Climate Change and Health in Indonesia

-What can Dokters van de Wereld do?-

Author: Jan Willem Knibbe 1473735 Supervisors: Remco van de Pas, MD (MdM) Arianne de Jong, MSc (MdM) Daniel Puente Rodriguez, PhD (VU) Frank Kupper, PhD (VU) VU University Amsterdam; Faculty of Earth and Life Sciences; Management, Policy Analysis and Entrepreneurship in the Health and Life Sciences Internship 1 (30 ECTS) at Dokters van de Wereld, Amsterdam Amsterdam, August 2010

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The rich will find their world to be more expensive, inconvenient, uncomfortable, disrupted and colourless; in general, more unpleasant and unpredictable, perhaps

greatly so. The poor will die. (Smith, 2008)

Preface

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Preface The report you are now reading was written as the final document of the internship I did from February till August 20101 at Dokters van de Wereld for the study Management, Policy Analysis and Entrepreneurship in the Health and Life Sciences at the VU University Amsterdam. The research was conducted to give Dokters van de Wereld a policy document on how to deal with the effects of climate change on health in their programs. I would like to thank Remco van de Pas and Arianne de Jong for supervising and helping me with doing this research. I would like to thank Daniel Puente for helping me to start up this research. And of course a big thanks to everybody at Dokters van de Wereld for having a great time at the office. Last, but not least, I would like to thank the interviewees for cooperating with this research. The quote on the previous page gives probably the best indication on what climate change will mean to us. I think this should be a motivation for all of us to try our best to prevent the effects of it. Jan Willem Knibbe Amsterdam, August 2010

Content

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Content

Preface ..................................................................................................................... 3

Content .................................................................................................................... 4

Summary .................................................................................................................. 6

1 Introduction ....................................................................................................... 7

1.1 Background Médecins du Monde .................................................................... 7

1.2 Climate change ............................................................................................. 7

1.3 Introduction Indonesia .................................................................................. 9

1.4 Problem definition ....................................................................................... 10

1.5 Objectives .................................................................................................. 11

1.6 Research questions ..................................................................................... 11

2 Conceptual framework ...................................................................................... 12

3 Methods ........................................................................................................... 16

3.1 Literature study .......................................................................................... 16

3.2 Interviews .................................................................................................. 16

4 Climate change in Indonesia .............................................................................. 20

4.1 Extreme rainfall........................................................................................... 20

4.2 Rising temperatures .................................................................................... 22

4.3 Flooding ..................................................................................................... 24

4.4 Extreme drought ......................................................................................... 25

4.5 Tropical cyclones ......................................................................................... 27

4.6 Conclusion .................................................................................................. 27

5 Policy Response MdM ........................................................................................ 28

5.1 Health facilities ........................................................................................... 28

5.2 Inter-sectoral policy .................................................................................... 30

5.3 Norms and regulations ................................................................................ 32

5.4 Disease-specific and integrated programs ..................................................... 34

5.5 Outbreaks ................................................................................................... 35

5.6 Threats and opportunities ............................................................................ 36

6 Early Warning Systems ..................................................................................... 38

7 Conclusion ....................................................................................................... 41

7.1 Sub research questions ............................................................................... 41

7.2 Main research question ................................................................................ 41

8 Discussion ........................................................................................................ 43

8.1 Literature study .......................................................................................... 43

8.2 Interviews .................................................................................................. 43

8.3 Policy ......................................................................................................... 43

9 Literature ......................................................................................................... 45

Appendices ............................................................................................................. 51

I. Definitions ........................................................................................................ 52

II. El Niño ............................................................................................................. 55

a. What is ENSO ................................................................................................ 55

Content

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b. El Niño and climate change .......................................................................... 56

III. Interview design ............................................................................................ 57

IV. Code Tree ...................................................................................................... 59

V. Matrix .............................................................................................................. 60

Summary

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Summary In this research the relation between climate change and health is investigated for Indonesia. Also a policy is formulated for the Dutch branch of the non-governmental organisation Médecins du Monde (MdM) on how to implement this topic in their projects. This is done with a combination of literature study and interviews. A theoretical framework is used that indicates several roles for the health sector to include the effects of climate change into the curricula. Six roles are indicated and for each of them it is investigated what the role of MdM can be. It is found that in Indonesia more weather related extreme events will occur than now is the case. There will be more periods of extreme drought, extreme rainfall and floodings happen more often, the average temperature will rise. Because of these changes several infectious and vector borne diseases will increase. Also the food production will be decreased, which may lead to food shortage and thus malnutrition. The main policy recommendation for MdM is to look for partners willing to cooperate on climate change theme. These partners should also be sought outside the health sector. The effects of climate change should be taken into account in new and existing projects and not as a standalone project. MdM should be prepared for the effects and should train the local health workers on how to deal with these effects.

Introduction

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1 Introduction In this research the relation between climate change and health is investigated and what this will mean for Dokters van de Wereld in the context of their projects in Indonesia. This first chapter gives an introduction on what climate change is within the framework of the current research and why this is important for Dokters van de Wereld. The problem is defined and the goals of the research are stated. The chapter will conclude with the research questions.

1.1 Background Médecins du Monde

Médecins du Monde (Doctors of the World) is medical aid organisation origination from France. It was established in 1980 by Bernard Kouchner who felt uncomfortable by the political neutrality of Médecins Sans Frontières1. Therefore one of goals of MdM is, besides from giving aid, to speak out against humanitarian violations. Dokters van de Wereld2 is the Dutch branch of the international medical aid organisation Médecins du Monde and is established in 1997. Its mission is to provide medical care to the most vulnerable groups all over the world, including the Netherlands, to improve the access and right to health care and to advocate against human rights abuses. Most of the work of MdM consists of long term aid (70%) and the other 30% of emergency aid. MdM has currently projects in Indonesia located at two locations: the highlands of Papua and the westerns part of Aceh. In Papua the focus is to improve the access to primary health care and prevention infectious diseases. The project in Aceh is on the improving and promoting of mother and child health. Both projects are developed in close cooperation with local organisations and the local community. They are located in the remote and rural areas of the country where health care is underdeveloped and not accessible for everyone. Currently a new Memorandum of Understanding will be signed between MdM and the government of Indonesia which grants the continuation of the projects for the coming years.

1.2 Climate change

It is now widely accepted that the climate is changing and that this change is human driven (Trenberth et al., 2006; Costello et al., 2009; UNDP, 2007). The worldwide 12 warmest years on record within the past 150 years have been during the past 13 years: 1998 was the warmest, followed by 2005, 2002, 2003, and 2004 (Costello et al., 2009). Figure 1 gives a comparison between climate models that include only natural factors (in blue) and models that also take human factors in account (Solomon et al., 2006). This figure shows two things clearly: (i) the temperatures are rising during the last 50 years and (ii) this change cannot be explained by taken only natural factors into account.

1 Médecins Sans Frontières is French medical aid organisation established in 1971 by French medical professionals. It gives medical assistance in areas affected by human or natural disasters. 2 In this report MdM is used as abbreviation of Dokters van de Wereld.

Introduction

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Figure 1 Comparison between various types of climate models with observervations. In blue models that only include natural factors, in red models that also include human factors

(Solomon et al., 2007).

The main driving force of climate change is the greenhouse gases such as carbon dioxide and methane. These gases allow the radiation of the sun to pass through the atmosphere, but absorb the radiation that comes from the earth. This leads to warming of the earth. The concentrations of these gases in the atmosphere have been increased since the industrial era (Dorland, Dubelaar-Versluis, & Jansen, 2010). The Intergovernmental Panel on Climate Change (IPCC)3 concludes in their latest reports that the temperatures will rise even more the coming decades. Most of the emission of greenhouse gases is produced by developed countries. To give an indication, in the United Stated this is almost 6 tC/yr and in Western Europe about 3 tC/yr. For developing countries the average emission per capita is 0.6 tC/yr, thus 10 times as low as for a US citizen (Patz, Gibbs, Foley, Rogers, & Smith, 2007). Although developing countries contribute only little to climate change; they will suffer the most from the effects (Patz, Gibbs et al., 2007).

3 The IPCC is the leading body for the assessment of climate change, established by the United Nations

Environment Programme and the World Meteorological Organization to provide the world with a clear scientific view on the current state of climate change and its potential environmental and socio-economic

consequences.

Introduction

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Climate change will have some wide-ranging consequences for the environment and thus will directly affect the way people live. Aspects one can think of are more natural disaster as floodings or extreme droughts. These aspects will also have an effect on the health of people. It is therefore an important theme for MdM to take into account in their projects in Indonesia, as climate change will have a great impact there.

1.3 Introduction Indonesia

The focus in this research is on Indonesia. Therefore the country and its health sector shall shortly be introduced. The information in this paragraph comes from The World Factbook4 of the Central Intelligent Agency of United States of America and country report of Indonesia made by MdM (MdM Indonesia, 2009).

Country profile

Indonesia is an archipelago that comprises more than 17,000 islands, of which approximately 6000 are inhabited. The country lies around the equator and forms a crossroad between the Pacific and Indian oceans and a bridge between two continents, Asia and Australia. The country extends 5,120 km from west to east and 1,760 km from north to south. Most of the country is coastal lowland, but the bigger islands (e.g. Java and Papua) have mountain regions. The highest point is the Puncak Jaya in Papua, which is 5,030 m high and permanently covered with glaciers. As Indonesia is located around the equator, the climate is tropical with average temperatures varying from 23 °C to 28 °C in the coastal regions and humidity ranging from 70% to 90%. The rain season is from December to March and the dry season is from June to September. About 240 million people live in Indonesia, from which almost half live on Java. The population can be divided in two major ethnic groups: in the western region most of the people are from the Malay ethnicity while in the eastern region there are the Papuans originating from the Melanesian Islands. Indonesia is a fast urbanising country. In 1980 22% of the population lived in cities, while in 2006 this number almost doubled to 42% (Firman, Kombaitan, & Pradono, 2007). The urbanisation growth is now estimated to be 3.88% (Globalis, 2005). This growth will have great impact on the availability of resources in the cities.

Health sector

The health sector in Indonesia is organised according the administrative regions. The basic health care is provided by Puskesmas (Pusat Kesehatan Masyarakat - Community Health Centre) and every subdistrict (3,625 in total) has at least one such basic primary health clinic, where one or more doctors, a public health nurse, midwives and other paramedics are posted. These Puskesmases are supported by two or three subcentres,

4 See https://www.cia.gov/library/publications/the-world-factbook/geos/id.html

Introduction

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usually headed by a nurse. In addition to the subcentres there are integrated health posts at village level. These are usually run by the community with assistance from Puskesmas staff. In Figure 2 shows this structure and indicates the number of the various clinics operating in Indonesia. In addition to the Puskesmases, there are hospitals at various (apex, central, provincial, district) levels. Patients are usually referred to one of the hospitals for curative care. At this moment a movement of decentralisations takes place within Indonesia. This means that the responsibility for implementation of health services is transferred to local governments at the district level. Therefore districts are also responsible for delivering health services and allocating resources. However regulations regarding to make decisions and budgets, and the capacity to carry them out, do not exist, largely because overall civil service reforms have stuck. Also the financing is managed centrally by the Ministry of Health, based on the previous year’s budget, instead of needs and demands.

Figure 2 Organisational structure of the health system at district level. The numbers in parenthesis indicate the number of each.

The projects of MdM are mainly focused at the district level. The main organisations to deal with are the Puskasmas. The main focus is on access to health care, especially primary health care.

1.4 Problem definition

There is major consensus among climate scientists that the climate is changing. This will have an impact on the health of people and the health system in Indonesia, where MdM has several projects to improve the health care. MdM has made climate change as one of their strategic themes for the years 2010-2013 they are thus interested in the relation between climate change and health in Indonesia. Therefore the research problem is to investigate the relationship of climate change with health and write a policy paper on how this theme can be implemented in projects of MdM in Indonesia.

Introduction

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The climate is changing according to the majority of scientists, which will also have an impact on health. MdM is a Non-Governmental Organisation (NGO) that tries to improve the health of vulnerable populations in the world. These people are among the most affected by the climate change. Therefore MdM has made climate change and health as one its strategic themes for the years 2010-2013. The focus will be on Indonesia where MdM has already several projects running. The research problem is to investigate the relationship of climate change with health and write recommendations on how this theme can be implemented in projects of MdM in Indonesia because it is a new theme for MdM.

1.5 Objectives

The objective of this research is to write a context paper on climate change and health in Indonesia with recommendation for the MDM programs by doing literature research on the effects of climate change on health in Indonesia and with interviews how this can be best implemented as policy.

1.6 Research questions

What expected elements of health affected by climate change are relevant for the projects of MdM in Indonesia, and how can the relation be incorporated as a strategic theme for MdM?

Sub research questions

1. Who will be most affected by climate change in Indonesia? 2. How will health be affected due to climate changes in areas of Indonesia where

MdM is working? 3. What are possible strategies that MdM can implement to mitigate the negative

effects of climate change on health in their program?

Conceptual framework

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2 Conceptual framework This chapter explains the framework that is used for this research. It is comparable with the framework McMicheal et al. (2003) use for studying climate change and health. However here it is adapted in such way that is suites this particular research. Figure 3 shows a schematic overall representation of the conceptual framework and Figure 4 and Figure 5 show the more detailed aspects of it. Figure 4 shows in detail the concepts of effects of the changing climate on health. Figure 5 shows what the most important concepts are to incorporate in the policy for MdM. These diagrams will be explained in detail hereunder. The climate has an influence on health, for example malaria only exists in certain areas where the temperature is high enough for the survival of the parasite and mosquito to survive. Also direct effects occur, for example during heat waves the mortality rate is higher because of heat stress (McMichael, Woodruff, & Hales, 2006). Within the context of multiple interactions between health and a changing climate, a relevant question is in what way the health of people will be affected due to this climate change. This is indicated by the question marks in the arrow that goes from the health in the current situation to the health in the new situation. The most important aspects of the possible interaction of the changed climate for this research are made specific in Figure 4, which is taken from McMicheal et al. (2006). In this research it is investigated which of these interactions are relevant for Indonesia. Depending on the context, different effects are relevant. This is indicated in Figure 4 by the rectangle with projects in it. For a given project one has to ‘filter’ to see what effects are relevant. Figure 5 shows 6 aspects that are crucial for a health system when looking at environmental health. These aspects are (i) ensuring that environmental health issues are adequately reflected in inter-sectoral policy development and implementation; (ii) setting and overseeing the implementation of health-protecting norms and regulations; (iii) incorporating environmental health in programmes; (iv) practising environmental health in health-care facilities; (v) preparing for and responding to outbreaks of environment-mediated diseases; and (vi) identifying and responding to emerging threats and opportunities for health (Rehfuess, Bruce, & Bartram, 2009). McMicheal et al. (2003) also mention these points as important when writing policy for successful assessment of the health consequences of climate change. In the policy advice these points are taken and it is investigated how these can be accounted for. This is done via interviews with experts on climate change, health and policy. In paragraph 03.2 the topics of the interviews are explained. The main concepts arising from this scheme are indicated in Table 1.

Conceptual framework

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(i) Work intersectoral

(ii) Norms & regulations

(iii) Incorporate in programs

(iv) Practice in facilities

(v) Be prepared

(vi) Threats & Opportunities Table 1 Main concepts of the policy

Figure 3 Schematic overview of the conceptual framework

Conceptual framework

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Figure 4 Schematic summary of main pathways by which climate change affects population

health (McMichael et al, 2006).

Conceptual framework

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Figure 5 Health sector functions to secure environmental health (Adapted from Rehfuess et

al., 2009).

Methods

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3 Methods This chapter explains what methods were used to answer the research questions. It states how was proceeded to find the literature and what the criteria were for using the various articles. The second part relates to the interviews. The criteria for selecting are stated, the interview topics are explained and finally a short description of the interviewees is given.

3.1 Literature study

The literature study was used to investigate what the impact of climate change will be on health in Indonesia. This makes it possible to answer the first two sub-research questions: (i) Who will be most affected by climate change in Indonesia? and (ii) How will health be affected due to climate changes in areas of Indonesia where MdM is working? To do this, literature was reviewed that gives information on climate change and that gives information on the relation between climate change and health. These two topics were combined to see what the specific connections are for Indonesia. Literature was searched via search engines as PubMed, Google Scholar or MetaLib with appropriate search terms. 5 Other sources included reports by the World Health Organisation (WHO) on the topic of climate change and environmental health. Also the latest reports of the IPCC were used as a source of information. Furthermore, references from review articles were followed. An attempt was made to find as many different sources of information to make triangulation of the information possible. Triangulation was performed by comparing different sources and only using certain information when it was found in various articles. To ensure that the latest information was used, mainly articles that were published no more than 10 years ago were selected. The use of literature study was also necessary because there is not much knowledge present in the field regarding the relation between climate change and health in Indonesia. Therefore it would be hard to conduct fieldwork to investigate this relation. Another reason was to gain knowledge on the theme, making it possible to ask in-depth questions during the interviews.

3.2 Interviews

Interviews were used for two reasons. One was to triangulate the conclusion of the literature study part and the other was to gain information on what the best practices are for MdM to develop its policy. By performing interviews it was possible ask in-depth questions and investigate what specific MdM could develop as a policy.

5 Search terms used include (combinations of): climate change, Indonesia, health care system,

environmental health, communicable diseases, extreme weather events, urban heat effect.

Methods

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The interviewees were contacted by email to which a preliminary version of the chapter on climate change in Indonesia was attached. This was done to give the interviewee background information. In total, six interviews were performed. Three people were selected on their knowledge of policy and climate change and three persons on their specific knowledge of Indonesia and MdM. The interviewees will be introduced below. The interviews were semi-structured; the topics discussed are explained below. The interviewee was asked for permission to record the interview, so that it would be possible to transcribe the interview later for analysis. The interviews took about 45 minutes and took place at a location that was best suited to the interviewee. The analysis was performed by first transcribing the interview. The transcripts were labelled and summarised based on the sub-research questions. With these summaries a grounded analysis was applied (Verschuren and Doorewaard, 1999). The labels and categories can be found in the appendix. The results of the interviews are integrated in chapter 4.65 on recommendations for MdM policy.

Topics of the interview

Effects of climate change Indonesia on health as identified from literature The first topic discussed is the relation between climate change and health in Indonesia. This is done for triangulation of the results found from the literature and to ensure that no important themes are missed. What are the risk areas? This topic is discussed to answer the first research question about who will be mostly affected by climate change. For this topic it is discussed what regions are most vulnerable, which groups are at highest risk et cetera. Who are possible partners to make alliances with? It is for MdM important to make coalitions in the field in order to reach its goals. Therefore the topic of indentifying potential partners is included in the interview. These partners can be other NGOs, but also governments or the profit sector. What is the role of the Indonesian health sector in the field of climate change? The second part of the first main research question is about what way MdM can include climate change in their programs. As MdM is a health organisation, it is important to know what the role of the health sector is in the field of a changing climate.

Methods

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What can be the role of primary health care? One of the main aspects in the projects of MdM is improving primary health care. This is also mentioned as one the primary roles of the health sector, see for example the 2008 World Health Report: Primary Health Care (Now More Than Ever). Therefore it will be investigated what the role of primary health care can be. What are the different roles for good environmental health? In the article of Rehfuess et al. (2009) several aspects are mentioned for good environmental health. This article is used as basis in the conceptual framework. Therefore it is asked to interviewees how they see the various roles mentioned. What specific knowledge is needed for health workers? The fundamental tasks have to be carried out by the local health workers. Therefore it is asked what knowledge and skills they need to have regarding climate change. This is done so that in the programs of MdM specific trainings can be included. Table 2 links these topics with the variables that are identified in the previous chapter.

(i) Work intersectoral Possible partners

(ii) Norms & Regulations Roles for good environmental health

(iii) Incorporate in programs Role health sector

(iv) Practice in facilities Knowledge health workers

(v) Be prepared Effects of climate change // Risk areas

(vi) Threats & Opportunities Roles primary health care Table 2 Main concepts of the policy related to the interview topics.

Interviewees

This paragraph gives the information on the interviewees. This information is adapted from the sites of the organisations they work for. The interviewees were selected on ground of their research expertise. People were found by searching on the websites of the Dutch universities for groups that perform research on a combination of the topics climate change, health and policy making, preferable with a link with Indonesia. Also, two people from MdM were interviewed, both experienced in working in Indonesia for MdM. Finally an interview was performed with four people from the Indonesian ministry of health. Anrik C.F. Engelhard, MD/PhD Mr. Engelhard is a public health specialist working in the field of leprosy and tuberculosis control for the Royal Tropical Institute. Trained as a medical doctor, he worked in Zambia as a district medical officer in both clinical and public health settings. He has also worked in Sulawesi, Indonesia, as a project leader for Netherlands Leprosy Relief. He now works mainly in Brazil, Nigeria and Mozambique.

Methods

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He is also the founder of My CO2 Track Foundation, an organisation that tries to contribute to global CO2 emission reductions in order to mitigate the climate changes that result from CO2 emissions. Community based activities serving this goal are directed towards and in participation with energy end-users like citizens, moderate sized companies, organisations and institutes. Phillip H. Pattberg, PhD Philipp Pattberg is a senior researcher at the Institute for Environmental Studies of the VU University Amsterdam, and Assistant Professor at the Department of Political Science, Faculty of Social Sciences, VU University Amsterdam. His current research focuses on the concept of transnational organisation, the overall architecture of global governance, the effectiveness and accountability of global public policy partnerships and the future of the global climate regime. Prof. Pier Vellinga, PhD Pier Vellinga is professor in Climate Change at Wageningen University Research and VU University Amsterdam. Originally, he specialised in Coastal Engineering contributing to the Deltaplan of the Netherlands. In 2007 he took up a position at Wageningen University Research as well, to lead the national climate change research programme Knowledge for Climate. Pier Vellinga is a board member of several research institutes and environmental organisations in the Netherlands and abroad. Remco van der Pas, MD Remco van der Pas is board member for MdM. He has worked for several years for the projects of MdM in Papua and Aceh. He is trained as medical doctor and has a master’s degree in International Public Health. He knows works at Wemos, an organistation that tries to strengthen the health care systems in developing countries. He has therefore good knowledge on all three key points of this research. Petra Wisse Petra Wisse is the general coordinator for MdM’s projects in Indonesia. Before, she was the program coordinator of the project in Aceh. She lives most of the year in Jakarta, Indonesia. As such, she has a lot of knowledge the situation of Indonesia and how climate change fits within Purwani Eko Prihatin, Syafdewiyani, Siti Hajar, & Akhiat This interview was held with all four together, where after a discussion in Bahasa Indonesia they came up with a common answer. Therefore this introduction and the results are combined. All four work at the Indonesian ministry of health, at the division of planning. This division is responsible for the allocation of health workers in different districts. Also, this department is in charge in case of an emergency.

Climate change in Indonesia

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4 Climate change in Indonesia The fourth assessment report of the IPCC gives an overview of the changes of the climate and their consequences per world region. In this chapter the effects of these changes for Indonesia will be summarised. These climate changes will be linked with the effects they have on health. The effects mentioned here will be used as background for the actions MdM can take in their new and existing projects in Indonesia.

4.1 Extreme rainfall

In Indonesia, more than halve of the 1,429 disasters between 2003 and 2005 were hydro-meteorology related. This means they were caused by extreme precipitation (State Ministry of Environment Indonesia, 2006).

Most studies indicate that extreme rainfall shall increase in Indonesia. For example, a study by Manton et al. (2001) shows that the number of rain days in Indonesia has increased significant. Also an increased difference in rainfall between the dry and rain period in Java is found (Chen, Xie, & Janowiak, 2002). This indicates that the rainfall is more concentrated and thus the amount that falls at a certain point has increased. This is sketched in Figure 6, where the annual rainfall patterns for Java and Bali are sketched (UNDP, 2007). This is also visible in Figure 7 which shows an indication on the changes in rain that falls during monsoons. Also the amount of water vapour in the air is increasing as temperature rises. This will lead to an increase in intensity, but also to reduced frequency or duration of precipitation (Trenbeth et al., 2007). On the contrary, Dai, Trenberth, and Qian (2004) found that Indonesia will become slightly drier. It should also be noted that rainfall patters greatly depends on atmospheric circulation patterns determined by El Niño (Trenberth et al., 2007), which is likely to have a much bigger impact on rain patters than climate change. In chapter II a short review of the El Niño/Southern Oscillation is given.

Climate change in Indonesia

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Figure 6 Likely future rainfall pattern in Java and Bali (UNDP, 2007).

There is a correlation between an increase of mean rainfall and a higher risk of extreme daily rainfall (Meehl et al., 2005). When the mean rainfall increases, the increase in precipitation extremes is greater than the overall increase in precipitation (Kharin & Zwiers, 2005). That is to say that relatively more precipitation will fall during extreme events. This extreme precipitation will have several effects on health, especially on waterborne infectious diseases. A study by Curriero, Patz, Rose, and Lele in 2001 showed a statistically significant association between rainfall and outbreaks of water-borne disease in the United States. As the US is a high developed country, with good health care and sanitation, one can expect that this relation in Indonesia will even be stronger. In 2006, only 37% of the rural population of Indonesia had access to improved water sanitation facilities6 (WHO, 2006). It is likely that this number is even lower in the more remote areas of the country, such as Papua. A cause of these outbreaks is that substantial shares of the total microbial loads in watercourses and in drinking water reservoirs result from rainfall and extreme runoff events (Kistemann et al., 2002). It was found in this study that concentrations of bacteria that cause diarrhoea increase. The reason for this increase of bacteria in the water can be understood because during heavy rainfall, the directions of water flow are changed

6 The WHO defines improved water sanitation as “the types of technology and levels of services that are more likely to be sanitary than unimproved technologies. Improved sanitation includes connection to a

public sewers, connection to septic systems, pour-flush latrines, simple pit latrines and ventilated improved pit latrines. Not considered as improved sanitation are service or bucket latrines (where excreta

is manually removed), public latrines and open latrines.”

Climate change in Indonesia

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and the water will flow through channels normally free of water. For example, the water runs across the surface of fields where cattle is grazing. The water with cattle faeces then pools around the head of the borehole and leaks into the water supply (Hunter, 2003). Also the efficiency of sewage systems is reduced during extreme precipitation, thus causing an increased likelihood of microorganisms in water systems (Rose et al., 2001).

Figure 7 Change in the mean annual range of precipitation: 1976 to 2003 minus 1948 to 1975

periods (mm per day). Blue/green (red/yellow) colour denotes a decreasing (increasing) annual range of the monsoon rainfall. Grey areas indicate missing values (oceans) or areas

with insignificant annual changes (Trenberth et al., 2007).

Summarising, it is expected that (extreme) rainfall will increase the coming years. This will lead to an increase in diarrhoea, thus articulating the importance of good sanitation.

4.2 Rising temperatures

It is projected that the temperatures in Indonesia will rise about 1 to 2 °C the coming 50 years (Cruz et al., 2007). This rising temperature will have several directs effects on health and on the distribution of vector-borne diseases. These changes are described below.

Effect of rising temperature on non-communicable diseases

The urban heat island is an important effect on the health in cities. The temperature is higher than in surrounding rural areas, because building and asphalt increase heat absorption and lower evaporative cooling. Dark areas such as roof tops or asphalt can reach temperatures up to 30 degrees warmer than the surrounding air. The overall temperature is a city can be 5-11 degrees warmer that of rural areas. These higher temperatures will lead to more temperature related diseases and deaths. The urban population in Indonesia is increasing in a high tempo (Globalis, 2005), as is stated in paragraph 0. This means that in combination with the rising temperatures the urban heat island will have an important contribution to health. Air pollution concentrations may also rise during heatwaves and may contribute to the raised death rates (Haines, Kovats, Campbell-Lendrum, & Corvalan, 2005).

Climate change in Indonesia

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The human body has a range of temperatures where it can function best, the so called ‘comfort zone’. When temperatures rise above this range, the amount of daily deaths rises quickly. Figure 8 sketches how the temperature influences the number of deaths. This figure also shows that a small increase in temperature might lead to relative large increase in deaths. The risks are the greatest among people with pre-existing cardiovascular disease or chronic respiratory diseases. As cities are more polluted (e.g. smog) than urban areas, this brings another increased risk for people living in cities (McMichael et al., 2006).

Figure 8 Schematic representation of how an increase in average annual temperature would affect annual total of temperature-related deaths, by shifting distribution of daily

temperatures to the right (McMicheal et al., 2006).

Changing patterns of diseases due temperature rising

Several diseases are sensitive to changes in temperature. Especially vector borne diseases are strongly influenced by temperature. For example, a study in the highlands of Kenya showed that a temperature change of 1% results in a 10% increase of the abundance of the mosquito which is the vector for the malaria parasite (Pascual et al., 2005). Also as the temperature rises, regions that are now too cold for the parasite to survive might be affected by malaria. For Indonesia this is especially a risk in the highlands of Papua that used to be free of malaria (Mueller et al., 2005). Another vector borne disease that is likely to increase is dengue. Like malaria, the distribution of dengue is highly dependent on climate. The most important parameter is the vapour pressure, which gives a significant predictor of dengue fever risk (Haines, Kovats, Campbell-Lendrum, & Corvalan, 2006). Due to rising temperatures and increasing humidity, the vapour pressure will rise and thereby increasing the risk of dengue. Already in the last 40 years the number of cases has been increased rapidly, also because of fast urbanization in Indonesia. This will give an extra burden for the disease on top of the effects of climate change (WHO, 2009). To conclude, the rising temperatures in Indonesia will have direct effect on humans, as temperatures will exceed the comfort zone, and secondly because several communicable diseases will occur more often. This will lead to an increase in several diseases, and also to the occurring of diseases in areas that used to be free of that disease, for example malaria in the highlands of Papua.

Climate change in Indonesia

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4.3 Flooding

Floods are defined as the overflow of areas that are not normally submerged with water or a stream that has broken its normal confines or has accumulated due to lack of drainage (Malilay, 1997a). Flooding can have different sources, for example high sea levels or rivers that are not able to carry all the water. Floods can also be caused due heavy rainfall, the effect of these are explained in paragraph 4.1. In Indonesia, about 65% of the population lives in coastal regions (State Ministry of Environment, 2007). In Figure 9 it is shown that that especially the western part of Indonesia is very vulnerable to flooding. This map is based on the floodings that happened in the last 20 years. As the sea level is rising (Dasgupta, Laplante, Meisner, Wheeler, and Yan, 2008) and glaciers are melting (Klein & Kincaid, 2008), one can expect that flooding will occur more often. The IPCC expects that all coastal regions in Asia are vulnerable to flooding caused by an increasing sea level. Around Indonesia, the sea levels are already rising with approximately 6 mm per year (Ishii et al., 2006). The sea flooding will inundate low lying areas, drown coastal marshes and wetlands, erode beaches, exacerbate flooding and increase the salinity of rivers, bays and aquifers (Cruz et al., 2007). A complicating factor is that groundwater is taken from natural reservoirs and thereby lowering the land. This effect can even be greater than the rising of sea level. The risk is especially great is densely populated coastal cities, like Jakarta or Surabaya (P. Vellinga, personal communication). There are several mountains in Papua that are the year round covered with snow. Because the temperatures are rising, the snow line will rise. Between 1972 and 1997, the snow line has already risen 70 meters (Prentice & Brackett, 2002). As glaciers melt they will form lakes behind the newly exposed terminal moraines. These lakes are boarded by instable natural dams, because they are formed rapidly. When such dams break down, huge amounts of water and debris are released, in what are known as a Glacial Lake Outburst Floods (Shrestha, 2007). The effects of flooding on health can be divided in two categories: effects directly related to the flooding, and effects arising after the flooding have been resolved (Hunter, 2003). The most important direct threat of flooding is drowning. For example in Bangladesh 15,000 people die each year due floods (Malilay, 1997a). Also non-fatal injuries may occur, but little data is known on the how often this happens (Ahern et al., 2005). In the post flood period the greatest health risks are outbreaks of infectious diseases; increases were found in faecal-oral diseases such as cholera, cryptosporidiosis, non-specific diarrhoea, poliomyelitis, rotavirus, and typhoid and paratyphoid (Ahern et al., 2005). Diseases transmitted by rodents may also increase during heavy rainfall and flooding because of altered patterns of contact (Ahern et al., 2005).

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Floodings can have opposite effects on vector borne diseases. The flooding can wash away the breeding sites of vectors, but on the other hand it can create breeding sites by the collection of stagnant water due to the blocking of drains. The last case is especially a risk in urban areas (Ahern et al., 2005). .

Figure 9 Areas in Indonesia that are prone to flooding.

It can thus be concluded that the incidence of several communicable and non-commutable diseases will increase. This is especially a risk for the projects in Papua and Aceh.

4.4 Extreme drought

The differences between the dry and wet season in Indonesia will increase (Cruz et al, 2007). This means not only that the rainfalls in the wet season will be extremer as aforementioned, but also that the dry season is getting drier, thus increasing the risks of extreme droughts. Droughts potentially occur during the dry season posing a serious problem when impacting food crop regions. It normally occurs during long dry seasons in specific regions, including the eastern region like East and West Nusa Tenggara and several areas in Sulawesi, Kalimantan and Papua. El Niño triggered drought in Indonesia during 1997-98 and 2004-05, which eventually also contributed on the destruction of crops, land fires and

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dried up water sources (MdM Indonesia, 2009). Figure 10 shows what regions are vulnerable to droughts. Droughts have several effects on health. These effects include deaths, malnutrition (undernutrition, protein-energy malnutrition and/or micronutrient deficiencies), infectious diseases and respiratory diseases (Menne and Bertollini, 2000). Probably the most impartment effect of droughts is crop failure. Because of water scarcity crops die, what may cause famine leading in turn to malnutrition (Bouma, Kovats, Cox, Goubet, & Haines, 1997). Lack of varied food intake can lead to protein-energy malnutrition and micronutrient deficiency (WHO, n.d.b). During droughts the breeding sites for mosquitoes are reduced, thus lowering the activity of the vectors. This means that the population of non-immune persons increases. When the drought ends, there is a much larger proportion of susceptible hosts to become infected, thus potentially increasing transmission (Bouma & Dye, 1997). Other drought-related factors that may result in a short-term increase in the risk for infectious disease outbreaks include stagnation and contamination of drainage canals and small rivers. Another cause for the outbreaks is that there is a lack of sanitation service (WHO, n.d.b). In the long term, however, the incidence of mosquito-borne diseases such as malaria decreases because the mosquito vector lacks the necessary humidity and water for breeding (Confalonieri et al., 2007).

Figure 10 Areas in Indonesia that are prone to drought.

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4.5 Tropical cyclones

At this moment there is only very only sporadic occurrence of tropical cyclones in Indonesia, but because of climate change the cyclones in the Eastern Pacific are expected to change paths to the equator and thus affecting Indonesia, mostly in Papua (Bengsston, Hodges, & Roeckner, 2006). It is therefore that this topic is included in the research. Even though there are uncertainties, it is might be good for MdM to prepared. Tropical cyclones, also called typhoons or hurricanes depending of the region, are intense circular storms that originate over warm tropical oceans and are characterized by low atmospheric pressure, high winds, and heavy rain (Zehnder, 2010). They can occur where the sea surface temperature is above 26.5 °C (Schultz, Russell, & Espinel, 2005). This means that rising sea temperature will give rise to more places cyclones can occur. Also in the last 35 years the number of cyclones that fall in the highest categories is increased significant, especially in South West Pacific Ocean (Webster, Holland, Curry, & Chang, 2005). Cyclones will have several severe effects on health; there are direct effects and effects that occur in the aftermath of a cyclone. Direct effects occur as people will be injured because of the high winds, buildings that collapse, and floodings caused by extreme rainfall (Malilay, 1997b). Most vulnerable are low-lying areas that are densely populated in combination with poor quality buildings (Schultz et al., 2005), which situation is common in Indonesia. During the cyclone, death and injuries occur due collapse of buildings, wind-borne debris, and falling trees. Also victims are affected when they try to drive to safety during the storm, which is especially the case when they use a motorbike (Schultz et al., 2005). After a cyclone has passed, there is an increased likelihood of outbreaks of infectious diseases. Factors that make an area even more vulnerable include high endemic rates of disease, low immunization rates, poor access to clean water, poor sanitation, prolonged crowding in shelters, and inadequate nutrition (Mosley, Singh, & Sharp, 2004; Schultz et al, 2005). The WHO (n.d.) states that the risk of outbreaks of vector- and waterborne diseases might increase. This is because of the physical conditions are changed making it easier for diseases to spread.

4.6 Conclusion

Summing up, several extreme weather events are very likely to occur more often. This will lead to higher burden on health care, as the diseases will spread and the frequency will increase. This increasing burden will have an effect on projects of MdM in Indonesia. The next chapter deals with how MdM can respond to these changes in their programs.

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5 Policy Response MdM The previous chapter identified the effects of climate change on health. The following chapter formulates a policy on how MdM can deal with these. This policy will be formulated using the six themes from the article of Rehfuess et al. (2009), which are also mentioned in the conceptual framework. For each theme an advice will be provided what MdM could do to adapt to the changes in environment due to climate change. Primary health car is a key aspect for MdM. In 1978 the WHO adopted the Declaration of Alma-Ata which underlines the importance of primary health care for the development of a health sector and gives a description on what aspects are important to obtain good primary health care. This document shall be used as background and guideline for writing the recommended policy. The policy shall thus focus on building strong primary health care facilities, thereby making it possible to deal with the consequences of the changing climate within the context of Indonesia. . Primary health care is defined in the Alma-Ata declaration as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination”. The key points from this definition are that health care should be practical and socially acceptable and that communities should participate in the health. Both these points urge that health care should be provided in close collaboration with the local people. This makes that one needs a clear understanding of the concerned society. In the context of climate change the concept of disaster risk reduction (DRR) appears very often. DRR deals with how to react on the consequences of a (natural) disaster such as tropical storms or floodings. There is a significant risk that the focus lays on one single approach, instead of the integrated approach where Rehfuess et al. and the Declaration of Alma-Ata aim for. Nonetheless DRR is factor that should be taken in account, but incorporated in a bigger approach. Therefore this research tries to implement DRR

5.1 Health facilities

The first topic discussed in the chapter in on health facilities. This is an important theme, because within the projects of MdM in Indonesia there is a lot of collaboration with the local clinics. Health facilities are also the places where there is direct contact between patients and care. It is therefore here that is most logical to focus on interventions. “So you should discuss the challenge of adapting the health systems or public systems at a regional level at least. So you can talk about this at a very aggregate scale, but you should discuss this at least at regional level.” (P. Pattberg) Setting standard for health-care facilities For a health clinic it is very important to be prepared for the effects identified in this research. Most of the risks come from various infectious diseases. It is therefore important

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that clinics are prepared for dealing with outbreaks of infectious diseases. This can be accomplished by setting several standards for health care facilities. Standards for health facilities should be, but are not limited to, enough clean water, adequate disinfection of materials, ventilation of wards. Health care workers can be trained the importance of working clean. Therefore there should be standard procedures for disinfecting materials and always be enough clean water available. “I believe that there is an enormous role for sanitations and water supply.” (A. Engelhard). Here lies a role for MdM to explain these standards to health workers and explain why this is of such importance. Budgeting for structural improvements and capacity building for behavioural change of staff Primary health is provided by Puskesmas, which are centrally financed by the Ministry of Health. This makes it difficult to allocate (new) budget from the Ministry of Health to train local personal. Still good primary health care is essential for good health care in general and for disaster risk reduction in particular. Puskesmases are in the more remote regions of Indonesia the only health facility that is available. It therefore important that the staff working in these clinics is well trained and is capable of dealing with the effects mentioned in this report that are likely to happen in Indonesia. A strong and capable primary health sector makes it possible to immediately deal with disasters when they are happening. The people of Puskesmases are already at the location, so they can give the first aid and it is not necessary to wait for people from other parts of the country or even abroad Part of the mandate of MdM is lobbying for access to good healthcare, thus the role for MdM is here to indicate problems and bring these to the attention of the Indonesian government. “We have a big advocacy role as MdM. But this is impossible if you don’t have implemented a program (…) Than you can go to the government and say: ‘I see this’, or ‘I have noticed that’ and try to change that together with the government” (P. Wisse) Health clinics can have a role model function. For example health clinics can have an important role in waste management. Another example is the installation of solar panels for electricity of the clinic. This is not only good for the climate, but also makes the clinic independent of generators and therefore reducing costs. “Living in a world that is warmer than today will necessitate substantially different behaviour in terms of how to deal with situations and you have to train this behaviour. One thing is, how to deal with water which in contaminated as a result of too much demand and less supply due climate change. So how do you deal with this? You have to train people new behaviour, hand washing for example, these kinds of things. (..) This is then the role of an organisation that you talk about, which is basically a mediator. It is a multiplication organisation that trains people. They then induce the change.” (P. Pattberg) Enforcing compliance through an independent oversight function For a good functioning health sector is it important that capable managers are present. This is important to encourage the staff to change their behaviour as stated above. Also

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in case of a disaster it is important that someone has an oversight on what is going on and where priorities should be. With a good oversight function it can be possible to react in advance when certain predictable disasters, like extreme rainfall or tropical storms, are going to happen. When these are expected it is important to prepare the clinic for the possible effects. Also the communities can be warned so that people can take their measures to reduce the effects of the expected extreme weather conditions. “It is not the case that you as a medical doctor can say: ‘this how it should be’, but one should make links with health problems and identify possible prevention measures. That way a doctor can use its creativity with others and can say: ‘I am going to help reducing the usage of groundwater’ or: ‘I am going to help planting trees’.” (P. Vellinga) Therefore it is important that there is participation between managers, health workers and the community to see what the needs are and what can be done to fulfil these needs. The role of MdM should be to bring these different persons together to find out what the needs and possibilities are. “You have to bring together a group of stakeholders and ask them: ‘what do you think is the problem?’, ‘how do you think this problem should be solved?’, ‘what is your role in solving this problem’. This is a very Western point of view, so you have to take time to do such an exercise. Nevertheless, it’s very essential. I believe that MdM can play part is it”. (R. van der Pas) To conclude, the main focus of MdM regarding health facilities would be to be mediator between the communities and the government. Another important aspect is to give trainings to health workers.

5.2 Inter-sectoral policy

The second topic deals with inter-sectoral policy. Health is affected by many factors, that are not necessary can be influenced by direct health interventions. This is especially the case with the effects of climate change, which direct effects and cause lie outside the health sector. It is therefore crucial to have expertise from different fields to deal with these effects. Building and maintaining expertise An important task for MdM is to give trainings to local health workers on how to deal with several diseases and make that the primary health care is improved in the regions they are working. In Indonesia, at the district level, the main import partners for MdM are the District Health Officers (DHO). They have the responsibility to implement local health policy, to manage the public health services and to monitor the health system via the health information system. The DHO also have an important role via the Environmental Health Department of the Ministry of Health. In this department there is a lot of expertise on how environmental issues (not per se climate related) can influence health. Another important, recently set-up department, is the National Crisis Centre, also part of the Ministry of

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Health. For MdM it is important to keep in touch with these departments, as they are responsible for the health policies in case of a disaster which are part of the programs in Indonesia. “It is important to work together with the local health officers. Every health program should be under supervision of the ministry of health to prevent duplication in the program. We only prevent from the duplication of the program, maybe if we didn’t know if you do something here and another NGO doing the same.” (Purwani Eko Prihatin,

Syafdewiyani, Siti Hajar, & Akhiat) Influence major policies & establish multi-disciplinary collaborations that impact health The cooperation with the Indonesian government and MdM is not smooth. The government is getting more reluctant on allowing foreign NGOs, especially in the political sensitive areas as Aceh and Papua. This is because Indonesia is getting more developed and the government is less dependent on NGOs. This change is mainly the case in the more central regions such as Java. More remote islands still need the help of NGOs. Therefore it can be important to find alliances with companies. At this moment, companies are paying more and more attention to corporate social responsibility. Relevant examples of include the growing importance of the Forest Stewardship Council witch promotes sustainable forest management (Forest Stewardship Council, 2011) and the goals Unilever has set regarding sustainability (Unilever, 2011). MdM can be linked to such initiatives and together with these companies it can be possible for MdM to put more pressure on the government so that policies change with regard to primary health care in the context of climate change. “The government will only act when there is more pressure than just medical doctors. There has to be commercial interests behind it, for example the health of employees or the safety of companies. So my strong advice would be to look for coalitions before you go to the government.” (P. Vellinga) On the other hand the government is crucial to implement regulation and laws regarding (environmental) health. Also the health sector is depending on the government and therefore it is necessary to work with the government. “Long term results that are accomplished by experiments and projects that are done together with the government. The flexibility of an organisation as the Leprastichting is an advertence, as the government lets the organisation experiment without problems, as it can profit from positive effects, but is not affected by negative outcomes. For an NGO a failure is always easier to deal with than for the government. (A. Engelhard) Policies that influence health are not limited to the health sector. Land use, waste management, living conditions, food security all influence the health of people. For example, rainforests are being cut down to use the land as oil plantation. This makes the land much more vulnerable for erosion and extreme droughts. This is a big problem in Indonesia where deforestation is still increasing. “If too many trees are cut down and the vulnerability for mud streams is getting bigger it makes sense that the logging is better regulated. (…) It is a well known phenomenon in Indonesia.” (A. Engelhard)

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As MdM is primary a health organisation, the expertise and knowledge on climate change and its effects is limited. Therefore it is important to work together with other organisations and institutions in non-health sectors that do have this expertise. For example with severe droughts Puskesmas can become pivots in coordinating the aid when famine occurs because they have the best indication on who needs the aid the most. Training of local staff is thus crucial to achieve this. Planting of trees can reduce the effects of flooding and extreme precipitation. To establish this MdM can seek partnerships with other NGOs and (local) governments to promote tree planting and reduce deforestation. Reducing all these effects ask thus for close cooperation with agriculture sector. Another example is working together with agriculture organisation to monitor the effects of droughts on potentially failed harvests. When it is clear in an early stage that a harvest might fail, it is possible to take measures to prevent (the effects of) a famine. In Indonesia the department of social welfare plays a key role in the distribution of food, water et cetera. “That is why you have to look, in a sense, for new coalitions, broader coalitions to make this transition. It is about making the whole society much more resilient to climate change. An important aspect from my perspective is institutional so it is about finding the right institutions to deal with this problem.” (P. Pattberg) Employing formal mechanisms for health impact Early warning systems (EWS) can be implemented to make it possible to have a quick response when an outbreak of diseases could start. It is therefore necessary to have network in the region that monitors potential outbreaks of diseases caused by the themes mentioned above. For example extreme rainfall can be predicted by the meteorology office, in order to develop coordination during the flooding. It is the task for MdM to help developing standardized protocols to help reducing the effects of disaster. At this moment monitoring and surveillance is done by the Ministry of Health. (Purwani Eko Prihatin, Syafdewiyani, Siti Hajar, & Akhiat) In this protocols can be described what the risks of the disaster are and what can be done to reduce these risks. Also should be described what organisations are operating in the given region and what their role should be. Several early warning systems are already operating and are showing their benefits (Patz, Campbell-Lendrum, Holloway & Foley, 2005). An overview of the important aspects of an EWS is given in chapter 6. When integrating climate change in their programs, it is for MdM important to look for broad coalitions. Partners that one could think of include companies, but it is also crucial to have a good relation and cooperate with the government.

5.3 Norms and regulations

This topic deals with the importance of norms and regulations that should be implemented in health clinics.

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Health protecting standards and regulations When a disaster happens it is very important that one knows how to deal with it. Therefore it is important to have protocols on how to deal with drought, floodings, extreme rainfall and tropical storms. When the event is happening it is too late to find out how to deal with it. In chapter 6 a description is given on how an Early Warning System (EWS) can be developed and implemented. This gives the various stages on how to deal with a (climate related) disaster. There is a mediating role for MdM to bring the various departments together that have should have a role in a EWS. “I believe that MdM and partners have a kind of mediating role. They can give capacity training. For example when the National Crisis Centre sets something as priority, MdM and partner organisations can work on that in the districts where they have a program.” (R. van der Pas) Most of the changes in the climate will lead to changing, and most often, increasing patterns of infectious diseases. Therefore it is important that norms are developed that minimise the risk on spreading of these diseases. Norms one has to think about to implement are minimum amount of water available, measure air pollution, protocols on dealing with infectious diseases, disinfecting instrumentation after using it, et cetera. “You have to make sure that your clinic is clean, there is enough clean drinking water available, the clinic is built on poles so that it is safe during floodings” (R. van der Pas) This is an aspect that MdM, together with local partners, It might be good to note that dead bodies are not a high risk of contamination. The quick and unceremonious disposal of the corpses is a far more serious threat than the bodies itself, because of the psychological effects on the survivors (Morgan, 2004; De Ville de Goyet, 2000). This can be an important norm when a disaster happens with a lot of deaths. Monitoring implementations and contribution to achieving population health gains Indonesia has a poorly functioning Health Information System. At the district level, the reporting system has been considered voluntary since decentralization and, as a result, there are no dedicated staffs for HIS at the Puskesmas level (MdM Indonesia, 2009). This makes it difficult to monitor the effects of the care given. It is thus important that MdM advocates the importance and probably helps setting up a good evaluation program. On the other hand, the Ministry of Health is increasing its surveillance program. To conclude, it important to have good norms and regulations, so that in case of an emergency it is clear what should be done and that clinics are prepared to do so. This is something that MdM can emphasise in trainings, together with local partner organisations and the government. Also it is important to monitor the effects of the norms and regulations and adjust them if necessary.

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5.4 Disease-specific and integrated programs

The effects of climate change will lead to a complex set of effects. Therefore it is important that a medical organisation such MdM looks for partners and determinates outside the health sector to integrate in the programs. Integrating environmental determinants into curricula, incorporating environmental health This report has made an investigation of the effects of climate change on health. It turns out that several diseases will be occurring more often than now is the case. Therefore MdM should be prepared to deal with this increase. Another thing is that several extreme events will occur more often. Indonesia is already prone to non-climate related disasters like earthquakes and volcanic eruptions and also land degradations caused by deforestation. The effects of these will be enlarged due to climate change, for example due to deforestation the effects of floodings will be more severe. These topics lay a bit out of focus for this research, but are nonetheless important to keep in mind when developing the policy. “But it is an extra factor that accentuates these already difficulty challengeable diseases. (..) As starting point I have: climate change leads to more diseases and therefore it is import to work on climate protection.” (A. Engelhard) It is important that the MdM-programs that try to reduce the effects of climate change are not stand-alone, but are integrated in the existing health sector. That way everybody will be committed and thus makes it easier to implement the plans. Also, when it is a separate program it means that it will have its own overhead, like coordinators. When it is integrated in existing system there will be no need for this and it will become more efficient as there is no need to hire new people. “That means that you have to integrate these topics, that means that you need the knowledge and expertise and also that you have to adapt your programs, your approach to the population needs to be changed. There we need to make a change if we want to play a role in that.” (P. Wisse) Messages and actions in health programmes and working with partners in raising awareness It is good to realise that a lot on environmental health can be done in cooperation with local companies. These companies are more and more responsible for the health of their employees. This is the case with Western companies, e.g. via the FSC-hallmark, but also local companies can be contacted about what can be done to improve the health of their employees. “I think that you have to look for coalitions with companies for primary health care. Companies are being held more responsible for the health of their employees. In the Third World I would say it is much more practical to seek alliances with companies as Heineken or Nike or local companies. When deliberating with them you can say as medical doctor what the health problems are and what possible solutions are. As a medical doctor you have to make links and identify health problems and possible prevention measures.” (P. Vellinga) For the community it is important to know what can be done to reduce the risks of an outbreak. Therefore it is good to educate people via community health workers on how

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to deal with the environment. This should include sanitation, diarrhoea management et cetera. Therefore is it important that local health workers are aware what these concepts are and are capable to react on it when an outbreak emerges. “Awareness raising is very important, because the concrete implications of climate change at the level of health are known to experts, you have all these projections on malaria and these kind of things, but if you look it from a public policy challenge, so what is the implication for the public health system, then is not so well known I think. Many people don't think about this. This is a long term challenge. This is something an NGO has to lobby for in the developed world but also in the developing countries themselves to alert the policy makers there is kind of problem coming up. This is very important.” (P. Pattberg) It is very important that the evaluation of risks is done in cooperation with the communities. You have to discuss with them what they think are problems regarding their environment. It then important to realise that prevention is a concept that is very Western and not something that is rooted in the Indonesian society. Therefore one needs to make the transition from Western concepts to local traditions and beliefs. “Therefore you need to engage the community. I think that this should be done in cooperation with local partners, with local NGOs that speak the language and know the country and that have a lot of knowledge on community mobilisation.” (P. Wisse) To conclude this section, MdM has to gain knowledge on the effects of climate change by looking for partnerships. It is important to find local partners to help to investigate the local needs and problems. It is also important that these findings are integrated in the health program and not developed as stand-alone programs.

5.5 Outbreaks

This section gives an overview on how to deal with outbreaks and what issues are important to address for the health sector. Maintaining a nucleus of knowledge of expertise to advice on and conduct outbreak This report gives various possible outbreaks of diseases that might occur. It is important that information on how to deal with these is kept up-to-date at the workplace. The local staff has to be trained so that know what to do when an outbreak occurs. Giving trainings is already part of the strategy of MdM in Indonesia. Therefore it is relative easy to include the climate effects in these programs and thereby strengthening the primary health sector. Also MdM can collect information on the several health issues and how to deal with these. For example, when drinking water in contaminated a warning can be given to boil the water. It is important that this is done in cooperation with the DHO, so that the norms are clear and there is interference with what the government already does. Investigation, testing implementing and revising procedures in cooperation with other actors A recent health information system (HIS) assessment indicates that Indonesia’s national policy on health information systems describes the components, however the strategic

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planning and operational guidance have not yet been developed (MdM Indonesia, 2009). Also the private health providers participate only lithe in the HIS. This has as result a lack of 50% of the total health care delivered. Another problem is that at a regional level the HIS is considered voluntary and as a result there is no dedicated staff at the Puskesmas level (MdM Indonesia, 2009). This makes it difficult for health organisations to have a good vision on where the main risks are during an outbreak. Also it makes it difficult to see what the effects of interventions are in the long run. Updating regulation and policy based on insights gained The programs developed to react on an outbreak of a disease should be evaluated regularly to see if they are still effective and what can be improved. See what lessons can be learnt and how improvement on the policy can be implemented. The most important aspect of outbreaks is that health clinics should be prepared on an outbreak and that it is evaluated whether this preparedness has the desired effect. The role for MdM would be to give trainings on the preparedness of local health clinics.

5.6 Threats and opportunities

Seeking evidence for causal associations between environmental factors and health When an outbreak of a certain disease occurs, it is of vital importance that the source of this outbreak is found. When the source of the outbreak is found it is possible to take measures and thereby eliminating it. A thing that has been ignored in the report is the case of environmental migrants. Due to climate change the living conditions might change dramatically. This can cause that certain areas are no longer suitable for agriculture or even living. While migration is not a new topic, the speed and number of migrants are likely to be much higher than what is known today (Reuveny, 2007). At this moment not much is known of the topic, but a lot of research is now being developed (P. Pattberg, personal communication). This [refugee migrations patterns – JWK] might be a great threat for health systems as migration is a heavy burden on health systems. This has a connection to health for a number of reasons that we can discuss. First of all, populations that are on the move are at higher risk. Health systems that are disturbed through migration are underperforming, are problematic. So if you have health system in a country where many people leave this has implications on the performance on that system, but also on the countries that will actually take in climate migrants you have huge stress in public systems (P. Pattberg). According to the International Organization for Migration Indonesia (2010) internal migration as a result of natural disaster is already happening. This increases the burden on the already weak health system. Assessing the potential harms and values of technology innovation and policy development When MdM sets up a project it is important to look at what the possible risks are for the environment. This is a two sided approach: one has to look at already existing threads

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caused by the environment, but it is also important to look at the impact on the climate and environment of the project. Make an analysis of every project. Take as starting-point of every project as a do-no-harm policy. Just like as one has with medicine with the oath of Hippocrates: you should not cause damage to the patient. (A. Engelhard) An example of an innovation that could be of great value for Indonesia is the replacing of indoor cook devices by with solar or electric cook devices. This will give a great benefit regarding indoor air pollution which is a big health threat in itself. Also it will reduce CO2-emissions and it is therefore a mitigation measure. “I think there are many small projects that I find interesting and one is to substitute indoor cooking devices with solar or rural electrification is an issue to bring energy to places where there is none. To substitute the burning of fuel woods. Because this is a huge health problem, indoor air pollution. Rural electrification can be different. So you can build coal plant to electrify. But you can also think about that is terms of climate change mitigations.” (P. Pattberg) This is just one example of a measure that gives co-benefit for health as well climate, but it is important to look for more of these (relative) easy implementable measures that can improve health and at the same time reduce the burden on climate.

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6 Early Warning Systems In the previous chapter the concept of Early Warning Systems (EWS) is mentioned several times. Therefore it is chosen to give an overview on what it is in this chapter. EWS are designed to alert the population and relevant authorities in advance about developing adverse meteorological conditions and then to implement effective measures to reduce adverse health outcomes during and after the event. It is therefore an important aspect of the Disaster Risk Reduction (DRR). In the book of McMicheal et al. (2003) an EWS is defined as “a system consisting of mathematical models and surveillance measures designed for early detection, prevention and control of an epidemic of infectious disease or other abnormal events (e.g. famine or heat waves)”. To have a good functioning early warning system, several concepts are crucial to implement (Ebi & Schmier, 2005). These concepts will be explained hereunder. Identify and forecast the event First of all it is of crucial importance to know when an event will happen and how big the impact will be. It is therefore important to work together with the meteorological office. Several types of data can be collected, depending on the event that is monitored (like malaria outbreaks, heat stress et cetera). Predict the possible health outcomes If it is known that a certain event might occur it is important that the possible effects on health are known. In this research it is investigated for the most likely extreme weather events what the possible impacts on health are. It is possible to develop algorithms that predict health outcomes depending on weather parameters (Sheridan & Kalstein, 2004; Patz, Campbell-Lendrum, Holloway & Foley, 2005). These algorithms or models should be developed by or in collaboration with researches. Have an effective and timely response plan There should be clear geographic boundaries where the response plan is implemented. This is especially the case when risk areas cross administrative regions and it becomes unclear who is responsible for what aspect of the plan. There should be clear threshold values which indicate when to implement the action plan. Also the uncertainty of the weather data should be taken in account. When too many false positives or false negatives occur, the reliability of the system will drop as the public willingness drops to rely on subsequent warnings. This should be done in cooperation with (local) experts. Every region has its own critical values depending on populations density, geography et cetera. Also terms used in the response plan should be familiar to people in the region.

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The interventions that are implemented should be effective and as specific as possible. There can be general interventions for the whole population, but also messages targeted to specific groups. Groups one can think of are disabled people, elderly or ethnic minorities. The final step is the implementation of the interventions, like media announcements (TV, radio stations, and the newspaper), health education, preparation of hospitals and public services, and ensuring the availability of water and power in health facilities. These should be coordinated by a single organization and it should beforehand be clear who is responsible for each of the various parts of the plan. This should be done to make sure that it clear who does what and minimise problems due to failed communication (Tan et al., 2003). Have an ongoing evaluation of the system and its components Finally the effects of system should be evaluated. In this evaluation it is important to look at the achieved effects of the warning system. Did it reach the target population? Were positive effects achieved in terms of mobility and mortality? The costs/benefits should be compared with the situation before the EWS was implemented. The various steps that should be taken before an action plan comes in action are indicated in Figure 11.

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Figure 11 Flow chart for the determination of whether or not to call a heat watch–warning.

(Sheridan & Kalstein, 2004)

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7 Conclusion This chapter gives the answers to the research questions that were stated in paragraph 1.6. First the three sub research questions will be answered and finally the main research question.

7.1 Sub research questions

Who will be most affected by climate change in Indonesia? The literature and all the interviewed experts agree that the already vulnerable people are at most risk for climate change: poor people, inhabitants of cities, people who suffer from cardiovascular diseases. Extra care should be taken at low lying areas, where the risk of flooding is very big. In cities his is amplified by the fact that also the ground is declining due the use of groundwater. Cities are also vulnerable for the urban heat effect. How will health be affected due to climate changes in Indonesia where MdM is working? The influence of climate change can be divided into two main categories: direct effects and indirect effect. The direct effects are caused by higher temperatures and indirect effects caused by changing patterns of diseases and extreme weather events. Higher temperatures cause more deaths due to the urban heat effect. Droughts will lead to lack of water and failed harvests. The most important effect will be that various infectious diseases will increase. Also the activity of vector borne diseases will increase. More extreme events will occur, causing a large burden on health and health systems. What are possible strategies that MdM can implement to include the negative effects of climate change in their program? The most important thing for MdM to do is to seek coalitions with other partners. These partners should be found also outside the health sector. Also MdM should be prepared on the events that might happen and train local staff on how to deal with these. The focus should lay on primary health care, as this is the foundation of the health sector. To be able to do so, the topic of climate change should be an integral part of the

7.2 Main research question

What expected elements of health affected by climate change are relevant for the projects of MdM in Indonesia, and how can the relation be incorporated as a strategic theme for MdM? Due to increasing temperature and changing weather patterns several infectious and vector borne diseases will increase. The effects will have most influence on the already vulnerable groups, especially in cities. To anticipate to these effects MdM should

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incorporate the effects of climate change in their programs by seeking partnerships and make sure to be prepared.

Discussion

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8 Discussion This chapter deals with the discussion of the results and methods used to find these results. First the literature study will be discussed, then the methods used for the interviews and finally the policy recommendations will be discussed.

8.1 Literature study

The knowledge of (the effects) climate change is a rapidly changing field. Many new insights have still been gained recently. Furthermore, the link between climate change and health is a very new topic. This means that new information is emerging quickly and a lot of theories are still under development. Therefore an attempt was made to find literature that has been appeared in the last decade or if possible in the last five years. Also an attempt was made to find literature from reliable sources, such as well-respected magazines like The Lancet or The Journal of the American Medical Association. An attempt was made to find different articles on the various aspects of climate change that could occur in Indonesia. This way it is possible to have triangulation of the results. A problem with this is that the field is new and only a limited number of researchers are working on it. This is reflected in the fact that some authors appear very often in the literature found, e.g. Haines, Patz, and McMichael. Therefore, there is a risk that only the opinion and results of a small group is represented. However, the risk of this is minimised because most of the information comes from peer-reviewed articles. Also the result from the literature study has been sent to the interviewees so that triangulation is possible.

8.2 Interviews

Interviewees were selected based on the topic of their research. These topics should be related to climate change, policy and/or health. In total, six persons were interviewed. Due to bad planning and the holiday period it was not possible to find more than candidates for the interviews. Still all three interviewees have different fields of expertise, so it still gives a good broad view of the subject. Together with the literature used this should give a complete view of the field under research. A preliminary version of chapter 4 was attached with the invitation of the interview. As not every interviewee read this, it might that there was a difference in knowledge and preparation on the interview. This might have influenced the focus of the interviews.

8.3 Policy

One of the goals was to investigate what potential NGOs could be partners for MdM. Therefore 10 different NGOs were written for an appointment for an interview. These organisations were selected from being linked with the HIER en DAAR climate campaign and suggestions from the office of MdM. Unfortunate all of these organisations reacted negatively to this invitation. Different reasons were given, varying from a lack of expertise to lack of time to being in a reorganisation. Therefore it was not possible to conduct the

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second part of the research to investigate what other NGOs do on climate and health and whether it is possible to cooperate with them. This is something that will be investigated further during the coming months. In this research very little attention was paid to climate driven migration. There is limited research known on this topic, but it is believed that migration will significantly increase. This is turn will a significant burden on health and health systems. It might be good to have more research on this topic and if this topic is something that MdM can pick up. All the interviewees agreed that working in coalitions is of vital importance when working on the impact of climate change on health. A NGOs as MdM simply does not have all the expertise to deal with this complicated subject. The views on who should be included in the coalition are divided. This could be the government, NGOs or commercial companies. Still all interviewees agree that it is important to seek contact with non-health organisations. One of the recommendations is to seek alliance with companies to improve the health of the employees. There is a risk that only employees are reached and do not reach the poor who do not have a formal job. This is directly related to health equity, one of the core concepts of health ethics and a starting point for MdM. Therefore it is important to not only have alliances with companies, but to look broader and make coalitions with organisations that focus on or have contact with unemployed people. In a coalition it is important that MdM stays at its fist principles. For example big mining companies, as Freeport in Papua, do not always take human rights into account. If MdM works together with them, the independence of MdM might be questioned or even reduced. It is therefore important that MdM do its work freely in a coalition. The opinions on the role of the government are divided. On one hand the government is crucial to implement regulation, but on the other hand it is not always willing to do so. Different approaches are mentioned, one can seek directly contact with the government, or one could first make coalition and then go together to the government. It will depend on the regional context and the subject what the best approach is. Broader coalitions are essential for projects to be successful. Therefore an analysis should be made to see what factors influence health and what sectors and partners are crucial to have alliances with to deal with these factors. As mentioned before, these partners can range from governments to companies to other NGOs. A topic that was mentioned by all the interviewees as very important is that MdM should be prepared for the effects of climate change. It should know what the risks are regarding the climate and the possible effects of it. This is something that should be incorporated in the activities MdM conducts.

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Appendices

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I. Definitions McMichael et al. (2003) give several definitions for concepts used in this reports for completeness these concepts will be defined in this appendix. Adaption: Adjustment in natural or human systems to a new or changing environment. Adaptation to climate change refers to adjustment in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities. Various types of adaptation can be distinguished, including anticipatory and reactive adaptation, public and private adaptation, and autonomous and planned adaptation. Climate: Usually defined as the “average weather” or more rigorously as the statistical description in terms of the mean and variability of relevant quantities over a period of time ranging from months to thousands or millions of years. The classical period is 30 years as defined by the WMO. These relevant quantities are most often surface variables such as temperature, precipitation and wind. Climate Change: Refers to a statistically significant variation in either the mean state of the climate or in is variability, persisting for an extended period (typically decades or longer). Climate change may be due to natural internal processes or external forcings, or to persistent anthropogenic changes in the composition of the atmosphere. The UNFCC defines climate change as “a change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods”. Disaster Risk Reduction: The conceptual framework of elements considered with the possibilities to minimize vulnerabilities and disaster risks throughout a society, to avoid (prevention) or to limit (mitigation and preparedness) the adverse impacts of hazards, within the broad context of sustainable development. Early Warning System: A system consisting of mathematical models and surveillance measures designed for early detection, prevention and control of an epidemic of infectious disease or other abnormal events (e.g. famine or heat waves). El Niño/Southern Oscillation (ENSO): El Niño in its original sense, is a warm water current that periodically flows along the coast of Ecuador and Peru. This event is associated with a fluctuation of the intertropical surface pressure patterns and circulation in the Indian and Pacific Oceans, called the Southern Oscillation. This coupled atmosphere–ocean phenomenon is collective known as the El Niño Southern Oscillation or ENSO. During an El Niño event, the prevailing trade winds weaken and the equatorial counter current strengthens, causing warm surface waters in the Indonesian area to flow eastward to overlie the cold waters of the Peru current. This event has great impact on the wind, sea surface temperature, and precipitation patterns in the tropical Pacific. It has climatic effects throughout the Pacific region and in many other parts of the world. The opposite of an El Niño event is called La Niña.

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Environmental health: Environmental health addresses all the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours. It encompasses the assessment and control of those environmental factors that can potentially affect health. It is targeted towards preventing disease and creating health-supportive environments. Extreme events: A weather event that is rare within its statistical reference distribution at a particular place. Definitions of “rare” vary, but an extreme event would normally be as rare as or rarer than the 10th or 90th percentile. By definition, the characteristics may vary from place to place. An extreme climate event is an average of a number of weather events over a certain period of time, an average which is itself extreme. Green house gases: Those gases in the atmosphere which absorb and emit radiation at specific wavelengths within the spectrum of infrared radiation emitted by the Earth’s surface, the atmosphere and clouds. Water vapour, carbon dioxide, nitrous oxide, methane and ozone are the primary greenhouse gases in the atmosphere. Moreover, there are a number of entirely human-made gases in the atmosphere, such as the halocarbons and others dealt with under the Montreal and Kyoto Protocols. Health Impact Assessment: A combination of procedures, methods and tools by which a policy, project or hazard may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population. Intergovernmental Panel on Climate Change (IPCC): A group of experts established in 1988 by the World Meteorological Organization (WMO) and the United Nations Environment Programme (UNEP). Its role is to assess the scientific, technical and socio-economic information relevant for the understanding of the risk of human-induced climate change, based mainly on peer reviewed and published scientific/technical literature. The IPCC has three Working Groups and a Task Force. Mitigation: Human intervention to reduce emissions or enhance the sinks of greenhouse gases. Primary health care: Essential health care made accessible at a cost the relevant country and community can afford, incorporating methods that are practical, scientifically sound and socially acceptable. This may include community education, promotion of adequate food supplies, basic sanitation and water, family planning and the prevention and control of locally endemic diseases. Sanitation: Refers to the provision of facilities and services for the safe disposal of human urine and faeces. It also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal.

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Urban heat island effect: Local human-induced climate conditions (high temperatures) in urban areas caused by heat adsorption in concrete, brick and pavement surfaces, education of convective cooling due to presence of tall buildings, and reduced evaporative cooling. Weather: Weather is a set of all the phenomena occurring in a given atmosphere at a given time.

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II. El Niño This chapter gives a short description of El Niño/Southern Oscillation, because it is one the most important global climate effects and has far reaching consequences for the weather in Indonesia. The chapter starts with an introduction on what the effect is and what it causes. This information is mostly excerpted from the El Niño theme page of the National Oceanic and Atmospheric Administration. The second part will be (short) review on the effects of climate change on El Niño and its counterpart La Niña. During an El Niño the rain season in Indonesia is significantly drier than the long term average. This drought causes forest fires and failed harvests. When a La Niña occurs, the effects are opposite and heavy rains will occur in Indonesia.

a. What is ENSO

An ENSO is an irregular phenomenon that occurs every three to seven years. It usually lasts for nine months up to two years. The underlying mechanisms why it occurs are not yet completely understood. The ENSO phenomenon consists of two interacting components, an oceanic part which is called El Niño and an atmospheric part which is called Southern Oscillation. Both effects will be explained hereunder. An El Niño is defined when the averaged sea surface temperature in east-central Pacific is 0.5 °C below normal conditions. The pacific winds, also known as trade winds, which usually blow towards the west, will be weakened in the Southern Pacific. Because of this the warm water pool that is localised around Indonesia starts to move towards South America. This implies that also the warm and humid air is transported towards South America, see Figure 12 and Figure 13. The effect of the changing direction of the wind is known as the Southern Oscillation. This implies that the weather in South America is unusual wet while in South East Asia the weather is unusually dry. This drought has severe effects on agriculture and increasing bush fire, worsening haze and decreasing air quality. La Niña is the opposite effect of El Niño. During La Niña the Eastern Pacific is cooler instead of warmer than usual, and the cool water extends farther westward than is usual. Also the trade winds blow stronger westwards than normal. This leads to opposite weather conditions compared with El Niño. This is shown in Figure 14. The mean temperature drops and heavy rains can occur in Indonesia.

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Figure 12 Normal Pacific pattern. Equatorial

winds gather warm water pool toward west. Cold water up wells along South American

coast (NOAA, n.d.).

Figure 13 El Niño Conditions. Warm water

pool approaches South American coast. Absence of cold upwelling increases

warming (NOAA, n.d.).

Figure 14 La Niña Conditions. Warm water is further west than usual (NOAA, n.d.).

b. El Niño and climate change

The number of El Niño events has been increased in the last decades, while the number of La Niña events has been decreased. It is not clear whether this is linked to climate change or just a random fluctuation of the phenomenon. Different models predict different outcomes (Marryfield, 2006). Although it is not clear if ENSO will change because of climate change, it is clear that the effects will be amplified because of climate change. For example because of climate change the periods of drought will increase in duration and strength. This drought will be amplified when an El Niño occurs (Haines & Patz, 2004).

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III. Interview design Do you have objection against recording this interview? I’m doing an internship at Doctors of the World, where a look at the effects of climate change on health. In particular, I’m interested the way climate change can be incorporated in the projects of Doctors of the World in Indonesia. For this I made an analysis of the effects of climate change in Indonesia.

1. For Indonesia, several effects are expected to occur more often and/or with greater burden. Effects of extreme rainfall Water borne diseases, bacteria, infected drinking water,

Effects of flooding Drowning, infectious diseases like cholera, diarrhoea.

Effects of severe droughts Stagnation of water causing contamination, malnutrition,

Effects of rising temperature Heat effects, air pollution, dengue&malaria increasing

2. What do you see as the most risky areas? Like coastal areas, river basins… And

what adaptations possible?

3. Indonesia has a fast growing urban population. What are the main risks for cities? (like lack of clean water, urban heat effect, dust,…)

4. What are the most important aspects that the health sector should be prepared

of? (DRR, clear protocols

5. What are key players to make alliances with? (Goverenments, others NGOs,

6. For a health organisation, what can be done to reduce burden on environment?

7. What role do you see for Primary Health Care?

8. How can the health sector be improved? In the literature 6 themes are mentioned, how do you see that these can be implemented?

(i) Ensuring that environmental health issues are adequately reflected in intersectoral policy development and implementation;

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(ii) Setting and overseeing the implementation of health-protecting norms and regulations; (iii) Incorporating environmental health in programmes; (iv) Practising environmental health in health-care facilities; (v) Preparing for and responding to outbreaks of environment-mediated diseases; (vi) Identifying and responding to emerging threats and opportunities for health

9. What do you see on the field of expertise health people should have? Thank you for your time.

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IV. Code Tree

Who will be affected by climate change?

• Cities

• Harbors

• Sea

• Landless people

• Vulnerable populations

• Migrants

• Floodings

• Disasters

• Sea level

• Groundwater

How will health be affected?

• Vector borne diseases

• Malaria

• Refugee migrations patterns

• Higher temperatures

• Health system

• Climate and nature

• Plagues

• Rainfall

• Failed harvests

• Air pollution

What are possible strategies?

• Ecologic point of view

• Political point of view

• Heath care

• Clean wate

• Deforestation

• Sanitation

• International approach

• Government,

• Work not alone

• Climate impact

• Do no harm policy

• Mainstreaming

• Adapt the health system

• Perform SWOT-analysis

• Resilient to climate change

• Lobbying

• Raising awareness

• Public policy change

• Institutional structure

• Training

• Proactive

• Identify other players

• Energy sector

• Coalitions

• Trade and industry

• Disaster risk reduction

V. Matrix Interviewee\Topic Risk areas and

populations Diseases Strategies Collaborations

Engelhard Cities, low lying areas, landless people

Vector borne diseases Clean water, reduce deforestation, sanitation & water supply, include CO2 reduction as do-no-harm-policy, advocate climate change

work in big structures preferable in cooperation with the government,

Pattberg Migrants, HIV/AIDS-patients, low income groups

Migration patterns cause failing health systems, higher temperatures

adapt health systems: see how money can be allocated, perform SWOT-analyses, raise awereness for concrete implementations, look for framework, train people to be able to anticipate,

Identify actors within countries that want change, probably government depending on context, Worldbank, funding agencies, energy sector

Vellinga Areas with low groundwater, coastal regions, cities

Plagues, food security Integrate climate change in (new) plans, don't use groundwater when land fall occurs, raise awareness on consequences of heat stress & air pollution, look at co-benefits, focus on local environment, focus national policy change

Corperations local en international, government not per se

Van der Pas East-Indonesia, cities dengue, malaria, diarrhoea

early warning systems, monitoring, coordination between different departments, trainings (e.g. capacity training), long time involvement

local partners, government

Wisse Coastal areas, Papua dengue, malaria Basic health care, community mobilisation, train local people on how to deal with changes

Local partner organisations, government (crucial!),

Indosesia Urban as well as rural Dengue, malaria, crop failure

Community development, surveillance, education

Ministry of Health, Min. Of social welfare, Min of Agriculture, local clinics