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National Guide

Chapter 21 | Health impacts of climate change







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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    22. Chapter 21 | Health impacts of climate change

Health impacts of climate change

A/Prof Veronica Matthews  Prof Sarah Larkins 

Key messages

  • In the current climate emergency, Aboriginal and Torres Strait Islander communities are disproportionately exposed to environmental degradation, rising seas and extreme weather, unjustly compounding existing health and wellbeing inequities.1
  • GPs and other primary healthcare professionals have a key role to play in preventing adverse health outcomes in their patients from climate change and extreme weather events and advocating for patient access to appropriate resources to reduce health risk. Consideration of the patient’s context is needed in developing preventive health strategies in relation to climate change. This may include their location and potential climate hazards, demographics and disease profile, access to financial and social resources, including adequate housing, and access to cooling, power and refrigeration.2
  • Best practice clinical care that holistically promotes physical, social and emotional wellbeing (SEWB), and includes activities that facilitate connection to and caring for Country, will support the health of patients, communities and the planet for future generations.3,4
  • Practice recommendations centre on identifying patients at risk of climate change effects, educating patients on physical and mental health impacts from climate change events, designing risk-reduction strategies appropriate to patient context, helping patients and their families to prepare disaster plans and strong advocacy where necessary to improve environmental, social and cultural determinants of health.
  • GPs and other primary healthcare professionals can also model behaviours that reduce carbon emissions and urge their profession and the broader health and political systems to adopt environmentally sustainable policies and practices.5
Type of preventive activity - Immunisation
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children Conduct regular reviews of all infants and children and recommend vaccination As per the NIP schedule and relevant state and territory immunisation schedules for Aboriginal and Torres Strait Islander children Strong National schedule9
National guideline10		 As per the NIP and Australian immunisation handbook
All people Ensure up-to-date tetanus immunisation for cover in case of floods and other extreme weather events Opportunistically, during outbreaks Good practice point Scoping review6 Flooding and other natural disasters may increase the risk of tetanus-prone wounds
All people Ensure up-to-date COVID-19, pneumococcal and influenza vaccinations for those eligible Opportunistically, seasonally and as clinically indicated Strong National guidelines7 Reduce other illnesses that might exacerbate respiratory distress at times of high air pollution or heat extremes
People identified at high risk of emerging vaccine-preventable infections based on geography or occupation Respond to any new regional, population or occupational recommendations for vaccinations (eg Japanese encephalitis) Opportunistically, as clinically indicated, during outbreaks Good practice point Jurisdictional guidelines8–10 Climate change is causing a wider spread of mosquitoes and other disease vectors, raising the risk of outbreaks
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people Ask about and holistically assess vulnerability to heat waves and other extreme weather events

Flag those with particular vulnerabilities in practice software and advocate where needed

Offer check-ups by telehealth or home visit to avoid exposure at times of temperature extremes or high air pollution		 Opportunistically Good practice point Peer-reviewed viewpoint article and peer-reviewed international policy document11,12 Climate change can impact all domains of wellbeing, so holistic assessment of the social, environmental, cultural and physical impacts of climatic extremes is important11
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people with chronic conditions (especially chronic obstructive pulmonary disease [COPD], asthma, other respiratory, renal, diabetes and cardiac disease), the frail and elderly (age over 65 years, or over 50 years if they have chronic conditions; see Box 1) Monitor mental and physical health and wellbeing, hydration and renal function regularly, particularly at times of temperature extremes Opportunistically, and at times of climate stress
As per specific chronic disease management guidelines.		 Strong National guidelines7,13 Increased allostatic load from natural disasters and extreme weather events is likely to worsen the control of chronic conditions
All people Be alert to increased risk of family violence (see Chapter 4: Child and family safety, Family abuse and violence) Opportunistically and at times of heat stress Good practice point International indigenous narrative review14 Overcrowding and irritability caused by heat stress can exacerbate domestic and family violence
All people with a focus on young people Assess mental health/social and emotional wellbeing using a culturally appropriate tool, including assessing climate anxiety Opportunistically and when clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific studies15,16 Due to close connections to Country, Aboriginal and Torres Strait Islander people are most affected by ecosystem degradation and climate anxiety15
People who are frail or elderly and those with chronic disease requiring regular medications Ensure people are equipped with disaster management plan, including:
  • access to power and essential medicines (especially for those who are oxygen dependent)
  • an evacuation plan
  • important contacts, medication and health summary
 Opportunistically, seasonally, as clinically indicated Good practice point Peer-reviewed viewpoint article and scoping review 6,17,18 Ensuring access to medical care and resources after a natural disaster is important for health and a major concern of the population17
Appropriate preparation might enhance self-care after a disaster
People with respiratory conditions (chronic suppurative lung disease, COPD, asthma) Advise (and arrange if needed) to stay indoors in air conditioning on days of high air pollution

Consider the provision of a home air pollution monitor or the use of self-management applications		 Opportunistically, seasonally, as clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific studies and general population study19–21 Education and self-monitoring for people with respiratory illnesses and their parents may help avoid the worst climatic conditions
All people Provide education and advice on sustainable living and small changes possible (eg low waste, active transport, low-/no-meat diet, renewable energy) Opportunistically  Good practice point National position statement22 Advocacy and leading by example is an important role of the GP

Changes that are good for the climate and environment also provide excellent benefits to individual health in terms of primary and secondary prevention
People at risk of temperature extremes Provide education and advice about the steps to take to mitigate the effects of extreme temperatures, including fluid intake, body cooling, modification of medications Opportunistically at times of temperature extremes Good practice point Peer-reviewed viewpoint articles2,18 Providing timely advice to those at risk on steps to take to mitigate and self-manage the risks of extreme temperature may be helpful
People who are elderly, those with respiratory disease and those most at risk from temperature extremes Recommend telehealth consultations during times of temperature extremes or air pollution extremes to avoid environmental exposure during travel Opportunistically at times of temperature extremes and poor air quality, as clinically indicated Good practice point Peer-reviewed viewpoint article18 Avoiding exposure to the worst climatic extremes by reducing travel may be important
All people Promote opportunities for connecting to Country and mob Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific single studies and international framework on child health4,23,24 Positive health effects have been demonstrated through connection to Country and caring for Country for Aboriginal and Torres Strait Islander communities, especially young people
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All clients with chronic diseases and/or requiring regular medication Conduct a medication review (ideally in the home) to assess temperature stability and storage conditions of prescribed medications, and adjust as needed Opportunistically, as clinically indicated Good practice point Peer-reviewed viewpoint article and international PHC study18,25 Medications might be more or less stable with extreme temperature fluctuations or in the absence of refrigeration

Changing to more temperature-stable alternatives might be helpful for chronic disease control
People with chronic conditions, frail, aged or on multiple medications Monitor hydration, postural blood pressure, symptoms and renal function for those at risk

Use temperature-stable preparations of medications where possible		 Opportunistically with extreme events Good practice point Narrative review13 Some medications (commonly used for chronic conditions) are associated with higher degrees of heat-related morbidity
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children Conduct regular reviews of all infants and children and recommend vaccination As per the NIP schedule and relevant state and territory immunisation schedules for Aboriginal and Torres Strait Islander children Strong National schedule9
National guideline10		 As per the NIP and Australian immunisation handbook
Practices and health services Advocate at broader policy level for climate change action, self-determination, renewable energy, appropriate urban design and adequate housing for all Opportunistically and ongoing Good practice point National position statement and international9,22 By virtue of advantaged status in terms of socioeconomic status and education, doctors have a responsibility to advocate for policy change in terms of climate change and environmental sustainability
Practices and health services working with those most vulnerable to climate conditions Advocate at the level of the individual patient, family or community for improved housing, access to stable power, refrigeration and access to adequate cooling Opportunistic Good practice point Opinion piece2 By virtue of advantaged status, doctors need to learn practical skills in advocacy and use them to support patients in advocating for improved housing and access to environmental determinants of health
Health services and practices in settings where environmental and living conditions have strong contribution (environmental attribution) to communicable disease transmission and other conditions such as mental health issues Know about diseases with a high environmental attribution

Develop a safe clinical relationship in order to ask sensitively about housing and living conditions (inadequate housing facilities; access to affordable and reliable energy supply for refrigeration and air conditioning; access to health hardware, such as working plumbing for clean drinking water and washing facilities; access to hygiene and sanitation supplies)

Know about local arrangements for environmental health referral
Offer an environmental health referral according to local arrangements, ensuring consent is obtained when a home visit is involved

Advocate with Aboriginal and Torres Strait Islander leaders for adequate housing, affordable and clean energy supply, facilities for washing and general living conditions
Provide community-based health promotion about environmentally attributable diseases

Check local guidelines		 Opportunistically, in response to any diagnosis or condition with an environmental attribution and as part of general healthcare Good practice point International and Aboriginal and Torres Strait Islander-specific narrative reviews26,27 Household crowding and quality of housing and environments exacerbate conditions promoting communicable disease transmission, including COVID-19, Streptococcus A infections, otitis media, strongyloidiasis, trachoma, tuberculosis and other respiratory tract infections

Aboriginal and Torres Strait Islander peoples have long recognised the links between human health, animal health and the environment. GPs can advocate for environmental living conditions and housing equity

Box 1. Identifying patients at higher risk of health impacts during climate change events
At-risk patient characteristics
Demographics Older people (aged >65 years), infants, young children, pregnant women and breastfeeding mothers
Chronic disease and risk factors Heart disease, hypertension, chronic obstructive pulmonary disease, asthma, other respiratory diseases, diabetes, renal disease, obesity, poor cardiovascular fitness, mental illness, substance use addictions
Physical, sensory or intellectual disability Poor mobility, autism, dementia, cognitive impairment, hearing impairment, visual impairment
During heatwaves: conditions that impair sweating, such as cystic fibrosis, scleroderma, skin disorders
Medication/s Beta-blockers, triptans, anticholinergics, sedating antihistamines, tricyclic antidepressants, phenothiazine antidopaminergic agents, selective serotonin uptake inhibitors, antipsychotic drugs, stimulants, sympathomimetics, diuretics
Social/environmental factors Living alone, socially isolated, poor-quality housing or homelessness, insecure or prepaid electricity
Occupation/recreation Outdoor workers, patients who exercise/play sport outside and school children who play outdoors

Practice level: Practising with a climate lens

  • Identify vulnerable patients with respect to climatic conditions and air pollution and add seasonal recalls and reminders for primary and secondary prevention. Including early advocacy by the GP in terms of appropriate housing, access to cooling and refrigeration and secure power supply for these individuals should be a priority. This register of at-risk patients could also be used to develop protocols for offering video or telephone visits, or home visits, rather than in-person visits, to avoid exposure on days with a high heat index or poor air quality.2,25
  • For closer monitoring and medication reviews, ensure identification and flagging in patient information software of patients on multiple medications, medications that might be unstable in extreme weather conditions or those that predispose to adverse events in conditions of climatic extremes (eg diuretics, beta-blockers, anticholinergics).
  • Use at-risk patient flags to automate the delivery of relevant disaster preparation and community service material for patients prior to GP appointments.18
  • Incorporate questions (and appropriate advocacy, educational and healthcare delivery responses) about housing, energy security and knowledge of personal climate risk reduction strategies into annual health checks and chronic disease management plans for relevant patients.
  • GPs and other key practice staff should participate in regional emergency and disaster planning, including planning around surge workforce and surveillance and response to communicable disease outbreaks.6,28 Enlist key community leaders in this planning.29 This should include appropriate clinical and pastoral checks for vulnerable people. Practices and health services may also need to consider the role of a surge workforce in providing in-home support following a disaster and possible digital literacy assessment for planning appropriate follow up and advice via telehealth.
  • Provide training for all clinical and non-clinical staff in appropriate responses to climatic extremes, environmental change and health.
  • Ensure training for all clinical practice staff (GPs, practice nurses, allied health professionals) in appropriate strategies for environmental health advocacy, awareness and promotion of vector distribution and immunisation recommendations and eligibility according to geography, occupation and vulnerability.30
  • Add practice clinical audit and quality improvement activities for climate disaster preparedness at the practice and individual patient levels.

Personal level : Walk the talk

  • Primary healthcare professionals can individually model physical and environmental health co-benefit strategies (eg walk or cycle rather than drive, eat less or no meat) and educate other professionals on environmentally friendly practices.5,31
  • Think about environmental sustainability in all clinical decisions to reduce low-value care, medical waste and carbon emissions. Promote the circular use of resources (reduce, reuse, recycle).32,33
  • Join an advocacy organisation such as Doctors for the Environment Australia or the Climate and Health Alliance (see Useful resources).31,32

Broader systems level: Public health advocacy

  • In the past, medical professionals have advocated on important societal issues, such as tobacco control and increased resourcing for Aboriginal Community Controlled Health Organisations. The climate emergency is a critical health and social justice issue requiring immediate advocacy and action at all levels to protect Aboriginal and Torres Strait Islander patients and future generations.32 Primary healthcare professionals can highlight the link between climate change and increasing demands on health services and expenditure to influence government policy.
    • Advocate for Aboriginal and Torres Strait Islander community inclusion in climate action and disaster risk reduction planning.
    • Continue advocating for ambitious government climate action policy and adequate resourcing of initiatives, such as the National Health and Climate Strategy (see Useful Resources).
    • Promote green spaces in urban areas for community access to parks, shaded spaces and exercise areas.11 This confers SEWB benefits and, if designed appropriately, can mitigate against urban island heat effects and improve neighbourhood air quality.23
  • Advocate for improvements in community housing designs, to conform with building codes and standards,34 along with strengthening of the other environmental determinants of health.
  • Advocate for community input into housing design to align with local culture and environmental conditions.

Professional and advocacy organisations

Disaster preparation, response and recovery planning

Heatwaves

Bushfire smoke and air quality

General resources

Background

Around the world, communities are experiencing rising sea levels and more dangerous, unpredictable and frequent extreme weather due to anthropogenic global warming.35 The climate change emergency has been declared as the greatest threat to humanity, with many direct and indirect consequences for our planet, its biodiversity and the survival of human populations.36

In Australia, climate change is predicted to increase average temperatures and cause more frequent and intense heatwaves, particularly across the north and centre of the country. Dangerous fire and weather conditions will become more prevalent. Coastal regions will be at risk of storm surges and erosion due to rising sea levels. Cyclones and rainfall events will intensify, raising flood risk. There will be decreased rainfall in southern parts of Australia, which will increase the likelihood of droughts.1 Such events will expose populations to heatwaves, bushfires, droughts and floods, reduce air, food and water quality and extend the ranges of certain infectious diseases and their vectors, increasing all-cause mortality and exacerbating chronic disease and mental illness.1,37

Like other First Nations peoples globally, Aboriginal and Torres Strait Islander communities will be disproportionately harmed, exacerbating health inequities and social injustice.1 For Aboriginal and Torres Strait Islander people, climate change is viewed as an extension of colonisation, further deteriorating the intrinsic link between health of mob (ie individuals and communities) and health of Country – the traditional lands and waters that are sacred and necessary for survival. Country is foundational to Aboriginal and Torres Strait Islander culture, identity and knowledge systems.1 Climate change is fundamentally a health and wellbeing issue and primary healthcare is integral to a multisectoral approach needed to mitigate adverse impacts and help populations to adapt.

To help patients navigate climate change risk, the expertise of primary healthcare professionals is required in four domains: personal, clinical, organisational and the broader health system.31,38,39

At a personal level, primary healthcare professionals should understand how climate change may harm health and be aware of local climate change trends and how they may affect their patient population. Professional networks such as Doctors for the Environment and the Climate and Health Alliance are reputable sources of educational material on climate and health, and how health professionals can contribute to better, sustainable healthcare31 (see Useful resources).

From a clinical perspective, climate change is a threat multiplier, exacerbating existing morbidity and socioeconomic disparities. Socioeconomically marginalised groups tend to be disproportionately exposed to extreme weather events. For example, 80% of households in the 2017 Lismore flood footprint came from the most disadvantaged socioeconomic quintiles and had significantly higher rates of riskier health behaviours (eg smoking, alcohol consumption), pre-existing mental health conditions (depression and anxiety) and poorer health compared with neighbourhoods outside the flood footprint.40 These same groups are less likely to have social capital and economic resources available to help with disaster preparedness and response.41

Rural and remote communities generally have lower incomes, poorer health outcomes and less access to services, including primary healthcare.42 Remote areas have more overcrowded, poorly insulated housing, with insecure access to electricity, cool water and refrigeration. Climate change will aggravate these existing disparities, particularly in locations that are ‘hotspots’ for extreme weather events and where there is a reliance on industries, such as agriculture, that are sensitive to climate change impacts. GPs have a vital role in advocating for community resources and safe housing that supports health and wellbeing.
GPs and other primary healthcare professionals are increasingly recognising the importance of preparing for significant events, such as the unprecedented 2019–20 bushfire season and the widescale floods in 2022 and 2023 across the country.43,44 Identifying patients at risk, advising with regard to appropriate prevention strategies and advocating where necessary will require GPs to approach clinical practice with a ‘climate lens’. Climate-sensitive presentations in GP clinics may include heat stress in heatwave conditions, allergic respiratory disease from increased dust, pollen or mould particulates and mental health distress from extreme weather events.44 Although time pressures can be a barrier to discussing climate-related issues during consultations, there are tools, such as electronic health system flags and patient information sheets, to help with the identification and communication of risk.18,43
At an organisational level, primary healthcare services should play a key role in disaster preparedness and response planning within their local community and alongside local councils, emergency services and other health and social support agencies. The Sendai Framework for Disaster Risk Reduction 2015–30, to which Australia is a signatory, advocates a community-centred preventive focus to disaster risk.45 It recommends a multisectoral and inclusive approach in designing and implementing policies by engaging all relevant stakeholders, including women, children, older people, people with pre-existing health conditions, people with low socioeconomic status and First Nations communities.45 In this way, understanding and managing disaster risk encompasses all dimensions of exposure, vulnerability and capacity of individuals and communities within the local region.45
In addition to educating patients and providing healthcare for climate-sensitive illnesses, as influential leaders in their communities GPs have a role to play in promoting community understanding about climate change (eg media contributions) and advocating at an individual and community level for access to environmental health determinants and environmentally sustainable practices and policies.46,47 They can also participate in research to grow the evidence base on the health impacts of climate change and effective strategies in healthcare.46,47
The focus of this topic is primarily on evidence-based action within primary healthcare clinical practice to mitigate impacts on public health from climate change-related events. There is limited research in Australia on actions to support health in relation to climate change risk. Much of the following relies on best practice preventive health measures recommended for specific chronic diseases, including mental health, and social and environmental determinants that are likely to be exacerbated by climate change.
Regarding the role of GPs and other primary healthcare professionals in agenda setting and advocacy related to sustainable primary healthcare and empowering communities, we mostly draw on professional organisation position statements and commentary. Detail on greening clinical practices is not in scope for this topic, but the Implementation tips include suggestions for GPs and other primary healthcare professionals to consider on a personal and broader system level to holistically respond to climate challenges. Links to where more detailed information can be sourced are provided in the Useful resources.

Climate change will have many direct and indirect effects on Aboriginal and Torres Strait Islander communities, affecting deep, spiritual ties to Country and exacerbating already disproportionate levels of ill health, stress and hardship (Figure 1). Many health promotion behaviours that are central to preventive health and should be promoted during annual well persons’ health checks, such as increased physical activity, family and social connections and healthy diets, are part of the solution to preparing for and mitigating the effects of climate change. Careful consideration of local context is always required because what may be appropriate for one patient may not be appropriate for another (eg access to public transport, advocacy for improved housing or access to finances to run cooling/heating devices).

Figure 1. Direct and indirect impacts of climate change on Aboriginal and Torres Strait Islander health.
Adapted from the California Department of Public Health, 2023.48

 

Climate change impacts amenable to preventive health strategies

Heat

Greenhouse gases (eg carbon dioxide and methane) in the atmosphere naturally hold heat from the sun. The accumulation of greenhouse gases from the burning of fossil fuels and increased carbon emissions have trapped heat in the lower atmosphere. Heatwaves (when the maximum and minimum temperatures are unusually hot over three days compared with the local climate and past weather) have intensified in Australia, becoming more frequent, longer and hotter over the past few decades.37,49 Known as the ‘silent killers’ of climate change, heatwaves directly (eg heatstroke, heat exhaustion) and indirectly (eg cardiac failure, mental illness) harm health.49 Most deaths attributable to heatwaves arise from exacerbations of pre-existing conditions rather than direct effects such as heatstroke.13,50 In addition to people with underlying diseases (particularly cardiovascular and respiratory), other vulnerable groups include the very old and very young, lower socioeconomic groups, people who are socially isolated, outdoor workers and communities with poor housing infrastructure.49 Across all populations, increases in heat-related mortality and morbidity are projected to occur with climate change.51 Hotter temperatures can also increase adverse pregnancy outcomes and increase hospital admissions for mental health and cardiopulmonary conditions.52,53 In urban centres, the combined effects of heatwaves and poor air quality have increased emergency department admission rates for Aboriginal people in Perth21 and for Aboriginal children in Brisbane due to respiratory conditions.54 Hot spells may also trigger instances of interpersonal violence, where social intolerance levels increase from heat irritation.14,55

The construction of Aboriginal housing in remote regions has been plagued by inappropriate design, the use of cheap, substandard materials and inadequate maintenance.56 In combination with overcrowding and regular power cuts that remote communities experience, often associated with mandatory prepaid power card systems,34 poor housing conditions in heatwave areas reduce the ability of households to control indoor temperatures and can lead to poor sleep, cardiovascular disease, respiratory illness and poor mental health.

Bushfires, drought and air quality

More drought periods and extreme fire danger conditions are expected to occur with climate change, establishing conditions ripe for widespread bushfires and dust storms. The immediate impact of bushfires is obvious, with loss of human life and wildlife and the destruction of homes, infrastructure and significant cultural sites increasing trauma and other mental health issues.13,37,57,58 Bushfire smoke can extend far beyond fire fronts, increasing morbidity and mortality, with most deaths resulting from exacerbation of pre-existing health conditions, including COPD, asthma and cardiovascular disease.13 Resultant ash and fire-retardant chemicals can cause siltation and contaminate water supplies.13,57 Studies have shown that populations affected by bushfire disasters have a range of long-term physical and mental health conditions, including gastrointestinal disorders, diabetes and post-traumatic stress in adults and children compared with communities that had not experienced a natural disaster.58,59

Climate change and warmer weather conditions may result in higher concentrations of ground-level ozone (the main pollutant in smog), which has harmful effects on respiratory health and has been associated with increased daily mortality.60 Other problematic airborne particulates driven by warmer conditions include fungal spores and plant pollen, which can cause respiratory, eye and skin conditions.57,61 There is also emerging evidence from a recent systematic review that poor air quality is linked to neurodevelopmental disorders in children62 and can negatively affect brain development.59 Exposure to bushfire smoke and other fine particulate matter during pregnancy has been associated with lower birth weights and gestational diabetes.63

Drought lowers the quality of air (from increased dust), food and water.57,64 Prolonged drought is known to negatively affect mental health for rural populations, including Aboriginal communities.65 In addition to employment and money worries, key wellbeing concerns of Aboriginal communities include the sense of loss triggered by seeing the land ‘sick’ and the effect on communities’ ability to undertake cultural responsibilities.64 Remote Aboriginal communities in arid areas will be increasingly exposed to particulate air pollution from geogenic (earth-derived) dust due to their geology, dry climate, exposure to wind erosion and, in some cases, proximity to mining activities. Geogenic dust is associated with eye irritation and has been implicated as a risk factor for trachoma (see Chapter 9: Eye health and vision), as well as exacerbation of underlying cardiovascular and respiratory disease.61

Food and water security

Climate change threatens the productivity of local crops and the availability of traditional food sources for Aboriginal and Torres Strait Islander communities due to biodiversity loss and effects on animal and plant distributions.55,66 The loss of locally sourced foods will mean changes to subsistence practices and, in rural and remote areas, communities becoming more reliant on store-bought foods that may be no longer fresh, of poor nutritional quality, expensive and unreliable due to supply chain disruptions and transportation and storage costs.57,67 Food security is further compromised by increased energy requirements and costs for refrigeration and to cool poorly designed and constructed houses.

Predicted declines in rainfall over central and southern Australia will add further stress to surface and underground water resources. In addition to drought conditions, salt water intrusions and intense storms and floods have the potential to contaminate existing fresh water supplies for Aboriginal and Torres Strait Islander communities.55,57 Poor water supply for communities also risks increasing the incidence of diseases, including diarrhoeal disease, hepatitis A and skin infections due to lack of sanitation mechanisms,68 as well as reducing the capacity of remote communities to provide renal dialysis.

Infectious diseases

Climate change will likely see a higher incidence of climate-sensitive infectious disease through several transmission pathways: insect vectors, air, food, water and soil. The distribution of endemic mosquito-borne diseases (Dengue, Ross River and Barmah Forest viruses) and emerging diseases, such as Japanese encephalitis, has increased due to geographical expansion of favourable breeding conditions, with warmer temperatures and increased humidity and rainfall/flooding creating stagnant water reservoirs.69,70 In the hotter parts of Australia, the spread of respiratory viruses, such as COVID-19 and influenza, tend to peak in summer due to overcrowded air-conditioned spaces. Water- and soil-borne diseases such as melioidosis, non-tuberculous mycobacteria and leptospirosis, may increase from higher rainfall and storm events.57,69 The contamination of water supplies from sewerage and other sources, such as storm run-off, may affect the incidence of gastroenteritis and hepatitis A.57

Mental health and social and emotional wellbeing

Climate change exposures (heat, drought, bushfires, floods) will compromise mental health and wellbeing in a number of ways: acute trauma experiences during extreme weather events, post-traumatic stress and chronic stress from long-term events, such as droughts, and permanent changes to landscapes, such as sea level rises making Country uninhabitable.71,72

SEWB issues can manifest in various ways, ranging from strong emotional responses (depression, anxiety, post-traumatic stress and suicide) to emerging conditions such as climate change anxiety and eco-grief.73 Due to close connections to Country, Aboriginal and Torres Strait Islander people are most affected by ecosystem degradation and climate anxiety.15 Psychological effects not linked to acute events are less well described, and there are currently no validated tools to detect issues such as climate anxiety. Although data are lacking on the psychological effects of climate change on children and young people (aged 10–24 years), they may be at particular risk of persistent worry and concern about their future and the future of the planet.74 Observed symptoms of climate anxiety in youth can include panic attacks, insomnia and obsessive thinking, and may lead to increases in stress-related behaviours, such as substance use.74

Witnessing land becoming ‘sick’ reduces Aboriginal and Torres Strait Islander people’s ability to carry out cultural responsibilities in caring for Country, which, in turn, further compounds ecosystem degradation. A recent international review of climate change, mental health and First Nations peoples globally reported psychological and emotional disruption from altered place attachment (similar to the notion of ‘solastalgia’,75,76 ‘the homesickness you have when you are still at home’), changes in food security systems, forced relocation and disrupted cultural continuity.73 The review also reported First Nations peoples’ emotions that are linked to historical and ongoing disempowerment due to colonisation:77 feelings of anger, abandonment and helplessness having to deal with problems caused by other people.73

When assessing the susceptibility of patients to climate change risks, a holistic approach is essential, incorporating a patient’s physiological, medical, social and environmental contexts in preparedness and adaptation planning. Each of these key domains interacts with the others and should not be considered in isolation.

Practice level: Supporting individual patient wellbeing, adaptation and empowerment

As climate disaster-related risks vary by region and personal context, it is important to work with patients to tailor guidance according to their local situations and concerns. Climate risk discussions should occur opportunistically; for example, as part of annual health assessments. To build patient wellbeing, preparedness and self-efficacy to cope during extreme weather, anticipatory guidance during preventive health well checks should focus on strengthening protective factors, such as SEWB, access to nature, secure housing and family and cultural connectedness, including access to Country. Discussions should also be had with patients and within practices and health services in preparation for and during periods of extreme weather (eg heatwaves, droughts, poor air quality/smoke from bushfires, dust storms and extreme rain events and flooding). Advocacy and letter writing to address issues outside of the control of individuals and households, such as appropriate housing and food, water and clean energy security, may be required. This may be on behalf of individuals and/or at a community or policy level.

Healthy living through co-benefit strategies (including secondary prevention of chronic disease)

GPs and primary healthcare professionals can educate about climate change and health co-benefits. Framing climate change as a health issue neutralises politics and is an effective communication strategy to help patients understand risks to their own health.25,78 Healthy behaviours can be powerful mitigators of climate change through reductions in CO2 emissions;11,22,23,78 while recognising differences in availability across the country and personal contexts, these might include:
  • switching to clean energy
  • encouraging active transport (cycling, walking, public transport), which also improves neighbourhood air quality
  • promoting a healthy diet, including high vegetable and fruit intake (preferably locally sourced), less or no red meat, accessing other sources of protein and minimising the consumption of processed food
  • encouraging patients to quit smoking
  • promoting family planning to avoid unwanted pregnancies
  • breastfeeding as opposed to the use of baby formula, which alone would save an estimated 95–153 kg CO2 emissions per baby.23

Preparing and responding to extreme conditions

Children, people aged over 65 years and people with underlying health conditions are particularly vulnerable to climate-related extreme events through direct biophysical effects and loss of health infrastructure, with subsequent disruption to care services.17 Before a disaster occurs, GPs can initiate discussions and motivate patients to prepare emergency plans based on local climate threats and personal situations.17 In preparation for any type of disaster, key issues include:
  • patient access to emergency communications, such as the State Emergency Service (SES), Bureau of Meteorology (BoM) and other emergency communications/public health advice, including heatwave warnings, bushfire alerts, flood warnings and air quality alerts
  • patient access to friends and family they can turn to for assistance during a crisis
  • patient access to essential medications, particularly for conditions that may be exacerbated by extreme weather (eg asthma)
  • patient ability to store heat-sensitive medications appropriately
  • patient dependence on medical aids, such as oxygen tanks or dialysis machines, and their ability to access alternative power supplies in case of blackouts
  • patient documentation of key contact details for emergency service providers, health/medication summaries and situations in which they may require early evacuation and relocation.2,18,23
Patients, particularly socially isolated individuals, may need information about specific community support services and assistance with individual advocacy. Depending on personal and geographical context, this could include raising awareness of cool spaces to access during heatwaves and preparing emergency stores of food, water and medications, torches and battery-operated radios.18 

Heatwaves

Although there is no universal definition of a heatwave, the BoM uses the Excess Heat Factor definition of three or more consecutive days of higher than usual maximum temperatures for a given location.49 The BoM website provides different levels of heatwave warnings (low, severe and extreme; see Useful resources), which can be used by GPs to help patients with individualised plans.2
When assessing patients’ risk status, their sociodemographic and disease profiles and use of medications should be considered. Box 2 provides a list of recommendations for at-risk patients during heatwave events, fully acknowledging that access to these resources is inequitable across the country. Certain medications can contribute to overheating and/or dehydration, including antihistamines, tricyclic antidepressants, antidopaminergics, selective serotonin uptake inhibitors, anti-psychotics, sympathomimetics, diuretics and anticholinergics.18,23,25

Box 2. Advice for patients during heatwaves2,12,79–81
  • Monitor for signs and symptoms of heat stress and heat exhaustion (headaches, thirst, temperature, sweating, clammy skin, lethargy, weakness, nausea and vomiting, rapid pulse, muscle cramps)
  • Monitor indoor temperature by purchasing inexpensive thermometers
  • Stay cool using fans, air conditioners, damp towels, taking cool showers, wearing light, loose-fitting clothes and blocking heat by closing blinds/curtains
  • Know locations of local heat refuges or community venues that have cooling (eg libraries, shopping centres and community centres, including some health services)
  • Minimise travel on hot days to reduce exposure to heat and air pollution
  • Stay hydrated
  • Ensure adequate supplies of medications and the ability to safely store heat-sensitive medications (eg insulin) in particular

A patient’s housing situation contributes to their climate risk. GPs should make explicit inquiries about the functional condition of housing, overcrowding, access to reliable, affordable and clean energy, air conditioners, refrigerators and other cooling devices to assess a patient’s ability to shelter and regulate temperatures indoors.34 Environmentally friendly tips are available online for households to keep their homes cool, such as closing blinds/curtains, sealing gaps around doors and windows and planting trees or using trees in pots to shade external walls (see Useful resources, Heatwaves). If required, patients can be referred to relevant housing or tenancy support services to advocate for improved thermal insulation, passive cooling strategies and shade structures. Including direct patient advocacy in referrals to these services is often effective. In addition, broader advocacy through letter writing by GPs is a powerful strategy. For guidance on advocacy tools and processes, contact the advocacy organisations listed in Useful resources.

Bushfires and air pollution

Bushfire survival plans and smoke avoidance plans are essential for bushfire emergencies and poor air quality. Freely available digital applications can help with the monitoring of air quality and can help people with respiratory conditions reduce their exposure to air pollution and self-manage symptoms. Lung Health for Kids is a multilingual app providing information on lung conditions (asthma, bronchiolitis, pneumonia and bronchiectasis), as well as healthy lifestyles to prevent asthma in children.19 The app is presented in English and several Aboriginal languages of the Northern Territory (see Useful resources). AirSmart is an app developed by Asthma Australia that provides real time information about air quality including pollen levels (see Useful resources, Bushfire smoke and air quality). AirRater® is a free app developed by Australian scientists that monitors small particulate matter (PM2.5) from smoke, traffic and industry and can help people with respiratory conditions to avoid exposure and manage symptoms20 (see Useful resources, Bushfire smoke and air quality).

Air pollution avoidance advice should be nuanced depending on patient circumstances.63 General advice to stay indoors and close the windows and doors is unlikely to be useful for patients living in ‘leaky’ homes with cracks and gaps that cannot be appropriately sealed. Depending on the length of the air pollution event, advice to stop vigorous physical exercise can be detrimental to cardiovascular and mental health. Keeping a supply of P2/N95 face masks within households and encouraging patients to exercise at gyms and indoor sports venues could be alternative options.63

Infectious disease surveillance and vaccination

GPs also play an important role in disease surveillance, including for vector-borne and infectious diseases that may arise after favourable environmental conditions (eg the increased incidence of Japanese encephalitis in 2022 following significant rainfall events).10,78 Overcrowding in evacuation centres can also increase the incidence of respiratory infections such as COVID-19.82 Consistent with best practice, consider vaccinations for an increased range and occurrence of vector-borne and other infectious diseases. Ensure patients are kept up to date with vaccinations, including pneumococcus, COVID-19 and influenza immunisation.

Promoting positive mental health and social and emotional wellbeing

Incorporating ecological approaches in primary healthcare models such as caring for Country activities has the potential to extend these documented benefits to all Aboriginal and Torres Strait Islander community members beyond ranger programs.3,4,24 Discussions about SEWB can be combined with assessment of access to Country and/or nature and guidance about regularly getting back on Country or ‘out bush’. For adolescents worried about climate change and their future, engagement with youth advocacy organisations such as SeedMob may improve wellbeing through connections to peers and involvement in meaningful change processes.23

In the development of a wellbeing measure for Aboriginal and Torres Strait Islander adults, destruction of the environment and culturally significant sites was a cause for sadness and distress.16 Belonging, connection and access to Country and protection of the environment are important for wellbeing.16 Social prescribing is increasingly being incorporated into primary healthcare to encourage the building of networks, boosting social capital and increasing mental health resilience.78,87 Social prescribing is an integrated model of care where GPs or link workers, such as wellbeing coordinators, refer patients to community-based programs or activities with eight general prescription types (arts, books, education, exercise, green [outdoors], healthy living initiatives, signposting/information referral and supported referral).88

A recent rapid review on social prescribing indicated mixed outcomes from mostly international studies; however, the quantitative health outcome measures used may not have adequately captured the more complex social capital concepts, such as community connectedness, empowerment and self-care.88 In addition to the lack of evidence on positive health impacts from social prescribing, there are no studies on social prescribing in Aboriginal and Torres Strait Islander populations.

Organisational level: PHC sector as part of a multisectoral community response

Community-level disaster preparedness

As a trusted source of knowledge and information, primary healthcare services, through GPs and other professionals, can advocate for and participate in service and community preparedness and adaptation planning and participate in disaster and disease surveillance.6,29 This includes advocating for appropriate resourcing for adequate community housing, clean energy and water infrastructure and strengthening the primary healthcare service and workforce capacity to appropriately respond during disaster situations, particularly in rural and remote locations.28 Integration of primary healthcare services into existing disaster and emergency preparedness, response and recovery plans is required to ensure the continuation of holistic care to meet the post-disaster mental, physical and social support needs of all community members, particularly the most vulnerable.17
Depending on geographical and community context, primary healthcare professionals can:

  • promote basic rights for housing tenants regarding proper insulation and the installation of cooling devices
  • advocate for reliable, affordable and clean power in remote communities, such as an on-roof solar supply and supporting policy prohibiting energy disconnection during times of extreme heat
  • support community gardens for local food production, green and blue spaces for outdoor recreation, safe walking and cycle paths and high-quality and affordable public transport systems.22
There are equity benefits too, through increased access to local fresh food, contact with nature and social inclusion.89 GPs and other primary healthcare professionals can be leaders in advocating for health-in-all-policies approaches to address both poor health, inequity and climate change.78

‘Greening’ primary healthcare services and strengthening preparedness and response capabilities

Under a climate change future, health services will struggle to meet increasing demands without appropriate service infrastructure and workforce. Greenhouse gas emissions generated by the health system have downstream consequences, contributing to the ill health of populations due to climate change and contradicting the core business of protecting and promoting human health.32,78

Within the primary healthcare service, GPs and other health professionals can advocate and investigate ways to adopt ‘green care’ (reducing carbon emissions) strategies to minimise waste, lower energy consumption and improve efficiencies.22,78 This can involve reducing low-value care,90 shifting away from fossil fuel dependency by transitioning to renewable energy and improving the thermal properties and energy efficiency of clinics and staff housing. Environmental sustainability can become a new health system quality domain, and quality improvement processes can be used to reduce healthcare waste and pollution.25,33,38

In addition, GPs can initiate and participate in organisational preparedness planning, including workforce planning and training for surges in health service needs immediately after a disaster and over the longer term with worsening climate-sensitive conditions such as respiratory and cardiovascular diseases. This may involve providing training programs for staff to identify, monitor and treat trauma and other mental health issues and build an inventory of available resources to provide to community members.72 Existing programs include Aboriginal and Torres Strait Islander mental health first aid training and the Skills for Life Adjustment and Resilience (SOLAR), which is designed to be delivered by community members/health workers to mitigate distress following disasters, contribute to suicide prevention and provide trauma-informed therapies (see Useful resources).

GPs and other primary healthcare professionals can generate informative campaigns for the service population and mobilise the health and community workforce, including emergency volunteers, in the surveillance and management of individuals tagged in patient information systems with known vulnerabilities in relation to extreme weather (see Implementation tips). For example, there have been positive outcomes from developing regional, multipronged heat action plans focusing on preventive reminders and the provision of resources, such as cooling spaces, to vulnerable population groups to cope with extreme heat. An international scoping review of the implementation of community heat action plans showed reductions in heat-related mortality based on historical trends.81

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