As health actors ramp up their game on climate change, in advance of the next UN Climate Conference (COP 29), the fact that global warming poses an ‘existential threat’ to health has become almost cliché. 

From extreme heat and flooding to the impact of drought on hunger and fossil fuel emissions that drive hazardous air pollution, the multiple, inter-related challenges remain difficult for policymakers to appreciate and even for scientists to measure – using classical methods of health research.   

Even so, global health actors are digging deeper beneath truisms in an effort to map, track and address a vast web of interactions – as well as synergies that could be obtained from more sustainable policies.  But as long as the world’s governments continue to pour billions of dollars of investments and trillions into fossil fuel subsidies, they face an upward battle. Meanwhile, the Green Climate Fund funded only one renewable energy project in Africa in the past four years. 

Those challenges were a cross-cutting theme at last week’s World Health Summit in Berlin, which devoted almost an entire day of its two-day event to health-related aspects of the climate question – from strategy sessions on how to amplify health and climate research and investments to the panels on the health damage done by fossil fuel investments.  Here’s a snapshot of what was discussed.  

Multiple health linkages of increasing levels of complexity

In a world dominated by medical models of research that emphasizes randomized clinical trials testing new vaccines and medicines, conclusive “proof” of the chain of climate impacts on health in many domains, remains elusive. 

But the range of unknowns and the need for more research, should not be an excuse for inaction either, say leading health voices, including Global Fund Director Peter Sands. 

“It’s absolutely true that there’s a lot about the impact of climate on health that we don’t understand, we need research – but that should not be an excuse for not doing anything. There’s much that’s a no-brainer …so we can’t let the need to know more get in the way of acting”, declared Sands at a plenary event on the closing day of the World Health Summit. 

Research methods exist, but funding lacking to draw conclusions about local impacts

In the no-brainer category, 30 years of research exists documenting the fact air pollution is a leading risk to health, killing some 7-8 million people annually – and fossil fuels are a major contributor to air pollution. Two decades of transport and health research also lends itself to clear, quantifiable conclusions about the benefits of curbing traffic, to reduce pollution and stimulate healthier alternatives like cycling and walking.  

For example, a recent study on the impact of London’s ultra-Low Emission vehicle zone documented how the ULEZ has not only reduced health damaging air pollution but stimulated more pedestrian activity, including a 40% uptick in children walking to school. That’s a knock-on effect of reduced traffic congestion However, traffic planners in developing cities that badly need to undertake such assessments, rarely have the money or technical tools to do so. They use standard traffic models that simply predict vehicle growth and, against that, recommend road-widening as economically beneficial – without regards for any externalities like air pollution, traffic injury or physical activity. 

Research linking climate and health outcomes – as a tool for policy action 

And then there are the even more complex range of ecosystem interactions – that are even more difficult to quantify in terms of linear cause and effect.  

Take deforestation, for instance. Along with leading to more CO2 release, deforestation stimulates biodiversity loss. That, in turn, affects rainfall patterns and water resource access, as well as leading to the migration of dangerous pathogens from the wild into human populations – which can in turn lead to more outbreaks, epidemics and pandemics.  

The multiple interrelationships can leave even the most expert health researchers and their funders scratching their heads over how to document such critical connections – and offer policymakers clear evidence of how unsustainable choices, e.g. how burning down a forest to expand soybeans crops for factory beef production [which also emits significant CO2], can be devastating for health in multiple arenas. 

One thing is increasingly clear, however, the old research models need to be re-invented, given the urgency of the moment, said Alan Dangour, the lead on climate change at the UK-based Wellcome Trust, one of the world’s oldest health research philanthropies, which has made climate and health a key part of its new strategic portfolio, including a $25 million grant to the World Health Organization, announced at the Berlin conference. 

The priority, said Dangour at WHS, needs to be “delivering research that is a pathway to impact rather than purely academic research- which is what academia is classically trained to do.

“We are here to say the urgency is now. The need is now. We must be delivering research that can be used… which is impactful, links to communities … and can engage policymakers and policy processes.”

Making catalytic investments in health and climate   

In line with the increased interest in health, donor funding at the climate and health nexus has also ballooned from less than $1 billion in 2018 7.5 – 9 billion in 2022- with further commitments since COP28, according to a landscape review of commitments by OECD donors, presented at another, more intimate WHS session, co-sponsored by Rockefeller Foundation. The Foundation has also made climate and health a key part of its strategic portfolio. 

But those investments still pale in comparison to the estimated $7 trillion in direct and indirect subsidies (2022), which the fossil fuel industry is receiving from governments, including nearly $1.7 trillion in direct subsides such as corporate tax breaks, multilateral bank and other public investments, consumer price controls and other incentives.  In terms of the other $5+ trillion in indirect, or ‘implicit’ subsidies,  air pollution impacts on health and climate damage are among the largest uncounted costs, accounting for about 30%  each, according to the International Monetary Fund.

It’s no surprise then, that clean energy investments remain stagnant in key developing regions, such as Africa. And finance is due to be a major issue on the agenda of the upcoming Climate Conference (COP 29) scheduled for 11-22 November in Baku, Azerbaijan. There, member states are supposed to finalize an agreement on a New Collective Quantified Goal for climate finance to support low income countries’ transition to a low-carbon future.  

Against that landscape, health actors – from UN agencies to government ministries and foundations and philanthropies –  are asking themselves what kinds of catalytic investments should be at the top of the list of their ‘asks’ or conversely, at the top of donor priorities  – so as to amplify the climate and health synergies.   

A two intimae sessions on Monday and Tuesday, several dozen key players in the philanthropic world huddled together with a select group of thinkers from governments in Africa and Europe, and WHO officials to ponder the optimal entry points. Key priorities that seemed to resonate included: 

• Investments in more climate resilient health systems – which range from energy starved clinics in developing countries to high tech, high energy modern medical centers that leave a massive carbon footprint.  
• Investments in country- and community-based research that document health co-benefits of climate mitigation; 
• Investments in stronger engagement and advocacy with economic sectors, like energy and climate, whose upstream climate investments affect health; currently only .5% of multilateral climate finance explicitly targets health, according to WHO. 

Demonstrating local impacts on health

“Climate change, for many of the policymakers in our countries, is a kind of new knowledge.  And one of the barriers [to action] is a lack of evidence that demonstrates how climate change is having a serious impact on health,” said Dr Eduardo Samo Gudo, director of Mozambique’s National Institute of Health, at the WHS session. 

That, despite the fact that Mozambique has now  become one of the six top countries in the world in terms of its experience of extreme climate events, he added.  

“So looking at the components that we think are urgent in terms of investment in our countries, the first is on evidence…. While there are many other competing issues, HIV, malaria, TB, and many others, conducting vulnerability assessment of the impact of climate change on health in our country is really crucial to demonstrate to the stakeholders that make decisions,  how serious this business is, in comparison with other diseases.”

Mozambique is one of only 11 countries out of 132 low- and middle income nations that has even developed a ‘health national adaptation plan (HNAP)’ for climate change. 

But even after such an assessment has been made, the vertical structure of international aid, dedicated to specific diseases, makes it challenging to implement a cross-cutting plan.  

“Why?  Because the funding is siloed.  We have Global Fund for HIV, Gavi [the Vaccine Alliance], for immunization and so forth.” 

Finally, he said, despite considerable hype at last year’s COP about the health sector’s own energy needs, little climate funding has been directed to promoting clean energy in the health sector. 

In OECD countries, China and India, the modern health sector’s footprint is estimated to be some 5% of national climate emissions while nearly a billion people worldwide, mostly in Africa, are either served by health clinics powered by costly and efficient diesel generators or no access to reliable electricity at all. 

“Everyone forgot that the health system is also contributing to emissions. But when you look at the ‘Nationally Determined Contributions’ (NDCs), health is not there,” Gudo lamented.

Attuning climate and health programmes to needs a community level 

Whether it’s energy, transport or more resilient health systems, changes designed by national ministries have to be attuned to the needs of the communities where they are to be implemented, said Dr Akosua A Owusu-Sarpong, Director of Health at the Accra Municipality, Ghana. And that’s another big challenge. 

“There’s little knowledge about climate change and health at the local level,” she observed. “Most of the time, these kinds of engagements are done at the national level. But you have to bring the knowledge down to the local level to understand what we are trying to attain in terms of immunization, infectious diseases, neglected tropical diseases – otherwise, the implementation becomes a challenge. 

“And when funders come in… some funders come in with their pre-prepared plan, and if that’s not what the community needs, it becomes a challenge.”

Finally, many climate-related plans that benefit health require cooperation between ministries other than health; empowering local government actors to take initiative and fund projects could help facilitate that process.    

“When it comes to the local level, we still have the same [vertical] pattern of ministries. If there was more district decentralization of ministries [such as] health, transport and environment, at the local level, they could also work hand in hand,” she said.   

Fossil fuel subsidy reform – ‘indispensable’ to health   

But to really leverage action, governments need to  close the tap on fossil fuels subsidies and investments, powering most of the planet’s unhealthy development, to achieve long-term, meaningful health benefits, panelists said at another WHS closing day session, on the fossil fuel subsidy reform as “indispensable” to a healthy energy transition. 

The meeting came against the background of a recent Clean Air Fund analysis documenting how international aid to low- and middle-income nations for fossil fuel projects increased nearly fourfold over the past year (2022-2023) to $5.4 billion.

Leading investors included: the Islamic Development Bank, Japan International Cooperation Agency, the Asian Development Bank, the European Bank for Reconstruction and Development and the World Bank’s private sector arm, the International Finance Corporation (IFC).  

And that’s only part of the picture.  Between 2020-2022, G20 countries spent $142 billion in international public finance to expand fossil fuel operations – three times more than monies invested in clean energy. And this despite a G7 pledge to stop funding such projects by 2022, according to an April 2024 study by Oil Change International and Friends of the Earth. 

Health case for a just transition away from fossil fuels is really clear

“The health case for a just transition away from fossil fuels is really clear,” declared Jeni Miller, of the Global Climate and Health Alliance, which co-sponsored the session. 

“Current health systems based on fossil fuels are driving tremendous impacts on people’s health, and that’s climate change, certainly, but fossil fuels have many, many other health impacts on people, and that’s from the extraction process through transport all the way through end use. And this is happening in communities all over the world. It’s driving air and soil and water pollution. It’s also having occupational health impacts. 

“They [impacts] are borne by families when kids are out of school with asthma.. And the industry is not covering those health costs. Those health costs are borne by health systems.

“And while we know that energy access is a vitally important determinant of health, the fossil fuel approach has not gotten that done either,” said Miller, referring to the nearly 600 million Africans still lack access to electricity at home. 

In South-East Asia, millions of rural Indians have been left out of the LPG boom that has benefited urban areas, noted Sunil Mani of Canada’s International Institute for Sustainable Development.  

“Obviously the [investment by] development banks and development agencies is only a drop in the ocean compared to indirect fossil fuel subsidies of some $5.4 trillion a year,” said Nina Rensaw, of the Clean Air Fund, noting that the latter costs, largely health-related, represent an estimated 6% drain on global GDP.

Africa is one of three regions of the world where demand for oil has grown sharply over the past two years (2022-2023) – as compared to 2015-2023. [The other two are Southeast Asia and the Middle East]. 

This, at a time where oil demand had dropped in absolute terms in Europe and North America. In China, as well, the pace of growth has declined to almost ‘0’ as compared to the previous decade, according to the latest International Energy Agency data.  

Climate or not, the rush to expand oil, gas, and oil shale extraction is in full-swing, from Nigeria and Ghana in the west to Tanzania, Kenya in the east, as well as within the Democratic Republic of Congo’s rich tropical forests.  

Green Climate Fund – only one African renewable energy project approved since 2021

Meanwhile, in the online portfolio of some 200 projects of the Green Climate Fund, the world’s largest dedicated climate finance instrument, only one African renewable energy project was approved over the past four years. That  was in Ghana in 2021, according to the online dashboard.  Four other previously-approved projects involving multiple countries are still ongoing.  

This is despite the fact that clean energy grids may have the largest array of multiple, cascading for health, that can be derived from climate investments. They open up new vistas not only for outdoor air pollution mitigation, but also for electrification of homes and health facilities, with knock-on benefits to women’s and girl’s health and gender equality. When harnessed to greener urban design, they can stimulate healthier, more climate resilient cities that reduce urban heat island impacts, stimulate electrified transit, increase physical activity, and more.  

Admittedly, the GCF remains chronically underfunded. it was supposed to receive $100 billion annually from donor countries already in 2020; instead its portfolio reached just $13.5 billion as of December 2023.  

But the key lever to change, observed Mani, of IISD, is not donor funding; it is political will.  

“One of the key reasons many policymakers or industry leaders argued for the continuation of subsidies for fossil fuel use [in the past] was because of its price advantage – of course made possible with government subsidies.  But in China, for example. the unit price of electricity generated by solar power is about $.20-.35 cents, as compared to $.45 for electricity generated by [conventional] thermal power. “The reasons that were used to justify the use of fossil fuels in the past don’t hold anymore.

“So, in my view, it really depends on how our political leaders commit to make a transition from relying heavily on fossil fuels to cleaner, more sustainable types of energy. 

“From a political standpoint, it is very hard for the existing industries to give up their territory to new technologies. 

“That’s why we are arguing for the market to be as competitive as possible, so that new commerce can come into the market with their so-called ‘creative disruptions’.” 

No private sector incentives for African renewables   

Against the billions allotted to oil and gas, small and medium sized solar developers in the private sector face multiple hurdles and delays in raising just a few million dollars to get projects off the ground, observed one leading private solar developer, heavily invested in Africa. 

“For all the talk and pledges about fixing climate finance for renewables in Least Developed Nations, there is virtually still none available for serious project preparation for the private sector,”  Josef Abramowitz told Health Policy Watch.  

Nine  years ago, his firm launched the first-ever solar field of 8.5 MW in Rwanda, increasing national power generation capacity by 6%. That was followed by a 7.5 MW field in conflict-ridden  Burundi in 2020, named Energy and Environment Trust Fund (EEP) Africa project of the year. The company currently has 10 other African projects in the pipeline in places ranging from Juba, South Sudan, which runs entirely on diesel generators, to Zambia. Most are still waiting for small grants or loans of $2-4 million to finalize project planning – that kind of finance is extremely scarce. 

“Project preparation means all of these studies and permits, which also get government agencies aligned and on board,” Abramowitz explained. “Once that’s all sewn together in a bankable beautiful bow, everyone is happy to put equity into these projects. But if there is no real money for project preparation, and it takes 5-10 years for a project to mature, it’s not worth it for the private sector to go in because of the high risk and long lead times. 

 “The net result is that trillions of dollars are available for project finance, which will never be unlocked and deployed without a massive increase in pre-development grants to platforms with pipelines and proven teams.”

Image Credits: Gellscom/CC BY-ND 2.0., Yoda Adaman/ Unsplash, US Centers for Disease Control and Prevention, HP-Watch, SEEK/World Health Summit, International Monetary Fund , WHO, UNDP/Karin Schermbrucker for Slingshot , IEA , Statista.com, Green Climate Fund, Energy and Environment Partnership Trust Fund Africa .