Weather and Climate Extremes 11 (2016) 95–102

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Weather and Climate Extremes

journal homepage: www.elsevier.com/locate/wace

Extreme events as sources of health vulnerability: Drought as an

example
Kristie L. Ebi a,n,1, Kathryn Bowen b,c,2
a
University of Washington, Seattle, WA, USA
b
Australian National University, Canberra, ACT, Australia
c
Melbourne Sustainable Society Institute, University of Melbourne, Melbourne, VIC, Australia

art ic l e i nf o a b s t r a c t

Article history: The health risks of climate change arise from the interactions of the hazards associated with a changing
Received 24 July 2015 climate (e.g. increases in the frequency and intensity of extreme weather and climate events, such as
Received in revised form drought), the communities exposed to those hazards, the susceptibility of communities to adverse health
30 September 2015
impacts when exposed, and the capacity to prepare for and cope with the hazard. However, there is a
Accepted 6 October 2015
very limited understanding of how extreme weather and climate events could themselves be sources of
Available online 8 October 2015
vulnerability. Drought is used as an example of an extreme event that can simultaneously be a current
Keywords: hazard and can directly and indirectly influence future vulnerability. A better understanding of droughts
Climate change and other extreme events as sources of vulnerability is needed, including (i) the patterns of risks and
Health
how these could change over time, (ii) the reasons for any changes, (iii) how these risks could affect
Extreme events
human health and well-being, and (iv) the longer-term consequences of extreme events for vulnerability.
Drought
Flood This knowledge will become increasingly important for managing risks to health as the frequency and
Vulnerability intensity of extreme weather and climate events increase with climate change.
& 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction to extreme events. As extreme events become more common and

more intense, these events themselves will be one factor de-
In vulnerable regions, extreme weather and climate events3 can termining vulnerability to subsequent events. Given the im-
lead to disasters with significant impacts on human and natural portance of these extreme events, it is surprising that there has
systems. Historically, extreme events were generally rare in any been limited attention to this issue in the scientific literature.
one location, with time between events when human and natural The paper first reviews a framework for evaluating the risks of
systems could recover from the impacts experienced. However, as extreme weather and climate events; review trends in these
climate change increases the frequency, intensity, and duration of events; and then focuses on drought as an example of an extreme
event that could affect the vulnerability of individuals, commu-
some extreme weather and climate events (IPCC, 2012; IPCC,
nities, and health systems to future events.
2013), the time between extreme events will shorten across this
century. Further, the type and pattern of extreme events may shift,
with alternating floods and droughts in many locations, leading to
2. Framework of the risks of extreme weather and climate
communities and nations requiring more integrated preparedness
events

n
Corresponding author. The magnitude and pattern of impacts from extreme weather
E-mail addresses: krisebi@uw.edu (K.L. Ebi), and climate events are due to the characteristics of the extreme
Kathryn.bowen@anu.edu.au (K. Bowen). event, the extent of exposure of human and natural systems to the
1
Center for Health and the Global Environment, School of Public Health, 4225
Roosevelt Way NE #100, Seattle, WA 98105, USA.
event, the susceptibility of those systems to harm, and their ability
2
National Centre for Epidemiology and Population Health, College of Medicine, to cope with and recover from the event (IPCC, 2012; NRC, 2013).
Biology and Environment, Australian National University, Canberra, ACT 0200, An extreme event can alter vulnerability to future events by
Australia. changing the extent of exposure (e.g. reducing the presence or
3
The definition of extreme weather and climate events used is the one used in
effectiveness of coastal barriers), the susceptibility of exposed
IPCC 2012: The occurrence of a value of a weather or climate variable above (or
below) a threshold value near the upper (or lower) ends of the range of observed human and natural systems (e.g. making individuals and com-
values of the variable. munities more or less susceptible by affecting access to and/or

http://dx.doi.org/10.1016/j.wace.2015.10.001
2212-0947/& 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
96 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102

effective functioning of healthcare facilities or the proportion of affect future vulnerability to extreme events include availability of
the population vulnerable to an event), or the ability of organi- safe water (including quality and quantity), food security, and
zations and institutions to effectively and efficiently prepare for consequences of extreme events that affect ecosystem services
and manage events. Understanding the magnitude and pattern of such as wildfires, coastal erosion, and saltwater intrusion into
impacts and of the factors increasing (or decreasing) susceptibility freshwater sources. Impacts on community services, livelihoods,
and coping abilities is vital to modifying current policies and to and social capital include economic resources, infrastructure, ac-
implementing new policies and programs to increase resilience to cess to services, and social capital. Impacts on health status and
extreme events. health systems include stress, mental illness as a consequence of
There is abundant literature on factors that increase vulner- the event or recovery, worsening chronic diseases, and
ability to extreme weather and climate events (e.g. IPCC, 2012), undernutrition.
with less emphasis on how extreme events themselves alter the
sensitivity and coping capacity of human systems to future events. 2.1. Trends in extreme weather and climate events
The wide range of factors that describe vulnerability can be di-
vided into environmental, social, and economic dimensions (Car- The IPCC Special Report on Managing the Risks of Extreme
dona et al. 2012). Environmental dimensions include physical Events and Disasters to Advance Climate Change Adaptation
variables (e.g. location-specific context for human-environment (SREX; IPCC, 2012) and the IPCC Working Group II contribution to
interactions); geography, location, and place; and settlement pat- the 5th Assessment Report (IPCC, 2013) assessed to what extent
terns and development trajectories. Social dimensions include current and projected climate change is affecting or could affect
demographic variables (education, human health and well-being); the magnitude and pattern of extreme weather and climate
cultural variables; and institutions and governance. Crosscutting events. Overall, Seneviratne et al. (2012) concluded that a changing
factors include relevant and accessible science and technology. In climate leads to changes in the frequency, intensity, spatial extent,
the health sector, important factors include the health of the po- duration, and timing of weather and climate extremes, and can result
pulation and the status of health systems (e.g. ability of healthcare in unprecedented extremes. Conclusions include that there is med-
facilitates, laboratories, and other parts of the health system to ium confidence that since the 1950s, some world regions experienced
manage an extreme event) a trend to more intense and longer droughts, particularly in southern
From the perspective of the health sector, vulnerability is Europe and West Africa. Droughts became less frequent, less intense,
viewed as the summation of all risk and protective factors that or shorter in central North America and northwestern Australia. For
determine whether an individual or subpopulation experiences precipitation and flooding, Seneviratne et al. (2012) concluded it is
adverse health outcomes from exposure, in this case, to an ex- likely that the number of heavy precipitation events increased sig-
treme event (Balbus and Malina 2009). Sensitivity to an event is nificantly in more regions than there were decreases, with strong
viewed as an individual or subpopulation's increased responsive- regional and sub-regional variations. There is limited to medium
ness, often for biological reasons such as the presence of a chronic evidence to assess whether there have been climate-driven changes in
disease. There is a rich literature describing particular factors that the magnitude and frequency of floods
increase human health vulnerability to particular extreme events. Projections for how climate change could affect the magnitude
The poor, pregnant women, children, individuals with chronic and pattern of future extreme events varies by event, with con-
medical conditions, and individuals with mobility and/or cognitive fidence in projections driven by robustness in understanding the
constraints are at increased risk of adverse health outcomes dur- drivers and processes leading to particular events and the under-
ing an extreme event (Balbus and Malina 2009). In addition, the lying evidence base. Natural climate variability is one of the key
social determinants of health influence vulnerability. These in- sources of uncertainty in projections over coming decades because
clude access to health care services, access to and quality of edu- the extent of climate change over this period is expected to be
cation, availability of resources, transport options, social capacity, small compared with natural variability (Seneviratne et al. 2012).
and social norms and culture. For some extremes, such as precipitation-related extremes, un-
Fig. 1 shows the framework used to explore the key drivers of certainties in climate models are key. For other extremes, such as
vulnerability in the health sector to extreme weather and climate temperature extremes, future greenhouse gas emissions and the
events. Impacts can be categorized into those that affect en- sensitivity of the climate system to those emissions are key drivers
vironmental services, social and economic factors, or health status of uncertainty. Given the complex nature of the climate system,
and health systems. Impacts on environmental services that could the authors concluded that low probability, high impact changes

Extreme Changes in:

weather &
climate Capacity to cope
Environmental
events: services
Intensity and Extent of Social and economic
scope exposure factors
Persistence
Health status and
Timing /
Susceptibility health systems
sequencing

Fig. 1. Key drivers of health vulnerability to extreme weather and climate events.
 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102 97

in extremes associated with crossing poorly understood climate Jordan, Myanmar, and Guatemala. Drought exposure increased as
thresholds cannot be excluded. the Human Development Index class decreased.
Projected changes in extreme weather and climate events in Adding the scores for each extreme event type resulted in a
the 21st century include that there is medium confidence that multi-country hazard ranking (Table 1). Countries in the top
droughts will intensify in some seasons and areas, due to reduced quintile are from all major world regions except Australia, and
precipitation and/or increased evapotranspiration, including in from low-, middle-, and high-income countries with varying de-
southern Europe and the Mediterranean region, central Europe, grees of baseline vulnerability. These analyses highlight countries
central North America, Central America and Mexico, northeast Brazil, at higher risk of experiencing an extreme weather and climate
and southern Africa (Seneviratne et al. 2012). For precipitation and event that could affect resilience to subsequent events, and re-
flooding, the authors concluded it is likely the frequency of heavy gions that are more likely to have multiple events. For example,
precipitation or the proportion of total rainfall from heavy rainfall Saint Kitts and Nevis and the British Virgin Islands are ranked
will increase over many parts of the globe, particularly in high lati- fairly high for cyclones and droughts, and Guatemala, Bangladesh,
tudes and tropical regions. It is likely that heavy rainfall associated and Nepal are ranked fairly high for drought and flood. Climate
with tropical cyclones will increase. There is medium confidence that change is reducing the return period of many extreme events,
some regions will see such an increase despite projected decreases in which means the magnitude and pattern of risks these countries
total precipitation. For a range of greenhouse gas emission scenarios, face could increase (IPCC, 2012; IPCC, 2013).
a 1-in-20 year annual maximum 24-hour precipitation is likely to The Human Development Index (HDI) was used to categorize
become a 1-in 5 to a 1-in 15-year event in many regions, with higher countries into four equally-spaced development classes (Low,
emission scenarios leading to greater decreases in the return period. Medium, High and Very High) based on the country's level of
And, there is medium confidence that projected increases in heavy education, gross national income per capita, and life expectancy at
rainfall would contribute to increases in local flooding in some birth (Christenson et al., 2014). The results illustrate the im-
catchments or regions. portance of poverty to vulnerability. Very high HDI countries are
Christenson et al. (2014) estimated population exposure to the most developed and generally the wealthiest. Countries with
cyclones, droughts, and floods, and ranked country-level popula- medium HDI had multi-hazard exposure 17% greater than the
global mean; countries with high HDI had the lowest multi-hazard
tion exposure to the individual extreme events and to all hazards
exposure (32% less exposure than the global mean). Not surpris-
combined. This analysis provides useful information on the like-
ingly, a low HDI was generally associated with greater exposure to
lihood that a location was exposed to a given hazard. Exposures for
droughts and floods. Exposures in urban populations were 40%
approximately 1980–2000 were calculated based on gridded da-
higher than for rural populations for cyclones and 34% lower for
tasets of population density and the relative frequency of climate-
droughts. There was no difference for floods.
related hazards events, differentiated between urban and rural
populations. A drought event was defined as when the magnitude
2.2. Extreme weather and climate events as sources of future
of monthly precipitation was less than or equal to 50% of its long-
vulnerability
term median value for three or more consecutive months. Drought
exposure was more broadly distributed than cyclone exposure.
The extent to which the impacts of an extreme event(s) could
During 1980–2009, populations with high drought exposure in-
affect future vulnerability is determined by the characteristics of
cluded residents of countries in South Asia, Southeast Asia, and
the events (e.g. magnitude and duration), the timing and sequence
Western Asia through to the Mediterranean. The ten countries
of events, and whether individuals, communities, and health sys-
with the greatest population exposure to drought were Gibraltar,
tems fully recover from an event before the next occurs. The focus
Lebanon, Malta, Nauru, Swaziland, Saint Kitts and Nevis, Djibouti, of research has been on identifying factors that increase individual
vulnerability, with less attention to the possible impacts of ex-
Table 1
treme events on healthcare facilities and public health services.
Countries with the greatest multi-hazard population exposure, with country
rankings for cyclones, drought, and floods.Source: Christenson et al. (2014). Recovery from significant extreme events can take decades
(UNESCAP, 2015). Further, cyclones, floods, or droughts can have
Country Cyclone Drought Flood Multi-hazard ex- long-term effects on communities and healthcare services. How-
rank rank rank posure rank ever, studies have typically viewed the relationship between ex-
Hong Kong 5 139 3 1
treme events, vulnerability, and impacts from the perspective of
Philippines 11 74 22 2 identifying factors that increase individual vulnerability to events,
Macao 10 132 1 3 and the impacts resulting from events. Studies rarely identify
Guatemala 63 10 5 4 which environmental, social, and economic factors increase in-
South Korea 22 118 15 5
dividual vulnerability at a particular point in time (before, during,
Bangladesh 53 29 2 6
Vietnam 36 80 12 7 or after an extreme event). This is important because the timing of
Saint Kitts and 20 6 181 8 exposure to an event will interact with characteristics of the
Nevis physical environment, social factors and livelihoods, and health
Guadeloupe 17 65 83 9 status and health systems in ways that can increase or decrease
Guam 1 68 132 10
Lebanon 93 2 42 11
vulnerability. Also, this information is needed for developing and
Ecuador 93 27 17 12 deploying effective policies and programs to increase resilience
Nepal 93 44 6 13 throughout an event. There has been less attention paid to factors
Japan 7 182 64 14 affecting the vulnerability of healthcare facilities and public health
British Virgin 8 45 181 15
services to extreme events, other than obvious factors such as
Islands
Thailand 73 35 20 16 location.
Puerto Rico 14 193 48 17 One exception is Lowe et al. (2013), who systematically re-
Antigua and 9 70 134 18 viewed factors increasing vulnerability to health effects before,
Barbuda during, and after floods. Limited research identified pre-flood
New Caledonia 6 66 166 19
Mozambique 40 31 73 20
vulnerability factors; these included existing gastrointestinal
conditions. Factors increasing during-flood vulnerability included
98 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102

gastrointestinal illnesses, psychological distress, and respiratory insufficient moisture to meet the needs of a particular crop.
diseases. One of the few studies examining risk factors for gas-
Socioeconomic drought occurs when the demand for a parti-
trointestinal illness (GI) up to three months post-flood found that cular economic good exceeds supply because of weather-related
the risk of GI among children whose home or property was floo- shortfalls in water supply or when water or agricultural
ded was 1.9 times higher than the risk among children without shortages begin affecting communities.
those experiences (Wade et al. 2004). Adults over the age of 50
years also were at increased risk of gastrointestinal illness if their Droughts are fundamentally related to water sources, with the
homes or yards were flooded (IRR 6.20, 95% CI: 3.34, 11.51). Per- typical categorization reflected in which sectors impacts occur, and
sistence of these factors after a flooding event would clearly in- indicated by the speed, scale, and complexity of the event. Me-
crease vulnerability to a subsequent flood or drought. teorological drought particularly affects rain-dependent areas;
It also may be possible to infer from other research that ex- agricultural drought can impact plant development; hydrological
treme events increase vulnerability to subsequent events. For ex- drought can affect freshwater ecosystems; and groundwater
ample, Sena et al. (2014) reviewed the health impacts of drought drought can affect pumped water supply (Stanke et al., 2013). A
in Brazil, concluding that although there has been great progress long-standing drought could be categorized as more than one of
in reducing social and economic vulnerability, many health and these.
well-being indicators are worse in semi-arid regions that experi-
ence drought more regularly than the rest of the country, implying 3.1. Health impacts of droughts
that drought may have played a role.
From 2003–2012, 15 major droughts affected nearly 36.5 mil-
2.3. Displacement as a source of vulnerability lion people worldwide; there were nearly 8 million people affected
in 2013 alone (EM-DAT, 2014). In Asia and the Pacific, drought
Extreme weather and climate events, particularly storms, affected 1.62 billion people between 1970 and 2014, and was as-
floods, and droughts, can lead to short- and long-term displace- sociated with about USD53 billion in economic losses (UNESCAP,
ment that often has negative consequences for health, social ca- 2015). Evidence of the magnitude and pattern of impacts of a
pital, and productivity. A review of disasters and displacement drought is difficult to document because the onset and ending of a
found that since 2008, an average of 26.4 million people have been drought are ill defined, and because droughts can last for years
displaced annually by disasters due to natural hazards, or one with accumulating effects. Socioeconomic choices, population
person displaced every second (IDMC, 2015). Drought and its im- growth and movement, infrastructure, land use change, the un-
pacts on water- and food-security is one driver of displacement. derlying population vulnerability, and other factors affect the se-
The likelihood of being displaced by a disaster today is 60% higher verity of droughts. Poor health, poverty, and conflict contribute to
than it was four decades ago, even after adjusting for population the impacts of a drought (Stanke et al., 2013).
growth. The peak year of displacement was 1998, when the Recent comprehensive reviews of the health risks of droughts,
strongest El Niño on record occurred. The review included an one international, one for Canada based on national and interna-
evaluation of protracted displacement, concluding there is a tional literature, and one for Brazil (Yusa et al., 2015; Sena et al.,
common assumption that displacement following disasters is 2014; Stanke et al., 2013) highlight the potentially significant
short-term and temporary, which is not true in some situations. consequences of long-term drought. Most of the health impacts of
There is relatively little known about such displacements, requir- droughts are indirect: food and water insecurity; loss of liveli-
ing increased research on the impacts and how they could be hoods; population displacement; and other mediating circum-
managed. A review of 34 case studies identified people who have stances, with the impacts largest on low-income countries (Stanke
been living in protracted displacement for up to 26 years (IDMC, et al., 2013). Conclusions include that drought can affect health
2015). Those displaced the longest from extreme weather and effects associated with inadequate nutrition (including under-
climate events or their consequences were in Bangladesh (cyclone nutrition, micronutrient deficiencies, and mortality), food- and
Alia) and Columbia (Gramalote landslide). Individuals and families waterborne diseases, airborne and dust-related diseases, vector-
in these types of events often are left behind in long-term re- borne infectious diseases, illnesses related to exposure to toxins,
covery. The hazards leading to long-term displacement include mental health effects (including distress and other emotional
those that persist for long periods and frequent short-lived events. consequences), and other health effects (including wildfire, effects
of migration, and damage to infrastructure) (Sena et al., 2014;
Stanke et al., 2013; Yusa et al., 2015). Droughts could also ex-
3. Drought as an example of an extreme weather and climate acerbate chronic diseases that leave individuals less able to cope
event that can increase vulnerability with and recover from another event.
The probability of a drought-related health effect depends on
Drought is a relative term for a period of abnormally dry drought severity, baseline susceptibility, access to adequate health
weather that persists long enough to cause a serious hydrological and sanitation infrastructure, and socioeconomic conditions of the
imbalance (IPCC, 2012). Arid regions and areas experiencing de- individual and community in which the drought occurs. The
sertification can be considered as permanently experiencing var- greater the impact of the drought, the more likely the drought will
ious degrees of drought. Humid and semi-arid regions can ex- increase vulnerability to the next extreme event, particularly an-
perience drought during specific seasons or over prolonged period other drought or flood in low-resource settings if there is not
of time. Drought can be categorized into the following based on adequate time for the individual and community to recover. Fac-
how it is measured: tors that could reduce longer-term resilience would likely include
poor food and water security, mental health issues, and

Meteorological drought is based on the degree and duration of displacement.
dryness. Sena et al. (2014) reviewed the consequences of drought for

Hydrological drought is based on the impacts of precipitation human health in Brazil, showing semi-arid regions making slower
shortages on surface or groundwater water supplies. gains in population health than the rest of Brazil. Between 1991

Agricultural drought is based on soil moisture deficiencies from and 2010, there were close to 17,000 drought events recorded in
either meteorological or hydrological drought resulting in the 2944 municipalities in the country; it was the leading type of
 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102 99

disaster with over 50% of total disaster events reported. Of the 96 Food security exists when all people at all times in a commu-
million affected persons in these 20 years, 48 million (50%) were nity or other spatial unit have physical and economic access to safe
affected by drought. Trends for the 1133 municipalities in the and nutritious food (and food preferences) that is sufficient to
semi-arid region of Brazil, compared with the rest of Brazil (4432 meet their dietary needs for an active and healthy life, and is ob-
municipalities), for the years 1991, 2000, and 2010 showed that tained in a socially acceptable and ecologically sustainable manner
although health improved over the nearly twenty-year time per- (WFS, 1996). The four dimensions of food security are (1) food
iod, the semi-arid region remained worse off in terms of health availability (i.e. production and trade); (2) stability of food sup-
and well-being, as measured by infant mortality rate, poverty, il- plies; (3) access to food; and (4) food utilization. Food security is
literacy, and municipal human development index. There also often used interchangeably with malnutrition. However, mal-
were differences in life expectancy by average income, with people nutrition indicates various forms of undernutrition that are caused
living in semi-arid regions having lower life expectancy and in- by many factors, including dietary inadequacy, infections, and
come. These differences between the regions would tend to make socio-cultural factors. Undernutrition includes stunting, wasting,
the semi-arid regions more vulnerable to concurrent or sub- and deficiencies of essential vitamins and minerals, as well as
sequent extreme events. obesity or over-consumption of specific nutrients (Ebi et al., 2010).
Drought can directly affect food availability and stability through
3.1.1. Drought effects on water security impacts on production, can affect food access, and can affect food
Drought is a key but not the sole driver of water security; utilization indirectly by affecting water quality and quantity in
mismanagement of resources can exacerbate or ameliorate the ways that could alter the burden of diarrheal diseases.
impacts of a drought. Drought can negatively impact the quality About 795 million people are below the minimum calorie
and quantity of safe water (Berry et al., 2014; Lemmen et al., 2014) threshold (FAO et al., 2015b). Being underweight is the number-
by increasing temperatures facilitating the growth of pathogens; one contributor to the burden of disease in Africa south of the
by reducing water levels and stream flows that lead to stagnation; Sahara and number four in South Asia (Lim et al., 2012). Under-
by increasing the concentration of contaminants in ground and nutrition during pregnancy and the first two years of life is a major
surface water; and through contamination of drinking water determinant of stunting of linear growth and subsequent obesity
sources with salt water in coastal areas. Droughts also can damage and non-communicable diseases in adulthood (Black et al., 2013).
water-related infrastructure, with the recovery timeline important Nutritional deficiencies are responsible for over 50% of years lived
for determining vulnerability to subsequent events. A wide range with disability in children age four and under (Vos et al., 2012).
of adverse health consequences are associated with insufficient Prevention of undernutrition in early childhood leads to hourly
safe water, including infectious diseases, diseases associated with earnings that are 20% higher, wage rates that are 48% higher, and
chemicals and pollutants found in water sources, skin diseases, individuals who are 33% more likely to escape poverty (Hoddinott
and algae-related diseases (Stanke et al., 2013; Yusa et al., 2015). et al., 2013). Asia and Africa lose 11% of GNP every year due to poor
The extent to which a community or region fully recovers access to nutrition (Horton and Steckel, 2013).
safe water will determine the sensitivity to and capacity to cope Through impacts on crops and subsequent changes in diet,
with a subsequent event. The challenges are much larger in low- drought can also affect micronutrient deficiencies, including re-
and middle-income country settings without adequate quality and ductions in concentrations of iron, zinc, vitamin A, and vitamin C
quantity of safe water before a drought. (Stanke et al., 2013; Yusa et al., 2015). Dietary deficiencies of zinc
The future vulnerability baseline for water stress on which and iron are a substantial global public health problem, with an
extreme events will interact is worrying. The number of people estimated two billion people suffering these deficiencies (Myers
affected by flooding and water stress is projected to increase with et al., 2014). Micronutrient deficiencies not only increase mortality,
climate change over at least the course of this century. Under a but can also contribute to children not reaching their development
middle of the road socioeconomic scenario, Arnell and Lloyd- potential (Black et al., 2013). Any reductions in micronutrients
Hughes (2014) projected that climate change by 2050 would in- could have important health consequences, particularly in regions
crease exposure to water resources stress for between approxi- with high levels of micronutrient deficiencies before the onset of
mately 920 and 3400 million people under the highest greenhouse drought.
gas emission scenario, and increase exposure to river flood risk for The burdens of undernutrition and micronutrient deficiencies
between 100 and 580 million people. Uncertainty in projected are high. Estimates of the total burden of undernutrition in low-
future impacts is dominated by uncertainty in the projected spatial and middle-income countries, including fetal growth restriction,
and seasonal pattern of change in climate, particularly precipita- stunting, wasting, and vitamin A and zinc deficiencies combined
tion. Using a different definition of water stress and different as- with suboptimum breastfeeding, are 3.1 million child deaths in
sumptions and scenarios, Hanasaki et al. (2013) projected higher 2011, or 45% of all child deaths (Black et al., 2013). Optimum fetal
population exposure to water resources stress in 2050 – between and child nutrition and development increase cognitive, motor,
7.1 and 7.9 billion people living in grid cells with withdrawals and socio-emotional development; school performance and
greater than 40% of runoff. learning capacity; and work capacity and productivity. The extent
to which the severity and/or persistence of drought directly or
3.1.2. Drought effects on food security indirectly affects nutrition would determine its potential impact
Extreme weather and climate events significantly affect food on future vulnerability.
security. A review of 78 post-disaster needs assessments between Although undernutrition and excess morbidity and mortality
2003–2013 in 48 low- and middle-income countries found that are directly and causally related, it is difficult to attribute adverse
22% of the total economic impact of USD 140 billion was in agri- health outcomes to a drought event because multiple other factors
culture, with 42% of all damage and losses in crops and 36% in influence the severity of impacts (Stanke et al., 2013). Further, the
livestock (FAO, 2015a). In total, 44% of crop and livestock produc- impacts of drought on some of these other factors, such as socio-
tion losses were caused by droughts and 39% by floods, with the economic status, can alter the susceptibility of communities to
livestock sub-sector particularly affected by droughts (86% of the subsequent extreme events.
impact due to droughts). This has important implications for hu- An important further consideration of the interaction between
man health and well-being and for future productivity through food security and extreme weather and climate events is that
direct and indirect pathways. many countries have failed to reach international hunger targets
100 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102

because of natural and human-induced disasters or political in- and wider society when addressing the issue of climate change
stability (FAO, 2015b). These protracted crises increased vulner- adaptation. Such benefits may take the form of (i) greater syner-
ability and food insecurity for large parts of the population. Over gism from community involvement with decision-making while
the past 30 years, crises shifted from catastrophic short-term promoting the legitimacy and sustainability of adaptation strate-
events to more structural and protracted situations, with natural gies, as well as (ii) the potential to shift the perception of climate
disasters and conflicts increasingly frequent among the exacer- change from being an insoluble global problem to that of a local
bating factors. In 1990, 12 countries in Africa faced food crises, of problem that may be at least partially solvable with the inclusion
which four were in protracted crisis. Twenty years later, 24 of community-initiated processes and projects (Adger, 2003).
countries were experiencing food crises, with 19 in crisis for eight Drought is an example of a natural hazard that can alter human
or more of the previous ten years. In 2012, approximately 366 and social capital in ways that could increase vulnerability to the
million people lived in protracted crisis situations, of whom ap- next extreme event. For example, in communities where liveli-
proximately 129 million were undernourished; this was about 19% hoods are heavily dependent on agricultural production, a stressor
of the global total of food-insecure people. Food security can be a such as drought and the subsequent decline of agricultural com-
cause and an effect of protracted crises, and can help trigger or modities has the very real potential to result in economic pressure
deepen conflict and civil strife. Protracted crises are the new norm, that is associated, possible causally, with mental health and well-
with significant implications for vulnerability to extreme weather being (De Silva et al., 2005; Sartorius, 2003; Whitley and
and climate events. McKenzie, 2005). Further, increased workloads in alternative sec-
Without explicitly considering extreme weather and climate tors (if available; this will require migration in some cases) as
events, climate change is projected to increase all aspects of food individuals compensate for loss of income from drought-affected
security (Porter et al., 2014). In tropical and temperate regions, agricultural activities, lack of time and money keep people from
climate change without adaptation is projected to negatively im- social activities, particularly from the vital informal social con-
pact production of the major crops (wheat, rice, and maize) for nections that are important for mental health (Berry et al., 2007).
local temperature increases of 2 °C or more above late-20th-cen- In addition, where pressure is placed on important relationships,
tury levels, although individual locations may benefit. Projected mental health problems are likely to increase (Berry et al., 2010).
impacts vary across crops and regions and adaptation scenarios.
The impacts increase after 2050, with projections showing con-
sistent and negative effects of climate change, particularly in low- 4. Discussion
latitude countries. Considering the impacts of changes in mean
climate along with changes in extreme events could lead to higher Many extreme weather and climate events are projected to
projected impacts, likely increasing baseline vulnerability in many increase in frequency, intensity, and duration over the coming
regions. decades with climate change. With such changes, it is apparent the
In summary, there are direct and indirect pathways by which events themselves could potentially increase the vulnerability of
drought can affect human health and nutrition. Continued con- individuals, communities, and regions to subsequent extreme
cerns over the health burdens of undernutrition and micronutrient weather and climate events. Long recovery times from an extreme
deficiencies are reflected in having hunger, food security, and event, particularly in low- and middle-income countries, may
nutrition as key elements of the second of the seventeen proposed mean the community, sector, or country is less resilient when the
Sustainable Development Goal 〈https://sustainabledevelopment. next event occurs. Drought is one example of these events and is
un.org/?page ¼view&nr ¼164&type ¼230&menu ¼2059〉. How- associated with a myriad of health outcomes, including under-
ever, this goal does not consider what additional efforts may be nutrition, mental illness, and the exacerbation of underlying
needed to address the future risks of climate change, including chronic diseases. The paucity of literature on extreme events as
droughts and other extreme events, to achieving the targets and sources of health and health system vulnerability to subsequent
goals. events is of concern, given that (i) the magnitude of impacts will
increase the severity of consequences following events and (ii)
3.2. Social capital as a determinant of susceptibility to drought and return periods will decrease in a changing climate. When recovery
other extreme weather and climate events time from disasters takes years or displacement occurs, and when
food security is compromised, there can be consequences for the
Social capital can be considered as the capacity of a population future health of children raised during this period. Better under-
to work harmoniously as a self-organizing unit, in which many standing is needed of the shape and drivers of recovery curves
individuals co-operate, but in which no single person or group over time, to identify opportunities for targeted interventions.
controls all activities. Social capital is broadly understood as the Development choices will be major determinants of the extent
social bonds and norms that contribute to social cohesion (Pretty, to which repeated extreme events will become sources of vul-
2003). Four central aspects of social capital are: relations of trust; nerability. The development level of a country and community is a
reciprocity and exchanges; shared rules, norms and sanctions; and key determinant of vulnerability to extreme events. Extreme
connectedness, networks and groups. events also affect development levels; a disaster can push those
There is a growing interest in the ways by which social capital just above to below the poverty line, increasing longer-term vul-
can influence collective action, particularly in relation to adapting nerability. Protracted and/or repeated cycles of extreme events
to environmental changes (including climate change). Securing have the potential to increase the numbers of vulnerable in-
livelihoods and maintaining well-being (at least partly) results dividuals in a population.
from levels of social capital that enhance shared access to re- Strengthening community adaptive capacity is one mechanism
sources (Bebbington and Perreault, 1999) and it has been argued by which individuals and their communities can build and sustain
that community-based adaptation has social capital at its core (Ebi the multiple resources that can increase resilience during times of
and Semenza, 2008). Where social capital is well-developed, local stress, such as recurring disasters associated with extreme events.
groups with locally developed rules and sanctions are able to Determinants of coping capacity include access to education,
make more of existing resources than individuals working alone or economic wealth, a healthy population, good governance, and high
in competition (Pretty and Ward, 2001). In addition, benefits may levels of human and social capital. Strengthening these determi-
accrue out of building trust and cooperation between government nants can enable individuals and communities to appropriately
 K.L. Ebi, K. Bowen / Weather and Climate Extremes 11 (2016) 95–102 101

prepare for and respond to the changing nature of extreme Ebi, K.L., Semenza, J.C., 2008. Community-based adaptation to the health impacts of
weather events. Also important is prioritizing investments in the climate change. Am. J. Prev. Med. 35 (5), 501–507. http://dx.doi.org/10.1016/j.
amepre.2008.08.018.
health aspects of disaster risk management, from research to im- EM-DAT, the Centre for Research on the Epidemiology of Disasters-CRED, 2014.
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equally critical to protect future generations from ever more, and FAO, 2015a. The Impact of Natural Hazards and Disasters on Agriculture and Food
Security and Nutrition: A Call for Action to Build Resilient Livelihoods. FAO,
more severe, extreme weather and climate events. Rome, p. 16, Updated May 2015.
FAO, IFAD, WFP, 2015b. The State of Food Insecurity in the World 2015. Meeting the
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IDMC (Internal Displacement Monitoring Centre, Norwegian Refugee Council),
However, we do not yet know how these impacts may be mag-
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