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As our future heats up, how well prepared is the health sector?

Australia’s health sector is worryingly under-prepared to respond to the consequences of a projected increase in extreme weather events, such as heatwaves.

That is the thrust of a handful of health-related submissions to the current Senate inquiry, Recent trends in and preparedness for extreme weather events. 

The inquiry by the Senate Standing Committees on Environment and Communications is due to hold hearings in Melbourne, Brisbane, Perth and Canberra over the next few months before reporting in March.

The Climate and Health Alliance submission says there is an urgent need to improve the health sector’s capacity:

“Australians are neither prepared for, nor informed about, the dangers of the warming climate and the severity and scale of extreme events they are likely to experience in coming years and decades. The unprecedented national heatwave of January 2013, floods of 2011, wild weather of 2012, and bushfires of 2009 give an insight into the weather of a warming world. It is a world that may be become increasingly dangerous in coming years, intolerable in coming decades and uninhabitable in coming centuries.

Australia healthcare systems are ill-prepared to cope with extreme events and Australia’s health professionals lack understanding of the health impacts of climate change. This affects the ability of both individuals and the health care system to prepare for and respond to extreme weather events. This puts lives at risk – not only the lives of those already threatened by climate change eg people who are chronically and/or mentally ill, elderly, homeless and infants and children – but of all Australians, as we are all vulnerable to extreme weather events.”

The Australian Psychological Society submission says that State and Federal agencies need to broaden their frame for examining extreme weather events, and accept that the altered, climate-changed world in which Australians now live requires a broader framing of risk communications and adaptation responses, that encompasses both extreme weather events and climate change.

The APS calls for a communication strategy to raise the health sector’s knowledge and awareness of the health impacts facing the population from the increased risks of extreme weather events.

A submission from Associate Professor Marion Carey, a public health physician at Monash University, says:

“Extreme weather events will present increasing threats to population health and well- being under climate change. These impacts are likely to be disproportionately felt by the most vulnerable in society, including those who are homeless. The capacity of community health and welfare services to cope with increasing service demands has not been adequately addressed to date, and effective policy solutions are needed to protect those who are among the most vulnerable in our society.”

Meanwhile, this PwC report, calling for a national framework for protecting human health and safety during severe and extreme heat events, notes that heatwaves kill more Australians than any other natural disasters but receive far less public attention than cyclone, flood or bushfires.

It says:

“By 2050 an extreme heat event in Melbourne alone could typically kill over one thousand people in a few days if we don’t improve the way we forecast, prepare for and manage these events. It is likely that Brisbane would face a similar death toll, with Adelaide, Sydney and Perth also increasingly impacted. To put this in perspective 173 people died in the Black Saturday fires in Victoria in 2009 and 35 in the floods in Queensland in 2010-11. However, more than 370 people died from extreme heat in Victoria in the same week as the Black Saturday fires. The morbidity impacts from future extreme heat events are likely to also be very large. Those who are affected come disproportionally from the vulnerable groups in our community.”

The report makes it clear that it is not only health services that have a role to play in reducing the health impacts. A case study from Shanghai suggests that changes to urban design and landscaping helped the city cope when in 2003 it recorded the hottest summer in over 50 years. One of the factors credited was an increase in the urban green area within Shanghai from 19.1 to 35.2 per cent.

In a recent Croakey post, health policy analyst Michelle Culhane-Hughes suggested that “innovation on a huge scale” will be needed if health services are to cope with the extra load from heatwaves.

Below are some comments on the health implications of heatwaves from Croakey contributors:

• Reviewing research and policy activity
Dr Leigh Wilson, University of Sydney

• The WA response
Prof Tarun Weeramanthri, Chief Health Officer, WA Department of Health

• We need more coordinated efforts and investment in skin cancer prevention
Terry Slevin, Cancer Council WA

• Focus on the health effects of coal
Ian McAuley, Fellow of Centre for Policy Development, lecturer in public sector finance, Canberra University

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Reviewing research and policy activity
Dr Leigh Wilson, Researcher, Climate, Heat and Health, University of Sydney

Q:  What are the likely short and longer term health impacts of the conditions this summer (heatwaves, bushfires etc)?

A: The short term health impact of heatwaves are acute (collapse, heatstress, heatstroke etc) and generally confined to vulnerable populations (the elderly, pregnant women, infants, the disabled, those with chronic illnesses, the morbidly obese or those who have mobility issues and cannot get to a cool location).

However, in many of these vulnerable populations heat exacerbates other conditions. For example, we know through recent research that those with cardiac problems and diabetes are much more likely to have serious health impacts in extremely hot weather.

Heart attacks are more prevalent, diabetic instability (through fluid balance alterations) is common and falls in the elderly (through dehydration and subsequent confusion or light-headedness) can lead to fractured hips or more serious complications.

We know that there are additional admissions to hospital on very hot days for all causes, but particularly cardiac and respiratory conditions, mental illnesses, renal conditions, diabetes and other disorders associated with fluid balance (dehydration, electrolyte imbalance, collapse etc).

Of concern is the fact that our temperatures are rising at the same time as our population is ageing and the burden of chronic illness s increasing. These factors, in combination, will ultimately have a significant impact on the healthcare system unless appropriate measures are taken now, and planning for extreme events is integrated into routine care.

One of the key issues with extreme heat is that power overload occurs and other sequelae such as bushfires, equipment failure, transport failure (roads melting and train tracks buckling) have a widespread population impact. These impacts are of course felt most keenly by those who are sick, old, disabled or unable to move to cool locations due to mobility issues. This scenario makes this group additionally vulnerable.

Q: Are you aware of any anecdotal or other evidence of the impact upon health services this summer? How well have services been coping?

A: The NSW Ministry of Health does real time surveillance of hospitalisations for certain conditions on extremely hot days.

I am not aware of any results that have been released after the most recent heatwave, however this data is available at the Ministry of Health level. One of the difficulties associated with determining how health services are coping, is that it is difficult to tease out which hospital admissions are related to heat per se, and which are routine (ie would have occurred anyway).

There are many conditions that are exacerbated by heat, and heatwaves often contribute to a ‘harvesting’ effect. In this instance, people who were going to get sick, or die anyway do so, but just earlier. This does not mean the heat caused their illness or death but may have hastened it.

Ambulance transportation data is available through the ambulance service and there statistics are indicative of additional transportations due to the heat on extreme days.

Q: Is there sufficient planning and resourcing work being done at local, state and national levels to ensure health services are equipped to respond to the impacts of extreme weather events?

A: There is a large amount of work being conducted around the country investigating extreme weather impacts. The National Centre for Climate Change Adaptation Research is one Commonwealth funded (sadly recently de-funded!) organisation that has facilitated a large body of research into extreme events of all types (flood, fire, heat, sea-level rise etc).

Through this organisation the University of Sydney and the University of Adelaide were funded to investigate the health impacts of heatwaves on: 1) the elderly in aged care facilities in three Australian states (NSW, Qld and SA) and 2) the culturally diverse and migrant populations. This research has provided a huge amount of knowledge and information on which heatwave planning and policy can be based. The research is due to be released in the next couple of weeks.

Q: Are there any useful examples of health services/agencies being innovative in this area?

A: South Australia has a great system, whereby through state government SAFECOM (Safety Commission), consisting of SES, Fire, Health, Ambulance, etc, these groups work collaboratively to plan and prepare services, infrastructure and the community for heatwave events and for other extreme weather emergencies. This is similarly replicated in Victoria (since Black Saturday) but not elsewhere in the country to my knowledge.

The Red Cross Redi-Tool, is an excellent assessment tool for the vulnerable during heatwaves. This assessment tool is used by volunteers who call people identified as vulnerable (and kept on a Red Cross list). When temperatures are extreme, telephone calls are made to those most vulnerable to ensure they are OK. This of course has limitations in situations such as bushfires, where people are asked to move quickly or are not by their phone. However in hot weather, it is an extremely effective way of monitoring vulnerable populations.

Q: How might e-health technologies be used in this area?

A: E-health technologies are useful in identifying those at risk in a heatwave or extreme weather event. Planned care, prior to such extreme events is important and could mitigate the severe health impacts experienced by many vulnerable people.

There are limitations to electronic communications in extreme weather though. For example when there is no power, mobile phones go flat and cannot be re-charged, so sending warning SMS messages is futile, as is internet based communication. Planning and preparedness at all levels of the community and service delivery is the most important message as then each individual has a plan.

Q. Are there examples we can learn from, whether in Australia or internationally, of successful efforts to bring together multiple agencies in planning and prep?

A: NSW is currently working on a Heatwave Health Warning System (MoH, SES, Fire). This, however, is not a plan, but more a mechanism by which to alert government agencies and the community that the weather will be extreme and to take care. I have been involved in research which forms the basis for the initiation points of the HHWS, and this research is currently under review.

Q. Do you recommend we check any particular initiatives elsewhere in the world?

A: Similar initiatives have been undertaken in the UK and in Europe (particularly France and Spain, following the extreme heatwave of 2003)

My belief is that research should underpin a really cohesive planning process which is undertaken at state and national level. The difficulty is that there is little cohesion at present across states, and this has very much been driven by the differing climatic conditions and temperatures experienced. For example, until Black Saturday, Victoria was not really thought of as a state that experienced extreme heatwaves.

There is little doubt now however that Australia as a whole is experiencing a phenomenon which is causing temperatures to be higher, more frequently and last longer. It would be great to have a national approach which is then tweaked at state and local level.

Services, infrastructure providers and community members all need to be actively involved in the planning process so that ownership of the process will occur. This, I believe will be more effective than a mobile, military response.

Of course there will always need to be an emergency team that is on standby for immediate response, in a similar way that public health units around the state respond each day to epidemics, environmental disasters and outbreaks but these should be targeted and specific.

Q: Any other comments you’d like to share on related issues?

A: Our recent research on how aged care facilities cope in the heat is a great example of how recommendations from ‘field based’ research can inform policy and planning for heatwave response in the future. This research is expected to be released in the next couple of weeks, and hopefully will be used to inform National Aged Care Policy around heatwave preparedness in Aged Care Settings.

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The WA response
Prof Tarun Weeramanthri, Chief Health Officer, WA Department of Health

Between Christmas Day 2012 and New Year’s Day 2013, Western Australia experienced a severe heatwave. The State Government response was guided by the newly authorised WESTPLAN HEATWAVE.

This whole of government emergency management plan has Health as the lead agency, and includes a forecasting tool that proved very valuable.

The ‘Excess Heat Factor’ (based on John Nairn and colleagues’ work at Bureau of Meteorology) was calculated using a three-day average of predicted maximum daytime and minimum nighttime temperatures.

It allowed us to stay a couple of days ahead in predicting when the heatwave would begin and end, and to move smoothly from Alert to Standby to Response phases in a planned manner.

The response attracted favourable comment from the other government agencies involved about the quality of communication to them and the public. WESTPLAN HEATWAVE can be viewed here.

***

A call for more coordinated investment in skin cancer prevention
Terry Slevin, Cancer Council WA

With ozone levels not expected to recover to pre-depletion levels until the middle of this century, UV levels are expected to continue to rise.

Combined with Australians favouring an outdoor life-style, when temperatures are warmer, under high levels of UV, the associated risk of skin cancer will increase.”  (Lemus-Deschamps L &   Makin J.K   Int J Biometeorol (2012) 56:727–735)

There is no doubt justified concern about the various effects of climate change.  One that seems to have gone a little under-reported is the change to the levels of ultra violet (UV) radiation reaching the earth’s surface.

Last week the Australian Bureau of Meteorology predicted that the UV Index in Perth on Monday would reach 15 and on Tuesday it would reach 16.  These are unprecedented forecasts, with Perth never having recorded higher than 14.  As it happened some well-timed cloud cover over the measurement device prevented the predictions coming to fruition. In Sydney the prediction of 14 was more than met.

The UV Index is the measure agreed by the World Meteorological Organisation and the World Health Organisation to measure and report the intensive to UV radiation reaching the earth.  It does not rely on or necessarily correspond with the temperature – so even days of moderate temperature can see extreme UV Index readings.

In Australia we currently see about 11,500 new cases of melanoma diagnosed each year.  In addition there are more than three quarter of a million non melanoma skin cancer lesions treated each year with that number likely to go over a million each year in a few years time.  We are world champs when it comes to skin cancer.  But it costs us.  Over half a billion dollars just on NMSC treatment in 2010.

And all that Sun Smart stuff we do is having an impact.  You see shade at your local municipal pool and SunSmart signs on the fences of schools and childcare centre.  You get pestered with ads on telly to cover up and protect your skin.

So there is a push to reduce UV exposure and related skin cancer risk.  At the same time there is an increasing quantity of the stuff driving skin cancer rates up 0 UV radiation – hitting the ground (and us!).  So who is winning?

Well, there are early signs that skin cancer in younger age groups is levelling off (before something comes down it need stop going up) and maybe even coming down.  But overall the age standardised rates are still increasing  – at a far more alarming rate in men than women.

So – what to do?  Well – it seems a greater investment in the prevention efforts.  In truth the SunSmart programs have been run on an absolute shoestring with only sporadic investment from the commonwealth government and state governments contributing at wildly variable levels – from little to nothing to a reasonable contribution.

In the meantime, let’s add skin cancer as one of those health issues that has a climatological aspect. I know – it is boring – it has been around a long time and you’ve heard it all before.  But guess what?

The sun is coming up tomorrow and the likelihood is the UV will be in the extreme range – again.

***

Focus on the health hazards of coal
Ian McAuley, public policy analyst

Reasonable people certainly know that global warming is happening, and can make some reasonably incontestable predictions: a hotter planet is a more energetic planet; greater energy is highly likely to generate more extreme weather events and to upset certain life-sustaining systems; there will be costly consequences both in terms of financial costs and misery.

Therefore the best approach is a precautionary one to try to slow or to halt the progress of anthropogenic warming.

The systems we are talking about are complex. The natural systems are complex enough, and the human-political systems with which they interact are even more complex. Who knows what the local effects will be?  The most credible predictions are that the agricultural regions of southeast mainland Australia will have lower winter rainfall, will be hotter, and will have higher but more variable summer rainfall. While there is some uncertainty surrounding these specific predictions, the local and global weather patterns over the last few years, including Australia’s particularly hot summer, are consistent with these models.

We may be tempted to say that in Victoria there will be more hot days and that more people will suffer heat stress and death from bushfire. Or, on a more general level, we may predict that the regions upon which we now rely for food production will become unproductive because of temperature and rainfall changes and sea level rises – therefore food stress will lead to poverty and health effects. These are reasonable predictions, but they are not hard forecasts.

We may be certain that the planet is warming, but there is uncertainty about local manifestations. Some will suggest that the regions of food production will simply move to higher latitudes – an argument that conveniently overlooks the time for soils to develop and the huge investment in fixed agricultural infrastructure. And some will say that the very low death rate in the current bushfires, in comparison with death rates in earlier fires, illustrates our capacity for adaptation – an argument that ignores the role of good fortune and the huge opportunity cost of resources devoted to emergency services. That’s why precaution, rather than a resort to optimistic scenarios, is the wisest policy.

But I urge caution, lest we be seen to be reacting to one extremely hot summer. We should not fall into the fallacy, as so many climate change deniers do, of mistaking noise and trend. After all, our recent run of cool and high rainfall years has probably fed the idea that climate change is not happening.

There is one specific issue that’s fairly clear, and that’s to do with coal. We are rightly concerned about coal as a source of CO2. The low-quality coal used for power generation is also a source of many other pollutants with adverse health effects. (Metallurgical coal is less harmful.)

These effects are more local than global warming.  These local health consequences can be far more effective than climate change in turning public opinion against coal. The immediate, visible and proximate threat looms more highly in people’s consciousness than that which is longer term, invisible and global.  I wouldn’t be surprised, for example, if China’s more to renewables (or possibly sequestration) is driven more by a political reaction to smog than by global warming.

Serious scientists will undoubtedly point out that these local health effects, bad as they are, are almost certainly minor compared with the health effects of climate change, thus implying that they should not be a high priority. But that is to miss the political point, which is that they can be mobilized to gain public support for a reduction in coal dependence.

In other words, those concerned with public health would do well to focus on the consequences of burning coal. If effective, the contribution to dealing with climate change will be a bonus – a case where the bonus is greater than the immediate benefit.

***

Further reading

• At The Conversation: Natural disasters have unexpected impacts on mental health, by Jan Golembiewski, Researcher in Environmental Determinants of Mental Health at University of Sydney

This article examines the complexity of social, environmental and psychological dynamics during an emergency, and explores the potential positive as well as negative effects of disasters upon mental health:

“When handled well (as they have been in the recent efforts), disasters are an opportunity for communities and people who are directly involved to galvanise, and this appears to inoculate against mental illness by strengthening social bonds, and feeding a sense of purpose and meaning.”

The flipside is that the elderly and those who are frail and who may feel like a burden suffer terribly from mental illness as a result of disasters. The big rise in mental health admissions after a bushfire happens in this group.

***

And finally two observations from Croakey arising out of personal experiences this summer:

• We appreciated our local council sending a natty little information and education pack about dealing with emergencies. A shame that the list of contacts, ideal for putting on the fridge, was in such small print that even those with 20-20 vision would struggle to read it.

• For the animal-lovers amongst us, it would be very nice to have public air-conditioned spaces that are pet friendly.

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  • 1
    Michelle Hughes
    Posted January 25, 2013 at 6:12 pm | Permalink

    Disclaimer: I will begin this comment by declaring that I had a major role in the development of the pwc report referred to in this post.

    In discussing extreme heat or in fact any extreme weather event that we can predict it is important to remember that a lot can be done to minimize mortality and protect those most vulnerable. At the moment the community, nfp and social services groups take a huge role in this and they must be involved in any health planning around this issue. In addition prevention will require coordination with a number of sectors – an example will be energy suppliers to ensure that, where possible, the most vulnerable have available, affordable power supply during these events.

    It is clear that we need a coordinated response from federal, state and local government around this issue. One simple but interesting issue raised in the pwc report is that we do not have a nationally agreed definition of an extreme heat event. The EHF discussed in the pwc report is important because it takes into account multiple factors including adaptation and is applicable anywhere, my understanding is that BoM’s work is world leading in this respect. Maximum temperatures, averages and length of event are not enough as what constitutes an extreme event in one place by those definitions may not be extreme elsewhere. Until we speak a common language on this then analysis of retrospective data to forecast future impact is difficult. This is complicated by the lack of readily usable data in this area – as previously noted health information rarely identifies heat as an issue and it is not only inpatient facilities dealing with the health impacts of such events. I come back to my point on prevention….

    I look forward to the publication of the studies referred to by Dr Leigh Wilson in the hope that they may have resolved or can shine further light on this issue.

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