Background

Climate changes, including rising temperatures and shifting patterns of  rainfall, are expected to impact public health across the nation in a variety  of ways. Though state and local governments have primary responsibility  for protecting the public health in their jurisdictions, the federal  government also plays an important role in supporting state and local  efforts by, for example, providing health departments with technical  support and other resources. The federal government has also taken  other targeted actions to help prepare the nation for climate change  impacts, such as by issuing a number of orders, actions, and plans to  provide state and local decision makers with information they need to  manage such impacts, including impacts to public health.

		Climate Change Impacts in the United States

Impacts from climate change in the United States have been observed,  are projected to continue, and are likely to accelerate over the next  several decades, with impacts varying considerably by region, according  to assessments by the National Research Council and USGCRP.  According to USGCRP’s third NCA, observed impacts in the United  States include increases in average temperatures and precipitation, as  well as changes to precipitation extremes, with variation across regions  (see table 1). These and other climate changes are projected to continue  over this century and beyond, according to USGCRP’s third NCA. The  magnitude of climate change beyond the next few decades depends  primarily on the amount of heat-trapping gasses emitted globally, and  how sensitive the Earth’s climate is to those emissions, according to  USGCRP’s third NCA.

		Climate Change and Human Health

According to USGCRP’s third NCA, climate change is expected to impact  human health in the United States by exacerbating some existing health  threats and by posing new risks. For example, projected changes in  temperature are expected to increase the length of pollen seasons, which  could increase allergies and asthma episodes. According to USGCRP’s  third NCA, extreme weather events, which are expected to become more  common with climate change, are linked with increases in injuries,  deaths, and mental health problems, such as anxiety and posttraumatic  stress disorder. Furthermore, according to this assessment, changes in  the climate may contribute to the spread of vector-borne diseases that are  transmitted to humans by animals, including invertebrate animals such as  mosquitoes and ticks. Examples of vector-borne diseases that currently  pose health risks in some regions of North America include chikungunya  virus, dengue, Lyme disease, Rocky Mountain spotted fever, and West  Nile virus. Table 2 summarizes these and additional risks that climate  change poses to human health.
Vector-borne diseases are transmitted by  mosquitoes, ticks, and fleas. West Nile virus is  one type of vector-borne disease and is most  commonly transmitted to people by the bite of  infected mosquitoes. First detected in North  America in 1999, it has since spread to all  states except Alaska and Hawaii, with  outbreaks occurring every summer. Most  people who are infected with West Nile virus  infected people will develop a fever with other  symptoms such as headaches and body  aches, and a very small number of infected  people—less than 1 percent—will develop a  severe neurological illness that can result in  paralysis or death. People who work or play  outside are especially vulnerable because of  greater exposures to mosquitoes.
Habitats of some pathogen-carrying vectors may  expand into previously unaffected regions, in part  because of climate change.
Heat-related illnesses and deaths may result from heat stroke or heat-sensitive conditions such as  cardiovascular disease, kidney disease, cerebrovascular disease, and other conditions exacerbated  by exposure to extreme heat.
The type and severity of health impacts that communities and individuals  face from climate change will depend on a variety of factors, and not  everyone is equally at risk, according to assessments by the National  Research Council, USGCRP, and others. Populations of special concern  include children, the elderly, those who are sick, those who are living in  poverty, those who work outdoors, some communities of color, and  Native American communities. According to the National Research  Council and USGCRP’s third NCA, key factors in determining health risks  include the following:
Location. Because climate change impacts are expected to vary  across the country, people will face different risks depending on  where they live, work, and travel. People located in cities may be at  increased risk for heat-related illnesses (e.g., heat stroke or heat- sensitive conditions such as cardiovascular disease), for example,  because land cover changes associated with urbanization, including  increases in the amount of paved areas, can result in higher air  temperatures compared to the surrounding rural areas, according to  USGCRP’s third NCA. Those who work outdoors, such as farmers,  fishermen, firefighters, and utility workers, may be adversely affected  by climate impacts because they have more frequent, intense, and  longer exposures to the climate than the general public, according to  CDC’s website. For example, as extreme weather events such as  floods become more frequent and severe, outdoor workers could be  at increased risk of traumatic injury. Figure 1 provides examples of  potential impacts by region.
Why Are Children Especially Vulnerable to  Some Health Risks from Climate Change?  Children are more vulnerable than adults to  some health risks from environmental  hazards— including hazards exacerbated by  climate change—because of differences in  their biology and behavior. Children breathe  more air relative to their body mass than  adults do and their natural defenses are less  developed, which makes them especially  vulnerable to health impacts from decreased  air quality. Asthma is one of the most common  serious chronic diseases among children, and  can be aggravated by poor air quality.  Children also behave differently from adults,  such as by spending more time outdoors and  playing closer to the ground, which makes  them especially vulnerable to mosquito and  tick bites that can cause disease.
Age. A person’s age also plays a role in determining his or her  vulnerability to health impacts, including those related to climate  change, according to USGCRP’s third NCA. For example, children  suffer disproportionately from the effects of heat waves and other  environmental hazards associated with climate change, according to  USGCRP’s third NCA. One reason is that children playing outside  during heat waves may not be aware that they need to drink more  water as a preventative measure, according to EPA. Older adults  are also vulnerable to some climate-related impacts, according to  USGCRP’s third NCA. Specifically, this assessment states that limited  mobility among older adults can increase their flood-related health  risks, and that older people are at much higher risk of dying during  extreme heat events.
Adaptive capacity. The extent to which people and communities  have the capacity to successfully adapt to adverse events also affects  the health risks they face, and is influenced by characteristics such as  disabilities and socioeconomic status. For example, according to  USGCRP’s third NCA, limited economic resources for adapting to or  escaping from health-sensitive situations will place the poor at higher  risk of health impacts from climate change than higher-income  groups. In contrast, communities that have access to early warning  systems, such as for forecasting and alerting people about impending  heavy precipitation events and flooding, may be better positioned to  reduce health risks from such adverse events.

		Roles and Responsibilities for Managing Public Health Risks in the United States

State, local, territorial, and tribal governments have primary responsibility  for managing public health risks within their jurisdiction. Public health  departments vary greatly in their size, responsibilities, and resource  levels, among other factors. Activities that public health departments  may undertake to help promote health and well-being include monitoring  and investigating health problems, educating people about health issues,  developing plans to support health efforts, and researching new solutions  to health problems, among other activities.
The federal government’s role in managing public health includes  providing leadership through setting and communicating health-related  policies, goals, and standards. Federal agencies also finance research  and higher education, support state and local health department efforts,  and support the development of data and decision support resources that  decision makers can use to manage for risks to public health, including  from climate change. For example, through its various programs, CDC  provides technical and financial support to state and local health  departments to enhance their capacity to monitor and promote public  health, including preparing for the risks posed by climate change. The  agency’s Climate and Health Program, established in 2009, supports  state and local health department efforts to plan for and address the  health risks posed by climate change. According to CDC, the program’s  three core functions are to translate climate change science into health  policy for action by health departments and communities, create decision  support resources to build capacity, and serve as a credible leader in  planning for the public health impacts of climate change.

		Federal Efforts to Enhance Resilience to Climate Change Impacts

The federal government has undertaken a number of efforts to enhance  the nation’s resilience to climate change impacts, such as strengthening  federal agencies’ adaptation planning and providing states and localities  with information for managing risks posed by climate change. In July  2014, we reported that investing in resilience—actions to reduce potential  future losses rather than waiting for an event to occur and paying for  recovery afterward—can reduce the potential impacts of climate-related  events. To facilitate federal efforts, the federal government has issued  the following orders, actions, and plans:
Executive Order 13514. On October 5, 2009, the President issued an  executive order calling for federal agencies to participate in the  existing interagency Climate Change Adaptation Task Force. Based  on the task force’s recommendations, the Council on Environmental  Quality within the Executive Office of the President issued  implementing instructions for the executive order, directing federal  agencies to establish agency climate change adaptation policies,  among other things.
The President’s Climate Action Plan. In June 2013, the White  House published a climate action plan detailing actions that federal  agencies would take to prepare the nation for the impacts of climate  change, among other goals.
Executive Order 13653. On November 1, 2013, the President issued  an executive order to help prepare the nation for the impacts of  climate change. Among other things, the order called on certain  federal agencies to provide information, data, and decision-support  tools on climate preparedness and resilience in support of federal,  regional, state, local, tribal, and other efforts to prepare for the  impacts of climate change. It also established a State, Local, and  Tribal Leaders Task Force on Climate Preparedness and Resilience  to inform federal efforts to support climate preparedness and  resilience.
April 2015 Administrative Actions. On April 7, 2015, the White  House announced a series of actions that the administration was  taking to better understand, communicate, and address the health  impacts of climate change, as well as commitments made by private  sector entities and institutes of higher learning to further our  knowledge in this area. Among other things, the administration  expanded the resources available for analyzing the climate change  impacts on health. (App. II provides a summary of these actions.)
June 2015 Climate and Health Summit and Administrative  Actions. On June 18, 2015, the White House hosted a summit on  climate change and health, which included the participation of the  President, the Surgeon General, and the HHS Assistant Secretary for  Preparedness and Response. At the summit, the administration  announced a set of actions to protect communities from the health  impacts of climate change that cannot be avoided. (App. III provides a  summary of these actions.)
In addition, USGCRP has undertaken efforts to support scientific research  with the goal of improving understanding of and response to climate  change and its impacts on the United States. To help address climate  change impacts on human health, USGCRP coordinates an Interagency  Crosscutting Group on Climate Change and Human Health (CCHHG);  officials from CDC, NIH, and NOAA chair this group. The mission of  CCHHG is to promote and protect the nation’s public health by leading  and coordinating federal scientific activities related to climate change and  human health, from basic research through public health practice.  CCHHG’s activities include working to address key gaps in understanding  of the health–related impacts of climate change and developing  informational resources.

	Federal Agencies Have Undertaken Various Activities to Enhance Understanding of Climate Change Risks to Public Health

Federal agencies have undertaken activities to enhance understanding  about the risks that climate change poses to public health, including  supporting and conducting research on or related to these risks. Agencies  have also provided some data and decision support resources, such as  guidance and tools, for state and local officials and others to use in  examining public health-related risks from climate change and potential  actions to address these risks. Agencies have also communicated about  such risks through reporting and outreach efforts to public health officials  and the general public.

		Supporting and Conducting Research on or Related to the Risks Climate Change Poses to Public Health

To enhance understanding of the risks that climate change poses to  public health, many of the federal agencies included in our review have  supported and conducted research on or related to these risks. While  governmentwide data on funding for such research is not available, NIH,  which awards financial assistance for research, reports that it awarded  about $6 million to support research on the health impacts of climate  change in fiscal year 2014. This amount comprised a relatively small  portion—about 0.025 percent—of the approximately $24 billion that NIH  awarded for research that year. Some of this research originated from an  NIH funding opportunity—a solicitation for exploratory research projects  on the health impacts of climate change—through which the agency  awarded a total of about $8.3 million for research from fiscal year 2011  through fiscal year 2014 for 21 projects. One of these projects, for  example, examined the relationship between climate change and  pediatric asthma. NIH officials told us that the agency has not issued  additional funding opportunities for research on climate change. These  officials said that they hoped researchers who received awards from this  opportunity would be better positioned to submit proposals in the future  through NIH’s most common submission process, in which researchers  submit unsolicited proposals based on the program interests of one or  more of the agency’s institutes or centers.
In addition to NIH, other federal agencies, such the National Aeronautics  and Space Administration (NASA), have also conducted or supported  research on or related to the risks that climate change poses to public  health, including by making awards for relevant research projects and  providing financial support for research teams or postdoctoral students  conducting relevant work. For example, NASA made an award to aid in  the development of climate change indicators related to heat waves in  urban areas through its 2012 research announcement entitled “Research  Opportunities in Space and Earth Sciences” that intended to, among  other things, facilitate the application of scientific knowledge to  management decisions. Indicators developed through this program may  be used by health officials to identify urban areas with increased  vulnerabilities to health impacts due to a lack of cooling green spaces and  other factors. Additionally, EPA sponsored a review of the effects of  climate change on the indoor environment and health, which concluded,  among other things, that climate change may worsen existing indoor  environmental problems that are known to exacerbate illnesses such as  asthma and allergies, and create new problems that have adverse health  impacts.
Officials from some of the federal agencies included in our review told us  that while their agencies have conducted or supported research that is  useful for advancing understanding of climate change impacts to public  health, the link to this topic is often indirect. For example, federally-funded  research about health impacts from natural disasters, such as floods,  does not always explicitly consider the associated impacts from climate  change but can help advance understanding of these impacts, according  to federal officials we spoke with. Appendix IV provides additional  examples of research on or related to the risks of climate change to public  health that some of the federal agencies included in our review have  conducted or supported.

		Providing Data and Decision Support Resources for Examining Risks

Federal agencies have provided some data and decision support  resources—such as guidance and tools—that state and local officials,  and others, can use to examine public health-related risks from climate  change and potential actions to address these risks. Table 3 provides  examples of these data and decision support resources.
Users of these data and decision support resources may include public  health officials or decision makers with responsibility for managing  systems that are necessary for protecting public health, such as hospital  administrators or wastewater management system operators, among  others. Other users may include researchers, community organizations,  or other interested individuals. The following are two key interagency  mechanisms that federal agencies leverage to provide climate and health  data and decision support resources to potential users:
Data.gov. In April 2015, data.gov, the federal government’s site for  open data, launched a theme page on climate and health that  provides information about data sources and tools maintained by  federal agencies. The site includes links to data on climate, weather,  and health from many federal agencies. One data source included on  the theme page is CDC’s National Environmental Public Health  Tracking Network, which includes heat-related health data, including  national data on the number of extreme heat days and future  projections of extreme heat. Another data source included on the  theme page is NOAA’s Climate Data Online, which includes data on  precipitation amounts, as well as a mapping tool and other decision  support resources.
The U.S. Climate Resilience Toolkit. The toolkit is an online portal  that is intended to help individuals, communities (including tribal  nations), and others respond to risks from climate change. Human  health is one of the topics highlighted in the toolkit. One tool  available in the toolkit is the Agency for Toxic Substances and  Disease Registry’s Social Vulnerability Index, which uses U.S.  Census Bureau variables to identify communities that may need  support in preparing for climate-related or other hazards or recovering  from disasters, and includes a mapping feature and downloadable  data. Another tool available in the toolkit is a software package  developed by EPA that allows users to predict levels of disease- causing pathogens at specific beach sites, where outbreaks can result  from climate change-related effects such as warming waters and  intense precipitation.
CDC has also developed some decision support resources intended to  help state and local public health officials identify and address risks from  climate change. In June 2014, CDC officials authored a journal article  which described a five-step risk management framework that the agency  developed for health officials to use in preparing for the health effects of  climate change. In July 2014, CDC issued a more detailed guide for  health departments on how to assess the vulnerability of their constituent  populations to the health impacts of climate change—a critical step for  health departments in planning for climate change risks to public health,  according to CDC. The guide includes a case study detailing how CDC  conducted a vulnerability assessment on heat impacts in the state of  Georgia. In addition, CDC’s National Environmental Public Health  Tracking Program published a communication toolkit in 2012 that focuses  on the relationship among climate change, public health, and extreme  heat—which is the only climate change-related area for which the tracking  network provides data. Among other things, the communication toolkit  provides health officials and other potential users with key messages and  tips for using social media to communicate effectively about this topic.

		Communicating through Reporting and Outreach

Federal agencies in our review have communicated information about the  risks that climate change poses to public health through reporting and  outreach efforts directed at multiple audiences, such as public health  officials and the general public. In several key communication efforts,  federal agencies have collaborated to report on what is known about  these risks. For example, in the third NCA published in May 2014,  USGCRP reported on the impacts of climate change on the United  States, including risks to human health. The report was the result of a  large multiagency effort that included the 13 agencies participating in the  USGCRP as well as other agencies that chose to support the production  of the report. It includes a chapter on human health—prepared  collaboratively by officials from several federal agencies participating in  CCHHG, as well as experts from outside the federal government— summarizing what is known about how climate change threatens human  health and well-being, populations that are at greatest risk, the extent to  which public health actions can help address these risks, and  opportunities to improve human health while combating climate change.  CCHHG is expanding upon this information in a report that is intended to  provide a comprehensive, evidence-based, and, where possible,  quantitative estimation of observed and projected climate change related  health impacts in the United States. The report, referred to as the  USGCRP Climate and Health Assessment, is being developed through a  multiagency effort and is expected to be finalized in 2016. The American  Public Health Association, with the support of CDC, recently reported on  threats that climate change poses to human health, and how state and  local public health departments have responded to these threats using  CDC resources. In addition to preparing reports, federal agencies have  also reported on the risks that climate change poses to public health  through their websites and through social media, and federal officials  have reported on these risks in peer-reviewed journal articles and other  publications.
Federal agencies have conducted outreach to inform public health  officials, as well as the general public, about the risks that climate change  poses to public health. Some ways in which federal agencies have  recently done so include the following:  In August 2014, HHS held a departmentwide briefing on climate  change risks to public health.
In December 2014, CDC addressed climate change in its Public  Health Grand Rounds—a publicly-available webcast that is intended  to foster discussion on major public health issues.
In addition, senior officials within HHS and EPA have also conducted  outreach on certain occasions about the risks that climate change poses  to public health. In April 2015, the Surgeon General spoke publicly about  climate change impacts to health following a roundtable discussion on the  topic with the President, the EPA Administrator, and others, and also  used social media to solicit and respond to questions about health  impacts from climate change. The EPA Administrator has also  communicated about these risks to a variety of audiences, citing climate  change as among the most significant threats to public health. App. V  provides additional information about federal activities related to climate  change risks to public health.

	State and Local Health Departments Have Used CDC and Other Federal Resources to Address the Risks That Climate Change Poses to Public Health

Selected state and local health departments included in our review have  used a CDC climate and health award that addresses the risks that  climate change poses to public health, as well as other federal resources,  to address and plan for the public health risks from climate change.

		Selected Health Departments Have Used a CDC Award to Directly Address and Plan for the Risks That Climate Change Poses to Public Health

Sixteen state and two local health departments have used awards from  CDC’s Climate Ready States and Cities Initiative to address and plan for  the risks that climate change poses to public health. The initiative is the  federal government’s primary investment in supporting state and local  health departments in addressing the risks that climate change poses to  public health, and is the only HHS financial resource that has been  offered to state and local public health departments that directly targets  these risks. In fiscal year 2014, Initiative awards to state and local health  departments totaled $3.6 million, with individual awards averaging about  $200,000. Figure 2 displays Initiative awardees as of fiscal year 2015.
CDC’s Climate and Health Program administers the Climate Ready  States and Cities Initiative. Under the initiative, CDC program staff are  substantially involved in program activities, above and beyond routine  grant monitoring. CDC activities for this program are described as  providing ongoing guidance, resources, consultation, technical  assistance, and training related to awardee activities.
Under the initiative, CDC requires awardees to implement CDC’s Building  Resilience Against Climate Effects (BRACE) framework—a five-step risk  management process intended to help public health departments identify  and prepare for the public health impacts of climate change by, among  other things, incorporating atmospheric data and climate projections into  public health planning. To implement the framework, CDC requires  awardees to work with internal and external stakeholders to forecast  climate trends, identify disease risks and vulnerable populations, and  develop action plans for addressing these risks, among other things.  Figure 3 describes the five steps of the framework and provides examples  of activities that can be included in its implementation. CDC officials told  us that they developed the BRACE framework to assist state and local  health departments in preparing for the public health impacts of climate  change. (App. VI provides information on the types of activities  undertaken by awardees in implementing the BRACE framework, and  app. VII provides information on activities by other selected state and  local health departments).
Under the initiative, CDC requires awardees to complete a range of  activities that complement their work implementing the BRACE  framework. For example, CDC requires that awardees take steps to  increase awareness among the public and decision makers about the  risks that climate change poses to public health, making use of available  CDC resources.
Awardees provided examples of the types of guidance and support that  CDC’s Climate and Health Program has provided to assist them in  implementing the BRACE framework and addressing climate and health  information needs in their jurisdictions. For example, CDC created  guidance for awardees on how to develop a Climate and Health Profile— a report detailing a jurisdiction’s climate-related exposures, health  outcomes of concern, and vulnerabilities of certain populations—a  required component of the first step of the BRACE framework. CDC  officials told us that they plan to issue guidance describing how to  approach each step of the BRACE framework. As of June 2015, CDC has  issued two guidance documents on the first step of the framework.  Awardees also told us about other types of support provided by CDC,  including tools that CDC developed in response to awardees’ specific  requests for assistance, such as a database of peer-reviewed literature  on climate change and public health impacts and a graphic summarizing  the impacts of climate change to public health. CDC has also organized  several communities of practice among awardees as forums to discuss  issues related to the implementation of the BRACE framework.  According to CDC officials, some public health departments that have not  received the Climate Ready States and Cities Initiative award have  expressed interest in implementing the BRACE framework, and such  departments are able to do so using the resources available on CDC’s  website.
Although awardees told us that they are in various stages of  implementing the framework, they also noted that they have already  observed a variety of benefits from the award. Specifically, awardees we  spoke with told us that the CDC award has enabled them to work on  climate change and health issues in a formalized way that would  otherwise not have been possible given, for example, competing priorities  and limited staff time. According to our analysis of awardee reports to  CDC, nearly all 18 awardees have created a climate and health program  with dedicated staff within their departments to work on this issue,  although doing so is not a requirement of the award. Awardees also  reported that the program allows them to address specific needs in their  jurisdictions and consider certain areas of interest while implementing the  framework. For example, some awardees in state health departments told  us that they have provided subawards to a small number of local health  departments in their jurisdictions to participate in the implementation of  the BRACE framework, such as by providing feedback on the usefulness  of materials developed by the state, or to develop their own initiatives on  or related to climate change and public health. Officials in these states  told us that the award allows staff in the local jurisdictions to spend time  considering the risks that climate change poses to public health and how  these risks may impact existing priorities in their health departments.  Additionally, some awardees have identified specific risks that climate  change poses to public health and are interested in exploring these  issues in further detail. For example, some awardees are examining  potential health affects related to climate change impacts on food  security—that is, the availability and affordability of nutritious and quality  foods.
Furthermore, awardees told us that the CDC award has allowed for their  programs to build relationships and engage with partners, such as  officials from other departments in their jurisdictions or regional partners  from federal agencies, in ways that could not be accomplished without  such awards or without a formalized climate and health program. For  example, officials from the New York City Department of Health and  Mental Hygiene told us that through the department’s climate and health  program, they worked collaboratively with their regional National Weather  Service office to study the appropriateness of the thresholds used to  issue heat advisories and warnings. According to these officials, the  National Weather Service had been using a Heat Health Watch and  Warning System in addition to heat index forecasts to determine when to  issue heat advisories and warnings; however, health officials were  concerned that this method was not sensitive enough for use in predicting  public health outcomes during excessive heat events. The health  department completed a retrospective study of heat-related deaths to  evaluate metrics that could be used to estimate risks, and it found that  maximum heat index is a useful metric for assessing public health risks  due to hot weather in New York City. The officials said that they have  changed the threshold at which warnings are set as a result of this study,  and they have continued to develop a working relationship with the  National Weather Service.

		Selected Health Departments Reported Leveraging Other Federal Resources to Address and Plan for Risks

State and local public health officials we interviewed reported leveraging  a variety of other federal resources, including funding and information  sources, to address and plan for the risks that climate change poses to  public health. In most cases, these federal resources were not specifically  designed for addressing and planning for these risks, but the resources  could be used in ways that support such efforts. State and local public  health officials we interviewed most commonly mentioned leveraging  resources provided by CDC’s National Environmental Public Health  Tracking Program to support their work in addressing and planning for the  public health risks of climate change. CDC’s Tracking Program made  awards to 25 states and one city to develop local tracking networks,  analyze data on local environmental exposures and related health  outcomes, and supply selected data to a national tracking network. The  national network includes indicators on climate change, among other  environmental hazards, related to extreme heat exposure. State and  local health officials we interviewed reported that this award provides an  important core source of funding for data infrastructure and environmental  health surveillance activities in their jurisdictions, which can be leveraged  to include activities such as monitoring patterns of heat-related illness.  Awards provided to state and local health departments for the tracking  program vary; in fiscal year 2014, awards totaled $22.6 million to  participating states and localities, ranging from about $500,000 to $1.2  million, with an average award of about $870,000.
State and local health officials also provided examples of how their  jurisdictions have leveraged funding resources from other CDC programs  to address and plan for the risks that climate change poses to public  health. For example, state and local health officials told us that they have  leveraged awards from CDC’s Public Health Emergency Preparedness  program—which provides state, local, tribal, and territorial health  departments across the country with resources to build public health  preparedness capabilities—to help consider climate change in emergency  preparedness planning or develop systems that can be used to monitor  climate-related public health risks. Awards provided to state and local  health departments vary; in fiscal year 2014, for example, awards ranged  from $325,000 to approximately $42.5 million, with an average award of  approximately $9.9 million and a total of about $611.8 million. Climate  change is not a specific focus of the program, but CDC officials  responsible for administering this program told us that awardees have  flexibility in determining how to use the funds while meeting CDC’s  requirements. State health officials also told us that they have used  awards from CDC’s National Institute for Occupational Safety and Health  to consider the impacts of climate change on worker safety and health,  such as by monitoring heat-related illnesses and deaths among worker  populations or specific industries. Officials from the National Institute for  Occupational Safety and Health also noted that, while climate change is  not a specific focus of the program, the award could be used to support  activities in this area.
Some public health officials we interviewed also reported leveraging  federal resources from agencies other than from CDC to address or  consider the risks that climate change poses to public health. Specifically,  officials provided examples of other awards and informational resources  that they had used in their work on this issue. For example, an official  from one state told us that the state used an award from U.S. Geological  Survey to assess the vulnerability and health risks of the state’s  watersheds to flooding and drought under a changing climate. Some state  and local health officials reported using the health and regional chapters  of USGCRP’s third NCA as key sources of information. Some officials  also told us that they have relied on a variety of NOAA information  resources, such as those provided through NOAA’s National Centers for  Environmental Information or through NOAA-funded Regional Integrated  Sciences and Assessment teams. For example, one state health official  told us that the state has relied on support from a NOAA Regional  Integrated Sciences and Assessment team to translate technical  information about climate change. In conducting work to address the risks  that climate change poses to public health, local health officials from one  jurisdiction also provided an example of using demographic information  from the American Community Survey—an official U.S. Census Bureau  survey that is part of the Decennial Census Program—to identify  populations in its locality that are vulnerable to the health-related impacts  of climate change.

	State and Local Health Officials Identified Multiple Challenges, Some of Which They Said Could Be Addressed by Federal Action

When asked to identify challenges related to their work planning for and  addressing the risks that climate change poses to public health, state and  local public health officials we interviewed identified challenges that we  grouped into the three most frequently reported themes, noting that some  of these challenges could be addressed by federal action, while others  could not. According to state and local officials, they face challenges  communicating about the risks that climate change poses to public health.  Officials identified related opportunities for federal agencies to enhance  public understanding of these risks. The officials also stated that they face  challenges in identifying potential health risks of climate change, for  example, as a result of research gaps. Officials said that federal agencies  may be able to address this challenge by continuing to advance research  and enhance decision support resources. Finally, state and local public  health officials said they face other challenges that federal action may not  be able to address, such as having insufficient data on health impacts in  areas where agreements between states and hospitals limit access by  health departments.

		Selected Health Officials Face Challenges Communicating about the Risks That Climate Change Poses to Public Health and Identified Opportunities for Federal Action

According to our discussions with selected state and local health officials,  officials face challenges communicating about the risks that climate  change poses to public health, in part because of limited awareness  about climate change as a public health issue. The officials also identified  opportunities for federal agencies to address these communication  challenges.

			Challenges Identified

Selected state and local health officials told us during interviews, site  visits, and small group discussion sessions that they face challenges  resulting from limited awareness about climate change as a public health  issue within their own health departments, among other state and local  partners, such as other agencies in their jurisdictions, and among the  public. As we have previously found, public awareness can play an  important role in the prioritization of climate change adaptation efforts.
In addition, if public health officials are aware of the risks that climate  change poses to public health, they can better assess the importance of  these risks and allocate resources appropriately. However, health  department leadership and staff are often not aware of the public health  impacts of climate change, or do not understand how the issue fits into  the health department’s priorities, according to state and local health  officials. This observation is consistent with results from a 2012  NACCHO survey of 174 local health department officials, which showed  that just over one-third of respondents thought that other relevant senior  managers in their health departments were knowledgeable about the  potential public health impacts of climate change.
Some local health officials also reported that officials from other sectors of  government in their jurisdictions, such as environmental agencies  responsible for climate change adaptation planning efforts, have a limited  awareness of climate change as a public health issue. This has resulted  in health officials having limited involvement in climate change adaptation  planning within their localities, according to officials we interviewed. Some  officials believe that progress has been made in this area in recent years,  but, according to our review of a 2014 analysis of states’ climate change  adaptation planning activities, only about one-quarter of all states have  incorporated public health considerations into their statewide climate  change adaptation plans.
In addition, health officials told us that stakeholders and the public have  limited awareness about climate change as a public health issue, in part  because climate change has historically been framed as an  environmental issue. State and local health officials discussed climate  change impacts on health as an emerging issue that they became aware  of within the last decade, in part as a result of educational efforts of the  American Public Health Association. In 2008, for example, the association  made climate change a focus of its National Public Health Week, issuing  communications to highlight climate change as a public health issue.
State and local health officials also told us that they face challenges in  communicating or enhancing awareness about projected changes to local  climate that can impact public health because of the complexity of the  issue. Specifically, officials told us that it is difficult to develop messages  about climate change impacts on health because of uncertainties inherent  in climate change projections. For example, officials from one state health  department told us that the state has faced challenges describing climate  projections for its jurisdiction in a way that is accurate but not overly  technical, while adequately acknowledging the uncertainties of these  projections. State and local health officials also said that it is challenging  for them to communicate about the risks that climate change poses to  public health because some of the potential effects have not yet been  observed in their jurisdictions and, therefore, are not perceived by the  public as risks. For example, officials in some states that do not frequently  experience heat waves told us that they face challenges convincing their  constituents that the risks of heat-related illnesses will increase. Officials  told us that they have used a variety of strategies to attempt to interest  their constituents and stakeholders in these risks, such as framing the  issue as planning for emergency preparedness or severe weather events.  However, state and local health officials find it difficult to communicate  and bring attention to long-term issues, such as climate change, when  there are more immediate public health concerns drawing attention, such  as the 2014 Ebola virus outbreak.

			Opportunities Identified

State and local health officials, as well as representatives from  associations representing these officials, identified opportunities for  federal action to help address challenges the officials face in  communicating about the risks that climate change poses to public health.  These opportunities were generally in two areas: enhancing public  awareness on climate change as a public health issue, and providing  guidance and tools on how to communicate about this issue.
Concerning enhancing public awareness, state and local health officials,  as well as representatives from associations representing these officials,  told us that federal agencies could help address this challenge by taking a  sustained leadership role in enhancing public and stakeholder awareness  and understanding. Specifically, officials told us that a federally-led public  awareness campaign on this issue could assist in informing decision  makers and the public. They also said a campaign could help and provide  legitimacy to the work of public health officials in addressing and planning  for these risks. Officials particularly pointed to the need for a sustained  leadership role from HHS and its component agencies, which could draw  on the department’s experience from engaging in previous successful  public health campaigns, such as the campaign to reduce tobacco use. In  a November 2014 report, the President’s State, Local, and Tribal Task  Force on Climate Preparedness and Resilience also recommended  actions that federal agencies should take to increase climate literacy and  public awareness, among other things. These actions included  coordinating federal communications on climate change to develop clear,  consistent and unified messages, and ensuring that communications  resources are accessible to state and local governments. (See app. VII  for a summary of the task force’s health-related recommendations.)
Federal officials, including those from HHS, told us that they are taking  steps to enhance public awareness. For example, as previously  mentioned, the White House held a climate change and health summit in  June 2015, which included the participation of the U.S. Surgeon General,  the HHS Assistant Secretary for Preparedness and Response, and the  EPA Administrator. In addition, CDC officials told us that through awards  the agency provides, the FrameWorks Institute is developing a series of  fact sheets for the general public that explain various impacts of climate  change on human health. In its 2014 Climate Adaptation Plan, HHS  reported that it considers climate change to be one of the top public  health challenges of our time, and it noted that its Office of the Assistant  Secretary for Health will develop a climate change communication and  outreach strategy to, among other things, promote outreach and  awareness among its stakeholders about climate change and its impact  on public health. The plan further notes that outreach and  communication to at-risk populations will be a significant part of this  strategy, and that the department will leverage its comprehensive network  of stakeholders involved in the receipt or delivery of health and human  services to disseminate climate change and health information. HHS  reported in its Strategic Sustainability Performance Plan that the strategy  was to be developed by the fall of 2014. In March 2015, a senior HHS  official from the HHS component responsible for developing this strategy  told us that limited progress had been made in developing the strategy,  and that the strategy was not anticipated to be formalized in a written  document. However, in July 2015, HHS officials told us that they plan to  refine and document the strategy over the next 12 months.
Concerning guidance and tools, state and local health officials, as well as  a representative from an association representing them told us it would  be helpful if federal agencies, including CDC, developed communications  guidance on a number of topics. For example, they said they could  benefit from guidance on how to frame climate change as a public health  issue or communicate based on best practices from the social sciences.  They also suggested the development of communication tools, such as  talking points or training on how to communicate about this issue.  Because protecting public health requires the participation of a variety of  stakeholders—including state and local public health departments and  other state and local entities—enhancing stakeholder awareness and  understanding about climate change as a public health issue could  bolster state and local preparedness for the risks that climate change  poses. In addition, as noted earlier in this report, enhancing awareness  among the public and decision makers about the risks that climate  change poses to health is a requirement of the Climate Ready States and  Cities Initiative. According to state and local health officials, including  Initiative awardees, communication guidance and tools would help them  enhance stakeholder awareness and understanding of the risks climate  change poses to public health.
CDC has developed limited guidance regarding communicating the risks  that climate change poses to public health for state and local health  officials. CDC has developed a toolkit related to communicating the  connections between climate change, extreme heat, and health.  However, the content of this document is focused on how awardees and  partners of the National Environmental Public Health Tracking Network  can use Tracking Network data to communicate about this issue, and is  therefore not as applicable to a wider audience. CDC officials were not  aware of any other agency guidance documents on communicating about  the risks climate change poses to public health. Officials from CDC’s  Climate and Health Program acknowledged that a commitment to  communicating about the risks that climate change poses to public health  is needed, and they identified some actions to help Climate Ready States  and Cities Initiative awardees address this challenge, such as reviewing  and sharing research findings on best practices for communicating about  climate change and providing technical assistance to state and local  health departments regarding communication upon their request.  However, these officials also told us that they do not currently have plans  to develop communication guidance for state and local health  departments on how to communicate about climate change because they  do not have the resources or capacity to develop such guidance at this  time. CDC officials told us that they have been focusing on assisting  awardees with resolving methodological and data issues related to  implementing the BRACE framework, such as identifying models for use  in developing projections of climate change in their jurisdictions.
As we noted earlier, the agency’s Climate and Health Program supports  state and local health department efforts to plan for and address the  health risks posed by climate change. CDC’s website states that the  program’s core functions involve translating climate change science to  inform health departments and communities, serving as a credible leader  in planning for the public health impacts of climate change, and creating  decision support resources to assist officials in preparing for climate  change. As the administrator of the Climate Ready States and Cities  Initiative, CDC is to provide ongoing guidance, resources, and technical  assistance, among other things, related to awardee activities. Because  CDC requires that awardees of this initiative take steps to enhance public  awareness of the risks that climate change poses to human health,  developing communications guidance would support their efforts. While  CDC’s current resources are focused on addressing methodological and  data issues related to the implementation of the BRACE framework, it is  also critical for the agency to establish a plan describing when it will  develop future communications guidance, to help ensure that health  officials have the tools they need to effectively implement the BRACE  framework and address required aspects of the award.

		Selected Health Officials Face Challenges Identifying Potential Health Risks of Climate Change and Identified Opportunities for Federal Action

According to our discussions with selected state and local health officials,  they face challenges identifying potential health risks from climate change  and have identified related opportunities for federal action. Specifically,  officials noted how gaps in research have made it difficult for them to  understand and plan for potential health impacts. For example, some  state and local public health officials said that limited research has been  conducted on how climate change may affect certain aspects of public  health, such as the spread of vector-borne diseases, the costs of climate  change impacts on human health, and the effectiveness of specific  management options. Other officials we interviewed told us that they had  difficulty using some of the climate-related data that federal agencies  have made available for decision makers. Officials we interviewed  explained that they typically do not have the scientific or technical  expertise to fully understand or use some federal data, particularly those  related to climatology. Public health officials have generally not been  trained in using geographic information systems, atmospheric data, and  climate projections, according to officials. In addition, conducting  analyses with these data can be complex and time-intensive.  Consequently, they said that the availability of technical assistance in  using such data, as well as in translating the results so that officials can  apply them at the local level, has been very helpful.
State and local public health officials we interviewed said that federal  agencies could help address these challenges by continuing to advance  the research they support, and by enhancing decision support resources,  including resources to assist decision makers in using federal datasets.  State officials noted that an expansion of interagency research  opportunities on the public health impacts of climate change, which is a  crosscutting research area, could be helpful. State and local public health  officials we interviewed said that federal agencies could also enhance the  decision support resources they provide, including through technical  assistance that would better position public health departments to  effectively use available datasets. For example, a Climate Ready States  and Cities Initiative awardee said that it would be helpful if CDC could  provide awardees with programming language to assist them in using  federal datasets to assess health vulnerabilities associated with climate  change.
Officials from federal agencies told us about actions that they have taken  or that they have planned that could help address some of these  challenges. Specifically, federal officials have acknowledged the need for  additional research on the public health impacts of climate change and  have taken some steps to fill those needs. In 2010, an ad hoc interagency  working group on climate change and health developed a white paper  summarizing research needs on the human health effects of climate  change. The intent of this paper was to provide a baseline picture of  research needs in this area that agencies could then build upon as new  information became available, according to the paper. Subsequently, NIH  officials analyzed the agency’s portfolio of research on climate change  and health, and summarized their results in an article published in 2013.  The article includes a discussion of challenges related to conducting this  research and opportunities to advance the research, including  opportunities to take a multidisciplinary approach through enhanced  interagency research opportunities. More recently, in an April 2015  Federal Register notice, EPA, on behalf of USGCRP, announced that a  draft of the CCHHG assessment of climate change impacts on health was  available for comment. According to the CCHHG co-chairs, the report  contains results that should advance the research in some needed areas,  and is likely to include some information on research needs. The CCHHG  co-chairs told us that they hope to use information on research needs  included in the final assessment to help inform the development of a  prioritized and focused research agenda for use in addressing research  needs. CCHHG officials also told that they would like to continue to help  foster a collaborative interagency approach to researching climate  change impacts on health.
Federal agencies, such as HHS, EPA, and NOAA, have also recently  taken steps to enhance data and decision support resources available to  state and local decision makers, for example, by enhancing air quality  surveillance and creating a national heat health information system.  These enhanced resources may address some needs of state and local  decision makers. CCHHG officials said that they have plans to solicit  feedback from state and local decision makers about these enhanced  decision support resources through town hall meetings and other  mechanisms.

		Selected State and Local Health Officials Face Other Challenges That Federal Action May Not Be Able to Address

According to selected state and local public health officials we  interviewed, they face a range of other challenges related to planning for  and addressing the health impacts of climate change that federal action  may not be able to address. For example, they said that insufficient data  and inadequate resources impede their ability to address or plan for these  risks. While some federal programs collect local data and provide  financial resources to selected states and localities, such as CDC’s  National Environmental Public Health Tracking Program, the federal  government does not collect local data on climate impacts or health  outcomes in all locations, and does not make awards to support the  climate and health activities of all state and local health departments.
State and local public health officials told us that some environmental  surveillance data that could help inform research on the health risks of  climate change—such as data on air quality, water quality, and pollen— are often not collected by their states and localities given limited  surveillance systems. Additionally, state and local officials explained that  some health outcome data can be difficult to obtain. State officials  explained that their access to health outcome data, such as the medical  conditions cited for emergency room visits, is limited by agreements that  states have with hospitals regarding the amount and type of information  that hospitals will share with state officials.
Some state and local officials told us that their health departments did not  have dedicated staff or funding to address and plan for climate change  impacts or that their staff resources and funding were not sufficient for  maintaining the ideal quality or quantity of work in this area. These  statements are consistent with findings from NACCHO’s 2012 survey of  local health department officials, in which less than 10 percent of  respondents said that their health departments had sufficient resources to  effectively protect local residents from the health impacts of climate  change, and less than 20 percent of respondents said their health  departments had sufficient expertise to assess the potential impacts from  climate change.

	Conclusions

Federal agencies have taken steps to enhance understanding about the  risks of climate change to public health. They have also supported state  and local efforts to address and plan for these risks, in keeping with an  executive order that calls on federal agencies to provide them with data,  information, and decision support tools on climate preparedness and  resilience. Nevertheless, state and local officials face challenges resulting  from limited awareness of climate change as a public health issue among  their own departments and the public. As we have previously found,  public awareness can play an important role in the prioritization of work  on climate change. HHS has acknowledged climate change as one of the  top public health challenges of our time and is developing a climate  change communication and outreach strategy, which has been delayed  by over a year, but is expected to be finalized by July 2016.
CDC requires public health departments participating in its Climate Ready  States and Cities Initiative to take steps to raise public awareness about  the risks that climate change poses to public health, and also engage  stakeholders in their planning. As the administrator of the Climate Ready  States and Cities Initiative, CDC is to provide ongoing guidance,  resources, and technical assistance to support state and local health  department work on this issue. Although the agency has provided  guidance on some topics, such as extreme heat events, it has not  provided specific guidance on how public health departments should  communicate about the risks that climate change poses to public health.  Officials from CDC’s Climate and Health Program acknowledged that a  commitment to communicating about the risks that climate change poses  to public health is needed. However, the agency does not currently have  plans to develop guidance on this topic, as it has been focused on other  priorities. Issuing such guidance would also be in line with the core  functions of CDC’s Climate and Health Program, which include translating  climate change science to inform communities. By developing such  guidance, CDC may help public health departments better meet the  requirements of the Climate Ready States and Cities Initiative and better  position all health departments to make progress in planning for the  health impacts of climate change.

	Recommendation for Executive Action

To enhance HHS’s ability to protect public health from the impacts of  climate change, we recommend that the Secretary of HHS direct CDC to  develop a plan describing when it will be able to issue climate change  communication guidance to state and local health departments, to better  position relevant officials to effectively communicate about the risks that  climate change poses to public health and address requirements of the  Climate Ready States and Cities Initiative.

	Agency Comments and Our Evaluation

We provided a draft of this product to HHS, EPA, NOAA, USGCRP, the  Council on Environmental Quality, the Department of the Interior, and the  National Science Foundation for comment. In its written comments,  reproduced in appendix IX, HHS stated that CDC generally concurred  with our recommendation. CDC noted its plans to develop and issue  climate change communication guidance to state and local health  departments after HHS finalizes its climate change communication and  outreach strategy, which is expected by July 2016. CDC stated that it  would use HHS’s strategy to inform their development of guidance, and to  build off of the same strategy. CDC said that the agency currently  provides support and technical assistance to state and local health  departments regarding communication upon their request, and would  continue to do so while HHS finalizes its strategy. CDC remarked that the  agency is also working with partner and professional organizations to  disseminate messages on the health impacts of climate change.
We also received technical comments from HHS, EPA, NOAA, USGCRP,  the Council on Environmental Quality, the Department of the Interior, and  the National Science Foundation, which we incorporated as appropriate  As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees; the Secretaries of Agriculture, Commerce,  Defense, Health and Human Services, Homeland Security, the Interior,  and the Smithsonian Institution; the Administrators of the Environmental  Protection Agency and the National Aeronautics and Space  Administration; the Director of the National Science Foundation; the  Executive Director of the United States Global Change Research  Program; and the Managing Director of the Council on Environmental  Quality; as well as other interested parties. In addition, the report will be  available at no charge on the GAO website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact J. Alfredo Gómez at (202) 512-3841 or gomezj@gao.gov, or  Marcia Crosse at (202) 512-7114 or crossem@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix X.

Appendix I: List of Agencies and Stakeholders Interviewed

We interviewed officials from federal, state, and local government  agencies, as well as representatives of stakeholder groups involved in  public health and climate change.

	Government Agencies

	State Public Health Departments

1.  Baltimore (MD)  2.  Benton County (OR)  3.  Columbus (OH)  4.  Dallas County (TX)  5.  Houston (TX)  6.  Multnomah County (OR)  7.  New York City (NY)  8.  Portsmouth (VA)  9.  Salt Lake County (UT)  10. San Diego County (CA)  11. San Francisco (CA)  12. San Luis Obispo County (CA)  13. Shelby County (TN)  14. Summit County (OH)  15. Toledo-Lucas County (OH)  16. Washington County (MD)  17. Wicomico County (MD)

	Stakeholder Groups

Appendix II: Summary of Actions Announced by the Administration in April 2015 to Address the Health Impacts of Climate Change

In April 2015, the administration announced a series of actions and  commitments that were intended to enhance the nation’s ability to  understand, communicate, and reduce the health impacts of climate  change. Specifically, the administration announced the following 12  actions that it plans to take to address this issue:  1.  hosting a climate change and health summit at the White House;  2.  issuing a report highlighting actions taken by state and local leaders to  reduce the impact of climate change on public health;  3.  releasing a health care facilities toolkit consisting of fact sheets,  checklists, case studies, and other resources to assist local decision  makers in promoting resilient health care infrastructure;  4.  circulating a draft climate and health assessment report that is  intended to synthesize the best available information on the public  health impacts of climate change;  5.  holding a community, culture, and mental health workshop to identify  factors that enhance resilience to climate change;  6.  integrating climate considerations into the Department of the Interior’s  health and safety policies;  7.  hosting a climate and health data challenge, whereby coders,  analysts, and researchers will use available government datasets to  generate insights into unresolved questions about the health impacts  of climate change;  8.  offer climate and health data to participants during the national day of  civic hacking (June 6, 2015) to encourage participants to develop new  climate and health solutions;  9.  improving air quality data with the Environmental Protection Agency’s  release of six new village green stations that measure air quality and  meteorological data;  10. challenging researchers to develop new models to forecast epidemics  of dengue and other infectious diseases through the consolidation of  federal and nonfederal data sets;  11. awarding prizes to those who have developed predictive modeling  capabilities that can assist government and health organizations to  predict the spread of chikungunya, a vector-borne disease; and  12. measuring nutrient pollution through a competition whereby federal  datasets are leveraged to develop educational and decision support  resources.
Additionally, the administration announced that it has secured  commitments with 14 businesses and other organizations to collect and  share data regarding the health impacts of climate change. For example,  Microsoft has committed to improve vector-borne disease surveillance  capabilities by developing and deploying drones that are capable of  collecting large amounts of mosquitos and automatically analyzing them  for various pathogens. Finally, the administration announced that a  coalition of deans from 30 medical, nursing, and public health schools  had committed to train their students to address the health impacts of  climate change.

Appendix III: Summary of Actions Announced by the Administration in June 2015 to Address the Health Impacts of Climate Change

In June 2015, the administration announced a set of actions and  commitments that were intended to protect our communities from the  health impacts of climate change. Specifically, the administration  announced the following actions to address this issue:  1.  creation of a map tool by the Department of Health and Human  Services to improve the ability of health officials and emergency  managers to rapidly identify residential areas where people who  depend on electricity to power life-critical durable medical equipment  live;  2.  development of a national integrated heat health information system  by the Centers for Disease Control and Prevention and the National  Oceanic and Atmospheric Administration, which is intended to provide  a suite of decision support resources that better serve public health  needs;  3.  launch of a climate and health innovation challenge series by the  National Institutes of Health and others to promote innovative  approaches and highlight technologies available for understanding the  health implications of climate change and improving resilience to  adverse effects;  4.  creation of a climate change impacts subcommittee within the Federal  Interagency Working Group on Environmental Justice, and the  workgroup’s launch of a climate justice initiative that is focused on  incorporating equity into climate adaptation planning;  5.  announcement of a local climate and energy webcast series on  climate change, heat islands, and public health, to be hosted by the  Environmental Protection Agency;  6.  plans to highlight examples of policy actions related to children’s  health during national Children’s Health Month;  7.  a commitment by CDP, a private organization, to release publicly  disclosed data from 61 U.S. cities that summarize the climate risks  that the cities are facing and the actions they are taking to improve  resilience; and  8.  an expansion in the number of medical, public health, and nursing  schools that have committed to educate and train their students about  the risks of climate change to public health.

Appendix IV: Examples of Climate Change and Health Research Conducted or Supported by Federal Agencies

Federal agencies conduct or support research on a range of topics that  can enhance understanding of the risks that climate change poses to  public health. In conducting our work, we interviewed officials from some  federal agencies involved in the United States Global Change Research  Program’s Interagency Crosscutting Group on Climate Change and  Human Health. Specifically, we spoke with officials from those agencies  whose focus was on understanding climate change risks to populations  within the United States. Table 4 provides examples of research some of  the federal agencies involved in this group have conducted or supported  on or related to the risks that climate change poses to public health.

Appendix V: Examples of Federal Agency Activities on or Related to the Public Health Impacts of Climate Change

Federal agencies have conducted a range of activities related to  understanding, communicating, and managing for the public health  impacts of climate change. In conducting our work, we interviewed  officials from 26 federal agencies, including some of those involved in the  United States Global Change Research Program’s Interagency  Crosscutting Group on Climate Change and Human Health. Specifically,  we interviewed officials from agencies whose focus was on understanding  or managing for climate change risks to populations within the United  States. We also interviewed officials from the United States Global  Change Research Program and the Council on Environmental Quality.  Table 5 provides information about activities conducted by these selected  agencies.

Appendix VI: Examples of Activities Conducted by Awardees of CDC’s Climate Ready States and Cities Initiative

State and local health officials from the 16 state and two local health  departments receiving awards through the Center for Disease Control  and Prevention’s (CDC) Climate Ready States and Cities Initiative told us  that they have conducted a variety of activities to address and plan for the  risks that climate change poses to public health. These activities support  awardees’ efforts to implement CDC’s Building Resilience Against  Climate Effects (BRACE) framework—a five-step risk management  approach intended to help public health departments identify and prepare  for the public health impacts of climate change by, among other things,  incorporating atmospheric data and climate projections into public health  planning. Examples of these activities include the following:
Developing community vulnerability and resilience indicators.
Awardees have developed indicators to measure community  vulnerability and resilience. Florida, for example, developed indicators  to identify relationships between measures of social and medical  vulnerabilities, such as age and access to health care facilities, with  risks to climate-related hazards in the state including hurricane winds  and wildland fire. Officials from the city of San Francisco also created  a series of community resilience indicators to provide quantitative  measurements of vulnerability to climate change stressors in the city,  by neighborhood. Indicators were developed in a variety of  categories, including in areas related to the environment, health,  housing, and the economy, and then mapped by census tract. See  figure 4 for an example of a map developed to display areas of  vulnerability to extreme heat based on the percentage of buildings  with air-conditioning.
Enhancing surveillance. Some awardees described taking efforts to  enhance the amount and type of surveillance data they collect. For  example, Vermont developed Web-based tools for the public to report  surveillance information related to the spread of ticks and algal  blooms. Specifically, through its interactive tick tracker, the public can  share information about where and what kinds of ticks have been  observed, in order to better prevent the occurrence of tick bites in  others.
Incorporating climate change into emergency preparedness  planning. Awardees told us that they have incorporated climate  change considerations into emergency preparedness planning, such  as by developing plans for hazards related to climate change, which  can include heat waves or other extreme weather events. For  example, Arizona created outreach materials on extreme heat and  flooding emergencies to support local health departments. In addition,  the state provided technical assistance to a county to create an  extreme weather response plan, which included responding to  extreme heat events. Illinois also incorporated climate change  considerations into emergency preparedness planning by requiring  that local health departments demonstrate that they are planning for  an increase in the frequency and severity of extreme weather events  in order to obtain public health emergency preparedness funding from  the state.
Developing communication materials. Awardees have developed  communication materials to share information on the risks that climate  change poses to public health in their jurisdictions, such as through  websites for their Climate and Health programs. Officials from one  county receiving funds through California’s Climate and Health  Program told us that its jurisdiction developed a climate change  communications campaign for the purpose of educating health  department staff and the community. As part of this effort, county  health officials developed public service announcements to air on  county-based radio stations—in English and in Spanish—that explain  climate change and health-related topics, such as food,  transportation, and energy.
Engaging communities. Awardees described efforts to engage  communities, particularly those vulnerable to the risks that climate  change poses to public health. For example, officials from New York  City described conducting focus groups with seniors and their  caregivers to obtain their perspectives on awareness of heat  warnings, prevention behaviors, and air-conditioning prevalence and  use during heat waves. Officials from San Francisco also reported  holding town hall style meetings with community groups from selected  neighborhoods to discuss issues related to climate and health,  including heat, sea level rise, and vulnerable populations in these  specific areas.
Partnering with academic institutions. Awardees reported forming  partnerships with academic institutions to, among other things,  develop vulnerability assessments and translate climate science  information. In some cases, these partnerships were the result of the  health department providing a small amount of funding to the  university to conduct these assessments, according to officials. For  example, officials from Maryland told us that they are collaborating  with researchers at the University of Maryland to develop vulnerability  assessments and develop county-level projections of the burden of  disease from climate change on particular health impacts, such as  asthma and waterborne illness. Maryland officials noted the  importance of partnering with the University to conduct this work,  given the limited resources of the health department and difficulties  associated with hiring staff to conduct this assessment.
Collaborating with other state or local entities. Awardees have  developed relationships with other state or local departments in  conducting activities related to addressing and preparing for the risks  that climate change poses to public health. Awardees mentioned that  these partnerships help others gain a better perspective of the health  impacts of climate change, which will help them to consider health  impacts as they make decisions in their respective fields. Awardees  also noted that they have shared information with partners or worked  collaboratively on projects. For example, officials from the Michigan  Department of Community Health reported partnering with the state’s  Department of Environmental Quality to receive data on topics related  to air or water quality. Some awardees also noted the importance of  developing partnerships with their state climatologist to provide their  health departments with technical assistance in interpreting climate  data.

Appendix VII: Activities of Other Selected State and Local Health Departments Related to Preparing for the Public Health Impacts of Climate Change

Officials from some of 13 state and local health departments that we  interviewed that have not received an award through the Centers for  Disease Control and Prevention’s (CDC) Climate Ready States and Cities  Initiative have conducted some activities related to addressing and  planning for the risks that climate change poses to public health, to the  extent that they have resources available. Some of these state and local  health department officials began working on this issue as a result of  receiving leadership direction to do so, whereas others did so in the  absence of leadership direction, because they believe it is an important  issue or because they have identified the need to acknowledge the issue  based on knowledge of climate change risks in their jurisdictions.
While some departments have conducted work in this area, others did not  have the resources to begin or sustain a robust level of activity. State and  local health officials told us that they have few staff to work on such  activities, and that those staff also have other assignments and  responsibilities. Efforts related to preparing for climate change risks to  human health are often conducted in an ad hoc manner compared to  those receiving awards through CDC’s Climate Ready States and Cities  Initiative. Some officials also told us that they have partnered with or  received support from academic institutions and nonprofit organizations,  which has been beneficial in beginning their work in this area since they  have few resources to devote to this issue within their health  departments.
State and local health departments not receiving the award that have  begun planning for the risks that climate change poses to public health  have undertaken activities such as conducting research on health impacts  associated with climate change, such as heat-related illness or asthma,  participating in workgroups, holding forums to raise awareness, and  producing reports. Among the state and local health departments that we  interviewed, Alaska and Washington were among those not receiving the  CDC initiative award that had undertaken a number of activities directly  related to preparing for the public health impacts of climate change.
Alaska. Officials from the Alaska Department of Health and the  Alaska Native Tribal Health Consortium—a nonprofit tribal health  organization—told us that they have engaged in a number of activities  to address and plan for the risks that climate change poses to public  health, given that Alaska residents are already seeing climate change  impacts to their health and livelihoods. The state’s Department of  Health is in the early stages of developing a health impact  assessment that seeks to identify the potential costs of climate  change to health, ways in which to minimize adverse health effects,  and ways in which to maximize potential health benefits. The results  of this assessment will serve as a baseline for future climate change  planning and preparedness activities in the state. Officials from the  Department of Health were also involved in studying an outbreak of  vibrio parahaemolyticus in July 2004, due, in part, to rising ocean  temperatures. The Alaska Native Tribal Health Consortium has also  conducted activities related to climate change and health. Through an  award provided by HHS’s Indian Health Service, the center has  conducted assessments to understand the broad range of community  impacts from climate change, including changes in disease, mental  health, food and water security, and infrastructure. The center is  integrating the results of these assessments into construction design,  operations, and maintenance considerations for specific health facility  improvements, such as new filtration systems for water treatment  plants. The center also developed a Local Environmental Observers  network, consisting of tribal environmental, natural resources, and  health professionals, to enhance monitoring of unusual events that  are climate change-related or climate-sensitive. Observations are  mapped on a Google maps platform and are communicated through  an electronic newsletter to provide information to decision makers on  current risks.
Washington. The Washington State Department of Health has  recently started to engage in activities related to climate change and  health at the direction of its Secretary of Health, who identified climate  change as a priority issue. The department is working to identify how  to measure and track the impacts of climate change, particularly in the  areas of food, water, and air quality, through its Washington Tracking  Network, which is funded by CDC’s Environmental Public Health  Tracking Network. The department also conducted a survey to  characterize local health jurisdiction’s perceptions, activities, and  needs related to climate change, and compared the results to similar  surveys of local health departments on this topic.

Appendix VIII: Summary of Health-Related Recommendations Made by the President’s Task Force on Climate Preparedness and Resilience

In November 2013, the President issued Executive Order 13653,  Preparing the United States for the Impacts of Climate Change, which,  among other things, established the State, Local, and Tribal Leaders  Task Force on Climate Preparedness and Resilience. The mission of the  task force was to provide recommendations to the President and  interagency council on how the federal government could, among other  things, support state, local, and tribal preparedness for and resilience to  climate change.
The task force issued a report to the President in November 2014, noting  that the federal government has an essential and unique role to play in  preparing for and responding to climate change impacts. Its report  includes 35 recommendations to the President across seven themes, and  it also listed suggested actions that federal agencies could take to  implement the recommendations. The themes addressed in the report are  (1) building resilient communities, (2) improving resilience in the nation’s  infrastructure, (3) ensuring resilience of natural resources, (4) preserving  human health and supporting resilient populations, (5) supporting climate- smart hazard mitigation and disaster preparedness and recovery, (6)  understanding and acting on the economics of resilience, and (7) building  capacity. Table 6 summarizes selected health-related recommendations  and suggested actions listed across various themes of the report.
The task force also developed five overarching principles for all federal  agencies to consider as a means to advance climate preparedness and  resiliency. These include:  1.  Require consideration of climate-related risks and vulnerabilities as  part of all federal policies, practices, investments, and regulatory or  other programs.  2.  Maximize opportunities to take actions that have dual benefits of  increasing community resilience and reducing greenhouse gas  emissions.  3.  Strengthen coordination and partnerships among federal agencies,  and across federal, state, local, and tribal jurisdictions and economic  sectors.  4.  Provide actionable data and information on climate change impacts  and related tools and assistance to support decision making.  5.  Consult and cooperate with tribes and indigenous communities on all  aspects of federal climate preparedness and resilience efforts, and  encourage states and local communities to do the same.

Appendix IX: Comments from the Department of Health and Human Services

Appendix X: GAO Contacts and Staff Acknowledgments

	GAO Contacts

J. Alfredo Gómez, gomezj@gao.gov or (202) 512-3841.
Marcia Crosse, crossem@gao.gov or (202) 512-7114.

	Staff Acknowledgments

In addition to the individuals named above, Diane Raynes (Assistant  Director), Mark Braza, Emily Hanawalt, Armetha Liles, Krista Mantsch,  Cynthia Norris, Patricia Roy, Emily Ryan, Jeanette Soares, Andrew  Stavisky, and Jennifer Whitworth made key contributions to this report.

Summary:
Why GAO Did This Study

The World Health Organization projects climate change will adversely affect health significantly over the next several decades. Some health effects of climate change are already being felt in the United States, according to assessments by the National Research Council, USGCRP, and others. Since the federal government is the nation’s largest purchaser of health care services, federal health care expenditures could increase in future years due to climate-related impacts.
GAO was asked to review federal efforts to increase public health system preparedness for climate change. This report addresses (1) federal activities to enhance understanding about the risks climate change poses to public health, (2) federal resources used by selected states and localities to address these risks, and (3) challenges states and localities face and actions federal agencies could take to mitigate them. GAO examined federal, state, and local documents, and interviewed officials from federal agencies such as CDC, NIH, USGCRP, as well as state and local health departments, including all 18 recipients of CDC’s Climate Ready States and Cities Initiative award.

What GAO Found

Federal agencies are enhancing understanding of climate-related risks to public health by (1) supporting and conducting research, (2) providing data and informational resources, and (3) communicating about risks. The Department of Health and Human Services’ (HHS) National Institutes of Health (NIH) supports a portfolio of research directly related to these risks. NIH reports awarding about $6 million for such research in fiscal year 2014, including for one study examining health risks posed by heat and air pollution. Federal agencies have also provided data on climate and health issues, such as the number of extreme heat days that state and local officials can use to assess health risks. They have also reported about these risks, such as through the third National Climate Assessment issued in May 2014 by the U.S. Global Change Research Program (USGCRP).
Selected state and local health departments have used resources from HHS’s Centers for Disease Control and Prevention (CDC) and other federal agencies to address and plan for the risks of climate change to public health. CDC’s Climate Ready States and Cities Initiative awards an average of about $200,000 per year each to 16 state and two local health departments to implement a risk management framework designed to help incorporate climate projections into public health planning. CDC also requires awardees to increase public awareness of the risks climate change poses to public health. Other federal resources used by health departments to prepare for these risks include funding provided through CDC’s National Environmental Public Health Tracking Program.
When asked to identify challenges they face in addressing and planning for the risks of climate change to public health, state and local health officials identified challenges that GAO grouped into the three most frequently mentioned themes. First, the officials said they face challenges communicating about the public health risks of climate change, due to limited public awareness and the complexity of the issue. These officials reported that enhanced federal leadership could help address this challenge. Although HHS plans to develop a climate change communication and outreach strategy, its development has been delayed by over a year. Also, CDC currently does not have plans to issue climate change communications guidance, which state and local officials said would be helpful. CDC’s limited resources are currently focused on resolving methodological and data issues related to its Climate Ready States and Cities Initiative. Given that health departments that have received awards under CDC’s initiative are required to take steps to enhance public awareness, such guidance may help awardees better meet this requirement. Issuing such guidance would also be in line with CDC’s core functions, which include translating climate change science to inform communities. Second, officials said they face challenges identifying health risks of climate change due to gaps in research and difficulties using climate data. Federal officials told GAO about actions they have taken or plan to take that could help address these challenges, such as issuing an assessment of climate change impacts on health, and creating a national heat health information system. Finally, the officials told GAO about other challenges they face that federal action may not be able to address, such as having insufficient local data on health outcomes, because states may not collect or have access to such data, and having insufficient staff resources for these activities.

What GAO Recommends

GAO recommends that HHS direct CDC to develop a plan describing when it will be able to issue climate change communications guidance to state and local health departments. CDC generally agreed with the recommendation, stating that it will issue guidance once HHS’s climate change communication and outreach strategy is final.