernmental Panel on Climate Change concluded with “very high confidence” that climate change has already negatively impacted mental health globally and will continue to do so and that these impacts will only get worse.24,92 The WHO, American Medical Association, IPCC, American Academy of Nursing and other bodies have recommended that the United States and other countries take actions including improving access to mental health services and clinical capacity, closing funding and research gaps, enhancing surveillance and monitoring, improving community preparation and response, and integrating mental health support with climate action to prevent and reduce mental health impacts of climate change across the lifespan.24,93-95 Efforts to address climate change’s mental health impacts must acknowledge and respond to the equity-related and moral dimensions of the climate crisis. Family physicians, particularly those in under-resourced communities, are primary sources of mental health care in the United States.96 As such, their contributions to better understanding and addressing the mental health impacts of climate change and helping to promote a climate-resilient future are essential.92

    Policy Implications

    The profound effects of climate change on human health call for widespread actions to influence policies at local, regional, national and international levels.97 Family physicians can play a critical role in informing and collaborating with elected leaders and promoting research, education, community outreach, clinical services, disaster preparedness and responses, and civic engagement.98,99

    Research

    Family physicians provide the greatest number of primary care visits in the United States. They provide continuity of care for patients and communities, including urban, rural and disinvested populations. As trusted leaders within the communities they serve, they can lead and expand research and outreach efforts related to climate change and health. By observing their patients, family physicians can collect and provide practice data to reflect changes in population health resulting from changing climatic conditions. Simultaneously, they can lead in crafting and refining a research agenda that further investigates the following: 

    • Impacts of climate change on primary, ambulatory and acute care
    • Environmental and climate footprint of health care (particularly primary care)
    • Opportunities to reduce the environmental and climate footprint of health care
    • Opportunities for communities and health care facilities to become more resilient to climate stressors
    • Opportunities for community-based and participatory climate mitigation and adaptation initiatives

    Family physicians can amplify their efforts through partnerships with community organizations, schools, health departments and academic health centers. The AAFP promotes policies that increase commitment to and investment in climate change research and opposes any federal or state government actions to reduce public access to environmental health research data.100

    Climate-Smart and Climate-Resilient Health Care

    Providing health care contributes to climate change because it consumes fossil fuels and generates toxic emissions and waste. In the United States, the health care sector contributes more than 8% of the country’s greenhouse gas emissions.10 It is estimated that the harm caused by these emissions is on par with the harm caused by preventable medical errors.101 Therefore, greenhouse gas emissions are increasingly framed as a quality of care and public health issue. The AAFP encourages health care facilities and systems to promote local and global public health by setting science-based reduction goals for greenhouse gas emissions and working toward achieving them.

    The health care sector and health care professionals must adapt to climate change. The AAFP encourages health care facilities and systems to integrate prospective, compounding climate risks while preparing for and adapting to a changing climate. Increased, integrated coordination with public health partners ahead of climate-related disasters (e.g., early warning systems) can save lives and improve community resilience. Conducting climate-informed hazard vulnerability analyses and engaging in updated disaster and emergency preparedness are crucial steps to improve health care access during climate-related disasters.

    The AAFP encourages family physicians to take the lead in determining what defines climate-smart and climate-resilient primary care. Transforming the health care sector to become climate smart and climate resilient will require a health care workforce that has knowledge, skills and expertise in both climate change and health and environmental sustainability. The AAFP promotes continuous investment in education on these topics at all levels of health professional education, particularly among family physicians who are currently practicing.

    Climate-Smart and Climate-Resilient Communities

    Beyond the walls of health care facilities, the AAFP promotes policies that empower governments, communities and private and public institutions to set ambitious, science-based greenhouse gas emissions reduction goals that improve public health. The AAFP will continue to highlight the immediate and long-term health benefits associated with decreased greenhouse gas emissions and clean air and water. It also promotes policies that enable the rapid reduction of land, atmosphere and water pollution. The AAFP opposes any actions by local, state or national governments that weaken existing stream and air protections. Furthermore, it supports policies that promote community adaptation and resilience in response to climate change and policies that improve environmental justice and climate justice. 

     

    References

    1. West JJ, Nolte CG, Bell ML, et al. Ch. 14. Air quality. In: Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed March 19, 2024. https://nca2023.globalchange.gov/downloads/NCA5_Ch14_Air-Quality.pdf
    2. Crimmins A, Balbus J, Gamble JL, et al, eds. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program; 2016. Accessed February 15, 2024. https://health2016.globalchange.gov/
    3. Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed February 15, 2024. https://nca2023.globalchange.gov/
    4. Ahdoot S, Baum CR, Cataletto MB, et al. Climate change and children's health: building a healthy future for every child. Pediatrics. 2024;153(3):e2023065505.
    5. Hayden MH, Schramm PJ, Beard CB, et al. Human health. In: Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed March 22, 2024. https://nca2023.globalchange.gov/chapter/15/
    6. Willetts E, Campbell-Lendrum D, Schachter B, et al. WHO policy brief: climate change, health, & intergenerational equity. November 2, 2022. Accessed March 22, 2024. https://cdn.who.int/media/docs/default-source/climate-change/who-unfccc-cop27_cchie_11122_lc.pdf
    7. Pichler PP, Jaccard IS, Weisz U, et al. International comparison of health care carbon footprints. Environ Res Lett. 2019;14(6):064004.
    8. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet. 2019;394(10211):1836-1878.
    9. Karliner J, Slotterback S, Boyd R, et al. Health care’s climate footprint: how the health sector contributes to the global crisis and opportunities for action. 2019. Accessed February 15, 2024. https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf
    10. Eckelman MJ, Huang K, Lagasse R, et al. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood). 2020;39(12):2071-2079.
    11. National Weather Service. Weather related fatality and injury statistics. 2022. Accessed March 24, 2024. https://www.weather.gov/hazstat/
    12. U.S. Environmental Protection Agency. Climate change indicators: heat-related deaths. April 2021. Accessed March 24, 2024. https://www.epa.gov/climate-indicators/climate-change-indicators-heat-related-deaths
    13. Booth JN 3rd, Davis GG, Waterbor J, et al. Hyperthermia deaths among children in parked vehicles: an analysis of 231 fatalities in the United States, 1999-2007. Forensic Sci Med Pathol. 2010;6(2):99-105.
    14. Hammett DL, Kennedy TM, Selbst SM, et al. Pediatric heatstroke fatalities caused by being left in motor vehicles. Pediatr Emerg Care. 2021;37(12):e1560-e1565.
    15. National Weather Service. 2023 Heatstroke Prevention Campaign. Accessed March 24, 2024. https://www.weather.gov/lmk/2023NationalPediatricHeatstrokePreventionDay
    16. Ebi KL, Capon A, Berry P, et al. Hot weather and heat extremes: health risks. Lancet. 2021;398(10301):698-708.
    17. Thiery W, Lange S, Rogelj J, et al. Intergenerational inequities in exposure to climate extremes. Science. 2021;374(6564):158-160.
    18. Centers for Disease Control and Prevention, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion. Older adults and extreme heat. June 9, 2021. Accessed February 13, 2024. https://www.cdc.gov/aging/emergency-preparedness/older-adults-extreme-heat/index.html
    19. Khatana SAM, Werner RM, Groeneveld PW. Association of extreme heat and cardiovascular mortality in the United States: a county-level longitudinal analysis from 2008 to 2017. Circulation. 2022;146(3):249-261.
    20. QuickStats: percentage distribution of heat-related deaths,* by age group - National Vital Statistics System, United States, 2018-2020. MMWR Morb Mortal Wkly Rep. 2022;71(24):808. 
    21. Flouris AD, Dinas PC, Ioannou LG, et al. Workers’ health and productivity under occupational heat strain: a systematic review and meta-analysis. Lancet Planet Health. 2018;2(12):e521-e531.
    22. U.S. Environmental Protection Agency. Climate change and social vulnerability in the United States: a focus on six impacts. 2021. EPA 430-R-21-003. Accessed March 24, 2024. https://assessments.epa.gov/risk/document/&deid=352694
    23. Shindell D, Zhang Y, Scott M, et al. The effects of heat exposure on human mortality throughout the United States. Geohealth. 2020;4(4):e2019GH000234.
    24. Lee H, Calvin K, Dasgupta D, et al. Climate change 2023: synthesis report. Intergovernmental Panel on Climate Change; 2023.
    25. NOAA National Centers for Environmental Information (NCEI). U.S. billion-dollar weather and climate disasters. Summary stats. 2024. Accessed February 15, 2024. https://www.ncei.noaa.gov/access/billions/summary-stats
    26. Keim ME. Climate-related disasters: the role of prevention for managing health risk. In: Lemery J, Knowlton K, Sorensen C, eds. Global Climate Change and Human Health: From Science to Practice. 2nd ed. John Wiley & Sons; 2021:25-46.
    27. Bell JE, Herring SC, Jantarasami L, et al. Impacts of extreme events on human health. In: Crimmins A, Balbus J, Gamble JL, et al, eds. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program; 2016: 99-128. Accessed March 22, 2024. https://health2016.globalchange.gov/extreme-events
    28. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(2):162-170.
    29. Mosley LM. Drought impacts on the water quality of freshwater systems; review and integration. Earth-Sci Rev. 2015;140:203-214.
    30. Caretta MA, Mukherji A, Arfanuzzaman M, et al. Water. In: Pörtner H-O, Roberts DC, Tignor M, et al., eds. Climate Change 2022: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge University Press; 2022:551-712. Accessed March 19, 2024. https://www.ipcc.ch/report/ar6/wg2/downloads/report/IPCC_AR6_WGII_Chapter04.pdf
    31. Lall U, Johnson T, Colohan P, et al. Water. In: Reidmiller DR, Avery CW, Easterling DR, et al., eds. Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II. U.S. Global Change Research Program; 2018:145-173. Accessed February 13, 2024. https://nca2018.globalchange.gov/chapter/3/
    32. Romanello M, Napoli CD, Green C, et al. The 2023 report of the Lancet Countdown on health and climate change: the imperative for a health-centred response in a world facing irreversible harms. Lancet. 2023;402(10419):2346-2394.
    33. DigDeep, US Water Alliance. Closing the water access gap in the United States: a national action plan. 2019. Accessed February 13, 2024. https://uswateralliance.org/wp-content/uploads/2023/09/Closing-the-Water-Access-Gap-in-the-United-States_DIGITAL.pdf
    34. Tanana H, Garcia J, Olaya A, et al. Universal access to clean water for tribes in the Colorado River Basin. University of Utah College of Law research paper no 466. September 7, 2021. Accessed February 15, 2024. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3919166
    35. United Nations. Blueprint for acceleration: sustainable development goal 6 synthesis report on water and sanitation 2023. May 26, 2023. Accessed February 13, 2024. https://www.unwater.org/publications/sdg-6-synthesis-report-2023
    36. U.S. Environmental Protection Agency. Drought resilience and water conservation. January 11, 2024. Accessed March 19, 2024. https://www.epa.gov/water-research/drought-resilience-and-water-conservation
    37. Nolte CG, Dolwick PD, Fann N, et al. Air quality. In: Reidmiller DR, Avery CW, Easterling DR, et al., eds. Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II. U.S. Global Change Research Program; 2018:512-538. Accessed February 13, 2024. https://nca2018.globalchange.gov/chapter/13
    38. Altman MC, Kattan M, O’Connor GT, et al. Associations between outdoor air pollutants and non-viral asthma exacerbations and airway inflammatory responses in children and adolescents living in urban areas in the USA: a retrospective secondary analysis. Lancet Planet Health. 2023;7(1):e33-e44.
    39. Heft-Neal S, Driscoll A, Yang W, et al. Associations between wildfire smoke exposure during pregnancy and risk of preterm birth in California. Environ Res. 2022;203:111872.
    40. Lemery J, Knowlton K, Sorensen C, eds. Global Climate Change and Human Health: From Science to Practice. 2nd ed. John Wiley & Sons; 2021.
    41. Mustafic H, Jabre P, Caussin C, et al. Main air pollutants and myocardial infarction: a systematic review and meta-analysis. JAMA. 2012;307(7):713-721.
    42. Peters A, Dockery DW, Muller JE, et al. Increased particulate air pollution and the triggering of myocardial infarction. Circulation. 2001;103(23):2810-2815.
    43. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1223-1249. 
    44. Vohra K, Vodonos A, Schwartz J, et al. Global mortality from outdoor fine particle pollution generated by fossil fuel combustion: Results from GEOS-Chem. Environ Res. 2021;195:110754. 
    45. Rahman MM, McConnell R, Schlaerth H, et al. The effects of coexposure to extremes of heat and particulate air pollution on mortality in California: implications for climate change. Am J Respir Crit Care Med. 2022;206(9):1117-1127.
    46. Hajat A, Hsia C, O’Neill MS. Socioeconomic disparities and air pollution exposure: a global review. Curr Environ Health Rep. 2015;2(4):440-450.
    47. Bowe B, Xie Y, Yan Y, et al. Burden of cause-specific mortality associated with PM2.5 air pollution in the United States. JAMA Netw Open. 2019;2(11):e1915834.
    48. Lane HM, Morello-Frosch R, Marshall JD, et al. Historical redlining is associated with present-day air pollution disparities in U.S. cities. Environ Sci Technol Lett. 2022;9(4):345-350. 
    49. Mailloux NA, Abel DW, Holloway T, et al. Nationwide and regional PM2.5-related air quality health benefits from the removal of energy-related emissions in the United States. GeoHealth. 2022;6(5):e2022GH000603.
    50. Beard CB, Eisen RJ, Barker CM, et al. Vector-borne diseases. In: Crimmins A, Balbus J, Gamble JL, et al, eds. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program; 2016: 129-156. Accessed March 22, 2024. https://health2016.globalchange.gov/vectorborne-diseases
    51. de Souza WM, Weaver SC. Effects of climate change and human activities on vector-borne diseases. Nat Rev Microbiol. Published online March 14, 2024.
    52. O'Kelly B, Lambert JS. Vector-borne diseases in pregnancy. Ther Adv Infect Dis. 2020;7:2049936120941725. 
    53. Mitchell R, Bolster C, Campbell A, et al. Agriculture, food systems, and rural communities. In: Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed February 15, 2024. https://nca2023.globalchange.gov/chapter/11/
    54. Hoegh-Guldberg O, Jacob D, Taylor M, et al. Impacts of 1.5°C global warming on natural and human systems. In: Masson-Delmotte Y, Zhai P, Pörtner H-O, et al., eds. Global Warming of 1.5°C: An IPCC Special Report on the Impacts of Global Warming of 1.5°C Above Pre-Industrial Levels and Related Global Greenhouse Gas Emission Pathways, in the Context of Strengthening the Global Response to the Threat of Climate Change, Sustainable Development, and Efforts to Eradicate Poverty. Cambridge University Press; 2022:175-312.
    55. Aminetzah D, Baroyan A, Denis N, et al. A reflection on global food security challenges amid the war in Ukraine and the early impact of climate change. August 17, 2022. Accessed February 13, 2024. https://www.mckinsey.com/industries/agriculture/our-insights/a-reflection-on-global-food-security-challenges-amid-the-war-in-ukraine-and-the-early-impact-of-climate-change
    56. El Khayat M, Halwani DA, Hneiny L, et al. Impacts of climate change and heat stress on farmworkers’ health: a scoping review. Front Public Health. 2022;10:782811.
    57. Zhu C, Kobayashi K, Loladze I, et al. Carbon dioxide (CO2) levels this century will alter the protein, micronutrients, and vitamin content of rice grains with potential health consequences for the poorest rice-dependent countries. Sci Adv. 2018;4(5):eaaq1012.
    58. Landon J, Jones A. Food insecurity is rising, and incarceration puts families at risk. February 10, 2021. Accessed February 13, 2024. https://www.prisonpolicy.org/blog/2021/02/10/food-insecurity/
    59. Bolster CH, Mitchell R, Kitts A, et al. Agriculture, food systems, and rural communities. In: Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed March 22, 2024. https://nca2023.globalchange.gov/chapter/11/
    60. Davis SJ, Dodder RS, Turner DD, et al. Mitigation. In: Crimmins AR, Avery CW, Easterling DR, et al., eds. Fifth National Climate Assessment. U.S. Global Change Research Program; 2023. Accessed March 22, 2024. https://nca2023.globalchange.gov/chapter/32/
    61. Willett W, Rockström J, Loken B, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems [published correction appears in Lancet. 2019 Feb 9;393(10171):530] [published correction appears in Lancet. 2019 Jun 29;393(10191):2590] [published correction appears in Lancet. 2020 Feb 1;395(10221):338] [published correction appears in Lancet. 2020 Oct 3;396(10256):e56]. Lancet. 2019;393(10170):447-492. 
    62. Clement V, Rigaud KK, de Sherbinin A, et al. Groundswell part 2: acting on internal climate migration. World Bank; 2021. Accessed March 19, 2024. http://hdl.handle.net/10986/36248
    63. Sorensen C, Murray V, Lemery J, et al. Climate change and women's health: impacts and policy directions. PLoS Med. 2018;15(7):e1002603. 
    64. United Nations Children’s Fund (UNICEF). Children displaced in a changing climate. 2023. Accessed March 26, 2024. https://www.unicef.org/reports/children-displaced-changing-climate
    65. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health. 2010;55(2):123-132.
    66. Charlson F, Ali S, Benmarhnia T, et al. Climate change and mental health: a scoping review. Int J Environ Res Public Health. 2021;18(9):4486.
    67. Cianconi P, Betrò S, Janiri L. The impact of climate change on mental health: a systematic descriptive review. Front Psychiatry. 2020;11:74.
    68. Clayton S, Manning CM, Hill AN, et al. Mental health and our changing climate: children and youth report 2023. American Psychological Association and ecoAmerica; 2023. Accessed February 13, 2024. https://www.apa.org/news/press/releases/2023/10/mental-health-youth-report-2023.pdf
    69. Crane K, Li L, Subramanian P, et al. Climate change and mental health: a review of empirical evidence, mechanisms and implications. Atmosphere (Basel). 2022;13(12):2096.
    70. Obradovich N, Migliorini R, Paulus MP, et al. Empirical evidence of mental health risks posed by climate change. Proc Natl Acad Sci U S A. 2018;115(43):10953-10958.
    71. Beaglehole B, Mulder RT, Frampton CM, et al. Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis. Br J Psychiatry. 2018;213(6):716-722.
    72. Schwartz RM, Liu B, Lieberman-Cribbin W, et al. Displacement and mental health after natural disasters. Lancet Planet Health. 2017;1(8):e314.
    73. Howard M, Ahmed S, Lachapelle P, et al. Farmer and rancher perceptions of climate change and their relationships with mental health. J Rural Mental Health. 2020;44(2):87-95.
    74. Santos EGO, Queiroz PR, Nunes ADDS, et al. Factors associated with suicidal behavior in farmers: a systematic review. Int J Environ Res Public Health. 2021;18(12):6522.
    75. Eisenman DP, Galway LP. The mental health and well-being effects of wildfire smoke: a scoping review. BMC Public Health. 2022;22(1):2274.
    76. Lowe SR, Wang C, Ma Y, et al. Particulate matter pollution and risk of outpatient visits for psychological diseases in Nanjing, China. Environ Res. 2021;193:110601.
    77. Coffey Y, Bhullar N, Durkin J, et al. Understanding eco-anxiety: a systematic scoping review of current literature and identified knowledge gaps. The Journal of Climate Change and Health. 2021;3:100047.
    78. Searle K, Gow K. Do concerns about climate change lead to distress? Int J Clim Change Strateg Manag. 2010;2(4):362-379.
    79. Perera F, Nadeau K. Climate change, fossil-fuel pollution, and children’s health. N Engl J Med. 2022;386(24):2303-2314.
    80. Olness K. Children’s mental health at times of disasters: a narrative review. Pediatr Med. 2022;5:17.
    81. Meltzer GY, Zacher M, Merdjanoff AA, et al. The effects of cumulative natural disaster exposure on adolescent psychological distress. J Appl Res Child. 2021;12(1):6.
    82. Witting AB, Bagley LA, Nelson K, et al. Natural disasters and the relational study of the family: A 2-decade scoping review. Int J Disaster Risk Reduct. 2021;52:101990.
    83. Niu L, Girma B, Liu B, et al. Temperature and mental health-related emergency department and hospital encounters among children, adolescents and young adults. Epidemiol Psychiatr Sci. 2023;32:e22.
    84. Léger-Goodes T, Malboeuf-Hurtubise C, Mastine T, et al. Eco-anxiety in children: a scoping review of the mental health impacts of the awareness of climate change. Front Psychol. 2022;13:872544.
    85. Hickman C, Marks E, Pihkala P, et al. Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. Lancet Planet Health. 2021;5(12):e863-e873.
    86. Barnwell G, Wood N. Climate justice is central to addressing the climate emergency’s psychological consequences in the Global South: a narrative review. South Afr J Psychol. 2022;52(4):486-497.
    87. Henritze E, Goldman S, Simon S, et al. Moral injury as an inclusive mental health framework for addressing climate change distress and promoting justice-oriented care. Lancet Planet Health. 2023;7(3):e238-e241.
    88. Rouf K, Wainwright T. Linking health justice, social justice, and climate justice. Lancet Planet Health. 2020;4(4):e131-e132.
    89. Gebhardt N, Schwaab L, Friederich HC, et al. The relationship of climate change awareness and psychopathology in persons with pre-existing mental health diagnoses. Front Psychiatry. 2023;14:1274523.
    90. Ingle HE, Mikulewicz M. Mental health and climate change: tackling invisible injustice. Lancet Planet Health. 2020;4(4):e128-e130.
    91. U.S. Department of Agriculture. Outdoor and emergency workers. Accessed March 19, 2024. https://www.climatehubs.usda.gov/hubs/northwest/topic/outdoor-and-emergency-workers
    92. Harper SL, Cunsolo A, Clayton S. Including mental health as part of climate change impacts and adaptation assessment: A critical advance in IPCC AR6. PLOS Clim. 2022;1(5):e0000033.
    93. Liu J, Potter T, Zahner S. Policy brief on climate change and mental health/well-being. Nurs Outlook. 2020;68(4):517-522.
    94. World Health Organization. Why mental health is a priority for action on climate change. June 3, 2022. Accessed February 13, 2024. https://www.who.int/news/item/03-06-2022-why-mental-health-is-a-priority-for-action-on-climate-change
    95. American Medical Association. Global climate change and human health H-135.938. 2022. Accessed February 13, 2024. https://policysearch.ama-assn.org/policyfinder/detail/climate%20change?uri=%2FAMADoc%2FHOD.xml-0-309.xml
    96. American Academy of Family Physicians. Mental and behavioral health care services by family physicians (position paper). December 2023. Accessed February 13, 2024. https://www.aafp.org/about/policies/all/mental-health-services.html
    97. Luber G, Prudent N. Climate change and human health. Trans Am Clin Climatol Assoc. 2009;120:113-117.
    98. Patz JA, Thomson MC. Climate change and health: moving from theory to practice. PLoS Med. 2018;15(7):e1002628.
    99. Patz JA, Frumkin H, Holloway T, et al. Climate change: challenges and opportunities for global health. JAMA. 2014;312(15):1565-1580.
    100. American Academy of Family Physicians. Environmental health and climate change. 2019. Accessed March 19, 2024. https://www.aafp.org/about/policies/all/environmental-health.html
    101. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11(6):e0157014. 

    Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.