The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels

1Because of human activity, the global mean surface temperature is 1·1°C higher than the pre-industrial average, and the past seven years were the warmest on record. Climate change is increasing the frequency and intensity of many extreme weather and weather-related events, resulting in severe damage to the natural and social systems on which health depends. The environmental changes caused by climate change are also driving shifts in the geographic range of climate-sensitive infectious diseases, affecting food and water security, worsening air quality, and damaging socioeconomic systems. While the world coped with the ongoing COVID-19 pandemic, weather events of unprecedented intensity took place in 2021 and 2022: record temperatures of nearly 50°C in British Columbia claimed 570 lives, floods in Australia, Canada, China, Malaysia, Pakistan, South Sudan, and western Europe led to thousands of deaths, hundreds of thousands of people displaced from their homes, and billions of US dollars in losses,, and wildfires caused devastation in the USA, Greece, Algeria, and Türkiye. Yet energy-related greenhouse gas emissions rebounded to a historical record in 2021, and atmospheric CO2 reached its highest concentration in more than 2 million years.

2Existing policies put the world on track to reaching 2·4–3·5°C above pre-industrial times by 2100, and there is a 48% chance that the 1·5°C threshold proposed in the Paris Agreement will be exceeded within 5 years.– COVID-19 recovery efforts have thus far been unable to deliver the transformation that the health community and others called for, and ongoing geopolitical conflicts make the 1·5°C threshold less likely to be met. The findings in this report show the urgency of climate action and can inform an aligned response to compounding crises, to protect the health of present and future generations (panel 1).

3The Lancet Countdown: tracking progress on health and climate change is an international, transdisciplinary collaboration of 51 academic institutions and UN agencies, monitoring the changing health profile of climate change.

4The 43 indicators (panel 2) have been refined continuously for seven years, and reflect the consensus of 99 multidisciplinary researchers, the guidance of the Lancet Countdown’s Scientific Advisory Group and High-Level Advisory Board, and the support of The Lancet and the Wellcome Trust. Most indicators have been refined this year to improve the monitoring of associations between climate change and health. New and re-introduced metrics monitor the impact of extreme temperature on food insecurity; exposure to wildfire smoke; household air pollution; the alignment of the fossil fuel industry with a healthy future; and health considerations in each country’s Nationally Determined Contributions (NDCs). All new or substantially modified indicators were assessed by an independent expert panel for appropriateness and robustness,, and some existing indicators were independently assessed to ensure continued relevance and rigour.

5This report, more concise than previous iterations, is supplemented by an online data visualisation platform that can be used to see indicators in full detail and geographical resolution. Reports from the Lancet Countdown regional centres in Asia (Tsinghua University, China), Europe (Barcelona Supercomputing Center, Spain), South America (Universidad Peruana Cayetano Heredia, Peru), and Australia (Macquarie University and The University of Sydney) offer more detailed regional assessments than this report. Newly established centres are working to explore in further depth the association between health and climate change in Small Island Developing States (University of the West Indies, Jamaica) and Africa (Medical Research Council Unit, The Gambia). With these expanding local networks, the Lancet Countdown now brings together more than 250 researchers from almost 100 institutions worldwide.

6As countries attempt to meet Paris Agreement commitments, Lancet Countdown indicators are contributing to national and international climate and health monitoring systems, and have been incorporated into the European Climate and Health Observatory and the climate and health assessment of the Italian National Institute of Health (Istituto Superiore di Sanità). In 2023, the UNFCCC will run the first Global Stocktake, an assessment of collective progress towards meeting Paris Agreement goals, designed to help countries adjust efforts to meet climate targets. Taking stock of the health impacts of climate action, this report can help countries realise the ambition of making the Paris Agreement the “most important public health agreement of the century”.

7Climate change is affecting the health of people worldwide directly with increased exposure to extreme weather, and indirectly with impacts on the physical, natural, and social systems on which health depends. Climatic changes are also amplifying the existing threats to food and water security, built infrastructure, essential services, and livelihoods.

8Section 1 tracks the health hazards, exposures, and impacts of climate change, with indicators that monitor vulnerabilities now detailed in section 2. Indicators have been improved and expanded to provide a comprehensive overview of the effects of climate change on health and the effects of climatic and demographic changes on health-related outcomes. Three new sub-indicators track the influence of wildfires on exposure to PM2·5 air pollution (indicator 1.2.1), the associations between heat and extreme precipitation with online sentiment expressions (indicator 1.2.3), and the increasing impact of extreme heat on global food security (indicator 1.4.1).

9Climate change is leading to an increase in average global temperatures and in the frequency, intensity, and duration of heatwaves. Exposure to extreme heat is associated with acute kidney injury, heatstroke, adverse pregnancy outcomes,, worsened sleep patterns, impacts on mental health, worsening of underlying cardiovascular and respiratory disease, and increases in non-accidental and injury-related deaths. Exposure to extreme heat also affects health indirectly by restricting people’s capacity to work and exercise.– Older people, pregnant women, newborn babies, people who are socially deprived, and people working outdoors are particularly at risk.,

10Inhabited land areas warm up faster than oceans. By overlapping gridded temperature and population data, this indicator shows that the average temperatures humans were exposed to during summer seasons in 2021 were 0·6°C higher than the average in 1986–2005, representing twice the global mean temperature increase in the same period (0·3°C).

11Between 2021 and 2022, record temperatures were registered in Oman, the Middle East, Australia, many Mediterranean countries, and Canada. This indicator overlaps daily temperature and demographic data to track the exposure of vulnerable age groups to heatwaves (a period of 2 or more days in which both the minimum and maximum temperatures are higher than the 95th percentile of temperatures in 1986–2005, as defined previously in the literature)., During the period 2012–21, children younger than 1 year experienced 600 million more person-days of heatwaves (4·4 more days per child) annually compared with the average in 1986–2005, and adults older than 65 years experienced 3·1 billion more days (3·2 more days per person; figure 1). In 2021, people older than 65 years in Canada experienced a record of 47 million more person-days of heatwaves (2·4 million in children under 1 year) than annually in 1986–2005, mainly due to an unprecedented heatwave that was at least 150 times more likely to have occurred because of climate change (panel 3).

12Regular physical activity contributes to a healthy body-weight, improves physical and mental health,– and helps to prevent many non-communicable diseases. However, hot weather reduces the likelihood of engaging in exercise, and increases the risk of heat illness when it is done.– This indicator has been improved to track the daily hours during which physical activity would entail heat stress risk. Compared with the baseline average in 1991–2000, the number of annual hours of moderate-risk of heat stress during light outdoor physical activity increased globally in 2012–21 by an average of 281 (33% increase) hours per person and high-risk heat stress increased by 238 (42%) hours per person. The greatest rise occurred in medium HDI countries, with an increase in the hours of moderate risk of heat stress during light outdoor physical activity of 310 (20%) hours per person and an increase of high-risk of 296 (26%) hours per person, annually.

13Heat exposure affects labour productivity and puts the health of exposed workers at risk. The resulting labour loss undermines livelihoods and the socioeconomic determinants of health. This indicator monitors the potential work hours lost because of heat exposure and solar radiation, in an improvement from previous reports, by associating wet bulb globe temperature with the typical metabolic rate of workers in specific economic sectors. Since 1999, the potential hours lost increased by 5·6 billion hours per year (figure 2). In 2021, 470 billion hours were lost—an increase of 37% from the annual average in 1990–99, and an average of 139 hours lost per person. Two thirds of all labour hours lost globally in 2021 were in the agricultural sector. This proportion was highest in low HDI countries, at 87%.

14A study of 43 countries published in May, 2021, estimated that 37% of heat-related deaths are attributable to human-induced climate change. However, insufficient data sharing and reporting restrict the capacity to produce accurate estimates globally, to assess adaptation measures, and to identify vulnerable populations., Using a generalised exposure–response function to provide an estimate of heat-related deaths globally, this indicator finds that annual heat-related mortality of people older than 65 years increased by an estimated 68% between 2000–04 and 2017–21.

15Detection and attribution studies show the increasing influence of anthropogenic climate change on weather extremes (panel 3). Resulting direct injuries and death are often compounded with impacts on sanitation and service provision, forced displacement, loss of assets and infrastructure, economic losses, and adverse mental health outcomes, often having long-lasting effects.– This group of indicators, complemented by indicators 2.3.2 and 4.1.1, details the association between climate change, extreme weather events, and health.

16Wildfires affect health with thermal injuries, exposure to wildfire smoke, loss of physical infrastructure, and impacts on mental health and wellbeing.– Drier and hotter conditions increasingly favour the occurrence, intensity, and spread of wildfires, and undermine control efforts. This indicator uses remote sensing to track exposure to days of high meteorological wildfire danger and wildfire exposure, with improved consideration of cloud cover in the detection of wildfire spots in this year’s report. New to this report, the indicator incorporates atmospheric modelling (IS4FIRES-SILAM model) to track exposure to wildfire smoke (PM2·5).,

17Globally, people experienced an average of nine more days of very-high or extremely-high meteorological wildfire danger in 2018–21 compared with 2001–04, with 110 (61%) of 181 countries having an increase (figure 3)—a pattern caused by climate variation rather than demographic shifts. The yearly average wildfire exposure increased by 9·17 million person-days between 2003–06 and 2018–21. Increases were observed in 21 (64%) of 33 low HDI countries compared with 27 (42%) of 65 very high HDI countries, which could reflect differences in wildfire prevention and management.

18Population exposure to wildfire-derived PM2·5 was modelled with the SILAM chemistry transport model. Data show a statistically significant increase in 16·5% of the global land surface from 2003 to 2021, and a significant decrease in 8·8% of the surface land area.

19Droughts put food and water security at risk, threaten sanitation, affect livelihoods, and increase the risk of wildfires and infectious disease transmission., This indicator uses the 6-monthly Standard Precipitation and Evapotranspiration Index (SPEI6) to capture changes in extreme drought (SPEI ≤–1·6) due to changes in precipitation and temperature-driven evapotranspiration. In the period 2012–21, on average, almost 47% of global land area was affected by at least 1 month of extreme drought each year, an increase of 29% from the period 1951–60. The Middle East and north Africa, where 41 million people lack access to safe water and 66 million do not have basic sanitation services, was particularly affected, with some areas experiencing more than 10 extra months of extreme drought.

20Heatwaves and extreme weather increase the risk of mental health disorders (panel 4).,, This indicator uses a multivariate ordinary least squares fixed effects model to monitor the influence of heatwaves on online sentiment expression (measured here as the sentiment expressed in tweets), in addition to the effect of extreme precipitation, which is new to this year’s report. This model was used to analyse 7·7 billion tweets from 190 countries and adjusts by month, calendar date, and location. Days of extreme precipitation during 2021 reduced the percentage of tweets that had positive expression by a statistically significant 0·26 percentage points, the highest recorded reduction in positive expression during extreme precipitation days since 2015. Since 2015, heatwave days and days of extreme precipitation have consistently worsened sentiment expression. In 2021, heatwave days increased the proportion of tweets that expressed negative sentiment by a statistically significant 0·20 percentage points, the largest effect in the historical series (from 2015 to 2021). The heatwave in the Pacific Northwest, in 2021, increased negative sentiment by 9·8 times and decreased positive sentiment by 3·7 times the average effects of heatwaves in 2015–20. The extreme rainfall events in western Europe, in 2021, increased negative sentiment by 4·9 times and decreased positive sentiment by 6·6 times the average effect of extreme precipitation on sentiment in 2015–20.

21Climate change is affecting the distribution and transmission of many infectious diseases, including vector-borne, food-borne, and waterborne diseases.– This indicator monitors the influence of the changing climate on the potential for transmission for key infectious diseases that are a public health concern.

22With the increased movement of people and goods, urbanisation, and climate change, Aedes-transmitted arboviruses spread rapidly in the past two decades, and half the world population now lives in countries where dengue is present.– Combining data on temperature, rainfall, and population, this indicator tracks the basic reproduction number (R0) for dengue, Zika, and chikungunya as a proxy for their transmissibility and, new to this report, the number of months suitable for their transmission. On average, during 2012–21, the R0 increased by 11·5% for the transmission of dengue by Aedes aegypti and 12·0% for the transmission of dengue by Aedes albopictus; and 12·0% for the transmission of chikungunya by A albopictus, and 12·4% for the transmission of Zika by A aegypti compared with 1951–60, globally (figure 4). During the same period, the length of the transmission season increased for all arboviruses by approximately 6%.

23The number of months suitable for the transmission of Plasmodium falciparum by Anopheles mosquitoes was computed with temperature, precipitation, and humidity thresholds, and, new to this year’s report, land classes (appendix 5 p 46) suitable for the vector. The number of suitable months in highland areas (≥1500 m above sea level) increased by 31·3% in the WHO region of the Americas, and 13·8% in Africa between 1951–60 and 2012–21.

24Non-cholera Vibrio bacteria survive in brackish waters, and can cause gastroenteritis if ingested in contaminated food, and potentially lethal wound infections if direct contact is made with contaminated water. Between 2014–21 and 1982–89, because of changes in sea-salt concentrations and temperature, the area of coastline suitable for Vibrio pathogens increased from 47·5% to 86·3% in the Baltic; from 30·0% to 57·1% in the US northeast; and from 1·2% to 5·7% in the Pacific Northwest; three regions where Vibriosis is regularly reported. An extra 4·3% of the coastal waters in northern latitudes (40–70°N) had temperatures suitable for Vibrio during 2014–21 compared with 1982–89, with 2021 being the second most suitable year on record (11·3% of the coastal area suitable), making brackish waters in these latitudes increasingly suitable for Vibrio transmission.

25The ongoing seventh cholera pandemic, which started in the 1960s, is responsible for more than 2·8 million cholera cases and 95 000 deaths annually., Although inadequate sanitation is the main enabler, climate conditions are increasingly favouring the survival of Vibrio cholerae in natural waters, keeping an environmental reservoir and favouring its spread. Deploying an ecological niche model, this indicator estimates that an additional 3·5% of global coastal waters have become suitable for the transmission of cholera since 2003–05.

26Food insecurity is increasing globally, with 720–811 million people hungry in 2020. Climate change is exacerbating risks of malnutrition via multiple and interconnected mechanisms (panel 5). Less-educated and lower-income households have an increased chance of experiencing food insecurity, and due to social roles and reduced land ownership, women, and the households they lead, might be more prone to malnutrition.–

27High temperatures during growing seasons lead to fast crop maturation, which reduces the maximum potential yield that could be achieved with no limitations of water or nutrients. Combining temperature and crop growth data, the first part of this indicator shows that, compared with the average during 1981–2010, average crop growth season lengths in 2021 continue to shorten globally for all staple crops tracked: by 9·3 days for maize, 1·7 days for rice, and more than 6·0 days for winter and spring wheat.

28Rising atmospheric CO2 concentrations are also increasing sea surface temperature, temperatures of inland water bodies, acidifying oceans, and reducing their oxygenation, which exacerbates coral reef bleaching and affects marine and inland fishery productivity.– With a shift to farm-based fish products of reduced nutritional quality, climate change is thus putting marine food security at risk.– The average sea surface temperature in coastal waters of 142 countries increased globally by nearly 0·7°C in 2019–21 compared with 1980–82.

29New to this year’s report, the third part of this indicator examines the impact of heatwave days during crop growth season of maize, rice, sorghum, and wheat, on self-reported experience of food insecurity. The indicator combines data from the Food and Agriculture Organization of the UN Food Insecurity Experience Scale from 103 countries with temperature, using a time-varying regression., Compared with 1981–2010, increases in the number of heatwave days resulted in an increase of 3·7 percentage points in self-reported moderate to severe food insecurity in 2020, approximately equivalent to an additional 98 million people reporting moderate or severe food insecurity (figure 5; panel 5).

30With an average global surface heating of 1·1°C, climate change is increasingly affecting mental and physical health. Changing climatic conditions are increasing the risk of heat-related illness (indicators 1.1.1–1.1.5), changing the pattern of infectious disease transmission (indicator 1.3), increasing health risks from extreme events (indicators 1.2.1–1.2.3), putting sanitation at risk, and having multidimensional impacts on food and water security (indicator 1.3 and panel 5). These impacts often occur simultaneously, exacerbating the pressure on health and health-supporting systems, and potentially triggering cascading impacts on the social and natural systems that good health depends upon.

31With the world projected to heat by 2·4–3·5°C by 2100, this section details the urgency of accelerating mitigation and adaptation to prevent the devastating health outcomes of a heating world.

32With rapidly increasing climate change-related health hazards, transformative, proactive, and effective adaptation measures are immediately required to manage the health threats of unavoidable global heating, reducing exposure and vulnerabilities, and increasing resilience. Because of the interconnected and multifactorial nature of health determinants and climate impacts, adaptation should be integrated across sectors, and into policies and programmes in health systems, governments, and private corporations.

33Three groups of indicators are presented in this section. Indicators 2.1.1–2.1.2 detail adaptation plans and risk and vulnerability assessments—key first steps in health adaptation. The implementation of health adaptation measures and their financing are detailed in indicators 2.2.1–2.2.5. The final set of indicators, shown in section 1 in previous Lancet Countdown reports, have been improved to assess population vulnerabilities, resilience and adaptation interventions, and the risks associated with changing climate hazards (indicators 2.3.1–2.3.3).

34Evidence-based policy making requires comprehensive evaluation of the health threats of climate change. Climate change and health risk vulnerability and adaptation assessments identify vulnerable populations, assess the influence of existing policies, programmes, and health systems capacities in building resilience, and identify future adaptation needs. These indicators monitor the extent to which such assessments are being done, and the contribution of assessments in informing adaptation plans that can protect populations from climate-related health impacts.

35With data from the 2021 WHO Health and Climate Change Global Survey, this indicator monitors whether countries have completed a health vulnerability and adaptation assessment. Although 48 (51%) of 95 countries reported completing an assessment, only nine reported that its findings strongly influenced the allocation of human and financial resources to address health risks of climate change, and only 18 reported that assessments strongly informed the development of health policies and programmes (appendix 5 p 68).

36This indicator monitors whether countries have a national health and climate change plan in place, based on data from the 2021 WHO Health and Climate Change Global Survey. Only about half of countries (49/95) reported having a national health and climate change plan in place. Of these countries, 62 (65%) indicated a moderate or lower level of implementation, with 67 (70%) countries citing insufficient finance as a main barrier. As part of the new COP26 Health Programme Initiative on Climate Resilient Health Systems, 59 countries committed to conducting a vulnerability and adaptation assessment and using the findings to inform the development of a Health National Adaptation Plan, which contributes to the UNFCCC’s National Adaptation Plan process. Implementing commitments to the COP26 Health Programme will strengthen access to climate finance, inform national roadmaps for investments in climate-resilient and sustainable health systems, and support the implementation of critical health adaptation interventions.

37More than half of the world’s population live in cities; with local interventions, cities are crucial for adaptation to climate change. With data reported to CDP, this indicator shows that, in the past 5 years, the number of cities that declared having undertaken climate assessments increased from 205 (46%) of 449 respondents in 2016, to 725 (78%) of 930 respondents in 2021, reflecting an increased recognition of the city-level impacts of climate change. Although 849 (91%) of the 930 cities responding to this question were in very high or high HDI countries, responding cities from low and medium HDI countries increased by 70%, from 24 (5%) of 471 in 2020, to 41 (8%) of 522 in 2021. 530 (64%) of 822 cities reported that climate change threatened public health or health services. In a shift from last year’s reporting, infectious diseases were identified as the most prominent climate-related health hazard (identified by 382 cities), followed by heatwaves (339 cities) and poor air quality (267 cities). The COVID-19 pandemic affected climate action at the city level, with 310 (39%) of 805 cities reporting that the pandemic increased emphasis on climate action, and only 116 (14%) reporting that the pandemic decreased this emphasis. However, 242 (30%) of 798 cities reported that COVID-19 reduced financing available for climate change, whereas only 178 (22%) reported an increase in financing.

38Interventions in health-related sectors can reduce climate-related exposure, vulnerability, and hazards, minimising risks to health and wellbeing. Interventions should be integrated across sectors, and include health system strengthening, capacity building, behaviour change, early warning systems, physical infrastructure, and climate-smart agriculture, with adequate financing essential to their implementation. Indicators in this section track progress on implementing these interventions.

39Building preparedness and delivering an adequate response to climate hazards requires health systems to have access to, and use, climate information. This indicator uses data from the 2021 WHO Health and Climate Change Global Survey, to monitor the use of climate information for health surveillance and early warning systems.

40In 2021, 30 (39%) of 78 countries reported having climate-informed health surveillance systems for vector-borne diseases, 25 (32%) for waterborne diseases, 23 (35%) of 65 countries for airborne diseases, and 14 (21%) of 66 countries for zoonoses. However, only six (13%) of 47 countries had surveillance for mental health risks and eight (11%) of 70 countries had surveillance for food-borne diseases.

41As extreme weather intensifies, climate-informed health early warning systems can help to restrict and respond to its health impacts. About a third (28) of 84 countries reported having climate-informed health early warning systems in place for heat-related events and 26 (30%) of 86 countries reported having them in place for other extreme weather events. Half (n=13) of the 26 very high HDI countries had health early warning systems for extreme weather events compared with only six (19%) of 31 low or medium HDI countries. Whereas 16 (64%) of the 25 very high HDI countries had climate-informed health early warning systems for heat-related events, only four (13%) of 30 low or medium HDI countries had them in place.

42Although air conditioning is effective at protecting against heat-related illness, 1·8–4·1 billion people in LMICs exposed to heat stress do not have any indoor cooling, and air conditioning is often unaffordable in these countries., Air conditioning also contributes to greenhouse gas emissions, air pollution, urban heat island effects, power outages, and energy poverty.– With data from the International Energy Agency (IEA), this indicator reports that about a third of households globally had air conditioning in 2020, an increase of 66% from 2000. The use of air conditioning in 2020 was responsible for 0·9 gigatonnes (Gt) of CO2 emissions and 24 000 deaths from PM2·5 exposure. Sustainable cooling alternatives need to be rolled out rapidly to avoid the worst health impacts from rising temperatures (panel 6).

43Nature-based solutions can contribute to climate change adaptation and have ecosystem benefits. Green spaces reduce urban heat islands, positively affect physical and mental health, and provide adaptation to extreme heat.– This indicator reports population-weighted normalised difference vegetation index (NDVI) as a proxy for green space exposure in the 1038 urban centres that have over 500 000 inhabitants. Despite increasingly extreme heat, average global exposure to urban green space has remained consistently low since 2015 (mean NDVI 0·34), and just 27% (278 out of 1038) of urban centres were moderately-green or above in 2021 (figure 6; appendix 5 p 79). Only 33% of cities in very high HDI countries, and 39% of those in medium HDI countries, had at least moderate levels of greenness; a proportion that is even lower in high and low HDI countries (16% for both).

44Financial resources are essential to implementation health adaptation interventions. This indicator uses transactional data from Kmatrix’s Adaptation and Resilience to Climate Change dataset to monitor global spending, with the potential to support adaptation in health-care sectors and in sectors of health relevance (eg, agriculture, water, and built environment). In the fiscal year 2020–21, US$21·78 billion was spent in transactions that could support health and health-care adaptation (5·6% of total adaptation-related spending), and $111·2 billion (28·5%) was spent in transactions with the potential to deliver adaptation in health-relevant sectors. In a reversal of trends from previous years, the share of spending in these two sectors with respect to total adaptation-related spending decreased slightly (by less than 0·1%).

45The second part of this indicator monitors global multilateral funding for health-related adaptation projects by the Green Climate Fund. In 2021, the Green Climate Fund approved $726 million for 15 adaptation projects and $414 million for eight mitigation and adaptation projects. Of the approved funding, only 15% ($166 million) went to projects with benefits that included increased resilience of health and wellbeing. Furthermore, of the 54 concept notes submitted for adaptation and cross-cutting projects ($1·6 billion), only four focused on health systems ($218 million), none of which were approved. These findings highlight a deficit in the prioritisation of health within adaptation funding.

46This indicator monitors implementation of core capacity 7 (health emergency management) of the International Health Regulations (IHR). With small changes from previous years, emergency management under core capacity 7 is now comprised of three capacity requirements: planning for health emergencies, management of health emergency response, and emergency logistic and supply chain management. In 2021, 112 (63%) of 177 countries reported high to very high implementation (capacity score of 61–100) of health emergency management. Considering HDI, large disparities existed, with only 35% of low or medium HDI countries reporting high to very high implementation status of health emergency management compared with 88% of very high HDI countries.

47The COVID-19 pandemic prompted a review of the IHR by the World Health Assembly in 2020., Proposed reforms include regular country reviews and monitoring mechanisms, increased support for their implementation, and improved information sharing, all of which can help strengthen health systems from health hazards related to climate change. Climate change emergency preparedness and response requires a multisectoral approach with strengthened leadership and coordination of international financial and health institutions, and increased ability to address public health misinformation. These preparedness and response measures would deliver subsequent benefits across the whole health system.,

48Climate change adaptation aims to reduce human exposure and vulnerability to climate hazards, minimising health risks, and ultimately minimising climate change-related health impacts. These indicators provide an insight into the effectiveness of adaptation and health system strengthening in modifying climate-related health risks.

49Dengue incidence increased eight-fold in the past two decades, driven by population movement, international trade, urbanisation, and increasing climatic suitability (indicator 1.3).–,, Although controlling the spread is challenging, timely and adequate treatment is essential to prevent severe health outcomes.,, This indicator tracks the relative vulnerability to severe adverse dengue outcomes in countries that have the suitable climatic conditions for dengue outbreaks (R0>1, as per indicator 1.3), combining two main determinants of dengue vulnerability: health-care access and quality (by using mortality from key preventable diseases as a proxy), and the proportion of population in urban environments., Between 1990 and 2019, improvements in health care contributed to a 43% reduction in vulnerability to severe dengue outcomes in low HDI countries, and a 23% reduction in medium HDI countries. However, urbanisation increased vulnerability to dengue in very high HDI countries by 5%.

50The number of reported climate and weather-related disasters has increased five-fold in the past 50 years. Using data from the Centre for Research on the Epidemiology of Disasters, data in this indicator show that the proportion of all climate-related events that were deadly has increased steadily since at least 1980. However, the lethality of these events has decreased globally from an average of 837 deaths per event in 1980–89 to 46 in 2012–21 (p<0·031). The average number of people affected per disaster is negatively correlated with GDP, HDI, and the percentage of GDP spent on health care, with the percentage of GDP showing the strongest correlation. With extreme weather events becoming increasingly frequent and severe, these results highlight the importance of strengthening health systems, including with the implementation of the priorities outlined in the Sendai Framework for Disaster Risk Reduction. Because of the socially defined gender differences in the impacts and response of extreme events, a gender-sensitive approach is particularly needed.

51The global mean sea level increased by 3·7 mm per year between 2006 and 2018, and will reach 0·28–1·01 m or more by 2100, depending on climate change mitigation efforts, ice sheet collapse, and local factors.,– With land elevation and population data, this indicator reports that there were 149·6 million people living less than 1 m above sea level in 2020, a slight increase from the 145·2 million people settled there in 2010. These populations are at risk of flooding, coastal and riverbank erosion, severe storms, soil and water salinisation, spread of infectious diseases, and permanent inundation.– With insufficient adaptation, human relocation (forced, or as a proactive adaptation measure) could be a response, and its health impacts will largely depend on the support given to migrant populations. The development of policies to protect the health of migrant and immobile populations is crucial. As of December, 2021, 45 policies connecting climate change and migration were identified in 37 countries.

52The indicators in this section exhibit some signs of progress in the adaptation to climate change, with national and city-level assessment of the climate-related health risks gradually increasing, and evidence suggesting that the strengthening of health systems might have reduced the impact of extreme events. However, data show that the pace and scale of climate change adaptation, planning, and resilience is far from what is necessary to reduce the health impacts of climate change. Despite increasing temperatures, only 27% of urban centres have at least a moderate level of greenness, and just 28 (33%) of 84 countries report having heat-related early warning systems for health. Funding to support health adaptation remains grossly insufficient and is seldom influenced by vulnerability and adaptation assessments. In 2022, unprecedented global health, economic, and conflict events have critically worsened public health, with climate change exacerbating the impacts of many of these events. Without global coordination, transparency, and cooperation between governments, communities, civil society, businesses, and public health leaders, the world will remain vulnerable to international emergencies. The gap between the health impacts of climate change, and adaptation investment and implementation continues to increase, to the detriment of all.

53Due to COVID-19-related responses, anthropogenic CO2 emissions decreased by 5·4% in 2020, the largest decrease in the past 25 years. However, with little structural change to limit fossil fuel use, emissions rebounded in 2021, by 6%, reaching an all-time high. The current 1·1°C of warming proved to be already dangerous to health (section 1). To limit the temperature rise to 1·5°C higher than pre-industrial levels, emissions should decrease by 45% from 2010 levels by 2030. However, even if commitments in every country’s NDCs were met, emissions in 2030 would be 13·7% higher than 2010 levels. The grossly insufficient decarbonisation, compounded by geopolitical conflict, has made it vastly more challenging to limit the temperature rise to 1·5°C, and the window of opportunity to limit the temperature rise is rapidly closing.

54Accelerated decarbonisation would not only prevent the most catastrophic health impacts of accelerated heating, but, if designed to maximise health benefits, could also save millions of lives with healthier diets, more active lifestyles, and improved air quality. Indicators in this section monitor the world’s efforts to reduce greenhouse gas emissions in energy (indicators 3.1 and 3.2), transport (indicator 3.4), food and agriculture (indicator 3.5), and health care (indicator 3.6), and monitor the health benefits that could arise from prioritising health in mitigation policies.

55Energy systems are the largest single source of greenhouse gas emissions and are major contributors to air pollution. Global energy system transition to renewables is not only crucial for climate change mitigation, but could also contribute to universal, affordable, and clean energy; reduce air pollution; and decrease dependence on international markets and foreign policies. With data from the International Energy Agency, this indicator shows that the carbon intensity of the global energy system continued to decrease in 2019 for the seventh consecutive year, to 55·4 tCO2/TJ. However, this is still not enough to keep global warming at 1·5°C, with a reduction of less than 1% from 1992 levels, the year the UNFCCC was adopted. At the pace recorded since 2014, fully decarbonising the energy system would take 150 more years. The increasing demand for energy means fossil fuel use is still rising, and fossil fuel-derived CO2 emissions increased again in 2021 by 6·0%, after a 5·1% decrease in 2020 during the COVID-19 pandemic (figure 7), putting CO2 emissions at a record high.

56Phasing out coal is particularly urgent because of its high greenhouse gas emissions and air pollution intensity. However, coal provides 26·7% of global energy supply, 2·8 percentage points more than in 1992. Responsible for 54% of global coal energy use in 2019, China’s coal expansion has been a major contributor to the rise in global greenhouse gas emissions since the early 2000s, with emissions at 7tCO2 per person in 2019, now equivalent to the Organisation for Economic Co-operation and Development (OECD) average.

57Growth in renewable electricity reached record levels in 2020, with the installation of 139 GW of solar PV and 93 GW of wind power. This corresponded to 90% of new electricity installation in 2020, and to renewables providing 8·2% of global electricity, twice the levels in 2013. However, big differences exist between countries globally, and only 1·4% of the electricity of low HDI countries is produced from modern renewables (mostly solar, wind, and geothermal), compared with 9·5% in very high HDI countries. Concerningly, 59% of health care facilities in low and middle-income countries lack the reliable energy services they need to provide basic care; only 2·2% of total world energy comes from renewable sources; and total fossil fuel use has increased faster. A low-carbon transition can help countries to increase local energy production, gain independence from volatile fossil fuel markets, and reduce energy poverty.

58Around 770 million people do not have access to electricity in their homes, and the use of dirty fuels is leading to high exposure to air pollution. In parallel, with residential energy contributing to 17% of global greenhouse gas emissions, transitioning to clean fuels in the domestic sector is essential to meet mitigation goals. With use of IEA data, this indicator reveals that biomass represented the largest individual source of residential energy in 2020, contributing to 31% of residential energy use (a proportion that rises to 96% in low HDI countries); electricity contributed to 25%; and fossil fuels contributed to 26%. Africa improved access to clean energy from 13% to 20% and southeast Asia improved access from 19% to 64% in 2000. However, both regions remain heavily reliant on solid biofuels. Data from WHO indicate that although 86% of the global urban population had access to clean fuels and technologies for cooking in 2020, only 48% of rural populations did. Inequities were also noted between countries, with 98% of the population in very high HDI countries having access to clean fuels and technologies for cooking, against just 13% in low HDI countries (figure 8).

59WHO estimates that the use of solid fuels for cooking resulted in 3·8 million deaths attributable to household air pollution in 2016. Providing the capacity to monitor changes in household air pollution exposure on a yearly basis, this new indicator expands on a previously published model to estimate household air pollution with a Bayesian hierarchical model that accounts for fuel usage, stove types, socioeconomic variables, and ambient air pollution in 62 countries. This indicator estimates that the use of solid fuels for cooking and heating resulted in a global average PM2·5 concentration in people’s homes of 150 µg/m3 in 2020 (168 µg/m3 in rural households and 91 µg/m3 in urban areas). With values broadly exceeding the 5 µg/m3 threshold recommended by WHO, the delayed transition to clean household energies is profoundly affecting people’s health.

60Economic hardship during the COVID-19 pandemic has worsened energy insecurity in households in countries of all HDI levels. The number of people without access to electricity increased in 2020 for the first time in six years, with shifts to the use of biomass and other unreliable fuels increasing exposure to household air pollution., The share of the population without access to electricity in sub-Saharan Africa increased by 3 percentage points to 77% in 2020. Russia’s invasion of Ukraine threatens to exacerbate energy poverty and the use of unhealthy and unreliable fuels in the domestic sector, with rising energy prices and supply chain disruption.,

61Exposure to air pollution increases the risk of respiratory and cardiovascular disease, lung cancer, diabetes, neurological disorders, and adverse pregnancy outcomes. This indicator estimates the mortality attributable to ambient PM2·5, combining atmospheric modelling with information about activity in emitting sectors. For this year’s report, baseline mortality data were updated, and attributable deaths from type 2 diabetes were also included. In 2020, exposure to ambient PM2·5 contributed to 4·2 million deaths, unchanged from 2015, and mortality per 100 000 decreased by 5% (figure 9). Of these deaths, 80% (3·3 million) were attributable to anthropogenic emissions; of which 1·2 million (35%) were directly related to the combustion of fossil fuels. Deaths due to coal combustion have decreased by 18% from 687 000 in 2015 to 561 000 in 2020, mostly because of strict air pollution control measures in China and coal phase down in Europe.

62The transport sector contributed to 25% of global CO2 emissions in 2019.,, If combined with energy grid decarbonisation, electric vehicles can be an important mitigation tool. The use of electricity for road transport increased by 237% in the past decade, but still represents just 0·3% of total fuel use for road travel. Sales of electric vehicles more than doubled in 2021, a growth led by China, with nearly 3·4 million sales (12% of the total). However, only 1% of the global car stock is electric.

63Road transport decarbonisation with a modal shift to active travel can have health benefits from reduced air pollution, which accounted for 497 000 deaths in 2020 (indicator 3.3) and increased physical activity., Smartphone data suggest that the use of public transit has returned to pre-pandemic levels in 85% of countries for which data are available, highlighting the need for robust policies that encourage shifts to active travel and public transit modes.

64The global food system contributes one third of all greenhouse gas emissions. Emissions from the agricultural sector are dominated by ruminant rearing, mostly mediated by methane emissions and land use change., Shifting to low-carbon, plant-forward diets can help mitigate agricultural emissions as well as have important health co-benefits from improvements in dietary risk factors and mortality from non-communicable diseases.,, These two indicators track agricultural emissions (indicator 3.5.1) and the health impacts of carbon-intensive diets (indicator 3.5.2), identifying the potential health opportunity of agricultural decarbonisation.

65This indicator, improved from previous reports to include data on 140 food types, estimates that emissions from the consumption of agricultural products have remained stable, at around 0·9 tonnes CO2 equivalent (tCO2e) per person, although total emissions have increased by 31% since 2000 (figure 10). In 2019, 55% of global agricultural emissions came from red meat and dairy products. Per capita emissions from red meat and dairy consumption in very high HDI countries were twice the emissions in the rest of the world (0·8 tCO2e per person vs 0·4 tCO2e per person). Increases in palm oil production account for some of the greatest changes since 2000, for which emissions in southeast Asia (mainly Indonesia) increased over 600%.

66This indicator monitors the health burden from unhealthy diets and, new to this year, the burden of imbalanced energy intake.

67In 2019, 11·5 million deaths were attributable to imbalanced diets. 17% (2 million) of them were related to red and processed meat and dairy consumption, of which 93% were in high and very high HDI countries. In low and medium HDI countries, the low consumption of fresh fruit and vegetables was the major contributor to diet-related mortality, at 44% of all diet-related deaths in low HDI countries, and 37% in medium HDI countries.

68Because of the health impacts of climate change, health systems need to lead decarbonisation, to comply with their duty of not harming health. This indicator monitors health-care sector emissions combining health-care expenditure data with a global, environmentally-extended multi-region input–output model. The indicator estimates that, in 2019, the health-care sector contributed to approximately 5·2% (2·7 GtCO2e) of global greenhouse gas emissions, an increase of more than 5% from the previous year. Of the 37 health systems analysed individually, the USA had the most emissions per person—50 times the emissions of India (figure 11). Yet, the USA has the sixth lowest healthy life expectancy at birth (66·2 years). Per capita emissions in the 10 countries with the highest life expectancy ranged from 1065 kgCO2e per person in South Korea, to 321 kgCO2e per person in France, highlighting that high-quality health care can be achieved with lower emissions. Recent decarbonisation commitments made as part of the COP26 health programme since November, 2021, by more than 50 national health services provide hope for emerging progress (panel 7).

69After COVID-19 pandemic lockdowns were lifted and restrictions were eased, CO2 emissions rebounded to record levels in 2021. With each year that global greenhouse gas emissions do not fall, reaching net-zero by 2050 becomes more challenging, putting lives at increased risk from climate change.

70Although impacts of COVID-19 on the indicators in this section are still emerging, many of the challenges for mitigation and health co-benefits have been entrenched since the start of the pandemic, including the domestic over-reliance on biomass, record levels of coal extraction in China, and rebounding emissions from road transport. The energy crisis, worsened by Russia’s war on Ukraine, threatens to deteriorate this situation, further under-mining progress and exacerbating energy poverty. However, increasing energy efficiency, conservation, and the use of renewable energy sources could give healthier, more resilient, and self-sufficient energy systems. Millions of lives could be saved each year by accelerating transition to cleaner fuels, healthier diets, and active modes of travel.

71Limiting the global temperature rise to 1·5°C requires rapid decarbonisation in all economic sectors. Although the initial investment required for a low-carbon transformation is substantial, the investment would lead to immediate economic and health co-benefits, in addition to avoiding long-term climate change impacts., With the right incentives, and market and governance conditions, the necessary private sector investment is available. However, wealthier parties to the UNFCCC have failed to meet their commitment of delivering the smaller sum of US$100 billion annually to support climate action in “developing” countries that they committed to 13 years ago; a commitment essential not only for attaining global climate goals, but also to ensure a just transition. In addition, the energy crisis, worsened by the COVID-19 pandemic and exacerbated by the war in Ukraine, is increasing energy poverty, and exposing further dimensions of the human costs of a fossil fuel-dependent global energy system. Indicators in this section detail the economic costs of climate change, and monitor the transition to a low-carbon, healthy, and just global economy.

72Climate change is causing additional health-care costs, loss of labour productivity, and economic losses through the damage caused by climate-related extreme events. These costs and losses subsequently affect household incomes and national economies. Indicators in this section monitor the economic costs associated with the health impacts of climate change, showing the potential benefits from accelerated climate action.

73The loss of infrastructure and resulting economic losses due to extreme events can exacerbate health impacts with disruption of essential services and effects on the social determinants of health. This indicator monitors the economic losses from climate-related extreme events, with data provided by Swiss Re.

74In 2021, climate-related extreme events induced measurable economic losses of US$253 billion, with 84% of these losses in very high HDI countries. As a proportion of GDP, losses in the very high HDI group are double the global average. Nearly half of these losses were insured, although insured losses represented only 8% of all losses in high HDI countries and 5% in medium HDI countries, with almost 0% in the low HDI country group. These high levels of uninsured losses worsen the economic burden of climate change in low HDI countries, with losses either not being replaced, or individuals and institutions incurring the cost of replacement.

75This indicator combines estimates of years of life lost data from indicator 1.1.6 with the value of statistical life year to estimate the monetised loss caused by heat-related mortality. The valuation of life across varying HDI levels presents methodological and ethical challenges, which this indicator addresses by presenting the cost of deaths attributable to heat as the proportion of GDP and the equivalent annual average income in the countries concerned. From 2000 to 2021, monetised losses increased at an average rate of $4·9 billion each year, equivalent to 0·16% of gross world product in 2021 (figure 12). The past 6 years show the highest losses, at an average equivalent to the income of 12·4 million people, 73% higher than in 2000–05. In 2021, very high HDI countries incurred the highest losses, equivalent to 5·3 million of their populations’ average income, with losses equivalent to 4·7 million in high HDI countries, 1·48 million in medium HDI countries, and 0·51 million in low HDI countries.

76This indicator quantifies the loss of earnings that could result from heat-related labour capacity loss, combining data from indicator 1.1.4 with hourly wage data from the International Labour Organization.

77The global potential loss of earnings was US$669 billion in 2021, equivalent to 0·72% of gross world product in 2021. In 2021, average relative income losses were equivalent to 5·6% of GDP for low HDI countries and 3·9% of GDP for medium HDI countries—the highest average relative income losses (figure 12; figure 13). Of all global losses, 40% occurred in the agricultural sector. Often being among the world’s poorest, agricultural workers in low HDI countries had losses of 82% and those in medium HDI countries had losses of 71%.– Affecting individual finances, these losses impact on people’s wellbeing, food security, and the social determinants of health, and cascade through the economies of the nations they live in.

78This indicator places an economic value on the years of life lost from exposure to anthropogenic ambient PM2·5 as per indicator 3.3. Whereas costs relative to average income and GDP decreased between 2019 and 2020 in all HDI groups, the total cost amounted to US$2·3 trillion in 2020—the equivalent of 2·7% of gross world product. The high HDI country group has the greatest costs relative to per capita income, equivalent to the average annual income of 92·3 million of its people. The medium HDI group has the greatest costs relative to the size of their collective economies, equivalent to nearly 4% of GDP.

79Meeting the Paris Agreement goals requires a low-carbon transition of the whole economy. Indicators in this section monitor jobs and investment in low-carbon energy, net carbon pricing, and the effect of global trade on emissions. A new indicator quantifies the extent to which the activities of oil and gas firms align with the pathways needed to keep global mean temperature rise to under 1·5°C of heating.

80As described in the previous section, phasing out fossil fuels, particularly coal, and investing in low-carbon energy supply is essential for both mitigating climate change and for reducing premature mortality caused by air pollution. With data from the IEA, this indicator monitors trends in global investment in energy supply and energy efficiency.

81Between 2020 and 2021, total investment increased by 14%, with investment increasing in all forms of energy supply and energy end use efficiency, except coal for electricity generation. In 2021, electricity generation accounted for 28% of investment. Of this investment, 80% was invested in zero-carbon sources. However, fossil fuels still account for more than 90% of non-electricity sector investment. Energy efficiency accounted for 15% of all investment—an increase from 13% in 2020. To fulfil net-zero global emissions by 2050, investment in low-carbon energy, efficiency, and electricity networks needs to nearly quadruple by 2030, and account for at least 90% of all energy investment.

82Employees in fossil fuel extraction industries, particularly coal mining, can have a greater incidence of non-communicable disease than the general population. Increasing employment in the renewable industry could improve health and livelihoods. In addition, it could improve gender balance, with a greater proportion of women employed in the renewable sector than in the fossil fuel industry.

83This indicator shows that more than 12 million people were employed directly or indirectly by the renewable energy industry in 2020—an increase of 5% from 2019. For the first time, direct and indirect employment in the renewable energy sector exceeded direct employment in the fossil fuel extraction industry, which recorded 10·5 million employees (a decrease of 10% from 2019), reaffirming that renewable energy could support job security, now and in the future.

84By divesting holdings in fossil fuel companies, organisations can both reduce the social licence of fossil fuel companies to operate, and hedge against the risk of losses caused by stranded assets in an increasingly decarbonised world., This indicator tracks the value of funds divested from fossil fuels, with data provided by stand.earth and 350.org.

85From 2008 until the end of 2021, 1506 organisations, with assets worth at least US$40·23 trillion, have committed to divestment. Of these organisations, only 27 are health institutions, with assets totalling $54 billion. The value of new funds committed to divesting in 2021 was $9·42 trillion, with no new health institutions divesting.

86Carbon prices help economies transition from high-carbon fuels, but many governments subsidise fossil fuels, encouraging health-harming emissions and slowing the low-carbon transition. This indicator compares carbon prices and monetary fossil fuel subsidies to calculate net economy-wide average carbon prices and revenues in 86 countries, responsible for 92% of global CO2 emissions. In 2019, 42 countries had a system for carbon pricing, but only 17 produced a net-positive carbon price—all of which were very high HDI countries (figure 14). 69 (80%) of 86 countries reviewed had net-negative carbon prices (ie, provided a net subsidy to fossil fuels) for a net total of US$400 billion that year, with ten countries each exceeding $10 billion of net subsidies. In 31 countries, net subsidies exceeded 10% of national health spending, and exceeded 100% in 5 countries.

87Redirecting government support from subsidising fossil fuels to low-carbon power generation, health protection, public health promotion, and health care is likely to deliver net benefits to health and wellbeing., International financing mechanisms are needed to support low-income countries that are most affected by fluctuating energy costs in their transition to sustainable energy sources, particularly with the current energy crisis, and to safeguard all dimensions of human health.

88The production of goods and services results in local greenhouse gas and PM2·5 emissions, which can be monitored with production-based emission accounting. However, these goods and services are often consumed in different locations than where they were produced. Consumption-based emission accounting allocates emissions to countries according to their consumption of goods and services. This indicator uses an environmentally-extended multi-region input–output model, and the same air pollution modelling described in indicator 3.3,– to assess each country’s consumption-based and production-based contribution to CO2 and PM2·5 emissions.

89In 2020, 18% of CO2 and 17% of PM2·5 global emissions were from the production of goods and services traded between countries of different HDI levels. Emissions were 3% lower for CO2 and 7% lower for PM2·5 than the year before—likely to be a result of restrictions during the COVID-19 pandemic. In 2020, the very high HDI country group contributed the most consumption-based (47%) CO2 emissions, whereas the high HDI country group contributed the most production-based (46%) CO2 emissions. However, consumption-based emissions per person were highest in very high HDI countries, 1·3 times higher than the global average, and 26·3 times higher than emissions per person in low-HDI countries.

90High HDI countries were the biggest contributors to both production-based (39%) and consumption-based (36%) PM2·5 emissions, even if their contribution share decreased from 2019 (figure 15). PM2·5 emissions per person were largest in low HDI countries, a reflection of poor air quality control measures and the use of more polluting fuels. The very high HDI country group was the only group with higher consumption-based than production-based emissions of both CO2 and PM2·5 emissions.

91Emissions from oil and gas need to be reduced drastically to enable a healthy future., This indicator assesses the extent to which current oil and gas company production strategies are compatible with Paris Agreement goals, regardless of their claims and commitments. The indicator uses data from the Rystad energy database on commercial activities for the eight largest publicly listed international oil and gas companies (IOCs) by production volume, and the seven largest state-owned national oil and gas companies (NOCs). These IOCs accounted for 14% of total global production in 2021 and NOCs accounted for 28% (42% overall). Projected emissions based on current strategies are compared with a pathway compliant with 1·5°C, assuming constant market shares at the 2015–19 average.

92Data in this indicator suggest that the production strategies of these companies would generate greenhouse gas emissions that exceed their share compatible with 1·5°C by an average of 39% for these IOCs, and 37% for the NOCs, in 2030. These excess emissions would rise to 87% for IOCs and 111% for NOCs in 2040 (figure 16). Cumulative production from 2020 to 2040 is projected to exceed their share of the 1·5°C target by 36% for IOCs and 38% for NOCs.

93According to these results, the activities of some of the largest oil and gas companies are far from compliant with the goals of the Paris Agreement. Strong government action and pressure from civil society could be essential to bring about such compliance, with a faster transition from fossil fuels to low-carbon energy sources.

94Indicators in this section highlight some of the extensive costs associated with the health impacts of climate change (panel 8). The economic impacts of climate change are affecting livelihoods and the socioeconomic conditions that good physical and mental health depend on. Substantial and sustained investment in the low-carbon transition is essential to minimise these impacts for a healthy future. Both governments and the private sector have crucial roles in making this happen. Indicators show that investments and employment are slowly transitioning from fossil fuels to clean energy, and divestment from fossil fuel assets is also increasing. However, the pace needs to be accelerated to prevent devastating economic and health impacts of climate change. Yet, governments continue to incentivise a carbon-intensive and health-harming economy by subsidising fossil fuels to a level of value often equivalent to substantial proportions of national health budgets. Meanwhile, oil and gas companies are on track to exceed their share of maximum emissions compatible with 1·5°C of heating by more than 100% in 2040. Increased regulations, scrutiny, and accountability mechanisms need to be urgently implemented to ensure the energy sector aligns its activities with agreed climate targets. Governments worldwide must urgently accelerate this transition, by setting regulations and redirecting investment to a low-carbon, healthy, and energy-resilient future.

95The integration of health and climate policies is essential for a rapid climate transition that protects human health,, particularly in countries and communities that have contributed least to rising global temperatures, yet are the most affected by them.– Public and political engagement with the health dimensions of climate change is essential to deliver equity-focused climate policies at speed and scale, and to close implementation gaps.,

96This section focuses on key domains of public and political engagement in health and climate change: engagement by the mainstream media (indicator 5.1), individuals (indicator 5.2), the scientific community (indicator 5.3), governments (indicator 5.4), and the corporate sector (indicator 5.5). Where relevant, data is analysed as from 2007, the year before the UN World Health Assembly made a multilateral commitment to protect people’s health from climate change. Where relevant, the analysis includes engagement with climate change adaptation and pandemic preparedness, to capture engagement with key dimensions of a coordinated response to climate change and the COVID-19 pandemic (appendix 5 p 164).

97Newspapers, in their print and online versions, are a widely used source of public information that influence public perceptions on climate change,, governments, and the social media agenda. This indicator covers analysis articles in newspapers across 37 countries, including China’s People’s Daily, and its method is based on keyword searches (in English, German, Portuguese, Spanish, and Chinese) of relevant newspaper databases.

98In 2021, global coverage of both climate change and health reached a new record high, with 14 474 articles that year, 27% more than in 2020 (figure 17). In China’s People’s Daily, climate change coverage also reached its highest recorded level. Coverage of health and climate change remained scarce, with only 1% of People’s Daily articles relating to both issues; none of these articles covered pandemic preparedness and only one referenced adaptation.

99In English language newspapers (n=51) across 24 countries, 2554 (20%) of 13 017 of articles referring to both health and climate change also referred to adaptation, and 6258 (48%) referred to the pandemic. Very few (645; 5%) referred to health, climate change, adaptation, and the pandemic.

100This indicator is based on global use of the online encyclopaedia Wikipedia, an information source with increasing coverage and comprehensiveness and wide public reach,– that amplifies the diffusion of science.,

101The indicator tracks people’s movements between articles on health and on climate change (known as clickstream statistics), based on the English Wikipedia, the most popular language edition in multiple countries worldwide.,

102Users click between articles on health or on climate change, with these domains heavily co-visited internally. There are fewer connections between domains: health and climate change are seldom topics that people engage with at the same time. Of all click views leading to a climate change-related article, 0·3% came from a health-related article; of click views leading to a health-related article, 0·02% came from a climate change-related article. These movements increased by 19% from 2020 to 2021, reversing the decline between 2019 and 2020. The COVID-19 pandemic continued to be a key driver of online engagement on health and climate change; for example, COP26 coincided with a higher engagement on health and climate change, but this was mainly driven by interest in the pandemic situation in its host country.

103Scientific engagement is tracked in peer-reviewed journals, the primary source of scientific evidence for the media and governments., This indicator uses an enhanced method in this year’s report, with supervised machine learning and associated methods (topic modelling and geoparsing) to map scientific articles on health and climate change over time, extending the time period to 1985–2021 from the previous report.

104In 2021, more than 3200 articles engaged with health and climate change, an increase of 22% compared with 2020 (figure 18). However, this number is a very small proportion of scientific articles on climate change and on climate impacts. The majority of health and climate change articles were located in, and led by, authors in WHO regions of Western Pacific and the Americas. As research on the health implications of climate change continues to dominate (86% of articles), climate solutions (mitigation and adaptation) are being given increasing attention. 20% of health and climate change articles engaged with pandemic preparedness.

105Government engagement, essential for climate action, is tracked by two indicators: the first tracks statements made by national leaders at the UN General Debate (UNGD), at the UN General Assembly, the policy making body of the UN. The second monitors mentions of health and climate change in NDCs—the major policy instrument set under the Paris Agreement to protect health from “dangerous anthropogenic interference with the climate system”. Analysis is based on the UNGD text corpus (a database that holds the text transcripts of speeches made at the UNGD), and on content analysis of the first and the updated NDCs accessed from the UNFCCC interim registry.–

106In 2021, the proportion of countries referring to the association between health and climate change at the UNGD increased to 60%, its highest recorded level, from 47% in 2020 (figure 19). As in 2020, the COVID-19 pandemic was the main driver for this engagement. St Lucia’s UNGD address noted that “The COVID-19 pandemic and the climate change challenge […] provide us with a harsh and timely reminder that human health and planetary health are linked.”

107Countries with low HDI, particularly Small Independent Developing States (SIDS), continue to lead engagement: 76% of SIDS discussed the association between health and climate change in the 2021 UN General Debate. However, increasing engagement with health and climate change is evident in all countries, including those with high and very high HDI.

108Increased engagement with health is evident in updated or new NDCs submitted by 126 UN member states (including the one representing 27 EU nations). Of these NDCs, 86% refer to health, an increase from 82% in the first NDCs. The increase is greatest for member states in the high HDI category, which all now refer to health, followed by the very high HDI group (71% made references in the updated NDCs, in an increase from 65% in the first round). The proportions have slightly declined for the medium (87% to 86%) and low (94% to 86%) HDI groups. Most health references are about adaptation needs or efforts (83% of the NDCs mentioned health compared with 87% in the first round), and 40% are also about climate change mitigation (from 18%).

109References to the health sector also increased from 74% in the first round to 81% in the second round. Health-care infrastructure was a particular focus, having increased from 39% to 73%. For example, Albania’s second NDC outlines how “health facilities could be damaged by climate-related changes, such as SLR [sea level rise], heavy rains or extreme temperatures”.

110The indicator tracks engagement in health and climate change in the annual Communication of Progress (COP) among companies signed up to the UN Global Compact, the world’s largest corporate sustainability framework operating across 165 countries without restriction by sector or company size., In an improvement from previous iterations, in which only English-language COPs were analysed, COPs in all languages are now included.

111Engagement in health and climate change reached its highest level in 2021, with 38% of corporations referring to the association between health and climate change in their COP report. However, as in previous years, there was increased corporate engagement in climate change (87%) and health (72%) as separate issues. Engagement in the association between health and climate change was greatest in companies based in the Western Pacific (53% COPs) and southeast Asia (43%) regions.

112Engagement in health and climate change reached its highest recorded level in 2021, with climate change solutions becoming an increasing focus of health and climate change engagement (eg, in scientific research and the enhanced NDCs). As in previous years, government engagement is led by countries most vulnerable to a climate crisis not of their making.,,

113As in 2020, the COVID-19 pandemic continues to be a major driver of health and climate change engagement. In the media, a large proportion of English language newspapers engaging with health and climate change referred to the pandemic. The pandemic also drove engagement by individuals and by government leaders in health and climate change. This raises the question of whether increased engagement is contingent on the pandemic context.

114Although health and climate change engagement increased in 2021, there is more engagement with health and climate change as separate issues, a pattern evident in individual Wikipedia users’ activities, government leaders’ speeches at the UNGD, and companies reports to the UN Global Compact. Similarly, media and scientific engagement in climate change continues to surpass engagement in health and climate change. Despite mounting evidence of the health burden of climate change, health and climate change have yet to be securely associated in the public, political, and corporate domains that are key to climate action.

115In its seventh iteration, the 2022 report of the Lancet Countdown shows the direst findings yet. At 1·1°C of heating, climate change is increasingly undermining every pillar of good health and compounding the health impacts of the current COVID-19 pandemic and geopolitical conflicts. The health harms of extreme heat exposure are rising, affecting mental health, undermining the capacity to work and exercise, and resulting in annual heat-related deaths in people older than 65 years increasing by 68% from 2000–04 to 2017–21 (indicators 1.1.1–1.1.5). more frequent and extreme weather events are increasingly affecting physical and mental health directly and indirectly, with economic losses particularly over-burdening low HDI countries, in which losses are mostly uninsured (indicators 1.2.1–1.2.3 and 4.1.1). The changing climate is exacerbating the risk of infectious disease outbreaks (indicator 1.3) and threatening global food security (panel 5), with heatwave days associated with 98 million more people experiencing food insecurity in 2020 than in 1981–2010 (indicator 1.4).

116These health impacts add additional pressure on overwhelmed health systems (panel 7). With a further 0·4°C temperature rise probably unavoidable, accelerated adaptation is more urgent than ever. Yet, national and city authorities are not acting fast enough and adaptation funding remains grossly insufficient (indicators 2.1.1, 2.1.2, and 2.2.4). The increased use of air conditioning and scant implementation of nature-based solutions (indicators 2.2.2–2.2.3) reflects a drift towards unplanned, maladaptive responses. Concerningly, and at least partly caused by wealthier countries’ failure to meet climate their finance commitments (panel 8), the adaptation response is often slower in low HDI countries, increasing their vulnerability to a climate crisis that they have had little, if any, contribution to.

117Despite these profound health impacts, mitigation efforts remain inadequate to avert a catastrophic temperature rise. CO2 emissions from fuel combustion increased by 6% in 2021 (indicator 3.1) and agricultural greenhouse gas emissions have increased by 31% since 2000 (indicator 3.5.1). The inaction came with major health costs: fossil fuels contributed to 1·3 million deaths from ambient PM2·5 exposure in 2020; the over-dependence on solid fuels, worsened by the energy crisis, increased exposure to indoor air pollution (indicators 3.3 and 3.2);,, and consumption of carbon-intensive meat and dairy resulted in 2 million deaths in 2019. Meanwhile, governments provide billions of dollars annually for fossil fuel subsidies (indicator 4.2.4).

118However, some indicators provide a glimmer of hope. Government engagement with health and climate change reached record levels in 2021, and the updated NDCs reflect increased awareness of the need to protect health from climate change hazards (indicator 5.4). Renewable electricity generation and electric vehicle use reached record growth, and investments and employment in the clean energy industry are slowly increasing (indicators 3.1, 3.4, 4.2.1, and 4.2.2). If sustained, these shifts could provide energy security, better jobs, cleaner air, and a path for a green COVID-19 recovery. Meanwhile, the health sector is increasingly preparing to face climate hazards (indicator 2.2.1), with 60 countries committing to developing climate-resilient and/or low-carbon or net zero-carbon health systems at COP26. An expanding number of countries are starting to develop their own observatories, to monitor and identify progress on health and climate change. However, this could come too little too late.

119With countries facing multiple crises simultaneously, their policies on COVID-19 recovery and energy sovereignty will have profound, and potentially irreversible consequences for health and climate change. However, accelerated climate action would deliver cascading benefits, with more resilient health, food, and energy systems, and improved security and diplomatic autonomy, minimising the health impact of health shocks. With the world in turmoil, putting human health at the centre of an aligned response to these concurrent crises could represent the last hope of securing a healthier, safer future for all.