9

Populations of Concern

9.1 Introduction

  • Janet L. Gamble
    U.S. Environmental Protection Agency
  • John Balbus
    National Institutes of Health
  • Martha Berger
    U.S. Environmental Protection Agency
  • Karen Bouye
    Centers for Disease Control and Prevention
  • Vince Campbell
    Centers for Disease Control and Prevention
  • Karletta Chief
    The University of Arizona
  • Kathryn Conlon
    Centers for Disease Control and Prevention
  • Allison Crimmins
    U.S. Environmental Protection Agency
  • Barry Flanagan
    Centers for Disease Control and Prevention
  • Cristina Marie Gonzalez-Maddux
    Institute for Tribal Environmental Professionals
  • Elaine Hallisey
    Centers for Disease Control and Prevention
  • Sonja Hutchins
    Centers for Disease Control and Prevention
  • Lesley Jantarasami
    U.S. Environmental Protection Agency
  • Samar Khoury
    Association of Schools and Programs of Public Health
  • Max Kiefer
    Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health
  • Jessica Kolling
    Centers for Disease Control and Prevention
  • Kathy Lynn
    University of Oregon
  • Arie Ponce Manangan
    Centers for Disease Control and Prevention
  • Marian McDonald
    Centers for Disease Control and Prevention
  • Rachel Morello-Frosch
    University of California, Berkeley
  • Margaret Hiza Redsteer
    U.S. Geological Survey
  • Perry E. Sheffield
    Icahn School of Medicine at Mount Sinai
  • Kimberly Thigpen Tart
    National Institutes of Health
  • Joanna Watson
    Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health
  • Kyle Powys Whyte
    Michigan State University
  • Amy F. Wolkin
    Centers for Disease Control and Prevention

Climate change is already causing and is expected to continue to cause a range of health impacts that vary across different population groups in the United States. The vulnerability of any given group is a function of its sensitivity to climate change related health risks, its exposure to those risks, and its capacity for responding to or coping with climate variability and change. Vulnerable groups of people, described here as populations of concern, include those with low income, some communities of color, immigrant groups (including those with limited English proficiency), Indigenous peoples, children and pregnant women, older adults, vulnerable occupational groups, persons with disabilities, and persons with preexisting or chronic medical conditions. Planners and public health officials, politicians and physicians, scientists and social service providers are tasked with understanding and responding to the health impacts of climate change. Collectively, their characterization of vulnerability should consider how populations of concern experience disproportionate, multiple, and complex risks to their health and well-being in response to climate change.

People in food line

Food is distributed to people in need at Catholic Community Service in Wheaton, MD, November 23, 2010. Populations of concern experience disproportionate, multiple, and complex risks to their health and well-being in response to climate change.

Some groups face a number of stressors related to both climate and non-climate factors. For example, people living in impoverished urban or isolated rural areas, floodplains, coastlines, and other at-risk locations are more vulnerable not only to extreme weather and persistent climate change but also to social and economic stressors. Many of these stressors can occur simultaneously or consecutively. Over time, this “accumulation” of multiple, complex stressors is expected to become more evident1 as climate impacts interact with stressors associated with existing mental and physical health conditions and with other socioeconomic and demographic factors.


9.2 A Framework for Understanding Vulnerability

Some populations of concern demonstrate relatively greater vulnerability to the health impacts of climate change. The definitions of the following key concepts are important to understand how some people or communities are disproportionately affected by climate-related health risks (Figure 9.1). Definitions are adapted from the Intergovernmental Panel on Climate Change (IPCC) and the National Research Council (NRC).2,3

 

Figure 9.1: Determinants of Vulnerability

Figure 9.1: Determinants of Vulnerability
Defining the determinants of vulnerability to health impacts associated with climate change, including exposure, sensitivity, and adaptive capacity. (Figure source: adapted from Turner et al. 2003)23
  • Vulnerability is the tendency or predisposition to be adversely affected by climate-related health effects, and encompasses three elements: exposure, sensitivity or susceptibility to harm, and the capacity to adapt to or to cope with change. Exposure is contact between a person and one or more biological, chemical, or physical stressors, including stressors affected by climate change. Contact may occur in a single instance or repeatedly over time, and may occur in one location or over a wider geographic area. Sensitivity is the degree to which people or communities are affected, either adversely or beneficially, by climate variability and change. Adaptive capacity is the ability of communities, institutions, or people to adjust to potential hazards, to take advantage of opportunities, or to respond to consequences. A related term, resilience, is the ability to prepare and plan for, absorb, recover from, and more successfully adapt to adverse events. People and communities with strong adaptive capacity have greater resilience.
  • Risk is the potential for consequences to develop where something of value (such as human health) is at stake and where the outcome is uncertain. Risk is often represented as the probability of the occurrence of a hazardous event multiplied by the expected severity of the impacts of that event.
  • Stressors are events or trends, whether related to climate change or other factors, that increase vulnerability to health effects.
 

Figure 9.2: Intersection of Social Determinants of Health and Vulnerability

Figure 9.2: Intersection of Social Determinants of Health and Vulnerability

VIEW
Social determinants of health interact with the three elements of vulnerability. The left side boxes provide examples of social determinants of health associated with each of the elements of vulnerability. Increased exposure, increased sensitivity and reduced adaptive capacity all affect vulnerability at different points in the causal chain from climate drivers to health outcomes (middle boxes). Adaptive capacity can influence exposure and sensitivity and also can influence the resilience of individuals or populations experiencing health impacts by influencing access to care and preventive services. The right side boxes provide illustrative examples of the implications of social determinants on increased exposure, increased sensitivity, and reduced adaptive capacity.

People or communities can have greater or lesser vulnerability to health risks depending on social, political, and economic factors that are collectively known as social determinants of health.4 Some groups are disproportionately disadvantaged by social determinants of health that limit resources and opportunities for health-promoting behaviors and conditions of daily life, such as living/working circumstances and access to healthcare services.4 In disadvantaged groups, social determinants of health interact with the three elements of vulnerability by contributing to increased exposure, increased sensitivity, and reduced adaptive capacity (Figure 9.2). Health risks and vulnerability may increase in locations or instances where combinations of social determinants of health that amplify health threats occur simultaneously or close in time or space.5,6 For example, people with limited economic resources living in areas with deteriorating infrastructure are more likely to experience disproportionate impacts and are less able to recover following extreme events,7,8 increasing their vulnerability to climate-related health effects. Understanding the role of social determinants of health can help characterize climate change impacts and identify public health interventions or actions to reduce or prevent exposures in populations of concern.5,6,9

Factors that Contribute to Exposure

Exposures to climate-related variability and change are determined by a range of factors that individually and collectively shape the nature and extent of exposures. These factors include:

  • Occupation: Certain occupations have a greater risk of exposure to climate impacts. People working outdoors or performing duties that expose them to extreme weather, such as emergency responders, utility repair crews, farm workers, construction workers, and other outdoor laborers, are at particular risk.10
  • Time spent in risk-prone locations: Where a person lives, goes to school, works, or spends leisure time will contribute to exposure. Locations with greater health threats include urban areas (due to, for example, the “heat island” effect or air quality concerns), areas where airborne allergens and other air pollutants occur at levels that aggravate respiratory illnesses, communities experiencing depleted water supplies or vulnerable energy and transportation infrastructure, coastal and other flood-prone areas, and locations affected by drought and wildfire.11,12,13
  • Responses to extreme events: A person’s ability or, in some cases, their choice whether to evacuate or shelter-in-place in response to an extreme event such as a hurricane, flood, or wildfire affects their exposure to health threats. Low-income populations are generally less likely to evacuate in response to a warning (see Ch. 4: Extreme Events).7
  • Socioeconomic status: Persons living in poverty are more likely to be exposed to extreme heat and air pollution.14,15 Poverty also determines, at least in part, how people perceive the risks to which they are exposed, how they respond to evacuation orders and other emergency warnings, and their ability to evacuate or relocate to a less risk-prone location (see Ch. 8: Mental Health).7
  • Infrastructure condition and access: Older buildings may expose occupants to increased indoor air pollutants and mold, stagnant airflow, or high indoor temperatures (see Ch. 3: Air Quality Impacts). Persons preparing for or responding to flooding, wildfires, or other weather-related emergencies may be hampered by disruption to transportation, utilities, medical, or communication infrastructure. Lack of access to these resources, in either urban or rural settings, can increase a person’s vulnerability (see Ch. 4: Extreme Events).16,17
  • Compromised mobility, cognitive function, and other mental or behavioral factors: These factors can lead to increased exposure to climate-related health impacts if people are not aware of health threats or are unable to take actions to avoid, limit, or respond to risks.18 People with access and functional needs may be particularly at risk if these factors interfere with their ability to access or receive medical care before, during, or after a disaster or emergency.

Characterizing Biological Sensitivity

The sensitivity of human communities and individuals to climate change stressors is determined, at least in part, by biological traits. Among those traits are the overall health status, age, and life stage. From fetus, to infant, to toddler, to child, to adolescent, to adult, to the elderly, persons at every life stage have varying sensitivity to climate change impacts.11,19,20 For instance, the relatively immature immune systems of very young children make them more sensitive to aeroallergen exposure (such as airborne pollens). In addition to life stage, people experiencing long-term chronic medical and/or psychological conditions are more sensitive to climate stressors. Persons with asthma or chronic obstructive pulmonary disease (COPD) are more sensitive to exposures to wildfire smoke and other respiratory irritants. Social and economic factors also affect disparities in the prevalence of chronic medical conditions that aggravate biological sensitivity.21,22

Adaptive Capacity and Response to Climate Change

Many of the same factors that contribute to exposure or sensitivity also influence the ability of both individuals and communities to adapt to climate variability and change. Socioeconomic status, the condition and accessibility of infrastructure, the accessibility of health care, certain demographic characteristics, human and social capital (the skills, knowledge, experience, and social cohesion of a community), and other institutional resources all contribute to the timeliness and effectiveness of adaptive capacity (see Ch. 1: Introduction and Ch. 4: Extreme Events).


9.3 Populations of Concern

Communities of Color, Low Income, Immigrants, and Limited English Proficiency Groups

Nurse and migrant worker

Nursing students and faculty at Emory University School of Nursing in Atlanta, Georgia volunteering to give checkups in migrant workers’ camps, June 12, 2006.

In the United States, some communities of color, low-income groups, people with limited English proficiency (LEP), and certain immigrant groups (especially those who are undocumented) live with many of the factors that contribute to their vulnerability to the health impacts of climate change (see Section 9.2). These populations are at increased risk of exposure given their higher likelihood of living in risk-prone areas (such as urban heat islands, isolated rural areas, or coastal and other flood-prone areas), areas with older or poorly maintained infrastructure, or areas with an increased burden of air pollution.24,25,26,27 These groups of people also experience relatively greater incidence of chronic medical conditions, such as cardiovascular and kidney disease, diabetes, asthma, and COPD,28,29,30 which can be exacerbated by climate-related health impacts.24,31,32,33,34 Socioeconomic and educational factors, limited transportation, limited access to health education, and social isolation related to language deficiencies collectively impede their ability to prepare for, respond to, and cope with climate-related health risks.24,26,34,35,36,37,38,39,40,41 These populations also may have limited access to medical care and may not be able to afford medications or other treatments.30,38 For LEP and undocumented persons, high poverty rates, language and cultural barriers, and citizenship status limit access to and use of health care and other social services and make these groups more hesitant to seek out help that might compromise their immigration status in the United States.39,42,43,44,45,46

The number of people of color in the United States who may be affected by heightened vulnerability to climate-related health risks will continue to grow. Currently, Hispanics or Latinos, Blacks or African Americans, American Indians and Alaska Natives, Asian Americans, and Native Hawaiians and Pacific Islanders represent 37% of the total U.S. population.47,48 By 2042, they are projected to become the majority.49 People of color already constitute the majority in four states (California, Hawaii, New Mexico, and Texas) and in many cities.48 Numbers of LEP and undocumented immigrant populations have also increased. In 2011, LEP groups comprised approximately 9% (25.3 million individuals) of the U.S. population aged five and older.50 In 2010, approximately 11.2 million people in the United States were undocumented.51

Vulnerability to Climate-Related Health Stressors

Key climate impacts for some communities of color and low-income, LEP, and immigrant populations include heat waves, other extreme weather events, poor air quality, food safety, infectious diseases, and psychological stressors.

Race is an important factor in vulnerability to climate-related stress, but it can be difficult to isolate the role of race from other related socioeconomic and geographic factors. Some racial minorities are also members of low-income groups, immigrants, and people with limited English proficiency, and it is their socioeconomic status (SES) that contributes most directly to their vulnerability to climate change-related stressors. SES is a measure of a person’s economic and social status, often defined by income, education, and occupation. Additional factors such as age, gender, preexisting medical conditions, psychosocial factors, and physical and mental stress are also associated with vulnerability to climate change. Because many of these variables are highly related to one another, statistical models must account for these factors in order to accurately measure the relative importance of various risk factors.52,53 For instance, minority race and low SES are jointly linked to increased prevalence of underlying health conditions that may affect sensitivity to climate change. When adjusted for age, gender, and level of education, the number of potential life-years lost from all causes of death was found to be 35% greater for Blacks than for Whites in the United States,54 indicating an independent effect of race.

Extreme heat events. Some communities of color and some low-income, homeless, and immigrant populations are more exposed to heat waves,55,56 as these groups often reside in urban areas affected by heat island effects.12,14,24,57 In addition, these populations are likely to have limited adaptive capacity due to a lack of adequately insulated housing, inability to afford or to use air conditioning, inadequate access to public shelters such as cooling centers, and inadequate access to both routine and emergency health care.24,26,29,34,35,38 These social, economic, and health risk factors give rise to the observed increase in deaths and disease from extreme heat in some immigrant and impoverished communities.24,32,33 Elevated risks for mortality associated with exposures to high ambient temperatures are also reported for Blacks as compared to Whites,32,40,58,59 a finding that persists once air conditioning use is accounted for (see also Ch. 2: Temperature-Related Death and Illness).60

Other weather extremes. As observed during and after Hurricane Katrina and Hurricane/Post-Tropical Cyclone Sandy, some communities of color and low-income people experienced increased illness or injury, death, or displacement due to poor-quality housing, lack of access to emergency communications, lack of access to transportation, inadequate access to health care services and medications, limited post-disaster employment, and limited or no health and property insurance.61,62,63,64,65,66 Following a 2006 flood in El Paso, Texas, Hispanic ethnicity was identified as a significant risk factor for adverse health effects after controlling for other important socioeconomic factors (for example, age and housing quality).67 Adaptation measures to address these risk factors—such as providing transportation during evacuations or targeted employment assistance during the recovery phase—may help reduce or eliminate these health impact disparities, but may not be readily available or affordable (see also Ch. 4: Extreme Events).61,62,63,65,66

Degraded air quality. Climate change impacts on outdoor air quality will increase exposure in urban areas where large proportions of minority, low-income, homeless, and immigrant populations reside. Fine particulate matter and ozone levels already exceed National Ambient Air Quality Standards in many urban areas.26,27,68,69 Given the relatively higher rates of cardiovascular and respiratory diseases in low-income urban populations,26,28,30 these populations are more sensitive to degraded air quality, resulting in increases in illness, hospitalization, and premature death.70,71,72,73,74,75,76,77,78 In addition, climate change can contribute to increases in aeroallergens, which exacerbate asthma, an illness that is relatively more common among some communities of color and low-income groups. People of color are especially impacted by air pollution due to both disproportionate exposures for persons living in urban areas as well as higher prevalence of underlying diseases, such as asthma and COPD, which increase their inherent sensitivity. In 2000, the prevalence of asthma was 122 per 1,000 Black persons and 104 per 1,000 White persons in the United States. At that time, asthma mortality was approximately three times higher among Blacks as compared to Whites (see also Ch. 1: Introduction; Ch. 3: Air Quality Impacts).59

Waterborne and vector-borne diseases. Climate change is expected to increase exposure to waterborne pathogens that cause a variety of illnesses—most commonly gastrointestinal illness and diarrhea (see also Ch. 6: Water-Related Illness). Health risks increase in crowded shelter conditions following floods or hurricanes,79 which suggests that some low-income groups living in crowded housing (particularly prevalent among foreign-born or Hispanic populations)80 may face increased exposure risk. Substandard or deteriorating water infrastructure (including sewerage, drainage, and storm water systems, and drinking water systems) in both urban and rural low-income areas also contribute to increased risk of exposure to waterborne pathogens.81,82 Low-income populations in some regions may also be more vulnerable to the changes in the distribution of some vector-borne diseases that are expected to result from climate change. For example, higher incidence of West Nile virus disease has been linked to poverty and to urban location in the southeastern and northeastern United States, respectively (see also Ch. 5: Vector-Borne Diseases).83,84

Food safety and security. Climate change affects food safety and is projected to reduce the nutrient and protein content of some crops, like wheat and rice. Some communities of color and low-income populations are more likely to be affected because they spend a relatively larger portion of their household income on food compared to more affluent households. These groups often suffer from poor-quality diets and limited access to full-service grocery stores that offer healthy and affordable dietary choices (see also Ch. 7: Food Safety).36,37,85,86

Psychological stress. Some communities of color, low-income populations, immigrants, and LEP groups are more likely to experience stress-related mental health impacts, particularly during and after extreme events. Other contributing factors include barriers in accessing and affording mental health care, such as counseling in native languages, and the availability and affordability of appropriate medications (see also Ch. 8: Mental Health).87,88

Indigenous Peoples in the United States

A number of health risks are higher among Indigenous populations, such as poor mental health related to historical or personal trauma, alcohol abuse, suicide, infant/child mortality, environmental exposures from pollutants or toxic substances, and diabetes caused by inadequate or improper diets.89,90,91,92,93,94,95,96 Because of existing vulnerabilities, Indigenous people, especially those who are dependent on the environment for sustenance or who live in geographically isolated or impoverished communities, are likely to experience greater exposure and lower resilience to climate-related health effects. Indigenous Arctic communities have already experienced difficulty adapting to climate change effects such as reductions in sea ice thickness, thawing permafrost, increases in coastal erosion97,98,99,100 and landslide frequency,101 alterations in the ranges of some fish,102 increased weather unpredictability,103 and northward advance of the tree line.104 These climate changes have disrupted traditional hunting and subsistence practices and may threaten infrastructure such as the condition of housing, transportation, and pipelines,103 which ultimately may force relocation of villages.105

Food safety and security. Examples of how climate changes can affect the health of Indigenous peoples include changes in the abundance and nutrient content of certain foodstuffs, such as berries for Alaska Native communities;106 declining moose populations in Minnesota, which are significant to many Ojibwe peoples and an important source of dietary protein;107,108 rising temperatures and lack of available water for farming among Navajo people;109 and declines in traditional rice harvests among the Ojibwe in the Upper Great Lakes region.110 Traditional foods and livelihoods are embedded in Indigenous cultural beliefs and subsistence practices.111,112,113,114,115,116,117 Climate impacts on traditional foods may result in poor nutrition and increased obesity and diabetes.118

Changes in aquatic habitats and species also affect subsistence fishing.119 Rising temperatures affect water quality and availability. Lower oxygen levels in freshwater and seawater degrade water quality and promote the growth of disease-causing bacteria, viruses, and parasites.120 Warming can exacerbate shellfish disease and make mercury more readily absorbed in fish tissue. Elevated sea surface temperatures, consistent with projected trends in climate warming, have been associated with increased accumulation of methylmercury in fish and increased human exposure.121 Mercury is a neurotoxin that adversely affects people at all life stages, particularly during the prenatal stage (see also Ch. 6: Water-Related Illness; Ch. 7: Food Safety).121,122,123 In addition, oceans are becoming more acidic as they absorb some of the carbon dioxide (CO2) added to the atmosphere by fossil fuel burning and other sources, and this change in acidity can lower shellfish survival.120 This affects Indigenous peoples on the West and Gulf Coasts and Alaska Natives whose livelihoods depend on shellfish harvests.124 Rising sea levels will also destroy fresh and saltwater habitats that some Indigenous peoples located along the Gulf Coast rely upon for subsistence food.125

Indigenous deckhand

Indigenous deckhand pulls in net of geoducks near Suquamish, Washington, January 17, 2007. Traditional foods and livelihoods are embedded in Indigenous cultural beliefs and subsistence practices.

Water security. Indigenous peoples may lack access to water resources and to adequate infrastructure for water treatment and supply. A significant number of Indigenous persons living on remote reservations lack indoor plumbing and rely on unregulated water supplies that are vulnerable to drought, changes in water quality, and contamination of water in local systems.109,126 Existing infrastructure may be poorly maintained or in need of significant and costly upgrades.127 Heavy rainfall events and warm temperatures have been linked to diarrheal outbreaks and bacterial contamination of drinking water sources (see Ch. 6: Water-Related Illness). Acute diarrheal disease has been shown to disproportionately affect children on the Fort Apache reservation in Arizona,128 and result in higher overall hospitalization rates for American Indian/Alaska Native infants.129 Increased extreme precipitation and potential increases in cyanobacterial blooms (see Ch. 6: Water-Related Illness) are also expected to stress existing water infrastructure on tribal lands and increase exposure to waterborne pathogens.122,130

Loss of cultural identity. Climate change threatens sacred ceremonial and cultural practices through changing the availability of culturally relevant plant and animal species.95,130 Climate-related threats may compound historical impacts associated with colonialism, as well as current effects on tribal culture as more young people leave reservations for education and employment opportunities. Loss of tribal territory and disruption of cultural resources and traditional ways of life131,132 lead to loss of cultural identity.133,134,135 The loss of medicinal plants due to climate change may leave ceremonial and traditional practitioners without the resources they need to practice traditional healing.114,136 The relocation of young people may reduce interactions across generations and undermine the sharing of traditional knowledge, tribal lore, and oral history.137,138

Degraded infrastructure and other impacts. Rising temperatures may damage transportation infrastructure on tribal lands. Changing ice or thawing permafrost, flooding, and drought-related dust storms may block roads and cut off communities from access to evacuation routes and emergency medical care or social services.139 Poor air quality from blowing dust affects southwestern Indigenous communities, particularly in Arizona and New Mexico, and is likely to worsen with drought conditions.140 Exposure to impaired air quality also affects Indigenous communities, especially those downwind from urban areas or industrial complexes.

Children and Pregnant Women

Pregnant woman

Climate-related exposures may lead to adverse pregnancy and newborn health outcomes.

Children are vulnerable to adverse health effects associated with environmental exposures due to factors related to their immature physiology and metabolism, their unique exposure pathways, their biological sensitivities, and limits to their adaptive capacity. Children pass through a series of windows of vulnerability that begin in the womb and continue through their second decade of life. Children have a proportionately higher intake of air, food, and water relative to their body weight compared to adults.19 They also share unique behaviors and interactions with their environment that may increase their exposure to environmental contaminants. For example, small children often play indoors on the floor or outdoors on the ground and place hands and other objects in their mouths, increasing their exposure to dust and other contaminants, such as pesticides, mold spores, and allergens.141 There is, however, large variation in vulnerability among children at different life stages due to differing physiology and behaviors (Figure 9.3). Climate change—interacting with factors such as economic status, diet, living situation, and stage of development—will increase children’s exposure to health threats.11,20,142,143,144 The impact of poverty on children’s health is a critical factor to consider in ascertaining how climate change will be manifest in children. Poor and low-income households have difficulty accessing health care and meeting the basic needs that are crucial for healthy child development. In addition, children in poverty are less likely to have access to air conditioning to mitigate the effects of extreme heat. Children living in poverty are also less likely to be able to respond to or escape from extreme weather events.11,20,142,143,144

 

Figure 9.3: Vulnerability to the Health Impacts of Climate Change at Different Life Stages

Figure 9.3: Vulnerability to the Health Impacts of Climate Change at Different Life Stages
Children’s vulnerability to climate change results from distinct exposures, biological sensitivities (developing bodies and immune systems), and limitations to adaptive capacity (dependency on caregivers) at different life stages.

Vulnerability to Climate-Related Health Stressors

Extreme heat events. An increase in the frequency and intensity of extreme heat events (see Ch. 2: Temperature-Related Death and Illness) will affect children who spend time outdoors or in non-climate-controlled indoor settings. Student athletes and other children who are susceptible to heat-related illnesses when they exercise or play outdoors in hot and humid weather may be poorly acclimated to physical exertion in the heat. Some 9,000 high school athletes in the United States are treated for exertional heat illness (such as heat stroke and muscle cramps) each year, with the greatest risk among high school football players.145,146 This appears to be a worsening trend. Between 1997 and 2006, emergency department visits for all heat-related illness increased 133% and youth made up almost 50% of those cases.147 From 2000 through 2013, the number of deaths due to heat stroke doubled among U.S. high school and college football players.148 Other data show effects of extreme heat on children of all ages, including increases in heat illness, fluid and electrolyte imbalances, and asthma. Children in homes or schools without air conditioning are also more vulnerable during heat events.

Other weather extremes. Climate change is likely to affect the mental health and well-being of children, primarily by increasing exposure to traumatic weather events that result in injury, death, or displacement. In 2003, more than 10% of U.S. children from infancy to 18 years of age reported experiencing a disaster (fire, tornado, flood, hurricane, earthquake, etc.) during their lifetimes.149 Exposures to traumatic events can impact children’s capacity to regulate emotions, undermine cognitive development and academic performance, and contribute to post-traumatic stress disorder (PTSD) and other psychiatric disorders (such as depression, anxiety, phobia, and panic).150 Children’s ability to cope with disasters is affected by factors such as socioeconomic status, available support systems, and timeliness of treatment. Negative mental health effects in children, if untreated, can extend into adulthood.150 (See Ch. 4: Extreme Events; Ch. 8: Mental Health).

Degraded air quality. Several factors make children more sensitive to the effects of respiratory hazards, including lung development that continues through adolescence, the size of the child’s airways, their level of physical activity, and body weight. Climate change has the potential to affect future ground-level ozone concentrations, particulate matter concentrations, and levels of some aeroallergens. Ground-level ozone and particulate matter are associated with increases in asthma episodes and other adverse respiratory effects in children.151,152,153 Nearly seven million, or about 9%, of children in the United States, suffer from asthma.154 Asthma accounts for 10 million missed school days each year.155 Particulate matter such as dust and emissions from coal-fired electricity generation plants is also associated with decreases in lung maturation in children.156

Changes in climate also contribute to longer, more severe pollen seasons that may be associated with increases in childhood asthma episodes and other allergic illnesses. Children may also be exposed to indoor air pollutants, including both particulate matter originating outdoors and indoor sources such as tobacco smoke and mold. In addition, high outdoor temperatures may increase the amount of time children spend indoors. Homes, childcare centers, and schools—places where children spend large amounts of their time—are all settings where indoor air quality issues may affect children’s health. In communities where these buildings are insufficiently supplied with screens, air conditioning, humidity controls, or pest control, children’s health may be at risk.157 (See Ch. 3: Air Quality Impacts).

Waterborne illnesses. Climate change induced increases in heavy rainfall, flooding, and coastal storm events are expected to increase children’s risk of gastrointestinal illness from ingestion of or contact with contaminated water.61,142,143,158 An increased association between heavy rainfall and increased acute gastrointestinal illness has already been observed in children in the United States.159 Children may be especially vulnerable to recreational exposures to waterborne pathogens, in part because they swallow roughly twice as much water as adults while swimming.160 In addition, children comprised 40% of swimming-related eye and ear infections from the waterborne bacteria Vibrio alginolyticus during the period 1997–2006161 and 66% (ages 1–19) of those seeking treatment for illness associated with harmful algal bloom toxins in 2009–2010.162 (See Ch. 6. Water-Related Illness).

Vector-borne and other infectious diseases. The changes in the distribution of infectious diseases that are expected to result from climate change may introduce new exposures to children (see Ch. 5: Vector-Borne Disease). Due to physiological vulnerability or changes in their body’s immune system, fetuses, pregnant women, and children are at increased risk of acquiring or having complications from certain infectious diseases such as listeriosis,163 dengue fever,164 and influenza.165 Children spend more time outdoors than adults, increasing their exposure to mosquito and tick bites that can cause vector-borne diseases that disproportionately affect children such as La Crosse encephalitis or Lyme disease.20,143,166 Lyme disease is most frequently reported among male children aged 5 to 9 years, and a disproportionate increasing trend was observed in all children from 1992 to 2006.167,168

Food safety and security. Climate change, including rising levels of atmospheric CO2, significantly reduces food quality and threatens availability and access for children. Because of the importance of nutrition during certain stages of physical and mental growth and development, the direct effect of the continued rise of CO2 on reducing food quality will be an increasingly significant issue for children globally.169,170,171 For the United States, disruptions in food production or distribution due to extreme events such as drought can increase costs and limit availability or access,172,173 particularly for food-insecure households, which include nearly 16% of households with children in the United States.174 Children are also more susceptible to severe infection or complications from Escherichia coli infections, such as hemolytic uremic syndrome.175 (See Ch. 7: Food Safety).

Vulnerability Related to Life Stage

Prenatal and pregnancy outcomes for mothers and babies. Climate-related exposures may lead to adverse pregnancy and newborn health outcomes, including spontaneous abortion, low birth weight (less than 5.5 pounds), preterm birth (birth before 37 weeks of pregnancy), increased neonatal death, dehydration and associated renal failure, malnutrition, diarrhea, and respiratory disease.20,176 Other risk factors that may influence maternal and newborn health include water scarcity, poverty, and population displacement.20,176 The rate of preterm births is relatively high in the United States (1 of every 9 infants born),177 where they contribute substantially to neonatal death and illness. Of the 1.2 million preterm births estimated to occur annually in high-income countries, more than 500 thousand (42% of the total) occur in the United States.178 Extreme heat events have been associated with adverse birth outcomes such as low birth weight, preterm birth, and infant mortality,179,180,181 as well as congenital cataracts.182 Newborns are especially sensitive to ambient temperatures that are too high or too low because their capacity for regulating body temperature is limited.183

In addition, exposure of pregnant women to inhaled particulate matter is associated with negative birth outcomes.184,185,186,187,188,189 Incidences of diarrheal diseases and dehydration may increase in extent and severity, which can be associated with adverse effects on pregnancy outcomes and the health of newborns.176 Floods are associated with an increased risk of maternal exposure to environmental toxins and mold, reduced access to safe food and water, psychological stress, and disrupted health care. Other flood-related health outcomes for mothers and babies include maternal risk of anemia (a condition associated with low red blood cell counts sometimes caused by low iron intake), eclampsia (a condition that can cause seizures in pregnant women), and spontaneous abortion.190,191,192,193

Infants and toddlers. Infants and toddlers are particularly sensitive to air pollutants, extreme heat, and microbial water contamination, which are all affected by climate change. Ozone exposure in young children and exposure to air pollutants and toxins in wildfire smoke are associated with increased asthma risk and other respiratory illnesses.78,142 Young children and infants are particularly vulnerable to heat-related illness and death, as their bodies are less able to adapt to heat than are adults.32,40,58,143,194 Children under four years of age experience higher hospital admissions for respiratory illnesses during heat waves.195 Rates of diarrheal illness have been shown to be higher in children under age five in the United States,196 and climate change is expected to increase children’s risk of gastrointestinal illness from ingestion or contact with contaminated water (see also Ch. 6: Water-Related Illness).61,142,143,158

Older Adults

Older adults (generally defined as persons aged 65 and older) are vulnerable to the health impacts associated with climate change and weather extremes.11,197,198,199 The number of older adults in the United States is projected to grow substantially in the coming decades. The nation’s older adult population (ages 65 and older) will nearly double in number from 2015 through 2050, from approximately 48 million to 88 million.200 Of those 88 million older adults, a little under 19 million will be 85 years of age and older.201 This projected population growth is largely due to the aging of the Baby Boomer generation (an estimated 76 million people born in the United States between 1946 and 1964), along with increases in lifespan and survivorship.18 Older adults in the United States are not uniform with regard to their climate-related vulnerabilities, but are a diverse group with distinct subpopulations that can be identified not only by age but also by race, educational attainment, socioeconomic status, social support networks, overall physical and mental health, and disability status.198,202

Vulnerability to Climate-Related Health Stressors

The potential climate change related health impacts for older adults include rising temperatures and heat waves; increased risk of more intense hurricanes (Categories IV and V), floods, droughts, and wildfires; degraded air quality; exposure to infectious diseases; and other climate-related hazards.120

Extreme heat events. Older adults exposed to extreme heat can experience multiple adverse effects.203 In the coming decades, extreme heat events are projected to become more frequent, more intense, and of longer duration, especially in higher latitudes and large metropolitan areas.24,204 Between 1979 and 2004, 5,279 deaths were reported in the United States related to heat exposure, with those deaths reported most commonly among adults aged 65 and older.205 Disease incidence among older adults is expected to increase even in regions with relatively modest temperature changes (as demonstrated by case studies of a 2006 California heat wave).40 In New York City, extreme high temperatures were associated with an increase in hospital admissions for cardiovascular and respiratory disorders, with the elderly among the most affected. Hospital admissions for respiratory illness were greatest for the elderly, with a 4.7% increase per degree Centigrade increase.33 Future climate-related increases in summertime temperatures may increase the risk of death in older people with chronic conditions, particularly those suffering from congestive heart failure and diabetes.206 The percentage of older adults with diabetes, which puts individuals at higher risk for heat-related illness and death, has increased from 9.1% in 1980 to 19.9% in 2009.207

Other weather extremes. Hurricanes and other severe weather events lead to physical, mental, or emotional trauma before, during, and after the event.208 The need to evacuate an area can pose increased health and safety risks for older adults, especially those who are poor or reside in nursing or assisted-living facilities.209,210 Moving patients to a sheltering facility is complicated, costly, and time-consuming and requires concurrent transfer of medical records, medications, and medical equipment (see also Ch. 4: Extreme Events).210,211

Degraded air quality. Climate change can affect air quality by increasing ground-level ozone, fine particulate matter, aeroallergens, wildfire smoke, and dust (see Ch. 3: Air Quality Impacts).212,213 Exposure to ground-level ozone varies with age and can affect lung function and increase emergency department visits and hospital admissions, even for healthy adults. Air pollution can also exacerbate asthma and COPD and can increase the risk of heart attack in older adults, especially those who are also diabetic or obese.214

Vector-borne and waterborne diseases. The changes in the distribution of disease vectors like ticks and mosquitoes that are expected to result from climate change may increase exposures to pathogens in older adult populations (see Ch. 5: Vector-Borne Diseases). Some vector-borne diseases, notably mosquito-borne West Nile and St. Louis encephalitis viruses,215,216 pose a greater health risk among sensitive older adults with already compromised immune systems. Climate change is also expected to increase exposure risk to waterborne pathogens in sources of drinking water and recreational water. Older adults have a higher risk of contracting gastrointestinal illnesses from contaminated drinking and recreational water and suffering severe health outcomes and death (see Ch. 6: Water-Related Illness).217,218,219,220

Interactions with Non-Climate Stressors

Vulnerable locations and condition of the built environment. Older adults are particularly vulnerable to climate change related health effects depending on their geographic location and characteristics of their homes, such as the quality of construction and amenities. More than half of the elderly U.S. adult population is concentrated in 170 counties (5% of all U.S. counties), and approximately 20% of older Americans live in a county in which a hurricane or tropical storm made landfall over the last decade.221 For example, Florida is a traditional retirement destination with an older adult population accounting for 16.8% of the total in 2010, nearly four percentage points higher than the national average.222 The increasing severity of tropical storms may pose particular risks for older adults in coastal zones.223 Other geographic risk factors common to older adults are the urban heat island effect, urban sprawl (which affects mobility), characteristics of the built environment, and perceptions of neighborhood safety.224,225

In neighborhoods where safety and crime are a concern, older residents may fear venturing out of their homes, thus increasing their social isolation and risk of health impacts during events such as heat waves.224 Degraded infrastructure, including the condition of housing and public transportation, is associated with higher numbers of heat-related deaths in older adults. In multi-story residential buildings in which residents rely on elevators, electricity loss makes it difficult, if not impossible, for elderly residents and those with disabilities to leave the building to obtain food, medicine, and other needed services.226 Also, older adults who own air-conditioning units may not utilize them during heat waves due to high operating costs.11,227,228,229

Vulnerability related to physiological factors. Older adults are more sensitive to weather-related events due to age-related physiological factors. Elevated risks for cardiovascular deaths related to exposure to extreme heat have been observed in older adults.32,230 Generally poorer physical health conditions, such as long-term chronic illnesses, are exacerbated by climate change.227,228,231,232 In addition, aging can impair the mechanisms that regulate body temperature, particularly for those taking medications that interfere with regulation of body temperature, including psychotropic medications used to treat a variety of mental illnesses such as depression, anxiety, and psychosis.233 Respiratory impairments already experienced by older adults will be exacerbated by increased exposure to outdoor air pollutants (especially ozone and fine particulate matter), aeroallergens, and wildfire smoke—all of which may be exacerbated by climate change.199,213

Vulnerability related to disabilities. Some functional limitations and mobility impairments increase older adults’ sensitivity to climate change, particularly extreme events. In 2010, 49.8% of older adults (over 65) were reported to have a disability, compared to 16.6% of people aged 21–64.234 Dementia occurs at a rate of 5% of the U.S. population aged 71 to 79 years, with an increase to more than 37% at age 90 and older.235 Older adults with mobility or cognitive impairments are likely to experience greater vulnerability to health risks due to difficulty responding to, evacuating, and recovering from extreme events.11,231

Occupational Groups

Climate change may increase the prevalence and severity of known occupational hazards and exposures, as well as the emergence of new ones. Outdoor workers are often among the first to be exposed to the effects of climate change. Climate change is expected to affect the health of outdoor workers through increases in ambient temperature, degraded air quality, extreme weather, vector-borne diseases, industrial exposures, and changes in the built environment.10 Workers affected by climate change include farmers, ranchers, and other agricultural workers; commercial fishermen; construction workers; paramedics, firefighters and other first responders; and transportation workers. Also, laborers exposed to hot indoor work environments (such as steel mills, dry cleaners, manufacturing facilities, warehouses, and other areas that lack air conditioning) are at risk for extreme heat exposure.236,237,238

For some groups, such as migrant workers and day laborers, the health effects of climate change can be cumulative, with occupational exposures exacerbated by exposures associated with poorly insulated housing and lack of air conditioning. Workers may also be exposed to adverse occupational and climate-related conditions that the general public may altogether avoid, such as direct exposure to wildfires.

Extreme heat events. Higher temperatures or longer, more frequent periods of heat may result in more cases of heat-related illnesses (for example, heat stroke and heat exhaustion) and fatigue among workers,237,238,239,240,241 especially among more physically demanding occupations. Heat stress and fatigue can also result in reduced vigilance, safety lapses, reduced work capacity, and increased risk of injury. Elevated temperatures can increase levels of air pollution, including ground-level ozone, resulting in increased worker exposure and subsequent risk of respiratory illness (see also Ch. 2: Temperature-Related Death and Illness).10,236,237,242

Other weather extremes. Some extreme weather events and natural disasters, such as floods, storms, droughts, and wildfires, are becoming more frequent and intense (see also Ch. 4: Extreme Events).120 An increased need for complex emergency responses will expose rescue and recovery workers to physical and psychological hazards.205,243 The safety of workers and their ability to recognize and avoid workplace hazards may be impaired by damage to infrastructure and disrupted communication.

From 2000 to 2013, almost 300 U.S. wildfire firefighters were killed while on duty.244 With the frequency and severity of wildfires projected to increase, more firefighters will be exposed. Common workplace hazards faced on the fire line include being overrun by fire (as happened during the Yarnell Hill Fire in Arizona in 2013 that killed 19 firefighters);245 heat-related illnesses and injuries; smoke inhalation; vehicle-related injuries (including aircraft); slips, trips, and falls; and exposure to particulate matter and other air pollutants in wildfire smoke. In addition, wildland fire fighters are at risk of rhabdomyolysis (a breakdown of muscle tissue) that is associated with prolonged and intense physical exertion.246

Other workplace exposures to outdoor health hazards. Other climate-related health threats for outdoor workers include increased waterborne and foodborne pathogens, increased duration of aeroallergen exposure with longer pollen seasons,247,248 and expanded habitat ranges of disease-carrying vectors that may influence the risk of human exposure to diseases such as West Nile virus or Lyme disease (see also Ch. 5: Vector-Borne Diseases).249

Persons with Disabilities

Disability refers to any condition or impairment of the body or mind that limits a person’s ability to do certain activities or restricts a person’s participation in normal life activities, such as school, work, or recreation.250 The term “disability” covers a wide variety and range of functional limitations related to expressive and receptive communication (hearing and speech), vision, cognition, and mobility. These factors, if not anticipated and accommodated before, during, and after extreme events, can result in illness and death.251 The extent of disability, or its severity, is reflected in the affected person’s need for environmental accessibility and accommodations for their impairment(s).252

Woman in wheelchair

Persons with disabilities often rely on medical equipment (such as portable oxygen) that requires an uninterrupted source of electricity.

Disability can occur at any age and is not uniformly distributed across populations. Disability varies by gender, race, ethnicity, and geographic location.253 Approximately 18.7% of the U.S. population has a disability.234 In 2010, the percent of American adults with a disability was approximately 16.6% for those aged 18–64 and 49.8% for persons 65 and older.234 In 2014, working-age adults with disabilities were substantially less likely to participate in the labor force (30.2%) than people without disabilities (76.2%), and experience more than twice the rate of unemployment (13.9% and 6.0%, respectively).254

People with disabilities experience disproportionately higher rates of social risk factors, such as poverty and lower educational attainment, that contribute to poorer health outcomes during extreme events or climate-related emergencies. These factors compound the risks posed by functional impairments and disrupt planning and emergency response. Of the climate-related health risks experienced by people with disabilities, perhaps the most fundamental is their “invisibility” to decision-makers and planners.255 There has been relatively limited empirical research documenting how people with disabilities fare during or after an extreme event.256

An increase in extreme weather can be expected to disproportionately affect populations with disabilities unless emergency planners make provisions to address their functional needs in preparing emergency response plans. In 2005, Hurricane Katrina had a significant and disproportionate impact on people with disabilities. Of the 986 deaths in Louisiana directly attributable to the storm, 103 occurred among individuals in nursing homes, presumably with a disability.257 Strong social capital and societal connectedness to other people, especially through faith-based organizations, family networks, and work connections, were considered to be key enabling factors that helped people with disabilities to cope before, during, and after the storm.258 In the aftermath of Hurricane Sandy, the City of New York lost a lawsuit filed by the Brooklyn Center for Independence of the Disabled (Brooklyn Center for Independence of the Disabled et al. v. Bloomberg et al., Case 1.11-cv-06690-JMF 2013), with the finding that the city had not adequately prepared to accommodate the social and medical support needs of New York residents with disabilities.

Risk communication is not always designed or delivered in an accessible format or media for individuals who are deaf or have hearing loss, who are blind or have low vision, or those with diminished cognitive skills.259,260 Emergency communication and other important notifications (such as a warning to boil contaminated water) simply may not reach persons with disabilities. In addition, persons with disabilities often rely on medical equipment (such as portable oxygen) that requires an uninterrupted source of electricity. Portable oxygen supplies must be evacuated with the patient.261

Persons with Chronic Medical Conditions

Preexisting medical conditions present risk factors for increased illness and death associated with climate-related stressors, especially exposure to extreme heat. In some cases, risks are mediated by the physiology of specific medical conditions that may impair responses to heat exposure. In other cases, the risks are related to unintended side effects of medical treatment that may impair body temperature, fluid, or electrolyte balance and thereby increase risks. Trends in the prevalence of chronic medical conditions are summarized in Table 1.1 in Chapter 1: Introduction. In general, the prevalence of common chronic medical conditions, including cardiovascular disease, respiratory disease, diabetes, asthma, and obesity, is anticipated to increase over the coming decades (see Table 1.1 in Ch. 1: Introduction), resulting in larger populations at risk of medical complications from climate change related exposures.

Excess heat exposure has been shown to increase the risk of disease exacerbation or death for people with various medical conditions. Hospital admissions and emergency room visits increase during heat waves for people with diabetes, cardiovascular diseases, respiratory diseases, and psychiatric illnesses.40,58,195,262,263,264,265,266 Medical conditions like Alzheimer’s disease or mental illnesses can impair judgment and behavioral responses in crisis situations, which can place people with those conditions at greater risk.228

Medications used to treat chronic medical conditions are associated with increased risk of hospitalization, emergency room admission, and in some cases, death from extreme heat. These medicines include drugs used to treat neurologic or psychiatric conditions, such as anti-psychotic drugs, anti-cholinergic agents, anxiolytics (anti-anxiety medicines), and some antidepressants (such as selective serotonin reuptake inhibitors or SSRIs; see also Ch. 8: Mental Health).233,267,268 In addition, drugs used to treat cardiovascular diseases, such as diuretics and beta-blockers, may impair resilience to heat stress.267,269

People with chronic medical conditions also can be more vulnerable to interruption in treatment. For example, interrupting treatment for patients with addiction to drugs or alcohol may lead to withdrawal syndromes.270,271,272 Treatment for chronic medical conditions represents a significant proportion of post-disaster medical demands.273 Communities that are both medically underserved and have a high prevalence of chronic medical conditions can be especially at risk.274 While most studies have assessed adults, and especially the elderly, with chronic medical conditions, children with medical conditions such as allergic and respiratory diseases are also at greater risk of symptom exacerbation and hospital admission during heat waves.144


9.4 Measures of Vulnerability and Mapping

Vulnerability associated with exposures to climate-related hazards is closely tied to place. While an understanding of the individual-level factors associated with vulnerability is essential to assessing population risks and considering possible protective measures, understanding how potential exposures overlap with the geographic location of populations of concern is critical for designing and implementing appropriate adaptations. Analytic capabilities provided by mapping tools allow public health and emergency response workers to consider multiple types of vulnerability and how they interact with place. The development of indices that combine different elements of vulnerability and allow visualization of areas and populations experiencing the highest risks is related to improved geographic information systems (GIS) capabilities.291

Approaches to Assessing Vulnerability

 

Figure 9.4: Mapping Social Vulnerability

Figure 9.4: Mapping Social Vulnerability

VIEW
CDC Social Vulnerability Index (SVI): This interactive web map shows the overall social vulnerability of the U.S. Southwest in 2010. The SVI provides a measure of four social vulnerability elements: socioeconomic status; household composition; race, ethnicity, and language; and housing/transportation. Each census tract receives a separate ranking for overall vulnerability at the census-tract level. Dark blue indicates the highest overall vulnerability (the top quartile) with the lowest quartile in pale yellow. (Figure source: ATSDR 2015)300

There are multiple approaches for developing vulnerability indices to identify populations of concern across large areas, such as state or multistate regions, or small areas, such as households within a county or several counties within a state.292 The Social Vulnerability Index (SVI) developed by the CDC aggregates U.S. census data to estimate the social vulnerability of census tracts (which are generally subsets of counties; Figure 9.4). The SVI provides a measure of overall social vulnerability in addition to measures of elements that comprise social vulnerability (including socioeconomic status, household composition, race or ethnicity, native language, and infrastructure conditions). Each census tract receives a separate ranking for overall vulnerability and for each of the four elements, which are available at the census-tract level for the entire United States. A similar methodology has been used to develop a vulnerability index for climate-sensitive health outcomes which, in addition to socioeconomic data, incorporates data on climate-related exposures and adaptive capacity.293

Application of Vulnerability Indices

GIS—data management systems used to capture, store, manage, retrieve, analyze, and display geographic information—can be used to quantify and visualize factors that contribute to climate-related health risks. By linking together census data, data on the determinants of health (social, environmental, preexisting health conditions), measures of adaptive capacity (such as health care access), and climate data, GIS mapping helps identify and position resources for at-risk populations.9,293,294,295,296,23 For instance, heat-related illnesses have been associated with social isolation in older adults, which can be mapped by combining data for persons living alone (determinants of health data), distribution of people aged 65 and older (census data), and frequency and severity of heat waves (climate data).

Vulnerability mapping can also enhance emergency and disaster risk management.297,298 Vulnerability mapping conducted at finer spatial resolution (for example, census tracts or census blocks) allows public health departments to target vulnerable communities for emergency preparedness, response, recovery, and mitigation.299 Geographic characteristics of vulnerability can be used to determine where to position emergency medical and social response resources that are most needed before, during, and after climate change related events.297,298,299

Emergency response agencies can apply lessons learned by mapping prior events. For example, vulnerability mapping has been used to assess how social disparities affected the geography of recovery in New Orleans following Hurricane Katrina.8 Maps displaying the intersection of social vulnerability (low, medium, high scores) and flood inundation (none, low, medium, high levels) showed that while the physical manifestation of the disaster had few race or class distinctions, the social vulnerability of communities influenced both pre-impact responses, such as evacuation, and post-event recovery.8 As climate change increases the probability of more frequent or more severe extreme weather events, vulnerability mapping is an important tool for preparing for and responding to health threats.


9.5 Research Needs

A number of research needs related to populations of concern have been identified. There are some limitations with current public health surveillance and monitoring of risk factors that impede the development of projections of vulnerability to climate change impacts. Obtaining detailed data on social, economic, and health factors that contribute to vulnerability is challenging, especially at the small spatial scales required for analyzing climate change impacts. Privacy concerns often limit the collection and use of personal health and socioeconomic data. Ultimately, data limitations determine the feasibility of developing alternative vulnerability indicators using existing data sources. The science requires comprehensive and standardized measures of vulnerability that combine data identification and collection with the development of appropriate vulnerability indices.

More comprehensive and robust projections of factors that contribute to population vulnerability would also enhance the value of predictive models. At present, there are only limited projections of health status of the U.S. population, and the U.S. Census no longer provides population projections at the state level. Projecting population vulnerability into the future, as well as the development of consensus storylines that characterize alternative socioeconomic scenarios, will facilitate more robust and useful assessments of future health impacts of climate change.

Future assessments can benefit from research activities that:

  • improve understanding of the relative contributions and causal mechanisms of vulnerability factors (for example, genetic, physiological, social, behavioral) to risks of specific health impacts of climate change;
  • investigate how available sources of data on population characteristics can be used to create valid indicators and help map vulnerability to the health impacts of climate change;
  • understand how vulnerability to both medical and psychological health impacts of climate change affect cumulative stress and health status; and
  • evaluate the efficacy of measures designed to enhance resilience and reduce the health impacts from climate change at the individual, institutional, and community levels.

References

  1. Abara, W., S. M. Wilson, and K. Burwell, 2012: Environmental justice and infectious disease: Gaps, issues, and research needs. Environmental Justice, 5, 8-20. doi:10.1089/env.2010.0043 | Detail
  2. ACIA, 2004: Impacts of a Warming Arctic: Arctic Climate Impact Assessment. 140 pp., Cambridge University Press, Cambridge, UK. URL | Detail
  3. AFHSC, 2007: Leishmaniasis in relation to service in Iraq/Afghanistan, U.S. Armed Forces, 2001-2006. MSMR: Medical Surveillance Monthly Report, 14(1), 2-5. URL | Detail
  4. AFHSC, 2015: Update: Heat injuries, active component, U.S. Armed Forces. MSMR: Medical Surveillance Monthly Report, 22(3), 17-20. URL | Detail
  5. AFHSC, 2015: Chikungunya in the Americas Surveillance Summary. Armed Forces Health Surveillance Center. URL | Detail
  6. Alderman, K., L. R. Turner, and S. Tong, 2012: Floods and human health: A systematic review. Environment International, 47, 37-47. doi:10.1016/j.envint.2012.06.003 | Detail
  7. Alessa, L., A. Kliskey, P. Williams, and M. Barton, 2008: Perception of change in freshwater in remote resource-dependent Arctic communities. Global Environmental Change, 18, 153-164. doi:10.1016/j.gloenvcha.2007.05.007 | Detail
  8. Armed Forces Health Surveillance Center (AFHSC), 2014: Brief report: the geographic distribution of incident coccidioidomycosis among active component service members, 2000-2013. MSMR: Medical Surveillance Monthly Report, 21, 12-14. PMID: 24978473 | Detail
  9. Armed Forces Health Surveillance Center (AFHSC), 2015: Update: Malaria, U.S. Armed Forces, 2014. MSMR: Medical Surveillance Monthly Report, 22, 2-6. PMID: 25643089 | Detail
  10. Arrieta, M. I., R. D. Foreman, E. D. Crook, and M. L. Icenogle, 2009: Providing continuity of care for chronic diseases in the aftermath of Katrina: From field experience to policy recommendations. Disaster Medicine and Public Health Preparedness, 3, 174-182. doi:10.1097/DMP.0b013e3181b66ae4 | Detail
  11. Åström, D. O., F. Bertil, and R. Joacim, 2011: Heat wave impact on morbidity and mortality in the elderly population: A review of recent studies. Maturitas, 69, 99-105. doi:10.1016/j.maturitas.2011.03.008 | Detail
  12. ATSDR, cited 2015: Social Vulnerability Index (SVI) Mapping Dashboard. Agency for Toxic Substances & Disease Registry. URL | Detail
  13. Babaluk, J. A., J. D. Reist, J. D. Johnson, and L. Johnson, 2000: First records of sockeye (Oncorhynchus nerka) and pink salmon (O. gorbuscha) from Banks Island and other records of Pacific salmon in Northwest Territories, Canada. Arctic, 53, 161-164. doi:10.14430/arctic846 | Detail
  14. Baja, E. S., J. D. Schwartz, G. A. Wellenius, B. A. Coull, A. Zanobetti, P. S. Vokonas, and H. H. Suh, 2010: Traffic-related air pollution and QT interval: Modification by diabetes, obesity, and oxidative stress gene polymorphisms in the normative aging study. Environmental Health Perspectives, 118, 840-846. doi:10.1289/ehp.0901396 | Detail
  15. Balbus, J. M., and C. Malina, 2009: Identifying vulnerable subpopulations for climate change health effects in the United States. Journal of Occupational and Environmental Medicine, 51, 33-37. doi:10.1097/JOM.0b013e318193e12e | Detail
  16. Bartra, J., and others, 2007: Air pollution and allergens. Journal of Investigational Allergology and Clinical Immunology, 17 Suppl 2, 3-8. URL | Detail
  17. Basu, R., 2009: High ambient temperature and mortality: A review of epidemiologic studies from 2001 to 2008. Environmental Health, 8, 40. doi:10.1186/1476-069x-8-40 | Detail
  18. Basu, R., and B. D. Ostro, 2008: A multicounty analysis identifying the populations vulnerable to mortality associated with high ambient temperature in California. American Journal of Epidemiology, 168, 632-637. doi:10.1093/aje/kwn170 | Detail
  19. Basu, R., B. Malig, and B. Ostro, 2010: High ambient temperature and the risk of preterm delivery. American Journal of Epidemiology, 172, 1108-1117. doi:10.1093/aje/kwq170 | Detail
  20. Becker-Blease, K. A., H. A. Turner, and D. Finkelhor, 2010: Disasters, victimization, and children’s mental health. Child Development, 81, 1040-1052. doi:10.1111/j.1467-8624.2010.01453.x | Detail
  21. Bernstein, A. S., and S. S. Myers, 2011: Climate change and childrenʼs health. Current Opinion in Pediatrics, 23, 221-226. doi:10.1097/MOP.0b013e3283444c89 | Detail
  22. Blackwell, D. L., J. W. Lucas, and T. C. Clarke, 2014: Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. 161 pp., National Center for Health Statistics, Hyattsville, MD. URL | Detail
  23. Blaikie, P., T. Cannon, I. Davis, and B. Wisner, 1994: At Risk: Natural Hazards, People’s Vulnerability, and Disasters. Routledge, 284 pp. | Detail
  24. BLS, cited 2015: Economic News Release: Table A. Employment Status of the Civilian Noninstitutional Population by Disability Status and Age, 2012 and 2013 Annual Averages. U.S. Department of Labor, Bureau of Labor Statistics. URL | Detail
  25. Booth, S., and D. Zeller, 2005: Mercury, food webs, and marine mammals: Implications of diet and climate change for human health. Environmental Health Perspectives, 113, 521-526. doi:10.1289/ehp.7603 | Detail
  26. Bowden, S. E., K. Magori, and J. M. Drake, 2011: Regional differences in the association between land cover and West Nile virus disease incidence in humans in the United States. The American Journal of Tropical Medicine and Hygiene, 84, 234-238. doi:10.4269/ajtmh.2011.10-0134 | Detail
  27. Brault, M. W., 2012: Americans With Disabilities: 2010. 23 pp., U.S. Census Bureau, Washington, D.C. URL | Detail
  28. Braveman, P. A., C. Cubbin, S. Egerter, S. Chideya, K. S. Marchi, M. Metzler, and S. Posner, 2005: Socioeconomic status in health research: One size does not fit all. JAMA: The Journal of the American Medical Association, 294, 2829-2888. doi:10.1001/jama.294.22.2879 | Detail
  29. Braveman, P., S. Egerter, and D. R. Williams, 2011: The social determinants of health: coming of age. Annual Review of Public Health, 32, 381-398. doi:10.1146/annurev-publhealth-031210-101218 | Detail
  30. Browning, C. R., D. Wallace, S. L. Feinberg, and K. A. Cagney, 2006: Neighborhood social processes, physical conditions, and disaster-related mortality: The case of the 1995 Chicago heat wave. American Sociological Review, 71, 661-678. doi:10.1177/000312240607100407 | Detail
  31. Brown, M. E., and others, 2015: Climate Change, Global Food Security and the U.S. Food System. 146 pp., U.S. Global Change Research Program. URL | Detail
  32. Brunkard, J., G. Namulanda, and R. Ratard, 2008: Hurricane Katrina deaths, Louisiana, 2005. Disaster Medicine and Public Health Preparedness, 2, 215-223. doi:10.1097/DMP.0b013e31818aaf55 | Detail
  33. Bullard, R., and B. Wright, 2009: Introduction. Race, Place, and Environmental Justice After Hurricane Katrina, Struggles to Reclaim Rebuild, and Revitalize New Orleans and the Gulf Coast, R. Bullard and Wright, B., Eds., Westview Press, 1-15. | Detail
  34. Bush, K. F., C. L. Fossani, S. Li, B. Mukherjee, C. J. Gronlund, and M. S. O'Neill, 2014: Extreme precipitation and beach closures in the Great Lakes region: Evaluating risk among the elderly. International Journal of Environmental Research and Public Health, 11, 2014-2032. doi:10.3390/ijerph110202014 | Detail
  35. Callaghan, W. M., and others, 2007: Health concerns of women and infants in times of natural disasters: Lessons learned from Hurricane Katrina. Maternal and Child Health Journal, 11, 307-311. doi:10.1007/s10995-007-0177-4 | Detail
  36. Carlisle Maxwell, J., D. Podus, and D. Walsh, 2009: Lessons learned from the deadly sisters: Drug and alcohol treatment disruption, and consequences from Hurricanes Katrina and Rita. Substance Use & Misuse, 44, 1681-1694. doi:10.3109/10826080902962011 | Detail
  37. Carter, L. M., J. W. Jones, L. Berry, V. Burkett, J. F. Murley, J. Obeysekera, P. J. Schramm, and D. Wear, 2014: Ch. 17: Southeast and the Caribbean. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 396-417. doi:10.7930/J0NP22CB | Detail
  38. CCSP, 2008: Analyses of the Effects of Global Change on Human Health and Welfare and Human Systems. A report by the U.S. Climate Change Science Program and the Subcommittee on Global Change Research. J.L. Gamble, Ebi, K.L., Grambsch, A.E., Sussman, F.G., and Wilbanks, T.J., Eds., U.S. Climate Change Science Program, U.S. Environmental Protection Agency. URL | Detail
  39. CDC, 2011: Health Disparities and Inequalities Report-United States, 2011. MMWR. Morbidity and Mortality Weekly Report, 60(Suppl), 1-116. URL | Detail
  40. CDC, cited 2012: Table 2-1: Lifetime Asthma Prevalence Percents by Age, United States: National Health Interview Survey, 2012. Centers for Disease Control and Prevention. URL | Detail
  41. CDC, 2013: Health Disparities and Inequalities Report--United States 2013. MMWR. Morbidity and Mortality Weekly Report, 62(Supp.3), 1-187. URL | Detail
  42. CDC, cited 2014: Health, United States, 2013--At a Glance. Centers for Disease Control and Prevention. URL | Detail
  43. CDC, cited 2014: Diabetes Public Health Resource: Rate per 100 of Civilian, Noninstitutionalized Population with Diagnosed Diabetes, by Age, United States, 1980-2011. Centers for Disease Control and Prevention. URL | Detail
  44. CDC, cited 2015: Confirmed Lyme Disease Cases by Age and Sex--United States, 2001-2010. Centers for Disease Control and Prevention. URL | Detail
  45. CDC, cited 2015: Disability and Health: Disability Overview. Centers for Disease Control and Prevention. URL | Detail
  46. CDC, cited 2015: Reproductive Health: Preterm Birth. Centers for Disease Control and Prevention. URL | Detail
  47. Cherry, K. E., S. Galea, L. J. Su, D. A. Welsh, S. M. Jazwinski, J. L. Silva, and M. J. Erwin, 2010: Cognitive and psychosocial consequences of Hurricanes Katrina and Rita among middle-aged, older, and oldest-old adults in the Louisiana Healthy Aging Study (LHAS). Journal of Applied Social Psychology, 40, 2463-2487. doi:10.1111/j.1559-1816.2010.00666.x | Detail
  48. Cheruvelil, J. J., and B. Barton, 2013: Adapting to the Effects of Climate Change on Wild Rice. 12 pp., Great Lakes Lifeways Institute. | Detail
  49. Chitra, T. V., and S. Panicker, 2011: Maternal and fetal outcome of dengue fever during pregnancy. Journal of Vector Borne Diseases, 48, 210-213. URL | Detail
  50. Choi, H., V. Rauh, R. Garfinkel, Y. Tu, and F. P. Perera, 2008: Prenatal exposure to airborne polycyclic aromatic hydrocarbons and risk of intrauterine growth restriction. Environmental Health Perspectives, 116, 658-665. doi:10.1289/ehp.10958 | Detail
  51. Coleman-Jensen, A., M. Nord, M. Andrews, and S. Carlson, 2012: Household Food Security in the United States in 2011. 29 pp., U.S. Department of Agriculture, Economic Research Service. URL | Detail
  52. Collins, T. W., A. M. Jimenez, and S. E. Grineski, 2013: Hispanic health disparities after a flood disaster: Results of a population-based survey of individuals experiencing home site damage in El Paso (Texas, USA). Journal of Immigrant and Minority Health, 15, 415-426. doi:10.1007/s10903-012-9626-2 | Detail
  53. Conti, S., M. Masocco, P. Meli, G. Minelli, E. Palummeri, R. Solimini, V. Toccaceli, and M. Vichi, 2007: General and specific mortality among the elderly during the 2003 heat wave in Genoa (Italy). Environmental Research, 103, 267-274. doi:10.1016/j.envres.2006.06.003 | Detail
  54. Cozzetto, K., and others, 2013: Climate change impacts on the water resources of American Indians and Alaska Natives in the U.S. Climatic Change, 120, 569-584. doi:10.1007/s10584-013-0852-y | Detail
  55. Crim, S. M., and others, 2014: Incidence and trends of infections with pathogens transmitted commonly through food--Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2013. Morbidity and Mortality Weekly Report, 63, 328-332. URL | Detail
  56. Crozier, M. J., 2010: Deciphering the effect of climate change on landslide activity: A review. Geomorphology, 124, 260-267. doi:10.1016/j.geomorph.2010.04.009 | Detail
  57. Crum-Cianflone, N. F., 2007: Coccidioidomycosis in the U.S. Military: A Review. Annals of the New York Academy of Sciences, 1111, 112-121. doi:10.1196/annals.1406.001 | Detail
  58. CSDH, 2008: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. 247 pp., World Health Organization, Geneva. URL | Detail
  59. Cunsolo Willox, A., and others, 2015: Examining relationships between climate change and mental health in the Circumpolar North. Regional Environmental Change, 15, 169-182. doi:10.1007/s10113-014-0630-z | Detail
  60. Cunsolo Willox, A., S. L. Harper, V. L. Edge, K. Landman, K. Houle, J. D. Ford, and Rigolet Inuit Community Government, 2013: The land enriches the soul: On climatic and environmental change, affect, and emotional health and well-being in Rigolet, Nunatsiavut, Canada. Emotion, Space and Society, 6, 14-24. doi:10.1016/j.emospa.2011.08.005 | Detail
  61. Davis, J. R., S. Wilson, A. Brock-Martin, S. Glover, and E. R. Svendsen, 2010: The impact of disasters on populations with health and health care disparities. Disaster Medicine and Public Health Preparedness, 4, 30-38. doi:10.1017/S1935789300002391 | Detail
  62. Dechet, A. M., P. A. Yu, N. Koram, and J. Painter, 2008: Nonfoodborne Vibrio infections: An important cause of morbidity and mortality in the United States, 1997–2006. Clinical Infectious Diseases, 46, 970-976. doi:10.1086/529148 | Detail
  63. DeGroote, J. P., and R. Sugumaran, 2012: National and Regional Associations Between Human West Nile Virus Incidence and Demographic, Landscape, and Land Use Conditions in the Coterminous United States. Vector-Borne and Zoonotic Diseases, 12, 657-665. doi:10.1089/vbz.2011.0786 | Detail
  64. Dejmek, J., S. G. Selevan, I. Benes, I. Solanský, and R. J. Srám, 1999: Fetal growth and maternal exposure to particulate matter during pregnancy. Environmental Health Perspectives, 107, 475-480. URL | Detail
  65. DHHS, 2001: Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, Rockville, MD. URL | Detail
  66. DHHS, 2009: A Profile of Older Americans: 2009. 17 pp., U.S. Department of Health and Human Services, Administration on Aging, Washington, D.C. URL | Detail
  67. DHHS, 2014: National Healthcare Disparities Report 2013. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, MD. URL | Detail
  68. Dijkstra, J. A., K. L. Buckman, D. Ward, D. W. Evans, M. Dionne, and C. Y. Chen, 2013: Experimental and natural warming elevates mercury concentrations in estuarine fish. PLoS ONE, 8, e58401. doi:10.1371/journal.pone.0058401 | Detail
  69. DOD, 2010: Quadrennial Defense Review Report. 105 pp., U.S. Department of Defense. URL | Detail
  70. DOD, cited 2012: Department of Defense FY 2012 Climate Change Adaptation Roadmap. Appendix to DOD's Strategic Sustainability Performance Plan 2012. U.S. Department of Defense. URL | Detail
  71. DOD, 2014: Quadrennial Defense Review. 64 pp., U.S. Department of Defense. URL | Detail
  72. Donaldson, K., M. I. Gilmour, and W. MacNee, 2000: Asthma and PM10. Respiratory Research, 1, 12-15. doi:10.1186/rr5 | Detail
  73. Donatuto, J., E. E. Grossman, J. Konovsky, S. Grossman, and L. W. Campbell, 2014: Indigenous community health and climate change: Integrating biophysical and social science indicators. Coastal Management, 42, 355-373. doi:10.1080/08920753.2014.923140 | Detail
  74. Donatuto, J. L., T. A. Satterfield, and R. Gregory, 2011: Poisoning the body to nourish the soul: Prioritising health risks and impacts in a Native American community. Health, Risk & Society, 13, 103-127. doi:10.1080/13698575.2011.556186 | Detail
  75. Donner, W., and H. Rodríguez, 2008: Population composition, migration and inequality: The influence of demographic changes on disaster risk and vulnerability. Social Forces, 87, 1089-1114. doi:10.1353/sof.0.0141 | Detail
  76. Doyle, J. T., M. H. Redsteer, and M. J. Eggers, 2013: Exploring effects of climate change on Northern Plains American Indian health. Climatic Change, 120, 643-655. doi:10.1007/s10584-013-0799-z | Detail
  77. Draut, A. E., M. Hiza Redsteer, and L. Amoroso, 2013: Recent seasonal variations in arid landscape cover and aeolian sand mobility, Navajo Nation, southwestern United States. Climates, Landscapes, and Civilizations, L. Giosan, Fuller, D.Q., Nicoll, K., Flad, R.K., and Clift, P.D., Eds., American Geophysical Union, 51-60. doi:10.1029/2012GM001214 | Detail
  78. Drayna, P., S. L. McLellan, P. Simpson, S. -H. Li, and M. H. Gorelick, 2010: Association between rainfall and pediatric emergency department visits for acute gastrointestinal illness. Environmental Health Perspectives, 118, 1439-1443. doi:10.1289/ehp.0901671 | Detail
  79. Dybas, C. L., 2009: Minnesota's moose: Ghosts of the northern forest? Bioscience, 59, 824-828. doi:10.1525/bio.2009.59.10.3 | Detail
  80. Ebi, K., P. Berry, D. Campbell-Lendrum, C. Corvalan, and J. Guillemot, 2013: Protecting Health from Climate Change: Vulnerability and Adaptation Assessment. 62 pp., World Health Organization, Geneva. URL | Detail
  81. Eder, W., M. J. Ege, and E. von Mutius, 2006: The asthma epidemic. New England Journal of Medicine, 355, 2226-2235. doi:10.1056/NEJMra054308 | Detail
  82. Egeland, G., and G. G. Harrison, 2013: Health disparities: Promoting indigenous peoples' health through traditional food systems and self-determination. Indigenous Peoples’ Food Systems & Well-Being: Interventions & Policies for Healthy Communities, H. Kuhnlein, Erasmus, B., Spigelski, D., and Burlingame, B., Eds., Food and Agriculture Organization of the United Nations, 9-22. URL | Detail
  83. Eisenman, D. P., K. M. Cordasco, S. Asch, J. F. Golden, and D. Glik, 2007: Disaster planning and risk communication with vulnerable communities: Lessons from Hurricane Katrina. American Journal of Public Health, 97, S109-S115. doi:10.2105/ajph.2005.084335 | Detail
  84. Eneriz-Wiemer, M., L. M. Sanders, D. A. Barr, and F. S. Mendoza, 2014: Parental limited English proficiency and health outcomes for children with special health care needs: A systematic review. Academic Pediatrics, 14, 128-136. doi:10.1016/j.acap.2013.10.003 | Detail
  85. EPA, 2010: Our Nation’s Air: Status and Trends through 2008. 54 pp., U.S. Environmental Protection Agency, Office of Air Quality Planning and Standards, Research Triangle Park, NC. URL | Detail
  86. EPA, Indian Health Service, Department of Agriculture, and Department of Housing and Urban Development, 2008: Meeting the Access Goal: Strategies for Increasing Access to Safe Drinking Water and Wastewater Treatment to American Indian and Alaska Native Homes. Infrastructure Task Force Access Subgroup, 2008. 34 pp., U.S. Environmental Protection Agency. URL | Detail
  87. Erwin, P. C., and others, 2002: La Crosse encephalitis in eastern Tennessee: Clinical, environmental, and entomological characteristics from a blinded cohort study. American Journal of Epidemiology, 155, 1060-1065. doi:10.1093/aje/155.11.1060 | Detail
  88. Espey, D. K., M. A. Jim, N. Cobb, M. Bartholomew, T. Becker, D. Haverkamp, and M. Plescia, 2014: Leading causes of death and all-cause mortality in American Indians and Alaska Natives. American Journal of Public Health, 104, S303-S311. doi:10.2105/ajph.2013.301798 | Detail
  89. Estrada-Peña, A., 2002: Increasing habitat suitability in the United States for the tick that transmits Lyme disease: A remote sensing approach. Environmental Health Perspectives, 110, 635-640. URL | Detail
  90. Evans-Campbell, T., 2008: Historical trauma in American Indian/Native Alaska communities: A multilevel framework for exploring impacts on individuals, families, and communities. Journal of Interpersonal Violence, 23, 316-338. doi:10.1177/0886260507312290 | Detail
  91. Fairbank, J. A., F. W. Putnam, and W. W. Harris, 2014: Child traumatic stress: Prevalence, trends, risk, and impact. Handbook of PTSD: Science and Practice, M.J. Friedman, Keane, T.M., and Resick, P.A., Eds., Guilford Press, 121-145. | Detail
  92. Filiberto, D., E. Wethington, K. Pillemer, N. Wells, M. Wysocki, and J. T. Parise, 2010: Older people and climate change: Vulnerability and health effects. Generations, 33, 19-25. URL | Detail
  93. Finch, C., C. T. Emrich, and S. L. Cutter, 2010: Disaster disparities and differential recovery in New Orleans. Population and Environment, 31, 179-202. doi:10.1007/s11111-009-0099-8 | Detail
  94. Finkelstein, M. M., M. Jerrett, P. DeLuca, N. Finkelstein, D. K. Verma, K. Chapman, and M. R. Sears, 2003: Relation between income, air pollution and mortality: A cohort study. Canadian Medical Association Journal, 169, 397-402. URL | Detail
  95. Ford, J. D., A. C. Willox, S. Chatwood, C. Furgal, S. Harper, I. Mauro, and T. Pearce, 2014: Adapting to the effects of climate change on Inuit health. American Journal of Public Health, 104 Suppl 3, e9-e17. doi:10.2105/ajph.2013.301724 | Detail
  96. Ford, J. D., and B. Smit, 2004: A framework for assessing the vulnerability of communities in the Canadian arctic to risks associated with climate change. Arctic, 57, 389-400. doi:10.14430/arctic516 | Detail
  97. Fothergill, A., and L. A. Peek, 2004: Poverty and disasters in the United States: A review of recent sociological findings. Natural Hazards, 32, 89-110. doi:10.1023/B:NHAZ.0000026792.76181.d9 | Detail
  98. Fox, M. H., G. W. White, C. Rooney, and A. Cahill, 2010: The psychosocial impact of Hurricane Katrina on persons with disabilities and independent living center staff living on the American Gulf Coast. Rehabilitation Psychology, 55, 231-240. doi:10.1037/a0020321 | Detail
  99. Frey, W., cited 2011: The New Metro Minority Map: Regional Shifts in Hispanics, Asians, and Blacks from Census 2010. Brookings Institution. URL | Detail
  100. Friel, S., M. Marmot, A. J. McMichael, T. Kjellstrom, and D. Vågerö, 2008: Global health equity and climate stabilisation: A common agenda. The Lancet, 372, 1677-1683. doi:10.1016/s0140-6736(08)61692-x | Detail
  101. Frumkin, H., 2002: Urban sprawl and public health. Public Health Reports, 117, 201-217. PMID: 12432132 | Detail
  102. Frumkin, H., J. Hess, G. Luber, J. Malilay, and M. McGeehin, 2008: Climate change: The public health response. American Journal of Public Health, 98, 435-445. doi:10.2105/AJPH.2007.119362 | Detail
  103. Fuentes-Afflick, E., and N. A. Hessol, 2009: Immigration status and use of health services among Latina women in the San Francisco Bay Area. Journal of Women's Health, 18, 1275-1280. doi:10.1089/jwh.2008.1241 | Detail
  104. Gamble, J. L., B. J. Hurley, P. A. Schultz, W. S. Jaglom, N. Krishnan, and M. Harris, 2013: Climate change and older Americans: State of the science. Environmental Health Perspectives, 121, 15-22. doi:10.1289/ehp.1205223 | Detail
  105. Garibaldi, A., and N. Turner, 2004: Cultural keystone species: Implications for ecological conservation and restoration. Ecology and Society, 9, 1. URL | Detail
  106. Gauderman, W. J., and others, 2004: The effect of air pollution on lung development from 10 to 18 years of age. New England Journal of Medicine, 351, 1057-1067. doi:10.1056/NEJMoa040610 | Detail
  107. Gibbons, R. V., M. Streitz, T. Babina, and J. R. Fried, 2012: Dengue and US military operations from the Spanish-American War through today. Emerging Infectious Diseases, 18, 623-630. doi:10.3201/eid1804.110134 | Detail
  108. Gilchrist, J., T. Haileyesus, M. Murphy, R. D. Comstock, C. Collins, N. McIlvain, and E. Yard, 2010: Heat illness among high school athletes --- United States, 2005-2009. Morbidity and Mortality Weekly Report, 59, 1009-1013. PMID: 20724966 | Detail
  109. Gottschalk, A. W., and J. T. Andrish, 2011: Epidemiology of sports injury in pediatric athletes. Sports Medicine and Arthroscopy Review, 19, 2-6. doi:10.1097/JSA.0b013e31820b95fc | Detail
  110. Green, R. S., R. Basu, B. Malig, R. Broadwin, J. J. Kim, and B. Ostro, 2010: The effect of temperature on hospital admissions in nine California counties. International Journal of Public Health, 55, 113-121. doi:10.1007/s00038-009-0076-0 | Detail
  111. Gubernot, D. M., G. B. Anderson, and K. L. Hunting, 2014: The epidemiology of occupational heat exposure in the United States: A review of the literature and assessment of research needs in a changing climate. International Journal of Biometeorology, 58, 1779-1788. doi:10.1007/s00484-013-0752-x | Detail
  112. Gubler, D. J., P. Reiter, K. L. Ebi, W. Yap, R. Nasci, and J. A. Patz, 2001: Climate variability and change in the United States: Potential impacts on vector- and rodent-borne diseases. Environmental Health Perspectives, 109, 223-233. doi:10.2307/3435012 | Detail
  113. G. Weller, P. A. and B. W., ed., 1999: Preparing for a Changing Climate: The Potential Consequences of Climate Variability and Change in Alaska. A Report of the Alaska Regional Assessment Group for the U.S. Global Change Research Program. Center for Global Change and Arctic System Research, University of Alaska Fairbanks, 42 pp. URL | Detail
  114. Gwynn, R. C., and G. D. Thurston, 2001: The burden of air pollution: Impacts among racial minorities. Environmental Health Perspectives, 109, 501-506. URL | Detail
  115. Hamilton, B. E., P. D. Sutton, T. J. Mathews, J. A. Martin, and S. J. Ventura, 2009: The effect of Hurricane Katrina: Births in the U.S. Gulf Coast region, before and after the storm. National Vital Statistics Reports, 58, 1-28, 32. PMID: 19754006 | Detail
  116. Hansen, A. L., P. Bi, P. Ryan, M. Nitschke, D. Pisaniello, and G. Tucker, 2008: The effect of heat waves on hospital admissions for renal disease in a temperate city of Australia. International Journal of Epidemiology, 37, 1359-1365. doi:10.1093/ije/dyn165 | Detail
  117. Hansen, A., P. Bi, M. Nitschke, D. Pisaniello, J. Newbury, and A. Kitson, 2011: Older persons and heat-susceptibility: The role of health promotion in a changing climate. Health Promotion Journal of Australia, 22, 17-20. doi:10.1071/HE11417 | Detail
  118. Hansen, A., P. Bi, M. Nitschke, D. Pisaniello, J. Newbury, and A. Kitson, 2011: Perceptions of heat-susceptibility in older persons: Barriers to adaptation. International Journal of Environmental Research and Public Health, 8, 4714-4728. doi:10.3390/ijerph8124714 | Detail
  119. Haq, G., J. Whiteleg, and M. Kohler, 2008: Growing Old in a Changing Climate: Meeting the Challenges of an Ageing Population and Climate Change. 28 pp., Stockholm Environment Institute, Stockholm, Sweden. URL | Detail
  120. Hardy, K., and L. K. Comfort, 2015: Dynamic decision processes in complex, high-risk operations: The Yarnell Hill Fire, June 30, 2013. Safety Science, 71(Part A), 39-47. doi:10.1016/j.ssci.2014.04.019 | Detail
  121. Harlan, S. L., A. J. Brazel, L. Prashad, W. L. Stefanov, and L. Larsen, 2006: Neighborhood microclimates and vulnerability to heat stress. Social Science & Medicine, 63, 2847-2863. doi:10.1016/j.socscimed.2006.07.030 | Detail
  122. Harlan, S. L., J. H. Declet-Barreto, W. L. Stefanov, and D. B. Petitti, 2013: Neighborhood effects on heat deaths: Social and environmental predictors of vulnerability in Maricopa County, Arizona. Environmental Health Perspectives, 121, 197-204. doi:10.1289/ehp.1104625 | Detail
  123. Harville, E. W., X. Xiong, and P. Buekens, 2009: Hurricane Katrina and perinatal health. Birth, 36, 325-331. doi:10.1111/j.1523-536X.2009.00360.x | Detail
  124. Hausfater, P., and others, 2009: Prognostic factors in non-exertional heatstroke. Intensive Care Medicine, 36, 272-280. doi:10.1007/s00134-009-1694-y | Detail
  125. Hennessy, T. W., and others, 2008: The relationship between in-home water service and the risk of respiratory tract, skin, and gastrointestinal tract infections among rural Alaska natives. American Journal of Public Health, 98, 2072-2078. doi:10.2105/ajph.2007.115618 | Detail
  126. Hess, J. J., S. Saha, and G. Luber, 2014: Summertime acute heat illness in U.S. emergency departments from 2006 through 2010: Analysis of a nationally representative sample. Environmental Health Perspectives, 122, 1209-1215. doi:10.1289/ehp.1306796 | Detail
  127. Hilborn, E. D., and others, 2014: Algal bloom-associated disease outbreaks among users of freshwater lakes--United States, 2009-2010. Morbidity and Mortality Weekly Report, 63, 11-15. PMID: 24402467 | Detail
  128. Hinzman, L. D., and others, 2005: Evidence and implications of recent climate change in Northern Alaska and other Arctic regions. Climatic Change, 72, 251-298. doi:10.1007/s10584-005-5352-2 | Detail
  129. Hodge, D. R., and G. E. Limb, 2010: A Native American perspective on spiritual assessment: The strengths and limitations of a complementary set of assessment tools. Health & Social Work, 35, 121-131. doi:10.1093/hsw/35.2.121 | Detail
  130. Hodge, D. R., G. E. Limb, and T. L. Cross, 2009: Moving from colonization toward balance and harmony: A Native American perspective on wellness. Social Work, 54, 211-219. doi:10.1093/sw/54.3.211 | Detail
  131. Hoover, E., and others, 2012: Indigenous peoples of North America: Environmental exposures and reproductive justice. Environmental Health Perspectives, 120, 1645-1649. doi:10.1289/ehp.1205422 | Detail
  132. HUD, 2007: Measuring Overcrowding in Housing. 38 pp., U.S. Department of Housing and Urban Development, Office of Policy Development and Research. URL | Detail
  133. Humes, K. R., N. A. Jones, and R. R. Ramirez, 2011: Overview of Race and Hispanic Origin: 2010. 23 pp., U.S. Census Bureau. URL | Detail
  134. Hurt, L., and K. A. Dorsey, 2014: The geographic distribution of incident Lyme disease among active component service members stationed in the continental United States, 2004-2013. MSMR: Medical Surveillance Monthly Report, 21, 13-15. PMID: 24885878 | Detail
  135. Hutton, D., 2010: Vulnerability of children: More than a question of age. Radiation Protection Dosimetry, 142, 54-57. doi:10.1093/rpd/ncq200 | Detail
  136. Imhoff, B., and others, 2004: Burden of self‐reported acute diarrheal illness in FoodNet surveillance areas, 1998–1999. Clinical Infectious Diseases, 38, S219-S226. doi:10.1086/381590 | Detail
  137. IOM, 2010: Providing Healthy and Safe Foods As We Age: Workshop Summary. Institute of Medicine. The National Academies Press, 192 pp. URL | Detail
  138. IPCC, 2014: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. 1132 pp., Cambridge University Press, Cambridge, UK and New York, NY. URL | Detail
  139. Jagai, J. S., J. K. Griffiths, P. K. Kirshen, P. Webb, and E. N. Naumova, 2012: Seasonal patterns of gastrointestinal illness and streamflow along the Ohio River. International Journal of Environmental Research and Public Health, 9, 1771-1790. doi:10.3390/ijerph9051771 | Detail
  140. Janakiraman, V., 2008: Listeriosis in pregnancy: Diagnosis, treatment, and prevention. Reviews in Obstetrics and Gynecology, 1, 179-185. URL | Detail
  141. Jan, S., and N. Lurie, 2012: Disaster resilience and people with functional needs. New England Journal of Medicine, 367, 2272-2273. doi:10.1056/NEJMp1213492 | Detail
  142. Jayachandran, S., 2009: Air quality and early-life mortality: Evidence from Indonesia’s wildfires. The Journal of Human Resources, 44, 916-954. doi:10.3368/jhr.44.4.916 | Detail
  143. Jesdale, B. M., R. Morello-Frosch, and L. Cushing, 2013: The racial/ethnic distribution of heat risk–related land cover in relation to residential segregation. Environmental Health Perspectives, 121, 811-817. doi:10.1289/ehp.1205919 | Detail
  144. Jhung, M. A., N. Shehab, C. Rohr-Allegrini, D. A. Pollock, R. Sanchez, F. Guerra, and D. B. Jernigan, 2007: Chronic disease and disasters: Medication demands of Hurricane Katrina evacuees. American Journal of Preventive Medicine, 33, 207-210. doi:10.1016/j.amepre.2007.04.030 | Detail
  145. Joseph, N. T., K. A. Matthews, and H. F. Myers, 2014: Conceptualizing health consequences of Hurricane Katrina from the perspective of socioeconomic status decline. Health Psychology, 33, 139-146. doi:10.1037/a0031661 | Detail
  146. Kailes, J. I., and A. Enders, 2007: Moving beyond "special needs": A function-based framework for emergency management and planning. Journal of Disability Policy Studies, 17, 230-237. doi:10.1177/10442073070170040601 | Detail
  147. Keim, M. E., 2008: Building human resilience: The role of public health preparedness and response as an adaptation to climate change. American Journal of Preventive Medicine, 35, 508-516. doi:10.1016/j.amepre.2008.08.022 | Detail
  148. Kellogg, J., J. Wang, C. Flint, D. Ribnicky, P. Kuhn, E. G. De Mejia, I. Raskin, and M. A. Lila, 2010: Alaskan wild berry resources and human health under the cloud of climate change. Journal of Agricultural and Food Chemistry, 58, 3884-3900. doi:10.1021/jf902693r | Detail
  149. Kent, S. T., L. A. McClure, B. F. Zaitchik, T. T. Smith, and J. M. Gohlke, 2014: Heat waves and health outcomes in Alabama (USA): The importance of heat wave definition. Environmental Health Perspectives, 122, 151–158. doi:10.1289/ehp.1307262 | Detail
  150. Keppel, K. G., 2007: Ten largest racial and ethnic health disparities in the United States based on Healthy People 2010 objectives. American Journal of Epidemiology, 166, 97-103. doi:10.1093/aje/kwm044 | Detail
  151. Kerr, Z. Y., D. J. Casa, S. W. Marshall, and R. D. Comstock, 2013: Epidemiology of exertional heat illness among U.S. high school athletes. American Journal of Preventive Medicine, 44, 8-14. doi:10.1016/j.amepre.2012.09.058 | Detail
  152. Kim, J. J., and others, 2004: Ambient air pollution: Health hazards to children. Pediatrics, 114, 1699-1707. doi:10.1542/peds.2004-2166 | Detail
  153. Kington, R. S., and J. P. Smith, 1997: Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health, 87, 805-810. doi:10.2105/AJPH.87.5.805 | Detail
  154. Kistin, E. J., J. Fogarty, R. S. Pokrasso, M. McCally, and P. G. McCornick, 2010: Climate change, water resources and child health. Archives of Disease in Childhood, 95, 545-549. doi:10.1136/adc.2009.175307 | Detail
  155. Kjellstrom, T., R. S. Kovats, S. J. Lloyd, T. Holt, and R. S. J. Tol, 2009: The direct impact of climate change on regional labor productivity. Archives of Environmental & Occupational Health, 64, 217-227. doi:10.1080/19338240903352776 | Detail
  156. Klein, T. A., and others, 2009: Plasmodium vivax malaria among U.S. Forces Korea in the Republic of Korea, 1993-2007. Military Medicine, 174, 412-418. doi:10.7205/MILMED-D-01-4608 | Detail
  157. Knowlton, K., M. Rotkin-Ellman, G. King, H. G. Margolis, D. Smith, G. Solomon, R. Trent, and P. English, 2009: The 2006 California heat wave: Impacts on hospitalizations and emergency department visits. Environmental Health Perspectives, 117, 61-67. doi:10.1289/ehp.11594 | Detail
  158. Kotwal, R. S., R. B. Wenzel, R. A. Sterling, W. D. Porter, N. N. Jordan, and B. P. Petruccelli, 2005: An outbreak of malaria in US Army Rangers returning from Afghanistan. JAMA: The Journal of the American Medical Association, 293, 212-216. doi:10.1001/jama.293.2.212 | Detail
  159. Kovats, R. S., and S. Hajat, 2008: Heat stress and public health: A critical review. Annual Review of Public Health, 29, 41-55. doi:10.1146/annurev.publhealth.29.020907.090843 | Detail
  160. Kravchenko, J., A. P. Abernethy, M. Fawzy, and H. K. Lyerly, 2013: Minimization of heatwave morbidity and mortality. American Journal of Preventive Medicine, 44, 274-282. doi:10.1016/j.amepre.2012.11.015 | Detail
  161. Kuhnlein, H. V., O. Receveur, R. Soueida, and G. M. Egeland, 2004: Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity. The Journal of Nutrition, 134, 1447-1453. URL | Detail
  162. Laditka, S. B., J. N. Laditka, S. Xirasagar, C. B. Cornman, C. B. Davis, and J. V. E. Richter, 2008: Providing shelter to nursing home evacuees in disasters: Lessons from Hurricane Katrina. American Journal of Public Health, 98, 1288-1293. doi:10.2105/ajph.2006.107748 | Detail
  163. Laidler, G. J., J. D. Ford, W. A. Gough, T. Ikummaq, A. S. Gagnon, S. Kowal, K. Qrunnut, and C. Irngaut, 2009: Travelling and hunting in a changing Arctic: Assessing Inuit vulnerability to sea ice change in Igloolik, Nunavut. Climatic Change, 94, 363-397. doi:10.1007/s10584-008-9512-z | Detail
  164. Lane, K., K. Charles-Guzman, K. Wheeler, Z. Abid, N. Graber, and T. Matte, 2013: Health effects of coastal storms and flooding in urban areas: A review and vulnerability assessment. Journal of Environmental and Public Health, 2013, 1-13. doi:10.1155/2013/913064 | Detail
  165. Larson, N. I., M. T. Story, and M. C. Nelson, 2009: Neighborhood environments: Disparities in access to healthy foods. American Journal of Preventive Medicine, 36, 74-81.e10. doi:10.1016/j.amepre.2008.09.025 | Detail
  166. Laumbach, R. J., 2010: Outdoor air pollutants and patient health. American Family Physician, 81, 175-180. URL | Detail
  167. Lazrus, H., B. H. Morrow, R. E. Morss, and J. K. Lazo, 2012: Vulnerability beyond stereotypes: Context and agency in hurricane risk communication. Weather, Climate, and Society, 4, 103-109. doi:10.1175/wcas-d-12-00015.1 | Detail
  168. Leikauf, G. D., 2002: Hazardous air pollutants and asthma. Environmental Health Perspectives, 110 Suppl 4, 505-526. URL | Detail
  169. Lemyre, L., S. Gibson, J. Zlepnig, R. Meyer-Macleod, and P. Boutette, 2009: Emergency preparedness for higher risk populations: Psychosocial considerations. Radiation Protection Dosimetry, 134, 207-214. doi:10.1093/rpd/ncp084 | Detail
  170. Lenarz, M. S., M. E. Nelson, M. W. Schrage, and A. J. Edwards, 2009: Temperature mediated moose survival in northeastern Minnesota. The Journal of Wildlife Management, 73, 503-510. doi:10.2193/2008-265 | Detail
  171. Lewitus, A. J., and others, 2012: Harmful algal blooms along the North American west coast region: History, trends, causes, and impacts. Harmful Algae, 19, 133-159. doi:10.1016/j.hal.2012.06.009 | Detail
  172. Lindsey, N. P., J. E. Staples, J. A. Lehman, and M. Fischer, 2010: Surveillance for human West Nile virus disease - United States, 1999-2008. Morbidity and Mortality Weekly Report - Surveillance Summaries, 59, 1-17. PMID: 20360671 | Detail
  173. Lin, S., M. Luo, R. J. Walker, X. Liu, S. A. Hwang, and R. Chinery, 2009: Extreme high temperatures and hospital admissions for respiratory and cardiovascular diseases. Epidemiology, 20, 738-746. doi:10.1097/EDE.0b013e3181ad5522 | Detail
  174. Lin, S., X. Liu, L. H. Le, and S. -A. Hwang, 2008: Chronic exposure to ambient ozone and asthma hospital admissions among children. Environmental Health Perspectives, 116, 1725-1730. doi:10.1289/ehp.11184 | Detail
  175. Little, B., and others, 2004: Rapid assessment of the needs and health status of older adults after Hurricane Charley--Charlotte, DeSoto, and Hardee Counties, Florida, August 27-31, 2004. Morbidity and Mortality Weekly Report, 53, 837-840. PMID: 15371964 | Detail
  176. Loladze, I., 2014: Hidden shift of the ionome of plants exposed to elevated CO2 depletes minerals at the base of human nutrition. eLife, 3, e02245. doi:10.7554/eLife.02245 | Detail
  177. Luber, G., and M. McGeehin, 2008: Climate change and extreme heat events. American Journal of Preventive Medicine, 35, 429-435. doi:10.1016/j.amepre.2008.08.021 | Detail
  178. Luber, G., and N. Prudent, 2009: Climate change and human health. Transactions of the American Clinical and Climatological Association, 120, 113-117. URL | Detail
  179. Luber, G., and others, 2014: Ch. 9: Human Health. Climate Change Impacts in the United States: The Third National Climate Assessment, J.M. Melillo, Richmond, T. (T.C.), and Yohe, G.W., Eds., U.S. Global Change Research Program, 220-256. doi:10.7930/J0PN93H5 | Detail
  180. Lundgren, K., K. Kuklane, C. Gao, and I. Holmer, 2013: Effects of heat stress on working populations when facing climate change. Industrial Health, 51, 3-15. doi:10.2486/indhealth.2012-0089 | Detail
  181. Lynn, K., and others, 2013: The impacts of climate change on tribal traditional foods. Climatic Change, 120, 545-556. doi:10.1007/s10584-013-0736-1 | Detail
  182. Makri, A., and N. I. Stilianakis, 2008: Vulnerability to air pollution health effects. International Journal of Hygiene and Environmental Health, 211, 326-336. doi:10.1016/j.ijheh.2007.06.005 | Detail
  183. Maldonado, C. Z., R. M. Rodriguez, J. R. Torres, Y. S. Flores, and L. M. Lovato, 2013: Fear of discovery among Latino immigrants presenting to the emergency department. Academic Emergency Medicine, 20, 155-161. doi:10.1111/acem.12079 | Detail
  184. Manangan, A. P., C. K. Uejio, S. Saha, P. J. Schramm, G. D. Marinucci, C. L. Brown, J. J. Hess, and G. Luber, 2014: Assessing Health Vulnerability to Climate Change: A Guide for Health Departments. 24 pp., Climate and Health Technical Report Series, Centers for Disease Control and Prevention, Atlanta, GA. URL | Detail
  185. March of Dimes, PMNCH, Save the Children, and WHO, 2012: Born Too Soon: The Global Action Report on Preterm Birth. 112 pp., World Health Organization, Geneva, Switzerland. URL | Detail
  186. Martin-Latry, K., M. P. Goumy, P. Latry, C. Gabinski, B. Bégaud, I. Faure, and H. Verdoux, 2007: Psychotropic drugs use and risk of heat-related hospitalisation. European Psychiatry, 22, 335-338. doi:10.1016/j.eurpsy.2007.03.007 | Detail
  187. McBride, G. B., R. Stott, W. Miller, D. Bambic, and S. Wuertz, 2013: Discharge-based QMRA for estimation of public health risks from exposure to stormwater-borne pathogens in recreational waters in the United States. Water Research, 47, 5282-5297. doi:10.1016/j.watres.2013.06.001 | Detail
  188. McCormack, M. C., P. N. Breysse, E. C. Matsui, N. N. Hansel, D. 'A. Williams, J. Curtin-Brosnan, P. Eggleston, and G. B. Diette, 2009: In-home particle concentrations and childhood asthma morbidity. Environmental Health Perspectives, 117, 294-298. doi:10.1289/ehp.11770 | Detail
  189. McGeehin, M. A., and M. Mirabelli, 2001: The potential impacts of climate variability and change on temperature-related morbidity and mortality in the United States. Environmental Health Perspectives, 109, 185-189. doi:10.2307/3435008 | Detail
  190. McMichael, A. J., 2013: Globalization, climate change, and human health. New England Journal of Medicine, 368, 1335-1343. doi:10.1056/NEJMra1109341 | Detail
  191. Melillo, J. M., T. (T. C. ) Richmond, and G. W. Yohe, eds., 2014: Climate Change Impacts in the United States: The Third National Climate Assessment. U.S. Global Change Research Program, 841 pp. doi:10.7930/J0Z31WJ2 | Detail
  192. Milburn, M. P., 2004: Indigenous nutrition: Using traditional food knowledge to solve contemporary health problems. The American Indian Quarterly, 28, 411-434. doi:10.1353/aiq.2004.0104 | Detail
  193. Miller, A. C., and B. Arquilla, 2008: Chronic diseases and natural hazards: Impact of disasters on diabetic, renal, and cardiac patients. Prehospital and Disaster Medicine, 23, 185-194. doi:10.1017/S1049023X00005835 | Detail
  194. Miranda, M. L., D. A. Hastings, J. E. Aldy, and W. H. Schlesinger, 2011: The environmental justice dimensions of climate change. Environmental Justice, 4, 17-25. doi:10.1089/env.2009.0046 | Detail
  195. Moerlein, K. J., and C. Carothers, 2012: Total environment of change: Impacts of climate change and social transitions on subsistence fisheries in northwest Alaska. Ecology and Society, 17, 10. doi:10.5751/es-04543-170110 | Detail
  196. Myers, S. S., and others, 2014: Increasing CO2 threatens human nutrition. Nature, 510, 139-142. doi:10.1038/nature13179 | Detail
  197. Nakashima, D. J., K. Galloway McLean, H. D. Thulstrup, A. Ramos Castillo, and J. T. Rubis, 2012: Weathering Uncertainty: Traditional Knowledge for Climate Change Assessment and Adaptation. 120 pp., UNESCO, Paris and UNU, Darwin. URL | Detail
  198. Naumova, E. N., A. I. Egorov, R. D. Morris, and J. K. Griffiths, 2003: The elderly and waterborne Cryptosporidium infection: Gatroenteritis hospitalizations before and during the 1993 Milwaukee outbreak. Emerging Infectious Diseases, 9, 418-425. doi:10.3201/eid0904.020260 | Detail
  199. NCHS, 2014: Table 49. Disability measures among adults aged 18 and over, by selected characteristics: United States, selected years 1997–2012. Health, United States, 2013: With Special Feature on Prescription Drugs, National Center for Health Statistics, 172-173. URL | Detail
  200. Nelson, G. C., and others, 2009: Climate Change: Impact on Agriculture and Costs of Adaptation. 30 pp., International Food Policy Research Institute, Washington, D.C. doi:10.2499/0896295354 | Detail
  201. Nelson, N. G., C. L. Collins, R. D. Comstock, and L. B. McKenzie, 2011: Exertional heat-related injuries treated in emergency departments in the U.S., 1997–2006. American Journal of Preventive Medicine, 40, 54-60. doi:10.1016/j.amepre.2010.09.031 | Detail
  202. Nick, G. A., and others, 2009: Emergency preparedness for vulnerable populations: People with special health-care needs. Public Health Reports, 124, 338-343. PMID: 19320378 | Detail
  203. Nilsson, M., and T. Kjellstrom, 2010: Invited Editorial: Climate change impacts on working people: How to develop prevention policies. Global Health Action, 3. doi:10.3402/gha.v3i0.5774 | Detail
  204. NIOSH, 2012: Fact Sheet: Wildland Fire Fighting. Hot Tips to Stay Safe and Healthy. 2 pp., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Washington, D.C. URL | Detail
  205. Nordon, C., K. Martin-Latry, L. de Roquefeuil, P. Latry, B. Beqaud, B. Falissard, F. Rouillon, and H. Verdoux, 2009: Risk of death related to psychotropic drug use in older people during the European 2003 heatwave: A population-based case–control study. The American Journal of Geriatric Psychiatry, 17, 1059-1067. doi:10.1097/JGP.0b013e3181b7ef6e | Detail
  206. Noyes, P. D., M. K. McElwee, H. D. Miller, B. W. Clark, L. A. Van Tiem, K. C. Walcott, K. N. Erwin, and E. D. Levin, 2009: The toxicology of climate change: Environmental contaminants in a warming world. Environment International, 35, 971-986. doi:10.1016/j.envint.2009.02.006 | Detail
  207. NRC, 2010: Adapting to Impacts of Climate Change. America’s Climate Choices: Report of the Panel on Adapting to the Impacts of Climate Change. National Research Council. The National Academies Press, 292 pp. URL | Detail
  208. NRC, 2012: Disaster Resilience: A National Imperative. National Academies Press, 244 pp. | Detail
  209. O’Neill, M. S., and K. L. Ebi, 2009: Temperature extremes and health: Impacts of climate variability and change in the United States. Journal of Occupational and Environmental Medicine, 51, 13-25. doi:10.1097/JOM.0b013e318173e122 | Detail
  210. O’Neill, M. S., A. Zanobetti, and J. Schwartz, 2005: Disparities by race in heat-related mortality in four US cities: The role of air conditioning prevalence. Journal of Urban Health, 82, 191-197. doi:10.1093/jurban/jti043 | Detail
  211. O’Neill, M. S., R. Carter, J. K. Kish, C. J. Gronlund, J. L. White-Newsome, X. Manarolla, A. Zanobetti, and J. D. Schwartz, 2009: Preventing heat-related morbidity and mortality: New approaches in a changing climate. Maturitas, 64, 98-103. doi:10.1016/j.maturitas.2009.08.005 | Detail
  212. O'Neill, M. S., P. L. Kinney, and A. J. Cohen, 2008: Environmental equity in air quality management: Local and international implications for human health and climate change. Journal of Toxicology and Environmental Health, Part A: Current Issues, 71, 570-577. doi:10.1080/15287390801997625 | Detail
  213. Ortega, A. N., H. Fang, V. H. Perez, J. A. Rizzo, O. Carter-Pokras, S. P. Wallace, and L. Gelberg, 2007: Health care access, use of services, and experiences among undocumented Mexicans and other Latinos. Archives of Internal Medicine, 167, 2354-2360. doi:10.1001/archinte.167.21.2354 | Detail
  214. Ostro, B., L. Roth, B. Malig, and M. Marty, 2009: The effects of fine particle components on respiratory hospital admissions in children. Environmental Health Perspectives, 117, 475-480. doi:10.1289/ehp.11848 | Detail
  215. Ostro, B., S. Rauch, R. Green, B. Malig, and R. Basu, 2010: The effects of temperature and use of air conditioning on hospitalizations. American Journal of Epidemiology, 172, 1053-1061. doi:10.1093/aje/kwq231 | Detail
  216. Parker, J. D., L. J. Akinbami, and T. J. Woodruff, 2009: Air pollution and childhood respiratory allergies in the United States. Environmental Health Perspectives, 117, 140-147. doi:10.1289/ehp.11497 | Detail
  217. Passel, J. S., and D. Cohn, 2011: Unauthorized Immigrant Population: National and State Trends, 2010. 31 pp., Pew Research Center, Washington, D.C. URL | Detail
  218. Pastor, M., R. D. Bullard, J. K. Boyce, A. Fothergill, R. Morello-Frosch, and B. Wright, 2006: In the Wake of the Storm: Environment, Disaster, and Race After Katrina. Russell Sage Foundation. | Detail
  219. Patz, J. A., and W. K. Reisen, 2001: Immunology, climate change and vector-borne diseases. Trends in Immunology, 22, 171-172. doi:10.1016/S1471-4906(01)01867-1 | Detail
  220. Peden, D. B., 2002: Pollutants and asthma: Role of air toxics. Environmental Health Perspectives, 110 Suppl 4, 565-568. URL | Detail
  221. Plassman, B. L., and others, 2007: Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29, 125-132. doi:10.1159/000109998 | Detail
  222. Polin, R. A., and S. H. Abman, 2011: Thermoregulation. Fetal and Neonatal Physiology, Elsevier, 615-670. | Detail
  223. Pope, C. A., and D. W. Dockery, 1999: Epidemiology of particle effects. Air Pollution and Health, S.T. Holgate, Samet, J.M., Hillel, S.K., and Maynard, R.L., Eds., Academic Press, 673-706. | Detail
  224. Pope, C. A., R. T. Burnett, M. J. Thun, E. E. Calle, D. Krewski, K. Ito, and G. D. Thurston, 2002: Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. JAMA: The Journal of the American Medical Association, 287, 1132-1141. doi:10.1001/jama.287.9.1132 | Detail
  225. Powell, L. M., S. Slater, D. Mirtcheva, Y. Bao, and F. J. Chaloupka, 2007: Food store availability and neighborhood characteristics in the United States. Preventive Medicine, 44, 189-195. doi:10.1016/j.ypmed.2006.08.008 | Detail
  226. Preston, B. L., E. J. Yuen, and R. M. Westaway, 2011: Putting vulnerability to climate change on the map: A review of approaches, benefits, and risks. Sustainability Science, 6, 177-202. doi:10.1007/s11625-011-0129-1 | Detail
  227. Ramin, B., and T. Svoboda, 2009: Health of the homeless and climate change. Journal of Urban Health, 86, 654-664. doi:10.1007/s11524-009-9354-7 | Detail
  228. Rasmussen, S. A., D. J. Jamieson, and T. M. Uyeki, 2012: Effects of influenza on pregnant women and infants. American Journal of Obstetrics and Gynecology, 207, S3-S8. doi:10.1016/j.ajog.2012.06.068 | Detail
  229. R., D., 2013: Special Issue: Climate Change and Indigenous Peoples in the United States: Impacts, Experiences and Actions. Climatic Change, 120, 509-682. doi:10.1007/s10584-013-0849-6 | Detail
  230. Redsteer, M. H., K. B. Kelley, H. Francis, and D. Block, 2011: Disaster Risk Assessment Case Study: Recent Drought on the Navajo Nation, Southwestern United States. Contributing Paper for the Global Assessment Report on Disaster Risk Reduction. 19 pp., United Nations Office for Disaster Risk Reduction and U.S. Geological Survey, Reston, VA. URL | Detail
  231. Redsteer, M. H., R. C. Bogle, and J. M. Vogel, 2011: Monitoring and Analysis of Sand Dune Movement and Growth on the Navajo Nation, Southwestern United States. 2 pp., U.S. Geological Survey, Reston, VA. URL | Detail
  232. Reeves, W. K., N. M. Rowe, R. K. Kugblenu, and C. L. Magnuson, 2015: Case Series: Chikungunya and dengue at a forward operating location. MSMR: Medical Surveillance Monthly Report, 22, 9-10. PMID: 25996171 | Detail
  233. Reid, C. E., and J. L. Gamble, 2009: Aeroallergens, allergic disease, and climate change: Impacts and adaptation. EcoHealth, 6, 458-470. doi:10.1007/s10393-009-0261-x | Detail
  234. Reid, C. E., and others, 2012: Evaluation of a heat vulnerability index on abnormally hot days: An environmental public health tracking study. Environmental Health Perspectives, 120, 715-720. doi:10.1289/ehp.1103766 | Detail
  235. Ren, C., M. S. O'Neill, S. K. Park, D. Sparrow, P. Vokonas, and J. Schwartz, 2011: Ambient temperature, air pollution, and heart rate variability in an aging population. American Journal of Epidemiology, 173, 1013-1021. doi:10.1093/aje/kwq477 | Detail
  236. Reynolds, P., J. Von Behren, R. B. Gunier, D. E. Goldberg, A. Hertz, and D. F. Smith, 2003: Childhood cancer incidence rates and hazardous air pollutants in California: An exploratory analysis. Environmental Health Perspectives, 111, 663-668. doi:10.1289/ehp.5986 | Detail
  237. Riera, A., A. Navas-Nazario, V. Shabanova, and F. E. Vaca, 2014: The impact of limited English proficiency on asthma action plan use. Journal of Asthma, 51, 178-184. doi:10.3109/02770903.2013.858266 | Detail
  238. Ritz, B., M. Wilhelm, K. J. Hoggatt, and J. K. C. Ghosh, 2007: Ambient air pollution and preterm birth in the Environment and Pregnancy Outcomes Study at the University of California, Los Angeles. American Journal of Epidemiology, 166, 1045-1052. doi:10.1093/aje/kwm181 | Detail
  239. Roberts, J. W., L. A. Wallace, D. E. Camann, P. Dickey, S. G. Gilbert, R. G. Lewis, and T. K. Takaro, 2009: Monitoring and reducing exposure of infants to pollutants in house dust. Reviews of Environmental Contamination and Toxicology, 201, 1-39. doi:10.1007/978-1-4419-0032-6_1 | Detail
  240. Roelofs, C., and D. Wegman, 2014: Workers: The climate canaries. American Journal of Public Health, 104, 1799-1801. doi:10.2105/AJPH.2014.302145 | Detail
  241. Ruckelshaus, M., and others, 2013: Securing ocean benefits for society in the face of climate change. Marine Policy, 40, 154-159. doi:10.1016/j.marpol.2013.01.009 | Detail
  242. Rylander, C., J. O. Odland, and T. M. Sandanger, 2013: Climate change and the potential effects on maternal and pregnancy outcomes: an assessment of the most vulnerable – the mother, fetus, and newborn child. Global Health Action, 6, 19538. doi:10.3402/gha.v6i0.19538 | Detail
  243. Sack, R. B., and others, 1995: Diarrhoeal diseases in the White Mountain Apaches: Clinical studies. Journal of Diarrhoeal Diseases Research, 13, 12-17. | Detail
  244. Sanders, S., S. L. Bowie, and Y. D. Bowie, 2004: Chapter 2 Lessons Learned on Forced Relocation of Older Adults. Journal of Gerontological Social Work, 40, 23-35. doi:10.1300/J083v40n04_03 | Detail
  245. Sarche, M., and P. Spicer, 2008: Poverty and health disparities for American Indian and Alaska Native children. Annals of the New York Academy of Sciences, 1136, 126-136. doi:10.1196/annals.1425.017 | Detail
  246. Satia, J. A., 2009: Diet-related disparities: Understanding the problem and accelerating solutions. Journal of the American Dietetic Association, 109, 610-615. doi:10.1016/j.jada.2008.12.019 | Detail
  247. Schifano, P., G. Cappai, M. De Sario, P. Michelozzi, C. Marino, A. Bargagli, and C. A. Perucci, 2009: Susceptibility to heat wave-related mortality: A follow-up study of a cohort of elderly in Rome. Environmental Health, 8, Article 50. doi:10.1186/1476-069x-8-50 | Detail
  248. Schulte, P. A., and H. K. Chun, 2009: Climate change and occupational safety and health: Establishing a preliminary framework. Journal of Occupational and Environmental Hygiene, 6, 542-554. doi:10.1080/15459620903066008 | Detail
  249. Schwartz, J., R. Levin, and R. Goldstein, 2000: Drinking water turbidity and gastrointestinal illness in the elderly of Philadelphia. Journal of Epidemiology and Community Health, 54, 45-51. doi:10.1136/jech.54.1.45 | Detail
  250. Semenza, J. C., J. E. McCullough, W. D. Flanders, M. A. McGeehin, and J. R. Lumpkin, 1999: Excess hospital admissions during the July 1995 heat wave in Chicago. American Journal of Preventive Medicine, 16, 269-277. doi:10.1016/s0749-3797(99)00025-2 | Detail
  251. Shannon, M. W., and others, 2007: Global climate change and children's health. Pediatrics, 120, 1149-1152. doi:10.1542/peds.2007-2645 | Detail
  252. Sheffield, P. E., and P. J. Landrigan, 2011: Global climate change and children’s health: Threats and strategies for prevention. Environmental Health Perspectives, 119, 291-298. doi:10.1289/ehp.1002233 | Detail
  253. Sheridan, S. C., A. J. Kalkstein, and L. S. Kalkstein, 2009: Trends in heat-related mortality in the United States, 1975–2004. Natural Hazards, 50, 145-160. doi:10.1007/s11069-008-9327-2 | Detail
  254. Shonkoff, S. B., R. Morello-Frosch, M. Pastor, and J. Sadd, 2011: The climate gap: Environmental health and equity implications of climate change and mitigation policies in California—a review of the literature. Climatic Change, 109, 485-503. doi:10.1007/s10584-011-0310-7 | Detail
  255. Singleton, R. J., R. C. Holman, K. L. Yorita, S. Holve, E. L. Paisano, C. A. Steiner, R. I. Glass, and J. E. Cheek, 2007: Diarrhea-associated hospitalizations and outpatient visits among American Indian and Alaska Native children younger than five years of age, 2000-2004. The Pediatric Infectious Disease Journal, 26, 1006-1013. doi:10.1097/INF.0b013e3181256595 | Detail
  256. Smit, B., O. Pilifosova, I. Burton, B. Challenger, S. Huq, R. J. T. Klein, and G. Yohe, 2001: Adaptation to climate change in the context of sustainable development and equity. Climate Change 2001: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Third Assessment Report of the Intergovernmental Panel on Climate Change, J.J. McCarthy, Canziani, O.F., Leary, N.A., Dokken, D.J., and White, K.S., Eds., Cambridge University Press, 877-912. URL | Detail
  257. Spector, J. T., and P. E. Sheffield, 2014: Re-evaluating occupational heat stress in a changing climate. The Annals of Occupational Hygiene, 58, 936-942. doi:10.1093/annhyg/meu073 | Detail
  258. Stöllberger, C., W. Lutz, and J. Finsterer, 2009: Heat-related side-effects of neurological and non-neurological medication may increase heatwave fatalities. European Journal of Neurology, 16, 879-882. doi:10.1111/j.1468-1331.2009.02581.x | Detail
  259. Stone, B., J. J. Hess, and H. Frumkin, 2010: Urban form and extreme heat events: Are sprawling cities more vulnerable to climate change than compact cities? Environmental Health Perspectives, 118, 1425-1428. doi:10.1289/ehp.0901879 | Detail
  260. Strand, L. B., A. G. Barnett, and S. Tong, 2011: Maternal exposure to ambient temperature and the risks of preterm birth and stillbirth in Brisbane, Australia. American Journal of Epidemiology, 175, 99-107. doi:10.1093/aje/kwr404 | Detail
  261. Strickland, M. J., and others, 2010: Short-term associations between ambient air pollutants and pediatric asthma emergency department visits. American Journal of Respiratory and Critical Care Medicine, 182, 307-316. doi:10.1164/rccm.200908-1201OC | Detail
  262. Tees, M. T., E. W. Harville, X. Xiong, P. Buekens, G. Pridjian, and K. Elkind-Hirsch, 2010: Hurricane Katrina-related maternal stress, maternal mental health, and early infant temperament. Maternal and Child Health Journal, 14, 511-518. doi:10.1007/s10995-009-0486-x | Detail
  263. Thacker, M. T. F., R. Lee, R. I. Sabogal, and A. Henderson, 2008: Overview of deaths associated with natural events, United States, 1979-2004. Disasters, 32, 303-315. doi:10.1111/j.1467-7717.2008.01041.x | Detail
  264. Tofighi, B., E. Grossman, A. R. Williams, R. Biary, J. Rotrosen, and J. D. Lee, 2014: Outcomes among buprenorphine-naloxone primary care patients after Hurricane Sandy. Addiction Science & Clinical Practice, 9, 3. doi:10.1186/1940-0640-9-3 | Detail
  265. Turner, B. L., and others, 2003: A framework for vulnerability analysis in sustainability science. Proceedings of the National Academy of Sciences of the United States of America, 100, 8074-8079. doi:10.1073/pnas.1231335100 | Detail
  266. Turner, N. J., and H. Clifton, 2009: “It's so different today”: Climate change and indigenous lifeways in British Columbia, Canada. Global Environmental Change, 19, 180-190. doi:10.1016/j.gloenvcha.2009.01.005 | Detail
  267. Turner, N. J., R. Gregory, C. Brooks, L. Failing, and T. Satterfield, 2008: From invisibility to transparency: Identifying the implications. Ecology and Society, 13, 7. URL | Detail
  268. TWWG, 2012: Water in Indian Country: Challenges and Opportunities. 25 pp., Tribal Water Working Group. URL | Detail
  269. Uejio, C. K., O. V. Wilhelmi, J. S. Golden, D. M. Mills, S. P. Gulino, and J. P. Samenow, 2011: Intra-urban societal vulnerability to extreme heat: The role of heat exposure and the built environment, socioeconomics, and neighborhood stability. Health & Place, 17, 498-507. doi:10.1016/j.healthplace.2010.12.005 | Detail
  270. U.S. Census Bureau, cited 2008: An Older and More Diverse Nation by Midcentury. URL | Detail
  271. U.S. Census Bureau, 2010: The Next Four Decades, The Older Population in the United States: 2010 to 2050, Population Estimates and Projections. 16 pp., U.S. Department of Commerce, Economics and Statistics Division, U.S. Census Bureau, Washington, D.C. URL | Detail
  272. U.S. Census Bureau, cited 2014: 2014 National Population Projections: Summary Tables. Table 9. Projections of the Population by Sex and Age for the United States: 2015 to 2060. U.S. Department of Commerce. URL | Detail
  273. U.S. Census Bureau, cited 2014: Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States, States, and Counties: April 1, 2010 to July 1, 2013. U.S. Census Bureau American Fact Finder. URL | Detail
  274. USDA, 2009: Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and Their Consequences. Report to Congress. U.S. Department of Agriculture Economic Research Service, Washington, DC. URL | Detail
  275. USFA, 2013: Firefighter Fatalities in the United States in 2012. 63 pp., U.S. Department of Homeland Security, Federal Emergency Management Agency, U.S. Fire Administration. URL | Detail
  276. Van Zutphen, A. R., S. Lin, B. A. Fletcher, and S. -A. Hwang, 2012: A population-based case-control study of extreme summer temperature and birth defects. Environmental Health Perspectives, 120, 1443-1449. doi:10.1289/ehp.1104671 | Detail
  277. Vargas Bustamante, A., H. Fang, J. Garza, O. Carter-Pokras, S. P. Wallace, J. A. Rizzo, and A. N. Ortega, 2010: Variations in healthcare access and utilization among Mexican immigrants: The role of documentation status. Journal of Immigrant and Minority Health, 14, 146-155. doi:10.1007/s10903-010-9406-9 | Detail
  278. Voggesser, G., K. Lynn, J. Daigle, F. K. Lake, and D. Ranco, 2013: Cultural impacts to tribes from climate change influences on forests. Climatic Change, 120, 615-626. doi:10.1007/s10584-013-0733-4 | Detail
  279. Walthall, C., and others, 2012: Climate Change and Agriculture in the United States: Effects and Adaptation. USDA Technical Bulletin 1935. 186 pp., U.S. Department of Agriculture and the U.S. Global Change Research Program, Washington, D.C. URL | Detail
  280. Wang, L., F. H. Y. Green, S. M. Smiley-Jewell, and K. E. Pinkerton, 2010: Susceptibility of the aging lung to environmental injury. Seminars in Respiratory and Critical Care Medicine, 31, 539-553. doi:10.1055/s-0030-1265895 | Detail
  281. Wang, M., and J. E. Overland, 2012: A sea ice free summer Arctic within 30 years: An update from CMIP5 models. Geophysical Research Letters, 39, L18501. doi:10.1029/2012GL052868 | Detail
  282. Weisler, R. H., J. G. Barbee, and M. H. Townsend, 2006: Mental health and recovery in the Gulf Coast after Hurricanes Katrina and Rita. JAMA: The Journal of the American Medical Association, 296, 585-588. doi:10.1001/jama.296.5.585 | Detail
  283. Werner, C. A., 2011: The Older Population: 2010. 19 pp., U.S. Census Bureau. URL | Detail
  284. Whatley, M., and J. Batalova, cited 2013: Limited English Proficient Population of the United States. Migration Policy Institute. URL | Detail
  285. Whitman, T. J., and others, 2010: An outbreak of Plasmodium falciparum malaria in U.S. Marines deployed to Liberia. The American Journal of Tropical Medicine and Hygiene, 83, 258-265. doi:10.4269/ajtmh.2010.09-0774 | Detail
  286. WHO, 2001: International Classification of Functioning, Disability and Health. 303 pp., World Health Organization, Geneva. | Detail
  287. Willox, A. C., 2012: Climate change as the work of mourning. Ethics & the Environment, 17, 137-164. doi:10.2979/ethicsenviro.17.2.137 | Detail
  288. Wolbring, G., and V. Leopatra, 2012: Climate change, water, sanitation and energy insecurity: Invisibility of people with disabilities. Canadian Journal of Disability Studies, 1, 66-90. doi:10.15353/cjds.v1i3.58 | Detail
  289. Wong, C. A., F. C. Gachupin, R. C. Holman, M. F. MacDorman, J. E. Cheek, S. Holve, and R. J. Singleton, 2014: American Indian and Alaska Native infant and pediatric mortality, United States, 1999–2009. American Journal of Public Health, 104, S320-S328. doi:10.2105/ajph.2013.301598 | Detail
  290. Wong, M. D., M. F. Shapiro, W. J. Boscardin, and S. L. Ettner, 2002: Contribution of major diseases to disparities in mortality. New England Journal of Medicine, 347, 1585-1592. doi:10.1056/NEJMsa012979 | Detail
  291. Woodruff, T. J., J. D. Parker, A. D. Kyle, and K. C. Schoendorf, 2003: Disparities in exposure to air pollution during pregnancy. Environmental Health Perspectives, 111, 942-946. doi:10.1289/ehp.5317 | Detail
  292. Xiang, J., P. Bi, D. Pisaniello, and A. Hansen, 2014: Health impacts of workplace heat exposure: An epidemiological review. Industrial Health, 52, 91-101. doi:10.2486/indhealth.2012-0145 | Detail
  293. Xu, Z., P. E. Sheffield, W. Hu, H. Su, W. Yu, X. Qi, and S. Tong, 2012: Climate Change and Children’s Health—A Call for Research on What Works to Protect Children. International Journal of Environmental Research and Public Health, 9, 3298-3316. doi:10.3390/ijerph9093298 | Detail
  294. Xu, Z., R. A. Etzel, H. Su, C. Huang, Y. Guo, and S. Tong, 2012: Impact of ambient temperature on children's health: A systematic review. Environmental Research, 117, 120-131. doi:10.1016/j.envres.2012.07.002 | Detail
  295. Yip, F. Y., and others, 2008: The impact of excess heat events in Maricopa County, Arizona: 2000–2005. International Journal of Biometeorology, 52, 765-772. doi:10.1007/s00484-008-0169-0 | Detail
  296. Younger, M., H. R. Morrow-Almeida, S. M. Vindigni, and A. L. Dannenberg, 2008: The built environment, climate change, and health: Opportunities for co-benefits. American Journal of Preventive Medicine, 35, 517-526. doi:10.1016/j.amepre.2008.08.017 | Detail
  297. Zanobetti, A., M. S. O'Neill, C. J. Gronlund, and J. D. Schwartz, 2012: Summer temperature variability and long-term survival among elderly people with chronic disease. Proceedings of the National Academy of Sciences of the United States of America, 109, 6608-6613. doi:10.1073/pnas.1113070109 | Detail
  298. Zimmerman, R., C. E. Restrepo, B. Nagorsky, and A. M. Culpen, 2007: Vulnerability of the elderly during natural hazard events. Proceedings of the Hazards and Disasters Researchers Meeting, Boulder, CO, 38-40. URL | Detail
  299. Ziska, L. H., R. C. Sicher, K. George, and J. E. Mohan, 2007: Rising atmospheric carbon dioxide and potential impacts on the growth and toxicity of poison ivy (Toxicodendron radicans). Weed Science, 55, 288-292. doi:10.1614/ws-06-190 | Detail
  300. Zoraster, R. M., 2010: Vulnerable populations: Hurricane Katrina as a case study. Prehospital and Disaster Medicine, 25, 74-78. doi:10.1017/s1049023x00007718 | Detail

Likelihood

Very Likely
≥9 in 10
Likely
≥2 in 3
As Likely as Not
≈ 1 in 2
Unlikely
≤ 1 in 3
Very Unikely
≤1 in 10

Confidence Level

Very High Strong evidence (established theory, multiple sources, consistent results, well documented and accepted methods, etc.), high consensus
High Moderate evidence (several sources, some consistency, methods vary and/or documentation limited, etc.), medium consensus
Medium Suggestive evidence (a few sources, limited consistency, models incomplete, methods emerging, etc.), competing schools of thought
Low Inconclusive evidence (limited sources, extrapolations, inconsistent findings, poor documentation and/or methods not tested, etc.), disagreement or lack of opinions among experts
 

Documenting Uncertainty: This assessment relies on two metrics to communicate the degree of certainty in Key Findings. See Appendix 4: Documenting Uncertainty for more on assessments of likelihood and confidence.

Key Finding 1: Vulnerability Varies Over Time and Is Place-Specific

Key Finding 1: Across the United States, people and communities differ in their exposures, their inherent sensitivity, and their adaptive capacity to respond to and cope with climate change related health threats [Very High Confidence]. Vulnerability to climate change varies across time and location, across communities, and among individuals within communities [Very High Confidence].

Key Finding 2: Health Impacts Vary with Age and Life Stage

People experience different inherent sensitivities to the impacts of climate change at different ages and life stages [High Confidence]. For example, the very young and the very old are particularly sensitive to climate-related health impacts.

Key Finding 3: Social Determinants of Health Interact with Climate Factors to Affect Health Risks

Climate change threatens the health of people and communities by affecting exposure, sensitivity, and adaptive capacity [High Confidence]. Social determinants of health, such as those related to socioeconomic factors and health disparities, may amplify, moderate, or otherwise influence climate-related health effects, particularly when these factors occur simultaneously or close in time or space [High Confidence].

Key Finding 4: Mapping Tools and Vulnerability Indices Identify Climate Health Risks

The use of geographic data and tools allows for more sophisticated mapping of risk factors and social vulnerabilities to identify and protect specific locations and groups of people [High Confidence].