Global health and climate action: achievements and imperatives from COP28 June 2024, Volume 34, Issue 2

Background

Climate change is described as the most significant threat to global health and its greatest opportunity.¹ The Lancet Countdown – which tracks progress in health and climate – continues to find that human health risks are increasing and that climate action, such as clean energy, healthy low-carbon diets, and health-centred urban design, has multiple health benefits.²

International cooperation on climate change is governed through the United Nations Framework Convention on Climate Change (UNFCCC), an international treaty to which 198 countries are party.³ There are annual ‘Conferences of the Parties’ or ‘COPs’, with the 28^th such meeting, COP28, held in Dubai, United Arab Emirates, in December 2023. The focus on political consensus across countries of great disparity in resources and climate impacts, and the reported influence of lobbyists from climate-damaging industries, have often resulted in disappointment and insufficient progress at COP meetings.

There has been slow progress in integrating health perspectives into climate negotiations. It wasn’t until the 2015 Paris Agreement (COP21) –most recognised for setting goals to limit global heating to less than 2 °C and ideally 1.5 °C above pre-industrial levels – that the human right to health was acknowledged in relation to climate action.⁴ Under this agreement, countries are legally required to submit ‘Nationally Determined Contributions’ (NDCs) – essentially climate action plans – every five years. Currently, 91% of countries have some reference to health in their NDC, but only 29% allocate climate adaptation finance to health actions.⁵ Only 2% of bilateral, and 0.5% of multilateral, climate finance provided through governments and international development banks and funds was targeted to health for the period 2009-2019.⁶

Health perspectives have increasingly been highlighted at COPs since the Paris Conference, most notably at COP26, where the World Health Organization (WHO) Alliance of Transformative Action on Climate and Health (ATACH) was launched, to support countries in building climate-resilient and environmentally sustainable health systems.⁷

By COP28, milestones such as the first-ever Health Day, the UAE Declaration on Climate and Health, and climate-health funding announcements signified notable progress for health and the healthcare community.⁸ This transition of health from a peripheral to a central theme, and the focus on climate-health finance, is largely thanks to concerted efforts of organisations, such as WHO and the Global Climate and Health Alliance, and is being led by countries including the UK (host of COP26), Brazil (host of COP30), Egypt (host of COP27), The Netherlands, Sierra Leone, India, Fiji, Germany, Kenya and the United States.

However, despite health gaining political recognition within the climate agenda, the journey to translate this awareness into tangible actions for just and equitable solutions is only just beginning.

COP28 outcomes for health

A record 49 health ministers attended COP28.⁹ A key outcome of the first-ever climate-health ministerial meeting is the UAE Declaration on Climate and Health, signed by 148 countries.¹⁰ This declaration acknowledges the interconnectedness of healthy populations and climate resilience across sectors, advocating for sustainable diets, green infrastructure, decarbonised healthcare, and climate-resilient health systems. It highlights the invaluable role of Indigenous knowledges and participation in climate action. While the declaration symbolises collective commitment from numerous countries to invest in climate-health solutions, it is not legally binding and neglects to mention fossil fuels or to call for economy-wide emissions reductions. It also has a greater focus on adaptation (i.e. response to impacts of climate change) than mitigation (preventing further climate in the first place). Notable absences among the signatories are India, Russia, Saudi Arabia and South Africa. India reportedly objected to the commitment to reduce health-sector emissions, given its need to provide universal health coverage and the importance of cooling (e.g. cold storage for vaccines and medicines) to its economically significant pharmaceutical industry.¹¹

To support implementation, a first tranche of funding of US$1 billion ($A1.5 billion) was pledged by development banks, climate funds, and philanthropic organisations, and financing principles for climate-health initiatives were published.¹² However, there is limited information to date about how these funds will be accessed or disbursed.

The first ‘global stocktake’ of progress against the Paris Agreement commitments demonstrated that implementation is insufficient to limit global heating to the target of 1.5 °C. Rather, it found that the world is still on track for a global mean temperature increase of 1.7–2.1 °C this century, even if all commitments are fully implemented¹³, with significant ramifications for global health. Countries were urged to intensify their actions in the next round of NDCs in 2025 – a critical opportunity for health perspectives to be incorporated to drive greater impetus for action.

The overall COP28 outcome, the UAE Consensus, includes a commitment to “transition away” from fossil fuels, hailed as the “beginning of the end” of the fossil fuel era.¹⁴ While this represents progress, there was significant disappointment that the commitment did not include the ‘phase out’ of fossil fuels and contained loopholes permitting continued fossil fuel extraction and combustion, such as reference to unproven emissions ‘abatement’ technologies and gas as a ‘transition fuel’. The rushed decision on the final text excluded members of 39 Small Island Developing States, countries that are disproportionately impacted by climate change¹⁵, creating doubts about whether all nations have a meaningful say in shaping the climate agenda.

COP28 also established the Loss and Damage Fund, fulfilling a commitment made at COP27. The Fund is intended to provide financial assistance to low-income countries grappling with severe consequences of climate change, including health-related losses. However, the absence of legally binding commitments, lack of clarity on access criteria and governance of the Fund, and limited quantification of health losses raise concerns about its long-term sustainability, accountability, transparency, effectiveness and equitable distribution of funding. Initial contributions of US$700 million ($A1.06 billion) fall short of the estimated annual amount needed of US$100–580 billion ($A150–$870 billion).¹⁶

While the UNFCCC Local Communities and Indigenous Peoples Platform was established in 2015 to strengthen the engagement of Indigenous peoples in the UNFCCC process¹⁷, and COP28 saw increased inclusion of Indigenous voices and higher representation of Indigenous leaders – including as part of the Australian delegation – significant barriers persist. Financial constraints hinder many Indigenous groups from participating effectively in global events like COP28, while bureaucratic procedures and language barriers further impede meaningful engagement. Despite progress, Indigenous voices often struggle to be heard compared to government officials and large corporations.

Australia’s COP28 involvement

Australia’s involvement in COP28 showcased increased ambition – the nation joined other signatories in pledging to triple renewable energy capacity, double the average annual rate of energy efficiency improvements by 2030¹⁸ and cease financing international fossil fuel projects.¹⁹ Australia also committed $A100 million to the Pacific Resilience Facility to support locally-led projects across the Pacific region and $A50 million to the Green Climate Fund.²⁰ While not explicitly linked to population health outcomes, these initiatives have an inherent potential for health benefit by addressing climate change, particularly if health and equity co-benefits are maximised.

Yet, balancing domestic interests with global responsibilities poses a challenge for Australia’s climate action. Australia’s continued reliance on fossil fuel exports, particularly coal and liquefied natural gas, and approval of new fossil fuel extraction projects, raises doubts about its commitment to global decarbonisation – and ultimately to global health – given the role fossil fuel combustion plays in global heating, greenhouse gas emissions and air pollution.²¹

More positively, the Australian Government launched its first National Health and Climate Strategy.²² The strategy outlines measures to address climate-related health impacts. These include health system resilience and emissions reduction, whole-of-government actions to protect health, and international collaboration. Australia joined more than 80 countries as a member of the ATACH and committed to including health in its 2025 NDC, being among the 9% of countries whose current NDCs have no mention of health.⁵ Australia’s new strategy was extensively consulted upon, is comprehensive and has a welcome emphasis on prevention and ‘health in all policies’ as key actions to increase the sustainability and resilience of the Australian health system. However, details of implementation, emissions reduction targets and financing are yet to be elaborated, and it is silent on fossil fuel phase-out.

Urgent actions for policymakers to advance climate and health agenda at global, regional and national levels

COP28 signalled increased momentum for the climate and health agenda. This must now be built upon to keep the Paris Agreement goals alive and protect global health. Rapidly phasing out the extraction and combustion of all fossil fuels, and ensuring a transition to renewable energy in a way that leaves no one behind, is paramount to a healthy future. Likewise, measures are rapidly needed to increase the resilience of populations to respond to climate health impacts that are already occurring and are expected to increase.

All countries should undertake health system vulnerability and adaptation assessments and baseline measurements of carbon emissions. These can be used to develop ‘Health National Adaptation Plans’, climate-resilient and environmentally sustainable health systems, in line with WHO recommendations.²³ A resolution committing to accelerated action on climate and health was adopted by 194 member states at the World Health Assembly in May 2024.²⁴

These broad actions apply at global, regional and national levels, although high-income countries bear greater responsibility to reduce emissions than lower-income countries given their disproportionate share of emissions currently and historically.²⁵ They also have a responsibility to assist more vulnerable countries to increase their resilience and to help compensate them for climate-related loss and damage. All countries, and especially those that are lower-income, should continue to focus on providing universal health coverage and basic social needs through climate-resilient and low-carbon sustainable development.

As one of the world’s largest exporters of both coal and liquified natural gas, Australia must cease the continued extraction of fossil fuels, and accelerate its transition to renewables both domestically and for export revenue. Disappointingly, all indications are that the Australian Government plans to continue the extraction and sale of fossil fuels beyond 2050, arguing that gas is necessary for an orderly transition to renewables, although this is disputed.²⁶ Australia hopes to hold COP31 in 2026 with Pacific partners, but to be credible, it must take more action to prevent climate change, alongside offering aid to regional partners to reduce the impact of climate change on their nations.

From a health system perspective, the new Australian National Health and Climate Strategy responds to WHO recommendations, but a robust implementation plan and sufficient and sustained funding are now necessary.

Urgent actions for public health practitioners

Climate change, and our collective efforts towards mitigation and adaptation, present both risks and opportunities for population health everywhere. To address this, public health practitioners must critically assess the implications of climate change for their practice and the health of the populations they serve, and use this information to minimise emissions, maximise health benefits and reduce health inequities. This will entail developing and maintaining knowledge, applying that knowledge to specific contexts, monitoring impact, and embedding this lens into all policy and practice.

For example, depending on role and context, public health practitioners could:

• Measure the current and future health impacts of key climate-related hazards on communities, with a particular focus on priority groups
• Assess community and service capacities to respond to these threats, and to develop and apply interventions to reduce identified health risks
• Measure the carbon footprint of their service and supply chains, and examine ways of reducing greenhouse gas emissions, while maintaining or improving service performance and health outcomes
• Understand the intersections between climate and health promotion activities such as healthy eating, active transport and smoking cessation, and emphasise the multiple benefits when engaging policymakers and communities
• Audit policies, procedures and contracts for impact on climate change, and resilience to climate impacts
• Join groups working on the interface between climate and health to learn from others and share challenges and solutions

While the health risks of climate change and the benefits of climate action are increasingly understood, gaps remain. In particular, we need to develop a greater understanding of the effectiveness of interventions at granular local levels, which can be more meaningful for policymakers. Quantifying the health benefits of low-carbon policies could strengthen the economic case for action in sectors such as energy, building, transport and agriculture, positioning health as part of the solution to climate change. Public health skills in health impact assessment, metrics and evaluation of interventions could be usefully applied to fill these knowledge gaps.

Public health practitioners also have an important role in public and political health advocacy and holding governments and other responsible parties to account on climate action. Given the fundamental role of fossil fuel combustion in driving climate change and air pollution, public health practitioners must exert continued pressure in advocating for the phase-out of fossil fuels. It is also important to make the voice of public health experts heard in advocating for greater investment and action on climate change resilience, arguing for the inclusion of health in NDCs, and monitoring action against commitments made through national and international processes, including the UAE Declaration on Climate and Health, the WHA resolution on climate change and health, and Australia’s National Health and Climate Strategy. Continued advocacy and tangible actions are also essential to ensure Indigenous communities are empowered to shape climate solutions that work for everyone.

Looking ahead, hosting COP31 in the Pacific region could energise local efforts to protect and enhance health, amplifying the voices of Indigenous and Pacific communities. However, true progress will necessitate a fundamental shift away from reliance on fossil fuel combustion and exports towards embracing the health and economic benefits of low-carbon economies. Australia’s health community can play a pivotal role in facilitating this transition, positioning the country as a leader in pathways to sustainability and climate resilience.

Conclusion

Despite their shortcomings, COP meetings remain a vital platform for global negotiations to address climate change. COP28 notably placed health at the forefront of climate change efforts, signalling a crucial shift in focus. To maintain this momentum, health must continue to be a central theme in negotiations, with policymakers and practitioners advocating for evidence-based policies that prioritise the wellbeing of all. Integrating health considerations into decision-making and action to address climate change can lead us towards a more sustainable, resilient and equitable future.

Acknowledgements

AB is a member of the Public Health Research & Practice Editorial Board. She had no involvement in the review of or decisions on this manuscript. AB is a board member of Doctors for the Environment Australia.

Peer review and provenance

Externally peer reviewed, not commissioned.

Copyright:

© 2024 Lokmic-Tomkins & Bone. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.