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A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Environmental Health".

Deadline for manuscript submissions: closed (31 July 2018) | Viewed by 113551

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Special Issue Editors

Dr. Peter Berry

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Guest Editor

1. Climate Change and Innovation Bureau, Health Canada, 269 Laurier Ave West, Ottawa, ON K1P 5J9, Canada
2. Interdisciplinary Centre on Climate Change, University of Waterloo, Waterloo, ON N2L 3G1, Canada
Interests: climate change impacts on health; vulnerability and adaptation assessments; adaptive capacity; adaptation to health risks; climate resilient health systems; climate change communications

Ms. Marielle Verret

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Climate Change and Innovation Bureau, Health Canada, 269 Laurier Ave West, Ottawa, ON K1P 5J9, Canada
Interests: climate change impacts on health; vulnerability and adaptation assessments; gendered impacts of climate change; small island developing states; climate change impacts in the Caribbean; climate change impacts to the marine environment; climate resilient health systems

Special Issue Information

Dear Colleagues,

Climate change poses significant threats to the health of people around the world. The Intergovernmental Panel on Climate Change (IPCC) and the World Health Organization recognize that health risks are increasing and that health authorities should prepare by developing effective adaptation measures. Direct health impacts associated with climate change result from warming temperatures and more severe and frequent extreme weather events (e.g., heatwaves, droughts, floods, storms) while indirect effects can include the spread of infectious diseases and long-lasting mental health impacts.

Drivers of vulnerability to climate change impacts on health are complex and often vary within and among communities, regions and countries. Climate change and health vulnerability and adaptation assessments provide health sector decision makers with information on associations between weather/climate and health outcomes and the populations most vulnerable to these risks. They also indicate the possible magnitude and pattern of future climate-related health risks and identify options for adapting to protect populations. Health authorities at local to national levels are beginning to undertake assessments. New knowledge from assessments which expand understanding of climate change impacts on health and address methodological and data challenges, stakeholder engagement strategies, and communication of findings to influence policy development will benefit health sector officials in the future.

This Special Issue of IJERPH invites papers based on assessments of climate change and health vulnerability and adaptation at local, regional and national levels. Research papers, analytical reviews, case studies, and policy-relevant articles are welcome from developing and developed country contexts.

IJERPH is fully open access. Open access (unlimited and free access by readers) increases publicity and promotes more frequent citations, as indicated by several studies. Open access is supported by the authors and their institutes and an Article Processing Charge (APC) of 1600 CHF applies to papers accepted for publication. You may be entitled to a discount if you have previously received a discount code or if your institute is participating in the MDPI Institutional Open Access Program (IOAP), for more information see: https://www.mdpi.com/about/ioap.

The submission deadline is 31 July 2018. Manuscripts are peer-reviewed and a first decision provided to authors approximately 27 days after submission.

There is no difference in the processing or indexing between regular and Special Issue submissions, except that Special Issue papers will be gathered together on the Special Issue website. After the Special Issue is closed we will share it with related scholars to promote your contributions.

Should you have any questions, please feel free to contact the corresponding editor of the Special Issue: Ms. Penny Gu ([email protected]).

Dr. Peter Berry
Ms. Marielle Verret
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

Climate change and health
Assessment
Adaptation
Infectious diseases
Heatwaves
Adaptive capacity
Vulnerable populations
Extreme weather
Mental health
Health systems
Climate resiliency
Climate models
Climate scenarios
Health co-benefits and harms
Climate change communications
Gender differentiated impacts

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Published Papers (12 papers)

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Research

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17 pages, 314 KiB

Open AccessArticle

An Assessment of Climate Change and Health Vulnerability and Adaptation in Dominica

by Rebekka Schnitter, Marielle Verret, Peter Berry, Tanya Chung Tiam Fook, Simon Hales, Aparna Lal and Sally Edwards

Int. J. Environ. Res. Public Health 2019, 16(1), 70; https://doi.org/10.3390/ijerph16010070 - 28 Dec 2018

Cited by 29 | Viewed by 7063

Abstract

A climate change and health vulnerability and adaptation assessment was conducted in Dominica, a Caribbean small island developing state located in the Lesser Antilles. The assessment revealed that the country’s population is already experiencing many impacts on health and health systems from climate variability and change. Infectious diseases as well as food and waterborne diseases pose continued threats as climate change may exacerbate the related health risks. Threats to food security were also identified, with particular concern for food production systems. The findings of the assessment included near-term and long-term adaptation options that can inform actions of health sector decision-makers in addressing health vulnerabilities and building resilience to climate change. Key challenges include the need for enhanced financial and human resources to build awareness of key health risks and increase adaptive capacity. Other small island developing states interested in pursuing a vulnerability and adaptation assessment may find this assessment approach, key findings, analysis, and lessons learned useful. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

14 pages, 2899 KiB

Open AccessArticle

Assessment of Risk, Vulnerability and Adaptation to Climate Change by the Health Sector in Madagascar

by Norohasina Rakotoarison, Nirivololona Raholijao, Lalao Madeleine Razafindramavo, Zo Andrianina Patrick Herintiana Rakotomavo, Alain Rakotoarisoa, Joy Shumake Guillemot, Zazaravaka Jacques Randriamialisoa, Victor Mafilaza, Voahanginirina Anne Marie Pierrette Ramiandrisoa, Rhino Rajaonarivony, Solonomenjanahary Andrianjafinirina, Venance Tata, Manuela Christophère Vololoniaina, Fanjasoa Rakotomanana and Volahanta Malala Raminosoa

Int. J. Environ. Res. Public Health 2018, 15(12), 2643; https://doi.org/10.3390/ijerph15122643 - 26 Nov 2018

Cited by 16 | Viewed by 13376

Abstract

Madagascar is cited as one of the most vulnerable countries to the effects of climate change, with significant impacts to the health of its population. In this study, the vulnerability of Madagascar’s health sector to climate change was assessed and appropriate adaptation measures were identified. In order to assess climate risks, vulnerability and identify adaptation options, the Madagascar Ministry of Public Health as well as the National Meteorological and Hydrological Service worked in close collaboration with a team of local experts to conduct a literature review, field surveys, and analyses of current and future climate and health trends. Four climate-sensitive diseases of primary concern are described in the study: acute respiratory infections (ARI), diarrhea, malnutrition, and malaria. Baseline conditions of these four diseases from 2000 to 2014 show acute respiratory infections and diarrheal diseases are increasing in incidence; while incidence of malnutrition and malaria decreased over this period. To assess future impacts in Madagascar, this baseline information was used with climate projections for the two scenarios—RCP 4.5 and RCP 8.5—for the periods 2016–2035, 2036–2070 and 2071–2100. Future climate conditions are shown to exacerbate and increase the incidence of all four climate sensitive diseases. Further analysis of the exposure, sensitivity and adaptive capacity to the climate hazards suggests that the health sector in four regions of Madagascar is particularly vulnerable. The study recommends adaptation measures to improve the monitoring and early warning systems for climate sensitive diseases, as well as to reduce population vulnerability. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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26 pages, 10398 KiB

Open AccessArticle

Performance of Excess Heat Factor Severity as a Global Heatwave Health Impact Index

by John Nairn, Bertram Ostendorf and Peng Bi

Int. J. Environ. Res. Public Health 2018, 15(11), 2494; https://doi.org/10.3390/ijerph15112494 - 8 Nov 2018

Cited by 47 | Viewed by 7411

Abstract

The establishment of an effective policy response to rising heatwave impacts is most effective when the history of heatwaves, their current impacts and future risks, are mapped by a common metric. In response meteorological agencies aim to develop seamless climate, forecast, and warning heat impact services, spanning all temporal and spatial scales. The ability to diagnose heatwave severity using the Excess Heat Factor (EHF) has allowed the Australian Bureau of Meteorology (the Bureau) to publicly release 7-day heatwave severity maps since 2014. National meteorological agencies in the UK and the United States are evaluating global 7-day and multi-week EHF heatwave severity probability forecasts, whilst the Bureau contributes to a Copernicus project to supply the health sector with global EHF severity heatwave projection scenarios. In an evaluation of impact skill within global forecast systems, EHF intensity and severity is reviewed as a predictor of human health impact, and extended using climate observations and human health data for sites around the globe. Heatwave intensity, determined by short and long-term temperature anomalies at each locality, is normalized to permit spatial analysis and inter-site comparison. Dimensionless heatwave event moments of peak severity and accumulated severity are shown to correlate with noteworthy events around the globe, offering new insights into current and future heatwave variability and vulnerability. The EHF severity metric permits the comparison of international heatwave events and their impacts, and is readily implemented within international heatwave early warning systems. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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16 pages, 337 KiB

Open AccessArticle

Stress Testing the Capacity of Health Systems to Manage Climate Change-Related Shocks and Stresses

by Kristie L. Ebi, Peter Berry, Katie Hayes, Christopher Boyer, Samuel Sellers, Paddy M. Enright and Jeremy J. Hess

Int. J. Environ. Res. Public Health 2018, 15(11), 2370; https://doi.org/10.3390/ijerph15112370 - 26 Oct 2018

Cited by 30 | Viewed by 8338

Abstract

Vulnerability and adaptation assessments can provide valuable input to foster climate-resilient health systems. However, these assessments often do not explore the potential health risks of climate change far outside the range of recent experience with extreme weather events and other climate-related hazards. Climate and health stress tests are designed to increase the capacity of health systems and related sectors to manage potentially disruptive climate-related shocks and stresses. Stress tests focus on hypothetical scenarios, during which it would be difficult for the health system to maintain its essential function of providing services to protect population health. The stress test explores approaches to effectively manage acute and chronic climate-related events and conditions that could directly impact health systems, and climate-related events in non-health sectors that can indirectly impact health outcomes and/or health system function. We provide detailed methods and guidance for conducting climate and health stress tests, centering on three primary activities: (1) preparing and scoping the stress test; (2) successfully conducting the stress test; and (3) communicating the results to key stakeholders to facilitate policy and programmatic reforms. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

15 pages, 17947 KiB

Open AccessArticle

The Impact of Climate Change on the Food System in Toronto

by Kimberly Zeuli, Austin Nijhuis, Ronald Macfarlane and Taryn Ridsdale

Int. J. Environ. Res. Public Health 2018, 15(11), 2344; https://doi.org/10.3390/ijerph15112344 - 24 Oct 2018

Cited by 10 | Viewed by 5877

Abstract

As part of its Climate Change and Health Strategy, in 2017, Toronto Public Health engaged stakeholders from across the food system to complete a high-level vulnerability assessment of the impact of climate change on the food system in Toronto. Using the Ontario Climate Change and Health Vulnerability and Adaptation Assessment Guidelines, the City of Toronto’s High-Level Risk Assessment Tool, and a strategic framework developed by the Initiative for a Competitive Inner City, Toronto Public Health identified the most significant extreme weather event risks to food processing, distribution and access in Toronto. Risks associated with three extreme weather events that are the most likely to occur in Toronto due to climate change were analyzed: significant rain and flooding, an extended heat wave, and a major winter ice storm. The analysis finds that while extreme weather events could potentially disrupt Toronto’s food supply, the current risk of an extended, widespread food supply disruption is relatively low. However, the findings highlight that a concerted effort across the food system, including electrical and fuel providers, is needed to address other key vulnerabilities that could impact food access, especially for vulnerable populations. Interruptions to electricity will have food access and food safety impacts, while interruptions to the transportation network and fuel will have food distribution and access impacts. Actions to mitigate these risks could include addressing food access vulnerabilities through ongoing city-wide strategies and integrating food access into the City’s emergency response planning. The next steps will include engaging with multiple partners across the city to understand and strengthen the “last mile” of food distribution and develop community food resilience action plans for vulnerable neighbourhoods. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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19 pages, 1172 KiB

Open AccessArticle

Development of a Climate Change Vulnerability Assessment Using a Public Health Lens to Determine Local Health Vulnerabilities: An Ontario Health Unit Experience

by Morgan M. Levison, Ainslie J. Butler, Steven Rebellato, Brenda Armstrong, Marina Whelan and Charles Gardner

Int. J. Environ. Res. Public Health 2018, 15(10), 2237; https://doi.org/10.3390/ijerph15102237 - 12 Oct 2018

Cited by 11 | Viewed by 6905

Abstract

Climate change is negatively impacting the health of Canadians and is accordingly expected to have a significant impact on public health agencies and their response to these health impacts throughout the twenty-first century. While national and international research and assessments have explored the potential human health impacts of climate change, few assessments have explored the implications of climate change from a local public health perspective. An applied research approach to expand local knowledge and action of health vulnerabilities through a climate change action plan and vulnerability assessment was utilized by a local public health agency. Adoption and adaptation of the approach used may be valuable for public health organizations to assist their communities. Through completing a vulnerability assessment, an evidentiary base was generated for public health to inform adaptation actions to reduce negative health impacts and increase resiliency. Challenges in completing vulnerability assessments at the local level include the framing and scoping of health impacts and associated indicators, as well as access to internal expertise surrounding the analysis of data. While access to quantitative data may be limiting at the local level, qualitative data can enhance knowledge of local impacts, while also supporting the creation of key partnerships with community stakeholders which can ensure climate action continues beyond the scope of the vulnerability assessment. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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11 pages, 1501 KiB

Open AccessArticle

Distribution of Ixodes scapularis in Northwestern Ontario: Results from Active and Passive Surveillance Activities in the Northwestern Health Unit Catchment Area

by Erin Schillberg, Dorian Lunny, L. Robbin Lindsay, Mark P. Nelder, Curtis Russell, Mike Mackie, Dave Coats, Alex Berry and Kit Ngan Young Hoon

Int. J. Environ. Res. Public Health 2018, 15(10), 2225; https://doi.org/10.3390/ijerph15102225 - 11 Oct 2018

Cited by 13 | Viewed by 3977

Abstract

The range of Ixodes scapularis is expanding in Ontario, increasing the risk of Lyme disease. As an effective public health response requires accurate information on disease distribution and areas of risk, this study aims to establish the geographic distribution of I. scapularis and its associated pathogen, B. burgdorferi, in northwestern Ontario. We assessed five years of active and passive tick surveillance data in northwestern Ontario. Between 2013 and 2017, 251 I. scapularis were submitted through passive surveillance. The submission rate increased over time, and the proportion infected with B. burgdorferi was 13.5%. Active tick surveillance from 2014 to 2016 found few I. scapularis specimens. In 2017, 102 I. scapularis were found in 10 locations around the city of Kenora; 60% were infected with B. burgdorferi, eight tested positive for A. phagocytophilum, and one for POWV. I. scapularis ticks were found in 14 locations within the Northwestern Health Unit area, with seven locations containing B. burgdorferi-positive ticks. We found abundant I. scapularis populations in the southern portion of northwestern Ontario and northward expansion is expected. It is recommended that I. scapularis populations continue to be monitored and mitigation strategies should be established for rural northern communities. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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14 pages, 2050 KiB

Open AccessArticle

Establishing Heat Alert Thresholds for the Varied Climatic Regions of British Columbia, Canada

by Kathleen E. McLean, Rebecca Stranberg, Melissa MacDonald, Gregory R. A. Richardson, Tom Kosatsky and Sarah B. Henderson

Int. J. Environ. Res. Public Health 2018, 15(9), 2048; https://doi.org/10.3390/ijerph15092048 - 19 Sep 2018

Cited by 10 | Viewed by 6625

Abstract

Following an extreme heat event in 2009, a Heat Alert and Response System (HARS) was implemented for the greater Vancouver area of British Columbia (BC), Canada. This system has provided a framework for guiding public health interventions and assessing population response and adaptation to extreme heat in greater Vancouver, but no other parts of BC were covered by HARS. The objective of this study was to identify evidence-based heat alert thresholds for the Southwest, Southeast, Northwest, and Northeast regions to facilitate the introduction of HARS across BC. This was done based on a national approach that considers high temperatures on two consecutive days and the intervening overnight low, referred to as the high-low-high approach. Daily forecast and observed air temperatures and daily mortality counts for May through September of 2004 through 2016 were obtained. For each date (day_t), day_t−2 forecasts were used to assign high temperatures for day_t and day_t+1 and the overnight low. A range of high-low-high threshold combinations was assessed for each region by finding associations with daily mortality using time-series models and other considerations. The following thresholds were established: 29-16-29 °C in the Southwest; 35-18-35 °C in the Southeast; 28-13-28 °C in the Northwest; and 29-14-29 °C in the Northeast. Heat alert thresholds for all regions in BC provide health authorities with information on dangerously hot temperature conditions and inform the activation of protective public health interventions. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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11 pages, 284 KiB

Open AccessArticle

Monitoring and Evaluation Indicators for Climate Change-Related Health Impacts, Risks, Adaptation, and Resilience

by Kristie L. Ebi, Christopher Boyer, Kathryn J. Bowen, Howard Frumkin and Jeremy Hess

Int. J. Environ. Res. Public Health 2018, 15(9), 1943; https://doi.org/10.3390/ijerph15091943 - 6 Sep 2018

Cited by 63 | Viewed by 11496

Abstract

Climate change poses a range of current and future health risks that health professionals need to understand, track, and manage. However, conventional monitoring and evaluation (M&E) as practiced in the health sector, including the use of indicators, does not adequately serve this purpose. Improved indicators are needed in three broad categories: (1) vulnerability and exposure to climate-related hazards; (2) current impacts and projected risks; and (3) adaptation processes and health system resilience. These indicators are needed at the population level and at the health systems level (including clinical care and public health). Selected indicators must be sensitive, valid, and useful. And they must account for uncertainties about the magnitude and pattern of climate change; the broad range of upstream drivers of climate-sensitive health outcomes; and the complexities of adaptation itself, including institutional learning and knowledge management to inform iterative risk management. Barriers and constraints to implementing such indicators must be addressed, and lessons learned need to be added to the evidence base. This paper describes an approach to climate and health indicators, including characteristics of the indicators, implementation, and research needs. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

10 pages, 2252 KiB

Open AccessArticle

Association between Precipitation and Diarrheal Disease in Mozambique

by Lindsay M. Horn, Anjum Hajat, Lianne Sheppard, Colin Quinn, James Colborn, Maria Fernanda Zermoglio, Eduardo S. Gudo, Tatiana Marrufo and Kristie L. Ebi

Int. J. Environ. Res. Public Health 2018, 15(4), 709; https://doi.org/10.3390/ijerph15040709 - 10 Apr 2018

Cited by 26 | Viewed by 5900

Abstract

Diarrheal diseases are a leading cause of morbidity and mortality in Africa. Although research documents the magnitude and pattern of diarrheal diseases are associated with weather in particular locations, there is limited quantification of this association in sub-Saharan Africa and no studies conducted in Mozambique. Our study aimed to determine whether variation in diarrheal disease was associated with precipitation in Mozambique. In secondary analyses we investigated the associations between temperature and diarrheal disease. We obtained weekly time series data for weather and diarrheal disease aggregated at the administrative district level for 1997–2014. Weather data include modeled estimates of precipitation and temperature. Diarrheal disease counts are confirmed clinical episodes reported to the Mozambique Ministry of Health (n = 7,315,738). We estimated the association between disease counts and precipitation, defined as the number of wet days (precipitation > 1 mm) per week, for the entire country and for Mozambique’s four regions. We conducted time series regression analyses using an unconstrained distributed lag Poisson model adjusted for time, maximum temperature, and district. Temperature was similarly estimated with adjusted covariates. Using a four-week lag, chosen a priori, precipitation was associated with diarrheal disease. One additional wet day per week was associated with a 1.86% (95% CI: 1.05–2.67%), 1.37% (95% CI: 0.70–2.04%), 2.09% (95% CI: 1.01–3.18%), and 0.63% (95% CI: 0.11–1.14%) increase in diarrheal disease in Mozambique’s northern, central, southern, and coastal regions, respectively. Our study indicates a strong association between diarrheal disease and precipitation. Diarrheal disease prevention efforts should target areas forecast to experience increased rainfall. The burden of diarrheal disease may increase with increased precipitation associated with climate change, unless additional health system interventions are undertaken. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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Review

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25 pages, 719 KiB

Open AccessReview

Assessing Health Vulnerabilities and Adaptation to Climate Change: A Review of International Progress

by Peter Berry, Paddy M. Enright, Joy Shumake-Guillemot, Elena Villalobos Prats and Diarmid Campbell-Lendrum

Int. J. Environ. Res. Public Health 2018, 15(12), 2626; https://doi.org/10.3390/ijerph15122626 - 23 Nov 2018

Cited by 48 | Viewed by 13033

Abstract

Climate change is increasing risks to human health and to the health systems that seek to protect the safety and well-being of populations. Health authorities require information about current associations between health outcomes and weather or climate, vulnerable populations, projections of future risks and adaptation opportunities in order to reduce exposures, empower individuals to take needed protective actions and build climate-resilient health systems. An increasing number of health authorities from local to national levels seek this information by conducting climate change and health vulnerability and adaptation assessments. While assessments can provide valuable information to plan for climate change impacts, the results of many studies are not helping to build the global evidence-base of knowledge in this area. They are also often not integrated into adaptation decision making, sometimes because the health sector is not involved in climate change policy making processes at the national level. Significant barriers related to data accessibility, a limited number of climate and health models, uncertainty in climate projections, and a lack of funding and expertise, particularly in developing countries, challenge health authority efforts to conduct rigorous assessments and apply the findings. This paper examines the evolution of climate change and health vulnerability and adaptation assessments, including guidance developed for such projects, the number of assessments that have been conducted globally and implementation of the findings to support health adaptation action. Greater capacity building that facilitates assessments from local to national scales will support collaborative efforts to protect health from current climate hazards and future climate change. Health sector officials will benefit from additional resources and partnership opportunities to ensure that evidence about climate change impacts on health is effectively translated into needed actions to build health resilience. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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19 pages, 378 KiB

Open AccessReview

Addressing Mental Health in a Changing Climate: Incorporating Mental Health Indicators into Climate Change and Health Vulnerability and Adaptation Assessments

by Katie Hayes and Blake Poland

Int. J. Environ. Res. Public Health 2018, 15(9), 1806; https://doi.org/10.3390/ijerph15091806 - 22 Aug 2018

Cited by 94 | Viewed by 21616

Abstract

A growing number of health authorities around the world are conducting climate change and health vulnerability and adaptation assessments; however, few explore impacts and adaptations related to mental health. We argue for an expanded conceptualization of health that includes both the physiological and psychological aspects of climate change and health. Through a review of the global literature on mental health and climate change, this analytical review explores how mental health can be integrated into climate change and health vulnerability assessments and concludes with recommendations for integrating mental health within climate change and health vulnerability and adaptation assessments. Full article

(This article belongs to the Special Issue Climate Change and Health Vulnerability and Adaptation Assessments)

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