The Paris agreement: charting a low-emissions path for a child born today
Authors: Courtney Howard, Yassen Tcholakov, Ceecee Holz
Journal: The Lancet Planetary Health (2019)

10 years have passed since The Lancet first stated that "Climate change is the biggest global health threat of the 21st century",1Costello A Abbas M Allen A et al.Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission.Lancet. 2009; 373: 1693-1733Summary Full Text Full Text PDF PubMed Scopus (1620) Google Scholar and almost 5 years ago, the 2015 Lancet Commission on Health and Climate Change concluded that tackling this threat could be the greatest health opportunity of this time.2Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (1017) Google Scholar Since then, initiatives such as the Planetary Health Clinicians' Initiative, fossil fuel divestment by health-related groups,3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar and declarations of a climate emergency by health actors are evidence that the world's medics are mounting ever-greater responses to this existential threat. The year 2020 is a key point in human history: countries' first Nationally Determined Contributions (NDCs) were submitted before the Paris Agreement in 2015, and 2020 represents the last chance to enhance them before they take effect. For today's children to thrive, reduction commitments for greenhouse gas emission must be ambitious enough to set a course to keep the global temperature rise to 1·5°C–2·0°C,4Intergovernmental Panel on Climate ChangeGlobal Warming of 1·5°C—Summary for Policymakers.https://www.ipcc.ch/sr15/Date accessed: October 8, 2018Google Scholar in line with the Paris Agreement goals,3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar and the policies to achieve these targets must have health and equity considerations woven throughout. Here, we aim to explain the essentials of the NDC process to the health community, and to identify key questions that they can ask of their governments immediately and throughout the year leading up to the UN Climate Change Conference 2020, COP26. In essence, NDCs lay out actions that countries commit to undertake to address climate change and represent one of the central mechanisms of the Paris Agreement. Countries set climate targets according to their individual circumstances and priorities. Of 184 NDCs analysed, only 121 (66%) include mentions of health, and these were generally insubstantial.5Wiley E Tcholakov Y Pétrin-Desrosiers C Al-Qodmani L Health in Intended Nationally Determined Contributions (INDCs). World Medical Association, France2019Google Scholar The 2019 Lancet Countdown on Health and Climate Change made starkly clear the two potential pathways possible for today's children.3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar If the global community continues along its business-as-usual, high-emissions pathway, a child born today will experience a world 4°C warmer than the preindustrial average, with the potential for their health to be marred by undernutrition, increased vector-borne disease, wildfires, and heat-related effects on work, and for both their health and health systems to be affected by the difficult to quantify effects of migration, conflict, and a less-stable world.3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar Alternatively, in a world embracing the Paris Agreement's ambition via rapid coal power phase-out, uptake of clean energy, electrification of transport, support for plant-rich diets, increased green space, and active commuting opportunities, a child born today will experience cleaner air, decreased chronic disease, strengthened social ties, and levels of warming in the latter part of the century likely to result in health and health system effects that are more manageable with adaptive measures compared with the high-emissions scenario.3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar Climate-related effects are unevenly distributed both within and between populations, with people of lower socioeconomic status, women, children, the unborn, and Indigenous communities6Cunsolo A Ellis N Ecological grief as a mental health response to climate change-related loss.Nat Clim Change. 2018; 8: 275-281Crossref Scopus (317) Google Scholar disproportionately affected.7Walpole SC Rasanathan K Campbell-Lendrum D Natural and unnatural synergies: climate change policy and health equity.Bull World Health Organ. 2009; 87: 799-801Crossref PubMed Scopus (23) Google Scholar An explicitly equity-focused approach that protects human rights and supports the social fabric necessary for a functioning global society is required to enhance the health of all in an increasingly warm world.7Walpole SC Rasanathan K Campbell-Lendrum D Natural and unnatural synergies: climate change policy and health equity.Bull World Health Organ. 2009; 87: 799-801Crossref PubMed Scopus (23) Google Scholar Ambition and equity are inseparable topics when considering nations' fair shares of emissions reductions, and, generally, current high-income countries' NDCs are inadequate on both counts.8Robiou du Pont Y Meinshausen M Warming assessment of the bottom-up Paris Agreement emissions pledges.Nat Comm. 2019; 94810Crossref Scopus (69) Google Scholar, 9Holz C Kartha S Athanasiou T Fairly sharing 1.5: national fair shares of a 1·5°C-compliant global mitigation effort.Int Environ Agreements. 2018; 18: 117-134Crossref Scopus (70) Google Scholar, 10Kartha S Athanasiou T Caney S Cripps E Dooley K Dubash N et al.Cascading biases against poorer countries.Nat Clim Change. 2018; 8: 348-349Crossref Scopus (37) Google Scholar Developed countries command larger financial and technical resources to respond to climate change (their capacity) and have produced most of the emissions to date (their responsibility), while lower-income and middle-income countries (LMICs) have less responsibility, more severe effects, less capacity to adapt or mitigate, and are increasingly experiencing losses and damages for which adaptation is no longer possible. These consequences include slow-onset events such as desertification and sea-level rise, and so-called non-economic losses, including loss of life, degraded health, and losses induced by human mobility, loss or degradation of Indigenous territory, and reductions in biodiversity. Attention to emergency preparedness, disaster response, social supports, and issues of human displacement will be essential to address these challenges. The UN Environment Programme Emissions Gap Report shows that nations must triple the level of ambition of their first NDCs, and implement them to limit warming to 2·0°C. A fivefold increase is needed to limit warming to 1·5°C. To meet the Paris Agreement goals, all countries must move together and maximise mitigation, even in the face of costs associated with adaptation and loss and damage. Thus, for all countries to do their utmost and for developed countries to do their fair share, high-income countries have a dual obligation9Holz C Kartha S Athanasiou T Fairly sharing 1.5: national fair shares of a 1·5°C-compliant global mitigation effort.Int Environ Agreements. 2018; 18: 117-134Crossref Scopus (70) Google Scholar to decrease domestic emissions as fast as technologically and economically feasible, and commit to substantial international cooperation in terms of finance, technology transfer, and other elements to support mitigation in LMICs.9Holz C Kartha S Athanasiou T Fairly sharing 1.5: national fair shares of a 1·5°C-compliant global mitigation effort.Int Environ Agreements. 2018; 18: 117-134Crossref Scopus (70) Google Scholar Anything less means either increasing an inequitable burden on LMICs, missing the 1·5–2·0°C target, or both.9Holz C Kartha S Athanasiou T Fairly sharing 1.5: national fair shares of a 1·5°C-compliant global mitigation effort.Int Environ Agreements. 2018; 18: 117-134Crossref Scopus (70) Google Scholar The health sector can serve as a voice for equity worldwide and articulate to decision makers the human cost of failing to meet ambition and equity-related goals. Many no-regret mitigation interventions exist that improve health and decrease health-related costs, including coal phase-out,3Watts N Amann M Arnell N et al.The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.Lancet. 2019; 394: 1836-1878Summary Full Text Full Text PDF PubMed Scopus (639) Google Scholar carbon taxation,2Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (1017) Google Scholar elements of sustainable health care, and enhanced active transport infrastructure.2Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (1017) Google Scholar These factors should be included in pathways to emissions reductions, with ambitious timelines designed to result in their adoption as soon as possible. Framing climate change in terms of health has been shown to generate hopeful emotions11Myers T Nisbet M Maibach E Leiserowitz A A public health frame arouses hopeful emotions about climate change.Clim Change. 2012; 113: 1105-1112Crossref Scopus (366) Google Scholar and nurses and doctors are some of society's most trusted messengers. Integrating health into NDCs might be the best way to create a narrative that unifies populations around a shared desire for a healthy response to climate change. Although climate change negotiations take place in international forums, decisions related to NDCs are made nationally. Global health workers must make clear that climate change is a health emergency and that ambitious NDCs are needed to map out an adequate treatment plan. Recognising that 2020 NDC updates are under development, national health sector actors—both clinicians and advocacy bodies—must focus energy on publicly communicating the catastrophic health risks for a child born today in a world continuing along its current high-emissions pathway. They must also communicate the opportunities for enhanced wellness and cost savings for health-care systems that are inherent in meeting the Paris Agreement goals. Health professionals with experience in climate-related health emergencies can contribute a humanitarian perspective via stories of patient and health-system effects.12Devine C Guevera M Biorklund B et al.The Lancet Countdown on Health and Climate Change. Policy brief on humanitarian impacts. Nov 2019. Lancet Countdown and Doctors Without Borders, London2019Google Scholar The health-sector must push for NDCs to be developed via an interministerial process. This push should include consultations with relevant sectors, the public, and public health, with a focus on ambition, equity, and the inclusion of policies that are mutually beneficial for health and climate. Initiatives like the NDC Partnership, which offers technical support for the development of NDCs, including from WHO, can be useful resources for governments. Between COP25 and COP26, continuous pressure must be applied by the health sector to ensure health is integrated into climate-related policy making across sectors, with a focus on creating an NDC roadmap for health. From a mitigation perspective, health economists can cost out co-benefits to health and wellbeing associated with various policy choices (eg, for a 2025 coal phase-out target vs a 2030 target) and ensure that these are incorporated into discussions. Additionally, the health costs of adaptation and the losses of life and damage to health-care systems associated with less ambitious mitigation should be factored into decision-making. Most importantly, the fact must be made clear that a healthy NDC is one that is enhanced to be in line with a nation's fair share of the global reductions necessary under the Paris Agreement to comprise both ambitious domestic emissions reduction and, in high-income countries, massive scale-ups in climate finance contributions. For example, via the Green Climate Fund or, under the right conditions, via global climate markets (article 6 of the Paris Agreement). Health organisations can also advocate for WHO, which currently has limited ability to receive funding from the Green Climate Fund, to become a full participant, in order for it be able to direct funds to health-focused programmes in LMICs. Finally, given the centrality of health to the wellbeing of a child born into today's changing climate, the global health sector should request that the presidency of COP26 make health a prominent focus of the gathering. NDCs are opportunities for nations to lay out roadmaps charting a course to a healthy, low-emissions pathway while maximising health and equity. COP25 and the interval between COP25 and COP26 are crucial time windows when the global community can influence the life trajectory of a child born today by considering health when updating NDCs in 2020. To facilitate, actors in the health sector should articulate national opportunities and risks related to different ambition scenarios and use their privileged voices to communicate those to decision makers and the public; contribute directly to the NDC review process and promote mechanisms to ensure links between ministries for years to come; and encourage public consultations in the process while bringing forth voices of their patients and those most affected. Populations will benefit from a health-centred, unifying conversation, and ministries of health and the environment should prepare for rich, ambitious dialogue. CoH is co-chair of the advocacy subcommittee of the WHO-Civil Society Working Group on Climate Change and Health and was employed by The Lancet Countdown on Health and Climate Change as a policy consultant in 2018 and 2019. YT and ChH declare no competing interests. A "super-year" for the environmentAs we enter a new year and decade, it is natural to reflect on past progress and goals for the future. It's not surprising then that 2020 is shaping up to be a critical year in establishing ambition for climate and biodiversity action. There is much optimism and anticipation that this year could be a turning point in our relationship with nature, leading to the notion of 2020 being a "super year" for the environment. But this will only happen through conscious effort, if we drift on as we are, it will be far from super for people or the planet. Full-Text PDF Open Access