Clean-Ver-16August-LAND UNDER PRESSURE – HEALTH UNDER STRESS · 2019-08-26 · Land under pressure – health under stress 1. Introduction Land resources are vital for human health

GLOBALLAND OUTLOOK WORKING PAPER

Prepared by:

Aderita Sena

August 2019

LAND UNDER PRESSURE – HEALTH UNDER STRESS

DISCLAIMERThe designations employed and the presentation of material in this information product do not imply the expression of any opinion whatsoever on the part of the United Nations Convention to Combat Desertification (UNCCD) concerning the legal or development status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or products of manufacturers, whether or not these have been patented, does not imply that these have been endorsed or recommended by UNCCD in preference to others of a similar nature that are not mentioned. The views expressed in this information product are those of the authors or contributors and do not necessarily reflect the views or policies of UNCCD.

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Landunderpressure–healthunderstressContents1 Introduction2. DLDDpathwaysimpactingonhumanhealth

2.1Watersecurityandsafety,sanitationandhygiene2.2Foodsecurityandsafety2.3Airquality2.4Soilquality2.5Socialandeconomicfactors2.6Healthcareservices

3. HealthconsequencesofDLDD

3.1Infectious,parasiticandnutritionaldiseases3.2Noncommunicablediseases3.3Injuries3.4ThemagnitudeofDLDDimpactsonhealth

4. Challengesanddirectionstoimprovehumanlivelihoods

4.1Poverty4.2Forcedmigration4.3Watersecurity4.4Foodsecurity

5. Respondingtothechallenges6. References

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Landunderpressure–healthunderstress

1. IntroductionLandresourcesarevitalforhumanhealthandwell-being,andtheyareunderpressure(UNCCD, 2014a). Land provides ecosystem services, as well as social, cultural, andspiritual benefits, which form a life support system for human health andwell-being(Sanz et al., 2017). Vital resources to society provided from ecosystems include: foodand essential nutrients; clean water and air; shelter; medicines and medicinalcompounds;wood;fuel;fibre;energy;climaticconstancy;regulationofrisksofnaturalhazardsanddiseases;pollination;waterpurification;livelihoods;andcultural,spiritualand recreational enrichment (Corvalan et al., 2005). Other benefits are related tobiodiversity,whichincludesdiversitywithinandamongecosystemsandspeciesthatareessential to ecosystem functions and service delivery, aswell as to the sustenance ofhumanhealth(WHO,2015;FAO,2019a).Humanactivitiesarenegativelyimpactingecosystemservicesandbiodiversitythroughland degradation. The drivers of land degradation and biodiversity loss are linked topopulationgrowthandrisingurbanisation,surgingconsumption,theexpansionofcropandgrazinglands,unsustainableagriculturalandforestrypractices,allinthecontextofunsustainableeconomicgrowth.Inaddition,climatechangecanaffecttheconditionsofenvironmentalandhumansystems,worseningthenegativeimpactsinalldimensionsofsustainabledevelopment,includingasregardshumandevelopment(IPCC,2014;IPBES,2018).There isgeneralagreement thatdesertification, landdegradationanddrought (DLDD)are challenges of a global dimension, which continue to pose serious threats to thesustainable development of all countries, particularly of developing countries, andspecificallythoseinAfrica(UN,2012).Thesechallengesincludehealthimpacts,yetthelinks betweenDLDD and humanhealth are complex (Box 1).Most of the impacts aredifficult tomeasure because they are indirect andmediated bymodifying global andlocal forces, such as climate change, level of deforestation, soil quality and erosion,human pressure on the environment, economic activity, exploitation of naturalresources,andotherfactors.Thenegative impactscanalsobedisplacedinspatialandtemporalscales(Corvalanetal., 2005; WHO & WMO, 2012). Considering health impacts, for example, ecosystemdisruption cause damages following complex pathways, with effects displacedgeographically(e.g.healthimpactsonlessdevelopedcountries,orthepoorwithinonecountry, fromoverconsumption inwealthiercountries)and intothe future(e.g.healthconsequencesofclimatechangeanddesertificationforfuturegenerations)(Corvalanetal., 2005). Similarly, DLDD poses multiple risks to livelihoods, and consequently tohumanhealth(Warneretal.,2009).DLDDreduces foodproduction, freshwateraccessandecosystemresources;asaresult,healthisplacedunderincreasingstress.The United Nations Convention to Combat Desertification (UNCCD) developed aStrategicFrameworkfor2018–2030incontinuationof itscommitmentsforthe2008–

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2018 strategic framework. This framework aims to restore productivity of degradedland, and reduce the impacts of drought in affected areas, in order to achieve a landdegradationneutral(LDN)world.Itisconsistentwiththe2030AgendaforSustainableDevelopment, specifically SDG15, and with the objectives of the Convention (UNCCD,2017a;UNCCD,2019).TheUNCCDworksinanintegratedapproachwiththeothertwoRioConventions–theConventiononBiologicalDiversity(CBD)andtheUnitedNationsFrameworkConventiononClimateChange (UNFCCC) inorder toaddress thecomplexchallenges and interconnections between land, biodiversity and climate change (UN,2012;Patzetal.,2012).

Box1–DLDDandhumanhealthDesertificationmeanslanddegradationinarid,semi-aridanddrysub-humidareasresultingfromvarious factors, including climatic variations and human activities. Land degradation meansreduction or loss, in arid, semi-arid and dry sub-humid areas, of the biological or economicproductivityandcomplexityof rain-fedcropland, irrigatedcropland,orrange,pasture, forestandwoodlands resulting from land uses or from a process or combination of processes, includingprocesses arising from human activities and habitation patterns, such as: soil erosion caused bywindand/orwater;deteriorationofthephysical,chemicalandbiologicaloreconomicpropertiesofsoil;andlong-termlossofnaturalvegetation.Droughtmeansthenaturallyoccurringphenomenonthatexistswhenprecipitationhasbeensignificantlybelownormalrecordedlevels,causingserioushydrologicalimbalancesthatadverselyaffectlandresourceproductionsystems(UNGA,1994).DLDDglobalpressuresandresponseslinkedtohumanhealth

TheWorldHealthOrganisation(WHO)defineshealthas“astateofcompletephysical,mentalandsocial well-being and not merely the absence of disease or infirmity” (WHO, 1948). Planetaryhealthisarecentconceptandisdefinedas“theachievementofthehighestattainablestandardofhealth, well-being, and equity worldwide through judicious attention to the human systems –political,economic,andsocial–thatshapethefutureofhumanityandtheearth’snaturalsystemsthatdefinethesafeenvironmentallimitswithinwhichhumanitycanflourish.Putsimply,planetaryhealthisthehealthofhumancivilizationandthestateofthenaturalsystemsonwhichitdepends”(Hortonetal.,2014;Whitmeeetal.,2015).Healthhasalsobeendescribedasa “precondition forandanoutcomeandindicatorofallthreedimensionsofsustainabledevelopment”(UN,2012).

Thedegradationofterrestrialandaquaticecosystemsisaproblemofglobaldimensions.Themostvulnerableandthreatened landareasaretheworld’sdrylands.However,78per cent of total degraded land is located in other terrestrial ecosystems (Sanz et al.,2017).Landdegradationaffectseverycontinent,fromcountrieswithlargeland-masses

Globalenvironment

Landdegradation:Long-termlossofecosystemservicesChronicimpactonhealthandwell-being

Droughtepisodes:TemporarylossofecosystemservicesAcuteimpactonhealthandwell-being

Desertification:PermanentlossofecosystemservicesChronic,long-termimpactsonhealthandwell-being

Globalenvironmentalchangepressures:

ClimatechangeBiodiversitylossWaterscarcity

Socialandeconomicpressures:

PopulationgrowthInequalitiesPovertyMigration

DLDDGlobalResponses:

Agenda2030andSDGs

UNCCDStrategicFramework2018-2030

UNFCCCParisAgreement

BiodiversityAichiTargets

SendaiFrameworkforDisasterRiskReduction

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tosmallislandsstates;fromwetanddryregionstocoldandwarmones;fromwealthydeveloped countries to poorer developing countries. At least 3.2 billion peopleworldwideareaffectedbythiscomplexphenomenon(IPBES,2018).Understandingtherelationship between ecosystem sustainability and health benefits would be animportant contribution to decision-making regarding environmental healthmanagement (includingwater, land, food, air, soil). Thiswould ensure benefits to thehealthandwell-beingofall(Corvalanetal.,2005;GBD,2015;Landriganetal.,2018).AlthoughDLDDaffectsbothdevelopedanddevelopingpartsoftheworld,thenegativeimpactsaredisproportionatelysufferedbythoselivinginvulnerableconditions.Theseinclude women, indigenous communities, children, elderly persons, people living inrural, marginal or fragile environments on land that is particularly vulnerable todegradation, as well as those with a lower-income status, or living in poorer areas(Barbier,2010;Barbier&Hochard,2016;Bermanetal.,2017);thisalsoappliestothosewithouteasyaccesstohealthcarefacilities(Ebi&Bowen,2016;GuzmánBeltránetal.,2019).The UNCCD places “humans at the centre of concerns to combat desertification and tomitigatetheeffectsofdrought”(UNGA,1994);andthesecondandthirdobjectivesoftheUNCCD Strategic Framework for 2018-2030 aim, respectively, to “improve the livingconditionsofaffectedpopulations”,andto“mitigate,adaptto,andmanagetheeffectsofdroughtinordertoenhanceresilienceofvulnerablepopulationsandecosystems”(UNCCD,2017a), (Figure 1). The United Nations Conference on Sustainable Development(Rio+20), also recognised that to achieve the goals of sustainable development it isnecessary to work to reduce the high prevalence of debilitating communicable, andnoncommunicable diseases, and to ensure populations are able to reach a state ofphysical, mental and social well-being (UN, 2012). A sustainable and equitabledevelopment regarding land and water management, combined with measures ofclimate changemitigation and adaptation, at local and global levels,will facilitate theachievement of the Sustainable Development Goals (SDGs), especially, in order toimprove nutrition and human health, and reduce poverty (UNCCD, 2017b). ProgresstowardsSDG3(health)andSDG15(land)willalsocontributetoaccomplishtheotherSDGs.

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Figure1. SchematicrepresentationoftheUNCCDStrategicFramework2018-2030,fromthepointofviewofhealthprotection

In recentdecades,humanactivitieshavehada substantial global effecton theEarth’ssystems.ThisrapidchangehasbeencalledtheAnthropocene(Whitmeeetal.,2015),aperiod in which trends of contamination and ecosystem disruption have grownexponentially.Paradoxically,duringthissameperiod,humanhealthhasimproved.Thisis mainly due to advances in public health, and other factors such as, inter alia,education,technologicaldevelopment,humanrights legislation,andpovertyreduction.It is unclear atwhat point in time healthwill no longer be sustainable. For example,providingfoodtoover7billionpeoplewithprojectiontoincreasetoover9billioninthenearfuture(in2050)isachallengewhenlandandwateravailabilityisunderincreasingpressure(UNCCD,2014a;Whitmeeetal.,2015).There is a high cost associatedwithDLDD.UNEP (2019) estimates the annual cost ofland degradation and desertification at USD 127 billion. Developing interventions toprotect biodiversity and ecosystems by avoiding land degradation and implementingland restoration interventions will contribute to the achievement of the SustainableDevelopmentGoals (SDGs), aswell as to the improvement of humanhealth andwell-being(IPBES,2018).Similarly, interventionsinthehealthsectorareneededtoprotectandpromotephysicalandmentalhealthlinkedtoDLDD(Senaetal.,2017).

DLDDDesertification/

landdegradation

anddrought

DLDDcontributestoandaggravateseconomic,socialandenvironmentalproblems

TheStrategycontributesto:

Achievingtheobjectivesofthe

convention

Achievingthe2030AgendaforSDGs

(SDG15;Target15.3)

Improvethelivingconditionsof

affectedpopulations

Enhanceecosystemservices

UNCCDstrategicobjectiveslinked

tohumanhealthandwell-being:

Strategicobjective2:Toimprovethe

livingconditionsofaffectedpopulations

Strategicobjective3:Tomitigate,adapt

to,andmanagetheeffectsofdrought

inordertoenhanceresilienceof

vulnerablepopulationsandecosystems

Reducedresilience

toclimatechange

Biodiversity

loss

PovertyForced

migration

Lackofwater

security

Lackoffood

security

Poor

health

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Box2.FactsandfiguresonDLDDandhealthLand

• Landdegradationnegativelyimpacts3.2billionpeople.Thisrepresentsaneconomiclossofaround10percentofannualglobalgrossproduct.

• Drylandstakeup41.3percentoftheEarth’ssurface.Thetotaldrylandspopulationisof2.1billion;thatis,oneinthreepeopleliveindrylands.ThelargestsuchareasareinAsiaandAfrica.

• Thelivelihoodsofmorethan1billionpeopleinsome100countriesarethreatenedbydesertification.Themostseverelyaffectedarepoorandmarginalisedpeoplewholiveinthemostvulnerableareas.

• Insub-SaharanAfricahalfabillioninhabitantsliveinruralareasandmostofthemdependontheland.Desertificationisaconstantthreattotheirlivelihoods.

• Globally,aboutonethirdofallagriculturallandiseitherhighlyormoderatelydegraded;10percent,however,isimproving.

• Globally,24percentofthelandisdegrading.Morethan1.5billionpeopledirectlydependonthesedegradinglands,and74percentofthemliveinpoverty.Nearly20percentofthedegradinglandiscropland;20-25percentisrangeland.

• Everyyear,12millionhectaresbecomeunproductiveduetodesertificationanddrought;20milliontonsofgrainsarenolongerproducedforthisreason.

• Droughtskillmorepeoplethananyothersingleclimate-relatedhazard.Theycreateconflictamongcommunities,andareacauseofforcedmigration.

• Inruralareaswherepeopledependonscarceproductivelandresources,landdegradationisadriverofforcedmigration.

• Availablelandfortheexpansionofagricultureisbecomingmorelimited.Moreagriculturalexpansiontakesplaceonmarginallands,whichincludelessfertilesoilsandless-favourableclimaticconditions,resultinginloweryields.

• ManycountriesarelosingAgriculturalGrossDomesticProduct(AGDP)throughlanddegradation.Thischallengecombinedwithincreasedpopulation,demandsonnaturalresourcesandclimatechangeimpactsfoodandwatersupplies,whichcouldinturnincreasethelikelihoodofconflict.

• Biodiversitylosswasestimatedat34percentin2010comparedtoanundisturbedstate,andisprojectedtocontinuewithsome10percentpointsofadditionallossupto2050.

Water• Everypersonrequiresaminimumof2,000cubicmetresofwaterperyear.Peoplein

drylandshaveaccessto1,300cubicmetres,andavailabilityisprojectedtodecrease.• 71percentoftheglobalpopulation(5.2billionpeople)hasaccesstosafelymanaged

drinkingwaterservices(availablewhenneededandfreefromcontamination,includinginsomeareaswhichexperiencewaterscarcity).

• 2.8billionpeopleworldwide(40percent)liveinregionswithwaterscarcity.Thehighestwaterscarcityoccursindrylands.

• In2015,263millionpeoplespentover30minutesperroundtriptocollectwaterfromanimprovedsource.

• Womenfromsub-SaharanAfricaspendagreaterfractionoftimecollectingwater.Collectively,thisamountstoabout40billionhoursperyear.

• Agriculturetakesthelargestshareofglobalwateruse.VastareasoftheMiddleEast,SouthAsiaandNorthAmericarely,forlargeproportionsoftheirwaterwithdrawals,onaquifersthatarenon-renewableandwillbecomedepleted.

Food

• Upto44percentofalltheworld’scultivatedsystemsareindrylands.Oneinthreecrops,includingoats,barley,tomatoes,potatoes,cabbageandsaffronoriginatefromdrylands.

• In2018,worldwide,149millionchildrenunder5yearsofagewerestunted,49millionwasted,and40millionwereoverweight.

• Poorpeoplespend50to80percentoftheirincomeonfood.Duringcrises,thepriceoffoodincreases,placingpoorpeopleatriskoffamine.

• Anestimatedonethirdofallfoodproducedgloballyiseitherlostorwasted,whichamountstoabout1.3tonnesperyear.Meanwhile,anestimated815million(approximatelyoneoutofninepeopleworldwide)areundernourished.

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• Five years (2013 to 2018) of acute food insecurity in South Sudan increased the risk offamine and led to one of themajor refugee crises in theworld in 2018,with 4.4millionpeopledisplacedand6.1millionpeopleincrisis.

• Conflictandinsecurityremainedthekeydriversofhungerin2018.Around74millionpeople(twothirdsofwhichwerefacingacutehunger)werelocatedin21countriesandterritoriesaffectedbyconflictorinsecurity.About33millionofthesewerein10countriesinAfrica;over27millionwereinsevencountriesandterritoriesinWestAsia/MiddleEast;13millionwereinthreecountriesinSouth/South-eastAsiaand1.1millioninEasternEurope.

• Climateandnaturaldisasterspushed29millionpeopleintosituationsofacutefoodinsecurityin2018,mostofthesewereinAfrica,with23millionpeopleaffected.

Futureprojections

• By2025,upto2.4billionpeopleworldwidemaybelivinginareassubjecttoperiodsofintensewaterscarcity.

• Currently,between1-2billionpeopleareaffectedbywaterscarcity,mostofthemindrylands.Furthermore,demandforwaterwillincreaseby30percentby2030,whichislikelytodisplaceafurther700millionpeoplecurrentlylivinginaridandsemi-aridareas.

• By2050,humanpopulationsindrylandsareprojectedtoincreaseby40to50percent.• By2050,atthegloballevel,increasesinagriculturalyieldsareprojectedslow,withyields

about10percentlowerthantheywouldhavebeenwithoutthehurdlesofclimatechange,mostlyduetowatershortagesandhighertemperatures.

• Agricultureintropicalandsub-tropicalregions,suchasIndiaandSub-SaharanAfrica,willbethemostnegativelyaffectedbyclimatechange.Loweryieldsduetoclimatechangewouldresultinmoreland(around10percent)havingtobeusedforagriculture.

• Currently,assumingnosignificantreductioninfoodwastecoupledwithfoodconsumptiontrends,theworldwillneedfoodproductiontoincreaseby60percentby2050.

• Approximately250,000additionaldeathsperyearareestimatedbetween2030and2050asaconsequenceofclimatechange.

• Drought,heatwavesandvariabilityinrainfallarelikelytoincrease,andwillthusresultinwaterscarcityissues,vegetationandsoillossanddecreasedcropyields,particularlyindrylands.

Source:UNCCD(2014b);WHO&UNICEF(2017);VanderEschetal.2017);FAO(2018);IPBES(2018);USAID(2018);FAO(2019b);UN(2019a);UN(2019b);FSIN(2019).

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2. DLDDpathwaysimpactingonhumanhealthLand degradation impacts negatively on biodiversity and ecosystem services affectingpopulations’ essential needs. Generally, it causes water and food insecurity,unemployment,genderinequality,conflictandmigration.AllecosystemconsequencesofDLDDcanimpacthumanhealthandwell-being,directlyorindirectly,aloneorcombined(Patzetal.,2012).Although landdegradation isamajorcontributortoclimatechange(IPBES, 2018), climate change also can aggravate these impacts, causing substantialcosts in theenvironmental, social, economicandpoliticaldimensions, including in thehealthsector(IPCC,2007;Patzetal.,2012,Smithetal.,2014a).Climatechangecontributes to increasedDLDD. Itacceleratessoilerosionondegradedland through extremeweather events. It can increase the risk of forest fires and cancausechangesinthedistributionofinvasivespecies,vectors,pestsandpathogens.Allofthese problems are likely to increase the threats to human health and quality of life(IPCC, 2014; IPBES, 2018). All impacts on human health associated to DLDD, whencombinedwithclimatechange,canbeexacerbated(e.g.impactsfromhottemperatures,from intense and prolonged extreme events such as drought and floods, and fromdeclined freshwater resources). Climate change can also influence the occurrence ofnewlyemergingdiseases,suchaszoonoticinfectionsandvector-bornediseases,inareaswithout previous exposures (WHO&WMO, 2012; Haines, 2016; Smith et al., 2014a).Moreover,whenenvironmentalvulnerabilityisplacedinthecontextofsocial,economicandpoliticalchallenges,includingpoorpopulationhealthstatus,itcanfurtherincreasethemagnitudeofallhealthimpacts(Smithetal.,2014a;Ebi&Bowen,2016).It isalsoworthnoting thatallpopulationsarenotequallyvulnerable,andrisksarenotequallydistributed(Stankeetal.,2013).DLDD can affect health through different pathways related to environmentaldeterminants of health, specificallywater security and safety, sanitation and hygiene;food security and safety; air quality; and soil quality. Modifying factors of theseenvironmentaldeterminants includesocialandeconomic factors.Thequalityofhealthcare services canmodify the health impacts of DLDD. Figure 2 shows these complexrelationships.

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Figure2. DLDDpathwaysandhealtheffects

2.1Watersecurityandsafety,sanitationandhygiene

Fresh water is essential for life and human health. It is also a human right. The linkbetween land management and the water cycle can determine water quantity andquality. Land degradation practices can reducewater supplies, increase disaster risk,and affect economic growth (WWAP, 2016; IPBES, 2018). Water resource-stressedconditionscouldbemadeworseduetoclimatechangeandnon-climaticdrivers,suchaspopulation growth, economic development, urbanisation, and land-use (JiménezCisneros et al., 2014). For example, in dry regions,more intense droughtswill stresswatersupplysystems,exacerbatingwaterscarcitywhich,togetherwithfoodshortages,canincreasefamineresultinginpopulationmigration(Patzetal.,2012).Droughtisanimportantfactorinwatersecurityandhealth.Itcanimpactthequalityandquantity of safe water in several ways, including: a) lack of management ormismanagement (Berry et al., 2014); b) contaminant concentration in ground andsurface water; c) growth of pathogens from increased temperatures; d) high level ofsalinityinwater;e)waterstagnationduetoreducedwaterlevelandstreamflows;andf) damage of water-infrastructure (Stanke et al., 2013; Yusa et al., 2015). Other

Respiratoryinfections

Skinandeyediseases

Protein-energynutrition

Zoonoses

Intentional

injuries

Unintentio

nal

injurie

s

Mental,beha

viouraland

neurologica

ldisorders

Kidneydiseases

DLDD

Social,economicandotherenvironmentalmediatingfactors

Food WASH Air Soil

Healthsystemmediatingfactors

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importantdeterminantsofhealthrelatedtowaterqualityareindustrialpollutantsthatcancontaminatethewatersystem.Theseincludeindustrialchemicals,pharmaceuticals,andpesticides(Landriganetal.,2018).Water scarcity and water quality put the provision of freshwater at risk, affect foodproduction, sanitation, safe food preparation, economic development (includingemployment), andhumanhealthandwell-being (Corvalanet al., 2005;WWAP,2016).Allthesefactorscandestabiliseenvironmental,economicandsocialsystems,especiallyif theyarealready fragile (Patzetal.,2012).Lowerandmiddle-incomecountrieswithfasturbanisationandindustrialisationprocesseshaveexperiencedtheworstbiologicalandchemicalpollutionofdrinkingwater.Serioushealthconditionshavebeenreported,andoftentherearenoalternativewatersources(Landriganetal.,2018).Lackofwaterqualityandquantitycannegativelyaffecthumanhealthwithawiderangeof consequences. Diseases linked with water pollution and water scarcity includeinfectious andparasitic diseases, noncommunicable diseases, diseases associatedwithchemicals and other pollutants in water sources, including diseases related to algalblooms (Stanke et al., 2013; Yusa et al., 2015). Water shortages can increase theoperating costs of water services (IPCC, 2007), impacting on health services and onpeople’s financial ability to buy water. This process can also increase mental healthdisorders,suchasstress,anxiety,anddepression(Stankeetal.,2013;Vinsetal.,2015;Ebi&Bowen, 2016; Alpino et al., 2016; Sena et al., 2017, 2018). Table 1 summarisesthesepathwaysandmainhealthimpacts.Everypersonshouldhaveaccesstosafewatersupplyandadequatesanitationservices,bothathomeandat theirworkplace.Butevenhealthcare facilities inmanycountries,lackadequateaccess towaterandsanitation.Theprovisionof these services, coupledwith hygiene, is essential for maintaining a healthy population and a productiveworkforce (WWAP, 2016). The WHO estimates that for low- and middle-incomecountries58percentofallcasesofdiarrhoeacanbeattributedtoinadequatedrinking-water(Prüss-Üstünetal.,2014).Lack of access to water, sanitation and hygiene (WASH) causes several infectiousdiseases,suchasincreasingintestinalnematodediseases(worms),diarrhoealdiseases,skin(e.g.scabies)andeyeinfections(e.g.conjunctivitis,trachoma)(Stankeetal.,2013;Sena et al., 2018). Furthermore,WASH has an important role inmalnutrition (Prüss-Üstünetal.,2016);andlackofWASHcandriveormaintainthecycleofpoverty(UNEP,2012).Morethanathirdoftheglobalpopulation(about2.4billionpeople)stilldonothaveaccess to sanitation facilities, andaboutonebillion still practiceopendefecation(UNICEF/WHO, 2017). In 2016, 870,000 deaths globally from diarrhoeal diseases,malnutrition and intestinal nematode infections were attributable to unsafe drinkingwater, unsafe sanitation and lack of hygiene (UN, 2019a). In addition, lack of WASHfacilitiesinschoolscancausedehydrationinchildren,affectingtheirconcentration,andcanalsoresultinhavingtouseinadequatelatrines,negativelyimpactingonadolescentgirlsschoolattendance(UN,2019c).

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Table1. DLDDandwatersecurity,watersafety,sanitationandhygienedriversimpactingonhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)

Watershortage

Consequencesofwaterquality(non-potablewater,salinewater)

Contaminationofwaterbyvariousmeans,suchasalgalblooms,bacteria,fungi,virus,toxins

Damagestohealthservicesfunctioning,withconsequencestotheprovisionofsomesanitaryprocedures

Consequencesonthewatersupplyanddistributionsystem(forpipedwater,watertrucks,cisterns,artesianwells,damsandotheralternativesources)

Householdwatercollectionandstorage,whichmaycompromisewaterquality

Watercollection,andtransport(whichmaycausephysicalinjuries)

Changeinvectors,hostsandreservoircycles

Effectonirrigationforagriculturalproductionandinlivestockandfishingincreasingthepossibilityoffoodshortages

Impairedhygiene(personal,household,food,healthserviceequipment)duetolackofwater

Consequencesofsanitationservices,urbancleaning,healthservicesandotherbasicservices

Gastrointestinalinfectiousdiseases(diarrhoea,hepatitisA,typhoidfever,andotherinfections)

Parasiticinfections(intestinalnematodesinfections)

Malnutrition

Dermatologicalinfectiousdiseases(scabies)

Diseasestransmittedbyvectorsandzoonoses(e.g.dengue,zika,chikungunya,malaria,leishmaniasis,leptospirosis)

Infectiousdiseasestransmittedbyvirus,bacteria,fungi(flu,pneumonia,conjunctivitis,trachoma,scabies,andotherdiseases)

Cardiovasculardiseases(e.g.hypertension)

Kidneydiseases

Cancers

Dehydration

Unintentionalinjuries(poisoningbytoxins)

Musculoskeletaldisorders(bonedamage,backandmusclepain)

Mentalandbehaviouraldisorders(anxiety,depression)

Source:CDC(2010);(WHO&WMO,2012);Patzetal.(2012);Stankeetal.(2013);Senaetal.(2014);OPAS/OMS(2015);Yusaetal.(2015);Vinsetal.(2015);Alpinoetal.(2016);Senaetal.(2018).Note:eachpathwaycanhavemultiplehealthimpacts(notshown)2.2Foodsecurityandsafety

Productive terrestrial and aquatic ecosystems are the source of basic nutrition andenergy, essential for health and overall well-being (Corvalan et al., 2005; Patz et al.,2012; FAO, 2018). In many parts of the world, because of increasing demographicpressures, agricultural practices have become unsustainable. These practices aredepleting land resources, resulting innegative impactson foodsecurity (FAO,2017a).Lackoffoodsecurityhasbeenachallengethatposesriskstobotheconomicstatusandhumanhealth,aswellastoproductivity(agricultural,fisheriesandlivestock)(Patzetal.,2012;Ebi&Bowen,2016;FAO,2017a).Whenecosystemsareaffected,foodsuppliesarereduced(essentiallycropsandlivestock),whichinturnreducesnutrientintakeinboth

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quantity and quality (Stanke et al., 2013; FAO, 2015; FAO, 2017a). Lack of foodavailability can cause increasing food prices; this reduces access for people with lowincomesor for those living inremoteareas,which inturn, impactsnegativelyontheirnutritionalstatus(Comptonetal.,2012;Greenetal.,2013;Berryetal.,2014).Inruralandinpoorareas,wherepeoplecannotpurchasefood,localfoodproductioniscrucialtoprevent hunger and to promote development and health (Corvalan et al., 2005;FAO/IFAD/UNICEF/WFP/WHO, 2018). Furthermore, the food-water nexus, if notsecure, poses the risk of food shortage, and thereby also negatively impacts humanhealth,economicgrowth,socialbenefitsandpoliticalstability(UN,2013).Unsafewaterand lackof hygiene,whenpreparing foodor in cooking, inadequate food storage, andparasitic and chemical contaminants are all elements, which jeopardise food safety(FAO,2017a).Climatechangeandvariability(causingdroughts,floods,andwarmertemperatures)canimpact on agriculture and fisheries, sometimes resulting in outbreaks of food-borneillnesses(Smithetal.,2014a;Porteretal.,2014).Theseriskfactorsalsoimpactoncropproductivity, increasing the risk of food shortage, thus increasing the risk ofundernutritionespeciallyinlow-incomecountries(Smithetal.,2014a;WHO,2014a).Amajordriveof food insecurity isdrought (Porteretal.,2014).Asanexample,droughtimpacts(databasedfrom2003to2013)affectedapproximately150millionpeopleandcausedUSD23.5billionworthoflossesoncropandlivestockproductioninsub-SaharanAfrica,which represents almost 77 per cent of all production lossesworldwide (FAO,2015).

Box3.ImpactsofacutefoodinsecurityinSouthSudanFood insecurity is determined by the lack of access to safe and nutritious food in sufficientquantitiesanddiversityneeded togrowanddevelop.Food security is essential tohaveanactiveandhealthylife.Acutefoodinsecurityreferstoanymanifestationoffoodinsecurity,whichreachessuchadegreethatlives,and/orlivelihoodsofapopulationinaspecifiedareaarethreatened.FiveyearsofconflictresultedinseverefoodinsecurityinSouthSudan.Theconflictstartedin2013with an estimated 1.6 million people affected. By September 2018, the estimated population incrisis increased by four, to around 6.1million people. The severity of acute food insecurity alsoincreasedinsomelocationsleadingtoemergencyandfaminesituations.Thepersistentconflicthascausedpopulationdisplacement,macroeconomicdeclineandlivelihoodloss.Theconflicthasledto380,000deathsandtothedisplacementof4.4millionpeople(around30percentofthepopulation)–displacedinternallyortoneighbouringcountries.Thedisruptionoftradeflows,coupledwiththedepreciationofthecurrency,duetoconflict-relatedoil production interruption led to high foodprices. This situation, togetherwith low salaries andfoodpriceincreases,affectedlargenumbersofpeople,inparticularpoorhouseholds.Lowlevelsoffood availability and access have caused severe acute malnutrition between 2014 and 2018,especiallyamongthosedisplacedtoremoteareas,andthosethatdonothaveaccesstohealthcareservices.Declineinconflictinsomeareasallowedforlargercultivationareasbuterraticrainfallhasadverselyimpactedoncropproduction.Humanitarianfoodassistancehasbeensupportingfamiliesandreducingvulnerabilitiestohouseholdsthatfacemoreextremeimpactsandfamine.Inaddition toSouthSudan,Yemen,SomaliaandNigeriaareundergoing the largesthumanitariancrisissince1945,accordingtotheUnitedNations,withmillionsescapingconflictanddrought,somewithintheirowncountries,othersmovingacrossborders.Source:Devi(2017);USAID(2018);FAO(2019c);FSIN(2019).

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Lackofquality foodsmayresult inreducedquantityand/orqualityofnutrient intake,increasingmalnutrition(inallforms)prevalenceandmortalityrisks(Stankeetal.,2013;FAO,2018).Undernutritioncanbechronic,whichleadstostunting(lowheightforage),or acute leading towasting (lowweight forheight).Bothare consideredunderweight(lowweightforage)(Smithetal.,2014a).Inthelasttwodecades,despiteprevalenceofstunting in children under five years of age decreasing worldwide, in 2018 it wasestimated that 149million children,with high prevalencewere living in Asia (55 percent) and in Africa (39 per cent). There was also high prevalence of wastingcorrespondingtomorethantwothirdsinAsia(68percent)andmorethanonequarterin Africa (28 per cent) (UNICEF/WHO/WB, 2019). Another aspect of malnutrition isoverweight, which can be caused by consuming low quality, high calorie food (FAO,2017a).Moreover, themechanisms that causemalnutrition are often indirect and thetype of deficit varies according tomicronutrient. For instance, lack of iron can causeanaemia; vitamin A deficiency can cause the specific problem of night blindness; andvitamin C deficiency can cause scurvy (Stanke et al., 2013). Micronutrients reductioncoupledwithundernutrition in low-andmiddle-incomecountries is linkedwith foetalgrowth restriction, neonatal and child deaths, and stunting and wasting in childrenunder 2 years of age, and also contribute to the development of children’s cognitivepotential.Adifferentformofmalnutritionleadstooverweight.Globally,anestimated40million childrenunder five yearsof agewereoverweight in2018 (Black et al., 2013;WHS,2018).Table2summarisesthepathwaysandmainhealthimpacts.Table2. DLDDandfoodsecurityandsafetydriversimpactingonhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)

Deficiencyinagricultural,livestockandfisheryproductioncausingfoodshortagesDifficultyinthesustainabilityoffamilyagriculture,livestockandfisheryFoodcontamination(microbiologicalandchemical)RisingfoodpricesDecreasedaccesstofood,especiallytohealthyfood

Nutritionaldeficiencies

Anaemia

Malnutritionanditscomplications(lowphysicalandcognitivedevelopment,deficiencyoftheimmunesystem)

Infectionsfromfoodcontaminatedbyviruses,bacteria,fungi,parasites(diarrhoea,cholera,hepatitisA,worms,otherinfections)

Chronicdiseases(hypertension,obesity,cancers)

Mental,behaviouralandneurologicaldisorders(anxiety,depression,suicide)

Unintentionalinjuries(poisoning)

Source:CDC(2010);Patzetal.(2012);Stankeetal.(2013);Blacketal.(2013);Senaetal.(2014);Smithetal.(2014a);OPAS/OMS(2015);Yusaetal.(2015);Vinsetal.(2015);Alpinoetal.(2016);Senaetal.(2018).Note:eachpathwaycanhavemultiplehealthimpacts(notshown)

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2.3AirqualityThegeneraleffectsofairpollutiononhumanhealth (morbidityandmortality)are: a)prematuredeathsduetocardiovascularandrespiratorydiseases,lungcancer,andacutelower respiratory infectious (e.g., pneumonia); b) irritation on the respiratory tract,causing respiratory disorders (e.g., asthma, tracheitis, pneumonia, allergic rhinitis,desertlungsyndrome);c)causingoraggravatingbronchitis,emphysema,cardiovasculardiseases (e.g., hypertension, stroke, increasing risk for acute myocardial infarction,inducingatherosclerosis),eyeinfection,skinirritations,andmeningococcalmeningitis;d)otherdiseases,suchasValleyfever,anddiseasesassociatedwithtoxicalgalblooms.Dust isalsorelatedtodeathsand injuriesduetoreducedvisibilityandroadaccidents(WHO&WMO,2012;Goudie,2014;UNEP/WMO/UNCCD,2016;Landriganetal.,2018),andalsoposesriskforaviationtraffic(Goudie,2014;UNEP/WMO/UNCCD,2016).Airbornepollutantsare increasing,andtheycanrapidlydisperseglobally(Berryetal.,2014; Landrigan et al., 2018), travelling long distances across national borders,continentsandoceans (NRC,2010;Zhangetal.,2017).Problemsassociatedwithduststormscanbeintensifiedbydegradationindrylands(MA,2005a;UNEP/WMO/UNCCD,2016).Physical,chemicalandbiologicalpropertiesofairbornedustpollution(includingmineraldustandduststormsexposure)andotherpollutantsposeriskstohumanhealth(UNEP/WMO/UNCCD,2016).Dustcanbeharmfulthroughpathogencarriageanddirecttrauma by inhalation of particulates. Hazardous dust particles include fine mineralparticulates, and a combination of pollutants, spores, bacteria, fungi and potentialallergens, which are carried along with mineral dusts (Goudie, 2014;UNEP/WMO/UNCCD,2016).Mineraldusts cancause some typesof cancers (e.g. liver,kidney),andotherseriousdiseases,suchasrenal failure,andosteoporosis(Lametal.,2013). Inhalationof fungalsporescarriedinairdustmayresult inoutbreaksofValleyfever(causedbyafungus–Coccidioidomycosis),forinstanceindrylandsareas,suchasSouthwest US, Northern Mexico, and Northeast Brazil (Goudie, 2014;UNEP/WMO/UNCCD,2016).Wildfires caused by heat waves, drought and increased soil erosion can affect largenumbersofpeoplefordaystomonthsduetoexposurestoparticulatematterandothertoxicsubstances,includingburnsandsmokeinhalation(Finlayetal.,2012;Handmeretal.,2012).Asanexample,prematuredeathsperyearworldwidefromairpollutionfromforest fires is estimated at 339,000 (range 260,000 to 600,000), with most affectedregionsbeingsub-SaharanAfricaandSoutheastAsia(Johnstonetal.,2012).In a recent study, Landrigan et al (2018) identified emerging evidence of additionalcausal association between fine particulate matter (PM2.5) pollution and some non-communicable diseases, such as diabetes (Meo et al., 2015), attention-deficit orhyperactivity disorders in children, decreased cognition function, occurrence ofneurodegenerativedisease(e.g.dementia)inadults(Pereraetal.,2014;Heusinkveldetal.,2016;Cacciottoloetal.,2017),aswellasincreasedprematurebirthandoccurrencesoflowbirthweight(Malleyetal.,2017).Otherstudiesindicatethatdryseasons,coupledwith lowhumidityandhighairbornedustconcentrationsmayresult inMeningococcalmeningitisoutbreakswithhighfatalityrates,specifically inAfrica inasemiaridregion

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knownas“themeningitisbelt”(Molesworthetal.,2003;Patzetal.,2012; Goudie,2014UNEP/WMO/UNCCD,2016).

Box4. Dustexposureandmeningitisinsub-SaharanAfricaSandstormsinAfricaareariskfactorofMeningococcalmeningitisintheSahel,asemi-aridregionof sub-SaharanAfrica. Exposure to airborne dust pollution, coupledwith high temperature andlow humidity causes outbreaks of bacterial meningitis (Meningococcal meningitis) every yearduring the Sahel’s dry season (thehottest timeof the year). This area is knownas the “Africanmeningitis belt”, stretching from Senegal (in the West) to Ethiopia (in the East), covering 26countries(WHOmap).Thepopulationisestimatedtobeofapproximately300million.

Meningococcalmeningitisisaninfectiousdiseasecausedbyseveralmicroorganisms,butwiththebacteriaNeisseriameningitides having the greatest epidemic potential. This disease is observedworldwide,butthehighestburdenoccursintheAfricanmeningitisbelt,withapproximately900thousand cases reported between 1995 and 2014 (average of 45 thousand cases per year), ofwhich10per cent resulted indeaths (averageof4,500deathsperyear). Largeepidemic cyclesoccurduringthedryseasonfromDecembertoJune.Socialandeconomicfactors,suchaspovertyand overcrowded housing, can influence the transmission of the disease. In addition, largeepidemicscandisruptthehealthcaresystems,posingriskstorapidresponseandrecovery.MajorepidemicsofMeningococcalmeningitishavebeenoccurringinthemeningitisbeltforover100years. Since the introductionofavaccine in2010andother strategichealthmeasures (e.g.risk assessment by monitoring the number of cases, reinforcement of surveillance, reactivevaccinationcampaigns,andtheuseofspecificantibiotictreatmentprotocols)theepidemiologicalpattern has changed. International organisations, such as the WHO, the World MeteorologicalOrganisation(WMO)andtheGrouponEarthObservations(GEO)aresupportingAfricancountriesin a project known as the Meningitis Environmental Risk Information Technologies (MERIT).Understanding the relationship between dust seasons and meningitis occurrence can predictseasonaloutbreaksandpromotevaccinecampaigns.Source:Molesworthetal.(2003);WHO&WMO(2012);WHO,(2014b);UNEP/WMO/UNCCD(2016);WHO(2019a);WHO/AFRO(2019).Map(WHO,2017a).

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Themostvulnerablepopulationsexposedtodustareinaridandadjacentareas,suchastheMiddleEast,NorthAfrica,theSahel,Australia,China,theUSSouthwest,andMexico;althoughexposurecanaffectpopulationsfarfromtheseregions(e.g.,dusttransportedfrom China and Mongolia to Japan and Korea) (Goudie, 2014; UNEP/WMO/UNCCD,2016).Insomepartsoftheworldduststormfrequencyischangingduetoland-useandclimaticchange(Goudie,2014).Vulnerablepeoplewhosufferthegreatest impactsarechildren, the elderly, and especially people with chronic health conditions likerespiratoryandheartconditionsandlungdiseases,andthosewhoareinhighexposuresituations(e.g.,agriculturaloroutdoorlabourers;andpeoplelivingclosetodesertareasor industries) (Berry et al., 2014; UNEP/WMO/UNCCD, 2016; Landigran et al., 2018).Forinstance,dustfromtheChihuahuanDeserthasledtoincreasedhospitaladmissionsforchildren(aged1-17)duetoasthmaandbronchitis,inElPaso,Texas.Thesamestudyalso found that girls aremore sensitive to acute bronchitis hospitalisations after dusteventsthanboys(Grineskietal.,2011).Meanwhile,respiratorymortalityamongelderlyinItaly(aged75orolder)andSpainincreasedduringSaharandustevents(Sajanietal.,2011;Jiménezetal.,2010).Table3summarisesthepathwaysandmainhealthimpacts.Table3. DLDDandairqualitydriversimpactingonhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)LowhumidityIncreasedtemperature(heat,warmerconditions)Duststorms,dustparticlesAircontaminationbyparticlesfromfires(wildfires,agriculturalpractices),andtoxinsaccumulatedinair,soilandwaterAccidentscausedbyreducedvisibilityReleaseofairborneallergens(fungalsporesandplantpollen)

Acuterespiratorydiseases(flu,sinusitis,rhinitis,bronchitis,pneumonia)Chronicrespiratorydiseases(asthma,allergicrhinitis)Cardiovasculardiseases(stroke,ischemicheartdisease,hypertensiveheartdisease)LungcancerSkinirritations(dermatitis)andeyeinfection(conjunctivitis)MeningococcalmeningitisDiseasescausedbyfungi,viruses,algae,bacteria,allergensUnintentionalinjuriesbyroadaccidents

Source:WHO&WMO(2012);Stankeetal(2013);Senaetal(2014);Goudie,2014;OPAS/OMS(2015);UNEP/WMO/UNCCD(2016);Alpinoetal.(2016);Landriganetal.(2018)Note:eachpathwaycanhavemultiplehealthimpacts(notshown)2.4Soilquality

Human lifedependsonecosystemservices.Soil isanessential resource forecosystemfunctions,and it isresponsible for95percentof foodproduction. Ithasan importantfunction in filteringandbufferingnaturallyexistingcompounds(contaminants).These

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compounds are mainly formed through soil microbial activity and decomposition oforganisms(e.g.,plantsandanimals)(FAO,2017b;FAO,2019d).Soilcontamination,degradationanderosionarereducingtheproductivityofagricultureandlivestockinmanyareasoftheworld,impactingonfoodsecurityandhumanhealth(UNCCD,2017b;UNCCD,2017c).Figure3.DLDDpathways

Source:ModifiedfromMA,2005b;OPAS/OMS,2015.Soildegradationandpollutioncanresultfrompooragriculturalpractices,highlevelsofchemical elements (native or introduced) or hazardous substances from industrial,military and extractive activities, inadequate irrigation process, improper solid wastemanagement(includinghazardousnuclearwasteandunsafechemicalstorage)(UNCCD,2017b;UNEP,2017;Rodríguez-Eugenioetal.,2018;FAO,2019d).Whensoilisdepleted,thefilterfunctioncanfailandthecontaminantscanbetransferredtowatersystemsandthefoodchain(FAO,2019d)(Figure3).Ecosystem degradation can cause soil erosion and contamination. In turn, soilcontaminantsmoveintosurfacewaterleadingtowatercontamination(UNCCD,2017c).Some heavy metals such as lead, mercury, arsenic, cadmium and chromium, coupledwith pesticides pollutants and pharmaceuticals used for livestock management (e.g.antibiotics) are degrading soil biodiversity and their function. This situation in turnposesriskstoagriculturalproductivity,livelihoods,foodsecurityandhumanhealth,aswellastowildlife(Tóthetal.,2016;UNEP,2017).Contaminated soil can affect human health through three main routes: inhalation,ingestionandtheskin.Theeffectsonhumanhealthare:a)increasedriskofcancer,b)harmful effects on the nervous, digestive and immune systems, lungs and kidney, c)

Politicalandeconomicinstability Politicalstabilityandeconomicprosperity

Expansionofcroppedareasandovergrazing Improvedcropandlivestockproduction

Reducedvegetationcover

Large-scaleexpansionofirrigation;

monocultures

Increasedsoilerosion

Soilcontaminationandsalinization

Reducedlandecosystemservices

Small-scaleirrigationofhighvaluecrops

Soil,water,rangeconservationand

improvedtechnology

Lowcontaminationandsalinizationrisk

Reducedsoilerosion

Increasedlandecosystemservices

Reducedhumanhealthandwell-being

Improvedhumanhealthandwell-being

PathwayleadingtointensifiedDLDDimpacts ApproachestoavoidDLDDimpacts

Increasedpoverty,inequalities,migration

Povertyreduction,landconservation

SocialDeterminantsDemographicEconomicPolitical

Science&technologyCommunityhealthstatus

Education

EnvironmentalDeterminantsClimatechangeWaterscarcity

SoiltypeBiodiversityloss

Reducedbiodiversity

Biodiversityispreserved

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skeletal andbonediseases, d) sterility and other reproductive disorders, e) immunitysuppression, f) neurological development damage and low IQ, and g) increasedantimicrobialresistance(Tóthetal.,2016;UNEP,2017;Rodríguez-Eugenioetal.,2018).Chemical industry and agriculture workers (via inhalation and direct contact) andpeople living close to chemical industries are particularly vulnerable, as are children,generally (SCU, 2013). Furthermore, when soil becomes very dry during droughts orduring a desertification process, dust can circulate in the air, causing respiratoryconditions such as dust pneumonia (Goudi, 2014; Nourmoradi et al., 2015). Table 4summarisesthepathwaysandmainhealthimpacts.

Table4. DLDDandsoilqualitydriversimpactingonhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)Lossofproductivesoilleadstolowerfoodproduction,fromdecreasingagriculturalyieldsandlivestock,causingfoodshortagesSoilcontaminationfromchemicalproductsSoilcontaminationfromanimalandhumanexcretaAircontaminationthroughcontaminateddust

Infectionsfromfoodcontaminatedbyviruses,bacteria,fungi,parasites(diarrhoea,cholera,hepatitisA,worms,otherinfections)

Noncommunicablediseases(cancers,neurologicaldamage,lungandkidneydiseases,skeletalandbonediseases,reproductivedisorders)Respiratoryinfections(e.g.pneumonia)Skinandeyeirritationandallergiesorinfections

Nutritionaldeficiencies

Unintentionalinjuries(poisonings)

Source:Goudi(2014);Tóthetal.(2016);UNEP(2017);Rodríguez-Eugenioetal.(2018)Note:eachpathwaycanhavemultiplehealthimpacts(notshown)

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Box5. Impactsofsoilerosiononecosystemsandhumanhealth: thecaseof theAralSea.Globally,landdegradationandsoilcontaminationarepressuresonthedemandfor agriculture and livestock production, for human settlements and natureconservation,andforhumanhealth.OneofthebestexamplesofenvironmentaldegradationwithseveralimpactsonecosystemsandhumanhealthisthatoftheAral Sea, on the border of Kazakhstan andUzbekistan. It is one of the largestecologicaldisastersintheworld,coveringthefivestatesofCentralAsia,therebyaffecting almost 50million people. In the 1900s, the Aral Sea was the fourthlargest inland lake in the world, an important ecosystem providing naturalresources tomany communities, with good access to fishing, water and land.The salinity and volume levels of the Aral Seawere held stable by inflows offreshwaterfromtworivers–theSyrDaryaintheeast,andtheAmuDaryainthesouth.After1918,policymakersfromtheformerSovietUniondecidedtodivertfreshwater from these rivers to an irrigation system for cottonproduction tobenefit exportation.Millionsof regional peoplewere thus employed, and cropproductionwas raised from6.4million acres to15.9million acreswithin twodecades.In the early 1960s the Aral Sea began shrinking, and a water crisis began.Around2005,halfofitssurfaceareawaslost.Severalimpactsontheecosystemresultedintheregion:thefishingindustrycollapsed(duetodeclinedfreshwaterinflux and increased salinity); 60 thousand fishing-related jobs disappeared;dust storms were created from the dried-up sea, carrying chemicals andpesticides originating from the intensive monoculture agriculture occurringalongthetworiversleadingtoairandwatertoxicpollution;evencropsgrownoutsidetheregionwerethusdamaged.Manyhealthimpactsemerged:cancers,respiratory diseases, anaemia, miscarriages, maternal and infant mortality,maternalmilktoxicity,kidneyandliverdiseases,andsomeinfectiousdiseases.Theaveragelifeexpectancydeclinedfrom64to51years,andalmostone-halfofthepopulationreportedemotional stress.Furthermore,with livelihood,healthandwell-beingdamagedandunfavourable livingconditions increasing,peoplewereforcedtomigrate.Currently,although,somemeasuresarebeingimprovedin the area by the government, with positive results on the ecosystem andhumanhealth,alargeareaoftheAralSeaisstilldisappearing.Source: Mamyrbayev et al. (2016); UNEP (2017); Omuto and Vargas (2018);WRI(2019).

2.5SocialandeconomicfactorsEconomicandsocialfactorscancontributetovulnerabilitiesatthelocallevel,especiallyof poor communities and in cases where the impacts are of long duration. However,these factors are also modified by other local forces, such as other non-DLDDenvironmentalrisks,aswellaslocalculturalandpoliticalfactors(Oviatt&Brett,2010;IPCC,2012,2014;Cardonaetal.,2012).

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ThesusceptibilityofpoorercountriesandregionstosufferdamagesfromDLDDcanbemade worse by direct impacts from climate extremes and climate variability (IPCC,2014;Senaetal.,2017;Hallegateetal.,2018),andbythelackofaccesstopublichealthcare services (Peters et al., 2008; Ebi and Bowen, 2016). Damage to, or inadequatephysical conditions of, infrastructures that support human livelihoods (e.g. supply ofpowerandwaterfordrinkingandhygiene,wastemanagement,andsanitation),aswellas reduced foodsecurityandaccess tohealthcare, can increasehealthrisks (UNISDR,2009; Smith et al., 2014a; IPCC, 2012, 2014; Sena et al., 2018). For example, in Cubawherethepublichealthsystemiswelldeveloped,the lackofdrinking-watersupply insomecommunitiesledtoinadequatestoragepracticesbythepopulation,contributingtopersistentdenguefevercases(Bultóetal.,2006).

Table5. DLDDandsocialandeconomicdriversimpactingonhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)Lossanddamageoflivestockandsubsistenceplantationsduetodifficultyinaccessingwater

Lossorlackofemployment,orlowincomeSocialimpactsfromtheneedtocollectwater(genderdifferences,opportunityloss)Lackofaccesstodrinking-waterleadingtoinadequatewaterstorage,anduseofcontaminatedwaterLackofhygieneconditionsandpracticesLackofaccesstofoodandabilityofsustenanceRisingwaterpricesduetoscarcityandhighpurchasedemand

Migrationofpopulationsduetoconflictorseekingimprovementintheirqualityoflife(resultinginothersocialandculturalchanges,andchangesintheepidemiologicalprofileofmigrants,andofthereceivingareas)Familyseparation(displacementofafamilymembertootherareasinsearchofemploymenttosupplyfamilyneeds)causingdisruptionandchangesinthefamilystructureanddynamicsLossofsocialidentityUncertaintyandconcernsforthefuture

Psychologicaldisorders(anxiety,stress,behaviouralchangegeneratingotherproblemssuchasviolence,alcoholism)DepressionSuicideIncreasingchronicnon-communicablediseases(cardiovasculardiseases,backandarmspain)Increasinginfectiousandparasiticdiseases(gastrointestinaldiseases,worms,waterandvector-bornediseases)Increasingdemandofhealthservicesandothersocialproblemsintheplaceswherepeoplemigrateto

Source:Freitasetal.(2012);Stankeetal(2013);Senaetal.(2014);Smithetal.(2014a);OPAS/OMS(2015);Vinsetal.(2015);Ebi&Bowen(2016);Senaetal.(2018).Note:eachpathwaycanhavemultiplehealthimpacts(notshown)

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Box6.DisastersandgenderThe effects of climate on human society are mediated by social factors. Theexpected roles and relations between men and women in a given culture candetermine gender differences, including norms and values, which in turn canincrease gender inequalities. Health risks related to climate are more likely toimpactwomenduetotheirculture’sexpectedgenderrole.Thisleadstogender-specificvulnerabilityofwomeninthefaceofnaturaldisasters,leadingtohighermortality rates as compared to men. Women, in particular young women andthose of low socioeconomic status, also show high risk of anxiety and mooddisordersafterdisasters.Someexamplesofwomen-specificconstraintsregardingappropriateresponseinthefaceofdisasters:

• Insomesocietieswomencannotleavetheirhousealone,increasingtheirvulnerability.

• InBangladesh,whenwomenlostclothesduetofloods,theyfeltinhibitedtoleavethehomeorshelterinordertofindhealthassistanceoressentialresources.

• Inthecaseofdroughts,inmanycountries,womenandgirlsareexpectedtocollectwater,sometimesfromlongdistancesandfromunsafesources.Theyarethereforemoreexposedtomusculoskeletaldamageandtoinfectiousdiseases,aswellastothelossofopportunityofemploymentandeducation.

• AfterHurricaneKatrina,ahighincidenceofanxietyandmooddisorderswasobservedinwomen.

• InacycloneinBangladesh(1991)manymoredeathsoccurredinwomen(90percent).Thecausewasattributedtowomen’sresponsibilitiesoflookingafterchildrenandvaluables,andalsowaitingfortheirrelativestoreturnhome.

• Afterdisasters,womenaremorevulnerabletotheriskofsexualviolence,exploitationandabuseduetothelackofprivacyinemergencyshelters.Inaddition,domesticviolencecanincreaseafterlosingtheprotectivesystemoffamilyandfriends.

• Incaseoflimitedlandaccessinruralareas,sometimescombinedwithotherissues(e.g.violenceandconflicts,divorce,unemployment),womenareforcedtomigratetomarginalisedareas,increasingtheirlikelihoodofdiseaseandpoverty.

Source:WHO(2014c);UN(2015).

Other factors that influence vulnerability include race, gender, ethnicity, socialinequalities and culture, all of which can impair health status and increase socialdisadvantage(Scandlynetal.,2010;IPCC,2012;Freitasetal.,2012;Smithetal.,2014a).Forinstance,someindigenouscommunitieshavehigherriskofeconomiclossandpoorhealth, if they live invulnerableareas forclimatechange,anddependon localnaturalresources(Ford,2012;Smithetal.,2014a).Forwomenandchildren,theunequalcarecanberelatedtoloweducationallevel,lowsocioeconomicstatus,lowperceptionoftheillnessseriousness,andculturalbehaviours(Corrarino,2013;Ebi&Bowen,2016).Forinstance, in Bangladesh, differences in prevalence of poverty, undernutrition and

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exposuretowaterloggedenvironmentsmadewomenmoreaffectedbyclimatehazardsthanmen (Neelormi et al., 2009). Table 5 summarises the pathways andmain healthimpacts.2.6HealthcareservicesHealth services can be affected by DLDD. Lack of water, water shortages andcontaminatedwater can pose risk to some basic health care and hospital procedures(e.g.vaccinesconservationandapplication,haemodialysistreatment,dressingwounds),and worsen working conditions, which may deteriorate the health conditions of thepopulation (Sena et al., 2014;OPAS/OMS, 2015; Ebi&Bowen, 2016). Simultaneously,the increasing impacts on human health arising from risk factors related to DLDDrequiremorehealthcareservices,andincreasecostsforexistinghealthsystems(Stankeetal.,2013).Disruptionandmigrationofpopulationscanalsoincreasenegativeeffectsonhealthandcreateothersocialchanges(Stankeetal.,2013;Ebi&Bowen,2016).ArecentstudycarriedoutbyGuzmánBeltránandcolleagues(2019)foundthatdelaysinhealthcareservices,inbothemergencyandinnon-emergencysituations,canincreasemortality, disability andmorbidity. This includes both delays in arrival at emergencyserviceand treatmentathealth care facilities.Therearealso factors thatdelayhealthassistance, such as availability and free access to health care facilities (Peters et al.,2008;GuzmánBeltránetal.,2019).Poorpeople,peoplelivinginremoteareas,women,and children under five are the most vulnerable to delays in health care services(GuzmánBeltránetal.,2019).Accesstohealthservicescanoftenbelimited,especiallyindevelopingcountries,and/orinthecaseofpoorpeople,and/orinthecaseofthosewhosufferdisproportionallyfromthe burden of disease (Ebi&Bowen, 2016).Migration and family disruption can alsoincrease health problems and create other familial and social changes; this alsopredominantlyaffectspoorpeople,whodonothavethenecessaryfinancialconditionsto receive adequate health care (Stanke et al., 2013; Ebi & Bowen, 2016; Sena et al.,2018).Empowermentofpeopleisimportantbecauseitprovideschoicesforprotectingtheir health (e.g. healthy food, healthy life styles) as well as the knowledge of whenhealth services are need (Peters et al., 2008). Table 6 summarises the pathways andmainhealthimpacts.Table6.DLDDimpactsonhealthcareservicesandhumanhealth

Environmentalandsocialpathways Humanhealthimpacts(morbidityandmortality)RisksofinterruptionofhealthcareproceduresduelackofwaterIncreaseddemandsforcareandsuppliesofhealthservicesRiskofimpactsinenergysupply,impairingtheuseofhealthequipment,refrigerationofmedicinesandvaccines,andthehealthcareofsomehospitalservices

Increasingcommunicableandnon-communicablediseasesLackof,orreductionof,healthcareduetolackofworkingconditions,whichmayworsenthehealthconditionsofthepopulation

Source:Stankeetal.(2013);Senaetal(2014);OPAS/OMS(2015);Ebi&Bowen(2016);Senaetal.(2018);GuzmánBeltránetal.(2019)Note:eachpathwaycanhavemultiplehealthimpacts(notshown)

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3. HealthconsequencesofDLDDHumanhealthconditionsaredescribedherefollowingtheWHOclassificationofmajordisease groups: Infectious and parasitic diseases (including nutrition),noncommunicable diseases, and injuries (intentional and unintentional). The diseasesand injuriesare related toDLDD impacts throughwater, sanitationandhygiene, food,air, soil, social and economic factors and the health sector, as described in section 2.Figure3showsseveralexamplesofhealthimpactsassociatedtoDLDDintheliterature.Figure4. ExamplesofhealthimpactsassociateddirectlyorindirectlywithDLDD.

Source:BasedonCDC(2010);WMO&WHO(2012);Patzetal.(2012);Stankeetal.(2013);Senaetal.(2014);OPAS/OMS(2015);Yusaetal.(2015);Vinsetal.(2015);Alpinoetal.(2016);Ebi&Bowen(2016);Senaetal.(2018).3.1Infectious,parasiticandnutritionaldiseasesInfections due to bacteria, viruses and fungi, human body parasites, and nutritionalproblems can be associated directly and indirectly with the land. Under this generalclassificationweshallidentifyseveralhealthconditions,explainedbelow.RespiratoryinfectionsRespiratory infections resulting from environmental causes include lower respiratoryinfections, such as pneumonia, bronchitis, bronchiolitis and influenza, and upperrespiratory infections, such as sinusitis, pharyngitis, laryngitis, and nose irritationmostly causedbyairpollution (Prüss-Üstünet al., 2016).These infections canalsobecaused by contaminated water and soil. Drought and dry and dusty conditions canincrease fine air particulate matter, allergens and dust particles, which lead to

Pneumonia,flu,bronchitis

Conjunctivitis,scabies

Malaria,dengue,chikungunya,Japaneseencephalitis,Lymphatic

filariasis,WestNilefever,Leishmaniasis,Schistosomiasis,

Onchocerciasis,Chagas

Leptospirosis,hantaviruses

Intestinalnematodesinfections

Zoonoses

Vector-bornediseases

Skinandeyediseases

Trachoma

Diarrhoealdiseases

Respiratoryinfections

Protein-energymalnutrition

Cancers

Mental,behaviouralandneurologicaldisorders

Cardiovasculardiseases

Chronicrespiratorydiseases

Stress,anxietydisorders,depression

Asthma,COPD,allergicdiseases

Stroke,hypertension

MusculoskeletaldiseasesUnintentional

injuries

Injuriesrelatedtonaturaldisasters

Poisonings

Intentionalinjuries

Self-harm

Violence

DLDDassociatedhealthconditions

Infectious,parasitic,andnutritionaldiseases

Noncommunicablediseases

Injuries

Trachea,liver,bronchus,lung

Kidneydiseases

Meningitis

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respiratoryinfections,posingincreasedmorbidityandmortalityrisks(Yusaetal.,2015;Prüss-Üstün et al., 2016). For example, dry soil, vegetation andwildfires can increasedusts,pollen,smokeandfluorocarbon,whichinturnincreaseacuterespiratorydiseases(e.g. bronchitis, pneumonia, includingdustpneumonia), aswell as chronic respiratoryconditions (e.g. asthma) (CDC, 2010). During dust storms, or in dusty conditions,respiratory infections (e.g. coccidioidomycosis, a fungal infection, also called Valleyfever)canbecausedby inhalationofspores thatbecomeairborne fromdisruptedsoil(Goudie,2014). Inaddition,underdroughtconditionsfreshwatercanbecontaminatedby cyanobacteria creating airborne toxins that affect airquality, and consequently therespiratorysystem,andirritationofnoseandeyes(CDC,2010).Respiratory diseases form a large part of the global disease burden. Risk factorsassociated to this group of diseases are poverty, overcrowding and environmentalexposures (FIRS, 2017). The WHO estimates over 566 thousand yearly deaths fromlowerrespiratoryinfectionsworldwideattributabletoenvironmentalrisks,allofwhichoccurinchildrenunderfive.Thelargestimpactisinsub-SaharanAfricawithover298thousandchildrendeaths.Intermsofburdenofdisease,lowerrespiratoryinfectionsareresponsible for 8.7 per cent of all deaths and disability-adjusted life years (DALYs)attributable to the environment. Upper respiratory infections have a lower impact,causing1190deathsworldwide(Prüss-Üstünetal.,2016).Vector-bornediseasesVector-bornediseasesarecommoninfectiousdiseasestransmittedbythebiteofblood-sucking arthropods, such asmosquitoes, ticks and other vectors. Examples of vector-bornediseasestransmittedbymosquitoesaredenguefever,malaria,zika,chikungunyafever,andJapaneseencephalitis.Examplesofthosetransmittedbyticksaretick-borneencephalitis,andLymedisease.Thetransmissionofthesediseasesdependsonclimatevariablesliketemperature,precipitation,andhumidity,whichcaninfluenceconditionsat both the local and global levels (Smith et al., 2014a). Mosquito density increasesthrough high precipitation but it can also occur following drought years (Chase andKnight,2003),asaresultofre-colonisation(Stankeetal.,2013).Dengue is considered to be themost rapidly spreadingmosquito-borne viral disease,with approximately 400million infections per year (Campbell et al., 2015a).Over thepast 50 years the disease incidence increased 30-fold globally (WHO, 2013). It is aclimate sensitive disease, with transmission occurring mostly during the wettestmonths,whenmosquitopopulationdensity increases(VanKleefetal.,2010;Campbelletal.,2015a).Temperature,humidityandrainfallareimportantfactorsassociatedwithdengueincidence(Campbelletal.,2015b),butdroughtordryconditionscanalsobeanimportant factor because such conditions provide mosquitos with suitable breedingsitesfromunprotectedwaterstorageinhouseholds(Bebeeetal.,2009).Environmentalfactorscauseover27thousanddenguecasesperyear(Prüss-Üstünetal.,2016).Malaria is the most important vector-borne disease worldwide. The disease istransmitted by infected Anopheles mosquitoes, which carry the protozoan parasitePlasmodium. The distribution and transmission of themalaria vector is influenced bytemperatureandprecipitation(Kelly-Hope&McKenzie,2009;Abiodunetal.,2016),andalso by human activities, such as deforestation, irrigation, and water management,

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whichleadstothecreationofmosquitobreedingsites(Corvalanetal.,2005;Abiodunetal.,2016). Although the proportion of theworld’s population affected bymalaria hasreduced (mainly inEastAfrica)due to effectivedisease control activities (Stern et al.,2011), the burden of disease is still high, and it has increased in some locations. Forexample, malaria is considered life-threatening to those living in a susceptibleenvironment,beingresponsibleformanychilddeaths.Thediseaseincreasedfrom210millioncasesin2013,to216millionin2016(UN,2019a).Ofthenearly259thousandmalaria deaths per year linked to environmental causes, 91 per cent occur in Africa(Prüss-Üstünetal.,2016).Over the last ten years, transmission of some arboviruses such as Chikungunya, ZikavirusandWestNilefeverhasbeenspreadinginmanycountriesoftheworld(Wahidetal.,2017).Modificationofecosystemsduetoanthropogenicaction,globalwarmingandglobalisation(namelyswiftglobal transportation)has influencedthe transmissionandspreadoftheseemergentdiseases.Forexample,Chikungunyafeverwasfirstidentifiedin Africa, but can now be found in other parts of the world, such as Asia, Europe(Campbell et al., 2015b;Wahid et al., 2017) and South America (Lima-Camara 2016).Chikungunya is transmitted by Aedes mosquitoes with higher risk of transmissioncaused bywarm temperature and heavy rains, although it has also been observed inareaswithdryconditions(coastalKenya)(Chretienetal.,2007).Mosquitoscanmultiplyindrought-proneareas,breedingincontainersforwaterstorage(Chretienetal.,2007;Lima-Camara2016). Aedesmosquitoes also transmit the Zika virus. The transmissionand circulation of this disease was also first reported in some African and Asiancountries and in the Pacific, followed by a rapid increase in the Americas. Themajorproblem of these emergent diseases is that they occur simultaneously in dengue-endemiccountries,furtherstressinghealthservices(Lima-Camara2016).The Japaneseencephalitisvirus isa flavivirusrelated to theWestNileandSaintLouisencephalitis virus. It is transmitted by some Culex mosquitos, and the distribution isassociatedwithtemperature(warmermonths),rainfallandland-use,inparticularland-usechangerelatedtoriceplantations,aswellasotherfloodingirrigations(Corvalanetal.,2005;Campbelletal.,2011;Prüss-Üstünetal.,2016). Itoccursmostly inruralandagriculturallocations,inparticularinmanyAsiancountries(Campbelletal.,2011;Baietal., 2014). Furthermore, climate change is likely to contribute to changes in thegeographical distribution of the disease due to changes in precipitation patterns, orchanges inmigrationroutesof thenaturalhostsof thevirus,ardeidbirds(Yun&Lee,2014). Estimates show that there are around 68 thousands cases of Japaneseencephalitisworldwide, annually,with case fatality rate reachingup to20,400deaths(30 per cent). There is no cure for the disease (Campbell et al., 2011;WHO, 2019b).Prüss-Üstünetal.(2016)estimatethatupto95percentoftheincidencesofthisdiseasecouldbereducedthroughenvironmentalinterventions.Tick-borne diseases are transmitted to human through ticks infected bywild animals(CDC, 2010). Some studies show that the frequency and distribution of tick-bornediseasesareattributedtoenvironmentalfactorslikeclimate(hightemperatureandlowprecipitation) (Kriz et al., 2012), and to socioeconomic factors, such as changes inagricultureandrecreationalactivities,andinhumanandanimalbehaviour(Randolphetal.,2008;Krizetal.,2012).Forexample,theincidenceofLymediseasecanincreaseindroughtperiodsasaresultofincreasedcontactbetweenhumansandwildanimals.This

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canhappen,forexample,whenanimalsseekwaterinareaswherehumansliveandstorewaterincontainers(CDC,2010).ZoonosesZoonosesarediseasestransmittedfromanimalstohumanseitherbydirectcontactwiththeanimal,orindirectlythroughvectorsthatcarrythezoonoticpathogen.Examplesofzoonosesdiseasesare leptospirosis,avian flu,hantavirus,plague, rabies (Portieretal.,2010). Hantaviruses are infectious diseases which include Hemorrhagic Fever withRenal Syndrome (HFRS) and Hantavirus Pulmonary Syndrome (HPS)/HantavirusCardiopulmonarySyndrome(HCPS).Theycanbe transmittedbyrodents,shrews,batsandmoles(Avsic-Zupancetal.,2019),predominantlyinruralareas,wherethereismoreproximity between rodents and humans. The transmission occurs predominantlythroughinhalationofaerosolsordustparticlescontaminatedbydryexcretafromwildrodents. There is a large distribution worldwide, and it is considered an emergingdiseasethreat,withimportantimpactsonhumanhealth,affectingabout30,000personsannually. The transmission is associated with environmental and climate changes,landscapeecology,andwithsocialfactors(GuterresandLemos,2018).Mostvulnerablepeoplearethosewholiveclosetoforestedareas,forestryworkers,andfarmworkers,aswellasconstructionworkersandsoldiers(Avsic-Zupancetal.,2019).Highprecipitationincreases vegetation growth and rodent densities, which in turn increases proximitybetween rodents and humans (Guterres and Lemos, 2018). Zoonoses are alsotransmittedwhenfoodisstoredduringthedryseasons,attractingrodents,orwiththepracticeofinitiatingfiresforclearingfields(Pintoetal.,2014).Leptospirosis is a zoonotic disease that is transmitted by the bacteria Leptospira.Outbreaks are usually associated with water, soil, mud or food contaminated withinfectedanimals’urine.Thebacteriamayenterthebodythroughcontactwithmucosasurface(eye,mouthornose),skinwounds,andswallowingcontaminatedfoodorwater.After flood events or heavy rains, risk of infection can increase due to contact withfloodwater,andcontaminatedsoilandfreshwater(e.g.rivers,streams)(CDC,2018a).Leishmaniasis is an infectiousparasitic disease. It is transmittedbyprotozoansof thegenusLeishmaniabythebiteofinfectedfemalephlebotominesandflies.Therearethreeformsofthedisease–visceral(alsoknownaskala-zar;this isthefatal formwhennottreated), cutaneous (the most common) and mucocutaneous. All are classified aszoonoticoranthroponotic,whichdependsuponthemainreservoirhost(WHO,2019c).Thevectorspeciesfordiseasetransmissionvariesdependingontheregion.Forvisceralleishmaniasisdisease,dogsarethemainreservoir,andwildanimals(opossums,sloths)for cutaneous leishmaniasisdisease. InAfrica andAsia,migrant agricultural labourerslivingininappropriatehousing,areathigherrisk(Argawetal.,2013;Prüss-Üstünetal.,2016). Deforestation, irrigation schemes, migration and urbanisation in Central andSouth America have contributed to leishmaniasis vectors spreading to otherenvironments(e.g. fromforests tocities),which inturn, increasehumantransmission.Annually, thediseasesareresponsible foraround700,000to1millionnewcases,and26,000 to 65,000 deaths. The poorest people are the most vulnerable, with othersocioeconomic factors linked to malnutrition, poor housing, domestic sanitaryconditions, migration (movement of non-immune people into areas with existingtransmissioncycles)andweakimmunesystems(WHO,2019c).Thefractionofburden

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of disease attributable to the environment is around 27 per cent (Prüss-Üstün et al.,2016).DiarrhoealdiseasesDiarrhoea isusuallyasymptomofan infection in the intestinal tract.Bacteria,vibrios,parasites and viruses can cause diarrhoeal diseases (WHO, 2017b). A predominantproportionofdiarrhoealdiseasesiscausedbyfaecal-oralpathogens,wheretherouteoftransmissiondependson the typeofpathogen, local infrastructure (e.g.easyaccess toadequatesanitationandsafewater)andpersonalbehaviour.Thetransmissioncanoccurperson-to-person via contaminated food, or via other humans through contaminatedhands by faeces (e.g. lack of hand-washing, faeces disposed improperly). In addition,faecal pathogens can contaminate surface and ground water (when there are notreatment or sewage systems) and soil (through open defecation and flies carryingpathogens to food) (Prüss-Üstün et al., 2016). Human exposure to these pathogensoccurs indifferentways, suchas ingestionofcontaminatedwaterand food; incidentalingestionduringswimming;ordirectcontactwitheyes,earsoropenwounds.Climatemayinfluencedirectlyinthegrowth,survival,persistence,transmissionorvirulenceofpathogens,and indirectlyonchanges in localecosystemsorthehabitatofspeciesthatworkaszoonoticreservoirs(Smithetal.,2014a;WHO,2017b).Climatechangeimpactsondiarrhoealdiseasemaybehigheramongpeople living inwater-limitedplaces, andwherehygieneandsanitationpracticesarelessdeveloped(Verner,2010;BartramandCairncross,2010).Themostcommonfood-andwater-bornebacterialpathogensworldwideareSalmonellaandCampylobacter,whichareresponsiblebothformanyisolatedcasesofdiarrhoea,orgeneralised outbreaks of the disease (Kolstad and Johansson, 2010). Rotavirus is animportant cause of childhood diarrhoea (Kotloff et al., 2013). Outbreaks of diarrhoeahavebeenassociatedwithhightemperatures(KolstadandJohansson,2010;Alexanderetal.,2013;Hornetal.,2018),whicharealsodirectlylinkedwithotherentericdiseases(BartramandCairncross,2010).Forexample,inBotswana,anaridcountryinSouthernAfrica, the peak in a diarrhoeal disease outbreak occurred in a prolonged dry seasonassociatedwithdryconditionscoupledwithhottemperatures(Alexanderetal.,2013).Environmental factors result in nearly 846 thousand diarrhoea deaths, annually. Of atotalof525thousanddiarrhoeadeathsinchildrenunderfiveworldwide,360thousandareenvironment-related.Intermsofburdenofdisease,thisrepresents9.5percentofallenvironment-relatedDALYs(Prüss-Üstünetal.,2016;WHO,2017b).Diarrhoealdiseaseisthesecondleadingcauseofdeathinchildrenunderfiveyearsold(WHO,2017b).SkinandeyeinfectionsSkin(e.g.scabies)andeye(e.g.conjunctivitis,trachoma)infectionsrelatedtoDLDDcanbe caused by poor hand-washing due lack of water supply, which in turn prejudicepersonal hygiene and increases the risks of other infectious diseases (Bartram andCairncross,2010;Stankeetal.,2013). These infectionscanalsobecausedbydustairpollution(UNEP/WMO/UNCCD,2016).

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TrachomaTrachoma is a chronic eye infection caused by the bacteria Chlamydia trachomatis,which is the main responsible for blindness globally (Prüss-Üstün et al., 2016).Worldwide,basedon2010data,around1.9millionpeopleareaffectedby thediseaseand of these, 450 thousand are irreversibly visually impaired by trachoma (WHO,2017c).Thetransmissionoccursduetolackofhygienepractices,especiallyinface-andhand-washing practices, transmitted through eye-seeking flies, or person-to-personcontactandviafomites(inanimateobjectsthatcarryinfectiousagents,suchastowelsorwash-cloths) (Bartram and Cairncross, 2010; Stocks et al., 2014). Poor, rural andmarginalised people living in hot, dusty and dry settings, and with lack of wateravailability,limitedaccesstosafesanitation,andhighnumberofflies,showhigherriskofdisease(Baggaleyetal.,2006;Harding-Eschetal.,2008;Smithetal.,2011).Globally,100percentofthetrachomadiseaseburdenisattributabletotheenvironment(Prüss-Üstünetal.,2016).MeningitisMeningococcal meningitis is an infection transmitted by several microorganisms (e.g.bacteria, virus), with the bacteria Neisseria meningitides as the greatest epidemicpotential. It is a serious infection because it affects the thin lining that surrounds thebrainandspinalcord,andcancauseseverebraindamage.Iftheinfectionisnottreated,the disease shows high fatality (50 per cent) and high frequency of severe sequelae(morethan10percent),forexampleneurologicdamage.Dryseasons,coupledwithlowhumidity and high airborne dust concentrations are risk factors for outbreaks ofmeningococcalmeningitisworldwide.However thehighestburdenof thisdiseaseandthehighestfatalityratesoccurinsub-SaharanAfrica,inasemiaridregionknownas“themeningitisbelt”(WHO&WMO,2012; UNEP/WMO/UNCCD,2016;WHO,2019d).IntestinalnematodeinfectionsIntestinal nematode infections are helminths (worms), such as ascariasis, trichuriasis,ancylostomiasis/necatoriasis. They are transmitted by soil contaminated with humanexcreta containing infectious eggs or larvae (WHO, 2012). The transmission may bethrough the ingestion of eggs and larvae by uncooked, unwashed or unpeeledcontaminated food products or through skin penetration (e.g.ancylostomiasis/necatoriasis diseases) (Stepek et al., 2006). Transmission may occurnear homes in the case of daily practice of open defecation (WHO & UNICEF, 2014,2017), and incommunaldefecation fields,or inpasturesor crops fields (Stepeketal.,2006).Theunsafeuseofwastewaterforagriculturalirrigationcanalsocontributetothetransmission (WHO, 2006). There is a high prevalence of these helminthsworldwide,with approximately two billion people affected,most living in low-income conditions,especially in South Asia and in sub-Saharan Africa (WHO, 2006; WHO, 2012). Opendefecationispracticedby892millionpeoplearoundtheworld(WHO&UNICEF,2017).Furthermore, nematode infections can impact on physical growth, child cognitivedevelopment, andmicronutrient deficiencies (including iron deficiency that can causeanaemia)(Jiaetal.,2012).Accesstosanitationfacilitiescanavoidtherapidtransmissioncycleofre-infectionaftertreatment(Prüss-Üstünetal.,2016).

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Protein-energymalnutritionProtein-energymalnutritionoccurswhenthereisinsufficientnutrientintake(Porteretal.,2014;WHO/UNICEF/USAID,2015),leadingtomalnutrition,whichinturncancreatesusceptibilitytocomorbidity,suchaspneumonia,diarrhoea,bacterialsepsisandotherinfectious diseases. Comorbidity conditions result in increased mortality risk.Malnutritionandinfectiousdiseasesfunctionasaviciouscycle.Malnutritiondecreasesthe functioning of the immunological system, which can increase susceptibility forinfections,andontheotherhand,infectiousdiseasescancauseundernutrition(Jonesetal.,2014).Micronutrientdeficienciescanadditionallyresultinsecondaryhealthoutcomes,suchasanaemia from lackof iron;eyeproblems, inparticularnightblindness fromvitaminAdeficiency, and scurvy from vitamin C deficiency (Stanke et al., 2013). Undernutritioncoupledwithmicronutrientdeficiencies,includingofzinc,iron,andVitaminsAandCareresponsibleforhighmorbidityandmortalityrates(Blacketal.,2013).Theseconditions,coupledwithinfectiousdiseases,canalsocauselostpregnancies,andprematurebirthsorlow-weightbirths(Campbelletal.,2015c;Malleyetal.,2017).Forexample,in2011,anestimated3.1millionchilddeaths(45percentof totalchilddeaths)werefromthetotal undernutritionburden in low- andmiddle-income countries (UNICEF/WHO/WB,2019). In addition, undernutritionduringpregnancy andduring the first twoyears oflifeisoneofthemostimportantcontributorsofwastingandstuntinggrowth,andalsocontributes to inadequate child development (Campbell et al., 2015c;FAO/IFAD/UNICEF/WFP/WHO,2018;UNICEF/WHO/WB,2019)andobesity,aswellasto noncommunicable diseases in adult life (Black et al., 2013; FAO, 2017a;UNICEF/WHO/WBG,2019).

Box7.FoodsecurityandmalnutritionFoodsecurityand foodsafetyare crucial forgoodhealth.However, social anddemographic changes, including population growth and rapid urbanisation, aswellasanincreasingdemandforfood,arethreateningfoodsecurityandsafetyinmanypartsof theworld.DLDDadds furtherpressures,whichmayresult inconflict,forcedmigrationandincreasedpoverty.Foodinsecuritycontributestodifferent forms of malnutrition: undernutrition (stunting and wasting),overweight,andobesity.Deficienciesofmicronutrients (includingreduction inconcentrationsofiron,zinc,vitaminsAandC)insoil,duetosoilerosion,affectcrops quality. Consequently, it affects people’s dietary nutrient consumption,especiallyforthosewholivinginremoteareasorthosewithlowincomesthathave no easy access to diverse food types and nutrients. For example, peoplelivinginlow-incomecountriesinsituationsofprolongedconflictorcrisisshowahigher (2.5 to3 times)proportionofundernourishedpersons thanother low-income countries. Globally, especially among vulnerable populations, foodinsecurity and the triple burden of malnutrition (undernutrition; overweightandobesity;andmicronutrientdeficiencies)areincreasing,posingchallengestoachieveSDG2(zerohunger)and,consequently,SDG1(nopoverty).

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Hunger and malnutrition are significantly worse in countries where people’slivelihoods depend on agriculture and livestock, and where the agriculturalsystems are highly sensitive to rainfall and temperature variability. Theproportionofchildrenunderfivewhoarestuntedisdeclining. Inthefive-yearperiodbetween2012and2017,thenumberofstuntedchildrendecreasedfrom165.2 million to 150.8 million, a 9 per cent decline. In 2017, 7.5 per cent ofchildrenunder five years of age suffered fromwasting (most of theburden isconcentrated in Asia), and 5.6 per centwere overweight. The obesity form ofmalnutritioncontinuestoriseinadultage.Itrosefrom11.7percentin2012to13.2 per cent in 2016 (i.e. 672.3 million people). Regarding anaemia, theprevalenceamongwomenofreproductiveagealsoincreased,from30.3percentin 2012 to 32.8 per cent in 2016. This means that one in three women ofreproductive age are affected by a condition that can cause significant healthanddevelopmentproblemsforbothwomanandchild.Source:Lametal.(2013);FAO(2017a);FAO/IFAD/UNICEF/WFP/WHO(2018).

Globally,2billionpeoplesufferdietarydeficienciesofzincandiron(Myersetal.,2014).According to the WHO’s Global Health Observatory (2019e), in 2018, 149 millionchildren under five years of age were stunted, 49 million wasted and 40 millionoverweight (WHO, 2019e; UNICEF/WHO/WB, 2019). Environmental factors areresponsiblefor27thousanddeathsperyear,alloftheminchildrenunderfive(Prüss-Üstün et al., 2016). Furthermore, impacts from water scarcity, land degradation andpopulation growth raise the risk of food insecurity, and consequently aggravatemalnutrition(Wheeler&vonBraun,2013;FAO,2017a),whichcanalsobeinfluencedbymigrationprocesses.Migrationcanalsoalterfamilydiet,bothonquantityandnutrientcomposition, exposing migrants to malnutrition (Zezza et al., 2011). The number ofundernourishedpeopleis50percenthigherincountrieswithhighexposuretoextremeclimateevents(specificallydrought).In2017,821millionpeoplewereestimatedtobeundernourished(WMO,2019).3.2NoncommunicablediseasesChronicrespiratorydiseasesSomeallergicrespiratorydiseasesareclimatesensitive.Inwarmerconditionsairborneallergens (fungal spores andplant pollen) areproduced and released, causing asthmaandallergicrhinitis(Beggsetal.,2010).Allergenscanalsoproduceeffectsontheskin(dermatitis) and eyes (conjunctivitis) (Goudie, 2014). Asthma is an inflammatoryrespiratory condition causing disability, high demand of healthcare and decreasedqualityoflife.Globally,asthmaisoneoftheworld’sleadingnon-communicablediseases,which affects 334 million people every year (UNEP/WMO/UNCCD, 2016). It isresponsibleforaround0.9percentoftheglobaldiseaseburden,ofwhich,4.3percentrelatestoadultsand14percenttochildren(Prüss-Üstünetal.,2016).Airbornemineraldusts can also cause or exacerbate asthmatic conditions. Atmospheric materials (e.g.pollens and spores) and wind-borne dust can be transported across regions by highwindscoupledwithsituationsofdrought,increasingairborneallergicdiseases(Smithet

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al., 2014b; UNEP/WMO/UNCCD, 2016). Natural allergens are also affected by climatechange. Total pollen counts increase due to the interface between high temperature,land-usechangeand theconcentrationofCO2.The latterhasa strong influence in theproductivity of pollen – e.g. when C02 concentrations double, ragweed pollenproductivityincreasesby60percent(WHO&WMO,2012).ChronicObstructivePulmonaryDisease (COPD) isagradual lossof lung function. It isresponsiblefor3.6percentofDALYsintheoverallglobalburdenofdisease.Mostoftherisk factors (35 per cent) are attributed to environmental and occupational risks,includingdust, chemicalpollutantsandairpollution.Estimatesof theCOPDburden in2012inDALYswas24percentforhouseholdairpollution,9percent,forambientairpollution,12percentforoccupationalrisks,and3percentforozone(Prüss-Üstünetal.,2016). Risk factors for the COPD burden vary between countries and genders. Thefractionsattributabletothepopulationarelargerinlow-andmiddle-incomecountries,especiallyinpoorandruralareas,becauseoftheexposuretosmokefrombiomassfuelsfor cooking and heating (Salvi & Barnes, 2009; Po et al., 2011). Generallywomen aremoreexposedthanmen(Poetal.,2011).Otherriskfactorsareantenatalandchildhoodexposure,whichislikelytoreducelungfunctionandcreateCOPDpredispositioninlaterlife (Narang&Bush, 2012; Stocks& Sonnappa, 2013; Postma et al., 2015). Extractingbiomassforfuelcombustion(wood,strawanddung)mayleadtoecosystemdestruction;andburningsuchfuelsreleasesparticulatematter,whichaffecttherespiratorysystemandcauseCOPD,aswellasthma(Poetal.,2011). CardiovasculardiseasesCardiovasculardiseases(CVDs)isacollectivetermthatreferstodiseasesandconditionsinvolvingtheheartandbloodvessels.Theseincludeadiversegroupofdisorderscausedby many different risk factors. Examples of CVDs are hypertension, coronary arterydisease, heart attack, stroke, cardiac dysrhythmias, thrombosis, and pulmonaryembolism(WHO,2019f).DespitetherebeingmanydirectriskfactorsforCVDsrelatedtohuman-behaviour,includingunhealthydiet,obesityandhighbloodpressure(Limetal.,2012),otherdeterminantsactasdrivingforcesofCVDsandmortality(thecausesofthecauses,ordistalcauses).Thesearerelatedtosocial,economicandculturalchanges(e.g.globalisation,urbanisation,populationageing,poverty,stress),aswellasenvironmentalstresses (e.g. air pollution, unhealthy dietary options), and climate-related exposures,especially by windblown dust from arid lands (Lowe et al., 2013; Goudie, 2014;UNEP/WMO/UNCCD,2016;WHO,2019f).Air pollution from increased PM2.5 can cause ischaemic heart disease, deep venousthromboses, and pulmonary embolism). Extreme weather events, meanwhile, lead tostressduetotheeventitself,andanxietyovereventrecurrence,whichisassociatedwithmyocardial infarction and cardiomyopathy (Portier et al., 2010; Prüss-Üstün et al.,2016).Hightemperaturesmaycausechestpain,acutecoronarysyndrome,stroke,andvariations in cardiac dysrhythmias. Moreover, chemicals (e.g. dioxins, pesticides,phthalates,higharseniclevelandradiationfoundinsoil,airandwater)canincreasetherisk of hypertension, which is a major risk factor for stroke (Moon et al., 2012;Abhyankaretal.,2012).Inaddition,displacementrelatedtodisasterscanincreasetherisksofchroniccardiovasculardiseasesduetointerruptionsofmedicalcare(Portieretal.,2010).

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According to theWHO (2019f), in 2016, noncommunicable diseaseswere responsibleforanestimated40.5milliondeaths,ofwhich,17.9millionwerefromCVDs,mostlyduetoheartattackandstroke(85percent).Mostdeaths(75percent)occurredinlow-andmiddle-income countries (WHO, 2019g). In addition, less access to effective andequitablehealthcareservices(e.g.integratedprimaryhealthcareprogrammesforearlydetection and treatment of people with risk factors) is responsible for a significantfractionofthemortalityrateofCVDsandothernoncommunicablediseases,inlow-andmiddle-incomecountries,especiallyamongpoorpeople(WHO,2019f).CancerAround 19 per cent of all types of cancer are attributable to environmental factors(Prüss-Üstün et al., 2016). Esophageal cancer cases andmortality are suggested to beassociated with high salinity levels of water, notably in regions or communities withwater scarcity. This condition can promote a carcinogen of esophageal cancer(nitrosamine)andalso createa toxin (fumonisinB1) that can contaminate corn crops(Zhangetal.,2010).Lungcancercanbecausedbyseveralfactors.Ambientairpollutionis responsible for 29 per cent of the cases (deaths and diseases) (WHO, 2019h).Lymphoma,multiplemyelomasandleukaemiahaveseveralcausallinks,withpesticidesandherbicidesusedinagriculturalpracticesaccountingforanimportantfraction(IARC,2015;Tóthetal.,2016).Livercancerislinkedwithatoxicchemical(aflatoxin),whichisproduced by the fungi Aspergillus flavus and Aspergillus parasiticus, which cancontaminatefood(AlavanjaandBonner,2013;IARC,2015).Furthermore,manytypesofcancermaybeindirectlyattributabletoclimatechangeimpactsontheenvironment.Forexample,hightemperaturescanmovevolatileandsemi-volatilecompoundsfromwaterand wastewater into the atmosphere, which in turn change the distribution ofcontaminants increasingpeople’s exposure.Moreover, toxicproducts can contaminatewaterfromintenseprecipitationandfloodingevents,throughthedisruptionofstoragefacilities for toxicproducts,or through landcontaminatedbychemicals (Portieret al.,2010;Tóthetal.,2016;PAHO,2017).KidneydiseasesChronickidneydiseaseisdefinedasanexpressionofkidneydamageorreducedkidneyfunction.Severalenvironmentalandoccupationalfactorsarepotentialrisksforchronickidneydiseases(PAHO,2017).Exposurescanoccur through ingestionor inhalationofheavymetals(e.g.cadmium,lead,arsenic,mercury)infoodandwater;throughairandsoil pollution; agricultural chemicals (e.g. exposure to pesticides and otheragrochemicals); salty food and water; occupational exposures to toxic pollutants;dehydration;andbysomepre-existingconditions(hypertension,diabetesandinfectiousdiseases)(PAHO,2017;Obradoretal.,2017;Herathetal.,2018).Poorpeople,especiallyin low- and middle-income countries are more vulnerable, because they experiencemultipleriskfactors,aswellaspublichealthchallenges,suchaslackorlimitedaccesstohealthcare,medicationandrenaltherapy(Obradoretal.,2017).Studieshaveconfirmedan increasing number of patients with chronic kidney diseases in rural agriculturalcommunities (PAHO, 2017). Agricultural workers are in particular at risk to developchronic kidney disease due to their large and frequent exposure to severalagrochemicals, heavy metals, heat stress and dehydration; even those who are not

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agricultural workers, but live in communities with high agricultural activity areadverselyaffected(PAHO,2017;Chapmanetal.,2019).Forexample,in2002,sugarcaneworkers in El Salvador experienced repeated episodes of acute kidney injury due tocombined factors, such as low fluid intake and dehydration, heat stress, and extremelabour (García-Trabanino et al., 2015). Another study, known as the U.S. AgriculturalHealth Study, found an association between pesticide exposure and end-stage renaldiseaseinNorthCarolina,andpesticidepoisoningleadingtoacutekidneyinjuryandtochronickidneydiseaselaterinlife(Lebovetal.,2016).Musculoskeletaldiseases(backpain)Lowbackpainandarmpainisoftenexperiencedinpersonswhoneedtocarrywaterforlongdistances,especiallyduringsevereandprolongeddroughtseasons.Forexample,inAfricathisconditioniscommonforwomenandchildrenwhoperformthistask(Geereetal.,2010),andalsoinsomemunicipalitiesoftheBrazilianSemiaridregion(Senaetal.,2018).Otheratriskgroupsareoccupational(land-related), includingfarmers,forestryworkersandfishers(Driscolletal.,2014).Mental,behaviouralandneurologicaldiseasesMental health has been associated with disaster (e.g droughts, floods) impacts onagriculturalproductivity, fishery, forestryand livestock losses (AlstonandKent,2008;Obrien et al., 2014). Extreme climatic events have been associated to post-traumaticdisorders (Berry et al., 2010; Hanigan et al., 2012). Climate changemay also have animportantimpactonsuicideriskduetothealteringfrequencyandintensityofadverseweather events,which in turn causes disasters,worseningdrought and floods events.Thesemechanismsarecomplex,andarealsointerrelatedwithnegativesocioeconomicdimensions,suchaslackof,orinsufficient,income,unemployment,orproductivityloss(Berryetal.,2010;Haniganetal.,2012;Vinsetal.,2015;Austinetal.,2018).The occurrence of climate-related disasters, such as droughts and floods, tends toincreaseanxietyreactionsintheshortterm(suchaspost-traumaticstress),andchronicanxiety, depression, aggression, and complex psychopathology (long-term impacts)(AlstonandKent,2008;Sartoreetal.,2008).Physicalsymptomsassociatedwithstressincludecrying, sleepdisturbance, and tiredness (Sartoreet al., 2008;AlstonandKent,2008).Forexample,farmersmayfacefinancialimpactsduetoproductivitylosscausedbydroughtevents,whichinturncancauseemotionalstress(Obrienetal.,2014;Austinetal.,2018).Somestudiesfoundthattheremaybeadistressingsenseofloss,knownas“solastalgia”,whichoccurswhenpeopleexperiencelossofamenityandopportunitywhentheirlandand subsistence is damaged (Albrecht et al., 2007; Sartore et al., 2008). However, forexample, in drought-prone areas in Australia, most mental stress occurs in elderlypeople because of their age constraints,which do not allow them to cope or respondrapidly tosocialandenvironmentalchanges,suchasagricultureand/or livestock loss.Moreover,olderageisalsoafactorthatinfluencestrustinusingmentalhealthservices(McMichael,2011).

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Inaddition,somestudieshaveidentifiedalcoholconsumptionandsuicidalthoughts inrural communitieswhere people suffermultiple impacts to their livelihood related todrought(AlstonandKent,2008;Alston,2012a;Vinsetal.,2015).Migrationisalsoariskfactor of some mental disturbances, such as stress (Stanke et al., 2013) and mayinfluence schizophrenia risk (Torrey and Yolken, 2014). Other reasons for mentaldisordersincludefamilyseparation,worriesregardingfamilysubsistence,identityloss,uncertainty,andsocialexclusion(Stainetal.,2011;Austinetal.,2018).Green spaces, particularly in cities are known to help reduce air pollution, regulatetemperatureandprovide cultural services and recreation. Importantly, this isnot justgood for the environment and for physical health, but also contribute to the mentalhealthofurbanpopulations(Whitmeeetal.,2015).3.3InjuriesUnintentionalinjuriesPoisoningUnintentional poisoning related to DLDD can be associated with environmentalcontaminationfromclimate,behavioural,agriculturalanddevelopmentalpathways.Soilcontaminated by constant use of pesticides, airborne toxins from contaminated dust,water and soil (e.g. algal bloom cyanobacteria), use of chemical products, and airpollutionbychemicalsfromindustriesorsomeoccupationalactivitiesareallriskfactorsfor thepoisoningof ecosystemsandpeople (Zhanget al., 2010;Dooyemaetal., 2012;Zhang et al., 2010). UNEP estimates that every year 25 million agricultural workersworldwideexperienceunintentionalpesticidepoisoning(UNEP,2017,2019).Water and soil contamination can cause food-related exposures. Chemicals, such ascadmium,lead,arsenic,nickel,whenconsumed,cancausearangeofhealthrisks(UNEP,2017;Obrador et al., 2017). Cadmium can cause renal failure, osteoporosis and sometypesofcancers(Bernard,2008;Lametal.,2013);leadcancauseincreasedhighbloodpressure and kidney damage, miscarriage, stillbirth, premature birth and low birthweight (in exposed pregnant women), and affect the development of the brain andnervoussysteminchildren(WHO,2019i);arsenic(withpotentialsourcesincludingfoodcontaminated by pesticides, seafood, and groundwater) can also cause renal failureleading to chronic kidney disease (Obrador et al., 2017). Fertiliser overuse can causealgal blooms that contaminate water and cause intoxication by toxic microcystins,causingdiarrhoea,livercancerandothereffects.Moreover, food poisoning can increase health care costs, and can affect economicgrowth.For instance, inChina, around20 thousands incidentsof foodpoisoningwerereportedfrom2002to2012.Thoseincidentswerecausedbytoxicanimalsandplants,aswell as from illegal additives and chemical contamination by industrialwaste (e.g.cadmium) (Lam et al., 2013). In 2007, in China, there were fatal cases related tocadmiumexposure, fromcontaminatedriceandotherenvironmentalroutes(Changetal.,2012).Thereisconcernaboutthepublichealtheffectstolargepopulations,asisthecaseofChina,butalsoglobally, sinceexposurecanalsoaffectmajor foodexporters to

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global foodmarkets (Lametal.,2013). InBrazil,astudyhasshownthat foreachUSDdollarspentonpesticides,nearlyUSD1.28maybespentonhealthcareandsickleave(Soares & Porto, 2012). Children are likely more vulnerable from behavioural andenvironmental factors that contribute to their exposure to soil, air, recreationalwaterandfood(Prüss-Üstünetal.,2016).InjuriesrelatedtonaturaldisastersExtremeevents suchasdroughts, floods andheatwaves can causediverse impactsonhumanhealth,includinginjuries,diseasesanddeaths.Thiscanmanifestinanumberofways, such as traffic accidents, wildfires, drowning, physical traumas and venomousanimalbites(WHO&WMO,2012;Yusaetal.,2015).Duststormscanalsocausetrafficaccidents and other injuries due to reduced visibility (UNEP/WMO/UNCCD, 2016).Climatechangeisexpectedtointensifysuchextremeevents.Trafficaccidentsareassociatedwithwildfiresandduststormsduetolowvisibilityfordrivers and pedestrians; they are also associated with intense flooding and tropicalstorms(Loweetal.,2013;Yusaetal.,2015).Wildfiresincreasetheriskofunintentionalinjuriesanddeathsfromextremeheatandsmokeinhalation(WHO&WMO,2012;IPCC,2013; Smith et al., 2014b). Animal bites may occur in cases of deforestation, floods,storms, drought events, water and food shortage, and excessively hot weather, whenanimalsmovetheirhabitat toareaswherehumans live(Prüss-Üstünetal.,2016).Themagnitudeof the impactsdependsonpolitical, socialandcultural factors (Loweetal.,2013). Intentionalinjuries(selfharm)SuicideProlongeddroughtasaslow-developingeventcancausechronicpsychologicaldistressandcanincreasetheincidenceofsuicide(AlstonandKent,2008;Haniganetal.,2012;Vinsetal.,2015).Ruralcommunitieshaveacloseandstrongconnectiontotheland,andfarmers often use their natural resources for their own subsistence (Alston, 2012a;UNCCD, 2017b). Rural farmers have different demand forwater for their agriculturalpractices,forthisreason,timeofrainfallisequallyimportantasquantity.Forinstance,in rural communities in Australia, higher rates of suicide were observed in farmersduring a prolonged drought period (between 2001 to 2008) (Hanigan et al., 2012;Obrienetal.,2014).ViolenceSome environmental pressures are potential causes of conflict and violence. Soildegradation, freshwater scarcity, food shortage, coupledwith social pressures such aspoverty,socioeconomicfactors,andotherscontributetotheserisks.Impactsonhealthand social well-being are increased through their incidence (Smith et al., 2014a). Incommunities that are agriculture-dependent, especially in a low-income context,droughtcanexacerbateviolenceandconflictduetofoodinsecurity,andcanthuscause

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social instability (FAO/IFAD/UNICEF/WFP/WHO, 2018). Forced migration may alsoresultinconflictandviolencewhenmigrantsareseenasathreat.3.4ThemagnitudeofDLDDimpactsonhealthTheInternationalDisasterDatabaseoftheUniversitéCatholiquedeLouvainmaintainsdataondroughteventsandimpacts.Inthedecade2006to2015therewere164droughtevents globally, which resulted in over 20 thousand deaths (an average of 2000 peryear),and726millionaffectedpersons.ThelargemajorityofdeathsoccurredinAfrica(EMDAT, 2019). Figure 1 shows the number of events, deaths and total number ofaffectedpersonsinthe50yearsfrom1966-2015.AfricaandAsiaaretheworstaffectedcontinents in number of deaths from droughts, with Africa being significantly larger.Asiasuffersmoredeathsfromfloods,followedbybothAfricaandtheAmericas(Figure5).Figure5 Number of events, deaths and total number of affected persons for

droughtsandfloodsfrom1966-2015.

Source:AuthorbasedonEMDATdata(2019)A WHO report on the burden of disease from environmental risks analysed the 133diseases listed in theWHO’s Global Health Observatory and found 101 linked to theenvironment (Prüss-Üstün et al., 2016). The report found that environmentaldeterminants of health are responsible for more than 23 per cent of the burden ofdiseases,globally.Environmentalriskfactors,suchaslackoffoodandwatersecurity,airand soil pollution, lack of sanitation and hygiene, exposure to hazardous chemicals,changeinvectordistribution,andclimate-relateddisastersresultincommunicableandnoncommunicablediseases,malnutrition,disability,andmortality.Thestudyquantifies61maindiseasesandinjuries(bothdeathsanddisabilityadjustedlifeyears,DALYs).Atleast29ofthesecanbeassociatedwithDLDD.

AfricaAmericasAsiaEuropeOceania

Drought

Floo

d

Ocurrence Deaths Totalaffected

Ocurrence Deaths Totalaffected

1000000000100000000100000001000000100000100001000100101

1000000000100000000100000001000000100000100001000100101

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TherearenostudiesthathavedeterminedwhatfractionoftheburdenofdiseasecanbeattributedtoDLDD,howeverthese29healthoutcomesareresponsiblefor10.3milliondeathsperyear(basedon2012data).Wecouldapproximatefurtherbytakingtheruralpopulation of each region used in the WHO study (ranging from 18.5 per cent indevelopedregions,upto59.6intheAfricanregion),andthiswouldreducethefigureto5.2 million deaths. There are no separate estimates for urban and rural areas in theWHO study, so taking the rural fractionwould bias the numbers because of the largeimpactsofairpollutionincitiesaswellasoccupationalfactors.Ifwe,therefore,furtherreducebyassumingthatonly10percentoftheburdenofdiseaseinruralareasofmoredeveloped (OECD) countries are DLDD linked, and we consider 25 per cent in lessdeveloped regions, thiswouldgiveusa crudeestimateof close to1.28milliondeathsperyear.Anin-depthstudyoftheburdenofdiseaseisrequiredtoaccuratelydeterminetherealimpactofDLDDonhumanhealth.

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4. ChallengesanddirectionstoimprovehumanlivelihoodsEnvironmentalandsocialchallengesforDLDDaffectedcommunitiesandtheirhealthiscomplexandintermingled.Farfrombeingtheonlychallenges,fourarehighlightedherebasedontheUNCCDStrategicFramework2018-2030(Figure6).Theseare:povertyandforcedmigration(twokeysocialchallenges);andlackofwatersecurityandlackoffoodsecurity(twokeyenvironmentalchallenges).Figure6.DLDDchallengesfromahealthperspective

4.1PovertyBy 2050, four billion people are projected to live in drylands areas, in which landproductivityisdecreased.Thisfactorcoupledwithothersocialstressescanmakepeoplemore vulnerable to socioeconomic instability and violent conflict (Neumann et al.,2015). Lower-income groups are more dependent on the agricultural sector, ascompared to the general population, and have access to lower productivity land,exacerbatingpovertyandincomeinequality(Smithetal.,2014a;Neumannetal.,2015).The outcome of an analysis done in some developing countries showed that peoplelivingonfragilelandspresentedahigheroverallproportionofruralpoverty(Barbier&Hochard,2016).Forinstance,50percentofthetotalpopulationofsub-SaharanAfricalivesindrylands,andthepercentageofpovertyinthoseareasisof75percent(IPBES2018). Timely and appropriate actions in avoiding, reducing and reversing landdegradationarenecessarytoobtainmultiplebenefits,whichinclude:providingfoodandwatersecurity;contributingtoadaptationandmitigationmeasuresforclimatechange;decreasingdisasterrisks;protectinghumanhealth; increasingsocioeconomicstability;andavoidingorreducingconflictandmigration(IPBES,2018).Poverty and access to health care forms a complex vicious cycle. Poverty leads to illhealth and this conditionmaintains poverty (Peters et al., 2008; Freitas et al., 2012).

DLDDDesertification/landdegradationanddrought

DLDDcontributestoandaggravateseconomic,socialandenvironmentalproblems

Reducedresiliencetoclimatechange

Biodiversityloss

PovertyForced

migration

Lackofwatersecurity

Lackoffoodsecurity

Poorhealth

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Although access to health care services is improving in low- and middle-incomecountries, thereare largedifferences in theequityofaccess to theseamongcountries.Forexample,poorpeoplehavelessorlimitedaccesstoservicesinsomesettings,whichin turnmayresult in increasedburdenofdisease (Petersetal.,2008).There isalsoalinkbetweenpovertyandgenderinequality.Theyareassociatedwithpowerandaccesstochoicesandresources.Inmanycountries,worktocollectdrinkingwaterisdonebywomen, creating other risks, such musculoskeletal diseases, and risks of sexualharassment.Forinstance,datafrom2005to2013showsthatthelargestproportionofpersonscollectingwateraroundtheworldaregirlsandwomen,bothinruralandurbanareas. Sub-Saharan Africa and Asian regions showed even higher percentages, with ahightimeburdenforwatercollecting.Forexample,inruralareasofMauritania,Somalia,TunisiaandYemen,asingletriptakesonaverageoveronehour(UN,2015).Poverty reduction goes hand in hand with declining vulnerability. In health terms,vulnerabilityisdeterminedbythesusceptibilityofpopulations,systemsorplacestobeadversely affected by a given hazard (e.g. a particular environmental risk) or to beincapabletocopewiththeadverseimpactsofsaidhazard(IPCC,2012;UNISDR,2015;WHO,2015).Table7showsexamplesofvulnerablepopulationgroupstotheimpactsofDLDDonhumanhealthandwell-being.Table7.Examplesofvulnerabilitiesrelatedtopoverty,DLDDandhealth.Vulnerablepopulations

DLDD-relatedhealthimpacts

Children • Highexposuretosoil,dust,andairpollutantsfromplayingwithsoil(SCU,2013;Grineskietal.,2011;UNEPWMOUNCCD,2016).

• Increased vulnerability to water contamination due to recreational wateractivities(SCU,2013).

• Increasingriskstonutritionaldeficiencies(FAO,2018),growthanddevelopment(CookandFrank,2008).

• Childrenunderfiveyearsofagehaveincreasedriskformajorimpactsrelatedtorespiratoryinfections(e.g.bronchiolitis,pneumonia)(WHO&WMO,2012).

Women(includingpregnant,andwithlactatinginfants)

• Increasedvulnerability to sexual harassment,when collectingwater, especiallywhenlongdistanceorinremoteareas(UN,2015).

• Morevulnerable tohouseholdairpollutionduetheuseofbiomass forcooking.Increased vulnerability to vector-borne diseases or infectious diseases fromhomewater-storage.

• Insomecultures,womenarenotallowedtoleavehomealone,increasingtheriskofinjuriesinthefaceofdisaster(e.g.flood,wildfire,hightemperature)(Ionescoetal.,2017).

• Pregnantwomenshowgreatvulnerabilitytoairandsoilpollutants,andtofoodshortages, which increase risks of premature birth and/or low birth weight(FAO,2018).

Men • Highexposure toairandsoilpollutiondue tooutdoorandchemical,orminingindustrywork(Berryetal.,2014;UNCCD,2017b;Landriganetal.,2018).

• Morevulnerabilitytomentalillness(includingsuicide)duetoworriesabouthowtosustaintheirfamily(Alston,2012a;Haniganetal.,2012;Vinsetal.,2015).

• Vulnerabilityrelatedtomigrationtofindemploymentandtoprovideforfamilyneeds(UNCCD,2017b).

Elderlypeople • Highvulnerabilitytoimpactsofcontaminatedair,food,soilandwateranddustpollutantsdue to fragile immunesystemandpresenceofhealthpre-conditions(Sajanietal.,2011;Jiménezetal.,2010;UNEP/WMO/UNCCD,2016).

• Difficultytogetsafetyresourcesandtorapidlyrespondwhenrequired(e.g.dust

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storm,flood,severedrought)(McMichael,2011).• Morevulnerabletomentalhealthduetodifficultiestocopewithsevereimpacts

from drought (especially in subsistence agriculture and livestock loss) byconstraintofage(McMichael,2011).

Peoplewithchronicconditions(respiratory,cardiovascularandcardiopulmonary)

• Increasedriskofmajor impacts fromairanddustpollution(Berryetal.,2014;UNEP/WMO/UNCCD,2016)

• Increased vulnerability for impacts of airborne diseases from soil and waterpollutants(UNEP/WMO/UNCCD,2016).

Peoplewithlowsocioeconomicstatus

• Higher vulnerability from lack of access to basic resources for improvedlivelihood (e.g. water and food security, health services, adequate housing,hygiene practices and sanitation services, employment or incomeopportunity)(Corvalanetal.,2005;WHO,2013;Senaetal.,2018).

• Increased impacts (e.g. undernutrition, mental illness) due to lower ability tocope(e.g.tobuyfoodandwater)orrespondtohazards(Berryetal.,2014;FAO2018).

Rural/agriculturalpopulations

• Highexposuretotoxinsfromair,waterandsoilpollution(PAHO,2017;Obradoretal.,2017)

• High vulnerability to loss of production crop and livestock, increasingpoverty,mental illness, and migration (Alston and Kent, 2008; Berry et al., 2014;Landriganetal.,2018).

• High exposure to ultraviolet radiation and risk of dehydration (WHO&WMO,2012).

• Morevulnerabletoviolentconflictwhenlandproductivity isdecreased(IPBES,2018).

Indigenouspeople

• High vulnerability from living in remote areas and depending on natureresources(UNCCD,2017b).

Outdoorsworkers • High vulnerability to air, soil and dust pollutants (Barry et al., 2014;UNEP/WMO/UNCCD,2016;Landriganetal.,2018).

• Highexposuretoultravioletradiationandriskofdehydration(Patzetal.,2012).Peoplelivingclosetoindustriesorworkingwithchemicalproducts

• High exposure to airborne diseases and poisonings (SCU, 2013; Berry et al.,2014;Landriganetal.,2018).

Displacedpersons • Increased lack of access to basic resources for improved livelihood (e.g.waterand food security, health services, adequate housing, hygiene practices andsanitation services, employment or income opportunities) (UNCCD, 2014a;McLeman,2017).

• Increased risk of mental illness, worsening disease pre-conditions, increasinginfectiousandchronicdiseases,diminishingaccess tohealth care services, andcreating other social vulnerabilities (conflict, violence, alcohol consumption)(Warneretal.,2009;Stankeetal.,2013;Senaetal.,2018).

4.2ForcedmigrationDLDDhasacomplexandfrequentconnectionwithpopulationmigration.Annually,tensof millions of people, many living in rural areas of developing and middle-incomecountries, migrate for reasons related to land degradation (e.g. food scarcity) andnaturaldisasters(e.g.drought,floods)(FAO,2018).ButDLDDisnottheonlytherootofthemigrationprocess.Depletionofnaturalresourcesduetoenvironmentaldegradationalso poses risks for rural people’s subsistence, especially those depending onagriculturalproduction,livestock,fisheriesandforest-basedlivelihoods.Otherdriversofmigrationarerelatedtotheeffectsofclimatechangeonagriculture(FAO,2018).Several

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mediatorfactorscanalsointerveneinthisinteraction,suchassocial,economic,politicalinfrastructure, and demographic factors (Neumann et al., 2015;McLeman, 2017). Forexample,mostmigrationfromruralareasisassociatedtopoverty,foodinsecurity,socialvulnerability,unemploymentandlackofwork,orlowincome(FAO,2018). The international migration process occurs mainly from low- and middle-income tohigh-income countries. However, most migration takes place within nationalboundaries, or between contiguous countries. The most common internal migrationpatternoccursfromruraltourbanareas,andalsowithinruralareasandbetweencities(inter-urban migration). The temporal dimensions for both vary, which can betemporarilyorpermanent(McLeman,2017).At present there are around 200 million international migrants worldwide (UNCCD,2017b). It is estimated that by 2050, between 150 and 200 million people could bedisplaced for environmental reasons including desertification, land degradation, sealevel riseand increasedextremeweatherevents (WWAP,2016; IOM).Someestimatesare as high as 700million (UNCCD, 2014a; IPBES, 2018). An average of 26.4millionpeopleworldwidearedisplacedeveryyearduetonaturalhazards(IDMC,2015).Peoplewhomigratecanfacemanychallengesatthedifferentstagesoftheprocess.Buttherearealsochallengesfacedbyfamiliesleftbehind,especiallyiftheydonothavetheability to copewith the vulnerabilities,which can be economic, social, environmental,political and security related (FAO, 2018). Socioeconomic inequality is a key factor indriving the migration process in areas where land degradation is occurring (UNCCD,2017b; FAO, 2018). In drylands,where land degradation, variability of rainfall, waterscarcity,andincreasingfrequencyofdroughtsoccurs,itislikelythathungerandpovertyrelated vulnerabilities shall increase (Neumann et al., 2015). Governments andcommercial interestsplay important roles in thenatureand scaleof landdegradationandotherenvironmentalchanges(UNCCD,2017b).

Box8.MigrationdecisionprocessPeoplemigrateforseveralreasons,andonestrongfactoriseconomic,i.e.havingenough to support their family. In dryland areas the migration process has astrongconnectionwithlanddegradationandlowprecipitation,drought,whichattimes,occurswithinawidercomplexbackdropofviolentconflict. InWest Africa, semi-nomadic pastoralism is in transition to an urban-orientedproduction.Thechangefromasemi-nomadiclifestyle,tooneofraisinglivestockand/orgrowingcropsontheedgeofcitiesandtowns(tosupplyurbanmarkets)ismotivatedbyseveredroughtsintheregion.Also,switchingfromdairycattletobeef cattle andgoats is anadaptationmeasure that improvesbetter income forpastoralistsandfurthersupportshouseholdstocopewithdroughtperiods.In another example from West Africa, among small-scale dryland farmers,seasonal labourmigrationhasbeenused to copewith thegeneralprecipitationvariability.Farmersmigratetonearbycitiesortoagriculturalregionswithyear-roundproduction,andthenreturntotheirlandswhentherainsreturn.Iffarmershaveaproductiveyear(becauseofhighprecipitationresultinginhighcropyields

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intheir farmland), theymaydecideif it isnecessaryandviabletosendafamilymember to a long-distance, sometimes international, migration destination.However, for poorer households only short distancemigration destinations arepossible.Inthe1970sand1980sthereweremassivemigrationsandfaminesthataffectedsomeregionsinEastAfrica,particularlytheSahelianregions,theCentralAfricanRift, Somalia, and theEthiopianhighlands. The reasonsweremultiple, not onlyattributed todrought, but also topolitical factors.Althoughdroughtsmayhavetriggeredthelarge-scalepopulationmovements,thefamineswerecausedbycivilconflicts, oppressive government regimes, and indifference on the part of theinternational community. In the case of Ethiopia, a government strategy toforciblyrelocatepeoplefromnortherntowesternpartsofthecountrywasalsoacausalfactor.Afteryearsofstruggle,largegroupsmigratedtoanareawithbetterrainfallwithpossiblecropfarming.Migrationflowstointernationaldestinationswerealsoevidentduringthisperiod.Nowadays,inmanypartsofEthiopiatherearestillchallenges,whichtriggerconflictsduetoafoodsecuritycrisiscausedbyacombination of factors such as drought events, soil erosion, high food prices,forest loss and a fragile governance structure. To cope with these challenges,migration in Ethiopia continues to be an important adaptation strategy. OthercasestudiesofAfricanconflictsinthe1990sandearly2000ssuggestedthatlanddegradation,resourcescarcity,andperiodiceventslikedroughtswerekeycausesof conflict.However,notall casesescalate intoviolentconflict; instead, insomeinstances, land degradation, drought and migration can lead to greatercooperationandresourcesharing.Source:McLeman(2017);Neumannetal.(2015).

The pressures of unsustainable development on the livelihood of vulnerablecommunities coupled with inequalities and social injustice amplify the degree ofvulnerability(UNCCD,2017b).Thissituationcanalsoproduceacycleofperpetuationofpoverty(Scandlynetal.,2010;IPCC,2012;Freitasetal.,2012;Senaetal.,2014).Theseconditions can cause a temporary or permanentmigrationprocess,which in turn canaffectboththosewhoaremigratingandthosewhoare leftbehind(Lavelletal.,2012;Kjellstrom&McMichael,2013;Yusaetal.,2015;Ebi&Bowen,2016;Alpinoetal.,2016).Alltypesofmigrationcanaffectfamilystructuresanddynamics.Changesinhouseholddynamicscanhavenegativeeffectsonfamilyhealthandwell-being(Zezzaetal.,2011).Family separation can cause negative effects on mental health and behaviouraldisorders, can heighten the risk of infectious diseases, and can worsen pre-existinghealthconditions(e.g.cardiovasculardiseases)(Warneretal.,2009;Stankeetal.,2013;Sena et al., 2018). Displaced people can experience changes to their routine hygienebehaviour, leading to a relaxing of practices that avoid infectious diseases and/orpromotehealth(Yusaetal.,2015).Ontheotherhand,migration(seasonalorlong-term)canprovidebasicsubsistenceconsumptionforfamilymembers,suchasfoodandwatersecurityandnutrition(Zezzaetal.,2011).

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4.3WatersecurityCurrent levelsofwaterwithdrawalsarenotsustainable.Waterdemandbetween2015and2030wasexpectedtoincreaseby30percent,asituationthatisalreadyleadingtoconflictsinsomepartsoftheworld(UNCCD,2014c;Kravitz,2017).Climatechangeisanimportant,additionaldriver,inwaterscarcity.Thereisrobustevidenceastoitsroleinthe reduction of renewable surface water and groundwater resources in most drysubtropicalregionsinthenearfuture(JiménezCisnerosetal.,2014).Thiswillhaveclearimplications for agriculture and livestock, and therefore also for food security, asmultiplesectorscompeteforwaterresources.DroughtsarelikelytointensifyinalreadyaffectedareasinsouthernEuropeandtheMediterraneanregion,centralEurope,centraland southern North America, Central America, northeast Brazil, and southern Africa(JiménezCisnerosetal.,2014).The IPCC identifies amedium- tonear-term (2030-2040) risk of significantly reducedrenewablewaterresourcesinmostdrysubtropicalregions,butadaptationmechanismscanreducetherisktothecategoryoflowrisk.Anincreaseof2oCinthelongterm(2080-2100)wouldresultinhighrisk,withadaptationmeasuresreducingtheriskcategorytomedium(JiménezCisnerosetal.,2014).

Box9.OvercomingwaterscarcityinBrazil’ssemiaridregion:Theonemillioncisternsproject

Brazilhasalargesemiaridarea,mostlyoccupyingtheNortheastregion,consistingofaround12percent of the national territory, covering 10 States and 1262 municipalities. The area has a totalpopulation of 26.5million people (12 per cent of the country), ofwhich almost 12millionwerereportedlivinginruralareas,affectedbyprolongedandfrequentdroughtevents,evenintherainyseasons. Several factors contribute to the region’s water deficit leading to extreme droughts.Rainfallisconcentratedinafewmonthsoftheyearanditsdistributionisveryirregular.Therearehightemperatureswithahighevaporationindex.Thetypeofcrystallinesoillimitstheabsorptionofrainfallandconsequentlythesupplyofundergroundaquifers(itisestimatedthat90percentoftherainfallisnotabsorbed).Inadditiontotheenvironmentalthreats,thisregionpresentsseveralsocialproblems.Nearly60percentofpeoplelivinginextremepovertyinBrazilliveintheNortheast,andmorethanhalfofthemliveintheruralareas.Tomaintainaccesstowaterhasbecomeahugechallenge.Duetorecurrentdroughts, hundreds of thousands of families depend on water supply provided by governmentagencies, or privately supplied; and such water supplies are neither always safe nor sufficient.People,mainlywomenandchildren,areforcedtolookforadditionalwatersourcesbywalkinglongdistances.A civil society organisation, called Articulação do Semiárido Brasileiro (Brazilian semiaridarticulation, or ASA)was created in 1999 during a parallelmeeting in the 3rd Conference of theParties of the Convention UNCCD, in Recife, Brazil. ASA implemented a rainwater collectioninitiative, based on an old regional practice. This group works in partnership with the federalgovernmentandtheprivatesectortoimprovebenefitsforthesemiaridpopulation.Theylaunchedaproject called “one million cisterns” putting together 800 civil society organisations (labourcooperatives,churches,NGOs, tradeunions,associationsofruralandagriculturalworkers,amongothers)andencouragedcommunityparticipationintheproject’simplementation.Themainaimofthe project is to provide access to water for human consumption in rural households, byaccumulatingrainwaterfromrooftopsandstoringitinthecisternsforuseduringdroughtperiods.Theaveragecisterncapacityisabout16thousandlitres,butitcanvarydependingonthenumberofpeopleineachhomeandthesizeoftheirroof.Thisquantitycanguaranteewaterforfivepeopleforup to eightmonths, for drinking and cooking.Theproject alsobuilds cisterns to supplywater toschools,forcommunityfoodproductionandforanimals.

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Somefamiliesaregivenpriority,suchashouseholdsheadedbywomen,orwiththehighestnumberof childrenunder sixyearsofage, school-agechildren, individualswith specialneeds, andhighernumbersofelderlyinthehousehold.Familiesaretrainedonawarenessoftheconditionswithinthesemi-aridclimateandtheirconsequences;onhowtousethecistern(careandtreatmentofwaterstorage,maintenanceofthecistern);andonhowtoensurethesafetyofwatertopromotehealth.Sometimes,whendrought is severeandprolonged thegovernment can fill the cisterns.After theinstallation of the cisterns, research on 21 affected municipalities showed that the incidence ofdiarrhoeal diseases had reduced significantly, and the health conditions were improved in thehouseholds with cisterns. For example, in houses without a cistern, the diarrhoeal incidencereached24.4percentincomparisonwiththehouseholdswithcisterns,whichshowedanincidenceof7.3percent.Anotherstudyshowedthattherewasareductionininfantmortalityrates(childrenunderfive)fromdiarrhoealdiseases.Source:ASA(2019);DSSBrasil(2019);Drynet(2015);Lunaetal.(2011);Silva(2015)

4.4FoodsecurityOne of humanity’s greatest challenges is to ensurewewill be able to provide healthydiets to a growing world population, while ensuring healthy and sustainable foodsystems. Globally, more than 820 million people have insufficient food, leading tomalnutrition and the risk of infectious diseases. An even larger number of peopleconsume an unhealthy diet that contributes to premature death and morbidity fromnoncommunicablediseases.Boththeseextremesoccurwhilepressuresonfoodsystemsincrease (Willett et al., 2019). As populations increase and standards of living andnutritionimprove,thedemandforfoodwillcontinuetorise.Thecurrentworldpopulationis7.6millionandisprojectedtoincreaseto8.6billionin2030,and9.8billionin2050.Theworldpopulationisprojectedtocontinuetoincreasetowards the end of the century (UN/DESA, 2019). This growth, together with anincreasingdemand formeatanddairyproducts,willadd furtherpressureon the foodproducing system, both land-based and aquatic (FAO, 2011). While the world’spopulationisexpectedtogrowby32percentbetween2015and2050,muchoftherateofgrowthwillbehighestinlow-incomecountries.Thepopulationofsub-SaharanAfrica,forexample,isprojectedtogrowby124percentinthesameperiod(UN/DESA,2019b).Thechallengeishowtoproducemorefood,ofbetternutritionalquality,toanincreasingpopulation,butwithoutfurtherstressingtheland.This situation requires an urgent and immediate shift in government policies and inpeople’sbehaviour.Fivekeystrategiestoovercomethissituationhavebeenproposed:making healthy foods more available, accessible and affordable; shifting priorities toproduce healthy foods instead of high quantities of food; revolutionising foodproduction to sustainably increasehigh-qualityoutput; ensuring stronggovernance toavoidfurtherecosystemdestructionbyexpandingagriculturalland;workingtowardsa50percentreductionoffoodloss(Willettetal.,2019).There is a link between disasters and food security. A review of 78 post-disasterassessments(includingdroughts, floods,tropicalstormsandforest fires)from48low-andmiddle-income countries (in Asia, Africa and Latin America) over a period of 10years (2003-2013) showed that the largest impacts occurred in developing countries,and in theagriculturalsector.Forexample, fromthepost-disastereconomic impactof

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USD 140 billion, 22 per cent related to the agriculture sector (with 42 per cent ofdamage and loss in crop production), and 36 per cent in livestock. From this total ofdamageand loss inproduction,44percentwascausedbydroughteventsand39percentbyfloods,withmajorimpactsparticularlyinAsiaandAfrica.Similarly,theindirectimpact of disasters such as forest fires is amajor risk for peoplewhose livelihood islinkedtoforests(FAO,2015).

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5. RespondingtothechallengesThe current state of DLDD calls for urgent actions to protect human health andwell-being.LackofawarenessofDLDDanditsdriversandimpactscanbecomeabarriertoaction.RaisingknowledgeandawarenessoftheDLDDdrivingforcesandconsequencesin the social, economic and environmental dimensions is crucial, and should beimplementedateverylevel.Actionsacrossjurisdictionsandsectorsareneededateverystage of the pathways from DLDD drivers, their exposures and their human healthimpacts (Patz et al., 2012; Gibbs & Salmon, 2015). Certainly, actions at the highestpossible level (drivers)aremoreeffective thanactions takenwhen thehealth impactshave already occurred (curative actions). Therefore, the protection of essentialecosystemservicesmustbeensuredandsustained.Interagency and intersectoral action can importantly contribute to achieve the 2030AgendaforSustainableDevelopment.ForDLDD,specificallySDG15“Protect,restoreandpromote sustainable use of terrestrial ecosystems, sustainably manage forests, combatdesertification, and halt and reverse land degradation and halt biodiversity loss” andtarget15.3,whichstates:“by2030,combatdesertification,restoredegradedlandandsoil,includinglandaffectedbydesertification,droughtandfloods,andstrivetoachievealanddegradation-neutralworld”. Implementing actions based on SDG 15 at the national and local levels, based oninternational agreements, is essential for development without land degradation andbiodiversity loss, thereforesupportinghealthandwell-being(IPBES,2018).RegardingSDG3 “Ensurehealthy livesandpromotewell-being forallatallages”,healthandwell-being depend on the sustainable management of natural resources, thus to ensurehealthy communities and societies we need healthy ecosystems. Land degradationneutralitywillsupportnutrition,andlong-termfoodsecurity,watersecurityaswellaspoverty reduction (Patz et al., 2012). Figure 7 identifies nine SDG targets that areparticularly linked to both SDG 3 (Good health andwell-being), and SDG 15 (Life onland).

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Figure 7. SDG targets linked toGoodhealth andwell-being (SDG-3) and Life on land(SDG-15)

Box10.Land,humanhealthandtheSustainableDevelopmentGoalsAmongthe17SDGsandtheir169targets,15SDGsand34targetsareconnectedtohealth(SDG3,Ensurehealthylivesandpromotewell-beingforallatallages)andland(SDG15,Protect,restoreandpromotesustainableuseofterrestrialecosystems,sustainablymanageforests,combatdesertification,andhaltandreverselanddegradationandhaltbiodiversityloss).KeySDG-3Targets KeySDG-15Targets3.3.By2030,endtheepidemicsofAIDS,tuberculosis,malariaandneglectedtropicaldiseasesandcombathepatitis,water-bornediseasesandothercommunicablediseases 3.4.By2030,reducebyonethirdprematuremortalityfromnon-communicablediseasesthroughpreventionandtreatmentandpromotementalhealthandwell-being 3.8.Achieveuniversalhealthcoverage,includingfinancialriskprotection,accesstoqualityessentialhealth-careservicesandaccesstosafe,effective,qualityandaffordableessentialmedicinesandvaccinesforall 3.9.By2030,substantiallyreducethenumberofdeathsandillnessesfromhazardouschemicalsandair,waterandsoilpollutionandcontamination3.D.Strengthenthecapacityofallcountries,inparticulardevelopingcountries,forearlywarning,riskreductionandmanagementofnationalandglobalhealthrisks

15.1.By2020,ensuretheconservation,restorationandsustainableuseofterrestrialandinlandfreshwaterecosystemsandtheirservices,inparticularforests,wetlands,mountainsanddrylands,inlinewithobligationsunderinternationalagreements15.2.By2020,promotetheimplementationofsustainablemanagementofalltypesofforests,haltdeforestation,restoredegradedforestsandsubstantiallyincreaseafforestationandreforestationglobally15.3.By2030,combatdesertification,restoredegradedlandandsoil,includinglandaffectedbydesertification,droughtandfloods,andstrivetoachievealanddegradation-neutralworld15.5.Takeurgentandsignificantactiontoreducethedegradationofnaturalhabitats,haltthelossofbiodiversityand,by2020,protectandpreventtheextinctionofthreatenedspecies

SDG1.Target1.5:By2030,buildtheresilienceofthepoorandthoseinvulnerablesituationsandreducetheirexposureandvulnerabilitytoclimate-relatedextremeeventsandothereconomic,socialandenvironmentalshocksanddisasters

SDG2.Target2.4:By2030,ensuresustainablefoodproductionsystemsandimplementresilientagriculturalpracticesthatincreaseproductivityandproduction,thathelpmaintainecosystems,thatstrengthencapacityforadaptationtoclimatechange,extremeweather,drought,floodingandotherdisastersandthatprogressivelyimprovelandandsoilquality

SDG3.Target3.D:Strengthenthecapacityofallcountries,inparticulardevelopingcountries,forearlywarning,riskreductionandmanagementofnationalandglobalhealthrisks

SDG5.Target5.A:Undertakereformstogivewomenequalrightstoeconomicresources,aswellasaccesstoownershipandcontroloverlandandotherformsofproperty,financialservices,inheritanceandnaturalresources,inaccordancewithnationallaws

SDG6.Target6.4:By2030,substantiallyincreasewater-useefficiencyacrossallsectorsandensuresustainablewithdrawalsandsupplyoffreshwatertoaddresswaterscarcityandsubstantiallyreducethenumberofpeoplesufferingfromwaterscarcity

SDG8.Target8.8:Protectlabourrightsandpromotesafeandsecureworkingenvironmentsforallworkers,includingmigrantworkers,inparticularwomenmigrants,andthoseinprecariousemployment

SG10.Target10.7:Facilitateorderly,safe,regularandresponsiblemigrationandmobilityofpeople,includingthroughtheimplementationofplannedandwell-managedmigrationpolicies

SDG11.Target11.5:By2030,significantlyreducethenumberofdeathsandthenumberofpeopleaffectedandsubstantiallydecreasethedirecteconomiclossesrelativetoglobalgrossdomesticproductcausedbydisasters,includingwater-relateddisasters,withafocusonprotectingthepoorandpeopleinvulnerablesituations

SDG12:Target12.3:By2030,halvepercapitaglobalfoodwasteattheretailandconsumerlevelsandreducefoodlossesalongproductionandsupplychains,includingpost-harvestlosses

SDG13.Target13.1:Strengthenresilienceandadaptivecapacitytoclimate-relatedhazardsandnaturaldisastersinallcountries

SDG15.Target15.3:By2030,combatdesertification,restoredegradedlandandsoil,includinglandaffectedbydesertification,droughtandfloods,andstrivetoachievealanddegradation-neutralworld

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SDG1–Endpovertyinallitsformseverywhere.Therelationshipbetweenpoverty,DLDDandhealthiswellestablished.In2015,736millionpeoplelivedinextremepoverty,with80percentinSouthAsiaandsub-SaharanAfrica.Moreover,twobillionruralpeopleliveonpooragriculturalland.Effortstoendextremepovertyandreducebyhalfpeoplelivinginpovertyby2030(Targets1.1and1.2)aswellaseffortstowardsensuringequalrightstoeconomicresourcesandownershipandcontroloverland(Target1.4)willrequirerenewedenergy,specificallyintheagriculturalsector,whichwhenpoorlymanagedcanbecomeamajordriveroflanddegradation.Inaddition,buildingtheresilienceofthepoorandofthoseinvulnerablesituationsandreducingtheirexposureandvulnerabilitytoclimate-relatedextremeeventsandothereconomic,socialandenvironmentalshocksanddisasters(Target1.5)willdependupontheextentofsustainablemanagementoftheland,aswellasupontheamountoffreshwaterandfoodsupplies,ecosystemlossreduction,andforestryrestoration.Theseimprovementscanstrengthenandempowerpoorpeople’sautonomy,whichcanalsopositivelyinfluencegoodhealthandwell-being.SDG2–Endhunger,achievefoodsecurityandimprovednutritionandpromotesustainableagriculture.FoodshortagerelatedimpactsonnutritionaresomeofthemostdirectDLDDimpactsonhumanhealth,especiallyinlow-incomecountries.TheseimpactspresentachallengetotheachievementofTargets2.1and2.2,whichaimtoendhungerandallformsofmalnutritioninchildrenunderfiveyearsofage,adolescentsgirls,pregnantandlactatingwomen,andolderpersons,andalsoensureaccesstosafe,nutritiousandsufficientfoodforallpeople.Inruralandinpoorareas,wherepeoplecannotpurchasefood,localfoodproductioniscrucialtopreventhungerandpromotedevelopment.AchievingTarget2.3(aimingby2030todoubletheagriculturalproductivityandincomesofsmall-scalefoodproducers,inparticularwomen,indigenouspeoples,familyfarmers,pastoralistsandfishers,includingthroughsecureandequalaccesstoland,otherproductiveresourcesandinputs,knowledge,financialservices,marketsandopportunitiesforvalueadditionandnon-farmemployment),willbeanimportantstepincombatingDLDD,andinhelpingtorelievepovertyandhunger.Target2.4,whichaimsby2030toensuresustainablefoodproductionsystemswithresilientagriculturalpractices,strengtheningcapacitiestocopewithclimatechange,extremeweather,anddisasters,andaimingtoimprovelandandsoilquality,willhelpreduceinequalities,foodsecurity,andwillprovidebetternutritionandqualityoflife(thesetargetsarecloselyconnectedwithTargets12.2and12.3,discussedbelow).SDG4–Ensureinclusiveandequitablequalityeducationandpromotelifelonglearningopportunitiesforall.Disparitiesineducationexistalongthelinesofgender,urban-rurallocation,andincomelevels.Therelationshipbetweeneducation(particularlyofmothers)andinfantmortalityrates,aswellasinfectiousdiseasesandotherillnesses,iswellestablished.Targets4.1and4.5aimtoensurethatallchildrencompleteequitablequalityprimaryandsecondaryeducationthatleadstorelevantandeffectivelearningresults,andalsotoeliminategenderdisparities,andprovideequalityofaccessatalllevelsofeducationandprofessionaltrainingforall.AchievingthesetargetsandTarget4.7onensuringknowledgeandskillstopromotesustainabledevelopment,canpromotelifelonglearningopportunitiesforbetterlifechoices.SDG5–Achievegenderequalityandempowerallwomenandgirls.Genderinequalitystillcontinuestoholdwomenbackanddeprivesthemofbasicrightsandopportunities.Theagriculturalsectorhasanimportantconnectiontogender,andtorightstolandandfoodproduction.Target5.A,forexample,referstoundertakingreformstogivewomenequalrightstoeconomicresources,aswellasaccesstoownershipandcontroloverlandandotherformsofproperty,financialservices,inheritanceandnaturalresources,inaccordancewithnationallaws.Ifachieved,therewouldbegreateropportunitiesforwomenindecision-makingregardingtheland,whichinturncouldincreasepositiveresultsonsustainableagriculturalpracticesandtheuseofnaturalresources.Furthermore,thisempowermentcouldcontributetobettermanagementandparticipationinfamilystructuresandsociety,andtotheimprovementofhealthconditions. SDG6–Ensureavailabilityandsustainablemanagementofwaterandsanitationforall.Lackofaccesstosafelymanagedwatersuppliesandsanitationfacilitiesisstillahugechallengeformanypeopleworldwide,mainlyinlow-incomecountries.AlltargetsinthisSDGarelinkedtohealth.Theseare:promotinguniversalandequitableaccesstowaterthatissecureandaccessible

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forall(Target6.1);providingaccesstoadequateandequitablesanitationandhygieneforall(Target2);reducingwaterpollution,untreatedwastewaterandincreasingrecyclingandsafereuseofwater(Target6.3);increasingtheefficiencyandsustainableuseofwaterinallsectors,andreducingthenumberofpeoplesufferingfromwaterscarcity(Target6.4);implementingintegratedwaterresourcemanagementatalllevels(Target6.5);andprotectingandrestoringwater-relatedecosystemsincludingmountains,forests,wetlands,rivers,aquifersandlakesTarget6.6).Achievingthesetargetsisindispensableforhealth,improvingthequalityofhumanlifeandwellbeingoftheglobalpopulation,inparticularforthoselivingindrylandareas,andinrural,remoteandpoorareas.Importantly,Target6.Baimstosupportandstrengthentheparticipationoflocalcommunitiesinimprovingwaterandsanitationmanagement,andthishasacrucialroleinallprevioustargets.SDG7–Ensuringaccesstoaffordable,reliableandmodernenergyforall.Target7.1aimstoensureuniversalaccesstoaffordable,reliableandmodernenergyservicesforall.Achievingthistargetwillprovideaccesstocleanfuelstoabout3billionpeople(41percentoftheworld’spopulation)whostillcookwithpollutingfuelsandstoves.Itwillalsohelpavoidtheuseofbiomassfuels,thusprotectingtheenvironment,andreducingdiseasesrelatedtoairpollution.SDG8–Promotesustained,inclusiveandsustainableeconomicgrowth,fullandproductiveemploymentanddecentworkforall.Target8.4aimstoimproveglobalresourceefficiencyinconsumptionandproductionandendeavourtodecoupleeconomicgrowthfromenvironmentaldegradation.Achievingfullandproductiveemploymentanddecentworkforallwomenandmen,includingforyoungpeopleandpersonswithdisabilities(Target8.5),wouldalsohelppeopleindrylands,avoidingforcedmigrationandpoverty. SDG9–Buildresilientinfrastructure,promoteinclusiveandsustainableindustrializationandfosterinnovation.Developingquality,reliable,sustainableandresilientinfrastructure,tosupporteconomicdevelopmentandhumanwell-being,withafocusonaffordableandequitableaccessforall(Target9.1)wouldalsobenefitpeoplelivingindrylands,orinareassufferingfromlanddegradation. SDG10–Reduceinequalitywithinandamongcountries.ReductionofsocialandeconomicimpactsandinequalitiesinregionsaffectedbyDLDDwouldpromotesustainabledevelopment,aswellashealthandwell-being.AddressingTarget10.2wouldhelpempowerandpromotethesocial,economicandpoliticalinclusionofall.RespondingtoTarget10.7,wouldfacilitateorderly,safe,regularandresponsiblemigrationandmobilityofpeople,reducingthecurrentsituationofforcedmigrationofpeopleaffectedbyDLDD.SDG11–Makecitiesandhumansettlementsinclusive,safe,resilientandsustainable.AchievingTarget11A,whichaimstosupportpositiveeconomic,socialandenvironmentallinksbetweenurban,peri-urbanandruralareasbystrengtheningnationalandregionaldevelopmentplanning,couldhelpreducethesocialandeconomicurban-ruralgap,positivelyimpactpersonslivingindrylandsandotherareassufferingfromDLDD.SDG12–Ensuresustainableconsumptionandproductionpatterns.Thesustainablemanagementandefficientuseofnaturalresources(Target12.2)iskeytoreducingDLDD.Foodlossisamajorproblemglobally,whilehungerandmalnutritionhavehighprevalenceinmanycountries.Target12.3aimstoreducefoodlossesatalllevels,includingalongproductionandsupplychains,andincludingpost-harvestlosses,whichwouldhelppeoplelivinginDLDDaffectedareas.Target12.4iscrucialtohealthandtocombatingDLDD.Itseekstoachievesustainableenvironmentalmanagementofchemicalsandallwastesthroughouttheirlifecycle,inordertoreducetheirreleasetoair,waterandsoil,soastominimisetheadverseimpactsonhumanhealthandtheenvironment.Thesetargetscanbeachievedthroughintegratedactionbetweentheeducation,healthandagriculturalsectors,andbyusingtechnologicaldevelopments,aswellasthroughtheimplementationofparticipativeformsofmanagement,includingsustainabletechniquesofirrigation,storageanddistributionofwaterandfood.

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SDG13–Takeurgentactiontocombatclimatechangeanditsimpacts.Climatechangeisariskmultiplier,bothforhealthandDLDD.Target13.1aimstostrengthenresilienceandadaptivecapacitytoclimate-relatedhazardsandnaturaldisastersinallcountries;Target13.3aimstoimproveeducation,awareness-raisingandhumanandinstitutionalcapacityonclimatechangemitigation,adaptation,impactreductionandearlywarning.Actionsonboththesetargetsmustbeimplementedurgentlytoavoiddisastrousimpactsonlandandpeople.Avoidinggreaterimpactsrequiresintegratedandcoordinatedmeasuresbymanysectors,workingwithcivilsociety,andatnationalandlocalgovernmentlevelstoincreasecapacity,resilienceandadaptationoptions. SDG14–Conserveandsustainablyusetheoceans,seasandmarineresourcesforsustainabledevelopment.Target14.1proposestopreventandsignificantlyreducemarinepollutionofallkinds,inparticularfromland-basedactivities,includingmarinedebrisandnutrientpollution.Unsustainableuseofthelandleadstocontaminationoflakesandrivers–contaminants,whicheventuallyendupintheocean.Thispollution,addedtoothercontaminationsources,impactnegativelyonmarineandcoastalecosystems,affectingboththeenvironmentandthehealthofpeople.SDG16–Promotepeacefulandinclusivesocietiesforsustainabledevelopment,provideaccesstojusticeforallandbuildeffective,accountableandinclusiveinstitutionsatalllevels.Target16.1aimstosignificantlyreduceallformsofviolenceandrelateddeathrateseverywhere;whileTarget16.7aimstoensureresponsive,inclusive,participatoryandrepresentativedecision-makingatalllevels.ManypeoplelivinginareassufferingfromDLDDexperienceviolencewhenmigratingtemporarilyorpermanentlytoseekbetteropportunities.Theyalsooftenlackparticipationandrepresentationindecision-makingregardingtheland.Empowermentoflocalpopulationsandstrengtheningofinstitutionsofjusticeinagriculturalandrural,regionalandlocal,plansandpolicies,specificallyinplacesaffectedbyDLDD,couldbeastrongstrategytoreducevulnerabilities,andalsotoincreasehumandevelopment.SDG17–Strengthenthemeansofimplementationandrevitalisetheglobalpartnershipforsustainabledevelopment. AchievingtheSDGs,specifically,thoserelatedtoDLDDandhealth,requiresanintegratedapproach,whichcanbeprovidedthroughstrategicpartnerships,promotedbySDG17,inallkeyareasaddressed:financeandresourcemobilisation;environmentallysoundtechnologydevelopment,transferanddiffusion;effectiveandtargetedcapacity-buildingandnon-discriminatoryandequitabletrade.TheywouldhelpachieveLandDegradationNeutrality(LDN)contributetoprotectthehealthofpeoplelivinginareasaffectedbyDLDD. Source:UN(2019a)

Sustainable land management practices based on research projects have beensuccessfullyutilisedtorestoreandrehabilitatedegradedland,whichinturnpositivelyinfluence the provision of ecosystem services. Land policies which lead to enablingsustainable environments focussed onwater and food security, aswell as on povertyalleviationareessentialtoimprovehumanhealthandwell-being.Suchpoliciesmustbecombined with measures for the promotion of social learning processes and healthsectoractionforoptimumresults.Successfulstrategiesbasedonlocalsustainablelandmanagementhaveagreatpotentialtobeadaptedforupscaling(Sanzetal.,2017).Forinstance,managementofcurrentwatersupplysystemsbyusingwatermoreefficiently,and/orincreasingthestoragecapacityinreservoirscouldreducetheimpactsofwaterscarcityduringintenseseasonaldroughts(JisménezCisnerosetal.,2014).Disasterriskmanagement is also a strategy toprotect ecosystemsandpeople and strengthen their

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resilience and livelihoods. Furthermore, it can contribute to sustainable development(UNISDR,2015).Healthsectoractionstoaddressthenewrealitiesemergingonourchangingplanetareneeded(Table8).Strategiestoavoidlanddegradationandtoensurelandsustainabilityandlandrestorationwouldprotectandpromotehealthinthelongterm(WHO/WPRO,2017). In addition, community participation is a keymeasure to avoid health impactsandpromotehealth(Kravitz,2017).Similarly, thereareopportunities tosupport localsystems, and to implement resilient policies, which respond to the DLDD challengesimpactingonhealth(Table9);(Patzetal.,2012;Senaetal.,2017;Sanzetal.,2017).ArecentIPCCspecialreportonClimateChangeandLandprovides important findings,challenges and response options related to human health and well-being (Box 11).Althoughmost findings refer to food security and nutrition, there are also importantfindingsonduststormsandgeneralriskstohumanhealth;andonpopulationsatrisk,includingwomen,theveryyoung,theelderly,andpoor.Findingsareorganizedinfourareas:People,landandclimateinawarmingworld;Adaptationandmitigationresponseoptions;Enablingresponseoptions;andActioninthenear-term(IPCC,2019).Table8. HealthsectoractionsneededtorespondtoDLDDchallengesStrategies/Approaches

Actions References

Ensurethatthehealthsectorworkacrosssectors,andincoordinationwithnationalpolicies,soastoaddressandrespondtodriversofDLDD,ratherthanfocussingonlyonreactiveresponsesintheformofcurativeservices.Anintraandinter-sectoraldialoguetodiscussDLDDdriversandimpactsonhealthisneeded.

UN,2012;WHO&WMO,2012;Wilhiteetal.,2014;Senaetal.,2018.

Adaptation/Coordination

Adaptpublichealthsystemstotherealitiesoflocalecosystems.Thisiskeytoimprovehumanhealthandwell-being,andavoidorreducefutureimpacts.

WHO&WMO,2012;OPAS/OMS,2015;Whitmeeetal.,2015.

EnsurepreparednessofpublichealthagenciestorespondtothehealthimpactsofDLDDwiththeaffectedcommunities;strengthencapacity-buildingforhealthprofessionalsandcommunities,accordingtolocalDLDDrealities,inordertoincreaseresilience.

CDC,2010;UN,2012;WHO&WMO,2012.

Strengtheningcapacity-buildingandresilience

Promoteaccesstoprevention,treatment,careandsupportwithregardtoallDLDDimpactsonhealth,suchasinfectiousdiseases,noncommunicablediseases,andinjuries.

UN,2012.

Develop(orstrengthen)strategicplansforemergencypreparednessandresponsetodisasters(e.g.drought,diseaseoutbreaks,landslides,duststorm,tropicalstorms),consideringthelocalinfrastructureandpoliticalcontext.

CDC,2010;CDC,2018b;IPCC,2012;UNISDR,2015;OPAS/OMS,2015;Ebi&Bowen,2016.

Emergencypreparednessand response todisasters

Implementearlywarningsystemstoreducevulnerabilityandimprovepreventiveandresponsecapacitiesofpeopleatrisk.

Wilhiteetal.,2014;Senaetal.,2018.

Monitoring andsurveillance

Strengthen(ordevelop)diseasemonitoringandsurveillancesystems(bothinfectiousandnoncommunicablediseases,including

OPAS/OMS,2015;Haines,

53

mentalhealthandmalnutrition)todetectandcontrolDLDDrelateddiseaseswithanintegrationofapproachesamongkeysectors.

2016.

Implementasystematicprogrammeofsurveillanceandanalysisofdrinking-waterbetweenwateragenciesandhealthsectorssoastoensurewaterqualityaccordingtoanationaldrinkingwaterqualitystandard.

WHO,2013;Grigolettoetal.,2016

Establishamechanismtointegrateclimateservicesintohealthsurveillancepolicyinordertomonitormeteorologicalforecastsandclimate-sensitivediseases.

WHO&WMO,2012;WHO,2013.

Assessment ImplementamechanismformappingandassessinglocalDLDDrisks,includingvulnerabilities,hazardsandexposures(populationandhealthinfrastructure)toidentifyparticularandeffectiveadaptationmeasures.Assesstheriskposedbytoxicchemicalsandpathogensfromagriculturalpractices.

Berryetal.,2014;Senaetal.,2017;CDC,2018b.

Implementeducationandcommunicationstrategiesinurban,rural,poorandremoteareastoincreasecommunityawarenessregarding:DLDDhealthrisksrelatedtowatersecurity;safewatersupplyandsanitation;sourcewaterprotection;householdwatertreatment,storageandreuse;foodsecurityandinformationonnutrition;mechanismstoreduceairpollution,includingdust;anduseofagriculturalchemicals.

WHO,2013;JisménezCisnerosetal.,2014;Grigolettoetal,2016;CDC,2018b.

Education andcommunication

Implementhealtheducationandpromotionstrategiestoincreasecommunityawarenessaboutriskfactorsforhumanhealth,consideringgenderdifferences,educationalgaps,socioeconomicstatusandculturalbehaviours.

UNESCO,2016;CDC,2018b;GuzmánBeltránetal.,2019.

Table9. PolicyactionsneededtorespondtoDLDDchallengesStrategies/Approaches

Actions References

DLDD impacts on human health and well-being are often notrecognised by the health sector, or even by other sectors andstakeholdersgroups.Thus, strengtheninghealth systems towardsthe provision of equitable and universal coverage must includehavinganintegrativeapproachwithDLDDinterventions.

UN,2012;Patzetal.,2012;WHO/WPRO,2017.

Increase government awareness and political commitments tosupport integrative actions for land and water managementaddressingthehealthsector,includingdisastermanagementrisks.

Patzetal.,2012;Shiferawetal.,2014;UNISDR,2015.

Governance

Developpolicies for reducing thedriving forcesofDLDD, suchashigh consumption, population growth, deforestation, overgrazinglivestock,soilerosion,andagriculturalsystems.Atthesametime,implement land restoration programmes. The health sectormustbeincludedinthedecision-makingprocess.

Gibbs&Salmon,2015;WHO,2014d.

Adaptation/Coordination

Implement coordinated policy agendas, through mechanisms orprogrammes for addressing food security and nutrition, watersupply, clean energy, climate change action, education for all,universalhealthcoverage,andotherareasofeconomic,socialandenvironmentaldevelopment.

IPBES,2018;Chiabaietal.,2018;CDC,2018b.

Develop pro-active approaches with community participation toreduce vulnerabilities and improve preventive and responsecapacitiesofpeopleatrisk.

WHO,2013;Crossman,2018.

Strengtheningcapacitybuildingandresilience Implement strategies for protecting the most vulnerable

populations in society fromall risks related toDLDDand climatechange. Implementmechanisms of communication to understandindividual sensitivity and collective exposure to current hazards

Maibachetal.,2011;Berryetal.,2014;Wilhiteetal.,2014;Sena

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and vulnerabilities, adaptation challenges and knowledge of theabilitytocopeandincreaseresilience.

etal.,2017.

Createamechanismtoincreaseresilienceinagriculturetoensurefood security and nutrition (e.g. policies tomanage disaster risk;creatingearlywarningsystems).

FAO,2015;UNISDR,2015;Senaetal.,2018.

Develop a national drought management policy with integratedactions among key sectors (including actions from the healthsector)regardingdroughtmonitoringandearlywarningsystems,aswellasprevention,mitigationandadaptationmeasures.

OPAS/OMS,2015;FAO,2015;Crossman,2018;CDC,2018b.

Emergencypreparednessand response todisasters

Implement or strengthen preparedness plans (for drought, dust,flood, food shortage, water scarcity, tropical storms) at bothregionalandlocallevels.

Wilhiteetal.,2014;UNISDR,2015.

Implement effective strategies for managing risks related toclimate change through adaptation measures, and vulnerabilityand exposure reduction with integrated multi-sectoral measures(e.g. poverty alleviation, human development, ecosystemmanagement, land-use management, disaster risk management,foodandwatersecurity,livelihoodsecurityandsupport).

WHO,2013;IPCC,2014;FAO,2015;Shiferawetal.,2014;UNISDR,2015;Willettetal.,2019.

Climatechangeandlandmanagement

Establishintegrativeapproacheswithprogrammesforsustainableland and water resource management across sectors andstakeholder groups in all levels (local, regional, national andinternational).

Kravitz,2017;Hancocketal.,2017;IPBES,2018.

Assessment Implement mechanisms for mapping and assessing local orregionalDLDDrisks,vulnerabilities,hazardsandexposures–soasto identify targeted and effective reduction and adaptationmeasures.

Berryetal.,2014;Senaetal.,2017;CDC,2018b.

Identifyresearchneedsandinstitutionalgapsandpromotestrongcommunication channels between science and policy, in order toaddress and respond to risks and vulnerabilities in order toenhancehumanhealthandwell-being.

Wilhiteetal.,2014.

Develop a mechanism for communication and informationexchangeamongsectorstoaddressdecisionpolicies.

Shiferawetal.,2014;Whiltmeeetal.,2015;CDC,2018b.

Education andcommunication

Establish access to education, technical information andknowledgeforallregardingDLDD.

Senaetal.,2018;CDC,2018b.

Establish financial mechanisms to support social protectionpoliciestoenhancelife-savingandproductivesafety-nets.Thiscaninclude food reserves, seed distribution, financial transfer tofamilies in food-shortage periods, andmeasures to ensurewatersecurity.

Alston,2012b;Slateretal.,2013;Shiferawetal.,2014.

Prioritiseandsupportsustainableprogrammes,suchas:drinking-water and sanitation; local family agriculture; farmingcommunities; risk communication; educational programmes;irrigationsystemtechniques;andsustainableproductionpractices.

WHO,2013;Slateretal.,2013;Crossman,2018;Wilhiteetal.,2014;Shiferawetal.,2014;FAO,2015;Grigolettoetal.,2016;Senaetal.,2018.

Financialresourcesforstrategicmeasuresandforsocialsupport

Support strategic and integrated plans and mechanisms forassessing risks and vulnerabilities, in order to reduce impacts onhumanhealth.

WHO&WMO,2012;UNISDR,2015;Senaetal.,2017.

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Box11.IPCCSpecialReportonClimateChangeandLand–Keyimpactsonhumanhealthandwell-beingTheSpecialReportonClimateChangeandLand,a summary forpolicymakers, launched in2019by theIPCC, highlights the latest evidence regarding land-based ecosystems, land use and sustainable landmanagementinrelationtoclimatechange,desertification,landdegradationandfoodsecurity.Systemsatriskincludethosedirectlyrelatedtohumanhealthandwell-being(Food,Livelihoods,Humanhealth),andthosethatsupporthumanwell-being(Valueofland,Ecosystemhealth,Infrastructure).Thefigurebelowshowstheextenttowhichthesesystemsareatrisk.

Manyofthereportfindingsarerelatedtohumanhealthandwell-being:People,landandclimateinawarmingworld• Changesinconsumptionpatternshavecontributedtoabout2billionadultsnowbeingoverweightor

obese.• Anestimated821millionpeoplearestillundernourished.• Dryland regions have experienced desertification. People living in already degraded or desertified

areasareincreasinglynegativelyaffectedbyclimatechange.• Climate change, including increases in frequency and intensity of extremes, has adversely impacted

foodsecurityandterrestrialecosystemsaswellascontributedtodesertificationandlanddegradationinmanyregions.

• Thefrequencyandintensityofduststormshaveincreasedoverthelastfewdecadesduetolanduseand land cover changes and climate-related factors in many dryland areas resulting in increasingnegativeimpactsonhumanhealth,inregionssuchastheArabianPeninsulaandbroaderMiddleEast,CentralAsia.

• Climatechangehasalreadyaffectedfoodsecurityduetowarming,changingprecipitationpatterns,andgreaterfrequencyofsomeextremeevents.Inmanylower-latituderegions,yieldsofsomecrops(e.g.,maize and wheat) have declined, while in many higher-latitude regions, yields of some crops (e.g.,maize,wheatandsugarbeets)haveincreasedoverrecentdecades.

• Climate change creates additional stresses on land, exacerbating existing risks to livelihoods,biodiversity,humanandecosystemhealth,infrastructure,andfoodsystems.

• The stability of food supply is projected to decrease as the magnitude and frequency of extremeweathereventsthatdisruptfoodchainsincreases.IncreasedatmosphericCO2levelscanalsolowerthenutritionalqualityofcrops.

1.5°

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Wildfiredamage

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Permafrost degradation

Systems at risk:Food

LivelihoodsValue of land

Human healthEcosystem health

Infrastructure

L Low

ExampleH

M MediumH High

Socio-economic choices can reduce or exacerbate climate related risks as well as influence the rate of temperature increase. The SSP1 pathway illustrates a world with low population growth, high income and reduced inequalities, food produced in low GHG emission systems, effective land use regulation and high adaptive capacity. The SSP3 pathway has the opposite trends. Risks are lower in SSP1 compared with SSP3 given the same level of GMST increase.

Increases in global mean surface temperature (GMST), relative to pre-industrial levels, affect processes involved in desertification (water scarcity), land degradation (soil erosion, vegetation loss, wildfire, permafrost thaw) and food security (crop yield and food supply instabilities). Changes in these processes drive risks to food systems, livelihoods, infrastructure, the value of land, and human and ecosystem health. Changes in one process (e.g. wildfire or water scarcity) may result in compound risks. Risks are location-specific and differ by region.

A. Risks to humans and ecosystems from changes in land-based processes as a resultof climate change

B. Different socioeconomic pathways affect levels of climate related risks

Final draft SPM

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Desertification Land degradation Food insecurity(water scarcity in drylands) (habitat degr., wildfire, floods) (availability, access)

Legend: Level of impact/risk

Undetectable

Moderate

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Legend: Confidencelevel fortransitionPurple: Very high probability of severe impacts/ risks

and the presence of significant irreversibility or the persistence of climate-related hazards, combined with limited ability to adapt due to the nature of the hazard or impacts/risks.Red: Significant and widespread impacts/risks.Yellow: Impacts/risks are detectable and attributable to climate change with at least medium confidence.White: Impacts/risks are undetectable.

Risks

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Over 100M people additionally exposed

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• Indrylands,climatechangeanddesertificationareprojectedtocausereductionsincropandlivestockproductivity.

• Asia and Africa are projected to have the highest number of people vulnerable to increaseddesertification.NorthAmerica,SouthAmerica,Mediterranean,southernAfricaandcentralAsiamaybeincreasingly affected bywildfire. The tropics and subtropics are projected to bemost vulnerable tocropyielddecline.Landdegradationresultingfromthecombinationofsealevelriseandmoreintensecyclones is projected to jeopardise lives and livelihoods in cycloneprone areas.Within populations,women,theveryyoung,elderlyandpooraremostatrisk.

• Extremeweatherandclimateorslow-onseteventsmayleadtoincreaseddisplacement,disruptedfoodchains,threatenedlivelihoods.

• Urbanexpansion isprojected to lead toconversionof cropland leading to losses in foodproduction.Thiscanresultinadditionalriskstothefoodsystem.Strategiesforreducingtheseimpactscanincludeurbanandperi-urban foodproductionandmanagementofurbanexpansion, aswell asurbangreeninfrastructurethatcanreduceclimaterisksincities.

Adaptationandmitigationresponseoptions• Mostofthe landmanagement-basedresponseoptionsthatdonot increasecompetitionfor land,and

almostalloptionsbasedonvaluechainmanagement(e.g.dietarychoices,reducedpost-harvestlosses,reduced food waste) and risk management, can contribute to eradicating poverty and eliminatinghungerwhilepromotinggoodhealthandwellbeing,cleanwaterandsanitation,climateaction,andlifeonland.

• Theproductionanduseofbiomassforbioenergycanhaveco-benefits,adversesideeffects,andrisksfor land degradation, food insecurity, GHG emissions and other environmental and sustainabledevelopmentgoals.

• Many activities for combating desertification can contribute to climate change adaptation withmitigationco-benefits,aswellastohaltingbiodiversitylosswithsustainabledevelopmentco-benefitsto society. Avoiding, reducing and reversing desertification would enhance soil fertility, increasecarbonstorageinsoilsandbiomass,whilebenefittingagriculturalproductivityandfoodsecurity.

• Reducing dust and sand storms and sand dune movement can lessen the negative effects of winderosionandimproveairqualityandhealth.

• Transitionstowardslow-GHGemissiondietsmaybeinfluencedbylocalproductionpractices,technicalandfinancialbarriersandassociatedlivelihoodsandculturalhabits(highconfidence).

Enablingresponseoptions• Policy mixes can strongly reduce the vulnerability and exposure of human and natural systems to

climate change. Elements of such policy mixes may include weather and health insurance, socialprotection and adaptive safety nets, contingent finance and reserve funds, universal access to earlywarningsystemscombinedwitheffectivecontingencyplans.

• Policies that operate across the food system, including those that reduce food loss and waste andinfluencedietarychoices,enablemoresustainableland-usemanagement,enhancedfoodsecurityandlowemissions trajectories.Suchpoliciescancontribute toclimatechangeadaptationandmitigation,reducelanddegradation,desertificationandpovertyaswellasimprovepublichealth.

• Publichealthpolicies to improvenutrition,suchas increasing thediversityof foodsources inpublicprocurement,healthinsurance,financialincentives,andawareness-raisingcampaigns,canpotentiallyinfluence food demand, reduce healthcare costs, contribute to lower GHG emissions and enhanceadaptive capacity. Influencing demand for food, through promoting diets based on public healthguidelines,canenablemoresustainablelandmanagementandcontributetoachievingmultipleSDGs.

• Addressing desertification, land degradation, and food security in an integrated, coordinated andcoherent manner can assist climate resilient development and provides numerous potential co-benefits.

• Agriculturalpractices that include indigenousand localknowledgecancontributetoovercomingthecombined challenges of climate change, food security, biodiversity conservation, and combatingdesertificationandlanddegradation.

• Empoweringwomencanbringsynergiesandco-benefits tohousehold foodsecurityandsustainablelandmanagement.

Actioninthenear-term• Earlywarning systems for extremeweather and climate events are critical for protecting lives and

property and enhancing disaster risk reduction and management. Seasonal forecasts and early

57

warningsystemsarecriticalforfoodsecurity(famine)andbiodiversitymonitoringincludingpestsanddiseasesandadaptiveclimateriskmanagement.

• Near-term action to address climate change adaptation and mitigation, desertification, landdegradationandfoodsecuritycanbringsocial,ecological,economicanddevelopmentco-benefits.Co-benefits can contribute to poverty eradication and more resilient livelihoods for those who arevulnerable.

• Near-term actions to promote sustainable landmanagementwill help reduce land and food-relatedvulnerabilities,andcancreatemoreresilientlivelihoods,reducelanddegradationanddesertification,andlossofbiodiversity.

• Prompt action on climatemitigation and adaptation alignedwith sustainable landmanagement andsustainable development depending on the region could reduce the risk tomillions of people fromclimateextremes,desertification,landdegradationandfoodandlivelihoodinsecurity.

• DeferralofGHGemissionsreductionsfromallsectorsimpliestrade-offsincludingirreversiblelossinlandecosystemfunctionsandservicesrequiredforfood,health,habitablesettlementsandproduction,leadingtoincreasinglysignificanteconomicimpactsonmanycountriesinmanyregionsoftheworld.

Source:IPCC(2019)

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