Climate Change

The Ultimate Determinant of Health

Carol Ziegler, DNP, APRN, NP-C, APHN-BC*, James Muchira, PhD, RN

KEYWORDS
 Climate change  Climate justice  Social determinants of health
 Commercial determinants of health  Carbon footprint  Allostatic load

KEY POINTS
 Climate change is the greatest threat to human health, and it influences the 5 domains of
social determinants of health (SDoH).
 It disproportionately affects low-income communities of color who have contributed the
least to greenhouse gas (GHG) emissions and have the lowest carbon footprints.
 The health-care sector must lead in connecting carbon emissions to health impacts, advo-
cating for adaptive mitigation and resource allocation in vulnerable communities and de-
carbonization of our own sector.

DEFINITIONS

Climate justice is a concept that addresses the just division, fair sharing, and equitable
distribution of both the benefits and burdens of climate change and responsibilities to
deal with climate change.
Carbon footprint: Total greenhouse gas (GHG) emissions caused by an individual,
event, organization, service, place, or product, expressed as carbon dioxide equiva-
lent (CO2e)
Allostatic load: Cumulative burden of chronic stress and life events.
Planetary health: A solutions-oriented, transdisciplinary field and social movement
focused on analyzing and addressing the impacts of human disruptions to Earth’s nat-
ural systems on human health and all life on Earth.
Commercial determinants of health (CDoH): The private sector activities affecting
public health, either positively or negatively.
Mitigation: Avoiding and reducing GHG emissions through reductions in emissions
and sequestration of existing emissions.

Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240, USA
* Corresponding author. Vanderbilt University School of Nursing, 461 21st Avenue South, Frist
Hall 364, Nashville, TN 37240.
E-mail address: Carol.c.ziegler@vanderbilt.edu
Twitter: @DrCarolZiegler (C.Z.); @JamesMuturi5 (J.M.)

Prim Care Clin Office Pract 50 (2023) 645–655

https://doi.org/10.1016/j.pop.2023.04.010 primarycare.theclinics.com
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646 Ziegler & Muchira

Adaptation: The process of adjusting to current or expected effects of climate

change.

INTRODUCTION

The World Health Organization has named climate change the greatest threat to
human health.1–3 Globally, ecological impacts from GHG emissions most severely
impact the health of communities that have contributed the least to the problem,
making climate change an urgent justice issue. Climate justice directly connects to
all social determinants of health (SDoH) and social determinants of equity.4 People
with the lowest carbon footprints are most likely to suffer the most severe conse-
quences to their physical and mental well-being, economic insecurity, and com-
munity instability due to climate change globally, including in the United
States.5–7 The disproportionate burdens accruing in communities who benefit
the least from the profits associated with GHG-emitting activities of industries illu-
minates the exploitive and complex relationships between SDoH and commercial
determinants of health (CDoH). The marked increase in fossil fuel consumption
accompanying the industrial revolution created wealth in industrialized nations
and for-profit companies and marked the beginning of the shift in atmospheric
GHG emissions that have resulted in the current climate crisis.8 Efforts to reduce
GHG emissions for planetary and human health priorities often conflict with the
financial and political interests of powerful entities.9 The health-care industry
must lead by example and meaningfully advocate for adaptive mitigation through
practice, education, research, and policy advocacy that centers health and
climate justice for those disproportionately affected.

Background
Increased accumulation of atmospheric GHG resulting from the burning of fossil fuels
for energy causes increases in extreme weather, temperature, and sea level rise.10 The
resulting ecological impacts on our planet directly and significantly influence human
and population health and well-being.2 The goal of the health-care sector, especially
primary care, is to provide people with the opportunity to achieve optimal health for as
long as possible—to live as well as they can, as long as they can—compressing
morbidity to the shortest time possible at the end of life.11,12 Optimal time on Earth
in a healthy state provides increased opportunities for meaningful actions that affect
families and communities for generations-like achieving personal fulfillment, accruing
intergenerational wealth, investing in rewarding social relationships and building com-
munities. Optimizing health not only “buys time” but also decreases costs (including
opportunity costs) to individuals, communities, the health-care system and the nation
as a whole.13
Ethical concerns connect climate justice and health equity—the equal access to
the opportunity to achieve optimal health and its innumerable connected intergen-
erational benefits. To ensure equitable access to optimal health span in the face of
climate change, we must focus on climate justice, integrating adaptation-directed
programs while simultaneously mitigating the effects of carbon emissions. The
health-care sector is a significant contributor to GHG emissions and must priori-
tize reaching net zero emissions as soon as possible.14 This article will explore
how climate change contributes to health disparities in vulnerable populations,
why this is a justice issue for primary care to address, and what we can do to pro-
mote equity, resilience, and adaption in our current economic system while miti-
gating GHG emissions.

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 Climate Change 647

Climate Justice: Who Is Vulnerable?

Geographically, persons in the global south are disproportionately affected by climate
change, and in the global north, low-income communities of color and communities
with geographic vulnerability are most affected.7,15 Within the United States and glob-
ally, carbon footprint correlates with income level,15,16 and the individuals and nations
who currently and historically contribute the least to carbon emissions suffer the most
severe burdens from climate change.17 Health impacts from climate change are most
often and most acutely felt in low-income communities of color.5,18 Some projections
suggest that nations in the global north may benefit from some aspects of climate
change, such as prolonged growing seasons, exacerbating current economic
inequality between the global north and south.19,20
Primary care providers (PCPs) must be able to identify sources of vulnerability and
exposure in individuals, families, and communities they care for. As mentioned in the
introduction, the health and economic impacts of climate change disproportionately
burden people who are already heavily burdened by SDoH and high allostatic
load.18,21–23 When assessing risk, be aware that much of our most granular risk
data are based on census tracts and within zip codes; 15-year gaps may exist in
life expectancy based on race alone24; and these life span gaps perpetuate economic,
educational, and health disparities. Additional climate vulnerability may result from
personal traits (age, gender); proximity to climate influences such as extreme weather
(heat waves, hurricanes, floods, fires, tornadoes, and droughts); or vulnerability to sec-
ondary and tertiary impacts such as economic status, social factors, and occupation.2
People at extremes of age, those exposed to climate impacts through occupational
exposure or unsafe housing, and women and people living with comorbidities related
to mental and physical health conditions are most vulnerable to the health impacts of
climate change.2,25,26 Occupational exposure poses a significant risk and people
whose work or activities leave them exposed to heat, poor air quality, and extreme
weather are especially vulnerable.27 Such workers include outdoor workers, athletes,
workers and children in outdoor camps, utility workers, groundskeepers, farmworkers,
first responders, and so forth.27,28 Persons experiencing homelessness or those in un-
safe, unhealthy housing are more vulnerable to climate-related health impacts.7,28,29

Health Impacts: How These Ecological Impacts Affect Mental and Physical Health
Climate change is projected to impact physical and mental health causing approxi-
mately 250, 000 additional deaths between 2030 and 2050, and costing US$2 to
US$4 billion per year in direct health-care costs by 2030.30 Deaths from extreme cli-
matic conditions such as extreme heat waves are now evident—both in high-
income and low to middle-income countries—most of the deaths resulting from car-
diovascular, kidney and respiratory diseases, and mental illness.31
In regards to mental health, the American Psychiatric Association recognizes that
climate change poses a significant threat to mental health with a disproportionate
burden imposed on children, elderly, and the chronically ill, those with mental illnesses
and mobility impairments, and women especially pregnant and postpartum
women.32–35 These mental disorders include posttraumatic stress disorder, depres-
sion, anxiety, phobias, sleep disorders, attachment disorders, and substance abuse.
In addition to the effects on individual mental health, the possibility of extreme weather
and climate disasters creating droughts, flooding, severe storm, tropical cyclone,
wildfires, and winter storm may lead to increased conflict and civil strife,36,37 which
significantly challenge mental health of vast populations of people simultaneously.
In the best of times, effective mental health resources are very limited, exacerbating

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648 Ziegler & Muchira

existing mental health issues and prolonging time to effective identification and
treatment.
In terms of physical health, it is important to note that the root cause of climate
change—the burning of fossil fuels—is a major contributor to worldwide mortality
through airborne particulate matter and ozone, and ambient air pollution, and is the
leading cause of global disease burden in low and middle income countries (LMICs).38
Fine particulate matter (PM2.5) emissions from fossil fuels were estimated to cause
10.2 million global excess deaths in 2012 alone via its cardiac and pulmonary disease
impacts.39 Increasing sea levels, too, can affect physical health, with our current un-
precedented increase in temperature,29 increasing injuries, drowning, and water and
soil salinization issues.40
The increases in extreme heat, which are now common in the United States and
around the globe, can have devastating physical effects—especially in low-resource
countries where adequate cooling measures are often unavailable.41,42 Heat stroke
is a condition requiring immediate medical attention that occurs from exposure to
extreme heat. It occurs when the body temperature increases above 40 C, which if un-
treated is fatal in 10% to 50% of cases resulting from brain, heart, and kidneys dam-
age.41 Heat stress or heat exhaustion, although less immediate, can cause severe
dehydration, acute cerebrovascular accidents, and may contribute to formation of
blood clots and other minor manifestations such as lethargy, irritability, headache.41
In addition, extreme heat compounds the health effects of outdoor air quality by
increasing the particulate levels/air pollutants, creating a more serious synergy of air
contamination and heat stress, and leading to more serious health harms that those
from either alone. People working outdoors are particularly at high risk of heat stress
due to increases in core body temperature from muscle activity and the combined ef-
fects of heat and humidity.41
The world continues to experience several intense climate-related variable weather
patterns such as intense heat waves, flooding, droughts, increase in forest fires, tor-
nadoes, and hurricanes. Extreme temperatures are expected to lead to more heat-
related illnesses and worsen some chronic medical conditions such as heart disease,
respiratory disease, and diabetes.43,44 At the same time, some medications (such as
some antidepressants, diuretics, and beta-blockers) taken for a chronic illness may in-
crease an individual’s sensitivity to heat and consequently, people with obesity and
heart disease will have at greater risk of heat illnesses or mortality.44 The climate-
related weather changes described above pose humanitarian crises and may lead
to civil conflict and forced migration resulting in health-related consequences, psy-
chological distress, risks during pregnancy and childbirth, exposure to violence and
discrimination, as well as a lack of adequate health-care services and social sup-
port.45,46 Lessons learnt from global terrorism and recent pandemics should gear us
to prepare for potential risks developing from climate change. Despite the over-
whelming evidence and lessons learnt from other threats, there is still underinvestment
and unpreparedness in public health measures and health systems preparation to
address climate change and subsequent large-scale health impacts.

Stress: Allostatic Load, Climate, and Economic Impacts

Allostatic load ensues when environmental challenges exceed the individual’s ability
to cope. Allostatic load reflects a cumulative effect of stressful experiences in daily
life including climate stress, work stress, behavioral factors such as poor sleep,
sedentary lifestyle, smoking, alcohol, or unhealthy diet, as well as major life alterations
such as death of loved ones or forced migration.47 Accumulative evidence from epide-
miological, genomic, and other biological studies show that experiences in the natural

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 Climate Change 649

environment or environmental degradation influence physiology and behavior, which

may lead to deleterious health effects.47 With the increasing occurrences of natural
and climate-related environmental disasters, the world has seen devastating costs
to both human well-being and economic functioning. The increased allostatic load
accumulating from climate disasters has a significant toll on health. As we continue
to see billion-dollar environmental disasters (in 2020–2021, the US recorded 42
such events48 and globally, such disasters have increased 1.7 fold in the last decade),
the allostatic load imposed will continue to exert its toll, being, in part, responsible for
an increase of 1.23 million deaths, and more than 4 billion people’s economic losses.49

The Impact of Climate on Social Determinants of Health

Increased heat, extreme weather, and sea level rise and the subsequent far-reaching
community impacts touch each of the SDoH, and although the direct economic and
health influences of climate change are clear, establishing direct links between climate
change and educational access, social and community context, and the built environ-
ment is more complex, and more research needs to be done in these areas. In addition
to economic devastation and health impacts, extreme weather events such as tor-
nadoes, hurricanes, and flooding may simultaneously and for extended periods of
time destroy the built environment and disrupt community context as well as educa-
tional access. Not only are structures affected but also families may be displaced. It is
important to note that renters are often unable to access Federal Emergency Manage-
ment Assistance and also are not included in home buyout programs in managed
retreat scenarios, leaving them with extensive losses in climate disasters.50,51
Heat poses a unique risk in urban communities due to the urban heat island effect, in
which the decreased vegetation and increased concrete further exacerbates heat and
also diminishes night time cooling—a key protective factor for heat-related morbidity
in households without air conditioning.41,52 Compounding this impact, in many com-
munities, there is no requirement for air conditioning in public housing leaving the un-
derserved especially vulnerable to heat-induced health issues.

Climate Change in the Clinical Encounter

In the clinical encounter, PCPs can assess climate-related risks and promote adapta-
tion and resilience in the following ways: (1) Be aware of local/regional climate vulner-
abilities, that is, temperature, extreme weather, and so forth. (2) Assess patients’
individual risk and vulnerabilities including baseline physical and mental health, occu-
pation, and environmental risk and exposures. (3) Specifically assess access to safe
and healthy housing and temperature control and refer for air conditioning assistance
programs and home energy retrofit assistance programs for those who are eligible. (4)
Educate patients about heat and air-quality indices and how to adjust behaviors to
optimize health based on their individual risk. (5) Talk to patients about safety planning
and emergency preparedness for extreme weather and extreme heat and share infor-
mation about passive cooling techniques. (6) Assess food security and dietary habits
and educate patients about optimal diet and hydration status. (7) Optimize manage-
ment of chronic conditions and ensure preventive care and vaccinations are up to
date.

Promoting Cobenefits
Providers can also advocate for cobenefits in the clinical setting. Cobenefits align car-
bon mitigation with health-promoting activities, and integrating these priorities into ed-
ucation, practice, research, and policy aligns the agendas of planetary and human
health. Project Drawdown cites the top 100 ways to mitigate GHG53 and Nurses

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650 Ziegler & Muchira

Drawdown54 outlines attainable cobenefits with adaptive mitigation for health-care

providers. Promoting plant-based diets improves health and reduces GHG emissions
from foods55,56 and the Planetary Health Diet aligns closely with the Mediterranean
diet,57 ideal for reducing cardiovascular risk. Increased life span, decreased cardio-
vascular and cancer risk, as well as avoided carbon emissions are cobenefits of
such diets.14,57,58 Access to gardens for locally sourced produce, as well as green
space and tree cover, promotes health and well-being on multiple fronts59 and se-
questers GHG.60–62 Certain trees improve air quality and reduce respiratory
illness.63–65 Food waste is a significant source of carbon emissions and dietary inter-
ventions to increase plant-based diets, reduce wasteful consumption, eliminate food
waste, and promote composting result in decreased GHG emissions.66,67 Home en-
ergy retrofit assistance programs for low-income home owners and the elderly have
been shown to improve health measures, decrease financial burdens from utility bill
reductions, and decrease emissions from utilities.68 Advocating for and utilizing all
of these strategies is within the scope of the primary care clinician (Appendix).

Maximizing Resilience and Promoting Mitigation: Advocacy from the Health-Care

Sector
The health-care sector must integrate climate justice principles in policy, research, ed-
ucation, and practice. We have social credibility, public trust, economic purchasing
power, and political power. Gallup ranks nurses as the most trusted profession for
the 21st year in a row, followed by medical doctors, and we are crucial voices in
addressing climate justice and promoting planetary health.69 We are the world’s front-
line health-care providers as well as the most trusted professionals, and our advocacy
is powerful.
Intentionally elevate leadership of indigenous communities and communities of co-
lor. To effectively shift our metaparadigm grounded and founded in colonial ways of
being, we have to think beyond mitigation and adaptation to envision a new global
community and invite and center the voices of leaders who will lead efforts to decol-
onize our ways of thinking and being and promote planetary health.70–73 Meaningfully
inclusive practices promote the types of disruptive innovation and radical collabora-
tion that will usher in creative practice models, and justice-centered policies. Educate
yourself about decolonizing health care and advocate for these practices in your
institutions.
Achieve net zero emissions within the health-care sector. If the global health-care
sector were a country, it would be the 13th largest emitter of GHGs in the world.14
In the United States, the health-care sector accounts for 18% of our GDP and contrib-
utes 10% of our GHG emissions.14 The sources of these emissions are supply chain
(pharmaceuticals, chemicals, food, and so forth at roughly 70%), purchased power (at
roughly 11%), and direct emissions (from things such as anesthesia.).14 Tertiary care is
expensive and carbon intensive, and there is a correlation between per capita GHG
emissions and health-care expenditures.14 Transparency, mandatory emissions
reporting and regulated accountability must be embedded into reimbursement for-
mulas and institutional accreditation in addition to increased investments in primary
care14 and support for the recent call to sign on to the fossil fuel nonproliferation
treaty.74 Institutions and professional organizations must lobby for clean energy, clean
transportation and just renewable transitions, account for the carbon emissions of
transportation for patient visits as well as professional activities and conferences,
and prioritize low carbon practices such as telemedicine and web-based
conferences.75–77

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 Climate Change 651

SUMMARY

Climate change is the greatest threat to human health today. The root cause of climate
change, fossil fuel emissions, also contributes significantly to the top 100 causes of
death globally. Therefore, transitioning to clean energy improves health and promotes
climate justice.

CLINICS CARE POINTS

 Low-income families contribute the least to carbon emissions yet bear the greatest health
and financial burdens associated with climate change.
 Heat exposure, respiratory conditions from poor air quality, vector and allergen-borne
illnesses, injuries from extreme weather events, and mental health impacts are climate-
related health issues that primary care providers must be aware of and prepared to manage.
 Climate education and planetary health must be integrated in education across all health-
related fields and required for continued licensure certification.
 Health-care sector emissions are a significant contributor to climate change and achieving
net zero emissions as a sector must be prioritized.

DISCLOSURE

The authors have nothing to disclose.

SUPPLEMENTARY DATA

Supplementary data related to this article can be found online at https://doi.org/10.

1016/j.pop.2023.04.010.

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