key: cord-1045805-6vqzpkny
authors: Zang, Sheryl M.; Benjenk, Ivy; Breakey, Suellen; Pusey‐Reid, Eleonor; Nicholas, Patrice K.
title: The intersection of climate change with the era of COVID‐19
date: 2021-01-31
journal: Public Health Nurs
DOI: 10.1111/phn.12866
sha: 9c54d1e921141cdfbd3de49da4b2a9d99f3a984b
doc_id: 1045805
cord_uid: 6vqzpkny

The purpose of this integrative review is to examine recent literature on the intersection of SARS‐CoV‐2 (COVID‐19 novel coronavirus) and climate change that will lead to a greater understanding of the complexities of the urgent pandemic linked with the emerging climate crisis. A literature search for peer‐reviewed, English language, literature published since the pandemic emerged was conducted using Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed, and the Cochrane Library. The final sample yielded a total of 22 commentaries, editorials, discussion papers, and a research study that explicitly addressed the intersection of COVID‐19 and climate change. Sixty articles emerged in the initial review of the intersection of the COVID‐19 pandemic and climate change with the final yield of 22 articles deemed valid for inclusion after full text review. With the emergence of COVID‐19 and scholarly discourse that addresses the intersection of the pandemic with climate change, key issues emerged that intersect with policy /advocacy, social justice, and nursing's public health role in clinical practice, education, policy/advocacy, and research/scholarship. Five themes that emerged included the role of public health in COVID‐19 and climate change efforts; global approach addressing human‐environment issues; intersection of COVID‐19 and climate change from a community and global perspective; impacts of COVID‐19, climate change and the environment and professional associations and specialty organizations’ views and responsibilities with a lens on COVID‐19 and climate change. Despite the importance of addressing racial inequities as well as systemic and structural racism that impacts those most affected by climate change and pandemics such as COVID‐19, no literature addressed this topic. Public health nursing has a critical role in addressing climate change and the pandemic response to COVID 19 in the 21st century.

(2020) suggested that the pandemic directly threatens individuals, populations, and health systems, while climate change undermines broader natural, ecological, human systems, and populations.

From a global perspective, it is well established that climate change represents a looming health emergency with Lancet and Intergovernmental Panel on Climate Change reports on climate change and health contributing to our current state of the science and understanding of the deleterious health consequences associated with climate change (Intergovernmental Panel on Climate Change, 2018; Watts et al., 2019) . There is a pressing need for health professionals to galvanize the response to both of these challenges for the health of the world's people. The purpose of this integrative review is to examine the intersection of climate change and COVID-19.

While the threat of COVID-19 is urgent for individual, community, population, and global health, climate change is more insidious in its impact and a slow march to progressively worsening human health. Nursing has a pivotal role in addressing climate change, climate justice, and health. In our institution at the MGH Institute of Health Professions School of Nursing, the first school of nursing-led Center for Climate Change, Climate Justice, and Health was established to address the deleterious health consequences of climate change and the critical need for health professions education.

Literature suggests that education of all of the health professions is integral to address the leading public health challenge of our time;

in health professions education curriculum development, integration of climate change knowledge in clinical practice, policy/advocacy efforts, and research and scholarship about climate and health are key areas for the future (Maxwell & Blashki, 2016) . In the midst of the COVID-19 pandemic, it is important to leverage both climate change and associated pandemics to address the future of public health in the 21st century. From a nursing professional lens from the International Council of Nurses, Catton (2020) notes:

The next decade is likely to produce any number of global challenges that will affect health and health care, including pannational infections such as the new coronavirus, COVID-19 and others that will be related to global warming (p. 4).

It is well known that animals including bats are reservoirs for several viruses and were a conduit for the Ebola epidemic as well as severe acute respiratory syndrome (SARS) Coronavirus 1, Middle Eastern Respiratory Syndrome (MERS), and the emergence of COVID-19 (Hemida & Ba Abduallah, 2020) . Habitat disruption is the main driver of loss of biodiversity, and climate change may play a role by forcing species to shift habitat and changing geographical range of species (Bale, 2020; Xiao et al., 2020) . As species shift habitats, this brings animals in closer range to humans and livestock which then serve as a vehicle for launching a global pandemic. Even more extreme conditions existed in Wuhan, China, the epicenter of the COVID-19 pandemic, where bats and pangolins-with pangolins recently emerging as vectors for transmission of viruses-are suggested as vectors for coronaviruses since they are housed in crowded, open markets with close and often squalid conditions (Bale, 2020; Xiao et al., 2020) . Pangolins are similar to bat species as mammals that are known to be able to be infected with viruses such as coronaviruses (Bale, 2020; Morens et al., 2020; Xiao et al., 2020) . Emerging evidence may support that in our climate-changing world, there is encroachment on animal habitats which may impact health and risk for infectious diseases; thus there is a need for urgent efforts to limit climate change to address the emergence of new pandemics in the future (Bernstein, 2020) .

As discussed by Schwartz (2020) , the intersection of climate change and COVID-19 has emerged as the most complex and threatening public health challenge ever encountered-surpassing the Influenza Pandemic that emerged in 1918 when environmental degradation had not yet accelerated. Further Schwartz suggests:

The question that haunts my mind is, how would the United States handle such a pandemic outbreak if it occurred as the coronavirus did in China, just as some kind of major climate change crisis was also stressing the American healthcare system. Are we prepared? I don't think so, do you? The reality is that not only America but the world is utterly unprepared for these outbreaks, and when one adds the migrations that climate change will compel things look very bleak indeed (p. 141).

Global Environmental Health Day was held on July 1, 2020 and Columbia University's Earth Institute released a State of the Planet report on COVID-19's Long-Term Effects on Climate Change-For Better or Worse (Cho, 2020) . Furthermore, because of recommendations for lockdowns, social distancing, and work from home advisories, significant decreases in transportation occurred globally and limited industrial activity resulted in a 17% decrease in daily carbon emissions in April (Cho, 2020 ). Cho's commentary suggested that there have been opportunities to both improve and detract from improving public health in the time of COVID-19 with a lens on climate change. Areas of concern included plans to withdraw from the Paris Climate Accord of 2015, delays in international negotiations regarding climate change and the planned climate meeting of November 2020, deforestation in the Amazon accelerating during the pandemic, weakening of climate policies in the US and rollback of US measures. Additional areas of concern identified by Cho are disruption of science research during the pandemic, less funding for climate resilience and renewable energy, and an increase in use of plastic to prevent spread of COVID-19. However, Cho notes that there are areas of improvement amidst COVID-19 that may positively impact public health including a green recovery in other countries with funding for renewable energy sources, more biking and walking as a COVID/climate change co-benefit, less international travel since transportation represents 23% off global carbon emissions and 11% reduction by aviation (Cho, 2020) . It is important to note that the pandemic has led to simpler living and increased engagement of many in the important role of science in both public health and pandemic response. Wu et al. (2020) at the Harvard School of Public Health also suggested that air quality may impact severity of illness in COVID-19.

They found that long-term exposure to fine particulate matter has been associated with a 15% increase in the COVID-19 death rate, even after controlling for other health conditions. Although this study did not explicitly link air quality with climate change, further research is needed on this important linkage. In the United States, we have also seen significantly higher rates of COVID rates and COVID morbidity and mortality among Blacks and Hispanics (Price-Haywood et al., 2020) . Racial and ethnic minorities are more likely to reside in communities with higher rates of pollution and particulate matter (Mikati et al., 2018) . The high rate of COVID mortality in these communities has been attributed to pre-existing conditions including respiratory illness and poor access to high quality care, but it does appear that climate change may also play a role in the etiology of poor air quality and increasing these disparities. Manzanedo and Manning (2020) analyzed the intersection of COVID-19 and the urgent climate crisis addressing the unique areas of overlap and differences between the two crises and the key lessons that can be learned. These lessons include "high momentum trends; irreversible changes; social and spatial inequality; weakening of international solidarity, and less costly to prevent than to cure" (p. 1). Notably, they view one critical difference: since the COVID-19 pandemic emerged rapidly while the climate crisis has had a decades-long emergence with a looming crisis by 2030 if urgent action is not taken. Regarding lessons of COVID-19 and climate change, high momentum trends also identified as time lags refer to the delayed response to the pandemic and to climate change science. The authors noted that ignoring calls to action are costlier in the long run. Irreversible changes are pressing for the climate crisis since unless greenhouse gases are reduced, there will be planetary changes that are irreparable with significant damage that may negatively impact health. Social and spatial inequality refers to aspects of social determinants of health including poverty, inequity between wealthy and poor nations, lack of access to care by many of the world's people, and increased risk by race/ethnicity for black/ brown populations. This is significant for both COVID-19 whereby African-American and Hispanic populations are disproportionately affected by the pandemic in the US and have significantly poorer outcomes (Azar et al., 2020) . The weakening of international solidarity since the Paris Agreement and the US withdrawal from the treaty is another key area of international weakening in the global commitment to address climate change. The fact that both the pandemic and climate change are less costly to prevent rather than to cure is a significant outcome of both challenges that we face.

As Kerry (2020) wrote "climate change and [are] truly the tale of two pandemics deferred, denied, and distorted, one with catastrophic consequences , the other with even greater risk if we don't reverse course [climate change]" (p. A8).

A search for peer-reviewed, English language, literature published in the scientific literature since the pandemic emerged in 2020 was developed using the following databases: Cumulative Index for Nursing and Allied Health (CINAHL), Pubmed, and the Cochrane Library. Search terms used were "climate change," "global warming," "pandemic," "SARS-CoV-2," and "COVID-19." Only articles published during 2020 were included since the COVID-19 epidemic globally emerged in late 2019 with the eruption of the pandemic in January to February 2020. In the initial review process, article titles and abstracts were reviewed for relevance for inclusion. Subsequently full text of the initial review was conducted by two authors to determine relevance based on the inclusion criteria. Exclusion criteria were aimed at limiting any articles that did not address COVID-19 and its intersection with climate change. The review of articles was 

The results of this integrative review represent the key insights, findings, and themes from the selected articles, as detailed in Table 1 .

Five themes, based on two independent reviews, emerged from the papers that were selected for inclusion: role of public health in COVID-19 and climate change efforts; global approach addressing human-environmental issues; COVID-19 and climate change from a community and global health perspective; environmental impacts of COVID-19 and climate change and built environment; and professional associations' and specialty organizations' views and responsibilities with a lens on COVID-19 and climate change. It is clear that the threat-amplifying effects of the intersection of COVID-19 and climate change require a cohesive, coordinated, and comprehensive response from public health professionals and particularly public health nurses who are at the forefront of care.

The response to COVID-19 demonstrates that a comprehensive approach that is embodied in the principles of public health practice is key. This pandemic response has resulted in grave concerns about the possibilities of a pandemic response intersecting with a climate change emergency (Catton, 2020) . Disasters that are occurring due to greenhouse gas emissions such as air quality issues, hurricanes, flooding, wildfires, heat stress, and heat stroke due to increasing ambient temperatures, and increased vector-borne illnesses should be considered amidst the COVID-19 pandemic. Although greenhouse gas emissions have decreased during the COVID-19 pandemic, it is important to consider resurgence of these emissions post COVID-19 that are likely to occur globally.

One article by Benjamin (2020) supported this theme and offered a recent opinion and analysis. As current president of the American Public Health Association, Benjamin noted that the recent COVID-19 pandemic has not only stressed public health systems in countries globally, but also has further uncovered gaps in health care for those deeply affected by poorer social determinants of health. It is important to note that both COVID-19 and climate change disproportionately affect disadvantaged populations with climate change affecting those who least contribute to greenhouse gas emissions. F I G U R E 2 Preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) checklist: climate change in the era of COVID-19

Title 1 Identify the report as a scoping review.

Integrative review identified in Introduction on page 2. ABSTRACT

Provide a structured summary that includes (as applicable): background, objectives, eligibility criteria, sources of evidence, charting methods, results, and conclusions that relate to the review questions and objectives.

Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.

Rationale described in Introduction and why climate change and COVID-19 should be explored in this review on pages 2-3.

Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Purpose statement and objectives described in Introduction and key elements on pages 2 to 3.

Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

No review protocol or registration exists. Only the approach to the literature review and library search on page 7.

Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

Sources of evidence and characteristics of the search are addressed in Methods including Cumulative Index for Nursing and Allied Health (CINAHL), Pubmed, and the Cochrane Library. Search terms used were "climate change", "global warming", "pandemic", "SARS-CoV-2", and "COVID-19". Only articles published during 2020 were included since the COVID-19 epidemic globally emerged in late 2019 with the eruption of the pandemic in January to February 2020. See page 7.

Describe all information sources in the search (e.g., databases with dates of coverage and Cumulative Index for Nursing and Allied Health (CINAHL), Pubmed, and the Cochrane Library. Search terms used SECTION ITEM PRISMA-ScR CHECKLIST ITEM REPORTED ON PAGE # contact with authors to identify additional sources), as well as the date the most recent search was executed.

were "climate change", "global warming", "pandemic", "SARS-CoV-2", and "COVID-19". Only articles published during 2020 were included since the COVID-19 epidemic globally emerged in late 2019 with the eruption of the pandemic in January to February 2020. See page 7.

Search 8

Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated.

Cumulative Index for Nursing and Allied Health (CINAHL), Pubmed, and the Cochrane Library. Search terms used were "climate change", "global warming", "pandemic", "SARS-CoV-2", and "COVID-19". Only articles published during 2020 were included since the COVID-19 epidemic globally emerged in late 2019 with the eruption of the pandemic in January to February 2020. See page 7.

Selection of sources of evidence † 9

State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review.

In the initial review process, article titles and abstracts were reviewed for relevance for inclusion. Subsequently full text of the initial review was conducted by two authors to determine relevance based on the inclusion criteria. Exclusion criteria were aimed at limiting any articles that did not address COVID-19 and its intersection with climate change. The final sample of articles represented 22 papers yielded in our search from January 2020 through June 2020 that addressed the intersection of COVID-19 and climate change. Sixty articles emerged in the original search of the intersection of the COVID pandemic and climate change with 22 articles determined for inclusion in this paper. Two reviewers conducted the full article reviews. See page 7.

Data charting process ‡ 10

Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators.

Data were independently reviewed by two reviewers and charted and then sources of evidence independently conducted the full article reviews and concurred on findings. Page 8.

List and define all variables for which data were sought and any assumptions and simplifications made.

Search terms used were "climate change", "global warming", "pandemic", "SARS-CoV-2", and "COVID-19". Page 7. Critical appraisal of 12 If done, provide a rationale for conducting a critical appraisal of Critical appraisal was accomplished of the individual sources of evidence by

SECTION ITEM PRISMA-ScR CHECKLIST ITEM REPORTED ON PAGE # individual sources of evidence included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate). two reviewers. Most papers were commentaries or discussion papers. Discussed in the Findings section on page 8.

Describe the methods of handling and summarizing the data that were charted.

Data are synthesized in Results Summary Table and Themes are described in the Findings. In Table 1 .

Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

PRISMA diagram illustrates included/excluded articles. In Figure 1 . For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

Summarize and/or present the charting results as they relate to the review questions and objectives.

Synthesis of results are presented in Findings beginning on page 8.

Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups. Lorentzen and colleagues offered their views on COVID-19 as a consequence of a biodiversity crisis related to climate change (Lorentzen et al., 2020) . With habitat destruction and climate change, they suggested that the biodiversity crisis will accelerate as the main driver of our current and future emerging pandemics. They also noted that the emergence of (2020) focused on the importance of water in the era of climate change and COVID-19 and examined the importance of access to fresh water for regular handwashing during the pandemic. They further urged that fresh water be provided free of cost to engage populations in hygiene recommendations and to limit spread of COVID-19. As they suggested, access to water is inextricably linked with climate change and integrally related to limiting the spread of the current pandemic.

A commentary by Herrero and Thornton (2020) inquired: "What can COVID-19 teach us about responding to climate change?" (p. e174).

Their most important lesson is that investment in behavioral responses such as social distancing and engagement of governments, businesses, and resource mobilization can be achieved and may limit the spread of the pandemic. They noted that "governments have found $8 trillion to help combat the spread and effects of COVID-19 in just 10 weeks" Rosenbloom and Markard (2020) offered a lens on COVID-19 recovery for our struggling climate and planet. One outcome may be that there are opportunities to catalyze change on climate change for communities, nations, and globally as we address the COVID-19 pandemic. Other key messages offered by Jin are that it is essential to act now before it is too late; that science and facts matter; that international collaboration is critical; and we must respect mother nature.

Goymann (2020) 

Although relatively few professional associations and specialty organizations have addressed the intersection of climate change and COVID-19, Coates and colleagues (2020) examined the critical role of advancing public health and climate action from the perspective of the International Society of Dermatology's Climate Action Committee.

They urged a wake-up call for the convergence of climate change and COVID-19 and meaningful action for both of these global health crises. The American Thoracic Society (ATS) discussed the importance of shared responsibility in engaging in action to confront COVID-19 and climate change (Shankar et al., 2020) . 

The themes that emerged from this integrative review of the inter- (Gostin & Powers, 2006) . Widely viewed as embedded in public health practice, social justice-the idea that benefits and burdens should be equally distributed within a society-is embedded in the efforts that were espoused by Beauchamp (1999) and Powers and Faden (2006) . (2014) noted that there are complex disparities and social inequalities related to health challenges for those who least contribute to greenhouse gas emissions, yet are disproportionately affected by the negative health outcomes in our climate-changing world.

Finally, Edmonds, Kneipp, and Campbell (2020) offered key considerations for public health nurses to address the pressing issues of the COVID-19 era. They argued that there are urgent acute and chronic health issues that are paramount during this unprecedented pandemic. Edmonds et al. described the key roles of public health nurses in investigating case contact searches, education about social distancing and face covers as key opportunities for minimizing COVID spread, and educating the public about guidelines from the CDC. Further they noted that public health nurses are experts in responding to infectious and chronic disease challenges, and offering safe, nondiscriminatory care that can successfully address systemic and structural racism and challenges that disproportionately affect black/brown people in our COVID-19 situation. These same populations are also disproportionately affecting these populations in our climate-changing world. In this review, we supported these views and further advocated that public health nursing has an important role in linking COVID-19 and the complex health challenges posed by the pandemic with the dire health consequences that are inextricably linked with climate change.

As evidenced by the themes yielded from this review, nursing has a global role which requires an urgent response in public health challenges locally, regionally, nationally, and internationally. Further were ambiguous and at times-conflicting-early in the pandemic.

Emerging knowledge and development of an effective vaccine will galvanize our future public health response and amplify current public health recommendations aimed at limiting the spread of COVID-19. Similarly, fostering a unified message and a comprehensive public health approach to address the crisis of climate change and associated health consequences also requires persistence by public health nurses in addressing the needs of individuals, families, communities, and populations in the face of this complex intersection of COVID-19 and climate change.

The authors report no conflicts of interest.

All data that emerged from this study are available from the corresponding author, Dr. Patrice Nicholas.

Suellen Breakey https://orcid.org/0000-0001-9298-2336

Patrice K. Nicholas https://orcid.org/0000-0001-9519-7587

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