Climate change has been coming to the forefront globally. Mitigating climate change by reducing greenhouse gas emissions has many health benefits. Climate change associated with diseases is becoming an umbrella covering all aspects of public health as a priority. Climate model output can then be used to drive disease models or investigate the risks of health pertinent to the climate in the future. In public health, creating programs with preparedness aiming to reduce exposure for the most vulnerable populations, training, and awareness-raising activities for clinicians and the public in areas with increasing warmer summer season to emergency interventions that could include public alerts, opening cooling centres, and distributing drinking water. In India, in warning populations address climate change by moving the neonatal unit from the top to the bottom floor of a hospital. This rearrangement had a significant effect on the population and required no forecasting, and as heat rises the most vulnerable stays cool. The problem with forecasting climate changes is that it is impossible to sample the full range of uncertainty within such an ensemble of projections measurements. They are imperfect for long-range forecasting, one has to consider the uncertainty about greenhouse gas and aerosol emissions trajectory, climate model errors, and variations in natures climate. “The science behind global warming is unequivocal, but the expectation that the temperature will be hotter at the end of the century says nothing about the trajectory between now and the long-term future” (Nissan & Conway 2018). As climate change, health impacts WHO's Climate and Health Country Profile Project proposes a guide for various economies on how to address climate change on local populations. A rational adaptation to measure with available and reliable climate information while keeping the future in mind for example, “warming in Ethiopia is raising the maximum elevation for malaria transmission in mountainous areas, exposing new highland populations to malaria risk, but projected temperature trends are uncertain” (Nissan & Conway 2018). The predictability can be used to focus on malaria eradication, a priority of the WHO Strategic Advisory Group on Malaria Eradication then laser focus additional resources into control programs. In Lima, Peru, a low-income country has implemented a long-term cost-effective “green infrastructure” master plan to manage inconsistent water supply to adapt to climate change.
“Climigration” was coined by Robin Bronen, an Alaskan human rights lawyer, to describe the forced irreparable migration of communities due to climate change. The change in environment can be evident post disasters, including climate-related disasters such as Cyclone Aila in Bangladesh or Hurricane Katrina in New Orleans and recovery is based on resources. The climate disasters like crop failures from drought can be the spark for violent conflicts, which lead to forced migration as well. A vulnerable society can be destabilised, making climate change a global threat.
The ethics of clinical practice with the focus on pushing benevolence will continue as a tsunami of “natural disasters, armed conflict, migration, and epidemics” continue to come in larger continuous waves causing more injury, displacement of people and economic loss. Their burden on health systems and healthcare workers is pushing everyone to new limits. The ethical problems can arise from disasters that create challenges that vary from daily practice that can cause harm or violate human rights.
The economics of migration effect varies from home country to the host country but “immigrants tend to leave the host country within five years of arrival” (Dustmann & Görlach 2016). Although migration temporariness induces behaviours that differ from those of permanent migrants that plan more leisure in the course of their life-span of their new host country, it is typically not considered in analyses of immigrant behaviour and immigration impact on home and host countries. The migrant staying for three to five years is focused on saving, remittance, and does not focus on leisure activities.
The adverse effect of climate change on health in the development of climate science and policymaking is evolving into a topic of conversation in healthcare education. The awakening of the prevalence of climate-sensitive diseases, in selected vulnerable areas of Bangladesh healthcare where data is being correlated on climate change related diseases such as malaria, Dengue fever, pneumonia & diarrheal diseases. A study was conducted to understand the level of knowledge as to how climate change affects one’s health; 224 cluster villages in Bangladesh were interviewed in the process. The results concluded that the knowledge level of the study participants of vulnerable communities on changing climatic factors and their impacts on health was higher (94 %). “The public health needs to connect more with primary health care by training health workers at field level to address climate change and health issues. The level of education is always an influential factor to understand climate change and adaptation to the impact on health at the community level.”
In East Africa, warm temperatures correlate with a rise in cholera epidemics and hospital admissions rate for malaria. During cold temperature days correlated to a rise of hospital admissions for heart failure and hypertension rates in Nigeria, and for preeclampsia in South Africa. African rainy seasons have lead to the data pointing to hospital admissions for hypertension in Nigeria, and to pneumonia, malnutrition, and snake bites in Zambia. In the country of Gambia, the association between temperature and respiratory syncytial virus (RSV) admissions depended on temperate or tropical climate, “while the association between precipitation and RSV was consistent regardless of climate region.” Climate-sensitive health outcomes comprise a substantial health burden on the local population creating an increase in the cost of care, hereby understanding the connection of weather and health may provide useful information for adapt and plan in localised-contexts globally. Then you have to integrate this knowledge and information directly into risk management for the hospital planning with a climate change preparedness plans. Healthcare facilities may be able to deal with the influxuation of patients.
The future holds for more “climate-resilient health systems” which includes climate sensitive disease surveillance, good governance, building human and institutional capacity, and design thinking on climate resilient health policies and procedure.
The use of “mobile technologies and social media has transformed the landscape of emergency and disaster management communication by enabling disaster-stricken citizens to produce digital, real-time, local information on critical events. Hurricane Sandy in 2012, Typhoons Haiyan or Hagpuit in 2013–2014, or the Nepal earthquake in 2015 offer examples of user-generated data by millions” (Poblet, García-Cuesta, & Casanovas 2017). The streams of big data, social media created crowd participation in emergencies and disasters. The refugee waves in Europe in 2016, there are many examples of populations using tech as well as first responders and diasporas with varying data management knowledge base. The mobile health (mHealth) market is expanding via disaster management apps to incorporate information from UN and FEMA as well as user-generated content from the “on the ground” citizen in real-time.
The world is becoming borderless, the migrant and refugee crisis from the Americas, Asia, North Africa, and the Middle East has forced immigrants to cross boundaries by any means with possible loss of life. While populations are shifting into neighbouring states or countries, healthcare systems are not designed to manage this dynamic shift in population. Patients ‘medical records do not travel with patients’ medical history, the history of allergies, surgeries are lost in the crisis and critical life-support medications or supplies do not travel with them because IT systems and policies do not yet exist to support this process internationally. The fact that we now live in a borderless world with shifting demographics has worsened the crisis in healthcare and lay heavily the burden of disease. In “Cybercare 2.0: meeting the challenge of the global burden of disease in 2030,” there is a reference to the term “cybercare” encompassing seven health technologies to provide medical care: genomics, telemedicine, robotics, simulation, including virtual and augmented reality, artificial intelligence (AI), including intelligent agents; electronic medical records (EMR); and smartphones. Global healthcare may help avoid or delay disease, foster prevention, and wellness, improve quality of life, minimise healthcare expenses, and predict future epidemics or healthcare crises by applying Cybercare. The Severe Acute Respiratory Syndrome (SARS) outbreak in Toronto, Canada where 257 people at a hospital transmitted from one person traveling from Hong Kong lead to the outbreak. The process of decentralising hospitals and moving more care into the community and home with cybercare makes patients better able to access and dictate care and makes the system more robust during normal operations and when under a crisis. A more distributed system with fewer critical access points will be more resilient to both natural and man-made crisis. The need for medical systems to scale to a natural or biological disaster will be enhanced greatly as the load can be distributed more evenly across the system.
The Organisation for Economic Co-operation and Development (OECD) reports a +78% of permanent migration into OCED member states in 2016. As reported by the OECD over the course of five years, permanent migration had increased for the following countries are as followed with variation between 2015-2016 in Germany +53%, Sweden +34%, and Finland +27% based on standardised statistics. By 2017, there was a decreased migration post economic recovery, refugee crisis and international migration were down 5%. In 2017, there has been a sharp decline in migration to Germany, Sweden, Austria, and Finland.
The life expectancy in the EU has slowed to 0.5 year from 2011-2016 from 2-3 years, due to an increase in circulatory and flu death among the elderly. The OECD (2018) states a person with a “lower level of education can expect to live six years less than someone with a higher level of education.” The initial cost for refugees for a host country is covered under public funds in the area's welfare system. Access to labour markets and social integration are based on language and professional training. The EU is shifting to a patient-centre and eldercare model using health technology from election healthcare record, eprescribing as well as moving from acute hospital center care to integrated community care. The EU residents are using the internet more to research information and connect with health services.
Women’s health is a challenge for a host country and mothers during pregnancy. A report from the OECD in 2018, points that “in Southern Italy, many pregnant migrants present with malnutrition, but also severe burns caused by spilled fuel during their boat travel.” The mental transition for a clinician from treating just the pregnancy to treating each migrant patient’s hospital stay as a crisis or an emergency. The care will be more extensive. “Eleonora, a gynaecologist at the Lampedusa maternity service since 2015, emphasised: “To take care of migrant women, our skills related to pregnancy are not enough, you must have a good knowledge also in general medicine, internal medicine, dermatology, and infectious diseases. The clinical problems these women present are not only gynaecological, so you have to know a little of everything.”
It is important to address women’s sexual and reproductive health specifically for asylum seekers. In Switzerland, suggests more of a tailored culture-sensitive care for best practice that women seeking asylum come with different needs. “The accommodation in the asylum centres provided gender-separate rooms and sanitary infrastructure.
1) A lack of a standard of healthcare from coordination between healthcare providers, unavailability of essential services such as interpreters, and fragmented healthcare, and
2) A specialised healthcare model specifically tailored to the needs of asylum-seekers.”
The challenges of mental health for a refugee that has newly migrate with high rates of mental health problems are consistently found among immigrants from refugee generating countries. Not surprising to see post-traumatic stress (PTS), depression and anxiety have been consistently after, patients experiencing “traumas such as war, violence, famine, torture, repression” and loss of a family member. In Norway, refugees are more likely to seek healthcare than migrant reunifying with family members from a war zone. “As part of the refugee resettlement programme in Norway, refugees will gain insight into Norwegian society and learn about the health system. Immigrants who come through family reunification do not necessarily receive the same support.
As mentioned in the Nordic Migrant Journal, Sweden is addressing the challenges of new migrant highly educated doctors and with alternative medicine approaches with an entrepreneurial mindset. Immigrants’ high representations in other secondary education and post-secondary education, particularly amongst the newly arrived, might signal a problem in terms of having foreign education validated.” Due to this fact new immigrants educated in the home country education “that is not classified in line with the ordinary statistical codes and that immigrants with these types of education (generally at a high level) are those who more often start businesses.”
Globally the World Health Organization framework for addressing climate change, refugee and migrant health. It is really a change in mindset from putting patients at the centre of care no matter where they are to where they settle. The use of health tech and social media to create community-generated data, tracking for preventative health and crisis management of health as refugees and migrants. The change in the concept of educating clinical staff from a singular disciple to more of a broad concept. A change in the frame of mind to think globally about the effects of climate change on patients’ health from the start of life to the end stages. It is truly a new outlook to think about clinical staff retention from a global point of view of inclusion to deal with shortages of health workers.
DANIELLE SIARRI, MSN, RN
Nurse Informatics Specialist and Health IT Advisor