Healthcare Systems Facing Climate Change: From Preparedness to Emergency Preparedness

In light of the increased frequency and intensity of extreme weather events, a resilient health system shouldn’t just bounce back to its previous state after a crisis; it should learn and transform to be better prepared for future challenges. A proactive and comprehensive approach are key steps for realising climate-ready healthcare systems as accountable factors of strength for communities.

Key Points

• The European Green Deal is an ambitious plan to address climate change and environmental challenges while fostering economic growth and social progress. The primary objective is to achieve net-zero greenhouse gas emissions by 2050.
• One Health Approach is a holistic and interdisciplinary framework that recognises the interconnectedness of the health of humans, animals, plants, and their shared environment.
• Sustainability is well-being and meeting today's needs without compromising tomorrow.
• Adaptation is the proactive adjustments and changes made to existing systems to minimise the negative impacts of climate change.
• Mitigation refers to actions taken to reduce the causes and severity of potential negative impacts in the immediate operational sense and in the long-term context of broader challenges like climate change.
• Resilience is the ability of systems to proactively foresee, absorb, adapt to, and recover from shocks and stresses while continuing to provide essential healthcare services.
• Redundancy in healthcare facilities refers to the practice of having backup options or alternatives in place to ensure the continuity of care.

Framework

The global landscape of human health is increasingly shaped by the pervasive and intensifying impacts of climate change. Scientists and researchers are deeply realistic about the devastating social effects of war-related environmental destruction and pollution, but they are especially pessimistic with regard to the parallel environmental situation, with rising average temperatures and related consequences, coupled with a greater frequency and severity of extreme weather events - no longer abstract projections but tangible realities. Taking all this into consideration, it is evident that there is now an even stronger need to increase attention on environmental problems and their impact on human and environmental health, stressing the danger of abandoning if not in words, in actions, the crucial 'One Health' approach and attacking the ‘Green Deal’ vision.

The environmental shifts are not only causing direct harm through events like heatwaves and floods but are also exacerbating existing health vulnerabilities and creating new public health challenges. The potential for a significant surge in mortality and economic losses by mid-century underscores the critical need for immediate and comprehensive action across all sectors, with healthcare systems occupying a central and indispensable role. The human tragedies developing in this dark period of history can’t diminish the effort to fight climate change and protect human and environmental health. 

A paradigm shift towards proactive, ready for emergencies,  preparedness is not merely advisable but absolutely essential for safeguarding public health in the 21st century. The considerations that will be exposed, will address some points, with regard to healthcare systems and, in particular, the healthcare facilities.

The Path Towards Understanding the Threats of Climate Change

Climate change has a wide array of impacts on human health, both directly through immediate consequences of altered environmental conditions and indirectly through complex ecological and social pathways. It can be seen as a stress test that hits all the pillars of the healthcare system.

It is certainly of some relevance to see the difficult path to reach a comprehensive nexus between climate, human health and its critical pillar: the healthcare system. 

The first alert about changes in the composition of the atmosphere and their negative effects was in the late 19th centurywhen the Swedish scientist Svante Arrhenius, in 1896, wrote about the greenhouse effect and predicted that changes in atmospheric carbon dioxide levels could significantly impact Earth's surface temperature, a concept central to modern climate science. In 1958, American scientist Charles David Keeling proposed the Keeling Curve, which provided clear evidence of rising atmospheric CO₂ levels. Early climate models began to predict the consequences of these increases. In 1988, NASA scientist James Hansen's testimony to the U.S. senate brought the term "global warming" into widespread public consciousness, highlighting the potential of climate change to impact weather patterns.

The negative aspects of global warming started to draw significant attention and reaction outside of the scientific world and brought as the first important action with the production of the Kyoto Protocol signed at the United Nations Convention on Climate Change of 1992, in parallel with initiatives such as the Conference of the Parties (COP) in the framework of the United Nations Framework Convention on Climate Change(UNFCCC) focusing on global climate policies and actions. The COP, held in Paris in 2015, was and is a legally binding international treaty on climate change, the point of reference for the environment and health global policies. Relevant was the creation of the Intergovernmental Panel on Climate Change (IPCC), the United Nations body for assessing the science related to climate change. IPCC, since 2001, provided “policymakers with regular scientific assessments on climate change, its implications and potential future risks, as well as to put forward adaptation and mitigation options.”

One of the most important actions was the launch by WHO with the World Bank and UNFCCC of the “2008-2009 Disaster Reduction Campaign”.This action was, in fact, of great relevance for the healthcare system, specifically for its facilities. It was focused on the theme "Hospitals Safe from Disasters: Reduce Risk, Protect Health Facilities, Save Lives."

Among the main goals of the campaign were:

• Raising awareness globally about the critical goal of protecting health facilities from natural hazards.
• Advocating for policy changes and increased investments to make hospitals and health services more resilient, encouraging the development of national strategies and plans for hospital safety in disaster-prone areas.
• Providing tools and resources to support governments, health professionals, and communities in reducing risks to health infrastructure.
• Facilitating knowledge sharing and the dissemination of good practices in making hospitals safe.
• Producing and disseminate information materials, including campaign kits, flyers.
• Promoting the implementation of the Hyogo Framework for Action (2005-2015) in the health sector.

The Global Vulnerability of Health Facilities

In parallel with the awareness of the climate change impact, in the first decade of the new millennium, the physical disasters produced by such impacts started to become known universally, outside the scientific and policy-managerial world of health, and with them, the aspect of the recognitions of the vulnerability of the health facilities. The media also conveyed to the general public the effect of Hurricane Katrina (2005) that resulted, in addition to 1500 deaths, the destruction of a number of hospitals. Other disasters involved hospitals due to excessive winds and storms, as well as big fires resulting from the cascade effects of hospital disruptions produced by hurricanes. Another event that was highly publicised was in 2017, in Texas, when Hurricane Harris damaged healthcare infrastructure, causing the evacuation of several hospitals.

In Europe, the event that gave evidence of another critical aspect impacting the healthcare facilities' functionality was the 2003 heat wave that swept a large part of Northern Europe and resulted in more than 70,000 deaths, mostly among elderly, fragile people of the lower social strata of the society. In these specific cases, the health facilities failed to assist the increased number of persons needing help and people with specific problems affecting the respiratory system.

The most relevant aspects of vulnerability in the European area were and still are related to floods and excess precipitations. In 2002, the media started to give relevance to the extent and scope of severe damages produced by the main European rivers. In a major report  published in 2013, the International Commission for the Protection of the Danube River listed eight countries in Central Europe hit by floods. The catastrophic Storm Boris in September 2024 caused widespread flooding across Central and Eastern Europe. A new word entered in the ordinary vocabulary - Medcanes, a new type of storm hitting the Mediterranean area. Heat waves, droughts, flooding and wildfireshighlighted the weakness in healthcare facilities mostly in terms of functionality and support for the increase in the number of services.

The major considerations about the physical conditions of the hospitals in Europe were related to the patient’s protection. For example, it was noticed that exceptionally strong winds could destroy windows and generate problems with the safety or comfort of hospitalised patients. Could these facts allow the conclusion that European hospitals have a high level of resilience with regard to climate risks?

The scarcity of data in this regard should prudently leave the question open. Many publications of the European Environment Agency (EEA) and a recent study give a different picture. The 2023 XDI Global Hospital Infrastructure Physical Climate Risk Report “takes into account damages from six different climate change hazards. The results are based on an analysis combining climate hazard projections with typical hospital-specific information and spatial context data to calculate risk probabilities". It shows that the impact of extreme weather on hospitals infrastructures and healthcare delivery. Globally, the number of hospitals at risk has increased, especially in low and middle-income countries. Also the European countries present an unexpected relevant percentage of hospitals at risk of destruction.

The Pressure for Change in the Health System

The pressure for change worldwide regarding the healthcare domain was brought by the increased awareness that the health sector was not an irrelevant contributor in the production of greenhouse gases (GHGs) with a heavy carbon footprint and a relevant ecological footprint due to the consumption of energy, basic natural resources such as water, plastic pollution and the complexity of its waste.

It cannot be underestimated the real shock produced by the COVID-19 pandemic.

In many areas, such as the U.S., Canada and Australia, there were signs of major improvements Also Europe, in spite of the variety of health systems of its 27 component countries, also accelerated changes brought by the complex events.

The first and more general was the Green Deal for EU sustainability and climate neutral “In November 2019, the EU Parliament declared a climate emergency asking the European Commission to adapt all its proposals in line with a 1.5 °C target for limiting global warming and ensure that greenhouse gas emissions are significantly reduced. In response, the Commission unveiled the European Green Deal, a roadmap for Europe becoming a climate-neutral continent by 2050.^” For the EU to reach the 2030 target, it approved a package of new and revised provisions in the 2023 legislation known as Fit for 55, comprising 13 interlinked revised laws and six laws on climate and energy.

More related to COVID-19 were a set of basic changes in EU policies concerning health, some directly stimulating more attention and stressing the need for more funding for the healthcare sector, such as additional funding for the EU4HEALTH Programme to address the crisis preparedness in the EU. Another initiative called the Health Emergency Preparedness and Response (HERA) was launched as a new road in the policies of the European Union with the aim to coordinate European responses to major threats to health.

Where is the Vision of Hospital Preparedness?

A deep analysis of the documents produced by the many agencies and organisations shows evidence of the difficulties involved in constructing a common European front for the mitigation of climate-change related natural disasters. Further evaluation has brought to the following conclusions. The first remarque is that the goals indicated in the studies refer to the ones exposed by Garry Cohen, President and Co-Founder of HCWH (Health Care Without Harm), in his presentation of 2015 in the COP 21 (Conference of Parties) of Paris by pointing out three fundamental sectors of activity to three major challenges posed by climate change: reduce impact, improve resilience and advocate.

The questions that arise are: what have these activities concretely produced? In an important survey conducted of the Joint Research Centre of the EU, the Covenant of Mayor, respondents, mostly public members of local governments, left out hospital facilities from the list of the critical infrastructure to be protected in case of natural disasters. In another survey, made in the framework of the EU project about measures for GHG reductions by hospitals, the vast majority of hospital managers indicated that they didn’t consider such actions part of their core business. COVID-19 provided other examples of the crucial, yet unrecognised role of a hospital's physical infrastructure and the required flexibility and functionality, as well as the role of technicians, necessary arms of the medical/sanitary sector.

In the preceding analysis, certain attention is paid to hospitals and their resilience, but it is less clear how to operatively address the risks related to climate change. The impact of climate change on healthcare facilities and their vulnerability doesn’t appear to be sufficiently explored.

Jérémy Guihenneuc et al. (2023) identify climate changeas the biggest global health threat of the 21st century and assert that whilehealthcare facilities play a central role in the care of populations, there has been no comprehensive assessment of the impact of climate change on them. The UNDRR also identifies climate change as "the defining issue of our time” and highlights the need to increase awareness and training of all health actors (decision-makers, purchasers, health professionals, health, students, technicians, logisticians, etc.) on climate change and its challenges.  

The conclusions are clear: there is a growing understanding of the critical role of health facilities facing possible increasing disastrous events of climate change, coupled with the need that health professionals in all capacities, medical as well as technical or administrative, acquire better awareness and ensure more participation in developing measures to ensure functionalities and efficiency during disasters.

Equally essential is a reflection on terms currently used, more as concepts than as operative goals. These include adaptation, mitigation, resilience and sustainability. Adaptation is conceived as taking  action to adjust to present and future impacts while Mitigation is defined as reducing climate change acting on the reduction of greenhouse gases heat-trapping in the atmosphere. Resilience refers to the capacity of the healthcare systems to withstand shock.

The book "Strengthening Health Systems –A Practical Handbook for Resilience Testing" published in 2024 in the framework of the Organisation for Economic Cooperation and Development (OECD),  addresses its attention to problems related to the most aggressive and problematic health problems of our historic period epidemics, air pollution etc. It is not taken into consideration the assumption that healthcare facilities are a crucial part of strengthening resilience of healthcare systems.

The situation regarding Sustainability is almost the same. The American Hospitals Association (AHA) defines the parameters for each hospital's sustainability as the reduction of carbon footprint. There were, especially in the U.S., events that produced the complete destruction of hospitals. In Boston in February 2023, historically low temperatures caused emergency rooms to close due to flooding from burst pipes. Disastrous events from different types of climate change factors are now more frequent and aggressive and require actions focused on:

• increased attention to the physical structure of healthcare facilities
• revises the notion of preparedness, which needs a different vision, concepts, and supporting actions.

There is a need for a different approach to the vulnerability of healthcare infrastructure. Emergency action has to become a normal necessity and needs a different level of preparedness.

Preparedness Using the Vulnerability of Healthcare Facilities Approach

Preparedness was interpreted, till recently, the result of actions developed in the framework of adaptation and mitigation, and it was ensured by the resilience of the healthcare facility. It needs to be said thata number of institutions have not fulfilled the request for adaptation plans. Even in cases in which normal procedures were followed, however, when an exceptional event hit, the situation after the impact has frequently shown that they were, in reality, insufficient safety measures and preparation. The conclusion that can be drawn is clear and unavoidable. The escalation and unpredictable strength of climate change related disasters unequivocally impose reconsidering the level and the quality of preparedness of healthcare facilities, taking into consideration also the territorial infrastructures (road, bridges etc.) connecting them to the areas that each facility should serve.

Emergency preparedness should now be accepted as the new normal. The focus of hospital-based preparedness covers certainly the necessity of protecting the persons already hospitalised, the hospitalisation of people getting worse in their chronic illnesses, and the absolute need for the preservation of the infrastructure’s functionality for the increased demand of care of the people directly hit by the disastrous events.

The path to preparedness of hospitals should have two fronts: one, forecasting the type and intensity of the estimated risks and two, unparallelthe capacity of the single healthcare facility to stand all types of risks. But this is not what studies show. The attention to preparedness by healthcare facilities doesn’t reach the level of analytical evaluation required for preparing health systems for climate change, confirming the findings highlighted above.

The first report on the European situation by EEA published in January 2024 with EUCRA (EUropean Climate Risk Assessment) offers a guide for risk analysis and assessment and presents thematic factsheets highlighting the risks of the different systems (e.g. terrestrial and freshwater, marine and coastal Ecosystem, food production and food security etc..…) and within the all-encompassing domain of human health.

What emerges in total evidence by now is the need to consider that the risk analysis working within the framework of historical patterns is no longer sufficient. Baugh et al. (2021) propose a new approach based on the specific work done by their team to achieve a different type of prevention for this setting. The core concept of this approach is a comprehensive, system-wide climate resilience assessment for a large, geographically diverse health network in New England. The initiative involved evaluating the vulnerability of over 30 facilities—including hospitals, rehab centres, and research buildings—to key climate threats such as extreme heat, flooding, and high winds, using future climate projections for 2030 and 2070. By integrating expert consultation, regional climate data, and probabilistic and consequence-based risk mapping, the team developed tailored threat scenarios for each site. These scenarios were categorised by likelihood and impact to inform both infrastructure upgrades and emergency preparedness planning.

Climate projections is the first step of the work and represents the first innovation of this approach. The climate patterns should not be based on historical data but on climate change projections over the short and long term. Europe could take advantage of the data of Copernicus, a component of the European Union’s space programme. It is also important to take into account and examine possible data and studies produced in the same area by other authorities, city governments or private entities that have worked on projected changes in weather patterns over time.

Climate-Health Innovative Analysis

The above description, covering the most difficult and innovative part of the suggested innovation, has to be seen as the first phase  of a two-phase process that is now being labelled in other reports as Climate-Health Innovative Analysis (CHVA), which can be synthesised as follows:

Phase1 focuses on vulnerability analysis, identifying potential threats (heat, flooding, high winds, seismic tremors) and their impact on hospital functions. The unique and evolving challenges posed by climate change necessitate a shift towards more advanced and climate-specific vulnerability assessment and resilience-building strategies. As stressed before and reported by now in important studies, relying solely on historical data, which is the basis of traditional HVA, can’t adequately address the non-linear and intensifying nature of climate change impacts. An interdisciplinary team of engineers, architects, technicians, facility managers, and clinical leaders, as reported in the New England work mentioned before,collaborated to project various event levels and categorise potential consequences according to three levels  (major, severe, catastrophic).

Phase 2 centres on developing a comprehensive plan to address the identification of vulnerabilities and related need of interventions. This involves:

• Technical experts defining necessary actions to reduce or eliminate each vulnerability.
• Discussions with management, hospital staff, the supply chain, and the local leaders.
• Involving the community and increasing awareness.
• Proposing solutions based on the hospital's structure and the severity of threats, potentially including equipment relocation or structural changes.
• Acknowledging potentially high total costs for addressing all vulnerabilities.
• Strategically prioritising interventions based on scientific and technical knowledge, infrastructure familiarity, and input from various specialists.
• Consideration of the situation and safety of essential territorial infrastructures (roads, bridges etc..) and services (water, electricity, sewage, waste etc.)

The resulting plan aims to improve short-term emergency preparedness by focusing on the most likely and impactful weaknesses. It also establishes the phases of a long-term programme for increasing resilience against evolving climate threats.

The methodology offers three key takeaways for hospital managers:

a. Awareness of ongoing vulnerabilitiesaimed to create a wide-ranging vulnerability list and the degree of urgency recognising that delayed interventions leave specific areas not prioritised at risk, necessitating therefore to be matter of control measures.

b. Understanding total costs and obsolescence and evaluating the cost for each activity that possibly can eliminate the vulnerability and assess the possibilities of economic interventions. It also provides a basis to evaluate when the facility might become unviable despite investments, potentially requiring replacement with a totally new one.

c.  Long-term, adaptable programme and creating a framework for continuous improvement and updates, facilitating seamless transitions between administrations and enabling post-implementation evaluation.

This model for an innovative CHVA assures a big step forward with regard to:

a) its larger view of predictable risks related to climate change

b) its vision starting with the single vulnerabilities in their totality and strategically operating on the most probably urgent, having in the meantime all under control

c) interdisciplinary contribution and community awareness

Conclusion

It is extremely important to be aware of the necessary actions, the tools available, the results, especially in the present planetary situation characterised by the many kinds of unrest producing further impact on human health and environment, and drawbacks in terms of the One Health vision. The specific risks and vulnerabilities of each hospital will differ according to location, social characteristics and features. The approach that was synthetically presented above can be broadly applicable. To adopt, to develop a proactive and comprehensive approach are key steps for realisingclimate-ready healthcare systems as accountable factors of strength for communities. The three goals pointed out are certainly among the most relevant of  the many recommendations that can be proposed. 

Conflict of Interest

None.