Climate Change and Public Health in Indonesia

Impacts and Adaptation

Budi Haryanto

Austral Policy Forum 09-05S

3 December 2009
Synopsis
Budi Haryanto of the University of Indonesia reviews expected global health impacts
of climate change, and then outlines both direct and indirect health impacts specific
to Indonesia. After setting out specific drivers of the climate change-health nexus in
Indonesia, Haryanto summarises the range of current Indonesian research on health
impacts. He then sets out adaptation issues and a method for approaching health
adaptation assessment. Haryanto concludes by proposing a suite of adaptation
measures, including health early warning systems; improved disaster response;
capacity building for government, private sector, and civil society on managing
prevention and control climate change on human health; empowering public health
services system for disease prevention and control; and generating epidemiology
and medical research to identify approaches for breaking disease transmission
chains.

About the Author

Budi Haryanto is Chairman of the Department of Environmental Health, Faculty of
Public Health, University of Indonesia.

Email: bharyant@cbn.net.id

Acknowledgements

This report is a revised version of a paper originally presented to the Nautilus

Institute RMIT workshop on Mapping Causal Complexity in Climate Change Impacts
and Responses - Australia and Indonesia, supported by the RMIT University Global
Cities Institute Climate Change Adaptation Programme, November 2008.

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Introduction

Global climate change will influence the functioning of many ecosystems and their
member species. Likewise, there will be impacts on human health. The first
detectable changes in human health may well be alterations in the geographic range
(latitude and altitude) and seasonality of certain infectious diseases – including
vector-borne infections such as malaria and dengue fever, and food-borne infections
such as salmonellosis, which peaks in the warmer months. Warmer average
temperatures combined with increased climatic variability would alter the pattern of
exposure to thermal extremes with resulting health impacts, in both summer and
winter. By contrast, the public health consequences of disturbances to natural and
managed food-producing ecosystems, rising sea-levels and population displacement
for reasons of physical hazard, land loss, economic disruption and civil strife, may not
become evident for up to several decades.

Climatic changes over recent decades have already had numerous damaging
impacts on human health. Spreading infectious disease, longer and hotter heat
waves, and extreme weather will all claim thousands of additional lives nationwide
each year. The warming of the climate is also creating the ideal conditions for spread
of infectious disease, putting millions of people at risk. In addition, climate change
has led to increased outbreaks and the spread of Dengue Hemorrhagic Fever (DHF),
malaria, cholera, encephalitis, hantavirus, and other diseases all over the world, not
only in third world countries but also in developed countries. Ironically, the countries
which have contributed less to global warming are highly susceptible and suffer more
outbreaks of diseases and deaths due to global warming.

The health impacts of known weather and climate changes are as follows:

1. Cardiovascular respiratory mortality and heat stroke mortality:

• Short-term increases in mortality during heat-waves
• V- and J-shaped relationship between temperature and mortality in
populations in temperate climates
• Deaths from heat stroke increase during heat waves
2. Allergic rhinitis:
• Weather affects the distribution, seasonality and production of
aeroallergens
3. Respiratory and cardiovascular diseases and mortality:
• Weather affects concentrations of harmful air pollutants
4. Deaths and injuries:
• Floods, landslides and windstorms cause death and injuries
5. Infectious diseases and mental disorders:
• Flooding disrupts water supply and sanitation systems and may damage
transport systems and health care infrastructure
• Floods may provide breeding sites for mosquito vectors and lead to
outbreaks of disease
• Floods may increase post-traumatic stress disorders
6. Starvation, malnutrition and diarrhea and respiratory diseases:
• Drought reduces water availability for hygiene
• Drought increases the risk of forest fires
• Drought reduces food availability in populations that are highly dependent
on household agricultural productivity and/or economically weak
7. Mosquito, tick-borne diseases and rodent-borne diseases:

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 •Higher temperatures shorten the development time of pathogens in
vectors and (such as malaria, dengue, tick-borne encephalitis and Lyme
diseases) increase the potential transmission to humans
• Each vector species has specific climate conditions (temperature and
humidity) necessary to be sufficiently abundant to maintain transmission
8. Malnutrition and undernutrition:
• Climate change may decrease food supplies (crop yields and fish stocks)
or access to food supplies
9. Waterborne and foodborne diseases:
• Survival of disease-causing organisms is related to temperature
• Climate conditions affect water availability and quality
• Extreme rainfall can affect the transport of disease-causing organisms into
the water supply

Current causes of impacts of climate change on human health in Indonesia

In Indonesia, cases of malaria, dengue, diarrhea and cholera are predicted to

increase as temperatures rise and water becomes contaminated, affecting scores of
poor populations that do not have the resources to cope. Water scarcity is an
additional issue as a result of global and regional climate change in which between
2010 and 2015 the country is predicted to experience a major clean water shortage,
and this is expected to occur mainly in urban areas (Boer et al., 2007). Air pollution is
proven as a major environmental hazard to residents in Jakarta, regardless of their
socioeconomic status. Transportation comprises 27% of Indonesia’s GHG emissions,
and traffic congestion is a huge problem in Jakarta (Pelangi, 1999). Diseases
stemming from vehicular emissions and air pollution include acute respiratory
infection, bronchial asthma, bronchitis, and eye and skin irritations (Boer et al., 2007),
and it has been recorded that the most common disease in northern Jakarta
communities is acute upper respiratory tract infection – at 63% of total visits to health
care centers (Indriyanti and Pedrique, 2006).

Among other indirect impacts of climate change, the impact on human health has
unique pathways transmission and is specific for every single disease. Once the
impact occurs, the spreading of disease will continue from one infected person to
others and from the new infected people to broader population due to the snowball
phenomenon. It can be noted that each step of the pathway has a set of unique
circumstances that will determine vulnerability. This spreading of disease may not be
controlled directly even by manipulating or modifying the environment. Analysis of
each of these steps allows a logical determination of vulnerability and subsequent
development of adaptive measures that aim to decrease vulnerability. It will need
specific technology, methods, and expertise such as public health, environmental
health, epidemiology, medical, and pharmacy specialists to deal with the prevention
and control to the impacts.

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 Figure 1. Temperature and DHF Cases in Indonesia, 1968 - Sept. 2007

Current research and reviews

The epidemiology of infectious diseases is changing rapidly; either new pathogens or

old pathogens re-emerge into old and new regions. The changing epidemiology is
certainly explained, at least in part and to a growing extends, by climate changes with
different effects on different pathogens, diseases and communities. The problem is
not restricted to specified regions, but it is a matter of global concern in which
communities are confronted with new health care problems or face an increase in the
current burden of infectious disease.

In Indonesia, research has focused on the identification of potential health impacts

arising from the various types of climatic effects and the possible environmental
consequences. The identification of potentially vulnerable groups and regions and an
assessment of current coping capacity were included. Potential health impacts were
considered for:
• Increases in extreme events.
• Increases in temperature.
• Increases or decreases in rainfall.
• Raises water sea levels and waves.

A lot of complete and ongoing research, and reviews concerning the relationship
between climate change and health impacts in Indonesia, that have been conducted
since 2006, include direct and indirect effects as follows:

Direct effects:
• Increase in injuries associated with extreme weather events

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Indirect effects:
• Increase in vector borne diseases (malaria, dengue, filariasis) associated with
increase in temperature, rainfall, humidity, and vector density.
• Increase in water borne diseases (diarrhea, cholera, typhoid, leptospirosis)
associated with a decrease in water quality and water supply as well as floods
and droughts.
• Increase in malnutrition cases related to food production and land use shifts
• Increase in cardio cerebral vascular diseases, hypertension, and mental
disorders associated with urban stress, life style, displacements and conflicts.
• Increase in influenza (ARI) and respiratory diseases (asthma, pneumonia)
associated with increasing of air pollution outdoor as well as indoor
• Increase in food borne diseases is associated with contamination, food
handling, and poverty.

Figure 2. Malaria endemic areas

Public health response and adaptation in Indonesia

Adaptive capacity describes the general ability of institutions, systems and individuals
to adjust to potential damages, to take advantage of opportunities and to cope with
the consequences. In health terms, coping capacity is a measure of what could be
implemented to minimize the negative health impacts of climate change that may
arise in the future and maximize any positives that may occur. An assessment of
coping capacity is necessary to determine current vulnerability and to plan
appropriate adaptations. Assessment of coping capacity at all levels and for all
relevant sectors will provide a thorough understanding of what is needed for
management of potential health impacts from climate change.
Approaches to assessing the potential effects of climate variability and change on
human health vary depending on the outcome of interest. Conventional
environmental health impact assessment is based on the toxicological risk
assessment model that addresses population exposure to environmental agents,
such as chemicals in soil, water or air. Most diseases associated with environmental
exposure have many causal factors, which may be interrelated. These multiple,
interrelated causal factors, as well as relevant feedback mechanisms, need to be

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addressed in investigating complex associations between disease and exposure,
because they may limit the predictability of the health outcome.

Assessments of the potential health effects of climate variability and change have
used a variety of methods. Both qualitative and quantitative approaches may be
appropriate depending on the level and type of knowledge; the outcome of an
assessment need not be quantitative to be useful to stakeholders. An integrated
approach is likely to be most informative, as the impact of climate is likely to
transcend traditional sector and regional boundaries, with effects in one sector
affecting the capacity of another sector or region to respond.

Health impact assessment should include:

• an evaluation of the impact of climate variability and change in a range of
areas and populations, especially among vulnerable populations and, when
possible, to determine the attributable burden of weather and climate,
including extreme events, to climate-sensitive diseases;
• an evaluation of possible threshold effects;
• an evaluation of the effects of multiple stresses, including changes in
socioeconomic systems;
• an evaluation of uncertainty and its implications for risk management;
• an evaluation of the effects of reducing emissions, such as by comparing the
impact under scenarios with business-as-usual and stabilization of emissions;
and
• an evaluation of coping capacity, especially under different socioeconomic
futures and in the context of sustainable development.

Assessment of vulnerability and adaptation uses similar concepts to those used in a

health impact assessment. The following steps are commonly used for assessing
vulnerability and adaptation of climate change health impacts:

1. Determine the scope of the assessment

The first step is to specify the scope of the assessment in relation to:
• the health and community security issues of concern today and of potential
risk in the future;
• the geographical region to be covered by the assessment; and
• the time period.

Interactions between weather and climate and health are location-specific; using
epidemiological evidence based on local data if they are available is therefore
important. Evidence of an association between weather and health outcomes may
not imply an increased burden from climate change. Assessments should include
current vulnerability to climate variability to inform an understanding of what could
occur with climate change. The extent to which an assessment addresses these
issues depends on the goals of the assessment and the resources available.

The national boundaries may not be the most appropriate geographical framework
for the assessment. Climate, diseases and vectors do not respect national
boundaries, and other countries may therefore need to be considered to assess the
national risk. Countries with similar health and climate problems may work together
for a regional assessment.

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2. Describe the associations between disease outcomes and climate variability and
change

For each chosen disease outcome, determining the factors that could modify its
association with weather and climate variables is important. Modifying factors will
vary by disease outcome and could include socioeconomic and other variables.
Consideration should be given to interacting effects. For example, morbidity and
mortality may be increased during periods of both extreme heat and high levels of air
pollutants. If epidemiological analyses cannot be conducted, because, for example, if
the data is not of sufficient quality and quantity, the available literature can be
reviewed to produce a qualitative assessment.

The current burden of the climate-sensitive diseases can be described using the
following indicators:
• the current incidence and prevalence of the disease and the trend (is the
disease increasing or decreasing), which may be available from routine
statistics from the appropriate national agency; and
• the attributable burden of a disease to climate and/or weather, such as what
proportion of all cardiovascular deaths are attributable to high or low
temperatures or the number of deaths caused by floods.

For vector-borne diseases, having a map showing the current geographical

distribution of human cases and vectors may be useful. Finally, environmental and
socioeconomic conditions also influence human vulnerability and need to be
considered within the assessment.

3. Identify and describe current strategies, policies and measures that reduce the
burden of climate-sensitive diseases

For each health outcome, activities and measures individuals, communities and
institutions currently undertake to reduce the burden of disease should be identified
and evaluated for effectiveness.

4. Review the health implications of the potential impact of climate variability and
change on other sectors

Climate change is likely to affect natural and human systems. Assessments should
therefore be integrated across the concerned scientific disciplines and non-health
sectors. International agencies (the IPCC) or regional or national authorities may
have assessed the potential impact of climate change on the environment (habitat
and land use) at the relevant spatial scale. These effects should be included in the
assessments to better understand issues such as the health implications of the direct
impact of climate change on the food supply and the risk of disasters (such as
coastal or river flooding).The impact of implemented strategies, policies and
measures in response to actual or projected climate change needs to be evaluated in
terms of potential health effects. For example, in cases where domestic water
storage is recommended, the implementation of this measure may have implications
for vector breeding and the transmission of dengue. Water development projects
should be subject to an environmental and health impact assessment.
Information at the regional, national or local scale about climate variability and
change should be used whenever possible.

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5. Estimate the future potential health impact

Climate variability and change are adversely affecting human health and well-being
and will continue to do so. The inherent inertia in the climate system means that the
impact of current greenhouse gas emissions will be delayed for decades to centuries.
The IPCC projections for the increase in mean surface temperature for the 21st
century range from 1.4°C to 5.8°C. As a consequence, anthropogenic warming is
projected, on average, to range from 0.1°C to 0.5°C per decade during this century.
Even larger changes may be expected beyond the 21st century. Greater climatic
changes are expected in higher latitudes in both hemispheres, with increasing risks
of heat-waves, flooding and drought events and the spread of infectious diseases.
This emphasizes that health and civil defense authorities need to design and
implement adaptation strategies, polices and measures to reduce potential health
impact. The climate change community often chooses reference periods for
projecting the impact of climate change from the present until 2050 or until 2100. This
requires using climate scenarios. Climate scenarios are now available for a range of
time scales. The time scale of the assessment depends on the scope and purpose of
the assessment. However, addressing potential effects both in the near term (the
next 20 years) and the long term (up to 2050 or 2080) is advisable. The focus on the
near term provides relevant information within the usual planning horizon of health
agencies. A further need is looking beyond the near term to develop comprehensive
adaptation measures.

The potential future impact of climate variability and change on health may be
estimated using a variety of methods. These methods imply a top-down approach in
which scenarios of climate change (and other changes) are used as inputs into a
model on climate and health. Such models can be complex spatial models or be
based on a simple relationship between exposure and response.

Models of climate change should include projections of how other relevant factors
may change in the future, such as population growth, income and fuel consumption.
Projections may be incorporated from models developed for other sectors, such as
flood risk, food supply and land-use changes. An assessment needs to address
uncertainty explicitly. Scientists, policy-makers and the public must recognize the
existence of multiple sources of uncertainty, from climate projections to the potential
future public health effects. This step should be realistic about the likelihood that the
uncertainty can be resolved in a meaningful time frame. Carefully estimating
uncertainty can help in further understanding the level of confidence in what is known
and can provide input into future research directions and policy-making.

Future capacity to adapt to the effects of climate change depends on the future levels
of economic and technological development, local environmental conditions and the
quality and availability of health care and of public health infrastructure. Social,
economic, political, environmental and technological factors strongly influence health.
These determinants of health are complex enough that future projections about
stresses on population health, including but not limited to projections of the potential
effects of climate variability and change on health, become increasingly uncertain
with expanding timelines. Future projections must make explicit their assumptions
about adaptive capacity.

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The adaptation focus for climate change on human health generated by the World
Health Organization (WHO) and adopted by the Government of Indonesia (GOI)
comprises the following points:

• Health security
• Strengthening health systems
• Health development
• Evidence and information
• Delivery
• Partnership

National Program of Adaptation and Mitigation for Health Sector (GOI):

• Infectious disease surveillance
• Health action in emergencies
• Safe drinking water
• Integrated vector management
• Environmental health capacity building
• Healthy public policy (healthy housing, school, forest, industry, city)

In order to bridge the GOI response and action for climate change adaptation
especially on human health, several preliminary steps and or scenarios should be
generated to assure the maximum efforts and significant results. They should at least
include:

• Empowering a ecological-disease surveillance system and developing a

public health early warning system
• Development of a response to disaster effects of climate change
• Enhancing capacity building for government, private sector, and civil society
on managing prevention and control climate change on human health
• Increasing political awareness of the relationship between climate change
and human health
• Empowering public health services system for disease prevention and control
• Generating epidemiology and medical research to identify approaches for
breaking disease transmission chains
• Preventing and eradicating climate change vector-related diseases

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The views expressed in this article are those of the author and do not necessarily
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