Climate Change, Public Health, and Policy: A California Case Study

Abstract

Anthropogenic activity will bring immediate changes and disruptions to the global climate with accompanying health implications. Although policymakers and public health advocates are beginning to acknowledge the health implications of climate change, current policy approaches are lagging behind.

We proposed that 4 key policy principles are critical to successful policymaking in this arena: mainstreaming, linking mitigation and adaptation policy, applying population perspectives, and coordination. We explored California’s progress in addressing the public health challenges of climate change in the San Joaquin Valley as an example.

We discussed issues of mental health and climate change, and used the San Joaquin Valley of California as an example to explore policy approaches to health issues and climate change. The California experience is instructive for other jurisdictions.

Climate change is currently affecting the health of populations and is projected to do so far into the future.¹ With the current chaotic policy environment in the United States, gains made in policy addressing climate change may be reversed or halted at the federal level. Without continued progress on these issues, it will likely become more difficult in the future to address the potential serious health implications of climate change. In this environment, it may be critical for states to lead when the federal government lags behind. The policy literature recommends several principles¹ that public health policymakers can use to address this important issue. We believe that 4 of these are the most important: mainstreaming, a linked approach, a population perspective, and coordination (Table 1).^3–6 Our choice of these 4 principles is further supported by the work of Gould and Rudolph, whose analysis of individual-level and structural barriers to greater public health engagement in climate change and public health indicated that these principles were supported by perceptions in the field.⁷ Our goal was to explore the health impacts of climate change and examine how California has implemented public health policy, based on these 4 principles. We performed a policy scan to identify associations between health and climate change, relied on published research, and used publically accessible state data for our analysis. We discuss public health policy and climate change in California, using mental health as an example. Our goal is to highlight larger policy issues and interrelationships among climate change, public policy, and the public, and how these 4 principles might be instructive to law and policy for other jurisdictions.

TABLE 1—

Key Principles That Public Health Policymakers Can Use to Address Health Implications of Climate Change

Key Principle	Definition	Example of Application of the Principle in SJV
Mainstreaming	The principle that climate change is integrated into all planning and policy processes across jurisdictions and sectors.	Include the effects of climate change when making policy and funding decisions regarding mental health services.
Linked approach	A principle that emphasizes the importance of considering adaptation and mitigation policies as part of one climate change policy rather than as separate domains.	Take into account that increasing affordable housing in an area may reduce GHG emissions but may worsen exposure to PM2.5 and other pollution exacerbating health conditions.
Population perspective	A principle that examines the health status and condition of populations as populations, not merely the aggregation of individuals, “an individual’s risk of disease cannot be isolated from the disease risks of the population to which s/he belongs.”2(p75) The principle is foundational to the field of public health.	Resiliency-based programming for mental health and increasing access to mental health services are important but will not address the larger determinants of poor health.
Coordination	The principle that any successful policy to address the health effects of climate change must be coordinated. Overcoming policy silos, jurisdictional issues and other coordination problems is likely the most daunting task for public health law and policy.	Institutions that direct financing and policy for mental health services should coordinate with state mitigation and adaptation agencies.

Note. GHG = greenhouse gas; PM2.5 = particulate matter ≤ 2.5 μm in diameter; SJV = San Joaquin Valley, California.

CLIMATE CHANGE AND THE SAN JOAQUIN VALLEY

To review policy “on the ground,” we narrowed our analysis to the San Joaquin Valley in central California. We chose to examine the San Joaquin region because of its significant climate disruptions and its concentration of vulnerable populations. We sought to study the resulting public health implications and to understand how California policy addressed health issues and climate change at the local level. The San Joaquin Valley is often called “the nation’s salad bowl” because of its fertile soil and the variety of produce grown in the region. It is a significant part of California’s agricultural industry, which generated $47 billion in 2015. The San Joaquin Valley has 8 counties—Kings, Fresno, Kern, Merced, and Stanislaus counties, and parts of Madera, San Luis Obispo, and Tulare counties—and had a population of 3.9 million according to the 2010 census. The socioeconomic conditions in the San Joaquin Valley are strikingly different compared with the rest of California and the rest of the nation; Hispanics made up 48.5% of the population, one fifth of the households in the region had incomes below the poverty level, approximately 30% of the population did not have a high school diploma, and most of the communities were linguistically isolated because 84% of the population had limited English proficiency.⁸

California became dramatically hotter in the last several years, with temperatures in 2014 more than 3°F higher compared with the historical data from 1949 to 2005. In the San Joaquin Valley, a persistent decline in both precipitation and run-off led to drought conditions, with 2012 to 2014 being the hottest and driest years recorded.^9,10 Although previous studies dismissed any link between anthropogenic climate change and the California drought,¹¹ recent studies concluded that anthropogenic activity accounted for up to 30% of the drought conditions from 2012 to 2014.¹² These conditions led farmers in California to dig 1800 feet down to tap into ground water. Increased pumping of groundwater led to land subsidence, with parts of the San Joaquin Valley sinking by as much as 28 feet. Land subsidence is known to stress water systems, which leads to permanent failures in wells.¹³ In March 2017, Tulare County’s Office of Emergency Services reported 1612 cumulative domestic well failures in Tulare County alone.¹⁴ The air quality in San Joaquin Valley is one of the nation’s worst and has repeatedly failed to meet federal standards for fine atmospheric particulate matter 2.5 micrometers in diameter or smaller (PM2.5) pollution. The PM2.5 pollution arises from farming practices (e.g., tilling, burning crop harvesting, and so on), dairy operations, animal feed, and off-road vehicles. Climate change may further affect exposures to PM2.5 by affecting weather patterns and anthropogenic emissions.¹⁵

We found that the health-related effects of climate change were particularly striking in the San Joaquin Valley. Compared with the state average of 11 per 100 000 of the population, the rates of heat-related emergency room visits from 2005 to 2010 were considerably higher in the San Joaquin Valley, ranging from 17 to 28 per 100 000 of the population. Because the main occupation in the region is agriculture, the rise in heat-related hospitalizations could be the result of the physical strain combined with continuous exposure to the heat outdoors, which could lead to fatigue and respiratory illnesses. A strong correlation was observed between exposure to particulate matter (PM2.5) and negative health outcomes, such as cardiovascular illnesses and exacerbation of asthma symptoms. A combination of heat waves, dust storms, and changing weather patterns also led to a 6-fold increase in Valley Fever (a disease caused by a fungus that is found in the soil) in California between 2000 and 2011, with more than 75% of the cases reported in the San Joaquin Valley.¹⁶

In addition to physical health implications, climate change can have grave consequences for the mental health of affected populations. In the United States, the mental health consequences among populations affected by extreme weather events, especially Hurricanes Katrina, Sandy, and Ike were well documented.¹ Most individuals affected by acute weather events experience trauma, shock, stress, grief, and distress symptoms, which ameliorate once safer conditions are restored. However, for many individuals, the experience leads to major clinical and anxiety disorders, substance abuse disorders, posttraumatic stress disorders, and suicidal ideation.¹ Persistent drought has financial implications for individuals who rely on rainfall for their economic survival, which places an increased burden on their mental health.¹ Individuals who live in drought-affected areas experience psychological distress and ongoing worry about future drought conditions that might affect their livelihood. Long-term stress further affects their physical health, strains social relationships, and creates a cycle of despair. Psychological distress contributed to suicides among farm workers in countries (e.g., Australia and India) that experienced prolonged drought.^17,18 Drought was also a major contributor to the increase in suicides among male farm workers in the Midwestern United States in the 1980s.¹⁹ Similarly, exposure to extreme heat was correlated with an increase in hospital and emergency room admissions, aggressive behaviors among those with mental illnesses, and death among those who experienced psychosis and dementia.^20,21 Another profound impact of climate change is solastalgia, which is a sense of desolation and loss of identity that an individual experiences as their familiar home environment changes, becomes uninhabitable, or hampers their livelihood.²² Loss of identity because of climate change is often associated with occupations such as farming and fishing, which are place-based.²³ Finally, the impacts of climate change are unequal. Many populations such as indigenous communities, low-income groups, women, children, older adults, individuals with disabilities, and those living in high-risk areas are more vulnerable to the mental health impacts of climate change.²⁴ Although the health burdens caused by climate change are significant, persistent, and intractable, the impacts of mental health consequences are particularly concerning and are the focus of our discussion.

We used published data to examine the mental health burden in the San Joaquin region and reviewed climate change policies for their inclusion of mental health. We also examined the current mental health burden in the region. According to the California Health Care Foundation, more than 16% of adults have a mental health need, and 5% have a serious mental illness in California.²⁵ San Joaquin Valley had some of the highest rates of mental illness in California, with 8% of adults with serious mental illness and 5.3% of children with serious emotional disturbances. The burden of mental illness and the unmet need became even more significant, when we examined the mental health workforce in the Valley. The numbers of all licensed mental health professionals in the San Joaquin Valley were well below the state average.²⁵ A community health needs assessment conducted by Kaiser found that in select San Joaquin Valley counties (i.e., Fresno, Kings, Madera, and Tulare), access to health care services was the main concern among residents. Other prominent issues included lack of transportation, difficulty in scheduling appointments and navigating the system, language barriers, and paying for copayments and medications. More than 80% of the population in these counties lived in a health professional shortage area for primary care.²⁶ The high rates of mental illness, low access to providers, and the likely impacts of drought and climate change on mental health made this a serious climate-related health issue. We consider California’s approach to addressing this issue in this article.

CALIFORNIA’S APPROACH TO CLIMATE CHANGE

There are 2 goals in addressing climate change: mitigation and adaptation. Mitigation seeks to reduce greenhouse gases (GHGs). Policy approaches here include cap-and-trade systems, carbon sequestration, changes to energy generation systems, and transportation policy. Adaptation seeks to respond to the inevitable changes resulting from climate disruption. Many of these policies provide opportunities or “co-benefits” to improve the health of communities.

Mitigation Policy

California has taken aggressive steps to reduce GHGs and has been singled out as a leader in climate change policy. The Global Warming Solutions Act of 2006 is the center of California’s mitigation policy. It originally required California to reach 1990 levels of GHG emissions by 2020 and was recently updated to require a reduction in GHGs to 40% below 1990 levels by 2030.²⁷ This policy also requires the state to evaluate mitigation efforts in terms of public health. Currently, California uses a cap-and-trade system to reduce GHGs and to achieve its reduction goals. This system generates funds that the state uses on projects that reduce GHG emissions. In 2012, the legislature passed SB 535, which requires that, in addition to reducing GHG emissions, 25% of the monies from the GHG fund must be spent to benefit disadvantaged communities (DACs). Specifically, 10% of these funds must be spent on projects located within DACs.²⁷

The California Environmental Protection Agency (CalEPA) created a tool, CalEnviroScreen, to identify these DACs for purposes of GHG mitigation by measuring pollution burden and population characteristics by census tracts.²⁸ We used CalEnviroScreen 2.0 to study the San Joaquin Valley and found that 38.4% of census tracts in the San Joaquin Valley had a CalEnviroScreen score in the highest 15% (i.e., 85%–100%). With such a high percentage of DACs, the San Joaquin Valley communities experienced a unique combination of environmental pressures and inequities.

Adaptation Policy

California’s first step toward preparing for the impacts of climate change—its adaptation policy—was the result of a 2008 Executive Order that required state agencies to develop a strategy to identify and prepare for climate impacts.²⁹ Since then, California has continued to update its Climate Adaptation Strategy.³⁰ Although these policies are not as well developed as California policies that target mitigation, the Climate Adaptation Strategy has now moved to include more structural elements in adaptation goals, and the state’s adaptation policy has continued to expand, to rely on regular assessment of the issue through the California Climate Change Assessments.³¹ In terms of public health explicitly, county public health departments have been working with the California Department of Public Health to identify public health risks in their communities, by building awareness and documenting climate change efforts in communities.³²

EVALUATING CALIFORNIA’S HEALTH POLICY

We propose 4 key principles to evaluate health policies focusing on climate change: mainstreaming, linked approach, population perspective, and coordination. The California example shows us how these principles have been incorporated, where they have fallen short, and the ensuing implications.

Mainstreaming

Mainstreaming is “a process whereby adaptation measures are integrated ‘into some aspect of related government policy such as water management, disaster preparedness and emergency planning or land-use planning.’ Mainstreaming is not, therefore, a specific policy proposal, like a carbon tax, but rather a policy for policy proposals.”^5(p25) With mainstreaming, the effects of climate change are integrated into public health policy and planning. California has taken steps to integrate climate change adaptation and resiliency into its requirements for the general planning process of communities.³³ The Governor’s office has also required the integration of climate adaptation planning into state policy, which also mandates the California Natural Resources Agency to develop a state adaptation plan. That adaptation plan, Safeguarding California, focuses on community resilience and response capacity to health threats, indicator development, and improved coordination.³⁴ The recommendations provided in these adaptation plans are in broad strokes and lack the granular detail available in other climate change policies, and may not be sufficient to address more serious health problems in California.

We noted that a mix of public sources fund mental health services in California when we reviewed California policy with regard to our issue of mental health in the San Joaquin Valley. California counties, through their public health systems, have significant responsibilities related to the provision of mental health services. Services are paid for through a combination of federal, state, and local funds that combine revenue from Medi-Cal, sales taxes, vehicle fees, property taxes, and other miscellaneous funding.³⁵ Low-income uninsured adults who have no other source of care receive care from a medical indigent program run by counties known as County Medical Services Program (CMSP). Although some counties have expanded their CMSP offerings, many others have considerably cut back on coverage and services provided because of financial constraints. County funding decisions for mental health are currently independent of statewide policy priorities.³⁵ We believe that if climate change adaptation planning were part of policymaking in this area, additional mental health resources might be made available to residents of the San Joaquin Valley counties, thus providing cobenefits. States and counties could include the effects of climate change when planning and then provide additional resources for areas particularly affected by climate disruptions. Counties participating in the CMSP have already embarked on several innovative approaches to manage care for the neediest patients (e.g., contracting with local health plans, changing program benefits, providing more preventative care rather than episodic care, using technology for application screening, and so on). Even if the structure of mental health funding makes this mainstreaming difficult initially, simply moving the issue into the mainstream of mental health policy would help to identify structural policy barriers that were previously unknown. The narrow focus of public health funding and the mandate of programs could contribute to the difficulty of mainstreaming climate change in policy discussions. Addressing the larger political, policy, and legal constraints to public health would be key here.⁷

Linked Approach

A linked approach that views adaptation and mitigation as parts of the same climate policy is required, as one can influence the other, and each can have serious implications for health.^4,5 For example, mitigation policy might promote smart growth solutions that emphasize public transit and dense urban development as a tool to reduce GHG emissions. An unintended consequence of this policy might be the development of urban heat islands that are detrimental to human health.⁵ In this example, a linked approach would include the possible exacerbation of heat islands in the adaptation planning process itself.

Mitigation and adaptation policies need better linkage in California. California took strides in explicitly and expressly linking mitigation policies to environmental justice policy goals when it enacted the California Global Warming Solutions Act of 2006: Greenhouse Gas Reduction Fund (SB 535), which required investments on GHG mitigation specifically in communities that experienced poor outcomes related to environment. California spent approximately $320 million for GHG mitigation projects in the San Joaquin counties (excluding the funding for the California high-speed rail project), with only $58 million of the total amount targeting or benefiting DACs. By comparison, the state spent approximately $2.2 billion dollars across California.³⁶ Although these SB 535 investments targeted DACs in California, they did not necessarily target investments that would reduce the health burden related to climate change in this area. For example, a number of projects in the San Joaquin counties related to affordable housing, vehicle replacement, irrigation improvements, and carbon sequestration received SB 535 investment funding under the California system of GHG mitigation. Although these projects succeeded in bringing resources to DACs, these mitigation strategies might have exacerbated or failed to address climate-related health issues in the short term. For example, SB 535 investments included additional affordable housing in Fresno,³⁷ although the San Joaquin counties had some of the highest PM2.5 concentrations in California. As stated earlier, exposure to PM2.5 is associated with poor health outcomes. The legislature acknowledged this issue in a series of reforms passed in August 2016 that sought to improve oversight of the Air Resource Board and improve data on individual pollution sites.³⁸ Even with this attempt at reform, there is no expressed link between mitigation cobenefits strategy for SB 535 and adaptation policy in California. This tenuous link could have serious health consequences in the short- and long-term, as we found in the San Joaquin region, where none of the currently funded projects addressed mental health issues. Although more work is needed here, SB 535 and the California approach demonstrated that it is possible to link mitigation policy to other policies, including adaptation. We also noted that an emphasis on the health co-benefits of climate change policy might facilitate improved linkages and engagement with the public health sector.⁷ Linking adaptation and mitigation, along with coordination, might be the 2 most difficult challenges facing any community or state that seeks to address the health effects of climate change.

Population Perspective

The California approach using CalEnviroScreen is an example of how societies might apply the population perspective to public health and health policy around climate change. By relying on a strong evidence base and indicators supported by research, CalEnviroScreen provides a fair tool for making comparative evaluations at the census level. It provides a useful way to compare and contrast populations in California and can allow policymakers to visualize health inequities, structural and social determinants of health, and other population-level health issues. Health policy planners could explore use of CalEnviroScreen data for mainstreaming issues related to climate change in California into public health and health policy planning, and direct funding to areas where the public health impact of climate change would be substantial. For example, policymakers in California could overlay the prevalence of mental illnesses, the current distribution of mental health resources, and the CalEnviroScreen Scores in the San Joaquin Valley to address the impact of climate change in this area and develop policies and investments to target affected communities. SB 535–related investments demonstrated how funding could be linked to clear policy goals. Inclusion of additional measures of health indicators in the CalEnviroScreen tool might help to identify vulnerable populations that might be particularly sensitive to the disruptions associated with climate change. However, CalEnviroScreen scores are calculated using parameters that rely heavily on pollution measures, and therefore, might not capture other climate change vulnerabilities. CalEPA continues to modify the tool and has recently included new indicators (e.g., cardiovascular disease and rent-adjusted income) to the CalEnviroScreen tool. This approach, although not perfect, is particularly effective and may help to facilitate the political process in addressing climate change. In addition to CalEnviroScreen, the CalEPA has other tools that focus on environmental justice³⁹; other states and jurisdictions have developed similar tools.⁴⁰ The use of the population perspective would facilitate the analysis of health policy problems. Inclusion of scores from tools such as CalEnviroScreen would provide a transparent and open system to guide policy decisions in this arena.

Coordination

Finally, any approach should focus on coordination. The Lancet Commission made this point most clearly:

[governments should] adopt mechanisms to facilitate collaboration between Ministries of Health and other government departments, empowering health professionals and ensuring that health and climate considerations are thoroughly integrated in government-wide strategies. A siloed approach to protecting human health from climate change will not work.^41(p1862)

Legal scholars suggested multiple approaches to achieving this coordination and noted the difficulties in designing a legal regimen that could manage the complex issues associated with this topic.⁶ California addressed this coordination issue in several ways. Three are worth noting: participation in subnational agreements; the Integrated Climate Adaptation and Resiliency Program (ICARP) at the Office of Planning and Research to coordinate among levels of government; and the Climate Action Team to coordinate within the state government. California worked with other jurisdictions on a subnational level to coordinate efforts around climate change. These included the Western Climate Initiative, which is made of up of several Western states and Canadian provinces and agreements with subnational counterparts in China.⁴² ICARP was created in 2015 to provide a framework for coordinating among state, regional, and local governments. The framework also created a Technical Advisory Council to assist planning efforts. At the state government level, California relies on a Climate Action Team composed of state agency secretaries and the heads of various boards and departments. This team is led by the Secretary of CalEPA. Each of these approaches are important steps in coordinating responses to climate change and might be the most important and challenging aspect of public health policy and its approach to climate change.

The actual approaches to coordination are less important than understanding the role of politics and political will in responding to initiatives linked to climate change. A key factor contributing to the creation of these systems has been strong grassroots and community support, coupled with strong leadership in state government. Public health advocates and practitioners must be more tightly integrated into these coordination initiatives. They must lead the efforts to coordinate health responses within our complex and uncoordinated health care systems. Without a formal mechanism to coordinate the various funding sources and state policy objectives, we see a mismatch between health burden and health resources. Although policies in California emphasize the importance of coordination and are taking great strides, this issue has not moved into the policy fore in the way SB 535 moved environmental justice concerns into the realm of mitigation policy. This coordination of policy efforts may be the most difficult legal and policy challenge facing the public health sector as it seeks to address the health impacts of climate change.

CONCLUSIONS

The California approach demonstrated how to link resources to outcomes in a way that emphasized accountability and to connect mitigation and adaptation concerns. However, the experiences of the San Joaquin Valley region suggested a need for greater coordination of resources. Importantly, we believe California might have benefited from linking adaptation and mitigation policy from the beginning. Legal theorists also suggested that an approach that addresses both mitigation and adaptation as part of one regulatory policy might be useful.⁵ California’s experience suggests that, to be effective, coordination must be incentivized, there must be political will, and the issues might need to be mandated. Finally, we believe that there are opportunities to link climate change and public health policy. For jurisdictions that rely on tools such as CalEnviroScreen to link climate change and health, policymakers must understand fully the inclusion and exclusion of population and environmental indicators and their implications for health equity. Focusing on the health implications of climate change and the health cobenefits of mitigation strategies might benefit the health of populations, as well as address the ongoing and future impacts of climate change. California’s successes, challenges, and willingness to update policy in this area are all instructive for communities working to prepare for the health effects of climate change and to mitigate its causes.