1.D. Workshop: Food and water insecurities in a warming climate: What role for Public Health?

Water sprays from an open fire hydrant in Brooklyn, New York, in the midst of a July 2010 heat wave that affected much of the eastern United States.In 2007 the New York City Department of Environmental Protection first teamed up with Alianza Dominicana, a Washington Heights community organization, to educate city residents about the appropriate use of fire hydrants and other ways

In the aftermath of the catastrophic 2019–2020 bushfires, the corona virus disease of 2019 pandemic and recent devastating floods in New South Wales and Queensland, Australians voted for climate action in the 2022 Federal election, and a new Climate Change Bill1 has already passed the House of Representatives. Climate change is recognised by scientists, public health experts, Indigenous leaders, economists and the Australian public at large as the most pressing issue at our doorstep.2-5 As we consider the veracity of net zero emission election commitments and the architecture of a post-pandemic recovery in Australia, we use science, public health expertise and a common chronic condition to explain the links between key issues and outline a road map for action in Australia. In this commentary, we highlight current evidence on the relationships between climate change, air pollution, fossil fuel use and their associated impacts on public health. We use asthma as a case study to examine the economic and human health burden arising from this climate-air pollution-fossil fuel triad. Australia's dependence on fossil fuels and gaps in energy policy are underscored as drivers of negative climate and public health outcomes. We provide a roadmap for action consisting of a mandate for: rapid de-carbonisation of Australia's energy systems; adoption of a healthcare without harm framework; and preparing public health systems to prevent and control asthma exacerbations. Climate change is the greatest threat to public health of the 21st century.6 The planet has warmed significantly over the past century by on average 0.8°C, largely as a result of increased global emissions of carbon dioxide and other greenhouse gases (GHG).7 Human activity and fossil fuel-based, carbon intensive energy systems have contributed substantially to global heating. Climate change is having profound effects on weather systems, exemplified by the increased frequency and duration of extreme weather events including floods, drought and bushfires. Climate change also adversely impacts on atmospheric air quality and air pollution.1 The relationship between climate change and air quality is bi-directional: climate change can exacerbate or increase existing air pollutants (e.g., atmospheric heating increases ground level ozone); air polluting emissions influence the climate (e.g., release of carbon-based materials such as black soot have a heating effect); several sources of air pollution are sources of GHGs (e.g., methane locks heat in the atmosphere, triggering climate change). Incomplete combustion of fossil fuels is a primary source of air pollutants (e.g., particulate matter [PM]2.5) and is harmful to human health.8 Higher temperatures and carbon dioxide levels arising from climate change also increase airborne allergenic pollens contributing to allergic asthma.9 The energy sector is the largest contributor to GHG emissions in Australia.8 Australia's primary energy consumption is dominated by fossil fuels (i.e., coal 40%, oil 34% and gas 22%)10 and its electricity system is founded on centralised, carbon-intensive coal-fired generation. Australia's coal burning (and exports) contributes to climate change and air pollution and hence health impacts. Every step of coal's lifecycle produces air pollutants that affect human health. Burning coal produces fly ash and particulate matter (PM2.5), which lodge in the lungs, causing irritation and inflammation.11 Transport (energy) is the second largest source of emissions after electricity production.12 The road transport sector, including passenger and commercial vehicles, is reliant on petroleum-based fossil fuels and is a significant contributor to air pollution in cities and regions.13 For example, petrol and diesel emissions arising from road traffic are a major culprit in asthma exacerbations: Nitrogen dioxide (NO2) exposure and living in close proximity to a major road are associated with an increase in the likelihood of asthma in children and adults.14, 15 Asthma is one of the most common and costly of all chronic disease conditions affecting more than 260 million people globally, and both its prevalence and incidence is strongly associated with air quality and atmospheric pollution16 In 2021, 2.7 million people (10.7%) of the Australian population had asthma, making it a common non-communicable disease17 and accounting for 417 deaths in 2020.18 Nationally, there were over 37 000 hospitalisations with asthma as the principal diagnosis in 2016 and around 2% of all general practitioner encounters were for asthma, representing the 14th most common reason for a general practitioner consultation in that year.19, 20 As asthma is a lifelong condition, the costs associated with the condition are high, both to the individual as well as to the health service, where it accounts for $770 million in direct expenditures annually.19 Studies of coal mine fires and coal town residency illuminate the fossil fuel, air pollution and asthma relationship. The Hazelwood coal mine fire in the Latrobe Valley, Victoria in 2014 created plumes of smoke and ash with high PM2.5 for 45 days. Guo et al.21 found increased risks of all-causes, respiratory diseases, and asthma related emergency presentations and hospital admissions. Casey et al.11 found living near coal-fired power plants is linked to higher rates of respiratory disease and increased asthma exacerbations, while shutting down a coal plant or upgrading emission controls decreases inhaler use, emergency department visits and hospitalisation for asthma among local residents. Gas has also been associated with childhood asthma: one study of Australian children reported the population attributable fraction for childhood asthma associated with household gas stoves (which release PM2.5, NO2) for childhood asthma was approximately 12%, corresponding to over 2700 disability adjusted life years.15 Climate change is increasing the frequency and intensity of bushfires in Australia. Smoke from bushfires is a major risk factor for asthma exacerbations: the 2019–2020 summer bushfires have been linked to 429 premature deaths, more than 2000 hospitalisations for respiratory health issues and 1500 emergency department presentations with asthma.235 The health-related economic costs of the 2019–2020 bushfires was estimated AU$1.95 billion, with the majority due to the economic costs of premature mortality associated with the bushfires; AU$25 million of healthcare costs, $24 million for cardiovascular and respiratory hospitalisations, and AU$1 million for asthma emergency department attendances.22 Climate change effects allergic diseases.23 Thunderstorm asthma is an allergic asthma response to airborne allergenic pollens that rupture due to osmotic shock following a thunderstorm event, and thereby allowing smaller allergenic sub-pollen particles to reach the lower airways to trigger the potentially deadly allergic response24 (see Figure 1). In November 2016, the phenomenon of thunderstorm asthma caused 10 deaths in Australia and more than 3300 ED presentations.19, 24 Several studies have shown that plants growing in highly polluted air produce more allergenic pollen.25 When combined with pollen rupture, it results in a volatile mix that turns such pollens into ‘biological time bombs’. Knox et al.26 have shown that the major allergen of rye grass pollen has the capacity to directly interact with diesel exhaust carbon particles (DECP). They assert allergen-loaded DECP has the capacity to penetrate the lower airways and prompt an episode of asthma. Figure 1 describes the relationship between air pollution, climate change, fossil fuels and thunderstorm asthma as a public health issue. Healthcare—one of the world's largest industries—contributes to climate change and air pollution. The Australian healthcare system is responsible for ~7% of national GHGs.27 In the United States, one study has estimated that healthcare-related air pollution was responsible for 9% of respiratory disease burden from PM emissions.28 Similar estimates of disease impact are not available locally, but Australian healthcare is responsible for around 3% of national PM footprint.29 Paradoxically, some asthma treatments are significant contributors to GHGs. Metered-dose inhalers for asthma contribute an estimated 3.9% of the total carbon footprint of the UK National Health Service,30 due to the extremely potent GHGs used as propellants in some delivery systems. Australian estimates are not available, but the same products are widely used in this country. This scenario demonstrates perverse feedback loops—air pollution and climate change drive each other, and both drive increasing asthma incidence through various pathways, while treating asthma can itself further drive climate change through GHG emissions. This is a critical decade. Linear, single issue and reductionist approaches will not cut through the complex public health challenges arising from the climate change, air pollution and fossil fuel triad. Here we offer the new federal government and health sector a three-point roadmap for action. The roadmap highlights key public health-oriented interventions, which will prevent health-harming emissions, promote a healthy recovery from the pandemic and help Australians prepare for increasing asthma prevalence due to environmental triggers. Australia remains heavily dependent on fossil fuels and is unlikely to keep its commitments to the Paris Agreement to which it is a signatory. Since 1990, there has only been a 10% reduction in the share of electricity generation produced from non-renewable fuels (89.9% in 1990 to 80.2% in 2019) with more than half of total generation still reliant on coal.31 Stopping fossil fuel development and decarbonising energy systems are the most urgent and far reaching challenges of this decade.32 To prevent health harming air polluting emissions and to meet the goals of the Paris Agreement, Australia requires a coherent and timely policy framework that enables disinvestment in fossil fuels and a rapid transition to renewable energy. Central to this policy framework are climate change mitigation targets—an essential upstream and long-term public health strategy for managing the underlying causes of the increasing bushfire risk and thunderstorm asthma. This critical, foundational government policy framework will also support emission reduction efforts within the Australian healthcare sector.33 Action must be taken now, as limiting global heating to 1.5°C will require deep emissions reductions of at least 45% from 2010 levels by 2030.7 Australia's healthcare sector needs to reduce its total emissions to net zero. By 2030, an 80% reduction in emissions is required for healthcare to help meet the 1.5°C Paris Agreement commitments and minimise the predicted catastrophic public health consequences of climate change.33, 34 Australian hospitals and health systems must implement interventions which will decarbonize healthcare delivery to ‘first do no harm’ whilst maintaining and improving health. Healthcare systems can take cost-effective action to transition toward zero emissions energy, buildings, travel and transport, waste management as well as low emissions pharmaceuticals, sustainable food system ectera.35 There are multiple health service level examples of successful action (see Global Green and Health Hospitals36) and state and territory government policy leadership can support compliance and implementation. Substitution of high emission products with more climate friendly alternatives and incentivising the production of green medications is another key strategy. This is particularly relevant to asthma medication. Alternative delivery mechanisms to metered dose inhalers without the high global heating potential propellants, such as dry powder based inhalers, are available and suitable for the majority of patients.35 Wilkinson et al.30 study found that switching to low global warming potential asthma inhalers has co-benefits for reducing GHGs and drug costs. Many peak health and medical bodies have declared a climate emergency. We support the call by Australia's peak associations including Doctors for the Environment Australia, Australian Medical Association, Royal Australian College of Physicians and the Climate and Health Alliance for the establishment of an Australian Sustainable Healthcare Unit to lead and coordinate initiatives and collaboration nationwide.33 Australia's recent bushfire smoke-related and thunderstorm asthma epidemics were climate change and air pollution driven disasters of national and/or state level significance. Both events tested public health system preparedness and responsiveness and capacity to prevent and control environmental health hazards. We support the Royal Commission into National Natural Disaster Arrangement's recommendations, specifically those pertaining to community education, air quality and health.37 Further, we endorse Vardoulakis et al.'s38 perspective that consistency of air quality information and related public health advice across jurisdictions in Australia is essential. We support their call for an independent national expert committee on air pollution and health protection to be established to support environmental health decision making in Australia. Likewise, the impact of climate change (longer pollen seasons, more extreme weather events) on asthma prevalence and severity needs to prioritised in public health planning and surveillance efforts. Notably, the current National Asthma Strategy (2018) is mute on climate change and air pollution. Australians voted for action on climate change in the 2022 federal election. The evidence is clear, we need rapid transition from fossil fuel toward renewable-energy powered systems, including net zero healthcare systems, which will provide benefits for public health, climate and economy. Yet, it remains to be seen whether the pace of change envisaged in the Climate Change Bill 2022 is sufficiently fast, or whether new coal and gas generation and mining projects will be phased out. Continued failure to rapidly act on the climate-air pollution-fossil fuel triad in Australia is likely to result in increased asthma prevalence and severity and exert an inexorable toll on the health, social and economic wellbeing of future generations. Asthma is just the tip of the iceberg. Health and medical groups have a key role in helping chart a new course with the incoming federal government to avert the cascading impacts of this ubiquitous climate-driven public health crisis. Open access publishing facilitated by Deakin University, as part of the Wiley - Deakin University agreement via the Council of Australian University Librarians. None. The authors declare no conflicts of interest except Rebecca Patrick. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Nurses play essential roles in reducing health problems due to climate change

The expanding petrochemical industry depends on fossil fuels both as feedstock and a source of energy and is at the heart of the intertwined global crises relating to plastics, climate, and toxic emissions. Addressing these crises requires uprooting the deep-seated lock-ins that sustain petrochemical plastics. This perspective identifies lock-ins that stand in the way of ambitious emission reductions and ending plastic pollution. We emphasize that addressing the growing plastic production and consumption requires confronting the political economy of petrochemicals. We put forward key elements needed to address the dual challenges of moving away from the unsustainable production of plastics and drastically reducing emissions from the petrochemical sector, and argue for attention to the links between fossil fuels and plastics, which in turn involves challenging entrenched power structures and vested interests linked to the fossil-based plastics economy. A critical step would be ensuring attention to the production of petrochemicals and related upstream issues in the upcoming global plastics treaty.

Introduction: The present study aimed to explore the associations between climate change, vector-borne diseases and health outcomes. Contemporary climate change has drawn growing recognition from the global public health community as an important global public health hazard (1). Vector-borne diseases like malaria, dengue, and Lyme disease also pose significant public health threats, and we know that they, too, are sensitive to climatic changes. But the exact links among climate change, vector-borne diseases and public health outcomes remain poorly characterized.Methods: The goal of this study was to determine whether climate change, vector-borne diseases, and public health outcomes are connected in some way. However, the role climate change plays to the environment and human health made it a serious global public health threat (2). Vector-borne diseases, including malaria, dengue, and Lyme disease, are another important category of high-impact diseases and are also known to be affected by climate change. But the direct links between climate change, vector-borne diseases, and public health outcomes are poorly understood.Results: Overall, the results of the study indicate that climate change plays a very important role in the distribution, seasonality and transmission of vector borne diseases. Rising temperatures and shifting weather patterns are associated with the expansion of the geographic range of vectors, causing increased transmission of diseases like malaria, dengue fever, and Lyme disease[3]. In addition, adapting measures to control disease will be critical in response to active ecological changes driven by climate change.Conclusions: This research draws attention to the pressing need for international action on climate change to limit the impacts on vector-borne diseases and public health. Therefore, vector-borne diseases will continue to rise with little to no processes in place to quell its influence without climate change remediation measures and it would lead to dire consequences with respect to human health and well-being. Further research is needed to not only understand but also identify mechanisms to mitigate the impacts of climate change on vector-borne disease and human health.

Language has the potential to cause harm when used unreflectively, e.g. the inaccurate and derogatory/stigmatising term ‘illegal migrant’, the terms ‘second (or third) generation migrant’ emphasising recency or lack of belonging, crude and imprecise descriptive labels such as ‘Blacks’ or ‘Asians’, historic terms such as ‘Oriental’ or ‘Easterner’, and other similar terms impliying second-class or outsider status, such as ‘alien’ or ‘foreigner’ (or indeed, ‘native’ when used to indicate a ‘first nation’ or autochthonous group lacking in status). This applies to everyday life, health care and research. In public health (e.g. in publications and study materials) and in policy and medical guidelines, there is a particular need for risk awareness of the potential for discrimination and stigmatisation through the language and terminology used. The issue has been discussed since the late 1980s and was identified as a clear challenge during the recent COVID-19 pandemic in light of the social and ethnic disparities of risks, incidence and vaccination uptake that were communicated in research, policies and interventions. However, there are only few guidelines or materials to support the responsible use of language. Moreover, reflection on language is often not considered as important as other aspects of public health research and practice. Yet it seems to be a basic requirement for ensuring responsible communication of policies and research results and within the research process itself. After all, classification and accuracy of decriptive terms and analysis categories are quality standards in public health research. In the workshop we will take stock of what has been achieved so far in the field of anti-discriminatory communication and language and what challenges were faced in terms of communicating evidence and policies in relation to the COVID-19 pandemic. This will be followed by a presentation of a specific example from the National Public Health Institute in Germany, which has developed a guideline on anti-discriminatory language. The important perspective of community/NGOs will be also included as a presentation. Building on the work of the last decades, the EUPHA conference offers a great opportunity to bring together perspectives and experiences from different researchers, institutions and countries. The workshop takes up the theme at a time when public health research on migrants and refugees is on the rise due to global crises including climate change and war, migratory movements, and the need for awareness and discourse on anti-discrimination and anti-racism within the modern globalised world. As a global public health community, we have a responsibility to shape the public discourse. It is in our hands to continue the discussion and to raise awareness for continuous (self-) reflection, responsible communication and appropriate terminology within the public health community. Key messages • The workshop aims to contribute to increased awareness for responsible and discrimination-sensitive language and terminology within the public health community. • The global public health community has a responsibility to represent the population in its diversity. Reflective, accurate and responsible discrimination-sensitive communication are essential.

Tackling the Research Challenges of Health and Climate Change

Climate change is the greatest public health disaster facing us today. Sucharita Yarlagadda, Premila Webster and Elizabeth Haworth from the University of Oxford suggest that only with firm and decisive action now can we hope to avert or mitigate an impending public health catastrophe1 While there is a scientific consensus that the global climate is changing, with increasing climate variability and extremes, rising temperatures and sea levels and increased frequency of natural disasters which impact on human health,2,3,4 against a backdrop of persistent world economic pressures, the role of the specialty of public health in responding to environmental and climate change is not clear and needs to be defined. Many governments, including those of the UK have committed to tackling climate change through adaptation and mitigation and carbon abatement measures. The Climate Change Act 2008 sets a legally binding target for reducing UK greenhouse gas emissions by at least 34% by 2020 and by 80% by 2050, using the 1990 baseline.5 The NHS has shown leadership in this area through the Good Corporate Citizenship model,6 the NHS carbon reduction strategy7 and the NHS Sustainable Development Unit's route map for sustainable health.8 These aim to, at least, meet government targets and demonstrate early success with a 10% reduction of the 2007 NHS carbon footprint by 2015. Since April 2010, a new mandatory emissions trading scheme has come into force, requiring increased efforts by NHS organizations to meet government carbon targets.9 Alongside this is growing evidence of substantial financial and health benefits of low carbon business models in response to climate change and sustainability.6,10 As recommended by the Lancet and University College London a new Public Health movement is needed.4 The time to act is now. However, there still seems to be a huge gap between knowledge/ evidence and coordinated public health action. To clarify the public health role, a UK-wide internet based survey of public health departments (service public health, academic public health and the health protection units) was conducted in April 2010. It sought to allow an assessment of climate change as a public health problem, identify actions and innovations already taken, and to promote a coordinated public health response. The preliminary results were presented at the 2010 Faculty of Public Health Conference. The response rate of 32% overall was disappointing, despite a reminder. Over 90% of this considerable UK public health workforce who responded agreed that climate change is an important health problem requiring public health action. Many respondents highlighted the need for a stronger NHS mandate and prioritisation, such as through the NHS operational framework. Most believed that further training and development is essential for effective action, but the urgency is sidelined by current restriction of financial resources to deal with this problem. Although the public health workforce believes that action is needed and there is a public health strategy11 and encouraging response by primary care trusts12 neither an overarching plan nor effective coordination exists. What is good for the planet is also good for health and policies and structural drivers to mitigate and adapt to climate change would have a large positive effect on population health, for example the health co-benefits of walking or cycling to work that both reduce emissions and improve health and wellbeing.13 Emergency plans must be improved, kept up to date and include an effective service response to unpredictable weather patterns because of climate associated disasters and problems. These include floods and related water contamination incidents, droughts, heat waves, food shortages, as well as the problem of emerging diseases such as arthropod-borne infections and other environmentally linked diseases such as skin cancers and cataracts due to reduction/loss of the ozone layer. …

Latin America faces a severe health crisis, where over 150 million people lack reliable access to water due to climate change. We conducted a mixed-methods study to understand perspectives and experiences surrounding water security and its relationship to climate change among predominantly Indigenous mothers in Maras, a rural Andean district in the Urubamba Province of Peru. A verbal survey was administered to 100 pregnant women and/or caregivers of children under 11 years of age. Surveys included questions on demographics, water sources and storage practices, water and food insecurity, and perceptions of climate change. Among survey participants, a subgroup of 22 mothers took part in focus group interviews to understand their personal experiences and concerns regarding water insecurity and climate change. Most survey respondents (92%) experienced water insecurity. Qualitative findings revealed multiple facets of water insecurity including quantity, quality, and predictability of water. Water insecurity had negative impacts on household sanitation, hygiene, and agricultural production, and thus income generation and food security. Household- and community-level strategies to deal with water insecurity include: (i) revitalization of ancient practices to maintain natural water sources, (ii) water recycling, and (iii) reforestation. Findings in this study highlight the extent of water insecurity and the resulting challenges faced by Indigenous community members within Peru. By understanding the multifaceted experiences of these communities facing the crisis of water insecurity, we can explore solutions and advocate for proactive measures to help Indigenous populations address the growing threat of climate change.

In early 2020, public health workers across the United States were called to respond to an emerging threat: COVID-19. Seemingly overnight, COVID-19 became a pandemic and, as many transitioned from offices and schools to home-based settings, essential workers braved the risk of infection to face the emergency and maintain essential health services. The pace of the response and the scale of the loss of life in the United States were unprecedented in recent history. Public health workers demonstrated their dedication to their mission by rising to these challenges, often stretching themselves beyond their capacity to meet the demands of the crisis. In the months and years since the first case of COVID-19, there has been a seismic shift in the way society engages the public health workforce. The 2021 Public Health Workforce Interests and Needs Survey (PH WINS) provides a snapshot of the burden carried by the public health community. Even before the emergence of COVID-19, many public health workers have moved from one emergency response to the next with little pause for recovery, exacerbating systemic challenges. Our experience managing multiple simultaneous and overlapping public health emergencies has demonstrated the fragility of our public health infrastructure and eroded public trust. As we face an increasing frequency and severity of public health disasters in the contexts of climate change and organized health disinformation, a deepening distrust of science has forever changed the nature of our work. In addition, as the field of public health recognizes systemic racism as a public health crisis and takes meaningful steps to dismantle it, it is threatened with mounting hostility from outside and within our government structures. These experiences, reflected in PH WINS 2021, have also brought to light a world of opportunities to build a better public health system that will sustain through and beyond the emergencies of the future (Table). TABLE - Pathways to Resilience Build internal tracks to leadership for staff from communities that are heavily impacted in emergencies. Transform COVID-19 temporary public health workers into a new public health workforce. Develop a dynamic public health emergency response infrastructure. Build resilience in essential basic public health functions. Create trauma-responsive environments for the public health workforce. Build Internal Tracks to Leadership for Staff From Communities That Are Heavily Impacted in Emergencies The COVID-19 pandemic highlighted long-standing health inequities. Structural oppression creates community- and neighborhood-level health vulnerabilities before, during, and after public health emergencies1–3; however, the makeup of our current public health leadership is limited by generations of exclusion of people from the communities that could most benefit from public health programming. Historic definitions of expertise in public health exclude some of the most critical “qualifications”—those gained by lived experience. During the COVID-19 response, health departments in need of critical community-level information often did not have to look far; highly adept individuals from heavily impacted communities were already part of the public health workforce, but their indispensable skills and knowledge were not measured in their job titles or work assignments. Emergency responses can exacerbate or dismantle long-standing inequities perpetuated by systemic racism within governmental agencies. Public health must embrace the opportunity to unravel systems of oppression by identifying staff who live in the hardest-hit communities, uplifting them into leadership roles, and developing intentional partnerships with communities. Such approaches during emergency response can give staff the opportunity to gain leadership experience, develop skills in rapid participatory action research and qualitative methods, and forge the robust partnerships with communities necessary to develop community-relevant solutions and meaningfully improve health equity.3 Transform Temporary Public Health Workers Who Worked in COVID-19 Into a New Public Health Workforce Public health emergencies create critical opportunities to invest in a dangerously underfunded system.4,5 Funding streams emerging after public health emergency responses should be invested in remediating the systemic challenges that prolong and exacerbate emergencies, particularly by building a workforce from impacted communities. During COVID-19, while rapid scaling of a temporary workforce resulted in public health gains, many workers hired through an influx of emergency funding were laid off as the response deescalated. For example, NYC Trace, the largest contact tracing operation in the country, rapidly hired thousands of New Yorkers at a time when unemployment was high and relatively safe remote jobs were scarce. Selective recruitment from highly impacted communities at that time increased the acceptability of services while both investing in impacted communities and cultivating a pool of trained public health workers.3 Unless these workers are reintegrated into the public health workforce, the field risks losing their newly gained expertise. Given massive workforce shortages experienced by public health departments across the country, decision makers could look to approaches adopted by global humanitarian response programs and the Public Health Corps and consider developing national assignments to fill short- and long-term gaps. Not only would this fulfill urgent, mounting workforce needs and support the development of the public health careers for many essential pandemic workers but this workforce would also bring greater community-centered knowledge and practice to the field, nationwide. Develop a Dynamic Public Health Emergency Response Infrastructure As we emerge from the acute phases of the COVID-19 pandemic, we have an opportunity to revisit the structure of our public health emergency response systems, building upon a strong backbone of essential public health competencies. Across the country, public health workers were reassigned from their day jobs to emergency roles, often for years on end. PH WINS 2021 shows that all public health program areas contributed at least 20% of their workforce time to COVID-19 response efforts.6 This approach creates gaps in ongoing public health activities, burnout among employees, and limited institutional memory to inform future emergencies. To be responsive, emergency response systems need long-term investments to modernize and improve core public health functions. There is a clear need to institutionalize lessons learned and quickly integrate corrective actions. During and after a response, innovation and accountability in “hotwashes” and after-action reports could support this process but only if evaluation is followed by swift, measurable action. The resultant dynamic response system would support the translation of knowledge and skills from one response to another and produce a more efficient allocation of public health resources toward foundational infrastructure required in emergencies and core public health services. Build Resilience in Essential Basic Public Health Functions COVID-19's devastating legacy exceeds its direct morbidity and mortality. As case counts exploded in early 2020, routine public health operations and health care services screeched to a halt. While organizations worked around the clock to create electronic versions of services previously provided in person and emergency response programs incorporated wraparound services, not all services translated effectively and not all people had the same access to digital platforms. This has resulted in unprecedented setbacks in disease prevention, social-emotional learning, education, chronic and acute disease management, life expectancy, and more. At the same time, we are not seeing any reprieve from public health emergencies. These 2 are not separate: widening gaps in our public health systems multiply the impacts of public health disasters when they hit.1–3 Public health agencies must build capacity in core public health functions including surveillance and accompanying data informatics, data and risk communication systems, and robust mental health infrastructure. Instead of skirting along the edge of staff capacity and shying away from innovative modernization of public health informatics, we must invest in core functions that will not only ensure continuity of basic public health services for all people in all places in the United States but also facilitate smooth pivots to emergency response activities that rely on these same competencies. Create Trauma-Responsive Environments for the Public Health Workforce None of these initiatives or investments can move forward if no one is around to make them happen. PH WINS 2021 shows the devastating toll the past few years have had on the public health workforce, with nearly one-third of the governmental public health workforce considering leaving their organization in the next year for retirement or other reasons.7 Sector-wide burnout and related behavioral health impacts must be addressed while building sufficient capacity to prevent this scale of trauma from recurring in the next disaster. However, trauma is complex, long-lasting, and impacted by culture and environment; mitigation requires awareness and understanding. Now is the moment to build trauma-responsive environments for the public health community. Trauma-responsive environments promote healing and wellness, allow public health workers to access services and space to process their experiences, and support workers to heal. They must be built on a foundation of accessible mental health supports and integrative care approaches, which will be critical to sustaining services long after pandemic recovery funding is exhausted. Behavioral health services can only be accessible if social stigma and other barriers are reduced across the field of public health nationally. Some of these barriers are explicitly embedded in licensing and board requirements, leave policies, and organizational culture.8 Similarly, just as systemic and structurally intersectional inequities persist, so too do historical and intergenerational trauma via oppression, racism, and prejudice. Meaningful action is needed to revise policies that prevent public health workers from accessing behavioral health services. We must do more than ask our workers to “power through” because the next disaster is looming. It is time to improve our systems and way of work to build a foundation for trauma-responsive care throughout disaster response and recovery.

Water security and food security in the Indus basin are highly interlinked and subject to severe stresses. Irrigation water demands presently already exceed what the basin can sustainably provide, but per-capita food availability remains limited. Rapid population growth and climate change are projected to further intensify pressure on the interdependencies between water and food security. The agricultural system of the Indus basin must therefore change and adapt to be able to achieve the associated Sustainable Development Goals (SDGs). The development of robust policies to guide such changes requires a thorough understanding of the synergies and trade-offs that different strategies for agricultural development may have for water and food security. In this study, we defined three contrasting trajectories for agricultural system change based on a review of scientific literature on regional agricultural developments and a stakeholder consultation workshop. We assessed the consequences of these trajectories for water and food security with a spatially explicit modeling framework for two scenarios of climatic and socio-economic change over the period 1980–2080. Our results demonstrate that agricultural system changes can ensure per capita food production in the basin remains sufficient under population growth. However, such changes require additional irrigation water resources and may strongly aggravate water stress. Conversely, a shift to sustainable water management can reduce water stress but has the consequence that basin-level food self-sufficiency may not be feasible in future. This suggests that biophysical limits likely exist that prevent agricultural system changes to ensure both sufficient food production and improve water security in the Indus basin under strong population growth. Our study concludes that agricultural system changes are an important adaptation mechanism toward achieving water and food SDGs, but must be developed alongside other strategies that can mitigate its adverse trade-offs.

Mental health and climate change: tackling invisible injustice

Effective public communication and engagement have played important roles in ameliorating and managing a wide range of public health problems including tobacco and substance use, cardiovascular disease, HIV/AIDS, vaccine preventable diseases, sudden infant death syndrome, and automobile injuries and fatalities. The public health community must harness what has been learned about effective public communication to alert and engage the public and policy makers about the health threats of climate change. This need is driven by three main factors. First, people’s health is already being harmed by climate change, and the magnitude of this harm is almost certain to get much worse if effective actions are not soon taken to limit climate change and to help communities successfully adapt to unavoidable changes in their climate. Therefore, public health organizations and professionals have a responsibility to inform communities about these risks and how they can be averted. Second, historically, climate change public engagement efforts have focused primarily on the environmental dimensions of the threat. These efforts have mobilized an important but still relatively narrow range of the public and policy makers. In contrast, the public health community holds the potential to engage a broader range of people, thereby enhancing climate change understanding and decision-making capacity among members of the public, the business community, and government officials. Third, many of the actions that slow or prevent climate change, and that protect human health from the harms associated with climate change, also benefit health and well-being in ways unrelated to climate change. These “cobenefits” to societal action on climate change include reduced air and water pollution, increased physical activity and decreased obesity, reduced motor-vehicle–related injuries and death, increased social capital in and connections across communities, and reduced levels of depression. Therefore, from a public health perspective, actions taken to address climate change are a “win-win” in that in addition to responsibly addressing climate change, they can help improve public health and well-being in other ways as well. Over the past half decade, U.S.-based researchers have been investigating the factors that shape public views about the health risks associated with climate change, the communication strategies that motivate support for actions to reduce these risks, and the practical implications for public health organizations and professionals who seek to effectively engage individuals and their communities. This research serves as a model for similar work that can be conducted across country settings and international publics. Until only recently, the voices of public health experts have been largely absent from the public dialogue on climate change, a dialogue that is often erroneously framed as an “economy versus the environment” debate. Introducing the public health voice into the public dialogue can help communities see the issue in a new light, motivating and promoting more thoughtful decision making.

Food and water security: Analysis of integrated modeling platforms

Objectives: Household water insecurity, the inability to reliably access sufficient water for domestic use, has been negatively associated with food security and dietary diversity in settings where undernutrition is common, but these relationships are unknown in countries with a high prevalence of overweight and obesity. We therefore aimed to assess whether water and food insecurity are associated with diets that decrease noncommunicable disease (NCD) risk among adults in Mexico. Methods: We used data from a random subsample of adults (≥18 years) from the 2021 Mexican National Health and Nutrition Survey (ENSANUT) who reported dietary intake in the prior seven days using a semiquantitative food frequency questionnaire (n=1,009 men, 1,513 women). Consumed foods were assigned to at least one of 29 groups, which were used to generate dietary indicators according to WHO guidelines: NCD-Protect (consume healthy foods, range: 0-9) and NCD-Risk (avoid foods to limit, range: 0-9). Water insecurity was measured using the Household Water Insecurity Experiences Scale and food insecurity using the Latin American and Caribbean Food Security Scale. We developed multilevel models of each diet indicator that included urbanicity as a fixed effect, adjusted for confounders (region, socioeconomic status, household size, education, and ethnicity), and were stratified by gender. Results: Water and food insecurity scores were positively correlated (r=0.21, p< 0.001). Among men, moderate-to-high water insecurity was associated with 0.26 lower (95% CI: -0.52, -0.01) NCD-Protect scores relative to those with no-to-marginal water insecurity; there was no observed association with food insecurity. Among women, severe food insecurity was associated with 0.38 lower (95% CI: -0.64, -0.12) NCD-Protect scores relative to those with no food insecurity; there was no observed association with water insecurity. Across men and women, neither water nor food insecurity were associated with NCR-Risk scores. Conclusions: Gender may modify how household water and food insecurity are associated with diet healthfulness. Improving water and food insecurity has the potential to reduce the risk of malnutrition and NCDs. Funding Sources: NICHD, NIMH. Data are publicly available from the National Institute of Public Health, Mexico.