Climate Change and Local Public Health in the United
States: Preparedness, Programs and Perceptions of Local
Public Health Department Directors
Edward W. Maibach1*, Amy Chadwick2, Dennis McBride3, Michelle Chuk4, Kristie L. Ebi5, John Balbus6
1 Center for Climate Change Communication, George Mason University, Fairfax, Virginia, United States of America, 2 The Pennsylvania State University, State College,
Pennsylvania, United States of America, 3 Milford Department of Health, Milford, Connecticut, United States of America, 4 National Association of County & City Health
Officials, Washington D. C., United States of America, 5 ESS, LLC, Alexandria, Virginia, United States of America, 6 Environmental Defense, Washington D. C., United States
of America
Abstract
While climate change is inherently a global problem, its public health impacts will be experienced most acutely at the local
and regional level, with some jurisdictions likely to be more burdened than others. The public health infrastructure in the
U.S. is organized largely as an interlocking set of public agencies at the federal, state and local level, with lead responsibility
for each city or county often residing at the local level. To understand how directors of local public health departments view
and are responding to climate change as a public health issue, we conducted a telephone survey with 133 randomly
selected local health department directors, representing a 61% response rate. A majority of respondents perceived climate
change to be a problem in their jurisdiction, a problem they viewed as likely to become more common or severe over the
next 20 years. Only a small minority of respondents, however, had yet made climate change adaptation or prevention a top
priority for their health department. This discrepancy between problem recognition and programmatic responses may be
due, in part, to several factors: most respondents felt personnel in their health department–and other key stakeholders in
their community–had a lack of knowledge about climate change; relatively few respondents felt their own health
department, their state health department, or the Centers for Disease Control and Prevention had the necessary expertise to
help them create an effective mitigation or adaptation plan for their jurisdiction; and most respondents felt that their health
department needed additional funding, staff and staff training to respond effectively to climate change. These data make
clear that climate change adaptation and prevention are not currently major activities at most health departments, and that
most, if not all, local health departments will require assistance in making this transition. We conclude by making the case
that, through their words and actions, local health departments and their staff can and should play a role in alerting
members of their community about the prospect of public health impacts from climate change in their jurisdiction.
Citation: Maibach EW, Chadwick A, McBride D, Chuk M, Ebi KL, et al. (2008) Climate Change and Local Public Health in the United States: Preparedness, Programs
and Perceptions of Local Public Health Department Directors. PLoS ONE 3(7): e2838. doi:10.1371/journal.pone.0002838
Editor: Matthew Baylis, University of Liverpool, United Kingdom
Received March 12, 2008; Accepted June 2, 2008; Published July 30, 2008
Copyright: ß 2008 Maibach et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was entirely self-funded by the authors and their institutions.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: emaibach@gmu.edu
Introduction
now, the world will face global public health and environmental
catastrophe.’’ [3]
‘‘Climate change is one of the most serious public health threats facing
our nation. Yet few Americans are aware of the very real consequences of
climate change on the health of our communities, our families and our
children.’’[1]
Georges Benjamin, MD, Executive Director
American Public Health Association
Alan Maryon-Davis, President
Faculty of Public Health
(and 20 other CEO-level co-signers of British health &
sustainability organizations)
‘‘We need to… convince the world that humanity really is the most
important species endangered by climate change.’’ [4]
Margaret Chan, MD, Director-General
World Health Organization
‘‘We now face a new and unprecedented change: climate change. (It is)
perhaps the greatest environmental health challenge for the remainder of
our careers, and perhaps for all those (public health professionals) who
will follow us.’’ [2]
Howard Frumkin, MD, Dr.PH, Director,
National Center for Environmental Health, CDC
The current and potential future toll of climate change on
human health is becoming increasingly clear [5–7]. Earth system
changes associated with climate change–rising temperatures,
increasing climate variability, increasing rainfall in some areas
and drought in others, more frequent severe weather events, rising
sea levels–have both direct potential to harm human health through
‘‘We the undersigned believe that climate change is the public health
challenge of the 21st Century and that, unless decisive action is taken
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increased heat stress, traumatic injuries and mental health
consequences of climate-related disasters, and indirect potential
through changes in air pollution and aeroallergens, infectious
diseases, and ultimately the likelihood of large-scale population
dislocation, and civil conflict [6,8–12]. Climate change-induced
alterations of ecosystems–i.e., patterns of pests, parasites and
pathogens affecting wildlife, livestock, agriculture, forests and
coastal marine organisms–can also have negative implications for
human health [13].
Over the past year, a growing number public health leaders in
the United States and internationally have issued strong statements
defining climate change as a critical threat to the public’s health
(see examples above). Efforts are currently underway to ensure
that public health professionals–as well as public officials who
oversee public health infrastructure–are aware of and understand
the threat of climate change to human health. For example, World
Health Day 2008 (April 7th) was themed Protecting Health from
Climate Change, and National Public Health Week, 2008 in the U.S.
(April 7th–13th) was themed Climate Change: Our Health in the
Balance. The medical community is also becoming active on the
issue. Leading medical journals, for example Lancet [14–19] and
British Medical Journal [20], have recently released theme issues
focused on climate change and health.
While climate change is inherently a global problem, the public
health impacts of climate change will mostly be experienced at the
local level, and some regions will be more burdened than others.
The public health infrastructure in the U.S. is organized largely as
an interlocking set of public agencies at the federal, state and local
level, with lead responsibility for each city or county often residing
at the local level. Thus, there is a critical need to understand the
current knowledge and perceptions of local public health officials
regarding public health impacts of climate change and assess
current preparedness for these impacts in the U.S. For this reason,
we conducted a nationally representative survey of local health
department directors.
With this research, we sought to answer four primary questions:
Methods
The 2,296 members of the National Association of County & City
Health Officials (NACCHO) provided the sampling frame for this
survey. A quota sample–with 12 strata based on four regions of the
country (defined as U.S. Census regions) and 3 jurisdictional
population sizes (small defined as less than 50,000, medium defined
as 50,000 to 499,999, and large defined as 500,000 and higher)–was
randomly drawn from the universe of possible respondents. Using a
method previously designed and used by NACCHO, to determine
the size of each stratum we ‘‘split the difference’’ between assigning
an equal number of possible respondents to each stratum and
assigning a number proportional to their representation in the
universe of NACCHO members. A total of 250 NACCHO
members were initially drawn for the sample. Of those, 33 were
removed from the list because they: were duplicate names (i.e., when
one person was the Director or Health Officer for several small
jurisdictions; n = 11); represented public health nursing services
(n = 6), home care services (n = 2), or boards of health (n = 7); had
inaccurate contact information for which no correct information
could be found (n = 6); were an investigator on this project (n = 1).
Thus, the final sample size was 217.
We developed a telephone interview instrument to measure key
constructs associated with our research questions. To measure
perceptions of climate change and its potential public health effects
on the jurisdiction, we asked four 4-point Likert-type questions
(i.e., strongly disagree, disagree, agree, strongly agree, with an
option to respond ‘‘don’t know;’’ see Table 1 for wording of the
questions). Also, for each of 12 specific threats to health that are
potentially caused or exacerbated by climate change (see Table 2
for a listing of the specific items) we asked two questions: (1) ‘‘Has
climate change already affected [this health problem] in your
jurisdiction?’’; and (2) ‘‘Over the next 20 years will climate change
make [this problem] more common or severe, less common or
severe, or will it remain the same in your jurisdiction over the next
20 years?’’ Lastly, to assess the relative priority of addressing
climate change (as compared to other public health priorities), we
asked: ‘‘Would you say that preventing or preparing for the public
health consequences of climate change is among your health
department’s top 10 current priorities?’’ Respondents who
indicated that climate change was a top 10 priority were also
asked to specify which number–1 to 10, with 1 being the highest
priority–best characterized the current priority being accorded
climate change in their health department.
To operationalize preparedness, we measured: (1) perceptions of
how knowledgeable key stakeholders in the jurisdiction are about
climate change (using 6 Likert-type items; see Table 3); (2)
perceptions of expertise on climate change mitigation and
adaptation planning available to the health department (using 7
RQ 1: What are local health department director’s
perceptions of climate change and its potential
public health effects?
RQ 2: How prepared are local health departments to
address potential health impacts of climate
change?
RQ 3: What activities are local health departments
currently performing, or planning, that can help
prevent further climate change?
RQ 4: What resources do local health departments
need to better address climate change?
Table 1. Local health department director’s perceptions about general climate change impacts and its priority.
Statement
SD
D
A
SA
DK
My jurisdiction has experienced climate change in the past 20 years.
0.8 (1)
10.5 (14)
60.2 (80)
9.0 (12)
19.5 (26)
My jurisdiction will experience climate change in the next 20 years.
0.8 (1)
2.3 (3)
55.6 (74)
22.6 (30)
18.8 (25)
In the next 20 years, it is likely that my jurisdiction will experience one or
more serious public health problems as a result of climate change.
1.5 (2)
8.3 (11)
48.1 (64)
11.3 (15)
30.8 (41)
Preparing to deal with the public health effects of climate change is an
important priority for my health department.
3.8 (5)
40.6 (54)
39.1 (52)
12.0 (16)
4.5 (6)
The first entry in each cell is the percent of respondents; second is the actual number of respondents. SD = Strongly Disagree; D = Disagree; A = Agree; SA = Strongly
Agree; DK = Don’t Know.
doi:10.1371/journal.pone.0002838.t001
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Table 2. Local health department director’s perceptions about specific local impacts of climate change.
Health issue:
Has climate change already affected this
health issue in your jurisdiction?
Over the next 20 years, will climate change make this issue
more common or severe, less common or severe, or will it
remain the same in your jurisdiction?
Yes
More
No
DK
NA
Less
Same
DK
NA
Heat waves and heat-related illnesses
56.4 (75)
33.1 (44)
8.3 (11)
2.3 (3)
72.9 (97)
0.8 (1)
15.0 (20)
8.3 (11)
3.0 (4)
Storms (including hurricanes) and floods
47.4 (63)
41.4 (55)
11.3 (15)
0.0 (0)
57.9 (77)
1.5 (2)
24.1 (32)
16.5 (22)
0.0 (0)
Droughts, forest fires, or brush fires
46.6 (62)
40.6 (54)
9.0 (12)
3.8 (5)
59.4 (79)
0.8 (1)
19.5 (26)
18.0 (24)
2.3 (3)
Vector-borne infectious diseases
42.1 (56)
38.3 (51)
19.5 (26)
0.0 (0)
56.4 (75)
3.0 (4)
21.1 (28)
19.5 (26)
0.0 (0)
Water- and food-borne diseases
18.0 (24)
64.7 (86)
16.5 (22)
.08 (1)
36.1 (48)
1.5 (2)
34.6 (46)
27.1 (36)
0.8 (1)
Anxiety, depression or other mental
health conditions
21.1 (28)
45.9 (61)
27.8 (37)
5.3 (7)
40.6 (54)
0.8 (1)
19.5 (26)
36.1 (48)
3.0 (4)
Quality or quantity of fresh water
available to your jurisdiction
42.9 (57)
40.6 (54)
12.8 (17)
3.8 (5)
63.2 (84)
3.0 (4)
18.0 (24)
13.5 (18)
2.3 (3)
Quality of the air, including air pollution,
in your jurisdiction
41.4 (55)
37.6 (50)
16.5 (22)
4.5 (6)
65.4 (87)
2.3 (3)
13.5 (18)
15.8 (21)
3.0 (4)
Unsafe or ineffective sewage and septic
system operation
12.8 (17)
72.2 (96)
12.8 (17)
2.3 (3)
18.8 (25)
6.0 (8)
47.4 (63)
26.3 (35)
1.5 (2)
Food safety and security
14.3 (19)
74.4 (99)
8.3 (11)
3.0 (4)
30.8 (41)
3.0 (4)
48.9 (65)
15.8 (21)
1.5 (2)
Housing for residents displaced by
extreme weather events
18.6 (25)
69.9 (93)
7.5 (10)
3.8 (5)
42.1 (56)
0.0 (0)
37.6 (50)
18.0 (24)
2.3 (3)
Health care services for people with
chronic conditions during service
disruptions, such as extreme weather
events
25.6 (34)
59.4 (79)
11.3 (15)
3.8 (5)
53.4 (71)
1.5 (2)
30.1 (40)
12.0 (16)
3.0 (4)
The first entry in each cell is the percent of respondents; second is the actual number of respondents.
DK = Don’t Know; NA = No answer was given.
doi:10.1371/journal.pone.0002838.t002
To measure mitigation (i.e., primary prevention) activities, we
asked if the health department currently had, or was planning to
have, a program focused on each of 8 specific objectives (see
Table 6). And lastly, to measure perceived resource needs, we
asked the following open-ended question: ‘‘Are there resources
that your department does not currently have that, if made
available, would significantly improve its ability to deal with
climate change as a public health issue?’’ If respondents answered
Likert-type items; see Table 4); (3) whether the health department
was currently operating a program to address each of the 12
specific threats to health; (4) whether the health department was
currently or planning to incorporate climate change adaptation
into the planning for each program that they were operating (see
Table 5); and (5) whether the health department was currently
using long-range weather or climate information in planning or
implementing each of the programs that they were operating.
Table 3. Local health department director’s perceptions of climate change knowledge in their health department and among
other relevant leaders in the jurisdiction.
Statement
SD
D
A
SA
DK
NA
I am knowledgeable about the potential public health impacts of climate change
2.3 (3)
28.6 (38)
60.9 (81)
4.5 (6)
3.0 (4)
0.8 (1)
The other relevant senior managers in my health department are knowledgeable about
the potential public health impacts of climate change
5.3 (7)
36.1 (48)
41.4 (55)
3.8 (5)
12.0 (16)
1.5 (2)
Many of the other relevant appointed officials in my jurisdiction–such as environmental,
agricultural, forestry and wildlife, energy, and transportation officials–are knowledgeable
about the potential public health impacts of climate change
8.3 (11)
33.1 (44)
27.8 (37)
2.3 (3)
27.8 (37)
0.8 (1)
Many of the relevant elected officials in my jurisdiction are knowledgeable about the
potential public health impacts of climate change
16.5 (22)
43.6 (58)
21.8 (29)
0.8 (1)
17.3 (23)
0.0 (0)
Many of the business leaders in my jurisdiction are knowledgeable about the potential
public health impacts of climate change
12.0 (16)
45.1 (60)
9.0 (12)
0.8 (1)
33.1 (44)
0.0 (0)
Many of the leaders of the health care delivery system in my jurisdiction–including
hospitals and medical groups–are knowledgeable about the potential public health
impacts of climate change
2.3 (3)
40.6 (54)
28.6 (38)
2.3 (3)
25.6 (34)
0.8 (1)
The first entry in each cell is the percent of respondents; second is the actual number of respondents.
SD = Strongly Disagree; D = Disagree; A = Agree; SA = Strongly Agree; DK = Don’t Know; NA = No answer was given
doi:10.1371/journal.pone.0002838.t003
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Table 4. Local health department director’s perceptions of expertise available to them on the public health aspects of climate
change
Statement
SD
D
A
SA
DK
NA
My health department currently has ample expertise to assess the potential public health impacts
associated with climate change that could occur in my jurisdiction.
27.8 (37)
49.6 (66)
18.8 (25)
3.8 (5)
0.0 (0)
0.0 (0)
My health department currently has ample expertise to create an effective climate change
adaptation plan.
31.6 (42)
51.1 (68)
15.8 (21)
0.8 (1)
0.0 (0)
0.8 (1)
My state health department currently has ample expertise to help us create an effective climate
change adaptation plan in this jurisdiction.
18.8 (25)
34.6 (46)
22.6 (30)
3.0 (4)
21.1 (28) 0.0 (0)
The Centers for Disease Control and Prevention currently has ample expertise to help us create an
effective climate change adaptation plan in this jurisdiction.
1.5 (2)
16.5 (22)
31.6 (42)
2.3 (3)
48.1 (64) 0.0 (0)
The health care delivery system in my jurisdiction–including hospital and medical groups–has
ample expertise to help us create an effective climate change adaptation plan.
22.6 (30)
41.4 (55)
15.8 (21)
0.8 (1)
18.8 (25) 0.8 (1)
My health department currently has ample expertise to create an effective climate change
mitigation plan.
38.3 (51)
47.4 (63)
11.3 (15)
0.0 (0)
1.5 (2)
My state’s health department currently has ample expertise to help us create an effective climate
change mitigation plan in this jurisdiction.
21.8 (29)
37.6 (50)
15.8 (21)
0.0 (0)
24.8 (33) 0.0 (0)
The Centers for Disease Control and Prevention currently has ample expertise to help us create
an effective climate change mitigation plan in this jurisdiction.
6.0 (8)
18.0 (24)
21.8 (29)
3.0 (4)
51.1 (68) 0.0 (0)
1.5 (2)
The first entry in each cell is the percent of respondents; second is the actual number of respondents.
SD = Strongly Disagree; D = Disagree; A = Agree; SA = Strongly Agree; DK = Don’t Know; NA = No answer was given.
doi:10.1371/journal.pone.0002838.t004
Twelve trained interviewers (including authors AC and MC)
conducted the interviews. The interviewers represented all of the
investigators’ institutions. Using an interviewer manual developed
to support interviewer training, one investigator (AC) trained all
the interviewers. The training consisted of general information
about conducting interviews, a review of the study’s protocol,
question-by-question review of the survey, and practice sessions for
recruitment and survey scripts. The participants were trained in
two sessions that lasted four hours total with additional time for
‘‘yes,’’ follow-up questions were asked to determine the nature of
those resources.
One investigator (AC) pre-tested the instrument for length, clarity
and comprehension with a convenience sample of six local health
department directors who were recruited at the 2007 NACCHO
Annual Meeting. Pre-test interviews took approximately 45 minutes
to complete. After completing the interview, participants were asked
to comment on the survey and the administration format. Minor
revisions were made and the instrument was finalized.
Table 5. Climate change adaptation activities of local health departments
Is this a current activity in your
health department?
Do you currently or are you planning to
incorporate climate change adaptation into your
planning?
Health issue:
Yes
No
DK
Currently
Planning
No
DK
Heat waves and heat-related illnesses
57.1 (76)
42.1 (56)
0.8 (1)
21.8 (29)
17.3 (23)
58.6 (78)
2.3 (3)
Storms (including hurricanes) and floods
76.7 (102)
23.3 (31)
0.0 (0)
36.1 (48)
20.3 (27)
40.6 (54)
3.0 (4)
Droughts, forest fires, or brush fires
37.6 (50)
62.4 (83)
0.0 (0)
13.5 (18)
10.5 (14)
72.2 (96)
3.8 (5)
Vector-borne infectious diseases
94.7 (126)
4.5 (6)
0.8 (1)
39.8 (53)
13.5 (18)
43.6 (58)
3.0 (4)
Water- and food-borne diseases
97.0 (129)
2.3 (3)
0.8 (1)
35.3 (47)
14.3 (19)
45.9 (61)
3.8 (5)*
Anxiety, depression or other mental health conditions
30.8 (41)
68.4 (91)
0.8 (1)
7.5 (10)
7.5 (10)
80.5 (107)
4.5 (6)
Quality or quantity of fresh water available to your jurisdiction
66.9 (89)
33.1 (44)
0.0 (0)
16.5 (22)
19.5 (26)
57.9 (77)
6.0 (8)
Quality of the air, including air pollution, in your jurisdiction
50.4 (67)
48.9 (65)
0.8 (1)
20.3 (27)
12.0 (16)
64.7 (86)
3.0 (4)
Unsafe or ineffective sewage and septic system operation
78.9 (105)
20.3 (27)
0.8 (1)
30.1 (40)
7.5 (10)
57.9 (77)
4.5 (6)
Food safety and security
89.5 (119)
10.5 (14)
0.0 (0)
33.1 (44)
13.5 (18)
48.9 (65)
4.5 (6)
Housing for residents displaced by extreme weather events
37.6 (50)
60.2 (80)
1.5 (2)
18.8 (25)
12.8 (17)
64.7 (86)
3.8 (5)
Health care services for people with chronic conditions during
service disruptions, such as extreme weather events
57.1 (76)
41.4 (55)
1.5 (2)
26.3 (35)
15.0 (20)
54.9 (73)
3.8 (5)
56.4 (75)
14.3 (19)
25.6 (34)
3.8 (5)
Emergency preparedness for the above issues
The first entry in each cell is the percent of respondents; second is the actual number of respondents. DK = Don’t Know.
One respondent did not answer this question.
doi:10.1371/journal.pone.0002838.t005
*
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Table 6. Climate change mitigation activities of local health departments
Do you currently have or are you planning to have a
program focused on this activity?
A program:
Currently
Planning
No
DK
A program focused on mitigating climate change by reducing greenhouse gas emissions from the
health department?
12.0 (16)
14.3 (19)
68.4 (91)
5.3 (7)
A program to help residents of your jurisdiction reduce their greenhouse gas emissions?
5.3 (7)
7.5 (10)
83.5 (111)
3.8 (5)
A program to reduce fossil fuel use or conserve energy in the operation of the health department?
21.1 (28)
18.8 (25)
54.9 (73)
5.3 (7)
A program to help residents of your jurisdiction reduce their fossil fuel use or conserve energy?
6.0 (8)
8.3 (11)
80.5 (107)
5.3 (7)
A program to encourage or help people to use active transportation such as walking, cycling?
50.4 (67)
11.3 (15)
36.1 (48)
2.3 (3)
A program to encourage or help people to use mass transportation?
15.0 (20)
6.0 (8)
76.7 (102)
2.3 (3)
A program to encourage or help people to change the way they purchase foods such as buying
locally-grown foods, organic foods, or plant-based foods?
33.8 (45)
9.0 (12)
54.1 (72)
3.0 (4)
A program to educate the public about climate change and its potential impact on health?
8.3 (11)
18.0 (24)
69.9 (93)
3.8 (5)
The first entry in each cell is the percent of respondents; second is the actual number of respondents. DK = Don’t Know.
doi:10.1371/journal.pone.0002838.t006
practicing the scripts with a partner. An investigator (AC) reviewed
each interviewer’s initial interview before she or he conducted
additional interviews. The survey instrument and the interviewer
manual are available upon request.
On November 2, 2007, members of the sample were e-mailed a
letter from NACCHO’s Executive Director and Senior Advisor for
Environmental Health (MC) that described the purpose of the
survey and encouraged members to participate in the survey when
an interviewer called them. Approximately one week later,
interviewers began contacting participants via e-mail and
telephone to request an interview. Approximately five contact
attempts were made to schedule an interview before a participant
was considered a passive refusal. Most of the interviews (79%,
n = 105) were completed by December 22, 2007. In mid-January,
a smaller set of interviewers attempted to schedule interviews with
participants who were previously too busy to participate. The
fielding of the survey ended February 22, 2008.
A total of 133 members of the sample agreed to be interviewed
and completed the survey. Of the remaining members of the
sample, 18% (n = 38) actively refused to participate, and 21%
(n = 46) passively refused by virtue of not responding to interviewer
calls or emails. Thus, the response rate and survey completion rate
for this study was 61%.
All data were entered into Excel, with verification. For this
article, only the quantitative data were analyzed. These data were
imported into SPSS version14.0 for analysis.
A significant proportion of respondents believed that climate
change had already affected 12 distinct threats to health in their
jurisdiction (e.g., vector-borne infectious diseases; see Table 2).
Participants were least likely to believe that safety of the sewage or
septic systems (13%) and food safety and security (14%) had already
been affected by climate change in their jurisdiction, and were most
likely to believe that heat waves and heat-related illness (56%) and
storms and floods (47%) had already been affected by climate
change. Most respondents felt that, as a result of climate change, at
least some these threats would become more common or severe in
their jurisdiction over the next 20 years. Specifically, they believed
that heat waves and heat-related illness (73%), reduced air quality
(65%), reduced water quality or quantity (63%), and droughts, forest
fires and brush fires (59%) were most likely to become more common
or severe as a result of climate change.
Despite their recognition of climate change as a threat to health
in their jurisdiction, relatively few respondents reported that
climate change was a top priority for their health department.
While about half of our respondents ‘‘agreed’’ or ‘‘strongly
agreed’’ that preparing to deal with the public health effects of
climate change was a priority for their health department,
relatively few of them strongly agreed (see Table 1). Moreover,
in response to a follow-up question, only 19 percent of respondents
indicated that climate change was among their department’s top
10 current priorities, and only 6 percent indicated climate change
was one of their health department’s current top five priorities.
Results
Research Question 2: How prepared are local heath
department to address potential health impacts of
climate change?
Research Question 1: What are local health department
directors’ perceptions of climate change and its potential
public health effects?
Perceived Knowledge. Most respondents (approximately twothirds) felt that they themselves were knowledgeable about the
potential public health impacts of climate change, but fewer than half
felt that other relevant senior managers in their health department
were similarly knowledgeable (see Table 2). Moreover, less than one
third of respondents felt that other relevant stakeholders in their
community (i.e., appointed and elected officials, business leaders,
and health care delivery leaders) had knowledge of the potential
public health impacts of climate change (see Table 3). It is important
to note that very few respondents (less than 5%) ‘‘strongly agreed’’
that any key stakeholder group in their community, including
themselves, was knowledgeable about the issue.
The majority of local health department directors surveyed
perceived climate change to be a relevant threat in their
jurisdiction (see Table 1). Nearly 70 percent believed that their
jurisdiction had experienced climate change in the past 20 years,
and 78 percent believed their jurisdiction would experience
climate change in the next 20 years. Approximately 60 percent
believed their jurisdiction would experience one or more serious
public health problems as a result of climate change over the next
20 years, while fewer than 10 percent believed their jurisdiction
would not experience such problems.
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Perceived Expertise. The large majority of directors (77%)
believed that their health department lacked expertise in assessing
the public health risks of climate change in their jurisdiction, and
lacked expertise to create either an effective adaptation plan (83%)
or an effective mitigation plan (86%; see Table 4). Relatively few
respondents believed that their state health department currently
had ample expertise to help them create an adaptation plan (26%)
or a mitigation plan (16%). Similarly, relatively few respondents
believed that the Centers for Disease Control and Prevention
(CDC) currently had ample expertise to help them create an
adaptation plan (34%) or a mitigation plan (25%) for their
jurisdiction.
Current Programs of the Health Department. Nearly all
respondents indicated that their health department currently had
program activity that addresses at least some of the 12 potential
direct effects of climate change on the public’s health (see Table 5).
The most common areas of relevant programmatic activity were
water- and food-borne diseases (97%), vector-borne infectious
diseases (95%) and food safety and security (90%). The least
common areas of programmatic activity were anxiety, depression
and mental health conditions (31%), droughts, forest fires and
brush fires (38%) and housing for residents displaced by extreme
weather events (38%).
help residents reduce their greenhouse gas emissions (8%) or fossil
fuel use (8%).
Of special note are current and planned efforts by health
departments to reduce the greenhouse gas emissions and energy
use associated with operation of their health department.
Relatively few health departments currently have a program to
reduce fossil fuel use or conserve energy in health department
operations (21%) or to specifically reduce their greenhouse gas
emissions (12%), and relatively few others are planning such
programs (19% and 14%, respectively).
Research Question 4: What resources do local health
departments need to better address climate change?
The large majority of respondents (77%) indicated that
additional resources, if available, would significantly improve their
department’s ability to deal with climate change as a public health
issue. A small segment of respondents (9%) indicated that
additional resources were not needed, and another small segment
(14%) indicated that they did not know if additional resources
would be helpful or not.
Among respondents who indicated that additional resources
would be helpful, the categories of resources specified were the
following: additional funding to support the activity (63%),
additional staff (54%), staff training (29%), equipment (10%),
and assorted other resources (17%).
Climate Change Adaptation Programs of the Health
Department. Some respondents indicated that they currently,
or plan to, incorporate climate change adaptation into at least
some of their programmatic activities (see Table 5). The most
common areas of current or future programmatic activity related
to climate change were emergency preparedness (71%), storms
and floods (56%), vector-borne infectious diseases (53%), and
water- and food-borne diseases (50%). The least common were
anxiety, depression and other mental health conditions (15%),
droughts, forest fires and brush fires (24%), housing for residents
displaced by extreme weather events (32%), and air quality (32%).
Discussion
This is the first nationally representative survey to assess the
perceptions and activities of local public health directors regarding
climate change and public health. As such, it provides a valuable
baseline for the public health community as it increases the
intensity of its efforts to respond to climate change. Overall, our
survey points to relatively widespread awareness of the importance
of climate change for public health among directors of local health
departments, but far lower levels of actual preparedness or
planned activities to detect, prevent and ameliorate climateassociated health problems. These findings extend, and are largely
consistent with, a recently released study of local public health
department directors in California [21].
A majority of the local health department directors who
responded to our survey felt that climate change was already a
problem in their jurisdiction and is likely to become more of a
problem over the next 20 years, yet only a small minority had yet
to make climate change one of their department’s top priorities.
There may be many reasons for this response. The results of our
survey suggest that key factors may include lack of knowledge
about climate change–both within the local public health sector
and among other key stakeholders in the community–and the
perceived lack of adaptation and mitigation planning expertise in
the public health community at large. Additional factors may
include that other public health priorities are seen as being more
immediately pressing (e.g., pandemic flu preparedness), and that
there is a chronic lack of resources in most local public health
departments, a factor that undermines their ability to effectively
address any of their top priorities. Respondents to our survey
offered additional perspectives in their open-ended comments, but
in the interest of bringing our main findings forward as rapidly as
possible, that information is not included in this paper; analysis of
the open-ended responses will begin shortly.
While addressing the energy, transportation, economic, and
environmental implications of climate change has increasingly
become a priority for the United States, the health implications of
climate change have largely been neglected. Research funding for
Use of Long-Range Weather or Climate Information.
Only 29% of respondents indicated that their health department
currently uses long-range weather or climate information in planning
or operating any of their programs. Among those departments using
such information, the average number of programs in which the
information is used was 5.5
Research Question 3: What activities are local health
departments currently performing, or planning, that can
help prevent further climate change?
Although climate change mitigation per se appears to be an
area of current activity for relatively few local health departments,
a substantial proportion of health departments do have programs
in areas consistent with mitigation objectives (see Table 6). The
most common relevant current programs are those that encourage
active transportation such as cycling and walking (50%) and
programs that encourage purchase of local grown, organic or
plant-based foods (34%). The least common are those than pertain
directly to climate change mitigation, including programs to help
residents reduce their greenhouse gas emissions (5%), programs to
reduce residents’ fossil fuel use or conserve energy (6%), and
programs to educate the public about the potential impact of
climate change on health (8%).
Relatively few health departments are currently planning new
public programs directly or indirectly relevant to mitigation. The
most common of these were public education programs about the
potential impact of climate change on health (17%) and active
transportation programs (11%). The least common were programs
to encourage use of mass transportation (6%) and programs to
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health impacts of climate change has been a relatively small part of
the overall U.S. Climate Change Science Program (CCSP), and a
National Academy of Science review committee has called on the
CCSP to place greater priority on health impacts [22]. Current
legislation regarding climate change generally omits measures to
assess and remediate health impacts. By highlighting the strengths
and gaps in our public health infrastructure’s preparedness for
climate-related impacts, this survey can help inform research and
legislative efforts to reduce climate change impacts through
mitigation and adaptation efforts.
Frumkin and his colleagues (at CDC’s National Center for
Environmental Health) recently suggested that public health
agencies–in coordination with academic institutions, non-governmental organizations, and the private sector–are well positioned to
respond to climate change by building on the essential public
health services that they already provide [23]. Our data support
this position, albeit indirectly, by documenting the significant
extent of programmatic activity relevant to climate change
adaptation in most local health departments, even if most of this
activity does not yet specifically address climate change. A small
proportion of local health departments have begun to leverage
their resources to protect the public’s health from climate change,
and others are beginning to consider how they will do so. Our data
make clear, however, that climate change adaptation is not
currently a major activity at most health departments, and that
most, if not all, will require assistance in making this transition.
Our findings also indicate that climate change prevention is not
currently a priority in the large majority of local health departments.
We see this as both a problem and an opportunity. Most Americans
view climate change as a threat to other species (e.g., polar bears) and
to elements of the environment (e.g., glaciers), rather than as a threat
to people [24]. That may be, in part, because the voice of public
health professionals–a highly respected community that has a unique
voice in promoting activities that can prevent adverse health
impacts–has been nearly silent on the issue of climate change.
Public health and health care professionals have myriad opportunities to make the case (in the media, at county or city council
meetings, etc.) that climate change is a profound threat to the health
and wellbeing of people, and we urge them to do so. Of particular
importance for local public health department directors is the need
to make the case that climate change threatens the health of people
in their jurisdiction. Most people associate climate change primarily
as a threat to things distant from them geographically, and
temporally, rather than as a direct threat to their community. [24].
This abstraction may impede effective individual responses and
appropriate behavior changes.
One additional finding is particularly worthy of note: the lack of
focus among local health department directors on reducing
greenhouse gas emissions from health department operations.
Admittedly, the aggregate contribution of greenhouse gas emissions
from local public health departments is inconsequentially small
(although the same is not true of the health care delivery sector as a
whole, which contributes substantially to the overall level of U.S.
emissions). For the reasons articulated above, however, we see this
lack of action as a symbolically important missed opportunity.
Because of the seriousness of climate change’s threat to public health,
public health departments should reduce energy use and greenhouse
gas emissions to the best of their ability. Such efforts made publicly
can reinforce the message that climate change is a threat to human
health, and provide a model for appropriate mitigation actions for
citizens and other organizations.
A comment about the limitations of our research is also in order.
While the response rate to our survey was robust (61%), it is
possible that non-respondents differed from respondents in critical
ways. We believe that a significant proportion of our non-response
rate is attributable to the timing of the survey: the survey was
conducted during the year-end holiday season, and again in
January during a large national influenza outbreak; anecdotally, at
least some people who actively refused to participate cited that
they were simply too busy to spend a half hour or more being
interviewed. It is also possible, however, that some of the nonparticipants were more likely than the participants to believe that
climate change is not a significant issue for the public health
community. Anecdotally, at least several people who actively
refused to be interviewed made comments to the effect of the
concern about climate change being ‘‘blown out of proportion.’’
Thus, there is a possibility that our findings may be overestimating
the true level of awareness and perception of seriousness of climate
change impacts among local public health directors nationwide.
The results reported here are descriptive only. Further research
is needed to determine what factors predispose and enable local
health departments to play an active and effective role in climate
change adaptation and mitigation. We continue to analyze the
results of this survey for that purpose and encourage others to
engage in similar lines of inquiry.
Acknowledgments
The investigators gratefully acknowledge the contributions of Cathy
Malina, Diana Yassanye, Karen Akerlof , Julia De Sevo, Bob Grive,
Alysa Lucas, Christy Ledford, Laura Pagliaro, Connie Roser-Renouf, and
Dan Walsh as interviewers, Carolyn Leep for preparing the sample, and
Hilda Maibach for data management.
Author Contributions
Conceived and designed the experiments: EWM DM MC KLE JB.
Performed the experiments: AC MC. Analyzed the data: EWM AC. Wrote
the paper: EWM JB.
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