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Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 PUBLIC HEALTH ETHICS VOLUME 8 NUMBER 2 2015 196–208 196 Caribbean Heat Threatens Health, Well-being and the Future of Humanity Cheryl C. Macpherson , St George’s University School of Medicine and Windward Islands Research and Education Foundation (WINDREF) Muge Akpinar-Elci, Old Dominion University, Center for Global Health, Health Sciences and Windward Islands Research and Education Foundation (WINDREF) Corresponding author. Cheryl C. Macpherson, Department of Bioethics, St George’s University School of Medicine, PO Box 7, St George’s, Grenada. Tel.: 1 473 444 1470 (ext 3011 or 3499); Fax: 1 473 439 4388; Email: email@example.com Climate change has substantial impacts on public health and safety, disease risks and the provision of health care, with the poor being particularly disadvantaged. Management of the associated health risks and changing health service requirements requires adequate responses at local levels. Health-care providers are central to these re- sponses. While climate change raises ethical questions about its causes, impacts and social justice, medicine and bioethics typically focus on individual patients and research participants rather than these broader issues. We broaden this focus by examining awareness among health-care providers in the Caribbean region, where geo- graphic and socioeconomic features pose particular vulnerabilities to climate change. In focus groups, Caribbean providers described rises in mosquito-borne, ﬂood-related, heat-related, respiratory and mental illnesses, and attributed these to local impacts of climate change. Their discussions showed that the signiﬁcance of these impacts differs in different Caribbean nations, raising policy and social justice questions. Bioethics and public health ethics are situated to frame, inform and initiate public and policy dialog about values and scientiﬁc evidence associated with climate change. We urge readers to initiate such dialog within their own institutions about the context- dependent nature of the burdens of climate change, and values and policies that permit it to worsen. ‘The better placed an individual is to do what is how humans are shaped by their natural environments, right, the greater the onus on him to do what is and how human activities are shaping these environ- right.’ (Garvey, 2008: 83) ments (Dupras et al., 2014). Moving in this direction, we conducted focus groups with health-care providers about which health impacts of climate change, if any, they had observed in their practices. We conducted our Introduction study in the Caribbean region which is particularly vul- Climate change harms health and well-being. Its conse- nerable to climate change due to the geographic and quences, including extreme weather events, cause injuries, socioeconomic features that deﬁne its nations as small exacerbate existing medical conditions, increase exposure island developing states (SIDS). This article frames cli- to infectious disease through displacement and over- mate change as a health and bioethics problem, de- crowding and burden health services. While the World scribes our study and the context in which it was conducted and presents our ﬁndings. It also discusses Health Organization, World Bank and similar bodies are investing in research, education and policy aimed at limit- the signiﬁcance and implications of the data for bioeth- ics, and for the future of humanity. ing health impacts of climate change that are already accru- Given the complexity of the problems and the many ing (Macpherson, 2013a), bioethics is primarily focused on sectors, disciplines and nations involved, interdisciplin- clinical practice and research. This overshadows attention ary and nonpartisan deliberation is essential to stabiliz- to broader harms like health impacts of climate change and ing emissions. To advance deliberation, we distinguish policies that permit these harms to accrue. between the measurable cause (accumulated atmos- Bioethics ought to loosen its dogmatic focus on au- tonomy (Dawson, 2010) and instead address issues like pheric emissions) and the less measurable impacts doi:10.1093/phe/phv008 Advance Access publication on 13 April 2015 ! The Author 2015. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 CARIBBEAN HEAT THREATENS HEALTH 197 (climate change and its diverse and often intangible (i) injuries and exacerbation of existing medical condi- manifestations). Although each impact damages or des- tions, including mental illness; (ii) displacement leading troys resources essential to health and survival, even to overcrowding and exposure to infectious and vector- highly educated individuals concerned about a single borne disease; (iii) release of chemicals, sewage and impact such as warming may not recognize the conse- pollutants that contaminate food and water; (iv) quences of warming for the range of resources or loca- reduced access to unpolluted fresh water; (v) dimin- tions affected, recognize other impacts (such as changes ished agricultural productivity and access to food; (vi) to seasonal precipitation) and their respective conse- disruption of communication, transportation and infra- quences or differentiate evidence from belief. structure essential to the distribution of supplies; and (vii) greater burdens on health services. These consequences have attracted relatively little attention in public health ethics, environmental ethics Emissions Matter in Bioethics and bioethics, but have prompted a range of work in and Beyond public health, medicine and beyond. Bioethics and its specializations tend to focus on health and health care Climate change refers to decades long and scientiﬁcally for individuals, and to be guided by principles of auton- established changes in regional patterns of wind and omy, utility and justice, or one of several theories. precipitation, seasonal weather and average annual Because emissions undermine health and the delivery temperatures. Its manifestations include extreme wea- of health care, and raise questions about the extent to ther which causes injuries and displacement and exacer- which any bioethics principle or theory is fulﬁlled by bates chronic conditions like asthma, heart disease and responses to emissions or to their consequences in any mental illness. Less visibly, it disrupts access to, and given setting, one might actually look to bioethics for availability of, environmental resources that are insight. Bioethics is expert in the analysis and commu- essential to health and the provision of health care nication of medical risks, and this expertise is equally (Macpherson, 2013b); increases exposure to pathogens applicable to the communication of climate risks and disease vectors; and damages the air, water and land (Valles, 2015). Bioethics has the potential to inform upon which we live, play, produce crops and agricul- and drive policies and governance toward mandating tural animals, store goods and provide health care. It substantial reductions in emissions, and by doing this, also contributes to global warming which, through might help to make health and access to care more even fractional increases in average temperatures, ex- equitable. pands the ranges and behaviors of some pathogens Many bioethicists recognize that emissions harm and disease vectors, and raises sea levels. Sea level rise health, and that the distribution of related beneﬁts and challenges coastal areas in rich and poor nations, par- harms is unfair. Surprisingly few, however, see this as ticularly those with high population densities. Two morally problematic, or something they can or should megacities with over 10 million inhabitants in 1950 do much about, other than perhaps switching off their have since multiplied to about 20 megacities, each gen- computers and lights when not in use. Taking such ac- erating more pollution and more demand for energy, tions may deﬁne us as conscientious citizens but, even water, air, food and housing (United Nations, 2010), collectively, cannot counteract the enormous amounts and creating more challenges for health-care providers, of emissions generated by industries, institutions and health systems and governments. governments; or by globalization that drives demand Unusual only 10 years ago, extreme weather has for products and the energy needed to produce, trans- become commonplace, causing serious economic and port, consume and dispose of them. A rigorous body of health consequences globally (Jamieson, 2014; Patz work on values and value judgments involved in assess- et al., 2014). Consequences include the growing risks ments, policies and practices that allow emissions to rise of extreme heat waves, precipitation and coastal ﬂood- would help leaders recognize that they themselves, and ing; aggregate economic damages that accelerate with other stakeholders, will beneﬁt from reducing their increasing temperature and loss of biodiversity, ecosys- tems, goods and services; large-scale singular events that emissions. Some bioethicists (including those cited herein and others) are undertaking such work abruptly and permanently disrupt physical systems and ecosystems; and uneven distribution of burdens that (Deckers, 2011; Dwyer, 2013), but on the whole, it is most harm already disadvantaged individuals and overdue in bioethics and other sectors, including policy communities (IPCC, 2014a). The burdens include and governance. Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 198 MACPHERSON AND AKPINAR-ELCI To ignite interest among bioethicists and others, we The Caribbean Context report here what Caribbean health-care providers per- ceive as impacts of climate change in their respective Before presenting ﬁndings, we highlight certain nations, and discuss the signiﬁcance of these percep- Caribbean features to show how health impacts, their tions. Some of the impacts mirror those reported in local signiﬁcance and the effectiveness of interventions, other regions by scientists, health professionals and vary with location. Clearly, socioeconomic, political and the news media. Paradoxically, while the coastal and geographic features inﬂuence vulnerability, prepared- low lying geographies of Caribbean nations make ness and willingness and capacity to reduce emissions. them more vulnerable than others to sea level rise and Low-income nations, for example, are more severely extreme weather, their relatively rapid economic growth affected by extreme storms because they lack the con- is changing consumption patterns in ways that increase struction standards of wealthy nations, have less cap- global emissions. acity to prepare and recover and are less able to provide health care to those who are injured or ill. Geographic factors including coastal, mountainous and desert environments and tropical, temperate and The Study polar climates inﬂuence regional ﬂora, fauna, food, Building on previous work (Macpherson and Akpinar- clothing, lifestyles and energy use, all of which bear on Elci, 2013; Maibach et al., 2008) and using a semi-struc- the signiﬁcance of speciﬁc impacts in those locations. In tured approach (Hull et al., 2001), we designed focus the Arctic, warming temperatures are melting the group questions to explore perceptions among permafrost foundation of roads and damaging build- Caribbean health-care providers including physicians ings, causing accidents, and impeding traditional hunt- and nurses, and at least one veterinarian and technician ing and ﬁshing practices that not only feed indigenous in each group. They discussed their professional observa- Arctic people and communities but also contribute to tions and experiences from within their respective institu- their sense of identity (Willox et al., 2012). Warming tions and nations. Only middle- and senior-level affects temperate regions differently, contributing in participants were included to ensure that they could dis- the USA and Russia to severe and prolonged droughts cuss changes over time. To minimize bias, government that disrupt seasonal weather patterns and agriculture, ofﬁcials who might express a ‘party line’ rather than reduce access to food and water, and hinder employ- honest perception were excluded, as were public and en- ment, economic growth and security (Associated Press, vironmental health experts and others whose knowledge 2014; Dreibus et al., 2012). about health impacts of climate change may have over- Such changes alter the life cycles and transmission of shadowed discussion of their experiences and perceptions. pathogens and disease vectors that affect humans and Institutional Review Board (IRB) approval and in- other species. Caribbean consequences include the formed consent were obtained to audiotape and tran- recent appearance or reappearance of mosquito-borne scribe discussions. Research coordinators in each viruses such as malaria and dengue fever in Jamaica, all nation recruited equal numbers of participants from four dengue serotypes in Grenada (GND) and in 2013, medicine, nursing, etc, roughly maintaining a gender bal- the ﬁrst cases of Chikungunya (CHKV) in the western ance. No inducements were offered. Discussion was con- hemisphere. Within months, CHKV had infected ducted in groups of eight in 2013 at times convenient to almost 1000 people in 20 different Caribbean nations participants, lasting until the data were saturated (over 2 (Caribbean Public Health Association, 2014) including hours). They were facilitated and audiotaped by C.C.M., over 60% of hospital staff in GND (Beyond the observed by M.A.E., minuted by the coordinator and tran- Headlines, Grenada Broadcast Network, 2 September scribed by a service. Grounded in content analysis, the 2014). authors and an external epidemiologist each independ- ently immersed themselves in, and coded, the transcripts, then compared ﬁndings to resolve the few discrepancies that arose. For each discrepancy, all analysts had agreed on Study Sites: Trinidad and Tobago content but coded it differently. Comments about ﬂoods and Grenada impacting on construction and housing, for example, were coded by two analysts as ‘housing’, and by the third as The Association of Small Island States represents SIDS ‘deforestation’. All data reported here were coded identi- within the United Nations. About 35 SIDS comprise its cally by at least two analysts. membership, including Trinidad and Tobago (T&T), Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 CARIBBEAN HEAT THREATENS HEALTH 199 Grenada (GND) and nine other independent English- the phrase climate change, asked ‘What environmental speaking Caribbean nations with varied socioeconomic, changes do you think are occurring that now affect, or will political, geographic, cultural and historic features. likely affect, health in your nation?’. Agreement was strong among both groups that envir- Despite their differences, they, like non-Caribbean SIDS, have extensive low lying coastal areas, relatively onmental changes are occurring in their respective na- tions and reducing agricultural productivity; increasing small percentages of global population, limited global inﬂuence, growing reliance on imported goods and dis- the frequency and magnitude of local landslides, ﬂoods and pollution; and affecting health and hospital admis- proportionate vulnerabilities to emissions while gener- ating relatively few (SIDSnet, 2014). sions. Discussions in both groups were animated and generated comments like those below, which were fur- Caribbean SIDS have tropical beaches, rain forests, deserts and volcanoes conducive to recreational, cre- ther addressed during subsequent questions. ative and inspirational activities that give pleasure, reduce stress and promote health. What remains of ‘Once there’s a ﬂood you know within the next weeks you expect to see people coming in with fever, gen- their disappearing coral reefs and coastal mangroves and ecosystems still support ﬁshing and tourism, and eralized body pain, rash, and all of a sudden they can’t pass urine .. . they have pneumonia or some help buffer effects of storms and sea level rise. These fungal infection.’ (T&T) geographies and natural resources generate economic ‘If anyone’s looking at what’s happening in the and health beneﬁts in the Caribbean and beyond. oceans and with our rivers. In the dry season if you These resources and beneﬁts seem less valued than in get close to these big industries, when it rains here the past, and how they are valued determines the extent and the rivers get plugged with the other stench and to which they are appreciated, enjoyed and protected, or stuff, and we don’t have an idea of what is in that exploited. black weed stuff.’ (T&T) We conducted our study in the larger and more in- ‘If you have a prolonged dry season, then you have 3 dustrial T&T, and the smaller and less developed GND, or 4 days of heavy rain, the week after that you tend to explore how the impacts and signiﬁcance of emissions to see a lot of cases of gastroenteritis coming in.’ differ with context. Separated by 100 miles, T&T’s (GND) population is predominantly of African and Asian ‘Deﬁnitely the air is more polluted, the quantity of Indian heritage with a small percentage of other back- vehicles we have on the road now ... We’re even grounds, and GND’s is primarily of African heritage. guilty at the hospital—our incinerators—because I Bachelor degree programs have been available for over have allergies and whenever they burn the stuff I can’t 50 years in T&T, and under 20 years in GND. World open my eyes.’ (GND) Bank data for 2012 (the most recent available at the time of writing) shows their respective surface areas as 5130 Based on 10 topics speciﬁed in a study of health depart- and 340 square kilometers; population sizes as 1,337,439 ment preparedness in the USA (Maibach et al., 2008), and 105,483; gross domestic products as US$17,000 and participants were then asked ‘What do you think is the US$7000; health expenditures per capita US$972 and signiﬁcance of the following health impacts in your nation US$478 contrasted with US$8895 in the USA and now, and 5 years from now?’. Responses are highlighted US$3495 in the UK; and most recent ‘CO2 emissions below by topic. (metric tons per capita)’ in 2010 as 38.2 and 2.5 con- trasted with 7.9 in the UK and 17.6 in the USA, with T&T’s emissions outranked only by Qatar at 40.3 Heat Waves and Heat-Related Illnesses (World Bank Data, 2014). Participants in both groups perceived air temperatures as hotter than usual and as contributing to more heat- related illness and hospital admissions. GND partici- The Data pants described an increase in hospitalizations for After introducing everyone present, and reminding par- dehydration and sunburn, while T&T participants ticipants that we did not expect them to have expertise talked extensively about heat stress, chronic obstructive in environmental health or climate change, we invited pulmonary disease and increasing deaths of working them to discuss a series of questions from the perspec- and domestic animals. One said ‘I can’t really tell you tive of their own observations and experiences. The ﬁrst for sure if it’s because of the number of dogs in society, question, to avoid imparting bias, intentionally omitted or the number of true cases as a result of what’s Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 200 MACPHERSON AND AKPINAR-ELCI happening with the temperature in the environment. Drought, Forest Fires or Brush Fires But we are seeing these dogs and they collapse, they’re Both groups described ‘bush ﬁres’ as more frequent suffering from heat stress. We have them on ﬂuids, and visible, and the burning of household and other trying to cool them down to save their lives’. waste as widespread. GND participants said that bush ﬁres are illegal but are used anyway. Lack of resources or ofﬁcial willingness with which to challenge traditional Storms Including Hurricanes and Floods or widespread practices like this may occur in many Both groups perceived increases in mosquito-borne dis- locations, and may also impede efforts to limit ease, diarrhea and ﬂood-related illness, and declines in emissions. subsistence agriculture which they described as once T&T participants described droughts as becoming widely undertaken by rich, as well as poor, families. more frequent due to changing seasonal patterns, and The disappearing distinction between dry and wet sea- described how droughts worsen ﬂoods and affect agri- sons was raised in T&T during this and subsequent cultural animals. One said ‘In the dry season when questions, and in GND, during subsequent questions. there’s limited water supply, birds [poultry] would T&T participants also described increasingly frequent just die. They need water all the time’. Another said ﬂoods affecting increasingly larger areas. ‘The undergrowth doesn’t seem to be as dry. Rain comes and dampens things and we don’t have the ex- ‘With 2–3 days of rain we get people dislocated when tensive wild ﬁres that we would have had lets say 3 years their homes are destroyed, and the more we clear ago .. . If we go back to very long dry spells I’m fairly down our lands to build houses, I think the more certain a return to those serious wild ﬁres would have we’re going to have ﬂooding with the slightest rain.’ consequences for ﬂooding’. ‘When the ﬂood comes, they [tethered animals] have no way to escape and they just stay and die. That’s a welfare concern for us as well. And this affects the Vector-Borne Infectious Diseases food supply here. .. . Every time there is a ﬂood, the price of vegetables goes up.’ Both groups perceived mosquito-borne disease as ‘A lot of the ﬂooding relates to indiscriminate land increasing, and attributed this to changing seasonal pat- use .. . but some is deﬁnitely due to increases in the terns that affect mosquito breeding and biting. amount of rainfall we’ve been getting. ... We used to have a distinct dry season or wet season. Now that no ‘As we lose the distinction between dry and wet longer exists, we have rain anytime. ... If we get one seasons, we may have an early mosquito season. heavy shower or rainfall, we get ﬂooding.’ That would contribute to more dengue, more yellow fever, malaria. .. . And if we have more ﬂood- After 49 years without a hurricane, GND suffered major ing, more water-borne disease, cholera, salmonella.’ damage from Hurricane Ivan in 2004. GND participants (T&T) described overcrowding and depression that persisted ‘We’re not having seasons anymore—you don’t see even a year later, and expressed concern that if a similar the clear cut rains and clear cut dry.’ (GND) event occurred today, there would be less foreign aid and investment in GND’s recovery due to the global Anxiety, Depression or other Mental Health economic downturn. Conditions Both groups perceived increases in mental illness and ‘If you have a house equipped to hold 5 people, you expressed concern that stigma hinders willingness to have 20 now. So when 1 person gets sick, everybody seek treatment. Attempted suicides were perceived as gets sick.’ increasing in GND but not linked directly with climate ‘We’re still recovering. Our nutmeg was wiped out, change. T&T participants agreed that ‘A lot of it [mental the animal population declined, and these are all just illness] is stress-related and increasing, and whether the starting to pick up again.’ increasing is a result of environmental changes or the ‘The world economy was a lot better then. We got a lot of help [foreign aid], but right now we won’t be greater stress of modern living we really don’t know’. One said that rising rates of depression affect ‘the way in able to get all this help.’ ‘If something like Ivan was to happen again, persons which we manage patients. Because they don’t have the are going to be even more depressed than before.’ zeal, they are not compliant’. Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 CARIBBEAN HEAT THREATENS HEALTH 201 GND participants said that local farming incomes Quality or Quantity of Fresh Water Available would improve if farmers moved into organics and im- Both groups described a growing reliance on bottled proved presentation of their produce. One said that a water, and the quality of tap water as poor during Caribbean Community workshop on food security had ﬂoods and the dry season. In T&T, tap water has ‘a recently been held in Grenada. GND’s comments bitter aftertaste’ and ‘a white cloudy foully stench some- (below) resemble those from T&T. times, and sometimes it’s so strong ... in some areas you cannot drink tap water now’. Several attributed this to ‘What was considered agricultural land has now pollution, and one to poorly dissolved water puriﬁca- become commercial land.’ tion chemicals. GND participants described some of ‘All imported foods are cheaper than the local.’ their rivers as drying up, and described their water qual- ‘They import the feed for the cattle, chicks, all these ity as good ‘most of the time’ but water storage and things.’ distribution systems as needing strengthening. GND ‘I think in the past we did a lot more farming. participants said: Actually people keep small farms and this is some- thing that is pretty much in the past. Now no one ‘They should be looking at more storage facilities wants to do that. Rather than plant a few tomatoes because during the dry season we do have severe and so, you go, you buy it in the supermarket and its problems.’ right there.’ ‘When it’s not good you know it. When it ﬂoods, it ‘We have to be able to take care of ourselves and we comes dirty. You can see and so you don’t drink it.’ are going to starve if something really was going to ‘Years ago if you thirsty you could stop at a pipe and happen worldwide. ... We have a supermarket, great, drink. Now everybody has their little water bottle.’ were happy about it. But if something was to happen we can’t sustain our selves.’ Unsafe or Ineffective Sewage and Septic System Operation Housing for Residents Displaced by Extreme T&T participants said that ﬂoods cause septic tank leak- Weather Events age and contamination that lead to infections requiring T&T participants described the cost of housing therein medical care. Reﬂecting GND’s economic reliance on as very high, and as a signiﬁcant source of stress, even to ﬁshing and tourism, participants focused on damages the wealthy, anticipating that this stress will worsen as to their beaches and ﬁsh from sewage being pumped out extreme weather increases demand for housing. GND to sea, saying: participants described construction standards as having improved, and emergency shelters as more available, ‘Well what is it [sewage] being treated with and how since Hurricane Ivan. would that affect us in the long run?’ ‘A lot of our corals are dying.’ ‘Some of the ﬁsh, the bottom feeders, are not safe to Health-Care Services for People with Chronic eat, barracuda and things like that.’ Conditions during Service Disruptions Food Safety and Security such as Extreme Weather Events T&T participants observed growing preparedness Both groups discussed growing reliance on imported foods. In T&T, one said ‘Trinidad has never been a within their health-care system but were uncertain about readiness. country that strives to be food sufﬁcient in terms of our own production, just because of the belief we have ‘I ﬁnd in normal times we can’t supply the needs of oil so we can buy foods’. T&T participants also said that farming is being disrupted by construction on what was the public. For instance with the dialysis, the people who need dialysis in this country on a regular basis— formerly agricultural land, and by the pursuit of educa- tion, urban lifestyles and higher salaries. They talked no [we are unprepared].’ extensively about crop damage due to heavy rains and ‘They have upgraded the health centers to have mini- changing weather patterns, for example, the ‘problem operating theatres ... we’re trying to extend the with tomato production now ... the rain is going to beat hours gradually, and the reason for doing that is to the ﬂowers off and we’re seeing it from crop to crop put less pressure on the main hospital .. . I’ll say our because of the changes in our weather pattern’. doctors are ready, our staff is ready for a major Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 202 MACPHERSON AND AKPINAR-ELCI disaster. The government has the money but ... the assistance if another hurricane were to strike. Issues gauze and the plasters and all these things—do we raised by T&T participants emphasized other features. have it in stock?’ They expressed more concern about ﬂoods which they repeatedly said occur more frequently, affect larger areas GND participants instead discussed the vulnerability of and cause greater damage and illness than in the past. They attributed this to changing seasonal weather pat- Grenada’s main hospital which is coastally located and has limited road access, and expressed concern that terns that compound the effects of clearing and con- struction on previously undeveloped land and stakeholders lack information. hillsides. While GND participants also discussed chan- ging weather patterns, they said relatively little about ‘We have a lot of connecting roads in Grenada that people use, but they are not equipped to handle the clearing of, or construction on, land. T&T’s discussions about air and water pollution are consistent with its oil heavy trafﬁc where a major road is disrupted.’ ‘I would hear “we’re doing this” and “we have this extraction and reﬁneries, and factories producing deter- gents and fertilizers. Despite contextual similarities be- plan in place.” Truthfully the doctors and nurses tween T&T and GND, the differences described here right on the ground don’t know anything about that.’ demonstrate that local context bears on the types and signiﬁcance of the impacts of emissions, and suggest Signiﬁcance of the Data that causes and effective responses will also differ with context. Similarities, Differences and Generalizability That health-care providers in the Caribbean perceive Implications emissions and climate change as impacting on their pa- tients now highlights the need to understand emissions For responses to be effective, development and aid pro- as a present, as well as future, problem. It also shows that grams must be sensitive to local socioeconomic, cultural providers are confronted with managing the health risks and environmental conditions, and designed to em- and changing health service requirements resulting from power communities and optimize environmental bene- the complex impacts of droughts, rain, ﬂoods and hur- ﬁts of their traditional practices (IPCC, 2014b). There is ricanes. Responses common to both nations include (i) limited commitment to providing such programs, and increasing heat- and respiratory-related illness due to limited capacity in low- and middle-income nations for rising temperatures; (ii) increasing mosquito-borne negotiating its provision, but bioethicists could inform and ﬂood-related illness due to changing seasonal wea- and initiate dialog in SIDS and other nations about the ther patterns; (iii) poor water quality during ﬂoods and value of implementing local and regional policies that the dry season; (iv) more mental illness deriving from mandate environmentally friendly construction stand- greater stress in society; and (v) declining agricultural ards or energy-saving materials and designs. Doing so productivity and food security as reliance on bottled could help build host nation capacity to negotiate, for water and imported food increases. That scientiﬁc and example, such standards into hotel and business devel- news media reports have documented some of these opment deals. Given global demand for, and depletion problems in other locations suggests that they are gen- of, sand used in cement production (Gillis, 2014), such eralizable within and beyond Caribbean SIDS. For ease capacity could have particular relevance in SIDS and of discussion, Table 1 summarizes and contrasts the im- other low- and middle-income countries (LMIC) with pacts described in T&T and GND and contrasts these sandy beaches. Aid, development and investment pro- with the differences between them. grams that use public goods like undeveloped beach- The differences are important because they reﬂect the fronts, mangroves, forests, rivers and hillsides ought to different contextual features of each. GND is econom- be designed to help prevent or offset harms to these ically reliant on ﬁshing and tourism, for example, and natural environments, particularly when disproportion- the beaches lining much of its coastline are enjoyed by ately large economic beneﬁts are involved. its people, many of whom live and work in close prox- Globalization can boost employment and economic imity. GND participants thus focused more on the sea growth but also raises massive corporate proﬁts, and and coastal regions than T&T participants. Experiences global emissions. While development through globaliza- of Hurricane Ivan and its aftermath grounded observa- tion can improve some socioeconomic and health indi- tions in GND regarding depression, infectious disease cators, policies that facilitate globalization by marketing and anxiety that it would receive less international Western products and lifestyles in LMIC, and raising Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 CARIBBEAN HEAT THREATENS HEALTH 203 Table 1. ‘What do you think is the signiﬁcance of the following health impacts in your nation now, and 5 years from now?’ Both T&T GND Heat waves and Increased Increased Increased Admissions for Heat stress Dehydration heat-related illnesses Heat stroke (human and animal) Sunburn Heart attack COPD Storms (including Increased Increased Increased hurricanes and Flooding Animal death Depression ﬂoods) Diarrhea Agricultural loss (especially elderly Mosquitoes Dengue fever and uninsured) Mosquito-borne Yellow fever Crowding disease Decreased Disease clusters Water quality (and related disease) Droughts, forest ﬁres Increased Increased Ignore ﬁre bans or brush ﬁres Bush ﬁres Harms involving Livestock Crops Water distribution Floods Seasonal patterns Vector-borne infectious Increased Increased Poor mosquito control diseases Mosquitoes Cholera Dengue fever Yellow fever Zoonotic diseases H1N1 Rabies Rat aggression Anxiety, depression or Increased Increased Increased Depression Mental illness Suicide attempts other mental health conditions Quality or quantity of Increased Questionable quality Rivers drying up fresh water available Use of bottled water Rusty pipes Inadequate storage Decreased Inadequate supply Water quality in ﬂoods and dry season Unsafe or ineffective Septic tanks leak Harms ﬁsh and corals sewage and septic (especially in ﬂoods) Has improved system operation Food safety and Increased Decreased Imported food use Farming security Housing for residents Increased Improved displaced by extreme Stress Construction quality weather events House prices Number of shelters Health-care services for Increased Vulnerable location people with chronic Preparedness of main hospital conditions during Upgrades to service disruptions health centres such as extreme weather events Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 204 MACPHERSON AND AKPINAR-ELCI global consumption and emissions, counteract the fewer beneﬁts. Jamieson (2008) documents some of beneﬁts. In his review of economic debates and the unfair and disproportionate harms to vulnerable models, Dale Jamieson (2014) shows that economic populations including increases in malaria in Africa and natural disasters in Central America, and the 2005 forecasts and risk assessments do not assign realistic monetary values to the environmental resources and Chicago heat wave that affected primarily elderly African American men. He argues that those who gen- weather patterns on which industrial and national prod- uctivity depend, or incorporate the costs to industries or erate the most emissions should bear at least some of the burdens, and willingness to accept this responsibility host nations of damaging these resources. This failure undermines existing economic arguments about emis- might be obtained by redeﬁning climate change as a moral problem, he says, because ‘that something is the sions, and along with lack of information and insight, underlies widespread acceptance of policies that permit morally right thing to do is a powerful consideration in its favor. It may not always carry the day, but it cannot emissions to rise. The balance between economic and health beneﬁts easily be ignored’ (Jamieson, 2008: 269–270). Emissions are a moral problem, says Madison Powers and burdens warrants reexamination. Where the bal- ance has turned, policies, practices and priorities must (2014), because international, national and other poli- cies that permit them to rise affect access to, and control be modiﬁed because, as economist Juliet Schor (2010: over, energy, food and water, and because emissions 22) explains, what ‘was efﬁcient for constructing the raise ‘fundamental questions about the paths to eco- nineteenth-century industrial economy is not what’s nomic development, poverty alleviation, and the most suited for the resource-scarce system of the capacity of individuals and nations to secure the basic twenty-ﬁrst’. Bioethicists, like other professionals, have requirements for decent human lives’. To reduce asso- opportunity and inﬂuence with which to alter emis- ciated injustices, we need broad stakeholder consensus sions-related policies. They can elucidate why patients, about the value of doing so. Public and policy dialog providers and others should care about, and work to about scientiﬁc evidence, economic perspectives, secur- reduce, emissions in medical specialties such as assisted ity concerns, human rights and social justice is needed to reproduction (Richie, 2014); and explore how to reduce attain this consensus, and these considerations must depression, speed recovery, improve patient outcomes, also be integrated into environmental and health law have a calming effect on staff, save money and conserve and governance (Wiley, 2010). energy in hospitals by, for example, adopting evidence- Bioethics often extends into, and should engage with, based designs like larger windows and easily accessible these issues, but only a handful of prominent bioethi- public gardens (Herbert, 2011; Sadler et al., 2011; cists have done so. While emissions, climate change and Yordy, 2011). connections between health and environment receive The concept of global bioethics put forth by Van little attention, even in environmental and public Rensselaer Potter enthusiastically promotes actions health ethics, they are explicitly addressed in climate and policies likely to beneﬁt the health of present and ethics literature—but this is seldom published in bio- future generations, underprivileged and vulnerable ethics journals. From climate ethics, Henry Shue (2008) populations and natural environments (Dupras et al., suggests that the wealthy ought to help rectify even 2014; ten Have, 2012). We use this bioethics to frame unintentional damage from emissions because they our ﬁndings in the hope of catalyzing interdisciplinary proﬁt the most from emissions, and that the poor are partnerships aimed at illuminating connections between less accountable for emissions because their circum- health and nature, and encouraging stewardship of nat- stances require them to prioritize the pursuit of food, ural environments for their extrinsic value to health and water and goods essential to their survival over the pro- well-being, and for their intrinsic value. tection of public goods. Distinguishing between subsist- ence and luxury emissions, Shue (2008) raises questions about what speciﬁc activities constitute subsistence Bioethics has a Responsibility needs, and contribute to subsistence emissions. Values and ethics must be part of policy dialog be- to Help cause they underlie determinations about the extent to Advancing Justice which nations should prioritize emissions reduction With exceptions like T&T, LIMC produce fewer emis- over other goods, and about what entities should con- sions than wealthy nations but suffer greater harms, tribute to reductions, James Garvey (2008) explains. He have less capacity than others to recover and receive describes wealthy nations’ production of emissions as Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 CARIBBEAN HEAT THREATENS HEALTH 205 akin to stealing because ‘We have not just consumed a economists; agricultural, atmospheric, biological, envir- little more than the poor. We’ve taken a possible future onmental, geographic, marine and veterinary scientists; from them and replaced it with something much wor- industrial, political and policy leaders; behavioral and se .. . at the very least, we should begin to redress the social scientists; and others. balance by reducing our [own] emissions’ (Garvey, One vehicle for such work is the One Health move- 2008: 73). We should do this now while the costs are ment that reﬂects the convergence of human, animal still relatively low, says Nicholas Stern (2008), who rec- and environmental health, and the need for integrated ommends that nations agree to proportional targets and approaches to improve management of associated chal- sanctions, and assess and report their successes in meet- lenges (Gomez et al., 2013). For example, the ﬁrst trans- ing those targets. mission of West Nile virus in the Western Hemisphere Peter Singer (2011) points out that negotiations occurred in 1999 when mosquitoes bit, infected and about emissions reduction targets and policies must be killed birds, horses and humans in New York: warm built upon a global ethic, but that identifying this ethic is temperatures helped spread the virus which ultimately difﬁcult because ‘causing imperceptible harm at a dis- caused over 1000 deaths across the USA including, in tance by the release of waste gases is a completely new 1999, 7 deaths, 10 cases of paralysis and 59 cases of form of harm, and so we lack any kind of instinctive meningoencephalitis among previously healthy people inhibitions or emotional response against causing it. We (Shomaker et al., 2013). Documentation, understand- have trouble seeing it as harm at all (237) ... given the ing and management of this outbreak required interdis- gravity of the risks ... the level of protest against in- ciplinary communication and partnerships. Bioethics action has, to date, been quite small’ (217). might have complemented and extended their successes. Potter’s global bioethics calls for interdisciplinary sci- Specialist expertise in science, medicine, governance, entiﬁc and moral analyses to promote the present and policy, etc. permits progress in these realms but can future well-being of humanity (ten Have, 2012). Despite hinder interdisciplinary work by impeding communica- its focus on patient care, bioethics has the ability to tions, conceptual understandings and opportunities, highlight the beneﬁts of emissions on one side and across specialties. This hindrance can be overcome by their harms to health and social justice on the other. those interested in advancing human well-being. The Across disciplines and sectors, bioethics can help us Cambridge Program for Sustainability Leadership at see emissions as the serious harms that they are. We Cambridge University, for example, engages business challenge readers to, at the very least, initiate dialog and health leaders in dialog about cost-effective means within their own institutions about the damages of of improving sustainability. The Global Alliance emissions, the intrinsic value of nature and its extrinsic for Assimilation of Information at Johns Hopkins value to health and well-being. University facilitates related dialog among scientiﬁc, health and security sectors. The Rock Ethics Institute at Penn State University, Centre for Sustainable Nurturing Interdisciplinary Partnerships Healthcare at Britain’s National Health Service and The ﬁrst bioethicists were physicians, philosophers, law- journals like ‘Nature Climate Change’ similarly show yers and nurses whose interdisciplinary collaborations that interdisciplinary communication and partnership addressed doctor–patient relationships, research ethics is feasible without discipline-speciﬁc jargon, dogma, and end of life care (Callahan, 2012). Relatively few were methodologies and journals. Interdisciplinary work on then concerned with the reliance of health on nature and emissions can help prevent further harms, and bioethics, environmental resources, or the well-being of present with its interdisciplinary history, ought to sign on. and future populations. The global bioethics framework offers a way to document health impacts and other Making Transitions harms of emissions; assess their relative burdens in dif- ferent places; advance and apply justice theories to poli- Rene Fox and Judith Swazey (2010: 280) describe how cies and practices; and catalyze constructive dialog cultural inﬂuences in wealthy Western nations point about the value of reducing emissions, perhaps partly bioethics toward autonomy and divert its attention by ﬁnding ways to meaningfully integrate them into from health, well-being and social justice. They call for medical and other curricula. Doing all this requires ‘a collective will to undertake the intellectual work that efforts to document, understand and respond meaning- we believe is needed to make the overarching conceptual fully to emissions; and partnerships with health-care framework and the ethos of the ﬁeld more knowledge- providers; mathematicians, computer modelers and ably responsive to social and cultural context and Downloaded from https://academic.oup.com/phe/article/8/2/196/2362751 by DeepDyve user on 15 July 2022 206 MACPHERSON AND AKPINAR-ELCI diversity’. In addition to beneﬁting health and well- from which bioethics can initiate and inform public and being for present and future populations, such work policy dialog about priorities, strategies and associated would enhance bioethics by broadening its appeal, bal- values. Here, we highlight the generalizability of the ancing its emphasis on individuals with attention to data; unfair distribution of emissions-related beneﬁts populations, and shifting away from its dogmatic and burdens; need for interdisciplinary and comparative focus on individual autonomy. information with which to assess relative health burdens This is a useful shift, says Angus Dawson (2010: 223), in different places, and respond sensitively to these dif- because ‘dependency is not a weakness but a fact of ferences; and need for interdisciplinary partnerships human life. Much of what we value in our lives arises that embrace a global bioethics perspective. from what we share together as social creatures. This fact We urge readers to reﬂect on connections between is morally relevant and ought to be the foundation for health, nature and values that might enhance care of the way we see bioethics. .. . How could we say anything our natural environment, and initiate dialog within interesting about animals if we are obsessed with auton- their institutions about emissions, altruism and social omy? How do we explain the obligations that many of us justice. Bringing these concerns into its research and feel towards those in need in far-off geographical teaching will advance bioethics and facilitate interdis- regions .. . Can we really do what we like to an environ- ciplinary partnerships needed to understand and reduce ment until our actions are banned?’ Grappling global emissions. Imagine the beneﬁts if even 5 per cent with these questions would enhance bioethics global of bioethicists shifted their work from clinical di- relevance. lemmas in wealthy settings to environmental conditions Jamieson (2008) posits that no one in 1900 would that threaten individual and collective health and well- have imagined that development of the car would lead being everywhere. to interstate highways, air and noise pollution or lengthy commutes. He thus suggests that conventional morality is unable to assign accountability for such damages, and Acknowledgements that doing so requires new conceptions of responsibility The authors thank Angus Dawson and Paul Garner for involving virtues like altruism (Jamieson, 2008). 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Public Health Ethics – Oxford University Press
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