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CLIMATE CHANGE IN AGRICULTURE AND WATER SECTORS:


COSTS OF INACTION FOR THE HEALTH OF THE POOR
By Rikard Elfving, Jacques Jeugmans and Benoit Laplante1

Background Paper for the Conference on the “The Environments of the Poor in the Context of
Climate Change and the Green Economy: Making Sustainable Development Strategies
Inclusive”, 24-26 November 2010, New Delhi2

SUMMARY

1. A generally warmer and unstable climate will lead to more extreme weather events,
floods and droughts, water and air pollution, all likely to adversely affect health. While all
populations are vulnerable to climate induced health risks, the poor will be particularly at risk
given their greater degree of exposure and lower capacity to adapt to the changes. Surprisingly,
little is currently known on the potential health impacts of climate change on the poor, and the
nature and costs of adaptation of particular relevance for the poor.

2. Two key recommendations emerge from our analysis. First, climate experts, sector
experts, health experts, and economists will need to work in close collaboration and
coordination with the aim of mitigating the health impacts of climate change on the poor. Too
often, the information made available by climate experts is of limited use to health experts, and
the information made available by health experts is of limited use to economists. This results in
policy-makers and local communities being poorly informed about the possible health impacts of
climate change, and poorly equipped with appropriate short term and long term mitigation
strategies. Second, while the health “shadow” of infrastructure projects on the poor, in terms of
either positive or negative impacts, may have been less than explicitly accounted for in the past,
it will undoubtedly become a more important part of any investment project or when preparing
country partnership strategies, as climate and disaster resilience becomes an increasingly
important factor in sustaining development gains. In the context of climate change adaptation
investments in the water and agriculture sectors, assessing the health impacts of such
investment projects should increasingly become an integral component of project financial and
economic analyses which are typically conducted. While a qualitative assessment of a project’s
health impacts remains of interest, the quantification and monetization of these impacts will
ensure that they are an integral component of a project’s financial and economic analysis, and
may impact thus impact decisions which are made about the project’s design or desirability.

I. CLIMATE CHANGE AND HEALTH

3. The Intergovernmental Panel on Climate Change (IPCC) concluded in 2007 that climate
change and the warming of the earth is without doubt happening and that in all likelihood (90%
probability) this warming is primarily caused by human activity Furthermore, recent observations
show that some climate indicators are near or beyond the upper range of the IPCC projections
of 1990. A generally warmer3 and unstable climate will lead to more extreme weather events,

                                                            
1
Rikard Elfving and Jacques Jeugmans are respectively health expert and health sector leader at the Asian
Development Bank (ADB). Benoit Laplante is a consultant to the ADB.  
2
For more information, see the conference website: http://www.adb.org/Documents/Events/2010/Environments-
Poor/default.asp. 
3
Though in some rare instances such as Mongolia, climate is projected to be cooler.  


 
floods and droughts, water and air pollution and likely to adversely affect health, with
disproportionably large impacts on the poor and the vulnerable, mainly through four courses:

(i) extreme weather events causing injuries and deaths, water contamination, infectious
diseases, food shortages, and mental health problems, all of which have detrimental effects
on the ability of an individual and/or a family to maintain livelihood activities;

(ii) droughts and heavy rainfall will cause significant reduction in crop yield which, along with
dependence on subsistence agriculture, may lead to malnutrition or even starvation, and
micronutrient deficiencies;

(iii) an increase in the number of very hot days in large cities, along with forest fires and dust
storms that will affect both urban and rural areas will adversely impact air quality over broad
areas and exacerbate the occurrence and intensity of poor health outcomes associated with
high temperatures (e.g. heat strokes) and respiratory diseases (e.g. asthma attacks); and

(iv) changes in temperature and rainfall patterns will impact not only the occurrence of vector
borne diseases such as malaria and dengue, but also change and possibly extend the
geographical habitat of vectors of such diseases. Warmer temperature will increase the
geographical habitat of vectors of diseases, such as mosquitoes (transmitting malaria,
dengue, chikungunya) or small rodents (transmitting viruses responsible for hemorrhagic
fevers or other diseases.

4. The number of natural hazards has increased substantially over the last century and is
expected to continue to do in this century. As shown in Figure 1, most of the events are
hydrometeorological disasters, including floods, droughts, and storms. Between 1960 and 2007,
extreme temperature events had increased 25-fold, followed by a 10-fold increase in floods, a 4-
fold increase in storms and a 2-fold increase in droughts.4 Overall, however, flood and storm
events have been much more frequent (Figure 2).

                                                            
4
Part of the increasing trends is likely due to better reporting over the last 30 years (Guha-Sapir et al. 2004). 


 
Figure 1
Trends in occurrence of natural disasters (1900-2005)

Source: http://www.unisdr.org/disaster-statistics/

Figure 2
Global trend in occurrence of weather-related natural disasters (1960-2007)

 
Source: Authors’ analysis based on EM-DAT: The OFDA/CRED International Disaster Database
www.em-dat.net - Université Catholique de Louvain - Brussels – Belgium.5

                                                            
5
To be entered in CRED’s EM-DAT database, a natural disaster must involve at least 10 people reported killed; 100
people reported affected; the declaration of a state of emergency; or a call for international assistance. Recorded
deaths include persons confirmed as dead and persons missing and presumed dead. Total affected persons include
people suffering from disaster-related physical injuries, trauma or illness requiring medical treatment; people needing
immediate assistance for shelter; or people requiring other forms of immediate assistance, including displaced or
evacuated people.
 


 
5. Numerous reports have pointed out that climate change has the potential to reverse the
gains towards achieving the Millennium Development Goals (e.g. World Bank, 2008). In
particular, climate change threatens to worsen poverty and burden marginalized and vulnerable
groups with additional hardships. In Southeast Asia for example, many of the poor live in coastal
areas and in low-lying deltas which are expected to experience the brunt of the impacts related
to sea-level rise and the intensification of storm surges (Dasgupta et al., 2010). Furthermore,
both the anecdotal and empirical evidence strongly support the hypothesis that the lower a
household’s level of income, the greater the likelihood of being adversely impacted by natural
disasters.6

6. A number of factors may explain the nature of this relationship. First, the livelihood of the
poor is known to be significantly dependent on natural resources. When disasters disrupt the
flow of goods and services provided by these resources and more generally by eco-systems,
the poor find themselves in a precarious situation. Furthermore, when disasters destroy capital
(be it machine, cattle, or otherwise), the poor typically lack access to financial resources to
restore the level of capital to its pre-disaster level. Second, it is known that increases in income
enable individuals and households to respond to increased risk (including risk associated with
disasters) by employing additional costly precautionary measures.7 Third, the poor are often
located in areas which are more susceptible to high variability in temperature and rainfall such
hilly and steep slopes, and flood plains.8 Fourth, it is also known that richer societies are more
resilient as a result of the positive correlation between income and education, openness,
financial development and greater institutional capacity. Finally, it is worth pointing out that poor
households and communities may have limited access to adequate information to make
informed decisions pertaining to climate change and its projected impacts, as well as limited
influence on policy-making processes.

II. CLIMATE CHANGE IMPACTS IN ASIA AND THE PACIFIC

7. Historically, more people in the Asia and the Pacific region have been affected by floods,
droughts, and storms than in any other region of the world: 83% of all people affected by
droughts, 97% of all people affected by flood, and 92% of all people affected by storms over the
period 1960—2007 resided in the East Asia and Pacific and South Asia regions (Figure 3). If the
frequency and/or intensity of these events is projected to increase in the course of this century,
the population of Asia and the Pacific region is set to experience significant difficulties.

                                                            
6
See Laplante (2010) for a review of the empirical evidence. 
7
Both the demand for security and the private capacity to invest in security (through better access to financial capital
and private savings) increase as income increases.  
8
“Ninety percent of the disaster victims worldwide live in developing countries where poverty and population
pressures force growing numbers of poor people to live in harm’s way on flood plains, in earthquake prone zones and
on unstable hills. The vulnerability of those living in risk prone areas is perhaps the single most important cause of
disaster casualties and damage.” (Secretary General of the United Nations Kofi Annan, 1999).  


 
Figure 3
Regional distributions of number of people affected by weather disasters

Drought
Europe and  Latin 
Central Asia America/Caribb
1% ean
3%
Sub‐Saharan 
Africa
14%

East Asia and 
South Asia Pacific
60% 22%

Middle East and 
Flood North Africa
Latin  1%
America/Caribb Sub‐Saharan 
ean Africa
2% 1%

South Asia
38%
East Asia and 
Pacific
58%


 
Latin 
Europe and  Storm America/Caribb
Central Asia ean
1%
Sub‐Saharan  4%
Africa
2%
South Asia
21%

East Asia and 
Pacific
72%

 
Source: Authors’ analysis of cumulative number of people affected in each region between 1960 and
2007 based on the EM-DAT.

8. In May 2009, Lancet et al. (2009) called climate change “the biggest global health threat
of the 21st century.” The “epidemiological outcome of climate change on disease patterns
worldwide will be profound, especially in developing countries, where existing vulnerabilities to
poor health remain”. It is projected that several health impacts will be exacerbated as a result of
climate change in Asia and the Pacific. While the nature of the relationship remains uncertain,
climate change is likely to affect health through a number of different pathways.

9. A most immediate pathway through which climate change may affect health is water.
Adequate and clean water resources are vulnerable to climate change stress, which in turn
heightens the risk of diarrhea, cholera, and other water-borne diseases in rural and urban areas.
Greater rainfall combined with warmer temperatures is likely to make provision of clean water
and adequate sanitation more complex and costly, and expand the vectors for waterborne
communicable diseases including malaria and dengue fever. For example, by 2080,
approximately 6 billion people may be at risk of contracting dengue fever as a consequence of
climate change, 2.5 billion more than if climate were to remain unchanged (Hales et al. 2002). In
Indonesia (Figure 4) and the Philippines (Figure 5 and 6), there is a clear correlation between
the incidence of dengue fever and La Nina years (Indonesia) and rainfall (the Philippines).


 
Figure 4
Incidence of dengue fever in Indonesia (per 100,000 people)

La Nina years

Source: ADB (2009a).

10. If the projected impacts of climate change on health of poor populations are severe,
whether these impacts can or should be mitigated by means of adaptation investment projects,
and the selection of the most effective options at doing so will require knowledge about the
expected costs of climate change on health (and therefore the benefits of mitigating these
impacts), and about the costs of alternative adaptation options to ensure that the most cost
effective or most efficient adaptation option be adopted. However, as shown below this
information is currently lacking.


 
Figure 5
Monthly rainfall and number of cases of dengue fever
Philippines (1990-1999)

Source: Philippine Atmospheric, Geophysical and Astronomical Services Administration (PAGASA)


and Department of Health, Philippines

Figure 6
Monthly rainfall and number of cases of dengue fever
Philippines (2008-2009)

600

500
Rainfall/Dengue

400

300

200

100

0
1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101
2008 2009
Week

Rainfall Dengue

Source: PAGASA and Department of Health, Philippines

III. COSTING THE HEALTH IMPACTS OF CLIMATE CHANGE


 
11. Estimating the costs of the future health impacts of climate change comprises a number
of different steps, each fraught with its own difficulties, uncertainty, and incomplete information.
Without being exhaustive, these steps include:

• Selecting an emissions scenario. The Special Report on Emissions Scenarios (SRES) was
a report prepared by the Intergovernmental Panel on Climate Change (IPCC) for the Third
Assessment Report (TAR) in 2001, on future emission scenarios to be used for driving global
circulation models to develop climate change scenarios. There exist 4 broad families of
emissions scenarios (A1, A2, B1, and B2) with the A1 emission scenario comprising 3
different subsets (A1F1, A1B, and A1T). These scenarios differ as to the assumptions
pertaining to economic growth, population growth, the adoption of new technologies, and the
degree of integration among nations of the world. Different emissions scenarios provide
different estimates of changes in climate, and (all other things being equal) different estimates
of climate changes will provide different estimates of the future incidence of health impacts. In
a recent study of the potential impacts of climate change in South East Asia, ADB (2009a)
used the A1FI and B2 emissions scenarios. In terms of greenhouse gas emissions (GHGs),
A1F1 represents a high emission scenario (rapid, fossil-intensive economic growth), and B2
represents a medium case scenario. In a recent World Bank study, the A2 emission scenario
is used (World Bank, 2010). Recent empirical evidence indicates that actual GHGs emissions
tend to follow emissions levels projected by high emissions scenarios of the A1 family.

• Selecting a Global Climate Model or General Circulation Model (GCMs). GCMs are
computer models used to simulate the earth’s climate systems. GCMs are the main tools used
to project future climate changes due to the continued anthropogenic inputs of greenhouse
gases. The major advantage of using GCMs as the basis for creating climate change
scenarios is that they estimate changes in climate for a large number of climate variables in a
physically consistent manner such as temperature, precipitation, pressure, wind, humidity, and
solar radiation. However: (1) GCMs typically provide projections at a scale in the order of
hundreds of square kilometers, which in many instances would be too large to project health
impacts; and (2) there currently exists 22 GCMs with their own sets of (uncertain) projections
about future climate variables. At the global level, it is generally found that the model
projections by 2050 do not diverge significantly insofar as temperature increases are
concerned, but do vary significantly for precipitation changes.

• Selecting a method of downscaling GCM projections. The problem that pertains to the
coarse resolution of GCMs can be overcome by downscaling. Downscaling increases both
spatial resolution (e.g., from hundreds to tens of kilometers) and temporal resolution (e.g.,
from monthly to daily). However, there are two main approaches for downscaling: Dynamical
downscaling (using regional climate models) and statistical downscaling (using empirical
relationships). These two approaches will yield different estimates of projected changes in
climate variables.9 As a result of the above (selection of an emission scenario, selection of a
GCM and of a downscaling approach), for each grid cell of the world (of say 50 km by 50 km),
there can be up to 264 estimates of future climate variables (including temperature and rainfall
among other variables). A possible approach to this multiplicity of estimates is to calculate the
mean (average) of the projected values. This, in effect, would assume that projected values of
future climate variables across all SRES and GCMs are equally likely. A possibly undesirable
outcome of such an approach is that it could result in projecting a zero change in the values of
                                                            
9
For more details on the issue of downscaling, see Wilby et al. 1997, Wilby et al. 1998, and Wood et al. 2004.
 


 
climate variables relative to the baseline. An alternative approach is to attempt capturing the
full range of results by selecting extreme values on either side of the projected change (e.g. if
rainfall or humidity is of interest, by selecting the ‘wettest’ and ‘driest’ projections.

• Selecting population projections. The number of cases of different types of climate-


dependent diseases will inherently depend on projections pertaining to the number of people
which may be exposed to these diseases. While this may be of relative ease at national levels
(using national or global datasets), the level of uncertainty pertaining to these population
projections will increase as one’s interest moves to sub-national levels. Particularly focusing
on a population of a specific nature, such as the poor, creates enhanced challenges (for
example, answering a relatively simple question such as “What could potentially be the
number of poor households in the Central Highlands of Viet Nam in 2050?” will require the use
of numerous assumptions);

• Selecting projections of future socio-economic characteristics. The incidence (e.g.


number of cases of a specific disease per 1,000 people) of climate-dependent diseases
depends not only on climate variables, but also on socio-economic characteristics among
which income and education are known determinants. This implies that estimates of the health
impacts of climate change will also depend on projections pertaining to these socio-economic
characteristics. Key to the nature of these projections is to recognize that future socio-
economic characteristics will themselves be a function of climate change. Hence, projecting
future values of socio-economic characteristics (in particular, income) must be consistent with
the selection of emissions scenarios; and

• Assessing the per unit financial and/or economic cost of diseases. While numerous
approaches to assess the financial or economic cost of diseases exist,10 each approach has
its strengths and weaknesses. For example, the cost of treatment methodology is relatively
straightforward to apply but may significantly under-estimate the economic costs of diseases;
on the other hand, while the contingent valuation approach may provide a better
approximation of the economic costs of diseases, it is not without controversy. Perhaps more
importantly, estimates of the costs of diseases will depend on the estimation approach
selected by the analyst.

12. Two important conclusions emerge from the above observations.

13. A first conclusion is that estimating the future costs of the health impacts of climate
change is a daunting task, fraught with uncertainty and incomplete information. This task is
made even more difficult when the interest lies on specific subsets of defined populations, such
as the poor. This may help explain the limited quantitative information pertaining to the health
impacts of climate change on the poor.

14. Using the PAGE2002 Integrated Assessment Model (IAM), Stern (2006) estimates the
total cost of a business-as-usual (BAU) climate change scenario over a period of 200 years.
This cost includes the “market impacts” of climate change (impacts on goods and services for
which market prices can be used to monetize the impacts into costs), as well as the ‘non-market
impacts’ of climate change which, in the Stern Review, includes impacts on environment and
human health. Based solely on market impacts, the study estimates the total cost of BAU
climate change to equate an average reduction in global per capita consumption of 5%, now
                                                            
10
See ADB (2010) for a brief survey of these approaches. 

10 
 
and forever. Once the impacts on the environment and human health (non-market impacts) are
included, the total cost of BAU increases from the estimated 5% to 11% (Table 1). In the case of
a high climate scenario, the estimated total cost of BAU increases from 6.9% to 14.4% once
non-market impacts are included. These results suggest that the costs of climate change on the
environment and human health may be as large as the costs on market impacts. Other studies
of a similar nature (based on the use of IAMs) are summarized in Table 2.

Table 1
Estimated losses in current per-capita consumption1

Climate scenario Economic Mean 5th percentile 95th percentile


Baseline climate Market impacts 2.1 0.3 5.9
Market impacts + risk of 5.0 0.6 12.3
catastrophe
Market impacts + risk of 10.9 2.2 27.4
catastrophe + non-market impacts
High climate Market impacts 2.5 0.3 7.5
Market impacts + risk of 6.9 0.9 16.5
catastrophe
Market impacts + risk of 14.4 2.7 32.6
catastrophe + non-market impacts
Source: Stern (2006).
1
The numbers in Table 1 represent the estimated reduction (in percentage terms) in per-capita
consumption relative to the business-as-usual scenario.

Table 2
Estimates of the welfare costs of climate change

Worst-off region
Study Warming Impact % of GDP Name
(0C) (% of GDP)
Nordhaus (1994) 3.0 -1.3
Fankhauser (1995) 2.5 -1.4 -4.7 PRC
Tol (1995) 2.5 -1.9 -8.7 PRC
Nordhaus and Yang (1996) 2.5 -1.7 -2.1 Developing
countries
Plambeck and Hope (1996) 2.5 2.5 -8.6 Asia (w/o PRC)
Mendelsohn et al. (2000) 2.5 0.0 -3.6 Africa
Nordhaus and Boyer (2000) 2.5 -1.5 -4.1 Africa
Tol (2002a) 1.0 2.3 -4.1 Africa
Maddison (2003) 2.5 -0.1 -14.6 South America
Rehdanz and Maddison 1.0 -0.4 -23.5 Sub-Saharan
(2005) Africa
Hope (2006) 2.5 0.9 -2.6 Asia (w/o PRC)
Nordhaus (2006) 2.5 -0.9
Source: Tol (2009)

15. While the Stern Review includes “non-market” impacts, the report notes these are
difficult to monetize and that the results from this monetization process are problematic in terms
of concept, ethical framework, and practicalities. Perhaps more importantly for purpose of this
paper, it is to be noted that the Stern Review systematically refers to the “environment and
human health” impacts of climate change, and not solely to the impacts on human health. Using
results from the Stern Review, one may conclude that the costs of the impacts of climate

11 
 
change on human health alone may range approximately between 0% and 6% of global per
capita consumption. Finally, while it is presumed that the health impacts of climate change will
fall disproportionately on the poor, studies such as those mentioned above do not systematically
attempt to assess the distribution of these costs across income groups.

16. As pointed out by Confalonieri et al. (2007), studies focusing on the welfare costs of
climate-change impacts (such as the Stern Review) rarely include health outcomes explicitly,
and if they do, the studies are generally limited to assessing the costs of extreme heat and cold
related mortality, and malaria. Where they have been estimated, the welfare costs of health
impacts contribute substantially to the total costs of climate change (Tol, 2002b).

17. Confalonieri et al. (2007) conclude their review by suggesting that the following major
challenges for research on climate change and health be addressed: (i) development of
methods to quantify the current impacts of climate and weather on a range of health outcomes,
particularly in low- and middle-income countries; (ii) development of health-impact models for
projecting climate-change-related impacts under different climate and socio-economic
scenarios; and (iii) investigations on the costs of the projected health impacts of climate change;
effectiveness of adaptation; and the limiting forces, major drivers and costs of adaptation. Of
similar importance, the authors conclude that “there is a need to strengthen institutions and
mechanisms that can more systematically promote interactions among researchers,
policymakers and other stakeholders to facilitate the appropriate incorporation of research
findings into policy decisions.”

18. A second conclusion along the lines expressed by Confalonieri et al. (2007) is that
collaboration and coordination among different fields of expertise is the only possible avenue for
reducing the uncertainty pertaining to the health impacts of climate change (Figure 7).
Furthermore, this collaboration and sharing of methodological approaches will deliver results if
at the outset one is very clear as to precisely what type of information is needed from each
subset of experts. Failure to do this is likely to result in information that is of little use to others.
Close collaboration and coordination is needed to achieve this objective.

Figure 7
Estimating the costs of climate change on health

Climate expertise Health expertise

Climate Health
change impacts and
costs

Economic expertise

Socio-economic
characteristics

12 
 
IV. INCORPORATING HEALTH IN FINANCIAL AND ECONOMIC ANALYSES OF NON-
HEALTH PROJECTS

19. The UNFCCC report estimated the adaptation costs for the health sector to be in the
range of $4–12 billion per year in 2030 (UNFCCC, 2007). The adaptation costs are for
preventing the additional climate-change-induced cases of solely diarrhoeal disease,
malnutrition and malaria in 2030 (Table 3). Note that malnutrition accounts for a very small
proportion of the estimated total costs (Figure 8), while malaria and diarrhoeal diseases
contribute to approximately the same proportion to this total cost (though for the high cost
scenario, diarrhoeal diseases account for a slightly higher share).

Table 3
Projected costs to manage additional climate change related cases of diarrhoeal diseases,
malnutrition, and malaria in 2030 (million US$)

Emissions Diarrhoeal diseases Malnutrition2 Malaria2


scenario1
Middle High Middle High Middle High
S550 1,706 6,024 63 131 1,859 3,876
S750 1,983 6,814 95 189 2,310 4,784
UE 2,731 9,010 72 146 3,664 7,537
1
S550: Stabilization of emissions at 550 ppm CO2 equivalent; S750: Stabilization of emissions
at 750 ppm CO2 equivalent; UE: Unmitigated emissions
2
Middle point of the provided cost estimates presented in Elbi (2008).

13 
 
20. As noted by Elbi (2008), a key assumption behind these estimates is that the number of
annual cases of diarrhoeal diseases, malaria, and malnutrition as well as the cost of treatment
remains constant over the period of analysis. Given the projected increase in population, this
implies that the rates of incidence of each of these health outcomes decrease over time in line
with the rate of population growth. Elbi (2008) notes:

Conducting a sensitivity analysis that incorporated these population increases would


require assumptions of future incidence rates of these health outcomes, based on
assumptions of socioeconomic development, including improvements in health care
delivery, the rate of deployment of current interventions, and the development of more
effective technologies. Using the current number of cases in the analysis in effect
assumes that incidence will decrease as population increases, without attribution of the
possible reasons for such a decline (page 6).

21. In a recent study (World Bank, 2010) such attribution was explicitly modeled insofar as
income is concerned. The study used econometric models developed by the World Health
Organization (WHO) using panel data on income and health to project cause-specific deaths
and disability-adjusted life year (DALY) rates by demographic group through 2030 (WHO,
2004). Accounting solely for this attribution (as income increases the rate of incidence falls), the
average global costs of adaptation in the health sector for the prevention and treatment of
diarrhea and malaria alone (not including malnutrition) over the period 2010 – 2050 was
estimated to reach $1.3 billion (dry weather scenario) to 1.6 billion per year (wet weather

14 
 
scenario), in 2005 dollars (Table 4).The East Asia and Pacific, and South Asia regions account
for half of this estimated cost of adaptation.

Table 4
Average annual adaptation cost for human health – preventing and treating malaria and diarrhea,
by region and decade, 2010-2050 (billion US$ at 2005 prices, no discounting)

Period EAP1 ECA LAC MENA SA SSA All


Wet scenario
2010-19 0.7 0.1 0.0 0.1 1.0 0.9 2.8
2020-29 0.2 0.0 0.0 0.1 0.7 0.7 1.7
2030-39 0.1 0.0 0.0 0.1 0.3 0.7 1.2
2040-49 0.1 0.0 0.0 0.0 0.1 0.8 1.0
2010-49 0.2 0.0 0.0 0.1 0.5 0.8 1.6
Wet scenario
2010-19 0.5 0.0 0.0 0.1 0.8 0.6 2.0
2020-29 0.1 0.0 0.0 0.1 0.7 0.6 1.5
2030-39 0.1 0.0 0.0 0.0 0.3 0.6 1.0
2040-49 0.0 0.0 0.0 0.0 0.1 0.6 0.7
2010-49 0.2 0.0 0.0 0.0 0.5 0.6 1.3
1
EAP: East Asia and Pacific; ECA: Europe and Central Asia; LAC: Latin America and Caribbean; MENA:
Middle East and North Africa; SA: South Asia; SSA: Sub-Saharan Africa.

22. As a result of the different modeling approaches, these estimates (World Bank, 2010)
are significantly lower than those reported by Elbi (2008). One concludes that: (i) there remains
large uncertainty as to the adaptation costs for climate change-related health outcomes, and (ii)
the analyses have so far captured a limited number of health outcomes which may be
associated with climate variables. For example, both Elbi (2008) and the World Bank (2010)
studies do not include estimates of the costs of many other infectious diseases which are known
to be climate sensitive (such as dengue for example), heat and cold stresses, population
displacement, and increased air pollution.

23. Perhaps more importantly for the purpose of the existing paper, World Bank (2010)
explicitly recognizes that the estimated adaptation costs in the health sector would be
considerably higher if adaptation investments in the water infrastructure sector (some of which
related to mitigating adverse health outcomes associated with the provision of poor water supply
and sanitation services), agriculture (some of which related to mitigating malnutrition) and
natural disasters (some of which with important health outcomes) were to fail delivering the
benefits for which they are intended. Similarly, Elbi (2008) and Kovats (2009) also recognize
that adaptation in other sectors is probably more important for reducing the health impacts of
climate change (through disaster mitigation, food and water security, and providing decent
infrastructure).

24. A key message from the above studies is that while planning adaptation investments in
the health sector itself must be a significant component of an overall climate change adaptation
strategy, it remains to a large extent an approach which is based on reacting to an increase in
the health impacts of climate change as opposed to preventing such increases. Sectors from
which the prevention of adverse health outcomes associated with climate change include water,
agriculture, and disaster risk management. A climate change adaptation strategy which focuses
on preventing the projected health impacts of climate change is likely to be more effective (in
terms of both impacts and costs) than a strategy focused solely on reacting to it. This offers
significant opportunities for ADB’s investment portfolios, as well as significant challenges.

15 
 
25. ADB’s Strategy 2020 makes several references to the role of health in ADB’s activities
(ADB, 2008):

ADB recognizes that health is vital to development, productivity, social inclusion,


and gender equity. (…) ADB will contribute to improvements in health mainly
through infrastructure projects such as water management and sanitation and
through governance work that focuses on public expenditure management for
cost-effective delivery of health programs and services to all population groups.

Key in the above statement is that achieving health improvements in DMCs will be addressed
through investment in infrastructure projects.

26. The World Health Organization (WHO) also makes explicit reference to the needs of
addressing health concerns in sectors other than the health sector per se. The WHO, through its
Regional Offices for South-East Asia and the Western Pacific, developed a Regional
Framework for Action to Protect Human Health from the Effects of Climate Change in the Asia-
Pacific Region. In a Resolution adopted in 2008, member states are urged to (among other
actions):

(4) assess the health implications of the decisions made on climate change
by other sectors, such as urban planning, transport, energy supply, food
production and water resources, and advocate for decisions that provide
opportunities for improving health.

27. ADB’s operational plan for health under Strategy 2020 (ADB, 2009b) explicitly states
support for improved health outcomes through infrastructure operations. As part of this process,
ADB will systematically incorporate key health and social indicators in the Design and
Monitoring Framework in all water and sanitation infrastructure projects. In addition, this implies
that health impacts (positive or negative) of investment projects, including climate change
adaptation investments, in sectors such as water and agriculture as well as natural disasters
mitigation need to be explicitly accounted for in the preparation, design, as well as in the
assessment of the costs and benefits of these projects.

28. However, experience thus far indicates that the health impacts of infrastructure
investment projects, particularly the health impacts on the poor (either positive or negative),
including climate change investment projects (though the latter remain limited in numbers) are
rarely explicitly accounted for. Even in projects where health impacts (either positive or
negative) are mentioned or referred to, most assessment of these health impacts remain of a
qualitative nature. Rightly or wrongly, financial institutions (whether private or public) assess the
desirability of an investment project mostly (if perhaps only) by means of financial and economic
analyses (cost-benefit analysis).

29. If the health benefits of adaptation measures in the water sector and agriculture sector
as well in the area of natural disaster mitigation and prevention are not fully accounted for in the
technical feasibility and economic assessment of these adaptation measures, then: (1) The
adaptation measure may fail to pass a cost-benefit analysis test (i.e. net present value (NPV) of
the adaptation measure under consideration is estimated to be negative), and therefore is not
be implemented (this situation may be characterized as under-investment in adaptation); or (2)
the ranking of adaptation measures may be wrong in that an adaptation measure which would
otherwise be ranked first (highest NPV) if health benefits had been accounted for may end-up

16 
 
being ranked inferior to other adaptation measures (this situation may be characterized as
misadaptation).

30. In most instances, there is no attempt to explicit quantify and monetize the health
impacts of the projects. These impacts thus remain peripheral to the assessment of the costs
and benefits of infrastructure projects, and not being explicitly (quantified and monetized)
included in such analysis, will therefore not play any decisive role in the decision-making
progress pertaining to the acceptance or rejection of projects, or the selection of a specific
option when many options are feasible. While the health “shadow” of infrastructure projects on
the poor, in terms of either positive or negative impacts, may have been less than explicitly
accounted for in the past, it will undoubtedly become a more important part of any investment
project as climate and disaster resilience becomes an increasingly important factor in sustaining
development gains. For this purpose, sector expertise is needed in addition to climate, health,
and economic expertise (Figure 9).

Figure 9
Estimating the costs of climate change on health: Revised

Climate expertise Sector expertise Health expertise

Climate Agriculture, Health


change water, natural Impacts and
disaster costs

Economic expertise

Socio-economic
characteristics

V. CONCLUSIONS

31. A generally warmer and unstable climate will lead to more extreme weather events,
floods and droughts, water and air pollution and likely to adversely affect health, with
disproportionably large impacts on the poor and the vulnerable, mainly through four courses: (i)
extreme weather events causing injuries and deaths, water contamination, infectious diseases,
food shortages, and mental health problems; (ii) droughts and heavy rainfall will cause
significant reduction in crop yield which, along with dependence on subsistence agriculture, may
lead to malnutrition or even starvation, and micronutrient deficiencies; (iii) an increase in the
number of very hot days in large cities, along with forest fires and dust storms will adversely
impact air quality over broad areas (both urban and rural) and exacerbate the occurrence and
intensity of associated with high temperatures (e.g. heat strokes) and respiratory diseases (e.g.
asthma attacks); and (iv) changes in temperature and rainfall patterns will impact not only the
occurrence of vector borne diseases such as malaria and dengue, but also change and possibly
extend the geographical habitat of vectors of such diseases

17 
 
32. Despite the fact that Asia and Pacific region being significantly exposed to the projected
impacts of climate change, despite the fact that more than 900 million people of its population
living in absolute poverty (defined as less than $1.25 a day in 2005 prices), and an additional
900 million lived in moderate poverty (defined as less than $2 a day; Bauer et al. 2008), and
despite the knowledge that climate change will have particularly severe impacts on the poor (as
a result of their higher degree of exposure to climate change and lower adaptive capacity), little
is currently known as the potential health impacts of climate change on the poor, and the nature
and costs of adaptation options of particular relevance to the poor.

33. When it comes to climate change and health, ADB’s Priorities for Action includes (1)
promoting climate resilient development (build the climate resilience of vulnerable sectors like
health, including preparation of climate resilient sector road maps and climate proofing of
projects); (2) helping DMCs to guide adaptation interventions to address health impacts and
cost-effective responses; (3) generating and disseminating knowledge including the
development of operational guidelines for health and adaptation actions; and (4) establishing
partnerships that compensate ADB's own capacities to strengthen regional cooperation and
climate change analysis and responses on health impacts.

34. Two key recommendations emerge from this analysis in support the above priorities for
action. First, climate experts, sector experts, health experts, and economists will need to work in
close collaboration and coordination with the aim of mitigating the health impacts of climate
change on the poor. Too often, the information made available by climate experts is of limited
use to health experts, and the information made available by health experts is of limited use to
economists. This results in policy-makers and local communities being poorly informed about
the possible health impacts of climate change, and poorly equipped with appropriate short term
and long term mitigation strategies. Second, while the health “shadow” of infrastructure projects
on the poor, in terms of either positive or negative impacts, may have been less than explicitly
accounted for in the past, it will undoubtedly become a more important part of any investment
project as climate and disaster resilience becomes an increasingly important factor in sustaining
development gains. In the context of climate change adaptation investments in the water and
agriculture sectors, assessing the health impacts of such investment projects should
increasingly become an integral component of the financial and economic analyses which are
typically conducted.

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