de Man and others, 2017). The pathways include waterborne diseases such as diarrheal disease and cholera, as well as vector-borne diseases like dengue, malaria, and leptospirosis. Additionally, floods can contribute to the spread of diseases such as skin infections, dermatitis, conjunctivitis, and others, particularly in densely populated areas where human–animal interactions are frequent (McIver and others, 2016). The standing pools of water created by more frequent flooding provide breeding grounds for mosquitoes that carry malaria and dengue virus, increasing the severity of outbreaks. Children are especially vulnerable: in Cambodia, diarrhea and malaria remain one of the primary causes of child mortality.

The two biggest dengue outbreaks were recorded in 1998 and 2007, affecting 15,000 and 17,000 people, respectively. Beauté and Vong (2010) highlight the high societal and individual family burden of dengue, with total costs ranging between 0.03 percent and 0.17 percent of GDP. These figures may substantially underestimate the real costs caused by endemic dengue, given that it primarily strikes children. According to the World Health Organization (WHO), climate-sensitive diseases cause up to 400,000 deaths per year in Cambodia, and this figure is projected to increase by 10 percent because of climate change. By 2050, the extra health burden from climate change on climate-sensitive diseases would therefore be about $120 million, or 0.85 percent of GDP. The Asian Development Bank’s 2009 climate change impact study cites a higher figure, suggesting that climate change could increase the burden of some climate-sensitive diseases by as much as 18 percent over the next 20-30 years.

Although the dangers of compromised health care are clear, health centers in flood-affected provinces have so far demonstrated resilience in past flooding events, including the 2011 floods. According to the ADB (2012), most health centers were able to resume their activities within a few days of the 2011 floods clearing, and most were overall in reasonably sound condition. Despite severe damage to rural road networks, health centers were able to overcome logistical and operational challenges by relocating to evacuation sites and safer areas away from flood zones. Furthermore, the WHO (2019) reported that in the aftermath of storm-induced flooding, health workers used boats to provide outreach services to the poorest and most vulnerable populations, running mobile clinics. Such initiatives underscore the critical role of health care in disaster response and the importance of directing investments in the sector to improve its resilience and preparedness for future flooding events.

Like the incidence of floods, outbreaks of disease will not be uniform across the period to 2050, especially for diseases related to floods. A substantia <mark>l economic burden could therefore arise from disease outbreaks linked to floods in the years that the floods occur. It is difficult to predict the overall economic impact of disease outbreaks because the effects would be non-linear. Such an estimate would need to include</mark> the loss of a productive labor force due to direct incidence of disease, the loss of productive labor force because of caregiving requirements for the sick, the redirection or suppression of economic activity to prevent further spread of disease, and the indirect multiplier effects that would restrict economic demand.

The economic costs would include the same factors, regardless of whether the disease outbreak resulted from a flood, although the incidence of a flood makes the occurrence more likely. It is important to note that disease outbreaks could also occur indirectly from flooding, especially if health care services are compromised. For example, routine treatments and vaccinations would likely be suspended in flooded areas.