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Competing Interests: Declaration of interests Thirteen of the authors (ZA, S-CH, LJ, AM, CO, MO, JP, YP-S, DS, LB-V, MRo, MW, and HW) were compensated for their time while drafting and developing the Lancet Countdown's report. LC was supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health. CD received funding from the European Research Council (FLORA, grant number 101039402). RD was supported by a grant from the High Tide Foundation and subcontracts on funds from the Wellcome Trust and US Centers for Disease Control and Prevention. GG-S received funding from the UK National Institute for Health and Care Research for the Global Health Research Group on Diet and Activity (NIHR133205, with sub-award contract number G109900-SJ1/171 with the University of Cambridge). SHG's research was supported by the National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise programme (grant number NRF2019-THE001-0006). JJH was supported by two grants from the Wellcome Trust and a grant from the US National Science Foundation. RH, RK, and MSo acknowledge funding from Academy of Finland projects HEATCOST (grant 334798) and VFSP-WASE (grant 359421), together with EU Horizon projects FirEUrisk (grant number 101003890) and EXHAUSTION (grant number 820655). OJ was supported by grants from the National Health Medical Research Council (Heat and Health: building resilience to extreme heat in a warming world, GNT1147789); Wellcome Trust (Heat stress in ready-made garment factories in Bangladesh and the Heat inform pregnant study); and Resilience New South Wales (A new heat stress scale for general public); holds a patent for the Environmental Measurement Unit; and has received consulting fees from the National Institutes of Health. HM received funding from the Oak Foundation to support work on climate change through RealZero, is partly funded by the National Institute for Health Research's Comprehensive Biomedical Research Centre at University College London Hospitals, and received fees from Bayer Pharmaceuticals and Chiesl for sustainability consulting. JM-U was supported by grants PID2021-127107NB-I00 from Ministerio de Ciencia e Innovación (Spain) and 2021 SGR 00526 from Generalitat de Catalunya (Spain). JRo's work is supported by the Alexander von Humboldt foundation. RL, JRo, and MRo were supported by Horizon Europe through the IDAlert project (101057554) and UK Research and Innovation (reference number 10056533). RNS reports a contract with Massachusetts General Hospital. MSo and AU were supported by the Finnish Foreign Ministry project IBA-ILMA (grant number VN/13798/2023). MSp was supported by funding from the Wellcome Trust, through Our Planet Our Health (Livestock, Environment and People, award number 205212/Z/16/Z) and a Wellcome Career Development Award (Towards the full cost of diets, award number 225318/Z/22/Z). JDSh was supported by the Canadian Institutes of Health Research, the Commonwealth Fund, and the Emergency Care Research Institute and has received consulting fees from the Institute for Healthcare Research. JT was supported by the Research Council of Finland (T-Winning Spaces 2035 project), the UK Medical Research Council (PICNIC project), and the Finnish Ministry of the Environment (SEASON project). JB is employed as a consultant by the Global Climate and Health Alliance. ML received consulting fees from YarCom for advisory services and was supported by general use gifts awarded to the Center on Global Energy Policy at Columbia University, USA. JMil acknowledges consulting fees from the C40 Climate Leadership Group. CZ-C received a consultancy from the University of Alberta and was supported by contracts with her university (Universidad Peruana Cayetano Heredia), University of Leeds, WHO, and the Wellcome Trust; she was also supported by a letter of agreement between her university and the Food and Agriculture Organization's Indigenous Peoples Unit. MD was supported by the Wellcome Trust via the Complex Urban Systems for Sustainability and Health project (grants 205207/Z/16/Z and 209387/Z/17/Z). IH, S-CH, MRo, CT, and RL were supported by the Horizon Europe CATALYSE project (CATALYSE grant number 101057131, HORIZON-HLTH-2021-ENVHLTH-02, with UK Research and Innovation reference number 10041512). The work of YH, YL, DT, and QZ was supported by the National Aeronautics and Space Administration's Earth Action programme (grant number 80NSSC21K0507). AJP was supported by the Bezos Earth Fund and the Schmidt Family Foundation. ER and SD were supported by a Process-based models for climate impact attribution across sectors (PROCLIAS) grant (COST Action PROCLIAS grant CA19139), funded by European Cooperation in Science and Technology. All other authors declare no competing interests.

Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy., (© 2024. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Importance: Cardiovascular disease is the leading cause of death in the US. However, little is known about the association between cumulative environmental burden and cardiovascular health across US neighborhoods., Objective: To evaluate the association of neighborhood-level environmental burden with prevalence of cardiovascular risk factors and diseases, overall and by levels of social vulnerability., Design, Settings, and Participants: This was a national cross-sectional study of 71 659 US Census tracts. Environmental burden (EBI) and social vulnerability indices from the US Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry were linked to the 2020 CDC PLACES data set. Data were analyzed from March to October 2023., Exposures: The EBI, a measure of cumulative environmental burden encompassing 5 domains (air pollution, hazardous or toxic sites, built environment, transportation infrastructure, and water pollution)., Main Outcomes and Measures: Neighborhood-level prevalence of cardiovascular risk factors (hypertension, diabetes, and obesity) and cardiovascular diseases (coronary heart disease and stroke)., Results: Across the US, neighborhoods with the highest environmental burden (top EBI quartile) were more likely than those with the lowest environmental burden (bottom EBI quartile) to be urban (16 626 [92.7%] vs 13 414 [75.4%]), in the Midwest (5191 [28.9%] vs 2782 [15.6%]), have greater median (IQR) social vulnerability scores (0.64 [0.36-0.85] vs 0.42 [0.20-0.65]), and have higher proportions of adults in racial or ethnic minority groups (median [IQR], 34% [12-73] vs 12% [5-30]). After adjustment, neighborhoods with the highest environmental burden had significantly higher rates of cardiovascular risk factors than those with the lowest burden, including hypertension (mean [SD], 32.83% [7.99] vs 32.14% [6.99]; adjusted difference, 0.84%; 95% CI, 0.71-0.98), diabetes (mean [SD], 12.19% [4.33] vs 10.68% [3.27]; adjusted difference, 0.62%; 95% CI, 0.53-0.70), and obesity (mean [SD], 33.57% [7.62] vs 30.86% [6.15]; adjusted difference, 0.77%; 95% CI, 0.60-0.94). Similarly, neighborhoods with the highest environmental burden had significantly higher rates of coronary heart disease (mean [SD], 6.66% [2.15] vs 6.82% [2.41]; adjusted difference, 0.28%; 95% CI, 0.22-0.33) and stroke (mean [SD], 3.65% [1.47] vs 3.31% [1.12]; adjusted difference, 0.19%; 95% CI, 0.15-0.22). Results were consistent after matching highest and lowest environmentally burdened neighborhoods geospatially and based on other covariates. The associations between environmental burden quartiles and cardiovascular risk factors and diseases were most pronounced among socially vulnerable neighborhoods., Conclusions and Relevance: In this cross-sectional study of US neighborhoods, cumulative environmental burden was associated with higher rates of cardiovascular risk factors and diseases, although absolute differences were small. The strongest associations were observed in socially vulnerable neighborhoods. Whether initiatives that address poor environmental conditions will improve cardiovascular health requires additional prospective investigations.

Competing Interests: Declaration of interests 14 of the authors (MRo, MWa, LJ, MBO'H, CO, HW, CdN, HK, PL, DS, CG, ZA, MY-G, and KRvD) were compensated for their time while drafting and developing the Lancet Countdown's report. OG was supported by the EU Horizon Grant: Climate Action To Advance Healthy Societies in Europe (Project 101057131–CATALYSE), for which there is overlap of data collection and preprocessing with the materials submitted in this report. MSp was supported by the Wellcome Trust Livestock, Environment and People (grant number 205212/Z/16/Z) and Wellcome Trust (grant number 225318/Z/22/Z). JT was supported by the Academy of Finland grants for the T-Winning (grant number 353327). CD was supported by the UK Natural Environment Research Council Independent Research Fellowship (grant number NE/N01524X/1), which ended in 2021, and by the European Research Council starting grant FLORA (grant number 101039402). OJ was supported by the NHMRC Investigator Grant entitled Heat and Health: Building resilience to extreme heat in a warming world (GNT20009507), the Wellcome Trust grant Heat stress in ready-made garment factories in Bangladesh (216059/Z/19/Z), and the Resilience New South Wales grant A new heat stress scale for general public (PJ-0000850). YL was supported by funding from the National Aeronautics and Space Administration (grant number: 80NSSC21K0507) for the wildfire population exposure and fire danger indicators. TO and IH were supported by the UK Research and Innovation Engineering and Physical Sciences Research Council Centre for Research in Energy Demand Solutions (grant number EP/R035288/1). MRo was supported by funding from IDAlert project (UK Research and Innovation project reference number 10056533). KB was supported by funding from the National Institute for Health and Care Research (NIHR) Centre on Non-communicable Diseases and Environmental Change (NIHR203247). All other authors declare no competing interests. The authors alone are responsible for the views expressed in this Commission, and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.

Property insurance is an important tool for resiliency from the accelerating impacts of climate-intensified extreme weather events. However, disparities in property insurance payouts may reduce their potential protective effects. The objective of this study was to quantify disparities in insurance payouts by Texas' insurers after the 2021 Winter Storm Uri, and to understand if any socioeconomic factors were associated with higher rates of declined relief. We extracted data from the Texas Department of Insurance on rates of denied insurance claims by zip code and county at 1 month and 13 months into the recovery period. We then linked these data to community-level socioeconomic information. Finally, we produced separate linear regressions for each predictor and covariate. Across both time points, communities with a higher proportion of Hispanic people, primary Spanish speakers, people who did not graduate high school, and people living below the federal poverty line were significantly more likely to experience denied claims. Communities with higher social vulnerability scores also experienced more denied claims. While financial security is a critical social determinant of health, findings suggest that insurers may be engaging in structurally discriminatory practices and failing to provide relief for people from socially vulnerable communities in the wake of climate-intensified events., Competing Interests: Conflicts of interest Please see ICMJE form(s) for author conflicts of interest. These have been provided as supplementary materials., (© The Author(s) 2023. Published by Oxford University Press on behalf of Project HOPE - The People-To-People Health Foundation, Inc.)

Climate change causes and exacerbates disease, creates and worsens health disparities, disrupts health care delivery, and imposes a significant disease burden in the US and globally. Critical knowledge gaps hinder an evidence-based response and are perpetuated by scarce federal research funds. We identified and described extramural US federal research funding (that is, grants provided to organizations and institutions outside of federal agencies) that both addressed health outcomes associated with climate change and was awarded between 2010 and 2020. During this eleven-year period, 102 grants met our criteria, totaling approximately $58.7 million, or approximately $5.3 million per year (2020 adjusted US dollars). Federal investments in climate change and health research during this period failed to address the breadth of climate-sensitive exposures, health outcomes, and impacts on vulnerable populations. Moving forward, in addition to increasing investment in climate and health research across all known hazards, critical attention should be placed on vulnerable populations and health equity. To achieve this, increased federal research coordination and cooperation are needed, as well as a mechanism to track this funding.

Climate change is a threat multiplier, exacerbating underlying vulnerabilities, worsening human health, and disrupting health systems' abilities to deliver high-quality continuous care. This review synthesizes the evidence of what the health care sector can do to adapt to a changing climate while reducing its own climate impact, identifies barriers to change, and makes recommendations to achieve sustainable, resilient health care systems.

Competing Interests: Declaration of interests CD was supported by the UK Natural Environment Research Council (NE/R010811/1) and the UK Natural Environment Research Council Independent Research Fellowship (NE/N01524X/1) and contributes to the Sustainable and Healthy Food Systems project supported by the Wellcome Trust (205200/Z/16/Z). MD was supported by the Wellcome Trust's Complex Urban Systems for Sustainability and Health (CUSSH) project (209387/Z/17/Z). YL was supported by the US National Aeronautics and Space Administration Applied Sciences Program (80NSSC21K0507). RL was supported by a Royal Society Dorothy Hodgkin Fellowship. MSo was supported by Horizon 2020 project EXHAUSTION (820655) and Academy of Finland HEATCOST (334798). SHG and JKWL were supported by Singapore's National Research Foundation, Singapore's Prime Minister's Office, under its Campus for Research Excellence and Technological Enterprise programme. IH was supported by the UK Research and Innovation (UKRI) Engineering and Physical Sciences Research Council Centre for Research in Energy Demand Solutions (EP/R035288/1) and UKRI APEx (NE/T001887/1). JM was supported by the German Ministry for Education and Research (01LA1826A and 03SFK5J0). ML was supported by the Sloan Foundation. All other authors declare no competing interests.

Competing Interests: We have read and understood BMJ policy on declaration of interests and do not have any conflicts of interest to declare.

Issue: As U.S. healthcare systems plan for future physician workforce needs, the systemic impacts of climate change, a worldwide environmental and health crisis, have not been factored in. The current focus on increasing the number of trained physicians and optimizing efficiencies in healthcare delivery may be insufficient. Graduate medical education (GME) priorities and training should be considered in order to prepare a climate-educated physician workforce. Evidence: We used a holistic lens to explore the available literature regarding the intersection of future physician workforce needs, GME program priorities, and resident education within the larger context of climate change. Our interinstitutional, transdisciplinary team brought perspectives from their own fields, including climate science, climate and health research, and medical education to provide recommendations for building a climate-educated physician workforce. Implications: Acknowledging and preparing for the effects of climate change on the physician workforce will require identification of workforce gaps, changes to GME program priorities, and education of trainees on the health and societal impacts of climate change. Alignment of GME training with workforce considerations and climate action and adaptation initiatives will be critical in ensuring the U.S. has a climate-educated physician workforce capable of addressing health and healthcare system challenges. This article offers a number of recommendations for physician workforce priorities, resident education, and system-level changes to better prepare for the health and health system impacts of climate change.

Climate change poses a multifaceted, complex, and existential threat to human health and well-being, but efforts to communicate these threats to the public lag behind what we know how to do in communication research. Effective communication about climate change's health risks can improve a wide variety of individual and population health-related outcomes by: (1) helping people better make the connection between climate change and health risks and (2) empowering them to act on that newfound knowledge and understanding. The aim of this manuscript is to highlight communication methods that have received empirical support for improving knowledge uptake and/or driving higher-quality decision making and healthier behaviors and to recommend how to apply them at the intersection of climate change and health. This expert consensus about effective communication methods can be used by healthcare professionals, decision makers, governments, the general public, and other stakeholders including sectors outside of health. In particular, we argue for the use of 11 theory-based, evidence-supported communication strategies and practices. These methods range from leveraging social networks to making careful choices about the use of language, narratives, emotions, visual images, and statistics. Message testing with appropriate groups is also key. When implemented properly, these approaches are likely to improve the outcomes of climate change and health communication efforts., (© Society of Behavioral Medicine 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

There is increasing understanding, globally, that climate change and increased pollution will have a profound and mostly harmful effect on human health. This review brings together international experts to describe both the direct (such as heat waves) and indirect (such as vector-borne disease incidence) health impacts of climate change. These impacts vary depending on vulnerability (i.e., existing diseases) and the international, economic, political, and environmental context. This unique review also expands on these issues to address a third category of potential longer-term impacts on global health: famine, population dislocation, and environmental justice and education. This scholarly resource explores these issues fully, linking them to global health in urban and rural settings in developed and developing countries. The review finishes with a practical discussion of action that health professionals around the world in our field can yet take., (© 2022 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Medical schools face a challenge when trying to include new topics, such as climate change and health (CCH), in their curricula because of competing demands from more traditional biomedical content. At the same time, an understanding of CCH topics is crucial for physicians as they have clear implications for clinical practice and health care delivery. Although some medical schools have begun to incorporate CCH into curricula, the inclusion usually lacks a comprehensive framework for content and implementation. The authors propose a model for integrating CCH into medical school curricula using a practical, multistakeholder approach designed to mitigate competition for time with existing content by weaving meaningful CCH examples into current curricular activities. After the authors identified stakeholders to include in their curricular development working group, this working group determined the goals and desired outcomes of the curriculum; aligned those outcomes with the school's framework of educational objectives, competencies, and milestones; and strove to integrate CCH goals into as many existing curricular settings as possible. This article includes an illustration of the proposed model for one of the curricular goals (understanding the impacts of climate change on communities), with examples from the CCH curriculum integration that began in the fall of 2020 at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. The authors have found that this approach does minimize competition for time with existing content and allows mapping of content to existing curricular competencies and milestones, while encouraging a broad understanding of CCH in the context of individual patients, populations, and communities. This model for curricular integration can be applied to other topics such as social determinants of health, health equity, disability studies, and structural racism., (Copyright © 2021 by the Association of American Medical Colleges.)

Competing Interests: Competing interests: none declared

Competing Interests: Declaration of interests We declare no competing interests.

Climate change increasingly threatens the ability of the US health care system to deliver safe, effective, and efficient care to the American people. The existing health care system has key vulnerabilities that will grow more problematic as the effects of climate change on Americans' lives become stronger. Thus, health care policy makers must integrate a climate lens as they develop health system interventions. Applying a climate lens means assessing climate change-driven health risks and integrating them into policies and other actions to improve the nation's health. This lens can be applied to rethinking how to take a more population-based approach to health care delivery, prioritize health care system decarbonization and resilience, adapt data infrastructure, develop a climate-ready workforce, and pay for care. Our recommendations outline how to include climate-informed assessments into health care decision making and health policy, ultimately leading to a more resilient and equitable health care system that is better able to meet the needs of patients today and in the future.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and do not have any conflicts of interest to declare.

Competing Interests: Conflicts of Interest: I have read and understood BMJ policy on declaration of interests and have no competing interests to declare.

The adverse influences of climate change are manifesting as health burdens relevant to clinical practice, affecting the very underpinnings of health and stressing the health care system. Emergency medicine is likely to bear a large burden, with its focus on urgent and emergency care, through its role as a safety-net provider for vulnerable populations and as a leader in disaster medicine. Clinically, climate change is affecting emergency medicine practice through the amplification of climate-related disease patterns and epidemiologic shifts for conditions diagnosed and treated in emergency departments (EDs), especially for vulnerable populations. In addition, climate-driven intensification of extreme weather is disrupting health care delivery in EDs and health care systems. Thus, there are significant opportunities for emergency medicine to lead the medical response to climate change through 7 key areas: clinical practice improvements, building resilient EDs and health care systems, adaptation and public health engagement, disaster preparedness, mitigation, research, and education. In the face of this growing health threat, systemwide preparation rooted in local leadership and responsiveness is necessary to efficiently and effectively care for our vulnerable communities., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The co-occurrence of the 2020 Atlantic hurricane season and the ongoing coronavirus disease 2019 (COVID-19) pandemic creates complex dilemmas for protecting populations from these intersecting threats. Climate change is likely contributing to stronger, wetter, slower-moving, and more dangerous hurricanes. Climate-driven hazards underscore the imperative for timely warning, evacuation, and sheltering of storm-threatened populations - proven life-saving protective measures that gather evacuees together inside durable, enclosed spaces when a hurricane approaches. Meanwhile, the rapid acquisition of scientific knowledge regarding how COVID-19 spreads has guided mass anti-contagion strategies, including lockdowns, sheltering at home, physical distancing, donning personal protective equipment, conscientious handwashing, and hygiene practices. These life-saving strategies, credited with preventing millions of COVID-19 cases, separate and move people apart. Enforcement coupled with fear of contracting COVID-19 have motivated high levels of adherence to these stringent regulations. How will populations react when warned to shelter from an oncoming Atlantic hurricane while COVID-19 is actively circulating in the community? Emergency managers, health care providers, and public health preparedness professionals must create viable solutions to confront these potential scenarios: elevated rates of hurricane-related injury and mortality among persons who refuse to evacuate due to fear of COVID-19, and the resurgence of COVID-19 cases among hurricane evacuees who shelter together.

Introduction: High altitude headache (HAH) and acute mountain sickness (AMS) are common pathologies at high altitudes. There are similarities between AMS and migraine headaches, with nausea being a common symptom. Several studies have shown ibuprofen can be effective for AMS prophylaxis, but few have addressed treatment. Metoclopramide is commonly administered for migraine headaches but has not been evaluated for HAH or AMS. We aimed to evaluate metoclopramide and ibuprofen for treatment of HAH and AMS., Methods: We performed a prospective, double-blinded, randomized, field-based clinical trial of metoclopramide and ibuprofen for the treatment of HAH and AMS in 47 adult subjects in the Mount Everest region of Nepal. Subjects received either 400 mg ibuprofen or 10 mg metoclopramide in a 1-time dose. Lake Louise Score (LLS) and visual analog scale of symptoms were measured before and at 30, 60, and 120 min after treatment., Results: Subjects in both the metoclopramide and ibuprofen arms reported reduced headache severity and nausea compared to pretreatment values at 120 min. The ibuprofen group reported 22 mm reduction in headache and 6 mm reduction in nausea on a 100 mm visual analog scale at 120 min. The metoclopramide group reported 23 mm reduction in headache and 14 mm reduction in nausea. The ibuprofen group reported an average 3.5-point decrease on LLS, whereas the metoclopramide group reported an average 2.0-point decrease on LLS at 120 min., Conclusions: Metoclopramide and ibuprofen may be effective alternative treatment options in HAH and AMS, especially for those patients who additionally report nausea., (Copyright © 2019 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no competing interests to declare.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].