|Volume 57 (4) — October 2008
Public health and weather services–climate information for the health sector
Climate is a key variable in managing the overall burden of disease, particularly in developing countries where the ability to control climate-sensitive diseases constrains the prospects of achieving the United Nations Millennium Development Goals. To mitigate their adverse effects, the health sector needs to understand and quantify the specific effects of climate variability and change both on the overall disease burden and on opportunities and effectiveness in the public health response.
This applies equally to future adaptation strategies and to understanding fully the impact of the climate on the existing disease burden and current interventions. For example, an accurate assessment of the impact of a bed net programme for malaria control depends on knowing the climate trend during the assessment period. In the absence of any intervention, increasingly wet years may well increase the mosquito population, resulting in a higher incidence of malaria, while conversely, periods of drought may well decrease the mosquito population and reduce the incidence of malaria. It is also possible that the trend could reverse in certain locations; dry spells favouring transmission when normally running streams leave intermittent pockets of water during drought periods which then become suitable for mosquito breeding. Thus, it is important to understand the environmental context to develop an accurate picture of the efficacy of any intervention strategy.
The health sector can also use climate information effectively in epidemic early warning systems. Seasonal forecasts of temperature and rainfall, which are useful indicators of the likely occurrence of malaria outbreaks, can be used to implement a programme of heightened epidemic surveillance, while real-time temperature and rainfall estimates can be used to initiate selective interventions and to support the early detection of disease outbreaks.
Climate change is high on the agenda of public health services worldwide. The recent World Health Assembly of the World Health Organization (WHO) (May 2008) reinforced the need for countries to develop health measures and integrate them into plans for adaptation to climate change; to strengthen the capacity of health systems for monitoring and minimizing the public health impacts of climate change through adequate preventive measures, preparedness, timely response and effective management of natural disasters; and for the health sector to effectively engage with all of the relevant sectors, agencies and key partners at national and global levels to reduce current and projected health risks from climate change. One approach is to build on existing decision-support and other tools, such as surveillance and monitoring, to include the capacity to assess vulnerability to, and the health impacts of, climate change, and to develop new responses, as appropriate.
Since the health sector is not usually engaged in climate and environmental monitoring, acquiring and using this type of information successfully depends on developing partnerships between health practitioners and the gatherers and providers of climate and environmental information. In most countries, the collection and provision of climate data and information are the responsibility of the National Meteorological Services. National climate service providers need to be developed to meet user needs for climate information in decision-making.
Until recently, climate records were collected primarily for the purpose of creating a general climatology, rather than meeting the particular needs of a specialized user group, such as the health sector. In Africa, climate observing networks are generally sparse and inadequate for the task. It is recognized that a significant investment is needed in new observations and information systems to provide useful sector-specific climate data and information (IRI, 2007). This challenge has been taken up by the African Union through the creation of ClimDevAfrica, sponsored jointly by the African Development Bank, the African Union Commission and the UN Economic Commission for Africa (APF 2007, Rogers et al., 2008).
From the health sector’s perspective, climate information needs to be geographically specific and readily available on the time-scales relevant to public health decision-makers. Achieving this depends on a high level of collaboration between environmental and health experts. Institutionally, this will only occur if there is an effective working relationship established between the providers of climate data and information and the Ministry of Health.
The Ethiopian Ministry of Health (MoH) and the National Meteorological Agency of Ethiopia (NMA) are pioneering such efforts. In the interest of helping other countries find the practical means to increase access to relevant climate information, this experience is documented here and the key ingredients needed for successful collaboration are synthesized and described.
Burden of malaria in Africa
Sub-Saharan Africa has more than 60 per cent of the world’s malaria cases and more than 80 per cent of the world’s deaths (WHO-UNICEF, 2005). The greatest burden of malaria in Africa is in endemic areas, where the parasite is continuously present in the community. Where control measures are inadequate, the distribution of the disease is closely linked to seasonal patterns of climate and the local environment. Those most at risk from endemic malaria are the very young who have not acquired immunity and pregnant women whose immunity is reduced during pregnancy (Connor et al., 2008).
In contrast, epidemic malaria occurs where the exposure of the population is infrequent and, therefore, they have little acquired immunity. Because immunity is low, all age groups are vulnerable and fatality rates can be high (Kiwzewski and Teklehaimanot, 2004). It is estimated that more than 124 million Africans live in epidemic prone areas; consequently, prevention of epidemics is also a major public health issue (Worrall et al., 2004). Epidemics occur when the conditions supporting the balance between the human, parasite and vector populations are disturbed in favour of the latter. This change in equilibrium is often brought about by climate anomalies which temporarily allow sufficient mosquito survival and parasite development.
The Ethiopian experience
Epidemic malaria risk is high in Ethiopia and other densely populated countries in the East African highlands. It is estimated that two-thirds of Ethiopia’s population of 77 million are at risk of epidemic malaria (Connor et al., 2008). A first step towards dealing with an epidemic is to ensure that the local health institutions have the capacity to respond adequately and are not overwhelmed by the number of cases. This can be achieved only if there is sufficient lead time for advanced preparation and prevention, which require early warning of where and when epidemics are likely to occur.
An early warning and response system depends on many things, including meteorology, which plays a significant factor in “triggering” malaria epidemics. Recognizing this, the MoH, with support from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), is in the process of building a climate-informed epidemic early warning and response system that comprises seasonal and shorter time-scale forecasts, real-time weather information and early detection of cases (Connor et al., 2008). Each of these indicators informs on opportunities for a particular response: for example, a seasonal forecast of increased epidemic malaria risk will result in opportunities for planning and preparedness; meteorological and environmental/hydrological monitoring offers opportunities for mobilizing preventive measures and heightened surveillance; and early detection of cases confirms the scale of the epidemic and may indicate the point at which efforts need to switch the balance of intervention from prevention to effective case management (WHO, 2004).
Together, the MoH and the NMA are in the process of increasing the capacity of the sentinel sites* to monitor climate anomalies by adding maximum and minimum temperature measurements to weather stations that previously only monitored rainfall, and by increasing the number of sentinel stations. Funding for the meteorological stations has been provided by the Ministry of Health through the GFATM grant. The stations are maintained by the NMA, which is responsible for making the data available to the general health care system of Ethiopia (Connor et al., 2008).
Rainfall, temperature and relative humidity data are combined to produce maps of the climatological conditions for malaria. These are published in monthly bulletins, which are distributed by the Ministry of Health’s National Malaria Control Team to regional malaria control departments. The information is also placed on the RANET (community RAdio-internET) Website (http://www.ranetproject.net/).
The expectation is that this information will be helpful in planning for the purchase of drugs; identifying where and when to implement more epidemiological surveillance; focusing vector control more accurately in space and time; raising community awareness of epidemic risk; and warning relevant players of any potential emergency as necessary (Connor et al., 2008).
Although in a relatively early stage of development, the cooperation between the Ministry of Health and National Meteorological Agency can provide a useful guide to others looking to deal more effectively with climate and health issues.
What is needed for an effective working relationship between the health sector and Meteorological Services?
Ethiopia’s Climate-Health Working Group
In order to provide a focus on climate and health issues, Ethiopia has created a Climate-Health Working Group, which brings together most of the actors. The structure and purpose of the Working Group are described here in detail as a guide to other countries wishing to establish similar mechanisms for the use of climate data and information to improve health outcomes.
The Working Group is chaired and co-chaired by representatives of the MoH and the NMA with a small secretariat organized and maintained by the Anti-Malaria Association (AMA), an Ethiopian Non-Governmental Organization. The other members are drawn from UN organizations and other Ethiopian health organizations, including representatives of the United Nations Environment Programme, the United Nations Children’s Fund, the World Health Organization, the Ethiopian Public Health Association, the Centre for National Health Development in Ethiopia, and the Ethiopian Health and Nutrition Research Institute. In addition, the activities of the Working Group are helped by the International Research Institute for Climate and Society, the Health and Climate Foundation and the Group on Earth Observations.
The vision of the Working Group is to engender a self-reliant, healthy and productive population through the proper use of climate information to improve health outcomes from climate-sensitive diseases. Its goal is to create a climate-informed health sector and beneficiary communities that routinely request and use appropriate climate information to improve the effectiveness of health interventions.
The objectives of the Working Group are to create awareness on the impact of weather and climate on health; to develop effective and functional means for the health sectors and beneficiary communities to routinely use appropriate climate information; to estimate populations at risk from climate-sensitive diseases (where and when and including early warning systems).
The tasks of the Working Group are to:
Concluding remarks and recommendations
The health risks posed by current climate variability and the growing threat of climate change require the health sector to take the lead, to bring on board relevant sectors and institutions to ensure that concerted effort is made to utilize available climate data and information to manage climate risk more effectively. The health sector is best placed to lead any effort to reduce the climate-sensitive disease burden, but it cannot do this without the active involvement and collaboration of key partners.
Developing climate networks and deriving climate information is ideally within the purview of National Meteorological Services with which Ministries of Health can develop effective partnerships. The Ethiopian experience has identified some of the key ingredients needed to sustain this working relationship and it may serve as a model for other countries dealing with the health risks caused by climate and climate change. In particular, a partnership between the Ministry of Health and National Meteorological Service will help to:
Build greater confidence for increased national and international investment in sustainable public health gains.
It is recommended that health sector and meteorological services set up a working group or task force at the national level with a structure, mission and objectives similar to the one described here with tasks tailored to specific climate-sensitive health problems. This will help provide a focal point for climate and health issues in the country and spearhead collaborative work beyond national borders to engage, when appropriate, the international community more effectively.
African Partnership Forum (APF), 2007: Climate Change and Africa. 8th Meeting of the Africa Partnership Forum, Berlin, Germany 22-23 May 2007, 28 pp (http://www.africapartnershipforum.org/dataoecd/57/7/38897900.pdf )
Connor, S.J., T. Dinku, T. Wolde-Georgis, E. Bekele and D. Jima, 2008: A collaborative epidemic early warning and response initiative in Ethiopia. In: Proceedings of International Symposium on PWS: A Key to Service Delivery, 3-5 December 2007, WMO, Geneva.
Grover-Kopec E.K., M.B. Blumenthal, P. Ceccato, T. Dinku, J.A. Omumbo and S.J. Connor, 2006: Web-based climate information resources for malaria control in Africa. Malaria Journal, 5 (38).
International Research Institute for Climate and Society (IRI), 2007: A Gap Analysis for the implement of the Global Climate Observing System in Africa. IRI Technical Report #IR-TR/06/01, 52 pp, (http://iri.columbia.edu/outreach/publication/report/06-01/report06-01.pdf ).
Kiszewski, A.E., A. Teklehaimanot, 2004: A review of the clinical and epidemiological burdens of epidemic malaria. American Journal of Tropical Medicine and Hygiene, 71 (Supplement 2), 128.135.
Rogers, D.P., M.S. Boulahya, M.C. Thompson, S.J. Connor, T. Dinku, K.B. Johm, H.R. Shalaby, B. Ahmadu and A. Niang, 2008: National climate and environmental service for development. In: Proceedings of International Symposium on PWS: A Key to Service Delivery, 3-5 December 2007, WMO, Geneva.
World Health Assembly, 2008: Climate Change and Health. 61st WHA Resolution, May 2008, Geneva. (http://www.who.int/gb/ebwha/pdf_files/A61/A61_R19-en.pdf))
WHO-UNICEF, 2005: World Malaria Report. WHO and UNICEF, Geneva, 295 pp.
WHO, 2004: Malaria epidemics: forecasting, prevention, early detection and control—from policy to practice. WHO/HTM/MAL/2004.1098
Worrall, E., A. Rietveld, and C. Delacollette, 2004: The burden of malaria epidemics and cost-effectiveness of interventions in epidemic situations in Africa. American Journal of Tropical Medicine and Hygiene, 71 (Supplement 2), 136-140.
1 Ministry of Health, Addis Ababa, Ethiopia