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. 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. 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. 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. 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 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. We interviewed officials from federal, state, and local government agencies, as well as representatives of stakeholder groups involved in public health and climate change. 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) 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. 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. 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. 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. 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. 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. 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. J. Alfredo Gómez, gomezj@gao.gov or (202) 512-3841. Marcia Crosse, crossem@gao.gov or (202) 512-7114. 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: 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. 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. 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.