Centring equity in emerging public health responses to climate change
This is the second blog in a series that explores the connections between climate change, health equity and public health. Click here to read the first blog in this series.
We look forward to your responses. Feedback, comments or stories from the field can be sent to author Pemma Muzumdar, NCCDH knowledge translation specialist, at firstname.lastname@example.org
Climate change, health equity and public health
Climate change is an urgent public health issue with many implications for health equity. In fact, in a recent conceptual framework from the Pan American Health Organization’s Equity Commission, the state of the climate is specifically named as a structural driver of health equity and a dignified life. This is because the climate, alongside racism, colonization and income, shapes vulnerability and overall opportunities for health. 
The relationship between climate change, health and health equity is explored in a previous blog post ("Climate change and health equity"),  as well as a 2020 curated reading list (Climate change, health equity and public health responses: A curated list). 
Considering equity in emerging public health responses to a changing climate
Today, questions remain about the current state of public health adaptation across Canada. What’s more, to our knowledge, there is no comprehensive synthesis of how health equity is (or is not) being conceptualized and integrated into emerging public health responses.
These responses include conducting climate change and health vulnerability assessments; supporting communities to adapt to climate change; participating in advocacy and policy development; and contributing to the formal research literature on climate change, equity and public health.
Each response is explored below, with specific consideration given to how health equity shows up in and informs this work. Opportunities to better integrate equity into future responses are also identified.
Climate change response 1: Public health organizations are conducting vulnerability and adaptation assessments related to climate change and health.
At a federal level, HealthADAPT, a multi-year program of Health Canada, is funding 10 projects across Canada  with the aim of supporting public health and the health system to prepare for and respond to the impacts of climate change. It’s also worth noting that climate change and health vulnerability assessments have already been published by certain health units in Ontario, including Middlesex-London  in 2014 and Simcoe Muskoka  in 2017. In 2018, the Ontario Public Health Standards were updated to include a Healthy environments and climate change guideline  that specifically names health vulnerability and adaptation assessments as a way to build public health capacity in responding to environmental risks.
Informal learning networks are also emerging at the local and regional level for those conducting health vulnerability and adaptation assessments. For example, representatives from eight — and sometimes more — health units have been meeting regularly to share resources, to discuss ideas and issues related to conducting assessments and to contemplate adaptations that support health.  [a].
Health equity in vulnerability and adaptation assessments
In a 2018 article,  Chris G. Buse, PhD, CIHR Postdoctoral Fellow, Centre for Environmental Assessment Research, University of British Columbia, argues that conducting such assessments can increase the resources directed towards reducing health inequities. This is because identifying and naming inequities, as well as considering how they may be exacerbated by climate change, is embedded into the assessment process. He also underscores that the way health equity is approached within assessments is important. This is because limited framing can lead to equally limited action, such as communicating the risks of climate change to vulnerable populations, rather than taking more upstream action on the root causes of health inequities.
Opportunities to centre health equity in future assessments
Resources for those conducting assessments include a 2013 guidance document from the WHO  and a 2017 Ontario-based toolkit.  The Ontario toolkit includes excellent advice and case studies from multiple Canadian jurisdictions, naming socioeconomic pathways as important drivers of climate change risk. Future guidance, however, could be improved with a stronger health equity focus, including guidance on how to conceptualize health equity within assessments; how to select indicators related to socioeconomic vulnerability and resilience,  and how to engage equitably with Indigenous and Racialized communities as partners and sources of knowledge and expertise. [14,15] The latter is particularly important in describing historical trends, assessing social cohesion and predicting a community’s ability to cope with and recover from climate impacts.
Climate change response 2: Public health is supporting communities to adapt to climate change through, for example, heat action programs.
Several jurisdictions have launched heat action programs. A 2016 report from the Institute for Catastrophic Loss Reduction  captures case examples from several jurisdictions. A 2012 Health Canada guidebook  also documents case examples and offers best practices to the field.
Health equity in heat action programs
In 2019, Montreal’s public health department reported that extreme heat caused 66 deaths between June 30 and July 8, 2018.  Montreal’s reporting on the relationship between deaths and health inequities during this extreme heat event provides a promising example; they specifically named social isolation and low income as a major factor in heat-related deaths. Taking this into account, the city’s 2019 heat response plans centred on engaging with municipal and community partners to target responses to those at highest risk.
Learn more about how Montreal responds to extreme heat, iincluding how it differs from other jurisdictions in tracking heat related deaths:
Opportunities to centre equity in future heat action programs
As promising practices for heat action programs emerge, future support for local public health could include more specific guidance on:
- how to assess and report on the role health inequities play in heat related deaths;
- how to integrate and consider social cohesion within adaptation plans; and
- how to engage socially disadvantaged (e.g., low-income and isolated) communities in program planning and implementation. 
Climate change response 3: Public health associations and related organizations are participating in advocacy and policy development.
In 2019, the Canadian Public Health Association published a position statement  on climate change and human health. Other statements on climate change and health have been released to call Canadian public health practitioners and policy-makers to action. This includes a 2019 collaborative call-to-action from organizations that represent doctors, nurses, medical officers of health and public health professionals across Canada  and a 2019 policy brief from the Lancet Countdown on Health and Climate Change. 
Health equity in policy statements
In the CPHA position statement mentioned above, health equity was an explicit focus in several recommendations. Public health practitioners and policy makers were encouraged to use an equity lens when reporting on climate health impacts; report on how climate change is affecting the health of Indigenous Peoples; integrate health equity impact assessments into policy processes; and conduct research on the physical, mental and health equity implications of a changing climate. 
However, few position statements and policy briefs from other organizations [22,23] have integrated a strong social justice focus within their otherwise excellent recommendations. For example, the Lancet Countdown on Health and Climate Change 2019 Canadian policy brief  does not contain a strong health equity focus. Rather, it explores the concept of intergenerational equity (describing what a child born today will experience in the years to come if carbon emissions are not drastically reduced). In contrast, the United States Lancet countdown policy brief  was written with an explicit health equity focus, with a graphic on page 5 depicting “unequal health vulnerability in a heatwave” through four case examples.
Image: Unequal health vulnerability in a heat wave 
This kind of graphic is a useful tool to bring to decision-makers when communicating about the intersecting factors, including race, income, social class, pre-existing health conditions and age, that influence vulnerability to climate change impacts.
Opportunities to centre equity in future policy statements
Future Canadian policy statements and calls to action could more clearly articulate how already disadvantaged groups are made even more vulnerable by climate change impacts. They could also recommend both universal and targeted policy and practice solutions to improve climate change related health outcomes for all Canadians.
Climate response 4: Researchers are exploring topics related to climate change, equity and public health responses.
Several researchers are contributing to the literature and the knowledge base on topics related to equity, public health and climate change. Contributing to the evidence base in this emerging area is critical. Some examples include:
- Chris G. Buse, PhD, CIHR Postdoctoral Fellow, Centre for Environmental Assessment Research, University of British Columbia
Buse’s research brings an equity lens to understanding and responding to the health impacts of environmental change.  Equity-focused public health practitioners may be particularly interested in his 2015 publication Health equity, population health, and climate change adaptation in Ontario, Canada. 
- Sherilee Harper, Canada Research Chair in Climate Change and Health and Associate Professor in the School of Public Health at the University of Alberta
Harper studies the associations between weather and Indigenous health in the context of climate change. She collaborates with Indigenous partners to prioritize climate-related health actions, planning, interventions and research. Visit her Climate change and global health research group website to learn more. 
- Katie Hayes, lead author for the climate change and mental health chapter for the upcoming National Climate Change Assessment led by Health Canada 
Hayes’ work focuses on climate change, social equity, mental health and public health policy. 
- Corrine Cash, Senior Program Staff, Coady International Institute at St. Francis Xavier University
Cash has a focus on environment, climate change, urban issues and social equity.  Her research relates to how people who live in informal settlements and coastal communities are adapting to a changing climate.
Concrete public health actions to address climate change
A 2018 report from the Office of the Auditor General of Canada  found that actions from governments across Canada are not meeting the needs of the current crisis. This observation validates the tremendous opportunity for public health to mobilize and engage in multisectoral responses to the climate crisis.  Because climate change is an emerging area of Canadian public health practice, there is also opportunity to better conceptualize and embed health equity in responses. [27,34]
The following list attempts to capture a range of concrete public health actions that could be taken in relation to climate change:
- Conduct a climate change health vulnerability and adaptation assessment 
- Contribute to a municipal environmental assessment 
- Collect and report on surveillance data (e.g. on heat-related deaths) 
- Identify and communicate the population health benefits of initiatives that aim to reduce greenhouse gas emissions 
- Participate in healthy built environment initiatives (e.g., greening)
- Plan and implement extreme weather responses (e.g. heat alert and response programs, efforts to weatherize housing)
- Promote positive mental health for eco-anxiety and grief
- Partner with intersectoral and municipal partners, and align strategies for resilient communities 
- Communicate climate-related health risks to the public 
- Work with civil society and advocacy organizations (e.g., public health associations) to advocate for policies at multiple levels to address climate change
Reflecting on actions to address climate change in the context of established public health roles to improve health equity
One approach to addressing climate change and health equity is to reflect on the above actions in the context of the Public health roles for improving health equity framework.  These four roles, well known to the NCCDH audience, are listed in the table below in relation to a range of public health actions to address climate change and health equity.
Public health role 
Actions to address climate change and health equity
Role 1: Assess and report on climate change impacts and health inequities
Conduct vulnerability assessments
Contribute to the knowledge base on public health actions to address climate change and health equity
Collect data on the health impacts of climate change with an equity lens
Role 2: Modify and orient mitigation and adaptation activities to reduce health inequities.
Consider health equity in planning and implementing actions to address climate change
Role 3: Partner and collaborate with others to build climate-resilient communities
Contribute to municipal and regional plans for climate-resilient communities 
Role 4: Participate in policy development related to climate change
Advocate for policies that reduce carbon emissions, contribute to climate resilient communities, and reduce health inequities
Assess the impacts of proposed climate-change policies on populations who experience health inequities 
We want to hear from you!
How is your public health organization addressing the changing climate?
Is the adaptation of the Public health roles for improving health equity framework to climate change action helpful? To what extent is your organization able to implement the actions identified in each of the roles? What supports are required to enable action?
Do you have a practice or policy experience to share related to climate change and health equity?
Questions, comments and practice stories can be sent to Pemma Muzumdar at email@example.com.
Photo credit: Andrew Seaman
[a] Representatives from Durham Region Health Department, Eastern Ontario Health Unit, Haliburton Kawartha Pine Ridge District Health Unit, Hastings Prince Edward District Health Unit, Kingston Frontenac Lennox and Addington Health Unit, Leeds Grenville Lanark District Health Unit, Ottawa Public Health, Peterborough Public Health have been meeting to share updates on their progress in developing adaptation plans. On occasion, others from northern and southwestern Ontario have also joined these meetings (Monique Beneteau, Peterborough Public Health, January 17, 2020).
 Pan American Health Organization. Just societies: health equity and dignified lives. executive summary of the report of the Commission of the Pan American Health Organization on equity and health inequalities in the Americas [Internet]. Washington (DC): PAHO; 2018 [cited 2020 Jan 21]. 285 p. Available from: http://iris.paho.org/xmlui/handle/123456789/51571.
 Muzumdar P. Climate change and health equity [blog on the internet]. Antigonish (NS): National Collaborating Centre for Determinants of Health, St. Francis Xavier University; 2020 [cited 2020 Jan 21]. Available from: http://nccdh.ca/blog/entry/climate-change-and-health-equity.
 National Collaborating Centre for Determinants of Health. Climate change, health equity and public health responses: a curated list [Internet]. Antigonish (NS): NCCDH, St. Francis Xavier University; 2020 [in press]. Available from: https://nccdh.ca/images/uploads/comments/NCCDH-Climate-change-health-equity-public-health-responses-A-curated-list-EN_2020.pdf.
 Austin SE, Ford JD, Berrang-Ford L, Araos M, Parker S, Fleury MD. Public health adaptation to climate change in Canadian jurisdictions. Int J Environ Res Public Health [Internet]. 2015 [cited 2020 Jan 21];12(1), 623-651. Available from https://doi.org/10.3390/ijerph120100623.
 Health Canada. Climate change and health adaptation capacity building program (Health ADAPT)[Internet]. Ottawa (ON): Government of Canada, Health Canada; 2019 [cited 2020 Jan 21]; [about 7 screens]. Available from: https://www.canada.ca/en/health-canada/news/2019/04/backgrounder-climate-change-and-health-adaptation-capacity-building-program-healthadapt.html.
 Middlesex-London Health Unit. Climate change [Internet]. [location unknown]: Middlesex-London health Unit; 2014, updated 2019 [cited 2020 Jan 21]; [about 3 screens]. Available from: https://www.healthunit.com/climate-change.
 Levison M, Whelan M, Butler A. A changing climate: assessing health impacts and vulnerabilities due to climate change within Simcoe Muskoka [Internet]. [location unknown]: Simcoe Muskoka District Health Unit; 2017 [cited 2020 Jan 21]. 174 p. Available from: http://health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Healthy_Environments_and_Climate_Change_Guideline_2018_en.pdf.
 Ministry of Health and Long-Term Care, Population and Public Health Division. Healthy environments and climate change guidelines [Internet]. Toronto (ON): MOHLTC; 2018 [cited 2020 Jan 21]. 9 p. Available from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Healthy_Environments_and_Climate_Change_Guideline_2018_en.pdf.
 Beneteau M (Peterborough Public Health, Ontario, Canada). Eastern Ontario climate change and health community of practice [Internet]. Message to Pemma Muzumdar (NCCDH). 2020 Jan 17 [cited 2020 Jan 21].
 Buse CG. Why should Canadian public health agencies conduct climate change and health vulnerability assessments? Can J Public Health. 2018;109(5):782-785.
 World Health Organization. Protecting health from climate change: vulnerability and adaptation assessment [Internet]. Geneva: WHO; 2013 [cited 2020 Jan 14]. 62 p. Available from: https://apps.who.int/iris/handle/10665/104200.
 Ebi K, Anderson V, Berry P, Paterson J, Yusa A. Ontario climate change and health toolkit [Internet]. Toronto (ON): Ministry of Health and Long-Term Care; 2016 [cited 2020 Jan 14]. 168 p. Available from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/climate_change_toolkit/climate_change_toolkit.pdf.
 Raval A, Asian Pacific Environmental Network, Chen T, Shah P. Mapping resilience: a blueprint for thriving in the face of climate disasters [Internet]. [location unknown]: APEN; 2019 [cited 2020 Jan 30]. 91 p. Available from: http://apen4ej.org/mapping-resilience/.
 Yuen T, Yurkovich E, Grabowski L, Altshuler B. Guide to equitable, community-driven climate preparedness planning [Internet]. [location unknown]: Urban Sustainability Directors Network; 2017 [cited 2020 Jan 14]. 67 p. Available from: https://www.usdn.org/products-climate.html.
 Levison MM, Butler AJ, Rebellato S, Armstrong B, Whelan M, Gardner C. Development of a climate change vulnerability assessment using a public health lens to determine local health vulnerabilities: An Ontario health unit experience. Int J Environ Res Public Health. 2018;15(10):2237.
 Guilbault S, Kovacs P, Berry P, Richardson GRA, editors. Cities adapt to extreme heat: celebrating local leadership [Internet]. Toronto (ON): Institute for Catastrophic Loss Reduction; 2016 [cited 2020 Jan 14]. 110 p. Available from: https://www.iclr.org/wp-content/uploads/PDFS/cities-adapt-to-extreme-heat.pdf.
 Kaiser D, Roy M, Racine-Hamel S.-É. Vague de chaleur été 2018 à Montréal : enquête épidémiologique [Internet]. Montréal (QC). Direction régionale de santé publique du CIUSSS du Centre-Sud-de-l’Île-de-Montréal [cited 2020 Jan 21]. 32 p. Available from: https://santemontreal.qc.ca/fileadmin/user_upload/Uploads/tx_asssmpublications/pdf/publications/Enquete_epidemiologique_-_Vague_de_chaleur_a_l_ete_2018_a_Montreal_version15mai_EUSHV_finale.pdf.
 Centre intégré universitaire de santé et des services sociaux du Centre-Sud-de-L’Île-de-Montréal. Chaleur accablante et extrême 2019 plan régional de prévention et de protection et guide à l’intention des établissements de santé [Internet]. Montréal (QC): Gouvernement du Québec; 2019 [cited 2020 Jan 21]. 108 p. Available from: https://ciusss-centresudmtl.gouv.qc.ca/sites/ciussscsmtl/files/media/document/2019_PlanChaleurAccablanteExtreme.pdf.
 Oved MC. Life and death under the dome [Internet]. Toronto (ON): The Star; 2019 [cited 2020 Jan 21]; [about 60 screens]. Available from: https://projects.thestar.com/climate-change-canada/quebec/.
 Baussan D. Social cohesion: the secret weapon in the fight for equitable climate resilience [Internet]. Washington (DC): Center for American Progress; 2015 [cited 2020 Jan 21]. Available from: https://www.americanprogress.org/issues/green/reports/2015/05/11/112873/social-cohesion-the-secret-weapon-in-the-fight-for-equitable-climate-resilience/.
 Canadian Public Health Association. Climate change and human health [Internet]. Ottawa (ON): CPHA; 2019 [cited 2020 Jan 12]. 12 p. Available from: https://www.cpha.ca/climate-change-and-human-health.
 Perrotta K, Howard C, Canadian Medical Association, Canadian Nurses Association, Urban Public Health Network, Canadian Public Health Association. Call to action on climate change and health [Internet]. Toronto (ON): Canadian Association of Physicians for the Environment; 2019 [cited 2020 Jan 21]. 5 p. Available from: https://cape.ca/wp-content/uploads/2019/12/Call-to-Action-ENGLISH-Dec-2019.pdf.
 Howard C, Buse C, Rose C, MacNeill A, Parkes M. The Lancet countdown on health and climate change: policy brief for Canada [Internet]. Lancet Countdown, CMA, CPHA: 2019 [cited 2020 Jan 12]. 8 p. Available from: https://storage.googleapis.com/lancet-countdown/2019/11/Lancet-Countdown_Policy-brief-for-Canada_FINAL.pdf.
 Salas RN, Knappenberger P, Hess JJ. Lancet countdown 2019: 2019 Lancet countdown on health and climate change policy brief for the United States of America [Internet]. London (UK): American Public Health Association; 2019 [cited 2020 Jan 12]. 11 p. Available from: https://www.lancetcountdownus.org/2019-lancet-countdown-us-brief.
 Salas RN, Knappenberger P, Hess JJ. Lancet countdown 2019: 2019 Lancet countdown on health and climate change policy brief for the United States of America [Internet]. London (UK): American Public Health Association; 2019. Figure 1, Unequal health vulnerability in a heatwave; [cited 2020 Jan 12]. p. 5. Available from: https://www.lancetcountdownus.org/2019-lancet-countdown-us-brief.
 Ecohealth knowledge to action research group[Internet]. Prince George (BC): University of Northern British Columbia; [date unknown, cited 2020 Jan 21]; [about 34 screens]. Available from: https://ecohealthkta.net/chris-buse/.
 Buse CG. Health equity, population health, and climate change adaptation in Ontario, Canada [Internet]. Health Tomorrow. 2015;3(1):26-51 [cited 2020 Jan 12]. Available from: https://ht.journals.yorku.ca/index.php/ht/article/view/40177.Buse CG. Health equity, population health, and climate change adaptation in Ontario, Canada [Internet]. Health Tomorrow. 2015;3(1):26-51 [cited 2020 Jan 12]. Available from: https://ht.journals.yorku.ca/index.php/ht/article/view/40177.
 Meet our team: climates change and global health research group [Internet]. Edmonton (AB): University of Alberta; [date unknown, cited 2020 Jan 21]; [about 34 screens]. Available from: https://www.climatechangeandglobalhealth.com/team-1.
 Natural Resources Canada. Health of Canadians in a changing climate [Internet]. Ottawa (ON): Government of Canada, Natural Resources Canada; 2019 [cited 2020 Jan 21]; [about 11 screens]. Available from: https://www.nrcan.gc.ca/maps-tools-and-publications/publications/climate-change-publications/canada-changing-climate-reports/health-canadians-changing-climate/21189.
 Corrine Cash [Internet]. Antigonish (NS): Coady International Institute, St. Francis Xavier University; c2020 [cited 2020 Jan 21]; [about 2 screens]. Available from: https://coady.stfx.ca/corrine-cash/.
 Auditors General of Canada. Perspectives on climate change action in Canada [Internet]. [location unknown]: Auditor General of Canada; 2018 [cited 2020 Jan 21]. 39 p. Available from: http://publications.gc.ca/collections/collection_2018/bvg-oag/FA3-137-2018-eng.pdf.
 Buse C. Intersectoral action for health equity as it relates to climate change in Canada: contributions from critical systems heuristics. J of Eval Clin Pract. 2013;19(6):1050-1054.
 Buse CG, Poland B, Wong J, Haluza-Delay R. ‘We’re all brave pioneers on this road’: a Bourdieusian analysis of field creation for public health adaptation to climate change in Ontario, Canada. Crit Public Health. 2019.
 Ontario Public Health Association. Public health and environmental assessments [Internet]. Toronto (ON): OPHA; [date unknown, cited 2020 Jan 21]. 27 p. Available from: https://opha.on.ca/getmedia/621adf7e-529d-4ecd-9006-54d9708d7079/Survey-Report-Public-Health%C3%A2%E2%82%AC%E2%84%A2s-Engagement-in-Environmental-Assessments.pdf.aspx.
 planH. Climate action and public health [Internet]. Victoria (BC): BC Healthy Communities Society; [date unknown, cited 2020 Jan 21]; [about 7 screens]. Available from: https://planh.ca/take-action/healthy-environments/natural-environments/page/climate-action-public-health.
 National Collaborating Centre for Determinants of Health. Let’s talk: public health roles for improving health equity [Internet]. Antigonish (NS): NCCDH, St. Francis Xavier University; 2013 [cited 2020 Jan 21]. 6 p. Available from: http://nccdh.ca/resources/entry/lets-talk-public-health-roles.
 Zupancic T, Westmacott C. Working with local governments to support health equity through the built environment: a scoping review [Internet]. Vancouver (BC): BC Centre for Disease Control; 2016 [cited 2020 Jan 21]. 81 p. Available from: http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/EH/Equity%20BE%20Scoping%20Review.pdf.
 Adaptation Clearinghouse. Guide to equitable, community-driven climate preparedness planning [Internet]. [location unknown]: Adaptation Clearinghouse; c2011 [cited 2020 Jan 21]; [about 6 screens]. Available from: https://www.adaptationclearinghouse.org/resources/guide-to-equitable-community-driven-climate-preparedness-planning.html.
 Inuit Tapiriit Kanatami. National Inuit Climate Change Strategy [Internet]. Ottawa (ON): Inuit Tapiriit Kanatami; 2019 [cited 2020 Jan 14]. Available from: https://www.itk.ca/national-inuit-climate-change-strategy/resources/.