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      Charting the systemic and cascading impacts of climate change on marine food systems and human health

      article-commentary
      BMJ Global Health
      BMJ Publishing Group
      Health policy, Public Health, Environmental health, Nutrition, Prevention strategies

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          Abstract

          Summary box The ocean is integral to the production of nutrient-rich marine foods, however, shifts in productive fish species due to climate change represent a serious threat to food security. Socioeconomic disparities within global food systems reinforce the case for food sovereignty, social-ecological resilience and the importance of harnessing indigenous knowledge to reframe the rights of local resource users. Preserving and supporting diverse local food systems to thrive through locally relevant and adaptive fisheries management will become increasingly important. The future of seafood contributions to global food supply will depend on effective, rapid, and sustained mitigation and adaptation actions and a combination of ecological, economic, policy and technological influences. Introduction Expected declines in global marine species and fish catch could increase climate change-related income, livelihood and food security risks, with consequences for seafood-dependent communities.1 As one of the most biologically diverse and productive natural resources in the world, the ocean provides ecosystem services such as biomedical compounds derived from marine species; supports food provisioning, cultural practices and identity; and performs critical ecosystem functions such as protecting coastal zones, regulating the global climate system and facilitating carbon sequestration.2–4 Globally, an estimated 3.3 billion people rely on ‘blue’ (aquatic) foods for nutrition, which accounts for almost 20% of the average per capita consumption of animal protein.5 Seafood, in particular, is a nutritious source of protein, providing wide-ranging health benefits. Even with its significant contribution to the global food system, seafood is still largely undervalued and interest in ‘seafood’ security has only recently gained traction.6 Higher global warming levels and business-as-usual emissions continue to threaten marine biodiversity and undermine the ecological capacity of the ocean to provide important ecosystem functions and services. Golden et al stress that the effects of ocean warming, coral bleaching and ocean acidification will likely degrade coral reefs, disrupt marine and inland fishery productivity, and thus weaken social-ecological system resilience.7 8 In effect, rising ocean temperatures are estimated to change the abundance, diversity and range of phytoplankton, zooplankton and fish stock that sustain ocean food webs.4 While shifts in the spatial distribution of fish stock are predicted to affect the level of capture fisheries production and impact the dietary intake and nutritional status of local communities that are highly dependent on marine resources for food, particularly developing countries located at the equator.9 Impacts of ocean warming on ecological resilience, marine food systems and nutrition security Marine habitats, species composition and food-web structures are being threatened by global warming to varying degrees.4 Research shows that for 142 countries, the average sea surface temperature (SST) in coastal waters rose on a global scale by almost 0·7o C in the 2019–2021 period relative to 1980–1982.10 Subject to their ecological resilience, marine species have varied internal responses to changing ocean stressors that cause shifts in their patterns of productivity.1 Once the resilience of natural ecosystems diminishes, a sudden reorganisation of their components may take place.11 Complex ecosystem reorganisations also include the tendency of fish species to shift locations when conditions are no longer favourable.4 Typically, regional trends will determine to what extent local climate impacts on ocean ecosystems will occur.1 The warming of oceans has already impacted fisheries catches and their composition in several regions by causing changes in the spatial distribution and abundance of fish stocks, which has steered tropical species to higher latitudes, and altered ecosystem structures.1 For instance, rising SST is forecasted to increase primary production in polar regions, while decreasing primary production in tropical ones.12 This has significant implications for global food supply, food stability and food security in some of the world’s most impoverished regions including in Least Developed Countries (LDCs) and Small Island Developing States (SIDS). Coastal indigenous populations, for one, are highly dependent on seafood, with a per capita consumption rate equivalent to 15 times that of non-indigenous groups.13 Seafood is also a source of nutrition in much of the Global South, delivering key micronutrients and vitamins, such as iron, zinc, vitamin A, vitamin B12 and fatty acids.7 Moreover, it has significant health benefits for lowering the risk of cardiovascular diseases such as coronary heart disease, supporting normal fetal development and ensuring healthy brain function.14 Owing to its diverse nutritional content and ability to avert, or to a lesser extent ease much of the environmental impacts resulting from terrestrial food production, seafood is well positioned to contribute to global food supply, and food and nutrition security.15 Although, given the impacts of climate change coupled with unsustainable fishing practices that diminish the availability of and access to fish stock, coastal populations in certain regions that customarily rely on fish and shellfish as part of a balanced seafood-based diet, may turn to alternate sources of protein with lesser nutritional value. Harnessing indigenous knowledge to protect blue food sovereignty ‘Blue’ foods constitute a critical part of the global food system and support sustainable, healthy and just food systems for billions of people.16 That notwithstanding, ‘green’ terrestrial foods tend to dominate policy dialogues and decision-making on food systems, overlooking the vital role of ‘blue’ foods in supporting food and nutrition security. As the dialogue on food security is oriented towards the global or national perspective, this can often discount the importance of resource-rich local food systems.17 For example—the role of coral reefs within local food systems traditionally managed by local and indigenous peoples—although lauded for its ecosystem benefits and cultural tenets, is not well understood in market-oriented spaces. Artisanal fishing communities therefore illustrate the complexity of food systems and the varying levels of food and nutrition insecurity that may not be ordinarily captured through national catch statistics18 or national food security assessments. The virtues of food sovereignty essentially lie in the ability to prioritise terrestrial and aquatic foods, including small-scale economic activities grounded on sustainability. Food sovereignty as a movement, underscores ‘the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods, and their right to define their own food and agriculture systems. It offers a strategy to resist and dismantle the current corporate trade and food regime, and directions for food, farming, pastoral and fisheries systems determined by local producers. Food sovereignty promotes transparent trade that guarantees just income to all peoples and the rights of consumers to control their food and nutrition’.19 Going further, the concept of indigenous food sovereignty extends the focus of a rights-based approach that includes indigenous communities’ bidirectional responsibility for environmental stewardship, while reviving food systems in line with their traditional practices and beliefs.20 This paradigm is all important as severe climate change impacts and biodiversity loss reveal the unintended power redistributions to the disbenefit of indigenous and local fisher communities. Socioeconomic disparities within global food systems thus reinforce the case for food sovereignty, social-ecological resilience, and the importance of harnessing indigenous knowledge to reframe the rights of local resource users.3 The role of blue justice in sustaining marine resources Blue justice demands a paradigm shift with respect to unchecked blue growth and a reimagining of alternative economic growth models that prioritise human health and environmental protection.21 As a starting point, fisheries are often depicted as the ‘local’ alternative to the global food system, producing less carbon emissions compared with terrestrial protein production.22 23 Small-scale fishers, on the whole, produce less waste by capturing more fish per gallon of fuel compared with commercial fleets and discarding less fish.24 25 Even so, the projected intensity of future blue growth—marked by the rapid and unregulated expansion of ocean-based economic activities—is expected to generate complex and quantifiable risks.21 In particular, international demand for seafood has caused an influx of distant water fleets, which have appropriated fish stocks through legal access agreements and illegal means, diverting resources from local communities and small-scale fishers.21 24 26 27 The predatory effects of unregulated commercial fishing vessels on local and indigenous food systems are especially concerning, as they accelerate the depletion of fishery resources and degradation of marine ecosystems. This ties in with the issue of ‘ocean grabbing’, which involves obscure access agreements that threaten local food security and well-being of small-scale fishers by (1) encroaching on marine protected areas; (2) facilitating the illegal harvesting of fishery resources; (3) redirecting marine resources away from coastal communities; (4) forcibly relocating coastal communities; (5) undermining historical access to marine areas and/or (6) enabling the loss of spatial tenure rights.24 26 Although, the intrinsic motivations behind development activities such as the reallocation of marine spaces and resources are not always insidious or clear-cut. Contrary to opportunity-seeking behaviours or exploitative interests, ocean grabbing—specifically the dispossession of marine spaces—can also take place to promote marine protected areas aimed at biodiversity conservation, leading to the displacement of local resource user groups.26 Bennett et al theorise that claims of ocean grabbing are implausible if initiatives promote local livelihoods, refrain from undermining human security and generate positive social-ecological effects.26 The spatial competition of marine areas between renewable energy and fishery activities is also expected to yield a complex mix of undesirable and positive social influences for various communities, further amplifying this issue.21 According to Farmery et al, blue food-related activities are seldom emphasised in global discourses on the blue economy and marine spatial planning exercises,28 resulting in a lower level of prioritisation among ocean-based economic activities. Equally important is the role that blue justice plays in promoting the sustainable and equitable governance of marine resources, protecting local livelihoods by securing formal access and harvesting rights of indigenous and local resource user groups, and ensuring social-ecological well-being.21 That notwithstanding, the idea that people—and in particular fisherfolk—need to be ‘managed’ to avert ecological crises is recurring theme in natural resource debates.29 Historically, this can be traced back to the introduction of indigenous fishing rights and access in North America. To give an example, policy-making and state-indigenous relations in the state of Alaska in the U.S. have led to the disenfranchisement of indigenous fisher communities and the attenuation of their fishing rights due to limited-entry permit systems, created in the interest of developing the fishing economy.29 30 According to Cohen, the prevailing Westocentric narratives at the time suggested that alternative fisheries management systems, in the absence of state control, were unsustainable despite the ‘sophistication’ of existing traditional systems.29 30 Fast-forward to present day, persistent and proximal threats to marine ecosystems linked to the blue growth agenda still need to be acknowledged and judiciously addressed to offset the unequal distribution of benefits to coastal communities and small-scale fishers, and to mitigate social harms as a result of exclusionary practices.21 To a large degree, this calls for policy-makers and state legislators to recognise the legitimacy of indigenous knowledge, customs, traditional livelihood practices and diets in order to effectively engage in dialogues around fisheries comanagement and policies incentivising local preservation of small-scale fisheries for whom the protection of common resource pools is vital.29 31 Another point of note with respect to blue justice is the nefarious human rights abuses that seek to exploit vulnerable labourers, so as to lower fishery production costs.32 Global supply chains, for example, are complex and murky, adding to the varied considerations of consumers when determining environmental impacts and labour abuses in production.31 Tickler et al suggest that the absence of transparency and product traceability, which enable illegal and unreported fishery products to enter supply chains, also facilitates the global trade of slave-caught and handled seafood.32 Blue food dialogues have more or less overlooked critical aspects of food and nutrition security, especially as it relates to access, affordability and utilisation of food resources.28 According to Chuenpagdee et al, the concept of food security at the local level is complex with myriad interacting influences such as livelihoods, climate change, community infrastructure and tenure systems—which shape the ways in which individuals access nutritious and traditional foods.22 For example, socially and economically vulnerable fisherfolk may relinquish the concept of ‘fish as food’ in favour of livelihood strategies focused on fish trade, which indirectly contributes to food security.25 Isaacs posits that protecting fish species with high nutrient profiles—such as small pelagic fish, which include sardines, mackerels, anchovies—for local consumption instead of diminishing it to fishmeal for cultured fish, animal feed and crop fertiliser is integral to tackling malnutrition in Africa.25 Maintaining healthy ocean ecosystems to ensure better health outcomes Local, traditional and indigenous diets constitute a high diversity of species and tend to have a high nutrient profile. And despite the fact that indigenous communities are inclined to consume more fish than non-indigenous communities, their consumption of reef fish is not measurably correlated to higher catches.17 This demonstrates how locally sourced, sustainably produced marine-source foods not only support better nutrition and health outcomes but sustain healthy ocean ecosystems. Notwithstanding the myriad health benefits of nutrient-dense aquatic foods, there are underlying adverse health effects from both naturally occurring and introduced toxicants in seafood.33 From a public health lens, microbial illness from seafood is acute, persistent and poses a high risk. Maintaining ecosystem resilience, in no small measure, helps lower the risk of exposure to environmental pollutants such as dioxins, polychlorinated biphenyls and pesticide residues, which can produce carcinogenic, immunotoxic, embryonic and hepatotoxic effects with prolonged exposure.34 Beyond this, the risk of contamination is greatly reduced by limiting seafood consumption to suitable harvest locations, paying heed to the appropriate fishing season and the age of fish catch, and selecting fish species with archetypally lower levels of contamination.34 In particular, determining harvest strategies that support seafood production is vital in meeting the dietary needs of a growing population in the face of compounded climate risks.35 Means of implementation for climate adaptive and integrated fisheries management Climate impacts combined with unsustainable fishing practices could lead to reduced levels of capture fisheries production that, if sustained, could cause local fishery collapses. Which is why, climate adaptive and integrated fisheries management stand to reinforce ecosystem-based approaches through the maintenance of ecosystem services and the use of flexible, participatory, climate-adaptive responses in the fisheries sector.36 Beyond the virtues of adaptive and integrated fisheries management, Golden et al theorise that along the chasm of food production and nutritional security, lie many governance and market institutions that determine varying access to food including the distribution of benefits to marginalised, poor and vulnerable resource user groups.7 Paradoxically, countries with persistently high levels of undernourishment and weak governance are typically net exporters of seafood to countries with well-nourished populations and strong governance structures.9 37 38 This illustrates a focus on profit maximisation in many countries around the world, characterised by high-priced products and export orientation in fisheries and aquaculture management.31 In effect, the global seafood trade has sustained systems of inequity whereby low-income countries export high-value seafood in exchange for low-cost and lower-quality seafood to meet their dietary needs.28 In response to this, the UN Special Rapporteur on the Right to Food, has advocated rebuilding local food systems through a bottom-up approach and shifting from a reliance on food imports.39 This further highlights the importance of strengthening systemic, governance and institutional capacities within integrated fisheries management, which creates greater efficiency and productivity to meet the demands of food production. For instance, adaptive and integrated fisheries management grounded on a rights-based approach could (1) support the identification and prioritisation of policies that champion the rights of artisanal fishers; (2) address the threats, risks and prospects of female fish traders, who make up a significant part of the postharvest sector; (3) impose greater restrictions on commercial fishing vessels; (4) moderate postharvest loss and increase food quality and safety; and (5) encourage the engagement of local fishers in decision-making processes across civil society, public and private sector institutions, at all governance levels. 31 40 International cooperation is equally important for the management of shared fish stocks, as climate-induced shifts in productive fish species add to the existing fishery challenges by violating ‘the ‘clear boundaries’ principle for sustainable governance of common pool resources’.41 Pinsky et al posit that future geographical shifts could continue to breach national boundaries making it difficult to maintain fish stocks within state-level jurisdiction. At the same time, current scholarship argues that managing the ‘boundary paradox’ entails reintegrating, rescaling and redefining boundaries on an ecological rather than anthropogenic basis.42 On another point of note, a weak enabling environment; lean public and private investment in the blue economy; and the comparatively high-risk nature of ocean economic sectors comprise key barriers that limit sustainable financing of ocean ecosystems.43 Access to finance is a critical component that drives adaptive management of marine resources. The Global Fund for Coral Reefs, for example, supports the development and acceleration of revenue-generating activities that sustainably finance the mitigation of the underlying drivers of coral reef degradation.44 Other financial mechanisms include blue bonds, debt-for-nature swaps and biodiversity offsets.45 Considering that climate-impacted reefs tend to support less fish biodiversity and flatten food pyramids, preserving and supporting diverse local food systems to thrive through locally relevant and adaptive fisheries management will become increasingly important.17 According to Free et al, climate-adaptive fisheries reforms would support the health of world fisheries and sustain future harvests and financial gains for all scenarios except the high-emissions RCP 8.5.46 Under extreme conditions, the most severe climate change impacts would occur when soft and hard limits are reached. To minimise loss and damage to ecosystem services, adaptation and mitigation options in the present will need to consider the potential long-term impacts of climate shocks to socio-ecological systems, depleted fisheries and degraded coral reefs. Conclusion Climate change is driving the reorganisation of marine food systems, displacing wild fisheries, disrupting food production and nutritional security.7 For all that, only a limited number of public health practitioners are aware of the systemic approaches to planetary health that consider the economic growth, environmental degradation and human health nexus.47 Seafood in the latest food security literature remains poorly researched relative to terrestrial animal and plant production.6 Furthermore, current scholarship on the role of blue foods and the blue economy offers limited insights into the pathways that link production and consumption.28 Observing low-income countries that benefit from seafood exports shows that profits rarely trickle-down to the local level.28 48 In the absence of social, food and nutrition security for local and indigenous fisher communities, the most vulnerable are at risk of being rendered worse off due to the global seafood trade.28 48 On par with this supply-side theory, lessons drawn from the green economy reveal that prioritising growth and technology does not necessarily cause declines in hunger and malnutrition.28 As a first step, governments can promote a systems approach to blue foods that will ensure equitable participation in production, access to blue foods for consumption and inclusive representation in decision-making.31 Taking this into account, interdisciplinary research will be paramount in addressing the systemic policy and market-level conditions linked to food and nutrition security among local and indigenous resource user groups. Bearing in mind the role and importance of blue food systems within complex social-ecological networks, policy-makers should prioritise the needs, cultural values and health of local and Indigenous fishing communities.3 In the event that traditional diets become unsustainable, the nutrition transition to mixed diets (of traditional and market-based foods) may become pronounced.6 Disruptions in coastal food systems, particularly in places with higher market integration and prohibitively priced import substitutes could prompt a transition to farm-based fish products or other animal-source proteins, which may cause nutritional challenges due to the low diversity of fish, worsening existing micronutrient deficiencies.9 49 50 For example, Heilpern et al suggest that in the Peruvian Amazon, where people suffer invariably from high malnutrition rates, substituting wild catch with farmed fish could satisfy specific nutritional needs.50 Yet, due to differences in iron and omega 3 fatty acids that capture fisheries provide, transitions to farm-based fish alternatives could largely undermine nutrition.50 Going further, when fisheries and aquaculture are managed independently of each other, policy-makers forgo possibilities to enhance their nutrition, livelihood and sustainability goals, and instead make unintended trade-offs.31 Most important is that aquaculture, and by extension mariculture, complement rather than displace fish harvested by wild-capture fisheries, particularly small-scale fisheries.28 In the short term to medium term, climate change adaptation interventions should ensure that marginalised, poor and resource-dependent groups have sufficient capacities to cope with ecosystem and market-based disruptions. Such considerations could include the integration of indigenous and local communities in negotiations on market-oriented production of fisheries and trade agreements.20 In the long-run, climate change mitigation actions will be critical to ease carbon emissions and the associated effects of ocean warming. Indeed, scientific uncertainties and risk perceptions on the effectiveness of ocean and fisheries governance has been described in literature, emphasising the importance of timely mitigation and adaptation responses.1 As climate change tests the ocean’s ability to meet the growing demand for food, the future of seafood contributions to global food supply will depend on effective, rapid, and sustained mitigation and adaptation actions and a series of ecological, economic, policy and technological influences.15 46

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          Coral reefs in the Anthropocene

          Coral reefs support immense biodiversity and provide important ecosystem services to many millions of people. Yet reefs are degrading rapidly in response to numerous anthropogenic drivers. In the coming centuries, reefs will run the gauntlet of climate change, and rising temperatures will transform them into
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            The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels

            Executive summary The 2022 report of the Lancet Countdown is published as the world confronts profound and concurrent systemic shocks. Countries and health systems continue to contend with the health, social, and economic impacts of the COVID-19 pandemic, while Russia’s invasion of Ukraine and a persistent fossil fuel overdependence has pushed the world into global energy and cost-of-living crises. As these crises unfold, climate change escalates unabated. Its worsening impacts are increasingly affecting the foundations of human health and wellbeing, exacerbating the vulnerability of the world’s populations to concurrent health threats. During 2021 and 2022, extreme weather events caused devastation across every continent, adding further pressure to health services already grappling with the impacts of the COVID-19 pandemic. Floods in Australia, Brazil, China, western Europe, Malaysia, Pakistan, South Africa, and South Sudan caused thousands of deaths, displaced hundreds of thousands of people, and caused billions of dollars in economic losses. Wildfires caused devastation in Canada, the USA, Greece, Algeria, Italy, Spain, and Türkiye, and record temperatures were recorded in many countries, including Australia, Canada, India, Italy, Oman, Türkiye, Pakistan, and the UK. With advancements in the science of detection and attribution studies, the influence of climate change over many events has now been quantified. Because of the rapidly increasing temperatures, vulnerable populations (adults older than 65 years, and children younger than one year of age) were exposed to 3·7 billion more heatwave days in 2021 than annually in 1986–2005 (indicator 1.1.2), and heat-related deaths increased by 68% between 2000–04 and 2017–21 (indicator 1.1.5), a death toll that was significantly exacerbated by the confluence of the COVID-19 pandemic. Simultaneously, the changing climate is affecting the spread of infectious diseases, putting populations at higher risk of emerging diseases and co-epidemics. Coastal waters are becoming more suitable for the transmission of Vibrio pathogens; the number of months suitable for malaria transmission increased by 31·3% in the highland areas of the Americas and 13·8% in the highland areas of Africa from 1951–60 to 2012–21, and the likelihood of dengue transmission rose by 12% in the same period (indicator 1.3.1). The coexistence of dengue outbreaks with the COVID-19 pandemic led to aggravated pressure on health systems, misdiagnosis, and difficulties in management of both diseases in many regions of South America, Asia, and Africa. The economic losses associated with climate change impacts are also increasing pressure on families and economies already challenged with the synergistic effects of the COVID-19 pandemic and the international cost-of-living and energy crises, further undermining the socioeconomic determinants that good health depends on. Heat exposure led to 470 billion potential labour hours lost globally in 2021 (indicator 1.1.4), with potential income losses equivalent to 0·72% of the global economic output, increasing to 5·6% of the GDP in low Human Development Index (HDI) countries, where workers are most vulnerable to the effects of financial fluctuations (indicator 4.1.3). Meanwhile, extreme weather events caused damage worth US$253 billion in 2021, particularly burdening people in low HDI countries in which almost none of the losses were insured (indicator 4.1.1). Through multiple and interconnected pathways, every dimension of food security is being affected by climate change, aggravating the impacts of other coexisting crises. The higher temperatures threaten crop yields directly, with the growth seasons of maize on average 9 days shorter in 2020, and the growth seasons of winter wheat and spring wheat 6 days shorter than for 1981–2010 globally (indicator 1.4). The threat to crop yields adds to the rising impact of extreme weather on supply chains, socioeconomic pressures, and the risk of infectious disease transmission, undermining food availability, access, stability, and utilisation. New analysis suggests that extreme heat was associated with 98 million more people reporting moderate to severe food insecurity in 2020 than annually in 1981–2010, in 103 countries analysed (indicator 1.4). The increasingly extreme weather worsens the stability of global food systems, acting in synergy with other concurrent crises to reverse progress towards hunger eradication. Indeed, the prevalence of undernourishment increased during the COVID-19 pandemic, and up to 161 million more people faced hunger during the COVID-19 pandemic in 2020 than in 2019. This situation is now worsened by Russia’s invasion of Ukraine and the energy and cost-of-living crises, with impacts on international agricultural production and supply chains threatening to result in 13 million additional people facing undernutrition in 2022. A debilitated first line of defence With the worsening health impacts of climate change compounding other coexisting crises, populations worldwide increasingly rely on health systems as their first line of defence. However, just as the need for healthcare rises, health systems worldwide are debilitated by the effects of the COVID-19 pandemic and the energy and cost-of-living crises. Urgent action is therefore needed to strengthen health-system resilience and to prevent a rapidly escalating loss of lives and to prevent suffering in a changing climate. However, only 48 (51%) of 95 countries reported having assessed their climate change adaptation needs (indicator 2.1.1) and, even after the profound impacts of COVID-19, only 60 (63%) countries reported a high to very high implementation status for health emergency management in 2021 (indicator 2.2.4). The scarcity of proactive adaptation is shown in the response to extreme heat. Despite the local cooling and overall health benefits of urban greenspaces, only 277 (27%) of 1038 global urban centres were at least moderately green in 2021 (indicator 2.2.3), and the number of households with air conditioning increased by 66% from 2000 to 2020, a maladaptive response that worsens the energy crisis and further increases urban heat, air pollution, and greenhouse gas emissions. As converging crises further threaten the world’s life-supporting systems, rapid, decisive, and coherent intersectoral action is essential to protect human health from the hazards of the rapidly changing climate. Health at the mercy of fossil fuels The year 2022 marks the 30th anniversary of the signing of the UN Framework Convention on Climate Change, in which countries agreed to prevent dangerous anthropogenic climate change and its deleterious effects on human health and welfare. However, little meaningful action has since followed. The carbon intensity of the global energy system has decreased by less than 1% since the UNFCCC was established, and global electricity generation is still dominated by fossil fuels, with renewable energy contributing to only 8·2% of the global total (indicator 3.1). Simultaneously, the total energy demand has risen by 59%, increasing energy-related emissions to a historical high in 2021. Current policies put the world on track to a catastrophic 2·7°C increase by the end of the century. Even with the commitments that countries set in the Nationally Determined Contributions (NDCs) updated up until November 2021, global emissions could be 13·7% above 2010 levels by 2030—far from the 43% decrease from current levels required to meet Paris Agreement goals and keep temperatures within the limits of adaptation. Fossil fuel dependence is not only undermining global health through increased climate change impacts, but also affects human health and wellbeing directly, through volatile and unpredictable fossil fuel markets, frail supply chains, and geopolitical conflicts. As a result, millions of people do not have access to the energy needed to keep their homes at healthy temperatures, preserve food and medication, and meet the seventh Sustainable Development Goal (to ensure access to affordable, reliable, sustainable, and modern energy for all). Without sufficient support, access to clean energy has been particularly slow in low HDI countries, and only 1·4% of their electricity came from modern renewables (mostly wind and solar power) in 2020 (indicator 3.1). An estimated 59% of healthcare facilities in low and middle-income countries still do not have access to the reliable electricity needed to provide basic care. Meanwhile, biomass accounts for as much as 31% of the energy consumed in the domestic sector globally, mostly from traditional sources—a proportion that increases to 96% in low HDI countries (indicator 3.2). The associated burden of disease is substantial, with the air in people’s homes exceeding WHO guidelines for safe concentrations of small particulate air pollution (PM2·5) in 2020 by 30-fold on average in the 62 countries assessed (indicator 3.2). After 6 years of improvement, the number of people without access to electricity increased in 2020 as a result of the socioeconomic pressures of the COVID-19 pandemic. The current energy and cost-of-living crises now threaten to reverse progress toward affordable, reliable, and sustainable energy, further undermining the socioeconomic determinants of health. Simultaneously, oil and gas companies are registering record profits, while their production strategies continue to undermine people’s lives and wellbeing. An analysis of the production strategies of 15 of the world’s largest oil and gas companies, as of February 2022, revealed they exceed their share of emissions consistent with 1·5°C of global heating (indicator 4.2.6) by 37% in 2030 and 103% in 2040, continuing to undermine efforts to deliver a low carbon, healthy, liveable future. Aggravating this situation even further, governments continue to incentivise fossil fuel production and consumption: 69 (80%) of 86 countries reviewed had net-negative carbon prices (ie, provided a net subsidy to fossil fuels) for a net total of US$400 billion in 2019, allocating amounts often comparable with or even exceeding their total health budgets (indicator 4.2.4). Simultaneously, wealthier countries failed to meet their commitment of mobilising the considerably lower sum of $100 billion annually by 2020 as agreed at the 2009 Copenhagen Accord to support climate action in “developing countries”, and climate efforts are being undercut by a profound scarcity of funding (indicator 2.1.1). The impacts of climate change on global economies, together with the recession triggered by COVID-19 and worsened by geopolitical instability, could paradoxically further reduce the willingness of countries to allocate the funds needed to enable a just climate transition. A health-centred response for a thriving future The world is at a critical juncture. With countries facing concurrent crises, the implementation of long-term emissions-reduction policies risks being deflected or defeated by challenges wrongly perceived as more immediate. Addressing each of the concurrent crises in isolation risks alleviating one, while worsening another. Such a situation is emerging from the response to COVID-19, which has so far has not delivered the green recovery that the health community proposed, and, on the contrary, is aggravating climate change-related health risks. Less than one third of $3·11 trillion allocated to COVID-19 economic recovery is likely to reduce greenhouse gas emissions or air pollution, with the net effect likely to increase emissions. The COVID-19 pandemic affected climate action at the city level, and 239 (30%) of 798 cities reported that COVID-19 reduced financing available for climate action (indicator 2.1.3). As countries search for alternatives to Russian oil and gas, many continue to favour the burning of fossil fuels, with some even turning back to coal. Shifts in global energy supplies threaten to increase fossil fuel production. Even if implemented as a temporary transition, these responses could reverse progress on air quality improvement, irreversibly push the world off track from meeting the commitments set out in the Paris Agreement, and guarantee a future of accelerated climate change that threatens human survival. On the contrary, in this pivotal moment, a health-centred response to the current crises would still provide the opportunity for a low-carbon, resilient future, which not only avoids the health harms of accelerated climate change, but also delivers improved health and wellbeing through the associated co-benefits of climate action. Such response would see countries promptly shifting away from fossil fuels, reducing their dependence on fragile international oil and gas markets, and accelerating a just transition to clean energy sources. A health-centred response would reduce the likelihood of the most catastrophic climate change impacts, while improving energy security, creating an opportunity for economic recovery, and offering immediate health benefits. Improvements in air quality would help to prevent the 1·2 million deaths resulting from exposure to fossil fuel-derived ambient PM2·5 in 2020 alone (indicator 3.3), and a health-centred energy transition would enhance low-carbon travel and increase urban green spaces, promoting physical activity, and improving physical and mental health. In the food sector, an accelerated transition to balanced and more plant-based diets would not only help reduce the 55% of agricultural sector emissions coming from red meat and milk production (indicator 3.5.1), but also prevent up to 11·5 million diet-related deaths annually (indicator 3.5.2), and substantially reduce the risk of zoonotic diseases. These health-focused shifts would reduce the burden of communicable and non-communicable diseases, reducing the strain on overwhelmed health-care providers. Importantly, accelerating climate change adaptation would lead to more robust health systems, minimising the negative impacts of future infectious disease outbreaks and geopolitical conflicts, and restoring the first line of defence of global populations. Emerging glimmers of hope Despite decades of insufficient action, emerging, albeit few, signs of change provide some hope that a health-centred response might be starting to emerge. Individual engagement with the health dimensions of climate change, essential to drive and enable an accelerated response, increased from 2020 to 2021 (indicator 5.2), and coverage of health and climate change in the media reached a new record high in 2021, with a 27% increase from 2020 (indicator 5.1). This engagement is also reflected by country leaders, with a record 60% of 194 countries focusing their attention on the links between climate change and health in the 2021 UN General Debate, and with 86% of national updated or new NDCs making references to health (indicator 5.4). At the city level, local authorities are progressively identifying risks of climate change on the health of their populations (indicator 2.1.3), a first step to delivering a tailored response that strengthens local health systems. Although the health sector is responsible for 5·2% of all global emissions (indicator 3.6), it has shown impressive climate leadership, and 60 countries had committed to transitioning to climate-resilient and/or low-carbon or net-zero carbon health systems as part of the COP26 Health Programme, as of July, 2022. Signs of change are also emerging in the energy sector. Although total clean energy generation remains grossly insufficient, record high levels were reached in 2020 (indicator 3.1). Zero-carbon sources accounted for 80% of investment in electricity generation in 2021 (indicator 4.2.1), and renewable energies have reached cost parity with fossil fuel energies. As some of the highest emitting countries attempt to cut their dependence on oil and gas in response to the war in Ukraine and soaring energy prices, many are focusing on increasing renewable energy generation, raising hopes for a health-centred response. However, increased awareness and commitments should be urgently translated into action for hope to turn into reality. A call to action After 30 years of UNFCCC negotiations, the Lancet Countdown indicators show that countries and companies continue to make choices that threaten the health and survival of people in every part of the world. As countries devise ways to recover from the coexisting crises, the evidence is unequivocal. At this critical juncture, an immediate, health-centred response can still secure a future in which world populations can not only survive, but thrive.
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              Nutrition: Fall in fish catch threatens human health.

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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2023
                23 February 2024
                : 8
                : Suppl 3
                : e014638
                Affiliations
                [1]Independent researcher , Cologne, Germany
                Author notes
                [Correspondence to ] Dr Martha Teshome; m.w.teshome@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-1790-0422
                Article
                bmjgh-2023-014638
                10.1136/bmjgh-2023-014638
                10897373
                38395450
                f14b413c-112b-4965-ae23-bf61cbf2c6c8
                © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 23 November 2023
                : 26 January 2024
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                health policy,public health,environmental health,nutrition,prevention strategies

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