ABSTRACT

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

Keywords
Climate change; health; research; developing countries; Caribbean Region

RESUMEN

En este documento se describe la elaboración de la Agenda para la Investigación de Acciones del Caribe, cuyo objetivo es empoderar a los pequeños Estados insulares en desarrollo del Caribe para que puedan reducir sus vulnerabilidades ante los efectos del cambio climático sobre la salud. La agenda surgió de la colaboración entre organizaciones no gubernamentales, instituciones académicas y organismos multilaterales que organizaron una conferencia sobre cambio climático y salud en el Caribe. Esta agenda se formuló a partir de la determinación de las áreas de investigación prioritarias; la síntesis de la evidencia procedente de las presentaciones efectuadas en conferencias y de la literatura científica; y las consultas celebradas con partes interesadas y expertos. Proporciona información sobre 18 áreas prioritarias para la investigación y la acción, divididas en cuatro categorías: impacto del cambio climático en la salud, exposición y vulnerabilidad; adaptación, planificación y resiliencia para la salud; medidas de mitigación y beneficios asociados en el ámbito de la salud; y recursos y compromiso para la acción en materia de cambio climático y salud. Los resultados transversales subrayan la necesidad de: aumentar la concientización del público general y de los profesionales; contar con un personal de salud con mayores conocimientos sobre temas climáticos; fomentar la colaboración interdisciplinaria para abordar los compartimentos estancos a nivel institucional; tener en cuenta los factores sociales y económicos involucrados; realizar intervenciones equitativas para los grupos vulnerables; y mejorar el seguimiento y la vigilancia de los resultados de salud sensibles al clima. La Agenda para la Investigación de Acciones del Caribe es una herramienta fundacional para fundamentar la investigación, orientar la colaboración multisectorial y el fortalecimiento de las capacidades, elaborar políticas basadas en la evidencia, e inspirar la promoción de la causa mediante la acción comunitaria relacionada con el cambio climático y la salud.

Palabras clave:
Cambio climático; salud; investigación; países en desarrollo; Región del Caribe

RESUMO

Este documento descreve a elaboração da Agenda do Caribe para Pesquisa e Ação, que visa empoderar os pequenos Estados insulares em desenvolvimento do Caribe a fim de reduzir sua vulnerabilidade aos efeitos da mudança do clima sobre a saúde. A Agenda do Caribe para Pesquisa e Ação surgiu de uma colaboração entre organizações não governamentais, instituições acadêmicas e agências multilaterais, que organizaram uma conferência sobre mudança do clima e saúde no Caribe. A formulação da Agenda acarretou a priorização de áreas de pesquisa, a síntese de evidências derivadas de apresentações em conferências e da literatura científica e a realização de consultas com partes interessadas e especialistas. A Agenda proporciona informações sobre 18 áreas prioritárias para pesquisa e ação, categorizadas em quatro domínios: impactos sobre a saúde, exposição e vulnerabilidade decorrentes da mudança do clima; adaptação, planejamento e resiliência para a saúde; ações de mitigação e cobenefícios para a saúde; e recursos e participação para ações relativas à mudança do clima e saúde. Os achados transversais destacam a necessidade de maior conscientização do público em geral e dos profissionais; maior nível de letramento climático da força de trabalho em saúde; colaboração interdisciplinar para lidar com silos institucionais; atenção a fatores mediadores sociais e econômicos; intervenções equitativas para grupos vulneráveis; e aprimoramento do monitoramento e da vigilância de resultados de saúde sensíveis ao clima. A Agenda do Caribe para Pesquisa e Ação é uma ferramenta básica para guiar a pesquisa, orientar a colaboração multissetorial e o desenvolvimento de capacidades, elaborar políticas com base em evidências e inspirar a promoção da causa com base em ações comunitárias relacionadas à mudança do clima e à saúde.

Palavras-chave
Mudança climática; saúde; pesquisa; países em desenvolvimento; Região do Caribe

Small Island Developing States (SIDS) are on the frontlines of the global climate crisis, despite contributing just 1% of global carbon dioxide emissions (¹1. United Nations Department of Economic and Social Affairs. UN Conference on Small Island Developing States delivers new era of resilience amidst SIDS’ crippling debt crisis New York: UNDESA; 2024 [cited 2024 Sept 29]. Available from: https://www.un.org/en/small-island-developing-states-delivers-new-era-of-resilience#:~:text=The%20major%20outcome%20of%20the%20SIDS4%20Conference,%20The%20Antigua%20and
https://www.un.org/en/small-island-devel... ). The unique vulnerability of SIDS is due to hazards resulting from climate change and characteristics of small islands that lead to numerous threats. Hazards include sea level rise, extreme heat and drought periods, and higher intensity of tropical cyclones. Characteristics that pose threats include dependence on marine and coastal resources, geographical remoteness, limited human resources, and undiversified economies with a high dependence on external markets. These vulnerabilities, which threaten financial security and income and the health and well-being of SIDS populations, affect people and islands differently depending on levels of preparedness, adaptation, and social vulnerability (²2. Otto IM, Reckien D, Reyer CPO, Marcus R, Le Masson V, Jones L, et al. Social vulnerability to climate change: a review of concepts and evidence. Reg Environ Change. 2017;17(6):1651–62. https://doi.org/10.1007/s10113-017-1105-9
https://doi.org/10.1007/s10113-017-1105-... ).

In 2018, the Third Global Conference on Health and Climate Change: Special Focus on SIDS, a World Health Organization (WHO) initiative, helped draw global attention to the vulnerabilities of SIDS (³3. Pan American Health Organization. Caribbean action plan on health and climate change. Washington DC: PAHO; 2019.). Nevertheless, a WHO review of articles published on climate and health between 2008 and 2019 showed that only 19, out of the more than 2000, were from the Caribbean and Central America. To address gaps in knowledge and practice of climate change and health in the Caribbean, key stakeholders established the Research for Action on Climate Change and Health in the Caribbean (R4ACCHC) initiative, which set out to achieve the following goals.

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

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

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

METHODS

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

The Conference

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

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

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

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

Desk review and development of the CRAA

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

Step 1: developing the conceptual framework. An organizational framework for synthesizing the evidence on climate change and health was chosen after reviewing the themes and subtopics of the Conference, various climate change and health conceptual frameworks (⁴4. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Beagley J, Belesova K, et al. The 2020 report of the Lancet Countdown on health and climate change: responding to converging crises. Lancet. 2021;397(10269):129–70. https://doi.org/10.1016/S0140-6736(20)32290-X
https://doi.org/10.1016/S0140-6736(20)32... –⁶6. World Health Organization. Operational framework for building climate resilient health systems. Geneva: WHO; 2015.), and the existing syntheses of climate change and health evidence for the Caribbean (⁷7. Caribbean Public Health Agency. State of public health in the Caribbean report 2017–2018 – climate and health: averting and responding to an unfolding health crisis. Port of Spain: CARPHA; 2018.–¹⁰10. World Health Organization. Climate change and health research: current trends, gaps and perspectives for the future. Geneva: WHO; 2021.). Criteria used to determine the utility of each framework included:

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

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

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

Step 2: choosing priority areas for the CRAA. Given the wide range of health outcomes and determinants that may be affected by climate change, it was necessary to identify priority areas. The team first reviewed results of previous work conducted in 2020–2021 in which in-depth interviews were conducted with key stakeholders in the Caribbean and other SIDS to identify the most relevant areas for monitoring progress in addressing climate change and health (¹¹11. Allen CF, West RM, Beagley J, McGushin A. Climate change and health in small island developing states. London: The Lancet Countdown on Health and Climate Change; 2021.). Twenty-four areas were identified and in a subsequent workshop, stakeholders narrowed these down to eight high-priority areas (¹¹11. Allen CF, West RM, Beagley J, McGushin A. Climate change and health in small island developing states. London: The Lancet Countdown on Health and Climate Change; 2021., ¹²12. Allen CF, West RM, Gordon-Strachan G, Beagley J, McGushin A. Developing indicators of climate change and health linkages in Caribbean and Pacific small island developing states: priority issues and measurement capacities (O-17). West Indian Med J. 2021;69(Suppl 2):26.).

To further inform the choice of priority areas, we reviewed the Conference preparatory documents (literature reviews conducted for each of the four Conference themes), topics and presentations, and previously published syntheses of Caribbean research and action on climate change and health (⁷7. Caribbean Public Health Agency. State of public health in the Caribbean report 2017–2018 – climate and health: averting and responding to an unfolding health crisis. Port of Spain: CARPHA; 2018.–⁹9. Taylor MA, Chen AA, Bailey W. Review of health effects of climate variability and climate change in the Caribbean. Belmopan: Caribbean Community Climate Change Centre; 2010.). We also conducted 16 stakeholder dialogue meetings with 14 Caribbean academic, civil society, governmental, private sector, professional, technical, and training organizations. These unstructured meetings, which were facilitated by members of the Committee, provided feedback about which areas to include as priorities and why. On average, five stakeholders (range: 1–16) attended each dialogue meeting.

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

We first used existing reviews of evidence on climate change and health in the Caribbean (⁷7. Caribbean Public Health Agency. State of public health in the Caribbean report 2017–2018 – climate and health: averting and responding to an unfolding health crisis. Port of Spain: CARPHA; 2018.–¹⁰10. World Health Organization. Climate change and health research: current trends, gaps and perspectives for the future. Geneva: WHO; 2021.). Targeted searches were then conducted on the PubMed database for Caribbean-specific information on climate change and health in each of the priority areas, covering the period (2018–2022) following the Caribbean Public Health Agency (CARPHA) 2018 report on climate change and health in the Caribbean (⁷7. Caribbean Public Health Agency. State of public health in the Caribbean report 2017–2018 – climate and health: averting and responding to an unfolding health crisis. Port of Spain: CARPHA; 2018.). Search terms included “Caribbean,” “climate change,” and the titles or derivatives of the titles of each of the priority areas. For example, for the priority area, “vulnerability to vector-borne diseases,” the term “vector-borne disease” was used. Further searches were conducted using “Caribbean” with priority area titles or their derivatives and environmental determinants of health associated with climate change, such as “flood” and “extreme heat.” We also reviewed the content of the 2021 Conference presentations and preparatory documents, as well as information from reputable technical agencies (e.g., Caribbean regional and United Nations agencies) via their websites or by contacting technical officers.

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

RESULTS

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

Determination of the conceptual framework

We determined that the Lancet Countdown on Health and Climate Change framework (⁴4. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Beagley J, Belesova K, et al. The 2020 report of the Lancet Countdown on health and climate change: responding to converging crises. Lancet. 2021;397(10269):129–70. https://doi.org/10.1016/S0140-6736(20)32290-X
https://doi.org/10.1016/S0140-6736(20)32... , ¹³13. Romanello M, McGushin A, Di Napoli C, Drummond P, Hughes N, Jamart L, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. Lancet. 2021;398(10311):1619–62. https://doi.org/10.1016/S0140-6736(21)01787-6
https://doi.org/10.1016/S0140-6736(21)01... ) was the framework most aligned with our criteria for choosing a conceptual framework (see Methods, step 1). The Lancet Countdown framework, which comprises tracking indicators grouped into five domains (Table 1), offers a broad ecological approach that considers the social and environmental determinants of health and includes characteristics of the health care system. The final CRAA domains corresponded to the five Lancet Countdown domains except for domains 4 (economics and finance) and 5 (public and political engagement). These were merged into a combined domain to better represent the objectives of the CRAA. This domain was named: resources and engagement for climate change and health action (Table 1).

Choosing priority areas

The eight areas identified in the 2020–2021 research to identify priorities for climate change and health monitoring in SIDS (see Methods, step 2) were adopted as priority areas for the CRAA. The remaining 16 areas identified in the same research (¹¹11. Allen CF, West RM, Beagley J, McGushin A. Climate change and health in small island developing states. London: The Lancet Countdown on Health and Climate Change; 2021., ¹²12. Allen CF, West RM, Gordon-Strachan G, Beagley J, McGushin A. Developing indicators of climate change and health linkages in Caribbean and Pacific small island developing states: priority issues and measurement capacities (O-17). West Indian Med J. 2021;69(Suppl 2):26.) were also considered by the Committee for inclusion, as were areas that emerged from the process described in Methods, step 2. The result was the selection of 18 priority areas for research and action on climate change and health in the Caribbean.

Overview of the CRAA

The emergent CRAA includes a detailed report on each of the 18 priority areas under the four domains described (¹⁴14. Allen C, West R, Gordon-Strachan G, Hassan S, McFarlane S, Polson-Edwards K, et al. Research for action on climate change and health in the Caribbean: a public, private, people’s and planetary agenda. Research for Action on Climate Change and Health in the Caribbean Project; 2024.). Table 2 gives a summary of research and surveillance recommendations by domain and priority area. In addition, we identified cross-cutting themes that we divided into two groups – those stemming from an analysis of the priority areas within domain 1 and those from domains 2 to 4. We discuss cross-cutting themes in the context of gaps.

Cross-cutting themes: domain 1

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

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

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

Gaps in health care workers’ knowledge of climate-related health issues. Frontline health care providers and public health officials must be prepared to treat health conditions affected by climate and counsel patients accordingly. Little information is available on the degree to which health professionals in the Caribbean are aware of or act upon climate change and health issues; what information is available suggests a large knowledge–action gap (¹⁵15. De Freitas L, Bahadursingh S, Basdeo D, Kotcher J, Hospedales CJ. Caribbean health professional views on climate change and health. J Clim Change Health. 2023;12:100248.).

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

Cross-cutting themes: domains 2 to 4

There are few Caribbean publications relating to domains 2 to 4 (adaptation, mitigation, and resources and engagement). Most climate change adaptation and mitigation projects and policies in the Caribbean, except the Smart Health Facilities initiative (¹⁶16. Pan American Health Organization. Smart hospitals toolkit. Washington, D.C.: PAHO; 2017., ¹⁷17. Pan American Health Organization. Smart health care facilities in the Caribbean Project: Final Report. Washington, D.C.: PAHO; 2023.), are not specifically designed with health outcomes in mind. The Conference and other consultative processes provided most of the information for these domains.

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

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

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

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

Case study: noncommunicable diseases

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

NCDs, the leading causes of death in the Caribbean (¹⁸18. Caribbean Public Health Agency. State of public health in the Caribbean Region 2014–2016 – building resilience to immediate and increasing threats: vector-borne diseases and childhood obesity. Port of Spain: CARPHA; 2017.), are climate-sensitive conditions. Rising ambient air temperature, extreme weather events, and poor air quality are associated with increased incidence or exacerbation of cardiovascular disease, diabetes, respiratory diseases and cancer (¹⁹19. Kjellstrom T, Butler A, Lucas R, Bonita R. Public health impact of global heating due to climate change: potential effects on chronic non-communicable diseases. Int J Public Health. 2010;55(2):97–103. https://doi.org/10.1007/s00038-009-0090-2
https://doi.org/10.1007/s00038-009-0090-... –²³23. Xing YF, Xu YH, Shi MH, Lian YX. The impact of PM2.5 on the human respiratory system. J Thorac Dis. 2016;8(1):E69–74. https://doi.org/10.3978/j.issn.2072-1439.2016.01.19
https://doi.org/10.3978/j.issn.2072-1439... ).

Disrupted access to health care due to damage to medical facilities, electric power, transportation, communications, or other infrastructure from climate-related disasters can adversely affect people living with NCDs. For example, an island-wide survey in Puerto Rico following Hurricane Maria in 2017 found that many people had disrupted access to health care due to factors such as the inability to obtain medicines, inability to use respiratory equipment, damaged roads, other barriers to transportation, and closed facilities. This contributed to the number of deaths in Puerto Rico in the three and a half months after the hurricane being 62% higher than during the same period in the previous year (²⁴24. Kishore N, Marqués D, Mahmud A, Kiang MV, Rodriguez I, Fuller A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018: 379(2):162–70. https://doi.org/10.1056/NEJMsa1803972
https://doi.org/10.1056/NEJMsa1803972... ). Addressing the effects of climate change on NCDs requires action to strengthen health systems and other infrastructure.

To address the cross-cutting theme of insufficient monitoring and surveillance of climate-sensitive health conditions and exposures, data are needed to orient action to reduce the adverse impact of climate change on NCDs. Caribbean ministries of health routinely collect mortality data on some NCDs and member countries of CARPHA provide these data to CARPHA, which enables national and regional mortality analyses (⁷7. Caribbean Public Health Agency. State of public health in the Caribbean report 2017–2018 – climate and health: averting and responding to an unfolding health crisis. Port of Spain: CARPHA; 2018., ¹⁸18. Caribbean Public Health Agency. State of public health in the Caribbean Region 2014–2016 – building resilience to immediate and increasing threats: vector-borne diseases and childhood obesity. Port of Spain: CARPHA; 2017.). However, national and regional systems to track the incidence of NCDs and NCD-related complications are generally lacking.

On the other hand, fledgling progress has been made through the establishment of a climate and health observatory at the Caribbean Institute for Health Research at the University of the West Indies (Mona, Jamaica) to collaborate with regional meteorological scientists to examine linkages between weather events and the incidence of NCDs (¹¹11. Allen CF, West RM, Beagley J, McGushin A. Climate change and health in small island developing states. London: The Lancet Countdown on Health and Climate Change; 2021.). Combining health and meteorological data can pinpoint populations and areas at risk and enable effective disaster preparedness and recovery. This points to the importance of addressing another cross-cutting theme: institutional silos among key agencies and sectors.

Breaking silos is also important in the field of disaster prevention and recovery. A study in Puerto Rico after Hurricane Maria on people who were obese, overweight, and/or had diabetes found that those who were prepared for the hurricane at a low to medium level were twice as likely to suffer harmful health effects than highly prepared people. Furthermore, people whose diet changed as a result of power outages, financial challenges, and/or disruption to their drinking water supply were significantly more likely to experience detrimental health effects (²⁵25. Joshipura K. Hurricanes Irma and Maria, preparedness, resilience and health. Conference on Climate Change and Health in Small Island Developing States: Focus on the Caribbean (A Virtual Conference); 5–8 October 2021.). Health and disaster management professionals should collaborate with academic and technical agencies on studies to identify evidence-based strategies that strengthen preparedness and access to health care, medication, and healthy food among people living with NCDs to reduce morbidity and mortality during and after disasters.

The cross-cutting theme, lack of knowledge, awareness, and skills across society on climate and health, is highly relevant to people living with NCDs. There is a need to empower these people with knowledge about the risks associated with heat, poor air quality, and extreme weather events and how to reduce these risks. Initiatives should include information sheets and preparedness checklists for specific NCDs (²⁶26. Hassan S, Nguyen M, Buchanan M, Grimshaw A, Adams OP, Hassell T, et al. Management of chronic noncommunicable diseases after natural disasters in the Caribbean: a scoping review. Health Aff (Millwood). 2020;39(12):2136–43. https://doi.org/10.1377/hlthaff.2020.01119
https://doi.org/10.1377/hlthaff.2020.011... ). Instruction about how to use these checklists is essential. Studies are needed to document the effectiveness of such educational initiatives and explore opportunities for scale-up.

WAY FORWARD

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

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

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

Disclaimer.

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

Acknowledgements.

The CRAA was made possible by the contributions of presenters and participants at the Conference on Climate Change and Health in Small Island Developing States: Focus on the Caribbean held on 5–8 October 2021; lead authors of the Conference preparatory documents (co-authors CFA, RD, GGS, SH, and Heather Harewood); expert reviewers of the Conference preparatory documents; participants in stakeholder dialogues/consultations held in 2022–2023 by the Research for Action on Climate Change and Health in the Caribbean Committee; and expert reviewers of drafts of the agenda. We thank the National Oceanic and Atmospheric Administration and the Pan American Health Organization for their financial support for the CRAA. We are also grateful to Jihana Mottley for administrative support.

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