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A n n a l s o f G l o b a l H e a l t h
ª 2 0 1 5 T h e A u t h o r s . P u b l i s h e d b y E l s e v i e r I n c .
o n b e h a l f o f I c a h n S c h o o l o f M e d i c i n e a t M o u n t S i n a i
V O L . 8 1 , N O . 3 , 2 0 1 5
I S S N 2 2 1 4 - 9 9 9 6
h t t p : / / d x . d o i . o r g / 1 0 . 1 0 1 6 / j . a o g h . 2 0 1 5 . 0 6 . 0 0 8
WH I T E PAP ER
Chile Confronts its Environmental Health Future After 25 Yearsof Accelerated Growth
Paulina Pino, PhD, Verónica Iglesias, PhD, René Garreaud, PhD, Sandra Cortés, PhD,
Mauricio Canals, PhD, Walter Folch, MSc, Soledad Burgos, PhD, Karen Levy, PhD,
Luke P. Naeher, PhD, Kyle Steenland, PhD
Santiago, Chile; and Atlanta and Athens, GA
This study
From the S
Research (C
of Public H
Departmen
Health Dep
Health Scie
Abstract
B A C K G R O U N D Chile has recently been reclassified by the World Bank from an upper-middle-
income country to a high-income country. There has been great progress in the last 20 to 30 years in
relation to air and water pollution in Chile. Yet after 25 years of unrestrained growth, there remain clear
challenges posed by air and water pollution, as well as climate change.
O B J E C T I V E The aim of this study was to review environmental health in Chile.
M E T H O D S In late 2013, a 3-day workshop on environmental health was held in Santiago, Chile,
bringing together researchers and government policymakers. As a follow-up to that workshop, here we
review the progress made in environmental health in the past 20 to 30 years and discuss the challenges
of the future. We focus on air and water pollution and climate change, which we believe are among the
most important areas of environmental health in Chile.
R E S U L T S Air pollution in some cities remains among the highest in the continent. Potable water is
generally available, but weak state supervision has led to serious outbreaks of infectious disease and
ongoing issues with arsenic exposure in some regions. Climate change modeling in Chile is quite
sophisticated, and a number of the impacts of climate change can be reasonably predicted in terms of
which areas of the country are most likely to be affected by increased temperature and decreased
availability of water, as well as expansion of vector territory. Some health effects, including changes in
vector-borne diseases and excess heat mortality, can be predicted. However, there has yet to be an
integration of such research with government planning.
C O N C L U S I O N S Although great progress has been made, currently there are a number of problems.
We suspect that the Chilean experience in environmental health may be of some use for other Latin
American countries with rapid economic development.
K E Y W O R D S air pollution, Chile, climate cha
nge, water pollution, policy© 2015 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
was supported by NIH Research Grant #D43TW005746-02. The authors have no competing interests to declare.
chool of Public Health, Faculty of Medicine, University of Chile, Santiago, Chile (PP, VI, MC, SB); Center of Climate and Resilience
R2) and Geophysics Department, Faculty of Physical Sciences and Mathematics, University of Chile, Santiago, Chile (RG); Department
ealth, Advanced Center for Chronic Diseases, Faculty of Medicine, Catholic University, Santiago, Chile (SC); Environmental Health
t, Division of Healthy Public Policy and Advocacy, Subsecretariat of Public Health, Ministry of Health, Santiago, Chile (WF); Environmental
artment, Rollins School of Public Health University of Emory, Atlanta, GA (KL, KS); and the College of Public Health, Environmental
nce, University of Georgia, Athens, GA (LPN). Address correspondence to K.S. ([email protected]).
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I N T RODUC T I ON
In 2013, the World Bank reclassified Chile from anupper-middle-income country to a high-incomecountry, based on its having a per capita grossnational product exceeding $12,600. The WorldBank does not take economic inequality intoaccount in determining a country’s status; Chile’s2011 Gini index (an index of inequality with higherscores indicating more inequality) rating was 51,among the highest in Latin America and 10 pointshigher than the Gini index for the United States in2010.1 In 2010, Chile became a member of theOrganization for Economic Cooperation andDevelopment (OECD), a grouping of 36 developedcountries; among these countries, which includeTurkey and Mexico, Chile has the highest Giniindex.
Although a good indicator of overall disparity,the Gini index does not reflect inequalities withinregions. In terms of economic activity, the north isdominated by mining. The center (the capital cityof Santiago, main ports and agrarian valleys) con-centrates political and financial power, as well asagricultural and industrial activity. Cattle, forestry,and fishing occur mainly in the south. Populationand production are both concentrated in Santiago(49.3% GDP) and Antofagasta, the main miningregion in the north (10.4% of GDP), respectively.2
Poverty (defined as <$7085/y income for a family of4), varies among regions from 4% in Antofagasta,up to 28% in the IX Region of Araucanía, wherethe population of Mapuche ethnic origin is mostlysettled (Fig. 1). Furthermore, inequality varies dis-tinctly within the country; data from 2003 indicatedthat county-level Gini coefficients (then 55 for thewhole country) varied widely across the country,ranging from 41 to 62.3
Compared with most countries in Latin Amer-ica, Chile had a long history of democracy beforethe military coup in 1973. The period since 1939laid the foundations for a successful industrialdevelopment under the state patronage, so that bymid-century the state owned or had interests inmore than 100 strategic enterprises, such as trans-port, energy, and water. Later, the exacerbation ofhistorical political struggles for more structuralchanges ended in the 1973 military coup, whichinterrupted the democratic trail and drasticallychanged the state-oriented policy to an extremeopen marketeoriented system.4 Though the mili-tary regime was characterized by strong business
development, it sharpened the extreme povertyand vulnerability of the poor. The return to democ-racy in 1990 began with 42% of the populationunder poverty and with public social protection sys-tems dismantled.5
Between 1990 and 2015, Chile experiencedunprecedented growth and managed to lower pov-erty to 14.4% (2013)6; however, this growth wasmostly based on raw materials. The OECD, in a2009 report, highlighted the impact of the acceler-ated growth on natural resources and the environ-mental burden generated by mining, agriculturaland forest overexploitation, as well as overcrowdingin Santiago, which was pointed to as among themost polluted the cities in the world.7
Here we describe the state of environmentalhealth in Chile, which may be seen as a model forthe future of other Latin American countries asthey become more developed. After the re-establishment of democracy and a period of rapideconomic growth, during which environmental con-cerns were somewhat on the back burner, now is agood time to assess the overall picture of environ-mental health in Chile and consider how to moveforward. We focus on air and water pollution andon climate change, which are among the mostimportant environmental issues in Chile.
This article reflects the findings of a workshopheld in Santiago, Chile, in October 2013, called“Planning for a Global Environmental Health HubBased in Chile,” which brought together researchersfrom around the country, as well as government per-sonnel working in environmental health. The work-shop was funded by the US National Institutes ofHealth Fogarty International Program, as part of anew initiative to support a multinational networkof regional hubs for Global Environmental andOccupational Health Sciences (GeoHealth).8 Fordetails of the workshop, see http://geohealthchile.blogspot.com/p/environmental-and-occupational-health.html. Chile, with a strong group ofenvironmental health researchers and a nucleus oftechnicians in government agencies devoted to envi-ronmental health, was considered as a possible areafor a future GeoHealth Hub; our team was awardeda Fogarty Planning Grant for a GeoHealth Hub inChile. However, when Chile was reclassified as arich country in 2013, it became ineligible for Fogartyfunding. We now plan that Chile will play an impor-tant role in south-south collaboration in environ-mental health training for a new GeoHealth Hubto be centered in Peru.
Figure 1. Regions of Chile by percentage of people under the poverty line (USD$7085/y for families of 4 members) in 2013. (Data from Chilean Ministry of SocialDevelopment.129)
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A I R PO L LU T I ON : P A S T ANDCHA L L ENG E S
In the past 40 years, air quality in Chile has becomean issue of high concern given the growing propor-tion of population exposed to high levels. Santiago,the capital city with almost 7 million inhabitants(40% of the country’s population), is located in avalley surrounded by mountains from the coastaland Andean ranges. Every winter this topography,along with an inverse temperature layer, limitedrains, and minimal airstream, results in a low disper-sion rate, insufficient to cope with the progressivelyhigher concentration of pollutants emitted.9
As noted earlier, the country has undergone aperiod of accelerated economic and industrialgrowth, with cities occupying land previously usedin agriculture.10,11 By the early 1990s Santiagohad levels of air pollution comparable to megacitiessuch as Sao Paulo and Mexico City, despite havingbarely one third of the population of these cities.12
Air quality monitoring in the metropolitan areaof Santiago was initiated as early as 1974 and stand-ards for criteria pollutants were established in 1978.However, regulatory plans began only in 1990, afterthe military dictatorship lost power. Key interven-tions of those plans aimed at reducing overall emis-sions or were directed at specific pollutants such asleaded gasoline and sulfur in diesel fuel. Particulatematter (eg, PM10 and PM2.5) data, which were reg-ularly collected only starting in 1989, indicated sig-nificant reductions of pollutants in Santiago in theearly years after emissions-reducing policies wereenacted (Fig. 2). However, current PM2.5 levels inSantiago still surpass the 20 mg/m3 Chilean stand-ard for PM2.5 established in 2012,13 as well as theWorld Health Organization’s (WHO’s) 10 mg/m3
annual standard.The interventions to reduce air pollution in San-
tiago, although significant, were not sufficient tooffset the growth of the city, particularly the increaseof mobile sources and the increased use of wood forheating (because of its lower cost compared with gasor electric energy). The public and private vehicularfleet in Santiago has doubled since 2001, reachingthe current 1,700,000 vehicles and accounting for40% of the country’s fleet.14 After decades of mon-itoring and decontamination plans, Santiago in2011 was still among the top 5 capitals in Latin
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Figure 2. Evolution of annual mean PM2.5 in Santiago, 1989e2012. Interventions: a,1990, removal of 3000 buses; b, 1991, arrival catalytic vehicles; c, 1993, sulfurreduction in diesel 5000-3000 ppm; d, 1997, sulfur reduction in diesel from 3000 to1500 ppm; e, 2000, sulfur reduction in diesel 1500 to 1000 ppm; f, 2001, removal oflead; g, 2005, removal of 2200 buses; h, 2007, new system of public transport. (Source:Ministry of the Environment.16,21)
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America with the highest annual mean PM2.5
(Lima, 38 mg/m3; Guatemala city, 33 mg/m3;Tegucigalpa, 32 mg/m3; Bogota, 27 mg/m3; andSantiago, 26 mg/m3).15
In 2004, air monitoring expanded to otherregions of the country, mainly because of the man-datory monitoring required for potentially pollutingprivate companies. Currently the network of airquality monitoring has 130 private and 58 publicstations nationwide that monitor PM10, PM2.5, car-bon monoxide, sulfur dioxide, nitrogen oxide, andozone.16 Five percent of the monitors are inSantiago.16
There are 3 air pollution areas of concern inChile: (1): a north-central zone, with mining andthermal power production that generate particulatematter,17,18 as well as heavy metals and sulfur diox-ide19,20; (2) a highly populated urban area (includingSantiago) of industrial development and largevehicle fleets emitting particulate matter, carbonmonoxide, sulfur dioxide, and ozone; (3) and acold-weather central-south area with heavy use ofwood for domestic use. As stated in the introduc-tion, the southern area has the largest proportionsof poor families, determining their highervulnerability.3
There are very high levels of contaminants insome areas outside of Santiago. Four Chilean citieshave been reported by WHO as being among thetop 5 Latin American cities with highest PM2.5 lev-els in 2011 (Rancagua, 54 mg/m3; Chillán, 53 mg/m3; Temuco, 48 mg/m3; and Talca, 44 mg/m3),15
although these rankings may partly reflect themore extensive regional air sampling in Chile com-pared with other countries. In the southern city ofCoyhaique, daily air PM10 surpasses 350 mg/m3 inwintertime, far exceeding the Chilean daily stand-ards for PM10 (150 mg/m
3).16 This and other south-ern cities, where burning wood is common forheating, register more than 30 “emergency” days(daily values for PM10 higher than 330 mg/m3).This finding has forced the environmental authorityto declare decontamination plans for these areas,which, over 10 years, should bring the 3-year mov-ing average level of the specific contaminant tobelow the annual standard.22
Research on the health effects of air pollutionis still relatively sparse. Most of this research hasbeen time series studies on registered emergencyvisits,23-27 hospitalization28-30 and mortality associ-ated with air pollutants.31-39 In the exposure sphere,some studies have measured personal exposure toparticulate matter40; others have proposed models
to predict the levels of pollutants41 or have identi-fied the source apportionment of outdoor particulatematter.42 Only a few publications have aimed atevaluating the economic significance of contaminantsreduction,43 and there are only a few publicationsdealing with indoor air pollution and its healtheffects.44,45 As expected, studies concentrate primar-ily on the SantiagoMetropolitan Region,23-27,33,34,44
with a some notable exceptions.35,37,45,46
These studies have reported relative risks (RRs) of1.05e1.10 for each 100 mg/m3 PM10 in Santiago forrespiratory mortality in the elderly,47 whereas inTemuco the RRs were higher, which led the authorsto suggest that particles could be more dangerousbecause of chemical composition.35 In terms of mor-bidity, increases of 100 mg/m3 of PM10 were associ-ated with elevated risks of acute respiratory infection(RR 1.16, 95% CI 1.14e1.18) and hospital admis-sions (RR 1.14, 95% CI 1.09e1.18) in those >65years of age.37 Another study conducted in Temucobetween August 2009 and June 2011 assessed thedaily concentration of ultrafine particles (particlessmaller than 100nm) and its relationship to daily out-patient visits for respiratory causes in health centers.The authors reported ultrafine particle valuesbetween 1.62 and 25.81 mg/m3 and significant riskin people older than 65 years for each 4.73 mg/m3
(interquartile range) increase (RR ¼ 1.15; 95% CI1.06e1.25).46 Chemical speciation of fine particleshas been studied, finding that PM2.5 with high con-tent of zinc, chromium, copper, sodium, and sulfurwas more strongly associated with mortality thanPM2.5 mass.48 Overall, these reported RRs are
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Figure 3. Historical coverage of urban sanitation in Chile, 1966e2012. (Data source:Superintendence of Sanitary Services [SISS].62)
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consistent with those found in developed industrial-ized countries, but it has been important to docu-ment these effects in Chile in terms of influencingpublic policy.
Future studies of air pollution effects need to beconsidered in conjunction with climate change,because sources such as burning fossil fuels and bio-mass are common to both.49-51 For example, arecent study (done outside of Chile) found thatthe effect of low or high temperature on mortalityis modified by air pollution and suggests that thereduction in the emission of particulate matter isclosely related to a decrease in mortality in extremetemperatures.50
WAT E R : P A S T AND CHA L L ENG E S
In a short time span, water provision and treatmentin Chile has changed substantially, from state man-agement with widely subsidized prices to privatesector management. Private companies weregranted water rights, and now provide water, sew-age, and waste treatment, with an allowed profitof 7% by law.
By the early 1970s, concurrent with the highrates of urban expansion, Chilean cities reached75% coverage of potable water and 40% coverageof sanitation. Thereafter, under the military dicta-torship (1973e1990), urban coverage of potablewater reached more than 95%. Yet, it should benoted that the official figures did not consider thehigh degree of disconnection of users for nonpay-ment, which was estimated at 30%, given the lowwages and unemployment at the time. This
situation led to a system of targeted subsidies forthe poor.52
With the return to democracy in 1990, the watersector was modernized.53 By the end of the decade,the drinking water system, still under state manage-ment, had achieved high efficiency but withsignificantly higher tariffs for consumers. This hap-pened in a context of unprecedented economicgrowth but with high socioeconomic inequality54
(those in the top 10% of income had 45% ofnational income in 2000),55 thus requiring increasedsubsidies to the poorest.56
After proposals from international agencies, thegovernment sold water and infrastructure rights toprivate enterprises in the late 1990s. The justifica-tion, still under debate,57,58 focused on the inabilityof the state to make investments in wastewatertreatment, which at the time was virtually nonexis-tent.59 The cholera epidemic at the beginning of the1990s was a potent warning, perhaps more for itsimpact on exports than for its health significance,60
because the epidemic was promptly stopped withfocused interventions.61
Figure 3 shows the evolution of urban coverageof supply, sewerage, and wastewater treatment. Atthe beginning of the 1990s only 2.8% of the urbanpopulation lacked access to potable water, but a sig-nificant number had no access to sewerage and therewas virtually no wastewater treatment. Wastewatertreatment was implemented and reached the currentcoverage of close to 98%, but only after users fundedthe cost.52,62
The high availability of potable water andadequate sanitation in urban areas, coupled with tar-geted interventions in children’s health, helpedlower infant mortality from 119.5 per 1000 livebirths (one of the highest in Latin America) inthe 1960s to 16.0 in the 1990s and 7.4 in 2012,one of the lowest rates in the continent.63 Typhoidfever and hepatitis rates, 2 indicators of improvedsanitation, fell sharply in the wake of targeted inter-ventions to curb the epidemic of cholera in thecountry in the early 1990s (Fig. 4).64 Althoughthere was 1 peak of hepatitis in 2002e2003, therehas since been a steady decline. The hepatitis A vac-cine, although available for the wealthy under theprivate health system (covering 13% of the popula-tion in 2011), has not been available to a wider pub-lic except for a few targeted campaigns, so it isunlikely that the large fall in hepatitis rates wasdue to vaccination.
Another challenge has been the long-standingproblem of arsenic in water, which has affected
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Figure 4. Trends in hepatitis and typhoid fever, Chile, 2000e2014. (Sources: Depart-ment of Statistics Ministry of Health, Chile,130 and National Institute of Statistics.131)
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communities in northern Chile, especially the city ofAntofagasta, located in the desert. Between 1958and 1971, this city had very high water arsenic lev-els, averaging 0.86 mg/L.65 Strong complaintsforced the installation of a first abatement plant in1970, resulting in a lowering to 0.12 mg/L, stillhigh compared with the WHO 1963 standard of0.05 mg/L.66 The current Chilean standard wasset at 0.01 mg/L in 2005, although allowing tempo-rary levels as high as up to 0.03 for 10 years.67
Health effects of arsenic in the highly exposed pop-ulations in the north of Chile have been widelydocumented, with excesses of lung cancer,68 bladdercancer,69 and heart disease, which decreased asarsenic concentrations decreased.70
Overall, Chile appears to have been successfulwith regard to its water treatment. However, watercoverage is still limited in some rural areas. Ruralwater is supplied through cooperatives, which regis-ter 99% coverage in more populated areas but only7% in semipopulated and 2% in low-populatedareas.71 In addition, some rural communities alsolack sewerage,72 and in specific northern regions,rural areas are also still exposed to high arsenic con-tent in water.73
The state role remains relatively weak in waterregulation; it is focused on commercial aspectssuch as setting rates, granting concessions, andsupervising that services are delivered. On theother hand, surveillance of water quality relies oncompanies self-monitoring with the support ofaccredited private laboratories, but with ratherloose control from the state. Each company (cur-rently 60 nationwide)74 reports compliance (yes/no) of each regulated item in 1 sample permonth.75
Compliance is high for mandatory parameters,such as total coliforms, turbidity, and residual freechlorine for urban water companies, but otherdata may be incomplete. For example, in December2013, only 54% of monthly reports (386/720)included arsenic measurement and 2% (8/386) sur-passed the current maximum allowance of arsenic inpotable water, with levels between 0.01 and 0.03mg/L.75 Other parameters that occasionally donot meet national regulations are nitrates (88.2%compliance) and sulfates (64.3% compliance), evenunder considerably more lax standards (50 mg/Land 500 mg/L, respectively) than, for example,the US Environmental Protection Agency require-ments (10 and 250 mg/L, respectively).76,77
Nitrates should be an agent of concern, particularlyin agricultural regions, because they can be an
indicator of contamination by fertilizers or organicwastes.78
Furthermore, failures in the current system haveoccurred. In 2010 and 2013, important norovirusoutbreaks occurred in 2 cities, affecting at least40,000 persons. In 1 case, treated wastewater thatwas still contaminated was used for vegetable irriga-tion and entered the food chain, which led to ques-tioning the efficacy of regulations.79 In the othercase, the origin of the outbreak was attributed todirect contamination of drinking water, showingfailures of surveillance in basic parameters of fecalcontamination.80 Both cases affected cities in north-ern Chile where water is scarce, a situation thataccording to the scenarios of climate change willworsen, as discussed later.
Chilean water standards have been slow tochange compared with international standardsthat have become stricter over time. Comparedwith the current WHO standards, Chilean regula-tion includes 23 fewer agents (especially pesti-cides); and among those that are included, theWHO reference value is between 0.5 and 20times more stringent than the Chilean nationalstandard.81,82 It seems likely that Chilean stand-ards have been slow to change as a result of sev-eral factors, including insufficient governmentattention to environmental problems, the opposi-tion of private water companies, and a lack ofpublic pressure.
Finally, as will be noted later, Chile is affected bynatural climatic phenomena and, since 2009, by apersistent drought. Rivers, lakes, and reservoirs aredepleted, a worrying preview of the drying trendexpected with climate change. Yet, though scarcity
Figure 5. Time series of the annual mean temperature at Santiago (upper line) and Antofagasta (lower line) from 1960 to 2013.
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may be a concern, experts have cited good watergovernance as a key for managing mitigation andadaptation under scientific uncertainties and haverecommend policy changes to promote transpar-ency, accountability, and coordination among perti-nent institutions.83,84 Among OECD countries,Chile appears as one of the least prepared for watershortages, with high fragmentation among regula-tory agencies.85
C L IMA T E CHANGE : P A S T AND FU TUR E
There are unambiguous indications of a planetary-scale climate change, as reflected in the warmingof the troposphere and upper ocean, decreases insnow and ice coverage, the rise in sea levels,86 andan overall global trend toward drying in dry regionsand wetting in wet regions.87,88 The magnitude andrate of these changes are unprecedented and largelyattributed to the human-driven increase in the
atmospheric concentration of greenhouse gases, aswell as massive changes in land use.
Climate change is more complicated at a regionalscale (eg, subtropical South America) than at theglobal scale because of more variability in year-to-year and decade-to-decade fluctuations of atmos-pheric and oceanographic conditions. A 2011 reportfrom Chile to the United Nations Framework Con-vention on Climate Change provides a good back-ground on climate change on Chile.89 Here weseek to provide a summary and update of this infor-mation, as well as to discuss potential health effectsof climate change in Chile.
In the case of central and northern Chile, therehas been a warming trend of about þ0.15�C perdecade in the inland valleys and Andean foothills(eg, Santiago) observed over the last few decades,in sharp contrast with a cooling trend of similarmagnitude along the coast and offshore (eg, Anto-fagasta) (Fig. 5).90,91 Much weaker temperature
Figure 6. Projected climate change in Chile.132 The Chile-Argentina border (dashedline) follows the crest of the Andes. (A) Difference in annual mean surface temper-ature (in �C) between the future (average 2070e2100) under the A2 emission scenarioand the baseline period (1960e1990). Note the warming everywhere but mostmarked over the Andes cordillera. (B) Relative change in precipitation (expressed in%) between the future (average 2070e2100) under the A2 emission scenario and thebaseline period (1960e1990). The change is calculated as the difference between thevalues in future and baseline period divided by the values in the baseline period. Thisratio is misleading in northern Chile (signaled by the large asterisk) because thebaseline precipitation is very low (Atacama Desert).
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trends are observed to the south of Santiago(<35�S). Superimposed on these trends one canobserve the impact of El Niño Southern Oscillation(ENSO) on the temperature record: There is acoastal warming during El Niño years, whereas LaNiña years feature an overall cooling.
Also prominent in Figure 5 is a climate shift thattook place in the mid-1970s both at the coast andinland: The decade after the shift has a mean temper-ature w0.5�C warmer than the previous mean tem-perature. It is thought that such climate shift has anatural origin and exhibits an ENSO-like structure.92
Precipitation records reveal a drying trend insouth-central Chile (most pronounced between37�S to 44�S) during the last 4 decades. No signifi-cant trends are detected in central Chile or farthernorth, where the impact of the ENSO cycle is par-ticularly prominent.93 As an example, the annualprecipitation in Santiago (average 280 mm) variedfrom 710 mm in 1997 (El Niño year) to 90 mmin 1998 (La Niña year).
Projections for the climate during the rest of 21stcentury are based on numerical models of thecoupled atmosphere-ocean systems, run at globalscale (global circulations models) or regional scale(regional circulations models). In the current gener-ation of model integrations performed in support ofthe Intergovernmental Panel on Climate ChangeFifth Assessment Report, the so-called representa-tive concentration pathways (RCPs) consider awide range of options of population growth andsocioeconomic development, each of them leadingto distinct greenhouse gas concentrations in thefuture. Which RCP will actually occur is unknown,yet it has major consequences for the magnitude andtiming of the climate change that will be felt inChile. As an example, the global mean temperatureis projected to increase between 0.5�C (under RCP2.6) and 4.0�C (under RCP 8.5) toward the end ofthe century relative to current values.86
Along continental Chile, different global circula-tions models and regional circulations models pro-duce projections differing in magnitude but not indirection.86,94 Generally, the projected trends aresimilar to those observed in the last few decades.Considering a continuation of the heavy emissionscenario sustained during the rest of century, thereis an overall predicted warming in north-centralChile that is modest along the coast (þ1�C abovecurrent values) but increases inland to reach a max-imum over the Andes (up to þ4�C) (Fig. 6A), aswell as a drying trend in central-south Chile thatcan reduce annual precipitation to 70%e80% of
the current values (ie, a rainfall deficit between20%e30%; see Fig. 6B).
These projections suggest that some impacts onpublic health may be expected over the long term.This situation is exemplified by the drought thathas afflicted central Chile since 2009, likely caused
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by a persistent La Niñaelike condition in the cen-tral Pacific. Whether this drought continues forthe next 5 years depends on the internal variabilityof the atmosphereeocean system. Currently, thereis little ability to predict this kind of interannualand interdecadal variability. Likewise, significantyear-to-year fluctuations in temperature and precip-itation will continue to characterize our climate inthe near and far future. These ENSO-relatedanomalies can produce short-lived but intenseclimate extremes, with the potential to triggervector-borne diseases and affect other healthoutcomes.
Although there is a large body of scientific liter-ature on the effect of climate change on the inci-dence of vector-borne diseases, potential impactsin Chile have not been described.95
Chagas disease, transmitted by Triatoma infes-tans, affects 1.5% of rural population and is endemicnorth of the capital city.96 Warmer climate hasbeen associated with spread of the Chagas vector,including decreased mortality, increased fertility,higher proportion infected, and wider breadth ofrange.97-108 In Chile, unexpected wild foci havebeen detected in uninhabited rural setting,109,110
suggesting that this new nondomestic rural settingfor T infestans may be related to warming ensuingafter an ENSO episode. Aedes aegypti, the vectorof dengue, was last reported in 1961 in continentalChile, but in 2000 new populations were detected inChile’s Easter Island,111 followed by a severe out-break in 2002. It reappeared in 2006 and intermit-tently up to now, giving rise to fear that it couldreach the mainland.112 Finally, the rodent-bornehantavirus disease has been endemic in Chile since1995. Increased rainfalls result in increased plantproductivity, which in turn gives rise to higherrodent populations, ultimately followed by increasesin human cases.113,114 This dynamic has beenstudied in relation to rains during El Niño.115-118
More extreme precipitation events accompanyingclimate change may increase rodent populationsand hantavirus cases.
Regarding the effects of climate change on airand water quality, some educated guesses can bemade. In south-central Chile, wintertime air pollu-tion episodes are mostly produced by particulatematter that is associated with cool, stable, and dryatmospheric conditions.119 On the other hand,models consistently predict a warming-drying trendfor this region. Given the already semi-arid climateof central Chile, the drying trend is likely the mostimportant driver in this region, leading to an
increase in wintertime air-pollution episodes incities like Santiago because of the dramatic reduc-tion of rainfall episodes that tend to clean the tropo-sphere. The warming trend may be the moreimportant driver in humid southern Chile, and themost probable outcome is a reduction of air pollu-tion episodes in cities like Temuco, by reducingthe number of very cold nights, when particulatematter is trapped in the lower troposphere. Sum-mertime air pollution events are largely producedby increase in lower-tropospheric ozone, whoserate of production increases with air temperature.Thus, the projected warming trend is conducive toan increase in this type of episode.
The projected increase in air temperature willalso modify the annual cycle of stream flow.Currently, the peak flow occurs around Decemberin Andean valleys of central Chile, but less precipi-tation and warmer temperatures could lead to amore rapid snowmelt and earlier peak flow, thuscausing an extended and more intense dry season.
There are some studies projecting the availabilityof surface water resources under climate change sce-narios.120,121 Given the projected reduction of pre-cipitation (between 20% and 30% of the baselinevalues), the annual mean flow in rivers should alsodrop. The flow reduction is about 10% more acutethan its precipitation counterpart, given theincreased losses by evaporation in a warmer climate.Reductions in surface water flows would reduce theChilean capability of hydropower generation, whichhas the potential to increase greenhouse gas emis-sions as a result increased reliance on thermal energysources if renewable sources do not emerge as aneffective alternative. The fate of Chilean aquifershas not yet been sufficiently investigated, but thedrying trend in south-central Chile will eventuallyreduce groundwater levels. Furthermore, pressureon groundwater will likely intensify with reductionsin surface flows, as evidenced by the current pro-longed drought period.122 Likewise, less precipita-tion and higher temperatures will result inshrinking glaciers, although a detailed, quantitativeestimate of this reduction is not yet known.
Less water in the rivers will have a negative impactespecially for agriculture, which currently uses 73% ofthe available water in Chile.123 The impact woulddiffer in the geographical regions. Decreased qualityand quantity of crops may be expected in the north,affected by severe drought, hot temperature in theinland, and decreased availability of water.89 Agricul-tural areas may be pushed to the south, changing thetype of crops as seen lately in southern Araucania
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(Chile’s poorest region) and Los Lagos regions,where production of corn and potatoes increased asmuch as 200% as a result of a favorable balance ofrainfall and maximum-minimum daily temperaturerange.124 Other anticipated effects include rises ofmeat prices because of reduced viability of cattle pro-duction and migration of agricultural workers tosouthern areas or to the cities.89 Possible adaptationstrategies include genetically improved crops, moreefficient use of irrigation systems, and sustainablemanagement of groundwater.89
Research on health effects of climate changeshould incorporate the impact of extreme hydrocli-matic events as that seen recently (March 2015) inthe north, where an unexpected rainfall exceededthe 18 mm annual average, causing floods of waterand mud, killing 30 people, and posing serioushealth risks to the survivors. The most affected arethe poor in the north, an area where inequality isvery high, who live in areas most likely to be affectedby the risks of water scarcity and contamination andflooding.
Children are of special concern for possiblehealth effects of climate change, because they aremore vulnerable to these threats.125 An area offuture research should be the differential healthimpacts of climate change in Chile on children.
D I S CU S S I ON
This overview of the current state of the environ-ment and environmental health research in Chileillustrates the limitations of the “neoliberal” modelof development in recent years (ie, free marketswith little state intervention). There have been nota-ble successes in terms of basic sanitation and avail-ability of safe drinking water, but state controlremains sporadic and private water companies maynot regulate themselves sufficiently, as the recentoutbreaks of norovirus suggest.126
The case of air pollution is another examplewhere Chile has met with some success, but thereare still persistently high pollutants in parts ofthe country. In spite of arduous efforts over 25years to lower PM2.5 levels, Chile has failed toreach national air pollution standards for PM2.5
(20 mg/m3) in the capital, and other cities are con-taminated at even higher levels as a result of mobilesources, large fossil-fuel power plants, and primi-tive use of wood in homes of central-south Chile.These flaws are likely to be typical of environmen-tal progress in many Latin American countries
emerging from poverty: initial successes followedby stagnation.
The threat of climate change adds urgency.Because many of the same sources of greenhousegases affect both climate change and air pollution,most experts believe that these issues should beaddressed in a coordinated manner.49,127 Climatechange is also likely to result in water shortagesin southern Chile, again requiring coordinationwith agencies regulating water, to address thisproblem.
In 2010, Chile joined the OECD, a group ofhigh-income countries, and recently was officiallyclassified as a high-income country by the WorldBank. However, economic inequality is far higherthan in other OECD countries.125 In our view, Chileshould take advantage of its new status to readjust itsinstitutions regarding the environment in order forthem to work in a transparent, coordinated, andcooperative manner.85,127 Profound structuralchanges will be required in Chile to reach the higherenvironmental standards of OECD countries.128
Research on environmental health to date inChile has been largely insufficient and has lackeda multidisciplinary approach. Lack of funds fromthe state, lack of or difficult access to private andeven public data, and unreliable laboratory capabil-ities pose significant limitations to environmentalhealth research. Chile has one of the leadingeconomies in Latin America and a growing bodyof researchers in environmental health. With thisstrong foundation, the government and theresearch community of Chile can and should iden-tify and implement necessary changes to movebeyond the current somewhat stagnant environ-mental health situation. It is likely that otheremerging economies in Latin America are orsoon will be coming to a similar juncture. If Chilecan find a way to move forward, perhaps it can be amodel not only for economic progress but also forprogress in environmental health.
ACKNOWL EDGMENT S
The author thank Julio Monreal for his helpful discus-sion and comments in the water section; FernandoMuñoz and Ivan Brstilo, who provided informationregarding the hepatitis A vaccine in Chile; and thespeakers and attendees of the GeoHealth-Hub work-shop held in October 2013 for their valuable contribu-tions to the discussion of the issues analyzed in thismanuscript.
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