Development of an agenda for research and action on climate change and health in the Caribbean

ABSTRACT

This paper delineates the development of the Caribbean Research for Action Agenda which aims to empower Caribbean Small Island Developing States to reduce their vulnerabilities to the effects of climate change on health. The Caribbean Research for Action Agenda emerged from collaboration between nongovernmental organizations, academic institutions, and multilateral agencies that organized a conference on climate change and health in the Caribbean. This Agenda was formulated by prioritizing research areas, synthesizing evidence from conference presentations and scientific literature, and holding consultations with stakeholders and experts. The Agenda provides information on 18 priority areas for research and action categorized into four domains: climate change health impacts, exposures, and vulnerability; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; and resources and engagement for climate change and health action. Cross-cutting findings underscore the need for: greater public and professional awareness; a more climate-literate health workforce; interdisciplinary collaboration to address institutional silos; attention to social and economic mediating factors; equitable interventions for vulnerable groups; and enhanced monitoring and surveillance of climate-sensitive health outcomes. The Caribbean Research for Action Agenda is a foundational tool to inform research, guide multisectoral collaboration and capacity-building, develop evidence-based policy, and inspire community action-based advocacy related to climate change and health.

Small Island Developing States (SIDS) are on the frontlines of the global climate crisis, despite contributing just 1% of global carbon dioxide emissions (1). The unique vulnerability of SIDS is due to hazards resulting from climate change and characteristics of small islands that lead to numerous threats. Hazards include sea level rise, extreme heat and drought periods, and higher intensity of tropical cyclones. Characteristics that pose threats include dependence on marine and coastal resources, geographical remoteness, limited human resources, and undiversified economies with a high dependence on external markets. These vulnerabilities, which threaten financial security and income and the health and well-being of SIDS populations, affect people and islands differently depending on levels of preparedness, adaptation, and social vulnerability (2).

In 2018, the Third Global Conference on Health and Climate Change: Special Focus on SIDS, a World Health Organization (WHO) initiative, helped draw global attention to the vulnerabilities of SIDS (3). Nevertheless, a WHO review of articles published on climate and health between 2008 and 2019 showed that only 19, out of the more than 2000, were from the Caribbean and Central America. To address gaps in knowledge and practice of climate change and health in the Caribbean, key stakeholders established the Research for Action on Climate Change and Health in the Caribbean (R4ACCHC) initiative, which set out to achieve the following goals.

1. Develop evidence-based recommendations for actionable research and capacity-strengthening to inform multilevel mitigation and adaptation strategies to reduce the adverse effects of climate change on health in the Caribbean SIDS. Through identification of what is already known about climate change and health in the Caribbean, we identify gaps in the evidence and provide corresponding recommendations.

2. Engage a broad coalition of civil society, government, and academic stakeholders in developing the recommendations to ensure relevance and practicability.

3. Disseminate the resulting Caribbean Research for Action Agenda (CRAA) widely to raise awareness, elicit funding, and mobilize key partners to implement the agenda.

METHODS

Two major activities informed the development of the CRAA: a Caribbean climate change and health conference and a desk review of information relating to climate change and health in the Caribbean. These activities, both of which involved substantial stakeholder engagement, were directed by the R4ACCHC Committee (the Committee) comprising representatives of the EarthMedic/EarthNurse Foundation for Planetary Health, the University of the West Indies, the Yale Center on Climate Change and Health, the Emory Rollins School of Public Health, and the Pan American Health Organization (PAHO).

The Conference

In 2021, during the coronavirus disease 2019 pandemic, the Committee organized the online Conference on Climate Change and Health in Small Island Developing States: Focus on the Caribbean (the Conference). The Conference had three objectives: (i) provide an overview of the health impacts of climate change in the Caribbean, mitigation and adaptation actions to address these impacts, and impediments to these actions; (ii) understand and prioritize knowledge gaps that will define an action-oriented research and implementation agenda to reduce the adverse health effects of climate change; and (iii) foster multisectoral and regional, North–South and South–South collaboration, innovation, and sharing to facilitate the implementation of a CRAA.

The Committee identified and established partnerships with more than 25 regional and international organizations, comprising development agencies (e.g., the Inter-American Development Bank), advocacy organizations (e.g., the Healthy Caribbean Coalition, Island Innovation Network), technical agencies (e.g., the Caribbean Institute for Meteorology and Hydrology), universities (e.g., University of Guyana), and other academic organizations (e.g., the Eastern Caribbean Health Outcomes Research Network). These organizations contributed to conference design and assisted in funding, publicity, and identification of potential speakers. Anyone who registered via the publicity links could attend the Conference.

Presentations were organized under four themes: (i) the varied effects of climate change on health; (ii) the immediate health benefits of climate change adaptation and mitigation; (iii) the health sector and its role in addressing climate change and health; and (iv) participation, representation, and collaboration to implement the CRAA.

Experts in a variety of health and environmental topics were invited to present, based on appraisal by the Committee and partners of the relevance of their knowledge to climate change and health in Caribbean SIDS. Sessions were recorded and results used to inform the content of the CRAA.

Desk review and development of the CRAA

The five collaborating organizations in the Committee were joined by Blue Sky Development Consulting to carry out a desk review and develop the CRAA.

Step 1: developing the conceptual framework. An organizational framework for synthesizing the evidence on climate change and health was chosen after reviewing the themes and subtopics of the Conference, various climate change and health conceptual frameworks (4–6), and the existing syntheses of climate change and health evidence for the Caribbean (7–10). Criteria used to determine the utility of each framework included:

• presents an ecological approach showing health outcomes and social and environmental determinants of health in the context of climate change;

• facilitates the analysis of policy and programmatic action in health and other sectors; and

• enables the organization of information from the scientific literature and Conference sessions.

Step 2: choosing priority areas for the CRAA. Given the wide range of health outcomes and determinants that may be affected by climate change, it was necessary to identify priority areas. The team first reviewed results of previous work conducted in 2020–2021 in which in-depth interviews were conducted with key stakeholders in the Caribbean and other SIDS to identify the most relevant areas for monitoring progress in addressing climate change and health (11). Twenty-four areas were identified and in a subsequent workshop, stakeholders narrowed these down to eight high-priority areas (11, 12).

To further inform the choice of priority areas, we reviewed the Conference preparatory documents (literature reviews conducted for each of the four Conference themes), topics and presentations, and previously published syntheses of Caribbean research and action on climate change and health (7–9). We also conducted 16 stakeholder dialogue meetings with 14 Caribbean academic, civil society, governmental, private sector, professional, technical, and training organizations. These unstructured meetings, which were facilitated by members of the Committee, provided feedback about which areas to include as priorities and why. On average, five stakeholders (range: 1–16) attended each dialogue meeting.

Step 3: gathering the evidence on each priority area. With the priority areas identified, scientific literature and other data sources were reviewed to identify information specifically relevant to Caribbean SIDS. We adopted an exploratory approach as the scope of potential climate change and health associations is wide. Notably, we did not conduct systematic reviews of evidence focusing on specific disease outcomes and risk factors in settings other than the Caribbean.

We first used existing reviews of evidence on climate change and health in the Caribbean (7–10). Targeted searches were then conducted on the PubMed database for Caribbean-specific information on climate change and health in each of the priority areas, covering the period (2018–2022) following the Caribbean Public Health Agency (CARPHA) 2018 report on climate change and health in the Caribbean (7). Search terms included “Caribbean,” “climate change,” and the titles or derivatives of the titles of each of the priority areas. For example, for the priority area, “vulnerability to vector-borne diseases,” the term “vector-borne disease” was used. Further searches were conducted using “Caribbean” with priority area titles or their derivatives and environmental determinants of health associated with climate change, such as “flood” and “extreme heat.” We also reviewed the content of the 2021 Conference presentations and preparatory documents, as well as information from reputable technical agencies (e.g., Caribbean regional and United Nations agencies) via their websites or by contacting technical officers.

Step 4: synthesizing the information to identify gaps and recommendations for action. For each of the priority areas a chapter was written that included two main sections: (i) a situational analysis of what is happening, which described what the problem is, and what Caribbean evidence is available, and (ii) what should be done. Gaps were identified and recommendations for action to address those gaps were defined. Recommendations are divided into sections covering individual and community actions, governmental and private sector actions, research and surveillance gaps, and capacity-strengthening needs. The CRAA therefore includes recommendations for action that directly address gaps in climate change and health that if addressed can improve health outcomes. Drafts of priority area chapters were reviewed by Conference presenters who were Caribbean-based experts in relevant fields of climate change and health. After incorporating their comments, an online workshop was held in May 2023 at which 78 experts, policy-makers, and civil society advocates provided feedback on the main findings in breakout rooms focusing on individual chapters. The feedback was incorporated into the final versions of each chapter.

RESULTS

The Conference was held on 5–8 October 2021 and included 1 057 general registrants (from more than 80 countries and territories, including 31 SIDS) and 162 presenters. The Conference successfully highlighted the current state of knowledge about climate change and health in the Caribbean, the remaining research gaps, and the opportunities to advance advocacy and climate action.

Determination of the conceptual framework

We determined that the Lancet Countdown on Health and Climate Change framework (4, 13) was the framework most aligned with our criteria for choosing a conceptual framework (see Methods, step 1). The Lancet Countdown framework, which comprises tracking indicators grouped into five domains (Table 1), offers a broad ecological approach that considers the social and environmental determinants of health and includes characteristics of the health care system. The final CRAA domains corresponded to the five Lancet Countdown domains except for domains 4 (economics and finance) and 5 (public and political engagement). These were merged into a combined domain to better represent the objectives of the CRAA. This domain was named: resources and engagement for climate change and health action (Table 1).

TABLE 1. CRAA domains on climate change and health mapped against conference themes and Lancet Countdown Domains.

Conference themes	Lancet Countdown Domains	CRAA domains
1. Varied effects of climate change on health	1. Health impacts, exposures, and vulnerability	1. Climate change health impacts, exposures and vulnerability
2. Immediate health benefits of adaptation to and mitigation of climate change	2. Adaptation, planning and resilience for health	2. Adaptation, planning and resilience for health
3. The health sector and its role in addressing climate change and health	3. Mitigation actions and health co-benefits	3. Mitigation actions and health co-benefits
4. Participation, representation and collaboration to implement the research agenda	4. Economics and finance	4. Resources and engagement for climate change and health action
	5. Public and political engagement

CRAA, Caribbean Research for Action Agenda.

Source: Prepared by authors based on: Watts et al., 2021(4); Romanello et al., 2021 (13) and Allen et al., 2024 (14).

Choosing priority areas

The eight areas identified in the 2020–2021 research to identify priorities for climate change and health monitoring in SIDS (see Methods, step 2) were adopted as priority areas for the CRAA. The remaining 16 areas identified in the same research (11, 12) were also considered by the Committee for inclusion, as were areas that emerged from the process described in Methods, step 2. The result was the selection of 18 priority areas for research and action on climate change and health in the Caribbean.

Overview of the CRAA

The emergent CRAA includes a detailed report on each of the 18 priority areas under the four domains described (14). Table 2 gives a summary of research and surveillance recommendations by domain and priority area. In addition, we identified cross-cutting themes that we divided into two groups – those stemming from an analysis of the priority areas within domain 1 and those from domains 2 to 4. We discuss cross-cutting themes in the context of gaps.

TABLE 2. Climate change and health research and surveillance recommendations in the Caribbean by priority area.

Domain/priority area	Recommendations with a focus on research and surveillance gaps in the Caribbean
Domain 1. Climate change health impacts, exposures and vulnerability
1. Health impacts of extreme weather events	Increase research and surveillance on the indirect effects of extreme weather events on mortality and morbidity (e.g., via the damage to food security and health facilities) Research and monitor health-related aspects of hurricane preparedness and response Strengthen monitoring of population displacement and migration resulting from severe weather events Strengthen integrated risk management and early warning systems
2. Vulnerability to vector-borne diseases	Improve prediction models for vector-borne diseases Identify best ways to communicate information from early warning systems to key persons Conduct studies on knowledge, attitudes, beliefs, and practices on vector-borne diseases Conduct research to determine effective behavioral and communication interventions to promote the adoption of strategies to limit vector populations Map the movement of vectors, vector-borne diseases and viral strains geographically and over time Strengthen surveillance systems to account for excess deaths and seroprevalence of diseases
3. Water, sanitation, and hygiene	Conduct research on how climate change is affecting the biological and chemical composition of water sources Conduct research on how floods and droughts are affecting the agriculture sector and food safety and security Improve prediction models for waterborne infections Conduct research on community and industrial water and waste management practices and integrated water resource management solutions Conduct research on water wastage, recycling and technologies to reduce water scarcity and insecurity Include water, sanitation and hygiene in research to develop disaster preparedness and response strategies Monitor waterborne and vector-borne disease outbreaks and water pollution Develop systems to monitor water and sanitation infrastructure and provide related data
4. NCDs and risk factors	Conduct studies to develop evidence-based strategies to reduce disruptions to health care service access in the event of a climate-induced disaster Evaluate the impact of disaster preparedness on NCD outcomes and develop evidence-based strategies to reduce the impact of disasters on NCDs Identify the impact of environmental determinants (e.g., extreme heat) on people living with NCDs Create and support national and local NCD registries Monitor the association between climate and severe weather and NCD incidence
5. Air quality	Research patterns and trends in respiratory, cardiovascular, and other illnesses in relation to air quality Research the links between climate change, Saharan dust and diseases Conduct operational research on the implementation and effectiveness of air quality monitoring Develop air quality information systems that enable comparisons among places and over time Monitor and strengthen the integration of air pollution into weather forecasting and early warning systems
6. Heat-related illness	Identify how increases in ambient temperature affect the health care system Use citizen science to inform interventions that address heat and health in the Caribbean Explore the relationship between increased ambient temperature and morbidity and mortality Monitor and map heat-related illness Develop robust early warning systems for heat
7. Mental health	Strengthen the evidence on the relationship between mental health and climate change, including climate-related extreme weather events Identify the challenges faced by the health care system with respect to mental health during and after extreme weather events Explore changes in cognition of vulnerable populations due to climate-related events Develop robust surveillance systems for mental health that can also integrate mental health outcomes and climate/weather information, both short term and long term Determine the effectiveness of interventions on mental health at the individual, community, structural/governmental, and private sector levels during climate-related events
8. Population displacement and migration	Identify and monitor the push factors for Caribbean migration Examine the relationship between climate-related migration and health outcomes Identify strategies to overcome challenges faced by the health care system with respect to providing high-quality health care to migrants Review national and regional policies/treaties/agreements on immigration and refugees to inform new and improved policies for the region Conduct disaster displacement risk assessments for both immediate climate-related disasters and long-term, slower-onset climate-related events Strengthen monitoring of population displacement and migration resulting from severe weather events Monitor reasons for migration and the health concerns of migrants
9. Distribution, equity and justice in climate change and health	Conduct research to identify populations vulnerable to health effects of climate change in the Caribbean Study relationships between social determinants of health, climate change and health inequalities Conduct research on the vulnerabilities and adaptation strategies of specific populations Conduct longitudinal studies to understand the impact of climate drivers on the health of people with preexisting genetic and medical conditions Involve vulnerable populations in research on and development of adaptation and mitigation solutions suitable for their needs Identify tailored and effective adaptation strategies to reduce the impact of climate change on the health of vulnerable communities Conduct surveillance of populations that allows for disaggregation by key dimensions of social and economic inequality
Domain 2. Adaptation, planning and resilience for health
10. Collaboration between agencies	Monitor and evaluate collaborations between agencies and between Caribbean SIDS Determine the most effective strategies to promote cross-sectoral collaboration
11. Research and surveillance on climate change and health	Integrate climate/weather and health surveillance data and test associations between them Improve the timeliness and quality of reporting of climate-sensitive health conditions Develop climate-smart and resilient health surveillance systems, linking epidemiological, climate, agricultural, socioeconomic and environmental information Develop and track climate and health indicators appropriate for Caribbean SIDS
12. Agriculture, food safety and security	Gain a better understanding of climate-smart agriculture and how it can benefit agriculture and food insecurity in the Caribbean Investigate the reasons for the overreliance on imported foods in the Caribbean and the extent to which this is driven by climate change effects on local fisheries and agriculture Explore the impact of food insecurity on vulnerable populations Conduct research on the role of fish in providing nutrition to Caribbean people Conduct studies to develop evidence-based strategies to reduce disruption to food availability in the event of a climate-induced disaster Monitor the association between climate change, extreme weather, and food security
13. Awareness- and skills-building	Conduct longitudinal and experimental studies of education, training and skills-building interventions Conduct media and communications research Learn what works internationally and adapt it to the local context Conduct repeated knowledge, attitudes and practice studies Monitor inputs and outputs of training and learning
Domain 3. Mitigation actions and health co-benefits
14. Marine resources and health	Conduct research on opportunities for sustainable development of the blue economy, including marine sources of energy Conduct research on repurposing Sargassum Research how international law can assist in protecting Caribbean marine and coastal environments Conduct research on responses of marine ecosystems to climate change Conduct research to preserve marine food security and quality Monitor key oceanic climate change drivers of ill-health and their consequences Monitor the status of fisheries and marine ecosystems Monitor harmful algal blooms
15. Climate-friendly health-promoting infrastructure	Build the Caribbean body of knowledge on the role of infrastructure in reducing or amplifying the effects of climate change on health Identify health hazards hotspots and opportunities for infrastructure adaptation Identify financial mechanisms to support climate- and health-friendly infrastructure development Critically examine the framework of laws and regulations concerning infrastructure through a climate and health lens Examine the climate resilience of infrastructure solutions developed by Caribbean people Conduct research on infrastructure options for promoting green mobility and physical exercise Conduct research on how to connect health specialists with the other infrastructure experts and officials to build a multisectoral approach Develop and use measures of equity and health impact for infrastructure assessment and monitoring Strengthen information systems that monitor energy and water consumption Develop integrated surveillance systems that monitor weather, health and emissions of greenhouse gases and other air pollutants Develop and use tools to assess the environmental and health benefits of infrastructure
16. Smart health facilities	Determine the cost–benefit and cost–effectiveness of the regional Smart Health Care Facilities in the Caribbean project and of other national new build and retrofitted health facilities Determine the barriers to increasing government leadership and participation in implementing smart health facilities Conduct studies that will enable certification of local materials Identify efficient plumbing system options suitable for Caribbean water supplies and pressure Investigate the effectiveness of alternative cooling and ventilation systems Monitor and evaluate preventive maintenance and repairs
Domain 4. Resources and engagement for climate change and health action
17. Funding streams for climate and health action	Determine how to generate sustainable funding streams and mechanisms to support policy and program implementation to address the effects of climate change on health Conduct cost–benefit and cost–effectiveness analyses to understand the financial implications of regional initiatives and action plans that address climate and health Determine the effectiveness of actions at the individual, community, structural/government and private sector levels Monitor national, regional, and international funding received by countries for climate and health
18. Government engagement in health and climate change	Identify best practices in developing and implementing national strategies on climate change and health Conduct studies to ascertain how equity should be integrated into the national climate change and health agenda Determine the effectiveness of actions at the individual, community, structural/government and private sector levels Monitor public statements of regional and national leaders for content related to climate and health Monitor government adherence to the implementation of action plans and frameworks

NCDs, noncommunicable diseases; SIDS, Small Island Developing States.

Source: Prepared by authors based on Allen, et al. 2024 (14).

Cross-cutting themes: domain 1

Insufficient monitoring and surveillance of climate-sensitive health conditions and exposures. Data are required to evaluate impacts of climate change on health and of any adaptation interventions or policies. Across health conditions, more uniform and consistent data collection is needed within and between Caribbean SIDS. For example, although some vector-borne, foodborne, and waterborne diseases are reported to and monitored by CARPHA, systems are not currently in place to monitor other conditions such as mental health and illnesses related to heat or air quality. There are no monitoring and surveillance systems to link climate indicators such as heat, humidity, precipitation, air and water quality, and flooding to health outcomes, and there is no consistent approach to assess health outcomes such as excess mortality in the aftermath of a severe weather event such as a hurricane.

Data shortages to channel interventions to vulnerable groups and people. There are insufficient disaggregated data to enable the analysis of the distribution of climate-sensitive health conditions among population subgroups. Some data are disaggregated by sex and age, but this is not universal. Data on the distribution of climate-related health conditions by other indicators of vulnerability such as education, ethnicity, and disability are generally unavailable. There is limited use of geographic information systems, which have not been used to map climate-sensitive health conditions against indicators of social and economic deprivation. Analysis of subgroup differences to enable the development of appropriate strategies to address health inequities and enhance universal access (e.g., gender-based, community-responsive, and life-course strategies) has also been limited.

Insufficient analysis of contextual factors mediating the effects of climate change on health. Regardless of which relationship between climate exposure and health outcome one is examining, it is important to build evidence for the role of contextual factors (environmental, institutional, social, and behavioral) in mediating the impact of climate change on health. These factors are amenable to intervention and policy changes that can reduce the impact of climate on health. Capacity-building in conducting multivariate analyses is needed to identify combinations of factors significantly affecting health outcomes and to develop evidence-based public health interventions based on the findings.

Gaps in health care workers’ knowledge of climate-related health issues. Frontline health care providers and public health officials must be prepared to treat health conditions affected by climate and counsel patients accordingly. Little information is available on the degree to which health professionals in the Caribbean are aware of or act upon climate change and health issues; what information is available suggests a large knowledge–action gap (15).

Institutional silos among key agencies and sectors. To generate the monitoring and surveillance data needed to enhance our understanding of climate change and health and develop appropriate policy and practice guidelines and better early warning systems in the Caribbean requires unprecedented collaboration and cooperation across agencies and sectors. Examples of cooperation are sporadic, with few mechanisms for systematic collaboration between key health, meteorological, and environmental agencies, professional and academic organizations, and other relevant government sectors.

Cross-cutting themes: domains 2 to 4

There are few Caribbean publications relating to domains 2 to 4 (adaptation, mitigation, and resources and engagement). Most climate change adaptation and mitigation projects and policies in the Caribbean, except the Smart Health Facilities initiative (16, 17), are not specifically designed with health outcomes in mind. The Conference and other consultative processes provided most of the information for these domains.

Lack of engagement and involvement of communities and vulnerable groups. Community-based participatory research is important to inform solutions to reduce the impact of climate on health. Communities, and vulnerable groups within them, can identify appropriate and effective ways to overcome climate-related challenges that should be incorporated into resilience planning. Further, through citizen science, communities can help conduct surveillance of local environmental conditions that augment national systems.

Lack of evidence to orient action and the need for increased funding. Across all the priority areas, evidence to inform policy and practice or the scale-up of existing interventions is scarce. There are hardly any scientifically rigorous trials of interventions, or monitoring and evaluation data, to address the impact of climate change on health and health determinants in the Caribbean. This makes it difficult to gain support from potential funders and leadership within and outside of government. This lack of evidence is in part due to the scarcity of national, regional, and international funds to develop and implement robust research to generate the information needed and translate that evidence into policy and practice.

Lack of knowledge, awareness, and skills across society on climate and health. Across social groups and levels of society, knowledge and awareness of climate change and health need to be enhanced. For example, at the individual level, education to recognize signs and symptoms of illnesses related to climate change should be prioritized. Skills in adaptation, mitigation, and resource mobilization must be improved at all levels. The media and faith-based and educational institutions can play important roles in enhancing knowledge, awareness, and skills.

Need for leadership and collaboration at the national, regional, and international levels and between sectors. Smaller countries with limited resources, such as most Caribbean countries, can be more effective and efficient by combining efforts, activities, and policies to address common climate-related challenges. Leadership is needed from national governments, regional entities such as the Caribbean Community (CARICOM) and its institutions, and international development agencies to establish and maintain the necessary collaborative mechanisms.

Case study: noncommunicable diseases

Noncommunicable diseases (NCDs) are one of the CRAA’s priority areas. This case study shows how selected cross-cutting themes described above are applicable to NCDs. It also provides insight into the potential of the CRAA to guide the way forward to build resilience to climate change and safeguard health and health systems in the Caribbean.

NCDs, the leading causes of death in the Caribbean (18), are climate-sensitive conditions. Rising ambient air temperature, extreme weather events, and poor air quality are associated with increased incidence or exacerbation of cardiovascular disease, diabetes, respiratory diseases and cancer (19–23).

Disrupted access to health care due to damage to medical facilities, electric power, transportation, communications, or other infrastructure from climate-related disasters can adversely affect people living with NCDs. For example, an island-wide survey in Puerto Rico following Hurricane Maria in 2017 found that many people had disrupted access to health care due to factors such as the inability to obtain medicines, inability to use respiratory equipment, damaged roads, other barriers to transportation, and closed facilities. This contributed to the number of deaths in Puerto Rico in the three and a half months after the hurricane being 62% higher than during the same period in the previous year (24). Addressing the effects of climate change on NCDs requires action to strengthen health systems and other infrastructure.

To address the cross-cutting theme of insufficient monitoring and surveillance of climate-sensitive health conditions and exposures, data are needed to orient action to reduce the adverse impact of climate change on NCDs. Caribbean ministries of health routinely collect mortality data on some NCDs and member countries of CARPHA provide these data to CARPHA, which enables national and regional mortality analyses (7, 18). However, national and regional systems to track the incidence of NCDs and NCD-related complications are generally lacking.

On the other hand, fledgling progress has been made through the establishment of a climate and health observatory at the Caribbean Institute for Health Research at the University of the West Indies (Mona, Jamaica) to collaborate with regional meteorological scientists to examine linkages between weather events and the incidence of NCDs (11). Combining health and meteorological data can pinpoint populations and areas at risk and enable effective disaster preparedness and recovery. This points to the importance of addressing another cross-cutting theme: institutional silos among key agencies and sectors.

Breaking silos is also important in the field of disaster prevention and recovery. A study in Puerto Rico after Hurricane Maria on people who were obese, overweight, and/or had diabetes found that those who were prepared for the hurricane at a low to medium level were twice as likely to suffer harmful health effects than highly prepared people. Furthermore, people whose diet changed as a result of power outages, financial challenges, and/or disruption to their drinking water supply were significantly more likely to experience detrimental health effects (25). Health and disaster management professionals should collaborate with academic and technical agencies on studies to identify evidence-based strategies that strengthen preparedness and access to health care, medication, and healthy food among people living with NCDs to reduce morbidity and mortality during and after disasters.

The cross-cutting theme, lack of knowledge, awareness, and skills across society on climate and health, is highly relevant to people living with NCDs. There is a need to empower these people with knowledge about the risks associated with heat, poor air quality, and extreme weather events and how to reduce these risks. Initiatives should include information sheets and preparedness checklists for specific NCDs (26). Instruction about how to use these checklists is essential. Studies are needed to document the effectiveness of such educational initiatives and explore opportunities for scale-up.

WAY FORWARD

The CRAA is a first-of-its-kind summation of what is known about the impact of climate change on health in the Caribbean and what is needed to inform actionable climate change and health research. It is intended to guide the development of an evidence base for action by public and private entities and civil society. Its implementation will require multidisciplinary and cross-institutional collaboration that involves fundraising, advocacy, education, research capacity-building, community engagement, and a range of dissemination efforts.

It is therefore imperative that the Caribbean SIDS community utilizes existing activities in the region to implement the CRAA. Funders that support climate change and health activities such as the Adaptation Fund, Climate Investment Funds, and Green Climate Fund, could use the CRAA to guide funding decisions. Furthermore, existing collaborations and initiatives that promote action in the area of climate change and health, such as the Special Initiative on Climate Change and Health in SIDS launched by WHO in 2018, the Caribbean Cooperation in Health IV that calls for resilient and health-promoting environments, and the Caribbean Public Health Law Forum that addresses many of the justice-related issues in climate change and health initiatives, could use the CRAA to inform their climate change and health activities. The CRAA highlights not only the importance of investing in projects and programs, but also underscores the need for capacity-strengthening and surveillance to ensure the sustainability of activities.

Implementing the CRAA will lead to strengthened national climate change and health policy ecosystems in the Caribbean that will drive effective climate action. The first step is active dissemination of the CRAA across different platforms to raise awareness of the research gaps and opportunities and identify potential funders and collaborators. The vision is for the CRAA to be a collaborative living document placed in the hands of leaders and advocates regionally and internationally to develop innovative action-oriented research to reduce the impact of climate change on health in the Caribbean region for this generation and generations to come.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública / Pan American Journal of Public Health and/or those of the Pan American Health Organization and the World Health Organization.