CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA A Special Report of the Montana Climate Assessment January 2021 www.montanaclimate.org CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA A Special Report of the Montana Climate Assessment Alexandra Adams1, Robert Byron2, Bruce Maxwell3, Susan Higgins4, Margaret Eggers5, Lori Byron6, Cathy Whitlock7 1 Director and Principal Investigator, Center for American Indian and Rural Health Equity Montana State University Bozeman, MT 2 Montana Health Professionals for a Healthy Climate Hardin, MT 3 Professor of Agroecology and Applied Plant Ecology, Department of Land Resources and Environmental Science, and co-Director of the Montana Institute on Ecosystems Montana State University Bozeman, MT 4 Community Research Associate, Center for American Indian and Rural Health Equity and Montana INBRE Montana State University Bozeman, MT 5 Research Assistant Professor of Environmental Health, and Associate Director, Environmental Health Program, Department of Microbiology and Cell Biology Montana State University Bozeman, MT 6 SCL Health, Retired Indian Health Service Hardin, MT 7 Regents Professor in Earth Sciences, and Fellow of the Montana Institute on Ecosystems Montana State University Bozeman, MT Fire in the Bridger Mountains, September 2020 Photo courtesy of Bruce Maxwell This report is funded by a grant from the Montana Healthcare Foundation. Additional support is provided by the National Science Foundation Experimental Program to Stimulate Competitive Research Cooperative Agreement #EPS-110134, and by the National Institute of General Medical Sciences of the National Institutes of Health under award #P20GM104417 to the Center for American Indian and Rural Health Equity at Montana State University. Any opinions, findings, statements, conclusions, and/or recommendations expressed in this report are solely those of the authors and do not necessarily reflect the views of these funding organizations. Climate Change and Human Health in Montana: A Special Report of the Montana Climate Assessment is available in digital format at www.montanaclimate.org. Madison Boone of Montana State University’s Institute on Ecosystems served as Project Manager for this Wildfire smoke, September 2020, East Wind Creek near Crow Agency Photo courtesy of John Doyle report. Scott Bischke of MountainWorks Inc. (www.emountainworks.com) served as the science editor for the report, as well as print-copy designer and website developer. Front cover photo from iStock by Getty Images. Photos throughout the report are credited, with the authors’ great thanks to the photographers. Photos in this report without credit come from sources requiring no attribution. CONTENTS iv Figures vii Tables Please cite this publication as: viii acknowledgmenTs Adams A, Byron R, Maxwell B, Higgins S, Eggers M, Byron L, Whitlock C. 2021. Climate change and human health in Montana: a special report of the Montana Climate Assessment. Bozeman MT: Montana State xiii lisT oF acronyms University, Institute on Ecosystems, Center for American Indian and Rural Health Equity. 216 p. https:// doi.org/10.15788/c2h22021. xiv Foreword Aaron Wernham MD, MS xvii summary oF key messages and recommendaTions xxi Literature Cited 1 01. inTroducTion Cathy Whitlock and Alexandra Adams 2 Concerns for the Vulnerable 4 Report Purpose and Genesis 4 Literature Cited 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | I 7 02. climaTe change and human healTh in monTana 91 American Indians Cathy Whitlock 93 People lacking adequate health insurance 93 People with mental health issues 8 Montana’s Unique Geography 95 What Conclusions Can We Draw? 8 Climate Differs from Weather 96 Literature Cited 9 The Science of Projecting Montana’s Future Climate: An Overview 12 Temperature 109 05. climaTe healTh acTions 14 Precipitation Margaret Eggers, Alexandra Adams, and Susan Higgins, 16 Climate Concerns for Human Health with contributing authors Robert Byron, Amy Cilimburg, Angelina Gonzalez-Aller, Paul Lachapelle, 17 Extreme heat Miranda Margetts, Jennifer Robohm, and Nick Silverman 17 Smoke and air quality 18 Climate “surprises” 111 Community Actions: Teaming Up for Success 21 Summary 112 Steps to create a community climate action plan 115 Act on climate change not only for public health, but also economic well-being 21 Literature Cited 115 Communities need climate and health data for planning and action 03. c - h i 120 Strategies and actions for communities25 limaTe relaTed ealTh mpacTs 129 Strategies and Actions for Healthcare Practitioners and Institutions Robert Byron, Bruce Maxwell, Nick Silverman, Philip Higuera, Madison Boone, and Dave McWethy 129 Practitioners 27 Extreme Heat 131 Healthcare institutions 29 Human impacts from excessive heat 135 Strategies and Actions for Individuals 30 Assessing heat impacts specific to Montana 136 Extreme events and disaster planning 36 Air Quality Issues 136 Heat 36 Overview 138 Air quality 38 Wildfires and wildfire smoke 141 Flood and drought 143 Food security 43 Water-related Illnesses 144 Vector-borne disease 44 Food Security and Nutrition Concerns 146 Mental health: getting involved and finding support 47 Vector-borne Disease 147 What Professional Organizations are Saying 51 Mental Health Concerns 149 Literature Cited 52 Literature Cited 159 06. moVing Forward 71 04. whose healTh is mosT Vulnerable To climaTe change impacTs? Alexandra Adams Susan Higgins, Alexandra Adams, and Margaret Eggers, with contributing authors Lori Byron, Paul Lachapelle, Sally Moyce, Richard Ready, Lisa Richidt, 161 appendix a. analysis oF VulnerabiliTy To heaT based on hisToric Jennifer Robohm, and Eliza Webber and FuTure TemperaTure, as well as socioeconomic FacTors 73 Montana’s Health Profile Nick Silverman, Bruce Maxwell, and Robert Byron 73 Montana is a rural state 161 Multi-criteria Decision Analysis 76 Health-wise, where you live matters 162 Exposure Calculations 78 Key health issues in Montana 162 Sensitivity Calculations 80 Populations Vulnerable to Climate Change 80 People with existing chronic conditions 164 Weighting Scheme 80 People threatened by increased heat 164 Results 83 People living in proximity to wildfire and smoke 167 Literature Cited 85 People facing food and water insecurity 87 People who are very young, very old, or pregnant 168 appendix b. communiTy Tools and resources 88 People with limited access to healthcare services 90 People living in poverty 175 glossary 183 lisT oF conTribuTors II | CONTENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | III FIGURES 38 Figure 3-5. Annual area burned by, and number of, wildfires in Montana 2001-2019. 39 Figure 3-6. NASA composite satellite image from 11 September 2017, showing fires in the Cascades and Rockies and smoke as far east as the Great Lakes. (Image source Wikipedia; used under Creative Commons attribution-share alike 4.0 international license [user “Bri”]. https:// commons.wikimedia.org/wiki/File:2017_September_5_MODIS_Pacific_to_Minnesota.jpg.) xvii Figure Key Messages-1. A depiction of evidence and agreement statements and their relationship to confidence. Confidence increases towards the top-right corner as suggested 41 Figure 3-7. Number of days with extreme fire danger over time in Montana. by the increasing strength of shading. Generally, evidence is most robust when there From top to bottom we show the historical pattern, the mid-century projection are multiple, consistent, and independent lines of high-quality evidence (figure and under RCP8.5 (upper-bound emission scenario), and the projected change caption following that presented in the IPCC Fifth Assessment Report [IPCC 2014]). in number of extreme fire days from 1971-2000 to mid century. 9 Figure 2-1. Montana consists of 56 counties. 42 Figure 3-8. The number of communities, counties, and regions in Montana where wildfire smoke led to varying air quality ratings (MTDEQ 10 Figure 2-2. Montana’s seven climate divisions. Note that NOAA undated), and number of acres burned by wildfire each year. officially names the northwestern division on this map as the western division. We use northwestern for geographic clarity. 49 Figure 3-9. Map showing 2018 detections of West Nile virus in humans and horses, by county (MTDPHHSc undated). 13 Figure 2-3. The projected increase in annual average daily maximum temperature (°F) for each climate division in Montana for the periods 2049-2069 and 2070-2099 for (A) stabilization 72 Figure 4-1. Montana’s 56 counties ranked with respect to health factors (factors (RCP4.5) and (B) upper-bound (RCP8.5) emission scenarios (Whitlock et al. 2017). that drive how long and how well we live including, for example, personal behaviors, socioeconomic factors, and the physical environment). The higher the 14 Figure 2-4. The Montana Drought and Climate report from the Montana Climate Office number, the greater the health challenges (Givens et al. 2019). Note: Figure 2-1 showing snowpack in 2018 as measured by the April 1 snow water equivalent (MCO 2019). provides a map showing and naming Montana’s 56 counties. Note that some This high snowpack was the result of interannual climate variability, which set up a strong counties are not ranked due to low population numbers and/or lack of data. La Niña-type climate pattern in the western US. With projected warming in the future, snowpack will be greatly reduced by April 1, making these high-snow years increasingly rare. 74 Figure 4-2. Population status of Montana’s 56 counties. The three statistical areas shown are defined as follows: Rural areas are counties with an urban cluster having less than 16 Figure 2-5. Projected monthly change in average precipitation (inches; color scale to the 10,000 people. Micropolitan areas have at least one urban cluster of at least 10,000 but right) for each climate division in Montana in the mid-century projection (2040-2069) for (A) less than 50,000 population, plus adjacent territory that has a high degree of social and stabilization (RCP4.5) and (B) upper-bound (RCP8.5) emission scenarios (Whitlock et al. 2017). economic integration with the core as measured by commuting ties. Metropolitan areas have at least one urbanized area of 50,000 or more population, plus adjacent territory 26 Figure 3-1. Ways climate change is harming, and will increasingly that has a high degree of social and economic integration with the core as measured harm, human health (Salas et al. 2018). by commuting ties. The analysis here was created from OMB (2010) and US Census 29 Figure 3-2. How heat affects our bodies. When temperature and humidity climb Bureau (2018a) data. Montana’s tribal reservations, numbered, are outlined in gray: 1) during extreme heat events, the body’s cooling mechanisms become less effective. Blackfeet Tribe of the Blackfeet Reservation; 2) Chippewa Cree Tribe of the Rocky Boy’s The symptoms shown here—ranging from minor annoyances to truly life-threatening Reservation; 3) Confederated Salish and Kootenai Tribes of the Flathead Reservation; 4) issues—include both those that are indicative of heat-related illness and those that Crow Tribe of the Crow Reservation; 5) Assiniboine (Nakoda) and Gros Ventre (Aaniiih) are signs of preexisting conditions exacerbated by extreme heat. Figure and caption Tribes of the Fort Belknap Reservation; 6) Assiniboine and Sioux Tribes of the Fort Peck used with permission from The Union of Concerned Scientists (UCS 2019). Reservation; and 7) Northern Cheyenne Tribe of the Northern Cheyenne Reservation. 32 Figure 3-3. The county average land-surface temperature on days with extreme heat from 76 Figure 4-3. Range of percent change in population for Montana’s 56 counties from 2010- 2000-2019. Note: Land-surface temperatures are higher than air temperatures measured 2018 (US Census Bureau 2018d). Montana’s tribal reservations, numbered, are outlined in at weather stations. The scale to the right shows color-coding for temperature in oF. gray: 1) Blackfeet Tribe of the Blackfeet Reservation; 2) Chippewa Cree Tribe of the Rocky Boy’s Reservation; 3) Confederated Salish and Kootenai Tribes of the Flathead Reservation; 34 Figure 3-4. Montana heat vulnerability ratings for mid century, using multi-criteria 4) Crow Tribe of the Crow Reservation; 5) Assiniboine (Nakoda) and Gros Ventre (Aaniiih) decision analysis and the RCP8.5 emission scenario (explained in Section 2). Darker Tribes of the Fort Belknap Reservation; 6) Assiniboine and Sioux Tribes of the Fort Peck shading indicates higher vulnerability. See text and Appendix A for details. Reservation; and 7) Northern Cheyenne Tribe of the Northern Cheyenne Reservation. Iv | CONTENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | v 82 Figure 4-4. Heat-related illness rate by industry (used with permission from Moyce and Nealy 2019). TABLES 89 Figure 4-5. Location and type of healthcare facilities in Montana (RHIhubb 2018). 75 Table 4-1. Distribution of Montana population growth, 2010-2018a 112 Figure 5-1. The CDC’s Climate-Ready States and Cities Initiative (see https://www.cdc. 77 Table 4-2. Differences in health outcome measures among counties gov/climateandhealth/climate_ready.htm) competitively funds states and large cities to and racial/ethnic groups in Montana (Givens et al. 2019) implement the five-step BRACE framework shown here and described in the text. 79 Table 4-3. Comparisons of Montana and US rates for incidence of five 144 Figure 5-2. An example of vector-borne disease tracking that citizens can priority health issues. See text for a description of each issue. access from the Montana Department of Public Health and Human Services website (start at https://dphhs.mt.gov/publichealth/cdepi/surveillance). 93 Table 4-4. Percentage of Montana residents with health insurance in 2017 (US Census Bureau undated) 146 Figure 5-3. Creating art of all kinds—painting, drawing, sculpture, poetry, literature, photography, and more—can help increase emotional resilience during times of stress, 130 Table 5-1. Information sources useful for healthcare providers, be they individuals or facilities.a including that related to climate change. Art provides anyone, young or old, a place to express his or her fears or hopes, or to encapsulate an idea or a moment in time. 163 Table A-1. County rankings based on socioeconomic variables that are sensitive to Here, for example, environmental engineer and painter Katie Lindberg has captured heat using 2013-2017 data (closeness not used for ranking, but ranking associated the essence of this report on climate change and human health in Montana. with vulnerability so median income and percent professional jobs are ranked high if values are low and all other variables ranked from low to high). Two notes associated 165 Figure A-1. Montana heat vulnerability ratings from the multi-criteria decision analysis. with the socioeconomic column: a) If average median household income was low for a county relative to the other counties in Montana then the rank would be high (i.e., more 166 Figure A-2. Monte-Carlo analysis of socioeconomic weights to predict closeness sensitive to heat); b) If the percentage of professional jobs in the county was low relative to ideal (not vulnerable) is used as the metric of human health vulnerability. to other Montana counties then the rank would be high (i.e., more sensitive to heat). 168 Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and teachers to help plan for, address, and inform about climate change impacts.a The “M” trail above Bozeman Photo courtesy of Scott Bischke vI | CONTENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | vII Summer fun, late June, Little Bighorn River Photo courtesy of John Doyle ACKNOWLEDGMENTS Assembling Climate Change and Human Health in Montana: A Special Report of the Montana Climate Assessment has involved the collaboration and valued expertise of many health practitioners and climate scientists. In the list below, we acknowledge and thank those individuals, as well as others who reviewed the report, provided strategic guidance or input, and/or helped in the literature review process. The authors of this report gratefully acknowledge the Montana Healthcare Foundation for providing funds to support this effort. Selena Ahmed, PhD, Associate Professor, Department of Health and Human Development, Montana State University, Bozeman, MT The authors would like to thank and acknowledge the report’s four external reviewers, who provided their vaulable time to help us verify and improve this work. We are most grateful for John Doyle, Crow Tribal Elder, Director and NSF Principal Investigator, Crow Water Quality their expertise. Project, Crow Environmental Health Steering Committee, Little Big Horn College, Crow Agency, MT Margaret Hiza Redsteer PhD, School of Interdisciplinary Arts and Sciences, University of Washington-Bothell, Bothell, WA, Crow Tribal Member Mike Durglo, Jr., BS, Tribal Historic Preservation Department Head, Confederated Salish and Kootenai Tribes, Pablo, MT Kelsey Jencso, Montana State Climatologist, University of Montana, Missoula, MT Termaine Edmo, BSW, Climate Change Coordinator, Blackfeet Nation, Browning, MT Philip J. Landrigan MD, MSc, Director of the Global Public Health Program and Global Pollution Observatory, Amherst College, MA Julia Hobson Haggerty, PhD, Associate Professor, Deptartment of Earth Sciences, Montana State University, Bozeman, MT Jonathan Patz, MD, MPH, Director of the Global Health Institute, University of Wisconsin- Madison, Madison, WI Greg Holzman, MD, MPH, State Medical Officer, Montana Department of Public Health and Human Services, Helena, MT vIII | ACKNOWLEDGMENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | Ix Meredith Howard, MS in Community Health, Bozeman, MT The authors of this report would also like to acknowledge the input and guidance of the following people who attended or advised a 2018 focus group regarding climate change and human health Kelsey Jencso, PhD, State Climatologist, Montana Climate Office, Missoula, MT in Montana. Affiliations shown are those each individual had at the time of that meeting. We hope, trust, and plan that the important conversation that started with this focus group, then built to JoRee LaFrance, Doctoral Student, Department of Environmental Science, University of Arizona, this report, will continue into the future. Tuscon, AZ Alexandra Adams, Director and Principal Investigator, Center for American Indian and Rural Myra Lefthand, MSW, violence Against Women Project Coordinator, and Member, Crow Health Equity, Montana State University, Bozeman, MT Environmental Health Steering Committee, Little Big Horn College, Crow Agency, MT Ann Bertagnolli, Program Coordinator, Montana INBRE, Montana State University, Bozeman, Katie Lindberg, Environmental Engineer, University of Colorado, Boulder, CO MT Sarah Lorch, Nursing Student and Climate Advocate, Montana State University, Bozeman, MT Kyle Bocinsky, Research Associate, Montana Climate Office, Missoula, MT Christine Martin, MS, Program Coordinator and US Department of Agriculture Principal Madison Boone, Program and Communications Manager, Montana Institute on Ecosystems, Investigator, Crow Water Quality Project, Crow Environmental Health Steering Committee, Montana State University, Bozeman, MT Little Big Horn College, Crow Agency, MT Zach Brown, Program Manager, One Montana, Bozeman, MT Christopher T. Migliaccio, PhD, Research Associate Professor, Skaggs School of Pharmacy, University of Montana, Missoula, MT Lori Byron, SCL Health, Retired Indian Health Service, Hardin, MT Raina Plowright, PhD, DvM, Associate Professor, Department of Microbiology and Immunology, Robert Byron, Montana Health Professionals for a Healthy Climate, Hardin, MT Montana State University, Bozeman, MT John Doyle, Director and NSF Principal Investigator, Crow Water Quality Project, Crow Julia Ryder BSN, RN, CEN, Board Member, Montana Health Professionals for a Healthy Climate, Environmental Health Steering Committee, Little Big Horn College, Crow Agency, MT Bozeman, MT Dorothy Dupree, Director, Indian Health Services, Billings, MT Mark Schure, PhD, Assistant Professor, Department of Health and Human Development, Montana State University, Bozeman, MT Margaret Eggers, Research Assistant Professor, Associate Director of Environmental Health Program, Department of Microbiology and Immunology, Montana State University, Emery Three Irons, MS, Principal Investigator, GIS Watershed Project, and Member, Crow Bozeman, MT Environmental Health Steering Committee, Little Big Horn College, Crow Agency, MT Matt Ferguson, Toxicologist, Montana Environmental Health Education and Assessment Gerald Wagner, BS, Director, Blackfeet Environmental Office, Blackfeet Nation, Browning, MT Program, Montana Department of Public Health and Human Services, Helena, MT Laura Williamson, MPH, State Epidemiologist, PHSD, Montana Department of Public Health and Ronni Flannery, Director of Advocacy, Healthy Air Campaign, American Lung Association, Human Services, Helena, MT Missoula, MT Sara Young, MEd, Consultant, Great Beginnings for Healthy Native Smiles, Northern Arizona Susan Higgins, Research Associate, Center for American Indian and Rural Health Equity and University, Flagstaff, AZ; and Member, Crow Environmental Health Steering Committee, Montana INBRE, Montana State University, Bozeman, MT Little Big Horn College, Crow Agency, MT Greg Holzman, State Medical Officer, Montana Department of Public Health and Human Services, Helena, MT x | ACKNOWLEDGMENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xI Kelsey Jencso, State Climatologist, Montana Climate Office, Missoula, MT LIST OF ACRONYMS Kristin Juliar, Director, Montana Office of Rural Health, Montana State University, Bozeman, MT Carson Kadas, Student, University of Montana, Missoula, MT CDC—Centers for Disease Control and Prevention Libby Khumalo, Program Manager, Climate Resilience, Center for Large Landscape ENSO—El Niño-South Oscillation Conservation, Bozeman, MT GCM—general circulation model Paul Lachapelle, Professor, Department of Political Science, Montana State University, GHG—greenhouse gas Bozeman, MT HEPA—high-efficiency particulate air (filters) Erin Landguth, INBRE Researcher, School of Public and Community Health Sciences, University HvAC—heating, ventilation, and air conditioning (systems) of Montana, Missoula, MT IPCC—Intergovernmental Panel on Climate Change Mitch Lassa, Member, Big Sky Watershed Corps, Bozeman, MT MCA—Montana Climate Assessment Bruce Maxwell, Co-Director of the Montana Institute on Ecosystems and Professor of MSU—Montana State University Agroecology and Applied Plant Ecology, Montana State University, Bozeman, MT MTDPHHS—Montana Department of Public Health and Human Services Amy Royer, Project Coordinator, Office of Rural Health, Montana State University, Bozeman, NOAA—National Oceanic and Atmospheric Administration MT NWS—National Weather Service Nick Silverman, Principal Hydroclimatologist, Adaptive Hydrology, Missoula, MT PM—particulate matter (most often seen as PM2.5 and PM10, describing particulates under 2.5 μm and 10 μm, respectively) Gerald Wagner, Director, Blackfeet Environment Office, Browning, MT PTSD—post-traumatic stress disorder Aaron Wernham, Chief Executive Officer, Montana Healthcare Foundation, Bozeman, MT RCPs—representative concentration pathways Cathy Whitlock, Regents Professor in Earth Sciences and Fellow of the Montana Institute on Ecosystems, Montana State University, Bozeman, MT xufei Yang, INBRE Researcher, Department of Environmental Engineering, Montana Tech, Butte, MT Heather Zimmerman, Epidemiology Program Manager, Cancer Surveillance and Epidemiology, Montana Department of Public Health and Human Services, Helena, MT Looking toward the Ten Lakes Basin near Eureka Photo courtesy of Scott Bischke xII | ACKNOWLEDGMENTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xIII impacts at the national level, such as increases in heat-related illness, sea-level rise and displacement of coastal communities, changing patterns in insect-borne diseases, and threatened water supplies. No report to date, though, has examined climate-related health risks in Montana. After publication of the MCA, public health and healthcare professionals made the point that, although its coverage of water, forests, and agriculture was a good start, there was a need for Nighttime fire glow near Roundup information on the state’s most valuable resource: its people. They saw an urgent need for a Photo credit: Casey Page, Billings Gazette state-specific health assessment and, most importantly, for practical ways to help communities address the health risks. To this end, in July 2018 a workshop was convened to discuss preparing a new special report to the MCA on health challenges related to climate change in Montana. That FOREWORD workshop, attended by 23 climate scientists, health professionals, and other stakeholders, laid the foundation for this assessment, which is the result of more than two years of work by members of that group, with robust peer review and input from Montana citizens. Aaron Wernham MD, MS Even though many face workforce shortages and limited funding, local public health agencies and Dr. Wernham is Chief Executive Officer of the Montana Healthcare Foundation healthcare providers lead the response to a long list of health challenges—from mental illness (2014-present). He is also a family physician with experience in both public health and and substance use disorders, to seasonal flu, to the current COVID-19 pandemic. In this context, medical practice. Dr. Wernham developed and led the Health Impact Project, a major the need for this report is evident: clear, practical recommendations will make it easier to respond national initiative of the Robert Wood Johnson Foundation and served on several National effectively and reduce the health risks of climate change given that staff and time are limited in Academy of Sciences committees. many public health and healthcare centers in Montana. January 2021 Climate Change and Human Health in Montana aims to provide up-to-date information and to explain the impacts and potential solutions in a way that can be understood by everyone. Groups In recent years, Montanans have seen record-breaking heatwaves and intense fire seasons. The that seldom work together—climate scientists, healthcare and public health professionals, and Montana Climate Assessment (MCA)1 indicates that the state will continue to experience rising leaders from non-governmental organizations—came together to contribute to the report. temperatures through the end of the century, along with increased smoke from wildfires and extreme climate events ranging from flood to drought. These conditions have the potential to The report reflects the proactive leadership of our state’s healthcare and public health threaten our health, particularly for the growing share of Montanans who are over the age of 65, communities, who came together to advocate for the topic and contribute to the report. Many of and for those who are more vulnerable due to disabilities, chronic health conditions, or the lack of the contributors have worked for years to educate peers about the health risks of climate change. health insurance and limited access to healthcare. This Special Report of the MCA, Climate Change Moreover, some tribes and rural communities are in the process of conducting, or have already and Human Health in Montana, focuses on climate change issues that impact Montanans. Its key conducted, climate and health assessments, and these efforts contributed to and helped pave the messages and recommendations highlight the challenges facing communities and healthcare way for this report. professionals, as well as provide important guidelines for better monitoring, preparedness, and action. The last section of the report provides practical recommendations for healthcare providers, public health officials, communities, and individuals on how to prepare for the future. These guidelines In 2016, under a mandate from the United States Congress, the US Global Change Research can serve as a template for planning and identifying areas of vulnerability and for assisting Program released a foundational report titled The Impacts of Climate Change on Human Health communities in preparing for and reducing the impacts of climate change on public health. in the United States: A Scientific Assessment2 . The report offered a view of climate-related health Climate Change and Human Health in Montana is a first step in preparing for our changing climate, and it deserves to be updated as new information becomes available and unforeseen situations 1 Whitlock C, Cross W, Maxwell B, Silverman N, Wade AA. 2017. 2017 Montana Climate Assessment. Bozeman arise. I hope the report is widely studied and becomes the go-to reference for public health and Missoula MT: Montana State University and University of Montana, Montana Institute on Ecosystems. officials, healthcare professionals, and communities as we work together to mitigate the effects of 318 p. Available online http://montanaclimate.org. Accessed 9 May 2020. doi:10.15788/m2ww82. climate change in Montana. 2 [USCGRP] US Global Change Research Program. 2016. The impacts of climate change on human health in the United States: a scientific assessment. Crimmins A, Balbus J, Gamble JL, Beard CB, Bell JE, Dodgen D, Eisen RJ, Fann N, Hawkins MD, Herring SC, Jantarasami L, Mills DM, Saha S, Sarofim MC, Trtanj J, Ziska L (eds). Washington DC: US Global Change Research Program. 332 p. Available online https://health2016. globalchange.gov/low/ClimateHealth2016_FullReport_small.pdf. Accessed 14 May 2020. xIv | FOREWORD 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xv SUMMARY OF KEY MESSAGES AND RECOMMENDATIONS During the preparation of Climate Change and Human Health in Montana, we developed key Air quality can be messages and recommendations about how climate change will impact the health of Montanans. tracked via Key messages refer to evidence-supported projections of those impacts. Recommendations are AirNow.gov, as described in Section 5 proposed behavioral and policy changes for coping with those impacts. For each key message, we provide a statement of confidence in our findings. We rate the certainty of key messages based on agreement and evidence following the approach used by the Intergovernmental Panel on Climate Change’s (IPCC’s) Fifth Assessment Report (IPCC 2014) (Figure Key Messages-1). Figure Key Messages-1. A depiction of evidence and agreement statements and their relationship to confidence. Confidence increases towards the top-right corner as suggested by the increasing strength of shading. Generally, evidence is most robust when there are multiple, consistent, and independent lines of high-quality evidence (figure and caption following that presented in the IPCC Fifth Assessment Report [IPCC 2014]). For each key message, authors of the relevant section rate agreement—the consistency of the evidence among scientific reports—as “low,” “medium,” or “high.” Authors also rate the evidence as “limited,” “medium,” or “robust,” depending on the type, amount, and quality of the scientific information supporting the message. The authors offer their expert judgment in these Flooding of Little Bighorn River, 2011 assignments based on the level of evidence and agreement, and provide details in the text to Photo courtesy of John Doyle support their ratings. The higher the level of author confidence in the key message, the greater the evidence and agreement. xvI | SUMMARY OF KEY MESSAGES AND RECOMMENDATIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xvII Key Messages This assessment draws from, and is an extension to, the 2017 Montana Climate Assessment (MCA) (Whitlock et al. 2017), which provides the first detailed analysis of expected impacts to Montana’s о Three aspects of projected climate change are of greatest concern for human water, forests, and agriculture from climate change. MCA presents 35 key messages, seven of health in Montana: 1) increased summer temperatures and periods of extreme which serve as important foundations to the work of this report: heat, with many days over 90oF (32oC); 2) reduced air quality from smoke, as wildfires will increase in size and frequency in the coming decades; and 3) more о Annual temperatures have risen 2-3oF (1.1-1.7oC) since 1950, and our growing season unexpected climate-related weather events (i.e., climate surprises), including is now 12 days longer. Montana has experienced an increase in warm days and rapid spring snowmelt and flooding, severe summer drought, and more nights, both in summer and winter. There is no trend in precipitation since 1950. [high extreme storms. [high agreement, robust evidence] agreement, robust evidence] о The most vulnerable individuals to the combined effects of heat, smoke, and о Climate models project that temperatures will continue to increase and by the end climate surprises will be those with existing chronic physical and mental health of the century average annual temperature may be 9.8oF (5.4oC) higher than those conditions, as well as individuals who are very young, very old, or pregnant. recorded between 1971-2000, given our present rate of greenhouse gas emissions. Montana’s at-risk populations include those exposed to prolonged heat and [high agreement, robust evidence] smoke, living in poverty, having limited access to health services, and/or lacking о Precipitation received at a state level may increase slightly in the future, but these adequate health insurance. [high agreement, robust evidence] gains will be offset by evaporation and transpiration due to higher temperatures. More о Projected increased summer temperatures and wildfire occurrence will precipitation will be received in winter, spring, and fall; summers will become drier worsen heat- and smoke-related health problems such as respiratory and than at present. [moderate agreement, moderate evidence] cardiopulmonary illness, and these potential problems are of most immediate о Rising temperatures will result in a shift from snow to rain earlier in the year than at concern. [high agreement, robust evidence] present. In turn, this shift will result in earlier dates for the onset of snowmelt and о Earlier snowmelt, more intense precipitation events, and projected increases associated peak stream runoff by the end of the century. [high agreement, robust in floods will endanger lives and lead to more gastrointestinal disease due evidence] to contaminated water supplies, as well as increased opportunities for other о The number of days >90oF (>32oC) will increase significantly by the end of the century, water-borne, food-borne, and mold-related diseases. [high agreement, moderate with the greatest warming in eastern Montana. The eastern part of the state will also evidence] experience more extreme heat (i.e., days when the heat index1 exceeds 105oF [41oC]). о Increased summer drought will likely increase cases of West Nile virus in [high agreement, moderate evidence] Montana, but the impact of climate change on other vector-borne diseases is о Increased wildfires are expected as wetter springs result in increased fuel less clear. [high agreement, moderate evidence] accumulation, and drier summers lead to fuel desiccation. The size of fires and the о Longer growing seasons, warmer temperatures and elevated carbon dioxide length of the fire season will increase in both forest and grassland. [high agreement, (CO2) levels are leading to increased pollen levels, worsening allergies and robust evidence] asthma. [high agreement, moderate evidence] о Unforeseen climate-related weather events will occur with projected increases in о Summer drought poses challenges to local agriculture, resulting in decreased temperature and drought in the coming decades, including greater likelihood of food availability and nutritional quality, and to the safety and availability of spring flooding, severe summer drought, and extreme storm events. [high agreement, public and private water supplies, especially for individuals and communities moderate evidence] relying on surface water and shallow groundwater. [high agreement, robust Following, then, is a summary of key messages and recommendations as developed in this report, evidence] Climate Change and Human Health in Montana. о Climate changes, acting alone or in combination, are reducing the availability of wild game, fish, and many subsistence, ceremonial, and medicinal plants, which threatens food security, community health, and cultural well-being, particularly 1 A glossary is provided at the end of this report for unfamiliar terms. Heat index, for example, is defined in the for tribal communities. [high agreement, moderate evidence] glossary as a measure of perceived heat when humidity, which can make it feel much hotter, is factored in with the actual measured air temperature. о Increased stress and increased mental illness are under recognized but serious health consequences of climate change. [high agreement, robust evidence] xvIII | SUMMARY OF KEY MESSAGES AND RECOMMENDATIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xIx Recommendations Literature Cited о Address the health and economic impacts of climate change by creating an adequately funded and coordinated statewide public health network that [IPCC] Intergovernmental Panel on Climate Change. 2014. Climate change 2014: synthesis report: engages public health and emergency and environmental management contribution of working groups I, II and III to the fifth assessment report of the Intergovernmental professionals, clinicians, climate scientists, elected leaders, and stakeholders in Panel on Climate Change. Pachauri RK, Meyer LA, eds. Geneva Switzerland: Intergovernmental Panel on planning and implementing climate mitigation and adaptation strategies. Climate Change. 151 p. о Improve information collected and shared at the state and local levels on Whitlock C, Cross W, Maxwell B, Silverman N, Wade AA. 2017. 2017 Montana Climate Assessment. climate and health to facilitate this public health network and medical decision- Bozeman and Missoula MT: Montana State University and University of Montana, Montana Institute on making by: Ecosystems. 318 p. Available online http://montanaclimate.org. Accessed 9 May 2020. doi:10.15788/ m2ww82. • working with government agencies to expand heat, smoke, air-quality, and water-quality monitoring, and improve data accessibility, especially for underreported and underserved areas; and • supporting efforts in the healthcare community to establish mechanisms for capturing and analyzing physical and mental health impacts related to heat, smoke and air quality, and water quality in Montana. о Boost statewide technical expertise in implementing climate change adaptation by funding trainings for diverse stakeholders, landowners, professionals, and leadership. о Continue the work of the MCA to update the information in this report and expand the understanding of climate change impacts on other sectors of importance in Montana. о Get involved and be part of the solution! Use the information in this report to help yourself, your community, and Montana address climate change. Everyone has a role to play! Smith River country near White Sulphur Springs Photo courtesy of Scott Bischke xx | SUMMARY OF KEY MESSAGES AND RECOMMENDATIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | xxI 01. INTRODUCTION Cathy Whitlock and Alexandra Adams The purpose of this assessment is to a) present understandable, science-based, Montana-specific information about the impacts of climate change on the health of Montanans; and b) describe how our healthcare providers, state leaders, communities, and individuals can best prepare for and reduce those impacts in the coming decades. This assessment draws from, and is an extension to, the 2017 Montana Climate Assessment (MCA1) (Whitlock et al. 2017), which provides the first detailed analysis of expected impacts to Montana’s water, forests, and agriculture from climate change. MCA explains historical, current, and prospective climate trends for the state based on the best-available science. The 2017 Montana Climate Assessment did not address the impact of climate change on the health of Montanans. This special report of the MCA fills that important knowledge gap; it represents a collaboration between climate scientists and Montana’s healthcare community and is intended to help Montanans minimize the impacts of climate on their health. The report is broken into five additional sections: о Section 2 summarizes key findings about climate change in Montana, drawing on information from the 2017 Montana Climate Assessment. о Section 3 details the consequences of climate change on human health, globally and in Montana. о Section 4 explains the health effects of climate change on our state’s most vulnerable populations, such as the very young and very old, people with chronic disease, pregnant individuals, and those living remotely and in poverty. о Section 5 provides recommendations and resources for planning, policy changes, adaptations, and actions to ensure positive health outcomes for Montanans in the face of climate change. о Section 6 provides important concluding remarks. Both Sections 4 and 5, which are less technical than previous sections, may be read as stand-alone resources. Throughout the report, we provide sidebars with stories specific to Montana. 1 This report uses “MCA” in discussing the Montana Climate Assessment program. We provide the reference (Whitlock et al. 2017) only when speaking of specific results published in the 2017 Montana Climate Assessment, not the overall program. Ennis, Montana Photo courtesy of Scott Bischke 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 1 (e.g., manufacturing, construction, mining, agriculture) collectively account for about 24% of the The purpose of this assessment is to a) present understandable, economy (Montana Department of Labor and Industry undated). Montana ranked 39th in median science-based, Montana-specific information about the household income in 2018, but poverty is a problem in several parts of the state, especially on Indian reservations (US Census Bureau 2019). About 14% of Montanans live in poverty; of those impacts of climate change on the health of Montanans; 6% live in deep poverty, earning <50% of the federal poverty level. and b) describe how our state can best prepare for and reduce those impacts in the coming decades. Montanans will experience both benefits and harm to human health from climate change, depending on location and individual. While warmer winters may help some Montanans, for example, a number of negative consequences are foreseeable for others. Added heat stress and other climate changes may cause or exacerbate cardiovascular and respiratory infirmities, C v gastrointestinal ailments, infectious diseases, premature births, and morbidity. vulnerability onCerns for the uLnerabLe to such impacts will vary depending on where individuals live, as well as on their age, gender, occupation, residence, socioeconomic status, and underlying medical conditions (see sidebar). Climate change is a global phenomenon, and the anticipated impacts to health and well-being affect all humankind to some degree. Given its northern and interior location in the US, Montana will avoid some of the health impacts of climate change facing other parts of the country and the world. Nonetheless, some of the health consequences experienced here will likely be more serious than elsewhere. Projected temperature increases in Montana, as described in the MCA (Whitlock et al. 2017), are of foremost concern to climate scientists and health practitioners alike. Populations Most Vulnerable to Climate Change For example: in Montana о Average temperatures in Montana have increased across the state by 0.42°F (0.23°C) per decade since 1950, which is faster than the US average (0.26°F [0.14°C]). Multiple sectors of Montana’s population are at special risk of having their health о Climate projections indicate continued warming in the coming decades with impacted by our warming climate, including people… temperature increases of 4.5-6.0°F (2.5-3.3°C) by mid century.2 о …threatened by increased heat о Days above 90°F (32°C) are anticipated to increase by 5-35 days by mid century, with о …living in proximity to wildfire and smoke greatest increases occurring in the southeastern part of the state. о …facing food and water insecurity Along with increased temperature, four other climate change projections in the 2017 Montana Climate Assessment are issues that threaten the health of Montanans. Those issues are о …who are very young, very old, or pregnant increased occurrence of wildfire and its impact on smoke and air quality; early snowmelt and intense precipitation events; projected changes in water availability and quality; and extreme о …having limited access to healthcare services and unexpected climate-related weather events. MCA finds that although there has been no о …living in poverty significant change in statewide average annual precipitation since 1950, summer precipitation has decreased, while spring and fall precipitation have increased slightly. Projections indicate о …lacking adequate health insurance more year-to-year and season-to-season variability in precipitation, earlier loss of snow, and more summer drought (Whitlock et al. 2017). о …with existing chronic conditions о …with mental health issues Montana is a rural state with widely spaced urban centers. Its population of 1,062,305 in 2018 included 5.9% under five years old, 17.6% over 65 years old, and 2% over 80 years old. Older о …whose livelihoods or traditional ways are closely tied to the land age groups—that is, people over 65—are increasing in number across the state. The state’s or environment, including those working outdoors in construction, economy has become more diversified in recent decades, with one-third of the workforce now agriculture, recreation, and resource-extraction industries in the service sector (e.g., health care, trade, leisure activities), while goods-based industries 2 The increase depends on the scenario of global greenhouse gas emissions, as described in Section 2. 2 | INTRODUCTION 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 3 report purpose and Genesis To date there has been no single source of information about how climate change will affect The Montana Climate Solutions Plan the health of Montanans. Climate Change and Human Health in Montana seeks to fill this gap in our knowledge, drawing on the best available, current information. Scientific assessments are In 2019, Governor Bullock issued an executive order creating the Montana essential tools for linking knowledge to decision-making, by surveying and synthesizing peer- Climate Solutions Council, tasked with developing a plan of recommendations reviewed scientific information across disciplines, sectors, and regions. Assessments highlight key and strategies to prepare Montanans for climate impacts, reduce greenhouse information that can improve understanding of complex issues and identify topics where study gas emissions (GHG) to achieve net GHG neutrality by mid century, and is needed. The work presented here on climate change and human health should be a sustained advance new technologies and other innovations to meet these goals. The effort, updated and expanded on a regular basis as part of the overall MCA program. Council was composed of members from state agencies, the universities, businesses, tribal communities, and non-governmental organizations; and Climate Change and Human Health in Montana is intended to help communities, healthcare during its deliberations received input from experts and the public. The professionals, and other decision makers understand the climate-health connection and evaluate Montana Climate Solutions Plana was released in September 2020 with a different strategies for response. The flow of information should also go in the opposite direction, broad list of recommendations, many of which are relevant and align with this with this report helping decision makers identify critical information gaps that require new report on climate change and human health: scientific investigation, tool development, and future assessment. Along with its statewide focus, Climate Change and Human Health in Montana contributes to the larger flow of information on this о Develop a Montana Climate Solutions Network to share climate topic that occurs between national, regional, state, and local levels. information and resources and build capacity in communities so that climate solutions connect at state, local, regional, and tribal Climate Change and Human Health in Montana is the product of a diverse partnership of over 40 nation levels scientists and healthcare professionals who first met in August 2018 to discuss the issue and plan the assessment. Before its release, the report received public comment and rigorous scientific о Build community resilience to climate change through better review by health and climate experts at state and national levels (see Acknowledgments section). coordination with existing planning efforts This report makes it clear that Montana’s changing climate will have measurable impacts on о Adapt buildings, homes, and other infrastructure to better our state’s human health and well-being in the future. We hope that this information motivates withstand climate change much-needed discussion on this topic, one that leads to greater awareness, considers multiple о Maintain a diverse and healthy economy, positive mental and sources of knowledge, and helps planning efforts and action in this important area. During the physical health outcomes, and a resilient high quality of life for 2020 COVID-19 pandemic, we have had to acknowledge how much we are all connected, and now Montanans and visitors more than ever realize how clearly our health and economic well-being are tied to the health of the planet. It is our hope that this report will motivate our collective action towards innovative о Safeguard Montana’s water quality and quantity from climate mitigation and adaptation strategies for improving health in the face of climate change. change о Enhance local air quality monitoring and support indoor air quality L C needs for vulnerable communities during intense periods of iterature ited wildfire smoke Montana Department of Labor and Industry. Undated. Montana labor market information: industry _______ employment by sector June 2020 [website]. Available online http://lmi.mt.gov/Industry/cesSector. Accessed 7 Aug 2020. a State of Montana. 2020. Montana Climate Solutions Plan: a report by the Montana US Department of Commerce. 2019. Washington DC: Census Bureau, American Community Survey Office. Climate Solutions Council. Helena MT. 73 p. Available online https://deq.mt.gov/ Analysis derived via Headwaters Economics’ Populations at Risk: Montana [web tool]. Available online Portals/112/DEQAdmin/Climate/2020-09-09_MontanaClimateSolutions_Final.pdf. headwaterseconomics.org/par. Accessed 7 Aug 2020. Accessed 4 Nov 2020. Whitlock C, Cross W, Maxwell B, Silverman N, Wade AA. 2017. 2017 Montana Climate Assessment. Bozeman and Missoula MT: Montana State University and University of Montana, Montana Institute on Ecosystems. 318 p. Available online http://montanaclimate.org. Accessed 9 May 2020. doi:10.15788/ wm2ww82. 4 | INTRODUCTION 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 5 Clouds over Flathead Lake Photo courtesy of Rick and Susie Graetz 02. CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA Cathy Whitlock1 As noted in the Introduction, this assessment brings scientific information about the impacts of climate change on human health to the people of Montana in an organized and understandable manner. In this section, we begin with a short description of Montana’s geography. We then describe how climate and weather differ, as well as past trends and future projections for temperature and precipitation in the state. We next review the climate changes that pose the greatest threat to the physical and mental health of Montanans. 1 With grateful acknowledgment to the contributions of Kelsey Jencso and Nick Silverman for their work on the climate chapter of the 2017 Montana Climate Assessment (Whitlock et al. 2017). 6 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 7 Montana’s unique GeoGraphy о El Niño phase.—During an El Niño phase, the tropical Pacific Ocean is warmer than normal and Montana, especially the northwestern region, tends to experience warmer Montana’s climate is as diverse as its landscapes, which vary from high plains grasslands to winters. alpine rock and ice. As the nation’s fourth largest state, and given our location in the interior of о La Niña phase.—During the opposite La Niña phase, the tropical ocean is cooler than North America, Montana is exposed to diverse weather systems that arise from air masses in the normal and Montana tends to experience cool, often wet winters. Arctic, Pacific, and Gulf of Mexico. The strength and location of these air masses shift seasonally, creating differences in climate and weather across the state and throughout the year. Montana’s о ENSO neutral phase.—When the tropical Pacific Ocean experiences near-average complex topography modifies weather systems as they travel over our western mountain ranges temperatures, circulation conditions in Montana are less predictable. and onto the Great Plains. Montana tends to be wetter in the west because of the proximity to Pacific moisture sources and the cooling and condensing effects that result as air masses rise to The important point is not to confuse weather and year-to-year climate variability with long-term cross the Continental Divide. The state is generally drier in the east where heating is stronger and climate trends. The former two describe short-term, continually shifting conditions observed over elevations are lower. days and years; the latter refers to climate conditions as summarized over decades, or longer. When we discuss climate change, we usually refer to a baseline or normal period for comparison. Montana’s mountains are headwaters to three of the continent’s major river systems: the In the 2017 Montana Climate Assessment (Whitlock et al. 2017) and in this report, that normal Missouri, Columbia, and Saskatchewan. As such, snow levels in our region affect water availability period is a 30-year time span from 1971-2000. far beyond the state’s border. Our mountain snowpack comes largely from Pacific storms. This winter precipitation is the primary water supply serving our state’s waterways, ecosystems, municipalities, farms and ranches, and recreational and tourism industries. the sCienCe of projeCtinG Montana’s future CLiMate: an overvieW CLiMate differs froM Weather Montana is made up of 56 counties, with climate issues ranging widely—including drought, floods, wildfires, extreme heat, and unexpected weather events—depending on location (Figure 2-1). Each Climate change is a description of a region’s average weather conditions as they vary over at county, likewise, has its own unique history, economy, and level of community connection and, least decades. Weather, in contrast, refers to the short-term changes, occurring over minutes to thus, access to healthcare is highly variable. months in the atmosphere, as measured by temperature, humidity, precipitation, atmospheric pressure, and other variables (NASA undated). While Montana’s climate has become warmer in recent decades, Climate change is a description of a region’s weather patterns have shown considerable variability on a day-to-day average weather conditions as they vary over and month-to-month basis. at least decades. Weather, in contrast, refers to the short-term changes, occurring over minutes In addition to relatively rapid changes in weather, Montana has also to months in the atmosphere, as measured experienced year-to-year variability by temperature, humidity, precipitation, in climate that relates to global-scale atmospheric pressure, and other variables fluctuations in ocean circulation and (NASA undated). … The important point is not their influence on the atmosphere. The El Niño-Southern Oscillation (ENSO) to confuse weather and year-to-year climate is an example of a climate pattern in variability with long-term climate trends. our region that varies from year to year depending on ocean-atmosphere patterns in the tropical Pacific Ocean and their influence on storm tracks and pressure systems at higher latitudes. Montana experiences different phases of ENSO, each leading to short-term Figure 2-1. Montana consists of 56 counties. climate conditions: 8 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 9 To more readily understand climate change across our state, the 2017 Montana Climate Assessment We all wonder about the current trajectory of warming and how it will develop in the future—will (Whitlock et al. 2017) aggregates the 56 counties into seven climate divisions, then describes it be rapid or gradual? In climate assessments, it is common to see graphs with multiple curves recent climate trends and future projections for those seven divisions. These climate divisions showing different trends in projected climate change through the end of the century. Each curve are the Montana subset of the 344 divisions identified by the National Oceanic and Atmospheric results from different assumptions regarding future greenhouse gas emissions; the assumptions Administration (NOAA) to report climate for the US (NOAAa undated). NOAA established the are based on a range of possible decisions that humankind makes globally from today forward. divisions based on climatic, political, agricultural, and watershed boundaries. For Montana, the Those decisions, called scenarios by modelers, include such factors as changing energy sources MCA identifies the seven NOAA divisions as the northwestern, southwestern, north central, (fossil fuel or renewable), technological advancements, economic trajectories, and population central, south central, northeastern, and southeastern climate divisions (Figure 2-2). growth. MCA analysis of historical climate trends started with the mid-20th century and drew on direct The current set of scenarios behind each curve are known as Representative Concentration measurements of temperature and precipitation from weather stations across the state. Using Pathways (RCPs), and their plausibility is continually re-evaluated as new information comes to statistical methods, these observations were used to derive a single temperature or precipitation light. Again, RCPs describe decisions society might make from today forward. Each scenario- value to represent each of the seven climate divisions. driven pathway results in a particular level of greenhouse gas (CO2, CH4, and others) emission in the coming decades and, as a result, a different amount of temperature increase, precipitation MCA future projections were based on a set of 20 climate models, selected from a larger suite change, and more. While multiple RCPs have been investigated, MCA (Whitlock et al. 2017) focuses of general circulation models (GCMs) developed by scientists to simulate global climate. GCMs on two scenarios for Montana’s future climate, RCP4.5 and RCP8.52, as described below: are complex mathematical depictions of the global circulation of the atmosphere and oceans (including the Earth’s frozen waters). These models provide ten-day weather forecasts, as well as о RCP4.5, often termed the stabilization scenario of expected carbon use, describes a projections of future climate. The 20 GCMs included in the MCA were independently developed future trajectory that involves some level of greenhouse gas mitigation (i.e., slowing at research laboratories around the world—as part of the fifth phase of the Coupled Model use because of decisions society makes). The curve shows a near-term rise in the rate Intercomparison Project (WCRP undated)—and chosen for their ability to accurately provide of greenhouse gas emissions, with maximum levels reached at about 2040, and a daily outputs of climate variables important in Montana. The Montana Climate Office statistically decline in the rate of emissions in the last half of the century (Clarke et al. 2007). downscaled the coarse-scale GCM output to a finer scale that incorporated the influence of topography on regional climate (Abatzoglou and Brown 2012). The result was projections of future о RCP8.5, which currently represents the upper bound of expected carbon use, describes climate for each Montana climate division. a future trajectory where greenhouse gas emissions rise at a high rate through the century. The scenario presents a future where humankind does not curb fossil fuel use and the release of greenhouse gases increases without mitigation. RCP8.5 is more extreme than RCP4.5 in its projections of climate change after the mid century, including higher temperatures. A key goal of this assessment is to identify those aspects of changing temperature and precipitation most likely to have A key goal of this assessment is to consequences on the physical well-being identify those aspects of changing and mental health of Montanans. In the temperature and precipitation following subsections, we provide a short review of projections for those two climate most likely to have consequences variables, which serves as the basis for on the physical well-being and understanding the impacts of climate change mental health of Montanans. on human health in our state. 2 The RCP number (i.e., 4.5 or 8.5) refers to the resulting watts/m2 of greenhouse-gas-derived heating by the year 2100 if this scenario plays out. Figure 2-2. Montana’s seven climate divisions. Note that NOAA officially names the northwestern division on this map as the western division. We use northwestern for geographic clarity. 10 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 11 Temperature Increasing temperatures, the most direct consequence of rising greenhouse gases, are a major health concern for Montana, the nation, and the globe. Air temperature has increased in recent decades and that warming will continue in the future. MCA shows that the rate of change per decade in average annual temperature for the period from 1950-2015 was about 0.4oF (0.2oC) statewide, which equates to 2-3oF (1.1-1.7oC) warming in the last 65 yr (Whitlock et al. 2017). More recently, the years 2015 and 2016 were the first and third warmest since 1950, with average annual temperatures 3.2 and 2.9oF (1.8 and 1.6oC) above the base period of 1971-2000 (NOAA b). Likewise, 2017 had average annual temperatures 1.5oF (0.8oC) above this base period, although average annual temperatures for 2018 and 2019 were average or slightly below average (NOAAb undated). A 70-yr warming trend since 1950 is evident across the state, with greatest warming in the south central climate division (Figure 2-2). Since 1895, Montana’s rate of warming (0.20oF/decade [0.1oC/ decade]) has been greater than that of the US (0.15oF/decade [0.08oC/decade]), and this condition reflects the state’s location far from the moderating effects of an ocean. Average maximum and minimum temperatures have also risen across the state since 1950 by 0.3-0.6oF/decade (0.2-0.3oC/ decade), amounting to an increase of approximately 3.3oF (1.8oC) for the hottest and coldest conditions (Whitlock et al. 2017). MCA temperature projections for 2040-2069 (mid century) and 2070-2099 (end of century) indicate that current warming trends will continue (Whitlock et al. 2017) (Figure 2-3). By mid century, annual average temperatures are 4.5oF (2.5oC) higher under the RCP4.5 scenario and 6oF (3.3oC) Figure 2-3. The projected increase in annual average daily maximum temperature (°F) for each climate division in Montana for the periods 2049-2069 and 2070-2099 for (A) stabilization (RCP4.5) and (B) upper-bound higher under RCP8.5 than the base period (1971-2000). All models agree on the direction of this (RCP8.5) emission scenarios (Whitlock et al. 2017). trend. End-of-century average annual temperatures for the state are more dramatic: increases of 5.6oF (3.1oC) in RCP4.5 and 9.8oF (5.4oC) in RCP8.5, again with full model agreement. Temperature projections show small differences across climate divisions, but overall warming is evident across Daily minimum and maximum temperatures also show a similar magnitude of increase in the the state. Projections of average monthly temperatures show temperature increases in all seasons coming decades. The number of frost-free days (days where the temperature does not drop and for all divisions, with summer and winter experiencing the greatest warming. August, in below 32oF [0oC]) is conservatively projected to increase by 24-30 days by mid century (RCP4.5 particular, has the greatest monthly change for all divisions. stabilization scenario), particularly in the western division. Extreme-heat days (where the daily temperature exceeds 90oF [32oC]) also increase in the model projections. In the stabilization scenario (RCP4.5), the western and north central climate divisions experience an additional five extreme-heat days, and the northeastern, southeastern, and south central divisions have an The upper-bound emission scenario (RCP8.5) shows approximately 34 additional increase of 25 extreme-heat days by mid century as compared to the base period (1971-2000). days exceeding 90oF (32oC) in the northwestern, southwestern, and north central divisions and 54 additional extreme-heat days in the south central, The upper-bound scenario (RCP8.5) elevates the number of days above 90 oF (32oC) days by mid century: 11 additional extreme-heat days in the northwest and north central divisions and 33 northeastern, and southeastern divisions. The significant increase in the number additional extreme-heat days in the northeastern, southeastern, and south central divisions. of extremely warm days in summer and the loss of cold days in winter by the end These numbers increase further by the end of the century, where the stabilization scenario of the century are important projections in the MCA (Whitlock et al. 2017). (RCP4.5) indicates 9-29 additional days. The upper-bound emission scenario (RCP8.5) shows approximately 34 additional days exceeding 90oF (32oC) in the northwestern, southwestern, and north central divisions, and 54 additional extreme-heat days in the south central, northeastern, and southeastern divisions. The significant increase in the number of extremely warm days in summer and the loss of cold days in winter by the end of the century are important projections in the MCA (Whitlock et al. 2017). 12 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 13 Precipitation Precipitation is a complex phenomenon to simulate in climate models because a number of interactive components in the atmosphere, land, and ocean govern where, when, and how much Montana is a semi-arid region. Thus, the availability and quality of water are critical for the health precipitation falls. These components must be incorporated correctly for general circulation of the state’s communities and ecosystems. The amount of precipitation varies widely across the models to accurately portray current conditions and provide credible projections for the future. As state, with elevation, topography, and distance from the Pacific Ocean determining the timing and a result, GCM projections show less agreement about future precipitation levels than they do for form of precipitation received. Generally, the western part of the state receives the highest levels future temperature; this is true at a global scale and also for Montana. MCA suggests that by mid of precipitation (average of 22-30 inches [56-76 cm]), and most of it falls in the form of winter century, precipitation will increase slightly across the state, with 1.3 inch/yr (3.3 cm/yr) more in and early-spring snow from Pacific storms. The eastern part of the state receives only half the the northwestern and north central regions and 0.9 inch/ yr (2.3 cm/yr) more in the southwestern, level of precipitation (average of 12-14 inches [30-36 cm]), with moisture sources coming from a central, and eastern climate divisions, as compared to the base period (1971-2000) (Whitlock et al. combination of Pacific storms in winter and convective storms in late spring and summer. These 2017). The upper-bound scenario (RCP8.5) for mid-century projections suggests an increase of 2.0 convective storms are associated with hail, lightning, and sometimes tornados in eastern and inch/yr (5.1 cm/yr) in the western half of the state and 1.8 inch/yr (4.6 cm/yr) in the eastern half. central Montana. For this scenario, model agreement ranges from 65% for the mid-century summer projections to 95% for the spring projections. Annual precipitation levels for the state have not changed significantly since 1950, although there is considerable variability among regions in the amount received each year. In general, since It is important to caution that projected increases in precipitation will likely be more than offset 1950 northwestern Montana has become slightly drier in winter, while eastern Montana has by the coincident rise in temperature. Warming will increase rates of evaporation from soils and become slightly wetter in spring. The year-to-year variation reflects the influence of topography on water bodies, and transpiration (water loss) from plants (Collins et al. 2013). While we may receive individual storm tracks, as well as large-scale climate patterns that vary year to year (e.g., ENSO), more precipitation, especially in the form of rain, effective moisture (that which remains on the and creates particular weather conditions. In the winter of 2017-2018, for example, Pacific storms surface and in the ground) will be reduced by the consequences of heat. were directed to our region (a La Niña condition), resulting in record-high snow accumulation in Montana. Places in western and central Montana received from 111-152% of normal snowpack, Seasonal differences in the projected changes in precipitation are striking, as analyzed in the as measured by the April 1 snow water equivalent (Figure 2-4). These high levels of snowpack are MCA (Figure 2-5). In all regions and under both scenarios for the mid century and end of century, likely to be rare in the future, as warmer temperatures force earlier melting and runoff. precipitation increases markedly in spring (March-May), and less markedly in winter (December- February) and fall (September-October). In contrast, summers (June-August, and in some regions, September) receive less precipitation in the future. The combination of slightly wetter conditions in winter, spring, and fall, coupled with drier summers, both as compared with the base period (1971-2000), is especially striking in the upper-bound emission scenario (RCP8.5) (Figure 2-5). In the end-of-the-century projection, for example, increases in winter and spring precipitation of 0.4 inch/month (1 cm/month) and decreases in summer precipitation of -0.2 inch/month (-0.5 cm/ month) are indicated, with 75% model agreement. MCA projections thus indicate that winter, spring, and fall will get wetter and summer will get drier in the coming decades, with the likelihood of effective moisture (that which remains on the surface and in the ground) decreasing in all seasons because of rising temperatures (Whitlock et al. 2017). MCA projections indicate that winter, spring, and fall will get wetter and summer will get drier in the coming decades, with the likelihood of effective moisture (that which remains on the surface and in the ground) Figure 2-4. The Montana Drought and Climate report from the Montana Climate Office showing snowpack in 2018 as measured by the April 1 snow water equivalent (MCO 2019). This high snowpack was the result of decreasing in all seasons because of rising temperatures. interannual climate variability, which set up a strong La Niña-type climate pattern in the western US. With projected warming in the future, snowpack will be greatly reduced by April 1, making these high-snow years increasingly rare. 14 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 15 Extreme heat Extreme heat is the most pervasive issue of health concern, with statewide increases in annual temperature of potentially 4-6oF (2.2-3.3oC) by mid century and possibly as great as 9.8oF (5.4oC) by the end of the century, based on RCP8.5 (upper-bound) emission scenario.3 This rise in temperature continues a warming trend that the state has already experienced during most of the last 120 yr, and especially since 1950. The coldest temperatures during winter will become warmer in the future, which may have positive consequences for some communities and livelihoods. However, the number of extremely warm days in summer will also increase, by over a month in most places and with rural areas of eastern Montana projected to experience the greatest heat stress (Whitlock et al. 2017). Across the US and world, populations living in areas that have experienced extreme heat have suffered from a variety of heat-related health illnesses, and even death. Given the state’s northerly location, Montanans have not lived through the summer heat experienced in other regions, but this situation will likely change in the future. Some areas of the world have already experienced the heat-index levels that the MCA projects for Montana. People living in those areas have suffered from heat stress and worse. In France, for example, heatwaves are blamed for the deaths of 1500 people in the summer of 2019 (Guardian 2019). Montanans, likewise, are at risk as we expect as many as 2.5 weeks of 105oF (41oC) in the northeastern and southeastern climate divisions by the end of the century (Figure 2-2). These two areas include a large sector of the population that works outdoors in agriculture. Most of the rest of the state is projected to experience up to 10 days reaching 105oF (41oC) by the end of the century. Smoke and air quality Smoke is likely to become a persistent seasonal feature of our climate, as wildfires become ever larger and more severe across the western US. Smoke fills our valleys from local wildfires, as well as those burning in other western states and Canada. Particulate matter from these fires traps Figure 2-5. Projected monthly change in average precipitation (inches; color scale to the right) for each heat, reduces visibility, and creates dangerous air quality conditions. Since the 1970s, the US fire climate division in Montana in the mid-century projection (2040-2069) for (A) stabilization (RCP4.5) and (B) season has lengthened from 5 to over 7 months/yr (see Section 3), and parts of the country now upper-bound (RCP8.5) emission scenarios (Whitlock et al. 2017). experience wildfires year-round. The link between rising temperature and fire activity is clear: warming summers dry vegetation, and increasing fuels set the stage for fires to ignite and spread. Learning to live with fire has become a priority for Montanans, as increased fire management will not return us to fire frequencies and sizes of the past. Likewise, making our communities better C C h h adapted and more resilient to fire and smoke is now a priority in planning efforts (Schoennagel et LiMate onCerns for uMan eaLth al. 2017; McWethy et al. 2019). Given this background of current climate trends and future climate projections for Montana, we turn to an overview of how those changes may affect the health and well-being of Montanans. Three elements of projected climate change are of particular concern in our state and deserve close attention from the health community. In subsequent sections of this report, we address the 3 The frequency and severity of these extreme heat events in the future depends on the level of greenhouse gases (CO2, CH4, and others) in the atmosphere, and our ability and willingness to reduce those levels.health consequences directly, but first the nature of the climate threats themselves deserves a brief explanation. 16 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 17 Climate “surprises” The 2017 Northern Great Plains Drought Climate “surprises” are extreme or unexpected events that can cause great damage to human The 2017 Northern Plains drought sparked wildfires, destroyed livestock, and reduced health and property. The list of events includes abrupt and marked changes in average agricultural production. It was the worst drought to impact North Dakota, South Dakota, temperature and altered patterns of storms, floods, droughts, and wildfire. These events take eastern Montana, and the Canadian prairies in decades. place so rapidly and unexpectedly that human and natural systems often have difficulty adapting. Neither the drought’s rapid onset—sometimes called a flash drought—nor its severity was Rising spring temperatures, for example, have led to a shift from snow to rain in early spring. In forecast. In May 2017, the northern Great Plains region was mostly drought free, and at addition, snowpack melts more rapidly in spring, resulting in ice jams and streams overflowing least average summer precipitation was forecast. By July 2017, the region was experiencing their banks, with sometimes disastrous consequences. Severe spring floods have occurred in severe to extreme drought, resulting in fires that burned 4.8 million acres (1.9 million snow-fed streams in Montana throughout history (NOAAc undated), but recent years have seen hectares) across both countries. US unusually large floods on the Clark Fork, Little Big Horn, Missouri, Musselshell, Poplar, Powder, agricultural losses alone exceeded and Yellowstone rivers. These events have led to extensive property and infrastructure damage, $2.6 billion dollars. as well as loss of human lives. Although it is difficult to predict spring flood events with certainty, they are likely to increase in frequency and severity in the future. Climate projections suggest that The unique circumstances of this the seasonal shift from snow to rain will occur earlier, as will the date of peak spring runoff. Peak drought provided an opportunity to runoff on most headwater streams in Montana now occurs 10-20 days earlier than in 1948, and by evaluate the evolution of this type the end of the century the date of peak runoff is projected to occur 5-35 days earlier than during of climate event, as well as improve the period from 1951-1980 (Whitlock et al. 2017). the effectiveness of drought-related coordination, communication, and Another consequence of earlier snowmelt is less water available in late summer, increasing the management in preparation for future risk of drought. Some droughts start abruptly; some can last a long time. In the former category droughts. The National Integrated are flash droughts, a recently coined phrase that describes a rapid shift from wet to dry conditions Drought Information System and following just a few weeks of hot, dry weather (see sidebar). As an example of the latter category, partners published two reports that Montana suffered a 307-week drought starting May 2000 (NIDIS undated). examine the evolution and impacts of Firefighters battle the Bridge Coulee Fire, part of the 2017 drought, as well as lessons the Lodgepole Complex, east of the Musselshell Regardless of length of drought, the impacts to human health range from respiratory issues River, north of Mosby. 21 July 2017. (Photo courtesy learned, data needs, and information due to poor air quality from fires or dust storms; to gastrointestinal strife due to declining of Jonathan Moor / Bureau of Land Management)gaps (Jencso et al. 2019). drinking water quality and/or sanitation services; to increased disease carried by vectors such as mosquitoes that breed in stagnant waters (CDC undated). Drought also negatively impacts Droughts of this type will likely be more frequent in the future, with rising temperatures, communities that rely in part on wild foods for sustenance (Smith et al. 2019; Martin et al. 2020). reduced snowpack and earlier snowmelt leading to warm dry summer conditions. The seasonal shift from warm and wet to warm and dry could be very rapid, as in 2017. Reduced streamflow in late summer has led to high temperatures in some waterways, stressing the region’s water supplies and ecosystems. Reduced late-season water availability threatens irrigation and community water sources, plus sets the stage for a host of health issues, including vector-borne diseases and mental health concerns (see Section 3). In 2016, Montana Fish, Wildlife, and Parks closed a 184-mile (296-km) stretch of the Yellowstone River because increased water temperatures led to a massive fish kill. The die-off was attributed to a proliferative kidney disease Other climate surprises are likely but tougher to predict. Tornado and severe thunderstorm events caused by the warmer temperatures (MTFWP 2016). currently cause significant property damage and loss of life every year. Of the US weather disasters that have inflicted more than $1 billion in damage costs in the last 25 yr, over one-third were due to severe storms (NOAAd undated). In Montana, a 2010 tornado in Billings, which caused city officials to declare a state of emergency, resulted in millions of dollars of property damage, including ripping the roof off the 12,000-seat Metra Park Arena (CBS News 2010; NOAA 2010). In May 2016, severe thunderstorms, tornados, and high winds in the Great Plains and Rockies, including Montana, cost over $1.1 billion (NOAAd undated). 18 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 19 The link between severe storms (e.g., tornados, hailstorms, severe thunderstorms) and climate change is not well understood or easily predicted, in part because their documented record is relatively short, going back only to the 1950s. Nonetheless, there is a clear physics-based linkage: Montanans and Climate Concerns as temperatures increase, convection and atmospheric circulation patterns become more extreme and less stable. Weather and extreme events are becoming more frequent and extreme, A 2019 statewide survey of Montana public health and environmental health and their variability is increasing. Past events have been responsible for lives lost and serious and professionals asked about climate change concerns (Byron 2019). Of the costly property damage, especially for those living in substandard housing. The uncertainty of 222 responses, 89% accepted that global warming is occurring and 69% such events also creates enormous mental stress. Evidence exists that the number of days with accepted human causation. They expressed stronger perceptions of climate tornados is increasing, and it is likely that a warmer world with more atmospheric instability will change risk than the public in recent surveys and US health professionals shift both the timing and extent of severe storm conditions (Kossin et al. 2017). The mechanisms in most previous surveys. Risk perception evaluates a person’s personal that create these storms, however, are complex and difficult to model (Diffenbaugh et al. 2013; concern about risks—whether or not an issue will affect their community Seeley and Romps 2015). or themselves. Risks seen as distant (affecting Africa, for example) do not translate into taking action, whereas risks that are close and personal result in more concern and cause for response. suMMary Most of the health professionals surveyed felt that their own health was In summary, extreme heat, early snowmelt, large wildfires, spring flooding, late-season drought, already being affected by climate change. They also felt that the mental and climate surprises challenge all aspects of our economy, infrastructure, and well-being. The health effects from climate change would be a concern in the future for their health effects of these climate extremes include direct injury and loss of life, as well as indirect community. Seventy-two percent of the professionals (160 out of 222) felt that consequences related to disease, illness, and stress. Human health issues derived from or health departments should prepare to deal with the public and environmental exacerbated by climate change are now taken seriously by health professionals around the world, health effects of climate change, although only 29% of the departments were and likewise require serious attention in Montana. In the sections that follow, we discuss the currently doing so. Nearly all wanted multiple entities to work together to physical and mental health issues associated with climate change in Montana, and offer possible address climate change, including governments (federal, state, local, tribal), actions needed to improve health outcomes. elected officials, non-governmental organizations, businesses, individuals, and healthcare providers. L C Analysis done in conjunction with the 2019 Yale Climate Opinion Maps for iterature ited Montana estimated that 60% of Montanans accept that global warming is happening, 45% believe it is mostly human caused, and 30% feel that global Abatzoglou JT, Brown TJ. 2012. A comparison of statistical downscaling methods suited for wildfire warming will hurt them personally in the future (Marlon et al. 2019). In a study applications, International Journal of Climatology 32:772-80. to assess Montanans’ opinions on energy and conservation, Metz and Weigel (2016) found that 51% of respondents felt that climate change needs to be Byron L. 2019. Significant concern about climate among Montana public health and environmental health addressed now, including taking actions to mitigate greenhouse gases and professionals [masters’ thesis]. Baltimore MD: Johns Hopkins University. 48 p. Available online https:// adapt to changing conditions. jscholarship.library.jhu.edu/handle/1774.2/62338. 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Scenarios of greenhouse gas emissions contribution of Working Group I to the Fifth Assessment Report of the Intergovernmental Panel on and atmospheric concentrations. Sub-report 2.1a of synthesis and assessment product 2.1 by the US Climate Change. Cambridge UK: Cambridge University Press. p. 1136. Global Change Science Program and the Subcommittee on Global Change Research. Washington DC: Department of Energy, Office of Biological & Environmental Research. 164 p. Available online https:// Diffenbaugh NS, Scherer M, Trapp RJ. 2013. Global warming and severe thunderstorms. Proceedings of the globalchange.mit.edu/sites/default/files/CCSP_SAP2-1a-FullReport.pdf. Accessed 22 May 2020. National Academy of Sciences 110:16361-6. doi:10.1073/pnas.1307758110. 20 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 21 Guardian. 2019. Summer heatwaves in France killed 1500, says health minister [article]. Available online https://www.theguardian.com/world/2019/sep/09/summer-heatwaves-in-france-killed-1500-says-health- [NOAAa] National Oceanic and Atmospheric Administration. [undated]. NOAA, National Centers for minister. Accessed 1 Mar 2020. Environmental Information: US climate divisions. Available online https://www.ncdc.noaa.gov/ monitoring-references/maps/us-climate-divisions.php. Accessed 15 Sep 2019. Jencso K, Parker B, Downey M, Hadwen T, Howell A, Rattling Leaf J, Edwards L, Akyuz A, Kluck D, Peck D, Rath M, Syner M, Umphlett N, Wilmer H, Barnes v, Clabo D, Fuchs B, He M, Johnson S, Kimball J, Longknife D, [NOAAb] National Oceanic and Atmospheric Administration. [undated]. NOAA, National Centers for Martin D, Nickerson N, Sage J, Fransen T. 2019. Flash drought: lessons learned from the 2017 drought Environmental Information: climate at a glance. Available online https://www.ncdc.noaa.gov/cag/ across the US northern plains and Canadian prairies [report]. Boulder CO: NOAA, National Integrated statewide/time-series. Accessed 15 Sep 2019. Drought Information System. 76 p. Available online https://www.drought.gov/drought/sites/drought. [NOAAc] National Oceanic and Atmospheric Administration. [undated]. NOAA, National Weather Service: gov.drought/files/NIDIS_LL_FlashDrought_2017_low-res_Final.pdf. Accessed 15 Sep 2019. flooding in Montana. Available online https://www.weather.gov/safety/flood-states-mt. Accessed 15 Sep Kossin JP, Hall T, Knutson T, Kunkel KE, Trapp RJ, Waliser DE, Wehner MF. 2017: Extreme storms [chapter 2019. 9]. In: Wuebbles DJ, Fahey DW, Hibbard, DJ, Dokken DJ, Stewart BC, Maycock TK (eds). 2017 Climate [NOAAd] National Oceanic and Atmospheric Administration. [undated]. NOAA, National Centers for Science Special Report: Fourth National Climate Assessment, volume I. Washington DC: US Global Environmental Information: billion-dollar weather and climate disasters: overview. Available online Change Research Program. p 257-76. Available online https://science2017.globalchange.gov/downloads/ https://www.ncdc.noaa.gov/billions/. Accessed 15 Sep 2019. CSSR2017_FullReport.pdf. Accessed 12 May 2020. [NOAA] National Oceanic and Atmospheric Administration. 2010. Billings tornado of June 20, 2010: Marlon J, Howe P, Mildenberger M, Leiserowitz A, Wang X. 2019 (Sep 17). Yale Program on Climate overview [internal report]. 3 p. Available online https://www.wrh.noaa.gov/byz/local_news/2010/ Change Communication; Yale climate opinion maps 2019 [website]. Available online https:// BillingsTornado10.pdf. Accessed 1 Mar 2020. climatecommunication.yale.edu/visualizations-data/ycom-us/. Accessed 25 Nov 2019. Schoennagel T, Balch J, Brenkert-Smith H, Dennison P, Harvey B, Krawchuk M, Morgan P, Moritz M, Rasker Martin C, Doyle J, LaFrance J, Lefthand MJ, Young SL, Three Irons E, Eggers M. 2020. Change rippling through R, Turner GG, Whitlock C. 2017. Adapt to more wildfires in western North American forests as climate our waters and culture. Journal of Contemporary Water Research and Education 169:61-78. changes. Proceedings of the National Academy of Sciences 114:4582-90. [MCO] Montana Climate Office. 2019 (April). Montana drought and climate [newsletter]. Available online Seeley JT, Romps DM. 2015. The effect of global warming on severe thunderstorms in the United States. https://climate.umt.edu/mtdrought/mtdrought-2019-april.pdf. Accessed 15 Sep 2019. Journal of Climate 28:2443-58. McWethy DB, Schoennagel T, Higuera PB, Krawchuk M, Harvey BJ, Metcalf EC, Schultz C, Miller C, Metcalf Smith E, Ahmed S, Dupuis V, Running Crane M, Eggers M, Pierre M, Flagg K, Byker Shanks C. 2019. AL, Buma B, Virapongse A, Kulig JC, Stedman RC, Ratajczak Z, Nelson CR, Kolden C. 2019. Rethinking Contribution of wild foods to diet, food security, and cultural values amidst climate change. Journal resilience to fire. Nature Sustainability 2:797-804. doi:10.1038/s41893-019-0353-8. of Agriculture, Food Systems, and Community Development 9(B):191-214. https://doi.org/10.5304/ Metz D, Weigel L. 2016. Montana voter attitudes on energy and conservation in 2016 [slide presentation]. jafscd.2019.09B.011. Available online https://climateadvocacylab.org/system/files/57ec4f056ad44.pdf.pdf. Accessed 12 May Whitlock C, Cross W, Maxwell B, Silverman N, Wade AA. 2017. 2017 Montana Climate Assessment. 2020. Bozeman and Missoula MT: Montana State University and University of Montana, Montana Institute on [MTFWP] Montana Fish, Wildlife, and Parks. 2016 (Aug 19). Yellowstone River closed in response to ongoing Ecosystems. 318 p. Available online http://montanaclimate.org. Accessed 9 May 2020. doi:10.15788/ fish kill [press release]. Available online http://fwp.mt.gov/news/newsReleases/headlines/nr_4277.html. m2ww82. Accessed 1 Mar 2020. [WCRP] World Climate Research Program. [undated]. WCRP climate model intercomparison project [NASA] National Aeronautics and Space Administration. [undated]. NASA—What’s the difference between [website]. Available online https://www.wcrp-climate.org/wgcm-cmip. Accessed 12 May 2020. weather and climate? Available online https://www.nasa.gov/mission_pages/noaa-n/climate/climate_ weather.html. Accessed 15 Sep 2019. [NIDIS] National Integrated Drought Information System. [undated]. Drought.gov: drought in Montana [website]. Available online https://www.drought.gov/drought/states/montana. Accessed 12 May 2020. 22 | CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 23 Walking along the Rimrocks above Billings Photo courtesy of Scott Bischke 03. CLIMATE-RELATED HEALTH IMPACTS Robert Byron, Bruce Maxwell, Nick Silverman, Philip Higuera, Madison Boone, and Dave McWethy The consequences of climate change in Montana—including more frequent and intense heat waves; and increases in spring flooding, late-summer drought, extreme weather events, and wildfires—have recognized potential to impact human health (Ebi et al. 2018). Though little studied for Montana to date, climate change is known to be adversely impacting global health, including some Americans, now. For example, an increase in climate-related extreme events has led to increased emergency room visits and hospital admissions in the US (Ebi et al. 2018). Those adverse impacts are expected to increase over coming decades (Wuebbles et al. 2017). Figure 3-1 depicts how climate pressures (also called stressors), following multiple exposure pathways, can lead to specific health outcomes for people. Those outcomes, discussed in this section, include heat-related illness; vector-borne diseases; mental health impacts; physical trauma, injuries, and death; respiratory, cardiovascular, and gastrointestinal conditions; and adverse effects on pregnancies and birth outcomes. 24 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 25 extreMe heat Climate change is increasing the intensity and frequency of heat waves (Meehi and Tebaldi 2004; Reid et al. 2009). Globally, 157 million more people were exposed to extreme heat in 2017 than in 2000 (Watts et al. 2018). Assuming no changes in the current trend of emissions, the Union of Concerned Scientists projects that by mid century “the number of people [in the United States] experiencing 30 or more days with a heat index above 105°F in an average year will increase from just under 900,000 to more than 90 million—nearly one-third of the US population” (UCS 2019). Similarly, by the end of the century parts of Montana could see as many as 54 additional days over 90oF (32oC) (Whitlock et al. 2017; Section 2). Multiple studies have demonstrated increased mortality associated with heat waves (Knowlton et al. 2009; Ostro et al. 2009; Isaksen et al. 2016), which is the major cause of weather-related deaths in the United States (NWS undated) (see next page). Gubernot et al. (2015) find that people who work in agriculture or construction jobs have the highest risk for heat-related death; that risk may be even higher for employees of Montana businesses such as farms and small construction firms that have no backup personnel. This finding should concern Montanans given that agriculture and construction are integral to our state’s economy. In addition, American Indian ceremonial practices (e.g., sundances) become more difficult during extreme heat and expose participants to risk for heat-related conditions (Doyle et al. 2013). Figure 3-1. Ways climate change is harming, and will increasingly harm, human health (Salas et al. 2018). While climate change affects all parts of the world, the severity of specific health impacts will vary by the specific climate pressure, as well as by location. Coastal regions, for example, will endure the most damage from sea-level rise, whereas inland states like Montana will be impacted most by the adverse effects of heat waves and reduced air and water quality (from wildfire smoke, desertification, land degradation, and other factors [Hughes and Diaz 2008; Sharratt et al. 2017]).1 In the subsections that follow, we describe some of the exposure pathways and health outcomes resulting from climate change as shown in Figure 3-1. Some of the discussion may apply globally, but we emphasize those pathways and outcomes more likely to impact Montanans. Late summer sun in south central Montana 1 Montanans could feel indirect influences of sea-level rise, for example if coastal populations are forced to Photo courtesy of Scott Bischke relocate inland or coastal grain export terminals important to the Montana economy must be moved. 26 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 27 Which is More Deadly— Human impacts from excessive heat Extreme Heat or Extreme Cold? Heat affects humans in a variety of ways, impinging on multiple body systems. As depicted in Figure 3-2, elevated temperatures directly cause heat-related conditions ranging from muscle This seemingly simple question actually has no clear answer. Temperature extremes in both cramps to heat exhaustion to heat stroke, the latter of which is deadly if not treated promptly directions kill hundreds of people in the US each year, but determining the actual death toll is (Becker and Stewart 2011; Epstein and Yanovich 2019). In addition, elevated temperatures have subject to large errors. Two US agencies, using different methods and datasets, came to opposite been associated with increases in respiratory disease (Anderson et al. 2013; Ho et al. 2015); conclusions about which is more deadly: heart disease and strokes (Knowlton et al. 2009; Wang et al. 2016; Achebak et al. 2018); and fluid and electrolyte disorders, kidney disease, and kidney failure (Bobb et al. 2014; Ross et al. 2018; о NOAA’s monthly publication Storm Data (NOAA-NCEIa) regularly reports many more Sorensen and Garcia-Trabanino 2019). A study by Li et al. (2012) found evidence of a potential deaths per year as heat-related than as cold-related (NOAA-NCEIb). For example, their high-temperature threshold for several age groups (15–64 yr, 75–84 yr, and >85 yr) and specific annual summary for 2011 indicates 206 deaths from extreme heat versus 29 from heat-related causes for hospital admissions that included endocrine, genitourinary, and renal extreme cold. morbidities, as well as accidental injuries and intentional self-harm. о The Centers for Disease Control and Prevention’s National Center for Health Statistics analyzed death certificates in the US and came to the opposite conclusion, finding roughly twice as many people die of “excessive cold” conditions than of “excessive heat” (Berko et al. 2014). About 1300 deaths per year from 2006-2010 were coded as resulting from extreme cold exposure, whereas 670 deaths per year were attributed to extreme heat. The different findings depend, at least in part, on whether the focus is on acute or short-term responses to extreme weather or, alternatively, seasonal differences in estimates of daily mortality. Abnormally cold conditions may have little effect on estimates of daily mortality; rather deaths in winter increase as a result of non-weather-related diseases, like influenza. In addition, a recent study noted that a large majority of cold-related deaths occur under moderately cold conditions, so a reduction in extreme cold due to global warming is not expected to cause a large reduction in cold-related deaths (Gasparrini et al. 2015). It is also widely accepted that direct attribution (in medical records) of cause of death underestimates the number of people who die from temperature extremes (Sarofim et al. 2016). For example, a person who dies from a heart attack that resulted from heat or cold exposure is listed only as having died from a heart attack, even though extreme temperature exposure may have hastened or triggered the attack. Looking to the future, the Fourth National Climate Assessment found that under an upper-bound (RCP8.5) emissions scenario we should expect a large increase in US extreme temperature deaths. In 49 large US cities, representing one-third of the nation’s population, the report projected that changes in extreme hot and extreme cold temperatures would result in 9300 additional premature deaths per year by 2090, at a cost of $140 billion per year in 2015 dollars (Ebi et al. 2018). Since the study only covered populations in large cities, Montana was not included. These mortality estimates may be reduced through adaptation efforts such as acclimatization programs (e.g., ensuring adequate heating and cooling systems, and improved insulation). The report also considered the reduction in extreme cold deaths expected in a warmer climate; approximately 100 fewer cold deaths per year were expected in the US by 2050, with no further reduction in cold deaths between Figure 3-2. How heat affects our bodies. When temperature and humidity climb during extreme heat 2050 and 2090 (Ebi et al. 2018) events, the body’s cooling mechanisms become less effective. The symptoms shown here—ranging from minor annoyances to truly life-threatening issues—include both those that are indicative of heat- The bottom line is that high and low temperature extremes affect vulnerable populations, such related illness and those that are signs of preexisting conditions exacerbated by extreme heat. Figure as the unwell, the poor, the young, and the elderly, among others. Understanding the extreme- and caption used with permission from The Union of Concerned Scientists (UCS 2019). temperature risk for the future requires additional in-depth study of the interaction between temperature-related deaths and socioeconomic factors. With additional information, we can avoid adverse policy outcomes and achieve effective adaptation strategies. 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 29 Elevated temperatures are also associated with increased risk of preterm labor (Auger et al. 2014; Ha et al. 2016; Avalos et al. 2017), as well as sudden infant death/sudden unexpected infant death syndromes (SIDS/SUID) (Jhun et al. 2017). Elevated temperatures also cause worsening mental health, as described in the Mental Health subsection later in Section 3. Factors Considered in Determining Vulnerability to Extreme Heat The severity and duration of high temperatures influence the health impacts resulting from extreme heat. In addition, air pollution and population vulnerability (Basu 2009) compound these vulnerability, in the present context, is the extent to which a person is susceptible impacts. vulnerability is also a function of the typical temperatures to which a population is to the impacts of climate change. As described in the text and below, many factors exposed, plus the extent to which a population adapts (Curriero et al. 2002; Baccini et al. 2008; Ho go into calculating a person’s vulnerability to extreme heat. Three key terms bear et al. 2015). definition: Workers, especially those who work outdoors or in hot indoor environments, are at increased risk о adaptive capacity.—The ability of a person (or society) to cope with of heat stress and other heat-related disorders, occupational injuries, and reduced productivity at climate change. work (Levy and Roelofs 2019). Workers in the agricultural sector face increased risk of heat strain and dehydration2 due to repeated exposures to high air temperatures, arduous physical exertion, о exposure.—The type and magnitude of a climate change. and limited fluid intake. These risk factors may result in acute kidney injury (Moyce et al. 2017), as well as increased heat-related traumatic injuries (Spector et al. 2016). Spector et al. (2016) suggest о sensitivity.—How easily affected a person is by climate change. that efforts should be made to address heat-related illness and prevent occupational injury for Vulnerability (the “V” in the diagram below) is assumed to be the intersection of high-risk populations exposed to high temperatures and high physical exertion. adaptive capacity, exposure, and sensitivity (Smit and Wandel 2006; Füssel 2010; Inostroza et al. 2016). We combine adaptive capacity and sensitivity into one group, The impacts of increased air temperature may increase workers’ exposure to hazardous chemicals which is based on socioeconomic factors (see Appendix A for details). We continue and, thus, the adverse health effects of those chemicals (Spector et al. 2016). Global warming is to use the intersection of the three areas to determine vulnerability, and asssume also increasing ground-level ozone concentrations with adverse effects on outdoor workers (Levy adaptive capacity is simply implicit in the socioeconomic layers that comprise our and Roelofs 2019). sensitivity factor. Assessing heat impacts specific to Montana Multiple studies—covering wide ranges of temperature, time, and geographic area—have sought to assess the health impacts of extreme heat (e.g., Morabito et al. 2014; Zhang et al. 2014). Some studies estimate how heat-related mortality differs between rural and urban landscapes (reviewed by Ho et al. 2015). Other studies develop indices to identify heat-vulnerable populations (Vescovi et al. 2005; Reid et al. 2009; Reid et al. 2012; Chuang and Gober 2015). Human health vulnerability to heat is most often expressed as a combination of three factors: adaptive capacity, exposure to heat, and sensitivity to heat (Smit and Wandel 2006; Füssel 2010; Inostroza et al. 2016) (see sidebar). In our analysis, heat vulnerability was calculated as a combination of a) the historical land-surface temperature and future projections of heat to describe exposure; and b) county-level3 socioeconomic factors to describe sensitivity and adaptive capacity (see Appendix A for details). We will refer to the climate impacts as exposure, and the socioeconomic factors as sensitivity, with sensitivity inclusive of adaptive capacity, but no health factors were directly included due to incomplete county health factor data. 2 Dehydration, or the excessive loss of body water, can have many causes, including heat exposure, kidney disease, and diseases of the gastrointestinal tract that cause vomiting or diarrhea. 3 Figure 2-1 provides a map showing and naming Montana’s 56 counties. 30 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 31 Heat exposure Heat vulnerability Heat exposure is modeled as the combination of historical land-surface temperatures and Human exposure to heat has been quantified and mapped, although only a few studies have projected heat. To determine the county average land-surface temperature on days of extreme combined socioeconomic sensitivity with heat exposure data to evaluate human vulnerability to heat, we use the 95th percentile of daily average land-surface temperatures from 2000-2019 the health risks associated with extreme heat (Buscail et al. 2012; Ho et al. 2015). Most studies (Figure 3-3). For future projected heat, we use the heat index of each county (UCS 2019) generated that examine health vulnerability to heat use aggregate data that matches the spatial units from from an ensemble of general circulation models.4 The heat index includes a combination of which sensitivity information is derived by the US Census Bureau (Ho et al. 2015). For example, temperature and humidity to create a “feels-like” heat rating. most socioeconomic factors are measured at the county scale so exposure measurements (i.e., land-surface temperature and change in future heat) must be averaged across a county. Despite this complication, heat vulnerability is a useful measure to relate climate to human health impacts (see further details in Appendix A). Municipalities can use heat vulnerability information to guide heat mitigation interventions, such as establishment of green or reflective roofs, urban parks, and water features (see Section 5). Little Bighorn River swimming hole at Crow Agency Photo courtesy of John Doyle Figure 3-3. The county average land-surface temperature on days with extreme heat from 2000- 2019. Note: Land-surface temperatures are higher than air temperatures measured at weather stations. The scale to the right shows color-coding for temperature in oF. Sensitivity We base our calculation of sensitivity to heat on socioeconomic variables from the US Census Bureau, 2013-2017 American Community Survey 5-Year Estimates (US Census Bureau undated).5 Socioeconomic factors include age, the average income for people in the county, the percent of county population under the poverty line, the percent of poverty households with children, the percent of population employed in construction and production (implying predominantly outdoor workers with greatest exposure to heat), the percent of population unemployed, and type of housing (see further details in Appendix A). 4 Both heat index and general circulation models are described in Section 2. 5 See Appendix A for a complete explanation of socioeconomic variables and their weighting to derive a heat vulnerability index. 32 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 33 Local temperature trends By combining exposure and sensitivity data, we identified counties with populations most vulnerable to extreme temperatures. vulnerability was split into four main categories represented To understand the local effects of extreme temperatures, we examined daily temperature data in Figure 3-4. The darker the color the higher the vulnerability to heat. from 38 NOAA weather stations across Montana. We determined the maximum and minimum temperature trends in summer months (June, July and August) at each station. The temperature Of Montana’s 56 counties, one county has a high vulnerability rating, while 17 have a medium-high records at individual stations may not coincide or reveal the same patterns as the Montana rating, 12 have a medium-low rating, and 26 have a low rating. A strong west-to-east increasing climate region results indicated in the MCA, which were averaged (Whitlock et al. 2017). Our intent trend in vulnerability exists. That trend largely represents the patterns of exposure (i.e., land was to examine recent temperatures and their trends at a scale where human health may be surface temperatures and projected heat). Roosevelt County ranked 29th for historical extreme monitored and impacted in the future. Our findings are: heat and 51st for future predicted heat (higher rankings indicate higher exposure), making it one of the top five counties for projected extreme heat in Montana. Along with its high heat ranking, о Summer maximum temperature.—Fifteen out of the 38 stations across Montana indicate other factors make the population of Roosevelt County vulnerable to the negative health impacts an increasing trend in summer (June, July, August) maximum temperatures over the of heat. Those include relatively high unemployment, low median income, high poverty levels, and last 30 yr. The easternmost stations show no trend in maximum temperatures. No many production jobs (agriculture and energy sectors). stations have a negative trend in maximum summer temperatures (i.e., cooling) over the last 30 yr (1990-2019). о Summer minimum temperature.—From 1990-2019 minimum summer night temperature has an increasing trend at 15 of the 38 stations across Montana, and a decreasing trend at four stations. All of the decreasing trends in summer night temperature (i.e., cooling) are in western Montana. Five of the 15 stations with increasing summer maximum temperature also show increasing trends in summer night temperature; three are in urban centers. In other words, stations that show a trend towards increasing temperature during the day also experience a trend towards warming night conditions. Warm nights represent a burden on the human thermoregulatory system, particularly for the elderly and those who rely on natural ventilation (e.g., open windows) to reduce body temperature (Mills et al. 2015). The number of continuous days and nights at high temperature results in cumulative, negative heat impacts on people. In a study that looked at large cities at sea level, human mortality increased when extremely hot nights followed hot days (xu and Tong 2017). While a different scenario than faced by Montanans, increased human mortality has the potential to become a concern here given projected increased extreme temperatures. о Winter minimum temperature.—Winter (December, January, February) minimum temperatures indicate an increasing trend (i.e., winter progressively getting warmer) at only two of 38 stations, both in southwestern Montana, and four stations indicate decreasing trends in winter minimum temperature from 1990-2019. Over the longer period of 1970-2019 (50 yr), 11 out of 35 stations show winters warming while no stations indicate decreasing winter temperature. Thus, the time span for analysis Figure 3-4. Montana heat vulnerability ratings for mid century, using multi-criteria influences the trend, as do the months included in a season. For example, when winter decision analysis and the RCP8.5 emission scenario (explained in Section 2). Darker shading indicates higher vulnerability. See text and Appendix A for details. is expanded to include November and March in a different study (not published), 13 out of 15 weather stations show winters getting warmer. 34 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 35 Increasing temperature trends over the last 30 yr at individual weather stations are not limited to Ground-level ozone forms when sunlight and heat act on nitrous oxides and volatile organic the larger cities in Montana where heat islands6 might exist. Small rural towns are also vulnerable compounds (Rani et al. 2011). It has been associated with asthma exacerbations, increased to increasing heat and, based on limited healthcare facilities and other factors (see Section 4), may hospitalizations, and premature mortality (Bell et al. 2004; Zanobetti and Schwartz 2008; Di et include citizens who are already vulnerable to extreme conditions. The number of summer days al. 2017), as well as with preterm birth (Olsson et al. 2013). Ground-level ozone is expected to with maximum temperatures over 90oF (32oC) is projected to increase 11-33 days by mid century increase with warming temperatures (Melillo et al. 2014). (Whitlock et al. 2017). In Montana, ozone levels are generally rated low (<50) on the USEPA air quality index (AQI), but particulate matter levels are seasonally elevated (>100 AQI) in some areas (AirNow undated).7 Ten air quaLity issues counties in Montana, for example, received grades of “F” for particulate matter in the American Lung Association State of the Air 2020 report card (American Lung Association 2020).8 Some local areas have elevated particulate-matter levels during winter months due to inversion layers and Overview high woodstove usage. In eastern Montana, particulate matter is expected to increase as summer drought increases dust emissions in agricultural areas where land gets tilled for crops (Gage et al. Degraded air quality, or air pollution, refers to myriad substances, both human-made and 2016) and tillage is employed as a common summer fallow practice (Cook et al. 2014; Dawson et naturally occurring, including tobacco smoke, carbon dioxide, nitrous oxides, sulfur dioxide, al. 2014). Wildfires also contribute significantly to high levels of particulate matter, as we discuss in particulate matter, ground-level ozone, and volatile organic compounds. Outdoor air pollution, the next subsection. some forms of which are also global warming gases, is estimated to contribute to 64,200 premature deaths in the US annually (Watts et al. 2019). Outdoor air pollution is expected to Separately, but related to air quality concerns, pollen counts in the United States are increasing worsen with climate change (Orru et al. 2014). with projections for doubling by 2040 (Zhang et al. 2015) due to warming temperatures with longer growing seasons (Ziska et al. 2019), and higher atmospheric carbon dioxide levels (Ziska Across the US, human health concerns related to air quality are dominated by particulate matter and Caulfield 2000). In addition to worsening seasonal allergies, this increase in pollen poses and ground-level ozone (American Lung Association undated; Ward and Smith 2001; Tao et al. risks of triggering exacerbations of asthma, which affects 9.1% and 6.8% of Montana adults and 2005). children, respectively (MTDPHHS 2013). Particulate matter (PM)—especially PM2.5 and PM10, describing particulates under 2.5 μm and 10 μm diameter, respectively—has been associated with multiple health effects. Those effects include cardiovascular, respiratory, and immunological problems, the latter manifesting as increased risk 7 The USEPA developed the AQI scale as a simple way to convey how clean or polluted air is. The AQI scale for pneumonia (Rappold et al. 2011; Reid et al. 2016b; Tinling et al. 2016), and neurological issues, has six levels: 0-50 good; 51-100 Moderate; 101-150 Unhealthy for sensitive groups; 151-200 Unhealthy; 201-300 Very unhealthy; 301-500 Hazardous. in the form of greater risk for dementia (reviewed by Peters et al. 2019). Particulate matter has 8 The report is based on data collected from 2016-2018. The ten Montana counties are Fergus, Flathead, been found to penetrate the blood-brain barrier—i.e., move into the human brain—and cross the Gallatin, Lewis and Clark, Lincoln, Missoula, Powder River, Ravalli, Rosebud, and Silver Bow. placenta in pregnant women (Bové et al. 2019). It has also been associated with possible increased risk of preterm birth (DeFranco et al. 2016; Trasande et al. 2016), low birth weight (Fleischer et al. 2014), and increased medication use in children with asthma (Gielen et al. 1997). 6 According to the US Environmental Protection Agency (USEPA undated): “Heat islands occur on the surface and in the atmosphere. On a hot, sunny summer day, the sun can heat dry, exposed urban surfaces, such as roofs and pavement, to temperatures 50–90°F (27–50°C) hotter than the air, while shaded or moist surfaces—often in more rural surroundings—remain close to air temperatures. Surface urban heat islands are typically present day and night, but tend to be strongest during the day when the sun is shining.” Smoky skies near Missoula, from Mount Sentinel Photo courtesy of Philip HIguera 36 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 37 Wildfires and wildfire smoke Between 1997 and 2006, 339,000 human deaths per year globally were attributed to smoke from landscape fires, which includes forest fires, peat fires, grass fires, prescribed burns, agricultural burns, and tropical deforestation burning (Johnston et al. 2012). Deaths and injuries occur to people caught in fast-moving fires, as well as to firefighters, emergency response personnel, and others assisting with fire management. Wildfires can result in large-scale, temporary evacuations, or permanent displacement following the destruction of homes or even entire towns (Insurance Information Institute undated). The 2019/2020 fires in Australia, for example, killed 33 people across the country; in New South Wales alone over 2000 homes were destroyed (BBC News 2020). Closer to home, the November 2018 Paradise Fire in California killed 85 people, displaced hundreds, and destroyed over 18,000 buildings (Vox 2019). Large fires with adverse impacts on communities throughout the western US, including Montana, are increasing as measured in numbers of acres burned (Figure 3-5) because a) climate warming produces longer, drier fire seasons and extensive burning; and b) patterns of human development are increasing human Figure 3-6. NASA composite satellite image from 11 September 2017, showing fires in the Cascades and exposure to wildfires (Abotzoglou and Williams 2016; Radeloff et al. 2018). Rockies and smoke as far east as the Great Lakes. (Image source Wikipedia; used under Creative Commons attribution-share alike 4.0 international license [user “Bri”]. https://commons.wikimedia.org/wiki/File:2017_ September_5_MODIS_Pacific_to_Minnesota.jpg.) In Montana, increased fire activity in recent decades has impacted people through an increase in hazardous air quality from wildfire smoke, originating locally or from distant sources (see, for example, Figure 3-6). For the western US, including Montana, warmer and drier conditions during Human response data connecting heat and smoke to human health are limited for Montana. In summer have contributed to longer fire seasons and more area burned by wildfires, producing nearby Boise, Idaho, however, seven of the last ten years have included smoke levels considered more and longer smoke events (Dennison et al. 2014; Westerling 2016; Dalton et al. 2017). Smoke “unhealthy for sensitive groups” for at least a week during the fire season (IDDEQ 2013), causing events in the western US from 2004–2009 were associated with a 7.2% increase in respiratory cancellation of some school-related sports activities (Nolte et al. 2018). In 2020, large fast-moving hospital admissions among adults over 65 yr of age (Liu et al. 2017). fires in California, Colorado, Oregon, and Wyoming resulted in days with the air quality index rated “hazardous” in locations across the western US. Air quality hazards from wildfire Wildfire smoke worsens local air quality (Navarro et al. 2016), with substantial public health impacts in regions with large populations near heavily forested areas (Liu et al. 2015; Reid et al. 2016a; Fann et al. 2018). Smoke decreases visibility causing hazardous conditions (Yue et al. 2013), and can be transported hundreds of miles downwind (Dreessen et al. 2016; Kollanus et al. 2016). Wildfire smoke contains many components that are hazardous to human health, including particulate matter (more below), polyaromatic hydrocarbons, carbon monoxide, nitrous oxide, aldehydes, benzene, among other components (Reisen et al. 2015; Adetona et al. 2016; Liu et al. 2016). Exposure to wildfire smoke can result in emergency room visits for a variety of conditions, newly caused or aggravated, including asthma and chronic obstructive pulmonary disease (Rappold et al. 2011; Tinling et al. 2016; Cascio 2018); and cardiovascular conditions, including stroke, heart attack, and heart failure (Dennekamp et al. 2015; Haikerwal et al. 2015; Hutchinson et al. 2018; Wettstein et al. 2018). Additionally, wildfires can lead to rapid ozone formation and increased Figure 3-5. Annual area burned by, and number of, wildfires in Montana 2001-2019. frequency of ozone pollution levels that exceed air quality standards (Jaffe et al. 2008; Jaffe and Widger 2012). Increased ozone pollution harms human health, as described previously. 38 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 39 Particulate matter danger increases by 10 days by mid century, doubling (100% increase) from the 1971-2000 benchmark (Figure 3-7). More days with extreme fire danger implies a longer, more active fire Wildfires are estimated to have contributed about 18% of the total atmospheric particulate matter season, which ultimately results in more area burned per year, and increased atmospheric emissions in the US from 2004-2009 (Liu et al. 2015). Wildfires are projected to become the particulate matter and smoke (Norby et al. 2010; Jenkins et al. 2014; Jolly et al. 2015). Wildfire principal driver of summer particulate-matter concentrations in the western US (Ebi et al. 2018). smoke is and will be most common in western Montana, primarily because wildfires in forested areas produce large amounts of smoke (Westerling et al. 2006; IDDEQ 2013) (Figure 3-7). A study by Liu et al. (2016) shows that on days in the US exceeding regulatory particulate matter (PM2.5) standards, wildfires contributed an average of 71% of total particulate matter (PM2.5). Under future climate change, they estimate that more than 82 million individuals will experience a 57% increase in frequency and a 31% increase in intensity of smoke waves, defined as two or more consecutive days with high, wildfire-associated increases in particulate matter. They additionally project that wildfire-associated particulate matter will increase 160% by mid century under the RCP4.5 scenario (see Section 2). Airborne particulate matter is expected to increase in Montana croplands with more soil-exposed fallow periods (Pi and Sharratt 2017). Wind erosion of soil in wheat production is likely to increase due to increased summer drought and changing precipitation patterns favoring winter wheat over spring wheat. Climate change is also likely to create more cropland abandonment leading to desertification and land degradation (Hughes and Diaz 2008). Exposure to particulate matter results in numerous negative health outcomes (described above), as well as reduced life expectancy or death (Schwartz et al. 1996; Dominici et al. 2006; Pope et al. 2009; Puett et al. 2009). New fire projections for Montana Warmer spring and summer temperatures in Montana and reduced summer precipitation (see Section 2 regarding drought) create conditions conducive to wildfires. In grassland regions, wet spring conditions favor wildfire activity by promoting growth of understory vegetation, which is subsequently flammable during warm, dry summers and even into the fall and following winter (McKenzie and Littell 2017; Holden et al. 2018). When fires ignite under unusually warm, dry conditions—whether caused by humans or lightning—they spread faster, are harder to suppress, and end up burning larger areas than in summers with average climate conditions. Fire danger ratings—a five-class system widely used in wildfire management (low, moderate, high, very high, and extreme)—summarize the ways weather and climate conditions influence the likelihood and spread of wildfires (Dennison et al. 2014). We compare the average number of summer days having extreme fire danger (the highest classification in the system) between a reference period (1971-2000) and mid century (2040-2069), the latter based on climate projections (Whitlock et al. 2017). The most extensive wildfire activity in Montana correlates well with extreme fire danger, and thus the latter provides a suitable representation of extensive wildfire activity and resultant smoke in the future. Under RCP8.5 climate projections, the number of summer days having extreme fire danger Figure 3-7. Number of days with extreme fire danger over time in Montana. From top to increases across all counties, relative to the 1971-2000 reference period. In many counties, bottom we show the historical pattern, the mid-century projection under RCP8.5 (upper- particularly in northwestern and south central Montana, the number of days with extreme fire bound emission scenario), and the projected change in number of extreme fire days from 1971-2000 to mid century. 40 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 41 In Montana, Department of Environmental Quality reports show that the number of communities Increased fire danger for Montana in coming decades will likely result in decreased air quality or counties whose air quality rated as moderate, unhealthy, very unhealthy, or hazardous generally in years with widespread wildfire activity, like 2017. Such years will be interspersed with years increased from 2010-2017 (Figure 3-8), as a result of increased acres burned by wildfires. having average or below-average fire activity. Communities can adopt a suite of actions to mitigate However, these trends were followed by declining smoke in the below-average fire seasons of adverse effects on citizens from poor air quality (McWethy et al. 2019; also, such actions are 2018 and 2019 but on track in 2020 to be similar to or exceed 2017. The number of smoke events described in Section 5). in each health category shows similar trends, with western Montana valleys receiving the most unhealthy smoke days followed by the southeastern region of Montana. In 2017, the most recent year with regionally extensive wildfire activity, Seeley Lake, Lolo, Superior, and Frenchtown all Water-reLated iLLnesses had ten or more days where air quality was rated unhealthy, very unhealthy, or hazardous, with Seeley Lake experiencing 38 days with unhealthy and worse smoke conditions (see a) Section 2, Climate change is affecting Montana’s water quantity and quality (Whitlock et al. 2017; MTDEQ b) sidebar Section 4 titled The 2017 Seeley Lake fires and lung function). Assuming that projected 2019), each of which may, in turn, impact human health9. For example, spring floods, which are increases in extreme fire danger result in increased wildfire activity, Montana could expect an expected to increase because of earlier snowmelt or extreme precipitation events (see Section increase in summers exceeding moderate air quality standards, with more communities affected, 2), affect people’s health in a variety of ways. Immediate impacts include injury, hypothermia, especially in western Montana. death from drowning, exposure to toxic substances and pathogens released by flood waters, and exacerbation of underlying conditions such as cardiovascular or pulmonary disease (due the flood itself or cleaning up afterwards). Later complications include respiratory and skin infections, vector-borne illnesses, and mental health conditions (Du et al. 2010; Ryan et al. 2015; Paterson et al. 2018). Floods also increase the risk of mold formation in homes (Bell et al. 2017), an environmental stressor that can impact anyone but particularly American Indian/Alaska Native children (Barros et al. 2018). Even in the absence of flooding, elevated rates of gastrointestinal disease have been associated with precipitation events (Carlton et al. 2016; Levy et al. 2016), as well as with dry conditions (Alexander et al. 2013; Friedrich 2013; Fouladkhah et al. 2019), though the latter association is weaker. Water quality issues resulting from climate change may also come about because of changes to precipitation runoff, land use, and the way agricultural lands are managed (MTDEQ undated). Changes to the timing and amount of runoff can impact stream turbidity and sediment deposition, plus non-point pollution runoff and subsequent increased stream concentrations of undesirable compounds. Late season droughts may result in higher concentrations of pollutants—including fertilizers and pesticides—in warmer waters, potentially leading to decreased levels of dissolved oxygen and/or increased algal blooms. Harmful algal blooms, often caused by cyanobacteria10, are special cause for concern. Cyanobacteria have increased across the US from under 100 incidents in 2013 to over 500 in 2019 (EWG undated), and are becoming increasingly common in Montana (MTDPHHSa undated). Many factors influence harmful algal blooms, including increased nutrients from agricultural runoff or sewage, changes in water circulation, Figure 3-8. The number of communities, counties, and regions in Montana where wildfire and increased water temperatures (Paerl and Huisman 2009; smoke led to varying air quality ratings (MTDEQ undated), and number of acres burned by wildfire each year. 9 Ecological health may also be impacted, but here we focus on human health. 10 Although commonly referred to as blue-green algae, cyanobacteria are a group of photosynthetic bacteria. 42 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 43 Moore et al. 2011; Davidson et al. 2014). Based on climate model projections, Chapra et al. (2017) indicate that concentrations of cyanobacteria are likely to increase across the US, primarily due to water temperature increases and increased nutrient inputs. They predict that the mean number Climate Impacts on Food Availability and of days of harmful algal bloom occurrence, which is about 7 days/year per water body under current conditions, will increase to 16−23 days in 2050 and 18−39 days in 2090. Nutrition Harmful algal blooms can harm human health. Depending on the causative organism and type of Food and nutrition concerns resulting from a warming world could outweigh all exposure, maladies include gastrointestinal symptoms, muscle cramps, skin rashes, liver damage, other human health impacts brought on by climate change (Springmann et al. 2016). and even death. In addition, harmful algal blooms can impair municipal water supplies, hamper Examples include: recreational activity, and cause significant economic hardships (e.g., if tourism declines in the affected areas). о Elevated CO2 levels can reduce the protein and micronutrient concentration in grains, putting larger swaths of the global population at risk for malnutrition and anemia (Medek et al. 2017; Smith and Myers f s n C 2018; Uddling et al. 2018). ood eCurity and utrition onCerns о Increased temperatures, both Climate change threatens human health through its effects on agriculture. For Montana, the MCA modest and extreme, can describes that global warming will influence the distribution of weeds, pathogens, and insect pests lower crop yields (Zhao et al. and introduce new pests (Whitlock et al. 2017) . These changes may alter the types and amount of 2017; Vogel et al. 2019), as pesticides used, potentially affecting the health of agricultural workers and others. can drought (Lesk et al. 2016) and extreme weather events In addition, food quantity and quality, including nutrition, are directly and indirectly impacted by (Nelson et al. 2014). climate change (Gowda et al. 2018b) (see facing page). Grains, for example, provide almost half the calories humans eat and wheat is a major crop in Montana. With increasing atmospheric CO2 о Increased food prices are an levels, plants grow larger and store more carbohydrates (sugars), yet they contain less protein, economic result of lower crop zinc, iron, and other nutrient concentrations (Myers 2014).11 Reduced nutrient quality leads to a yields, making some foods less number of health problems, including: available to those who may already be undernourished. о Inadequate nutrition can permanently affect the physical and mental development of Increased food prices children. In the US, low iron levels are experienced by one of out of every five children disproportionately affect lower for part of their childhood (Irwin and Jeffrey 2001). income people (Lake et al. 2012). о Low iron levels have been associated with decreased cognitive function (Jáuregui- Lobera 2014), reduced work capacity (Haas and Brownlie 2001), decreased quality of о Given the interconnected food life, and reduced life expectancy (Shander et al. 2014). supply, global crop failures or shortages in distant locations о Reduced protein decreases muscle mass. can impact food prices and availability in Montana. о Undernourished people have greater difficulty fighting infections. о Montana has seen longer growing seasons, offset by summers becoming о Severe zinc deficiency can cause diarrhea, weight loss, skin lesions, and decreased hotter and drier. Hence, it is hard to project whether local food production immunity (NCHS undated). will increase. 11 Conversely, in some cases drought can increase the concentration of nutrients (Balla et al. 2011; Gooding et al. 2008). 44 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 45 Climate change can also lower the overall quantity of food produced, resulting in multiple impacts including to traditional sources for American Indians (Zhao et al. 2017; Gowda et al. 2018b; see Section 4 sidebar: Changes Rippling Through Our Lives and Waters). The salt content of underground water sources (aquifers) and coastal lands globally is increasing due to greater withdrawal of groundwater and sea-level rise, making these regions less productive or non-productive. Some pests and weeds that lower the productivity of food crops can thrive better in a CO2-enriched atmosphere (Deutsch et al. 2018; Ziska et al. 2019). Increasing extreme weather (e.g., flood and precipitation events), growing season drought, and increasing fire severity can also be a detriment to food production. Food and nutrition concerns resulting from a warming world Livestock, not just plants, are impacted by climate could outweigh all other human change. Milk production decreases as dairy health impacts brought on by climate cows are exposed to increased heat (reviewed in Whitlock et al. 2017; Summer et al. 2018). Deaths change (Springmann et al. 2016). in all animals, including livestock, increase with excessive heat, and animals with dark coats are more sensitive to extreme heat. Heat waves make livestock less fertile (Takahashi 2012). Extreme weather events, such as flash floods and drought, also lead to increased animal mortality. veCtor-borne disease Vectors—primarily arthropods such as ticks, mosquitoes and fleas—are organisms that transmit diseases from one host to another. Globally, vector-borne diseases include Zika, plague, dengue, malaria, yellow fever, Chagas disease, and Chikungunya, among others. In the US, Rocky Mountain spotted fever, Lyme disease, and anaplasmosis, all carried by ticks, and West Nile virus, transmitted by mosquitoes, are most prominent. Zika, dengue, Chikungunya, and Eastern Equine Encephalitis are also of concern. Overall, climate change is expected to increase the range of vectors, primarily ticks and mosquitoes in the US, thereby increasing the number of people exposed to the diseases that these arthropods transmit (Beard et al. 2016; Sonenshine 2018). Recent work by Rosenberg et al. (2018) shows that the number of vector-borne diseases tripled in the US between 2004 and 2016, with over 100,000 cases reported in 2016. Whereas the marked increase is unlikely to be fully attributable to climate change given the complexities of vector life cycles, disease prevalence, and human interactions (well discussed by Ogden 2017), neither can the contribution of climate change be discounted. Thus, concern is reasonable. The interactions between climate, vectors, and pathogens are complex. For example, for certain mosquitoes increased temperatures boost the rate of reproduction and feeding, lengthen the breeding season, and shorten the maturation time for the pathogens they carry (Patz et al. 1996; Epstein et al. 1998; Epstein 2005). However, such complex relationships vary by locale and species. Temperatures that benefit mosquitoes may be detrimental to ticks; flooding may wash away larval Cattle in Valley County stages of mosquitoes; drought may contribute to a decline in tick numbers. Rodent vectors, such Photo courtesy of Erik Adams as deer mice that carry Hantavirus, demonstrate equally variable relationships (Mordecai et al. 2012, 2017, 2019). 46 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 47 Lyme disease.—According to the Centers for Disease Control and Prevention (CDC), Lyme disease is the most common vector-borne illness in the US, with approximately 300,000 total cases diagnosed annually (CDCa undated). Lyme disease is most prevalent in the Northeast, but has been spreading westward and northward into the Midwestern states and farther into Canada. The main vector, the deer or blacklegged tick, is not found in arid parts of the West, requiring more moisture to thrive. Although Lyme disease is the most common tick-borne disease in Montana— averaging 10 cases per year—all cases reported through 2018 came from people infected outside of Montana (MTDPHHSb undated). West Nile virus.—West Nile virus, first reported in the United States in 1999, is found in nearly every country and is the most common mosquito-borne illness in the United States, with 2647 cases and 167 deaths reported in 2018 (CDCb undated). West Nile virus is considered the most important cause of viral encephalitis globally (Chancey et al. 2015; Paz 2015), with increased spread projected with climate change (Paz 2015). Drier weather, especially drought, leads to higher rates of West Nile virus infection in people (Wang et al. 2010; Paull et al. 2016). In the last several years, the northwest region of the US has seen an increase in some infectious diseases, including West Nile virus. The Washington Department of Health’s vector surveillance program observed earlier arrival of West Nile virus-carrying mosquitoes than some other states (likely associated with higher temperatures), and an increasing number of human infections, including some resulting in fatalities (WSDOH 2018). Figure 3-9. Map showing 2018 detections of West Nile virus in humans and horses, by county (MTDPHHSc undated). Montana had no cases of West Nile virus until 2002. By 2018, the Montana Department of Public Health and Human Services (MTDPHHS) reported 51 cases across 18 counties. Nine counties reported mosquito pools12 that tested positive for West Nile virus out of 30 counties tested (Figure 3-9). Three people have died from West Nile virus in Montana since it was first detected (MTDPHHSc undated). MCA projects longer droughts, warmer temperatures, and minimal change in average annual precipitation, likely concentrated in fewer precipitation events (Whitlock et al. 2017; also see Section 2), factors that favor both the virus and the primary vector, the Culex spp. mosquito (Epstein 2001; Harrigan et al. 2014; Paull et al. 2017). Thus, concern exists for climate change resulting in increased numbers of West Nile virus infections in Montana. 12 A mosquito pool is described by the West Umatilla Mosquito Control District as a collection of mosquitoes (usually about 50) of any given species or group (e.g., Culex spp. mosquitoes) that are likely to carry and potentially transmit a virus (WUMCD undated). 48 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 49 Photo: James Gathany / Wikimedia Climate Change and Mental Well-being—Perspectives from Montana Farmers and Ranchers MentaL heaLth ConCerns The mental health impacts of climate change are profound and varied. Elevated temperatures Meredith Howard, Selena Ahmed, Paul Lachapelle, and Mark B. Schure have been related to worsening a) mental health status (Obradovich et al. 2018); b) diminished cognitive function (Laurent et al. 2018); c) increased violence (Clayton et al. 2017); d) increased While the physical and economic implications of climate change have been studied widely, including interpersonal aggression in the form of domestic violence, abuse, and rapes (Hsiang et al. 2013); effects on agricultural systems, the mental health implications have been largely overlooked. and e) suicide (Page et al. 2007). Even small increases in temperature, in one case comparing Farmers and ranchers—who contribute to local, national, and global food security—represent an average monthly temperatures between 25-30oC (77-86oF) with those over 30oC (86oF), can lead to especially vulnerable and critical population for consideration. Montana State University researchers significant increases in mental illness (Obradovich et al. 2018). surveyed farmers and ranchers (n=125) in Montana using a mixed-method approach to investigate the relationship between climate change perceptions and mental well-being (Howard et al. 2020). People with preexisting mental illness Survey results revealed the following: are at increased risk following weather- related events (Trombley et al. 2017), as Montana has one of the highest per о The majority of respondents (72%) agreed that climate change is having an adverse are youth (Paulson et al. 2015; Orengo- capita suicide rates in the country effect on their farm or ranch. Aguayo et al. 2019). Likewise, climate (CDC 2018; AAS 2020a,b). This “surprises” (see Section 2) such as flooding о Nearly three quarters of respondents reported feeling moderate to high levels of anxiety (Lamond et al. 2015), wildfires, or storms unfortunate reality, coupled with when thinking about climate effects on their agricultural business. have been shown to impact mental health. limited access to mental health о The greater the reported perceived risk regarding climate change, the greater the level of Those impacts include increases in post- professionals in most rural areas reported anxiety. traumatic stress disorder (PTSD), anxiety, of the state, greatly heightens the depression, substance abuse, and suicidal о The impact of climate change on farm/ranch profitability was perceived as a main cause thoughts. A sense of community loss and, importance of preparedness planning of distress. in many cases, displacement can also result in Montana to address anxiety, following sudden extreme events, or they One Montana producer commented, “[I am] worried about crop losses of current and future years, stress, and other mental health issues may occur over time with slower, sustained and about where funds will come for dealing with climate change on the farm. As with most, my climate change impacts (e.g., persistent exacerbated by climate change. worries generally stem from financial stress.” drought or sea-level rise) (Hayes et al. 2018; Palinkas and Wong 2019). Another respondent shared, “Climate change contributes to my distress because it makes planning for long-term crops more difficult and predicting weather patterns less predictable.” Montana has one of the highest per capita suicide rates in the country (CDC 2018; AAS 2020a,b). This unfortunate reality, coupled with limited access to mental health professionals in most rural Public-health preparedness efforts are areas of the state, greatly heightens the importance of preparedness planning in Montana to warranted to provide mental health support address anxiety, stress, and other mental health issues exacerbated by climate change (see facing for the agricultural sector. Research and page). The Montana health workforce does not have widely available access to training on how to outreach efforts are further called for to address climate anxiety and post-disaster trauma; nor does it have information on the tracking of promote the adoption of practices that climate stressors (Doppelt 2016). mitigate climate risk and enhance personal and food-system resilience. Linkages between climate-induced anxiety and an increasingly aging and female farm and ranch population should also be studied. 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What weather variables are important in predicting heat-related seasonality across the northern hemisphere: a retrospective data analysis. Lancet Planetary Health mortality? A new application of statistical learning methods. Environmental Research 132:350-9. 3(3):e124–31. doi:10.1016/s2542-5196(19)30015-4. Helena at -15oF (-26oC) Photo courtesy of Scott Bischke 68 | CLIMATE-RELATED HEALTH IMPACTS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 69 04. WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? Susan Higgins, Alexandra Adams, and Margaret Eggers, with contributing authors Lori Byron, Paul Lachapelle, Sally Moyce, Richard Ready, Lisa Richidt, Jennifer Robohm, and Eliza Webber Some people are more vulnerable to climate change impacts than others. When considering all Americans, Gamble et al. (2016) identify those at higher risk to include children, older adults, pregnant females, tribal communities, communities of color, people with lower incomes, and people living in rural or remote regions. People with disabilities or mental health conditions, as well as people who are displaced, suffer from social isolation, or live without insurance are also more likely to suffer adverse consequences from climate change (Forman et al. 2016). Montanans fit into a number of the categories just noted, as we describe below. 70 | WHOSE HEALTH IS MOST vULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 71 Photos (left to right): Engin Akyurt / Pexels, Lori Byron; John Turner / US Air Force; Vlad Chețan / Pexels Montana’s heaLth profiLe We recognize that some people in Montana are already health-challenged with issues like chronic disease, poor diet and nutrition, and/or limited access to food and healthcare, regardless of Before describing Montanans who are most vulnerable to climate-related health concerns, we climate change impacts. Such challenges are depicted annually for nearly every county in the acknowledge our state’s current health profile. A health profile describes access to and availability United States in the County Health Rankings and Roadmaps report (Givens et al. 2019). Figure 4-1 of health resources, social and demographic characteristics, current health status, health risk shows how Montana’s 56 counties rank with respect to a set of health factors that determine how factors, and quality of life (Durch et al. 1997). Montana has many health-related inequities and long and how well we live. Those factors—e.g., personal behavior, socioeconomic status, and the complexities, as described below, even before adding climate-related complications. physical environment—strongly influence health concerns resulting from climate change. We find ten sectors of Montana’s population are at particular risk of having their health impacted Montana is a rural state by Montana’s warming climate. We base that assessment on an understanding of our state’s warming climate (Whitlock et al. 2017; also see Section 2), known climate impacts on human health The most important aspect of Montana’s health profile is that Montana is a rural state. As such, (see Section 3), and Montana’s health profile, as follows. many Montanans live in frontier areas 1 that lack essential services like healthcare, and thus must travel long distances for such vital needs. Figure 4-2 shows the population status of Montana’s 56 counties, and the boundaries of tribal reservations (OMB 2010). 1 A frontier area is defined as having fewer than 7 people/mile2 (2.7 people/km2) (RHIhuba 2020). Figure 4-1. Montana’s 56 counties ranked with respect to health factors (factors that drive how long and how well we live including, for example, personal behaviors, socioeconomic factors, and the physical environment). The higher the number, the greater the health challenges (Givens et al. 2019). Note: Figure 2-1 provides a map showing and naming Montana’s 56 counties. Note that some counties are not ranked due to low population numbers and/or lack of data. 72 | WHOSE HEALTH IS MOST vULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 73 Photo facing page: iStock by Getty Images Montana averages just 6.9 people/mile2 (2.7 people/km2), making it the third most sparsely Between 2010 and 2018, Montana’s population populated state in the country (US Census Bureau 2010). The 2018 census estimates show that grew 7.4%, faster than the average national 33.1% of Montana’s 1,062,305 residents live in rural areas, as defined by Office of Management growth rate of 5.9% during the same period. The most important aspect of and Budget’s Core-Based Statistical Areas (OMB 2010; US Census Bureau 2018b). In comparison, Yet, even though Montana as a whole is Montana’s health profile is that just 5.6% of the total US population resides in a rural area (US Census Bureau 2018b). Montana’s growing quickly, its rural areas continue to lose population is 88.9% White. American Indians comprise 6.6% of Montana’s population, one of numbers: 18 of 56 counties lost population Montana is a rural state. As such, the highest percentages of any state (US Census Bureau 2018c). Other ethnic and racial groups (US Census Bureau 2018d). Growth has many Montanans live in frontier represent 4.6% of the population. been concentrated in Montana’s most highly areas that lack essential services populated counties, with urban county growth in Gallatin, Yellowstone, Flathead, Missoula, and like healthcare, and thus must travel Lewis and Clark counties accounting for 83% of long distances for such vital needs. the state’s total population increase (US Census Bureau 2018d) (Table 4-1; Figure 4-3). Table 4-1. Distribution of Montana population growth, 2010-2018a Location Net Growth Urban/rural growth share (%) status MT net growth, statewide 72,890 Growth share by county Gallatin County 22,363 30.7% Urban Yellowstone County 12,165 16.7% Urban Flathead County 11,178 15.3% Urban Missoula County 9492 13.0% Urban Lewis and Clark County 5305 7.3% Urban Other countiesb—rural (n=46) 3903 5.4% Rural Other countiesc—urban (n=5) 2853 3.9% Urban a Data sources: US Census Bureau 2018b,d b Combined net growth of the following rural counties: Beaverhead, Big Horn, Figure 4-2. Population status of Montana’s 56 counties. The three statistical areas shown are defined as follows: Blaine, Broadwater, Carter, Chouteau, Custer, Daniels, Dawson, Deer Lodge, Rural areas are counties with an urban cluster having less than 10,000 people. Micropolitan areas have at least Fallon, Fergus, Garfield, Glacier, Golden Valley, Granite, Hill, Judith Basin, one urban cluster of at least 10,000 but less than 50,000 population, plus adjacent territory that has a high Lake, Liberty, Lincoln, Madison, McCone, Meagher, Mineral, Musselshell, Park, degree of social and economic integration with the core as measured by commuting ties. Metropolitan areas Petroleum, Phillips, Pondera, Powder River, Powell, Prairie, Ravalli, Richland, have at least one urbanized area of 50,000 or more population, plus adjacent territory that has a high degree of Roosevelt, Rosebud, Sanders, Sheridan, Sweet Grass, Teton, Toole, Treasure, social and economic integration with the core as measured by commuting ties. The analysis here was created Valley, Wheatland, and Wibaux from OMB (2010) and US Census Bureau (2018a) data. Montana’s tribal reservations, numbered, are outlined in c gray: 1) Blackfeet Tribe of the Blackfeet Reservation; 2) Chippewa Cree Tribe of the Rocky Boy’s Reservation; 3) Combined net growth of the following urban counties: Carbon, Cascade, Confederated Salish and Kootenai Tribes of the Flathead Reservation; 4) Crow Tribe of the Crow Reservation; 5) Jefferson, Silver Bow, and Stillwater Assiniboine (Nakoda) and Gros Ventre (Aaniiih) Tribes of the Fort Belknap Reservation; 6) Assiniboine and Sioux Tribes of the Fort Peck Reservation; and 7) Northern Cheyenne Tribe of the Northern Cheyenne Reservation. 74 | WHOSE HEALTH IS MOST vULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 75 Health outcomes for Montana’s American Indian communities are worse than for its non- American Indian communities. For example, the rate of premature death in Montana is much higher for American Indians than for non-Native residents (MTDPHHS 2019a). The life expectancy for Montana American Indians is nearly 20 yr less, and their rates of death from cancer, injury, cirrhosis, diabetes, and heart disease are higher than for non-Native residents (MTHCF undated). Table 4-2 compares the differences in health outcomes for Montana’s different ethnic and racial groups (Givens et al. 2019). These inequities stem from systemic, long-standing issues such as racism, historical trauma, and rural isolation; and/or lack of access to healthy foods and healthcare, inadequate water and wastewater infrastructure, problems of safety or crime, loss of tribal connections, high stress levels, and poverty. In addition, funding disparities for education, housing, healthcare, and food have perpetuated this vulnerability (US Commission on Civil Rights 2003, 2018). Table 4-2. Differences in health outcome measures among counties and racial/ethnic groups in Montana (Givens et al. 2019) Healthiest Least MT county healthy AI / Asian a a Black Hispanic White MT county AN / PI Premature death (yr lost/100,000)b 4900 21,000 19,400 2900 10,000 6800 6600 Poor or fair health (%) 11% 26% 25% NA* NA* 18% 13% Figure 4-3. Range of percent change in population for Montana’s 56 counties from 2010-2018 (US Poor physical health Census Bureau 2018d). Montana’s tribal reservations, numbered, are outlined in gray: 1) Blackfeet (days/month)c 3.0 5.4 5.1 NA* NA* 3.4 3.3 Tribe of the Blackfeet Reservation; 2) Chippewa Cree Tribe of the Rocky Boy’s Reservation; 3) Confederated Salish and Kootenai Tribes of the Flathead Reservation; 4) Crow Tribe of the Poor mental health (days/month)c 2.9 4.5 5.3 NA* NA* 4.6 3.4Crow Reservation; 5) Assiniboine (Nakoda) and Gros Ventre (Aaniiih) Tribes of the Fort Belknap Reservation; 6) Assiniboine and Sioux Tribes of the Fort Peck Reservation; and 7) Northern Cheyenne Low birth weight Tribe of the Northern Cheyenne Reservation. (%) 5% 7% 9% 10% 12% 8% 7% a AI = American Indian; AN = Alaska Native; PI = Pacific Islander; NA = not applicable (data for all racial/ ethnic groups may not be available due to small numbers) b Premature death is defined in the Montana State Health Assessment (MTDPHHS 2019a) as: “A death Health-wise, where you live matters which occurs before a person’s life expectancy. In the US, premature death is dying before the age of 75.” It is not surprising that healthcare access is a challenge to Montanans in low-population counties c Past 30 days at time of survey and— combined with other risk factors described below—translates into poorer health outcomes when compared to those living in high-population counties. Montana ranks higher than the national average in percentages of people over the age of 65, housed in mobile homes, without health insurance, or with disabilities (Headwaters Economics 2019). Thirty-three percent of adults in Montana report having two or more chronic health conditions, and the prevalence of multiple chronic conditions is significantly higher among adults living in low-population counties (MTDPHHSa undated). 76 | WHOSE HEALTH IS MOST vULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 77 Key health issues in Montana …potentially traumatic events that occur in childhood (0-17 years) such as The CDC (2017) identified the leading causes of death in Montana as respiratory disease, heart experiencing violence, abuse, or neglect; witnessing violence in the home; and having disease, accidents, suicide, cancer, and stroke. Building from that knowledge, Montana’s State a family member attempt or die by suicide. Also included are aspects of the child’s Health Improvement Plan identified five priority areas for healthcare focus (MTDPHHS 2020a). We environment that can undermine their sense of safety, stability, and bonding such summarize each of the priority areas below, plus compare Montana to the national averages in as growing up in a household with substance misuse, mental health problems, or Table 4-3. All declarations in the bullets that follow, unless otherwise credited, are derived from instability due to parental separation or incarceration of a parent, sibling, or other Montana’s State Health Improvement Plan (MTDPHHS 2020a). member of the household. о Behavioral health, including suicide prevention, depression, substance abuse, and opioid Adverse childhood experiences are directly related to negative outcomes in chronic misuse.—Suicide-related deaths in Montana are the fourth highest per capita in the disease, substance abuse, and mental health. In 2011, 60% of Montana adults reported US, and almost twice the national average (CDC 2018). This rate is significantly higher having one or more adverse childhood experiences (CDCb undated). Due to the in rural counties and in American Indian populations. Precursors to suicide often established links between adverse childhood experiences and negative behavioral and include depression and/or substance abuse. The number of adults treated with mental health outcomes, this is an important area for health improvement in our state (CDCc illnesses in Montana between 2009 and 2013 was higher than the national average, undated). People with higher probability of chronic disease and mental health issues and nearly 64,000 Montana adults struggle with substance abuse. Alcohol is the most related to adverse childhood experiences are also more vulnerable to climate-related commonly abused substance in Montana, but opioids are the leading cause of drug- health impacts. overdose deaths in Montana, accounting for 44% of such deaths. о Chronic disease.—Chronic diseases are long-term conditions lasting one or more years that require ongoing medical attention or limit activities of daily living (NCCDPHP 2019). Chronic disease in Montana is attributable in large part to smoking, obesity, Table 4-3. Comparisons of Montana and US rates for incidence of five priority health issues. See text for a description of each issue. poor nutrition, and physical inactivity. Tobacco use is the leading cause of preventable death, with 1600 tobacco-related deaths each year. Per capita, these deaths strike Priority health issue in Montana Unit of measure Montana US Montana’s American Indian population disproportionately (Campaign for Tobacco-free Suicide mortalitya per 100,000 population 28.9 14.0 Kids 2017). Two factors adding to chronic disease in our state are a) 75% of Montana adults and 72% of youth do not meet the national physical activity recommendations Chronic diseaseb % of adults with multiple (two or 33.2% 25.7% (MTOPI 2019); and b) only 62% of Montanans are up-to-date with colorectal cancer more) chronic conditions screening (MTDPHHS 2016). Infant mortalityc per 1000 live births 5.4 5.8 о Maternal health and newborns.—Approximately 12,000 live births occur each year in Motor vehicle crash mortalityd per 100,000 population 17.1 11.2 Montana. Infant mortality in Montana is 5.7 per 1000 births for White populations, % of adults experiencing one or closely matching the rate for all races nationally of 5.8 per 1000 births. In great Adverse childhood experiencese more such experiences 60% 61.5% contrast, infant mortality for American Indians in Montana is 10 per 1000 births (MTDPHHS 2017). Data sources (all accessed 4 April 2020) ª https://www.cdc.gov/nchs/pressroom/sosmap/suicide-mortality/suicide.htm о Motor vehicle crashes.—Motor vehicle crashes are one of the most common causes of b https://www.cdc.gov/mmwr/volumes/65/wr/mm6529a3.htm#T1_down fatal and non-fatal injuries in Montana. In 2014, the rate of death due to crashes was c https://www.cdc.gov/nchs/pressroom/states/montana/montana.htm 19.4 per 100,000 in Montana, approaching twice the national figure of 10.3 per 100,000 d https://www.cdc.gov/nchs/pressroom/states/montana/montana.htm in the same year (MTPHIS undated). The rate is higher among American Indians and for e https://dphhs.mt.gov/ahealthiermontana/ACEs; https://www.cdc.gov/violenceprevention/ those living in rural versus urban areas (MTDPHHSb undated). From 2011–2016, 60% childabuseandneglect/acestudy/ace-brfss.html of all crash-related fatalities involved a driver impaired by alcohol or drugs (MTDPHHS 2020a). о Adverse childhood experiences.—The Centers for Disease Control defines adverse childhood experiences as (CDCb undated): 78 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 79 popuLations vuLnerabLe to CLiMate ChanGe workers come to Montana to work in agriculture, construction, and other industries involving outdoor labor. These workers are at increased risk due to inadequate or Review of Montana’s health profile reveals that our state’s rural nature—including limited access substandard housing facilities, cultural and linguistic isolation, lack of health insurance, to healthcare facilities—has a wide-reaching impact on our citizens’ well-being. Montanans suffer and poverty. As depicted in Figure 4-4, fatalities are highest in the occupational sector from chronic disease, inadequate maternal and childhood healthcare, a high rate of vehicular that includes agriculture and forestry (North American Industry Classification Sector deaths, and mental illness, suicide, alcoholism, and substance use disorders. We next consider 111). An analysis of workers' compensation data revealed that workers in these what concerns result when climate-related impacts are added to these existing health conditions. industries are at particular risk of injuries on high heat days (Moyce and Nealy 2019). The remainder of this section describes ten groups in Montana having particular health о Housing and air conditioning.—Inhabitants of mobile homes may be more susceptible vulnerabilities to climate change. to higher heat days.2 Some mobile homes may be unbearably hot in summer if they lack adequate air conditioning and/or insulation. In 2017, there were 45,496 mobile People with existing chronic conditions homes in Montana, or 10.8% of the total housing units, which is nearly double the national average of 5.7% (Headwaters Economics 2019). In addition, mobile homes Why it matters.—People living with chronic conditions (e.g., asthma, obesity, heart disease, are more likely to be damaged during extreme storms, which poses a risk for both the pulmonary disease) are more vulnerable to the risks of climate change (Gamble et al. 2106). structure and its occupants. Extreme heat and degraded air quality that result from wildfires greatly aggravate these existing health problems (USEPA 2016). Data on air conditioning in Montana are sparse. Based on a small-sample survey, NEEA (2012) estimates that 19% of rural Montana households and 35% of urban households What we know in Montana.— Rural Montanans, regardless of race or ethnicity, have higher have some type of air conditioning (NEEA 2014). People living in urban areas tend to mortality rates for six of the ten leading causes of death, including heart disease, diabetes, and have central air conditioning systems, while those in rural areas tend to have window chronic liver disease, compared to residents of more urban counties. Rural risk factors for health or roof units. disparities in Montana include geographic isolation, fewer healthcare providers, more health risk behaviors (e.g., binge drinking and unhealthy diets), lower socioeconomic status, and limited employment opportunities. The story becomes even more stark when considering Montana’s 2 Mobile homes are defined by the Montana Department of Revenue as any trailer, house trailer, or trailer American Indian communities. From 2011 to 2015, for example, the median age at death in coach that is over 8 ft wide or 45 ft long and designed to be moved by connecting to another vehicle, or Montana was 16 and 19 yr younger for American Indian men and women, respectively, when under 8 ft wide or 45 ft long and used as a principal residence (Montana Department of Revenue undated). compared to their non-Native counterparts (MTDPHHS 2019a). People threatened by increased heat Why it matters.—National data show that increasing heat negatively impacts mental health and risk of heat stroke (see Section 3). People without access to shade, air conditioning, and cooling places are at much greater risk than those having adequate protection from heat. In addition, heat exposure during pregnancy carries with it the risk of premature births and birth defects (Ravanelli et al. 2019; Section 3). What we know in Montana.—Increased heat poses the greatest risk for migrant agricultural workers and others working outdoors, as well as those living in inadequate housing (without, for example, adequate insulation or air conditioning). о Those working in the outdoors.—Over 62% of Montana lands are in farm and ranch production (NASS 2019). In summer, farmers, ranchers, and workers labor outside on these lands through the heat of the day. Researchers are exploring the impacts of heat on agricultural and other outdoor occupations. For example, migrant and seasonal 80 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 81 Photo facing page: M. Thivierge / Wikimedia People living in proximity to wildfire and smoke Why it matters.—Particulate matter from wildfire smoke impacts incidence of lung disease and asthma (see next page). Smoke and fire damage can also cause or accentuate depression and anxiety. Montanans living in or near areas prone to wildfire are most vulnerable, although smoke travels great distances. Section 3 provides more information on health effects of wildfire and smoke. What we know in Montana.—The wildland-urban interface is where human development and wildlands meet or intermingle, placing houses or other structures near or within fire-prone forests. In 2010, 64.1% of Montana houses were located in the wildland-urban interface (Martinuzzi et al. 2015), the second highest percentage of all western states behind Wyoming. In Montana’s 25 western counties, located in forested areas and for which contiguous fire hazard data are available, over 10% of homes are in high fire hazard, forest interface areas (Headwaters Economics 2018). Houses and structures in such areas are at highest risk of burning, with the risk decreasing the more distant houses are from the wildland-urban interface. Figure 4-4. Heat-related illness rate by industry (used with permission from Moyce and Nealy 2019). Lolo Peak Fire south of Missoula, 2017 Photo courtesy of Philip Higuera 82 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 83 People facing food and water insecurity The 2017 Seeley Lake Fires and Lung Function Why it matters.—Montanans face the stark reality of losing nutritious—and for some, indigenous— Higher incidence of wildfire due to climate change is resulting in more large wildfires (Whitlock foods due to wildfires, drought, and flood events resulting from climate change. Drought and flood et al. 2017). Emergency room visits and hospitalizations for cardiovascular and respiratory can diminish local crop yields and floods can carry and distribute crop diseases. Drinking water complaints have increased due to wildfire smoke exposures. As exposures to wildfire increase in supplies, likewise, can be threatened, first due to diminished water availability during drought, and number and intensity, research on the resulting health impacts becomes more vital (Reid et al. 2016; second due to public water and wastewater disruption and potential for water-borne pathogen Black et al. 2017). spread during flooding. Home wells that are inundated can become contaminated, thereby posing a health risk. Aging water infrastructure is also an issue. For example, one of the five 100-year- In a local example, Orr et al. (2020) found long-term respiratory complications resulting from wildfires old concrete drop structures in the St. Mary Canal failed in 2020 flooding, making it impossible around the town of Seeley Lake, Montana. For 49 days in 2017, Seeley Lake was exposed to smoke to divert water from the canal into the Milk River (Havre Daily News 2020). This canal supplies up from multiple nearby wildfires (NPR 2019). A group of 95 participants from Seeley Lake (average age to 80% of the water to communities along the Hi-line and northeastern Montana, and this loss of 63 yr) was administered spirometry, a test used to assess how well the lungs work by measuring conveyance greatly threatens irrigation and municipal water supplies. Regarding food security, only about 10% of the food we consume in Montana is grown here (Montana Department of Agriculture 2013), Thus, our food security is threatened by climate changes outside of Montana, a fact that strengthens the need for increasing local food production and processing. The USDA’s Federal-State Marketing Improvement Program (USDA undated) and many instate partners (e.g., agriculture departments , agricultural experiment stations, universities) are working to improve Montana’s food supply chains among producers, processors, food services, grocers, pantries, and distributors to assure food availability and improve instate production to support local needs. Disussing healthy foods at Galatin Valley Food Bank, Bozeman Photo courtesy of Adrian Sanchez-Gonzalez, Montana State University Pulmonary function changes from predicted values. The graph depicts the changes to lung function (FEV1/FVC) in 2018 and 2019 following the Rice Ridge fire in Seeley Lake, Montana. In both years following the exposure the observed (solid lines) was significantly lower than predicted (dashed lines) for males (*M), while significantly lower in 2019 for females (*F). In addition, the male What we know in Montana.—In 2017, 42,745 (10.2% of total) households received food stamps from values were significantly lower as compared to the observed values in 2017. (* P<0.05 observed vs predicted within sex; ++ P<0.01 Significant compared to 2017 for corresponding group) the Supplemental Nutrition Assistance Program 3; 19,564 (4.7% of total) received Supplemental Security Income4; and 8696 (2.1% of total) received cash public assistance income (Headwaters amount and rate of air inhaled and exhaled. Economics 2019). A decrease in lung functiona was observed over time. Specifically, measured lung capacity decreased significantly compared with predicted values (age and sex matched), with a greater effect on males. 3 The Supplemental Nutrition Assistance Program (SNAP) provides benefits to people who are elderly, The effect appears to continue at least two years post exposure. These observed decreases highlight homeless, unemployed, have low or no income, or are disabled with low incomes. Recipients can purchase the need for longitudinal studies to assess the health effects of smoke exposures. groceries with SNAP benefits. _______ 4 Supplemental Security Income (SSI) gives financial assistance to people who are disabled, aged, or blind a The ratio of FEV1/FVC, shown as the y-axis in the plot, is a measure of the amount of air a person can forcefully exhale and of limited income. Unlike Social Security benefits, SSI benefits are not determined by the recipient’s from their lungs. lifetime earnings. 84 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 85 Nearly 10 percent of Montanans struggle with hunger, and 37,000 children live in food-insecure People who are very young, very old, or pregnant homes. Thirty of Montana’s 56 counties have areas considered food deserts, i.e., low-income areas where at least 500 people and/or 33% of the residents must travel more than 10 miles (16 km) Why it matters.—Beginning at the fetal development stage, exposures to air or water pollution can to the nearest supermarket (or 1 mile [1.6 km] in urban areas). This equates to nearly 72,000 increase the risk of impaired brain development (Clifford et al. 2016), stillbirth (Siddika 2016), and Montanans without fresh, affordable food on a daily basis (Montana Food Bank Network undated). preterm births (Peterson et al. 2015; Sun et al. 2015). Infants and children are disproportionately affected by toxic exposures because they eat, drink, and breathe more in proportion to their body Most Montanans (86%) get their drinking water from public water supplies and most public water size (Heindel et al. 2016; Anderko et al. 2020). In addition, children spend more time outdoors, systems meet the Environmental Protection Agency’s Safe Drinking Water Standards (MTDEQ putting them at greater risk for respiratory problems from airborne particulates, wildfire smoke, undated). Still, the MCA (Whitlock et al. 2017; also see Section 2) describes multiple threats to and allergens. Children are also more sensitive to infectious diseases brought on by natural Montana’s domestic water supply, including drought, flooding, and extreme storm events; and disasters that compromise water sanitation (Balbus and Malina 2009; Cooley et al. 2012). also to Montanans using domestic wells susceptible to contamination from flood events. MCA also states that Montana will experience reduced snowpack and diminished late-season flows Mental and developmental with changing climate. Both are critical to public and private water supplies, as well as agricultural health issues also impact the production and, hence, food security5. young. For example, Clayton et al. (2014) suggest that young Tribal members in Montana are observing people may face increased risk impacts from climate change on traditional of anxiety, depression, and post- foods and water sources. For the Crow Tribe, traumatic stress disorder from warming streams are affecting the distribution Nearly 10 percent of Montanans extreme climate-driven weather and health of fish species. Multiple berry shrub struggle with hunger, and 37,000 events. Studies have shown that species and other traditionally harvested plants early-childhood health status are also impacted (Doyle et al. 2013; Martin et children live in food insecure homes. also influences health and al. 2020). Devastating spring floods inundated ... [N]early 72,000 Montanans socioeconomic well-being later in the Crow Reservation in 2007 and 2011, the [go] without fresh, affordable life (Anda and Brown 2010; Currie latter of which set a gaging station record food on a daily basis (Montana et al. 2014). and damaged more than 200 homes (Billings Gazette 2011a,b). Lacking the resources to Food Bank Network undated). Advanced age is a top risk factor remediate the problems caused by the floods, related to illness or death from many families had to move back into damaged extreme heat (CDCa undated) and now mold-infested homes, in spite of health due to hormonal changes risks (Martin et al. 2020). and health issues that make thermoregulation and hydration Interviews with both Native and non-Native low-income residents of the Flathead Indian more difficult (Brennan et al. Reservation in northwestern Montana found that half reported being food insecure or having 2019). In addition, the likelihood inconsistent access to adequate food. About 28% of those interviewed hunt, fish, and/or gather of chronic disease increases wild foods such as berries, and on average were more food secure than those who did not. Fish, with age (Prasad et al. 2013). The game, and wild plants were valued for their taste, freshness, nutritional value, and traditional elderly are more likely to have significance, as well as for promoting self-sufficiency. These residents perceive that their local wild preexisting medical conditions foods are being adversely impacted by climate change, particularly by wildfires and increased such as diabetes, pulmonary seasonal variability in precipitation and temperature (Smith et al. 2019). disease, and congestive heart failure, all of which will be exacerbated by the higher temperatures expected with climate change. For example, the elderly often have compromised mobility that reduces their ability to respond to 5 Food security, as defined in the glossary of this report, describes an individual or community’s ability to reliably access a sufficient quantity of affordable, nutritious food. natural disasters. Given chronic obstructive pulmonary disease (and other chronic diseases), the elderly are also highly susceptible to air pollution, such as ground-level ozone, particulate matter, or dust associated with drought, wildfires, and high-wind events (Bell et al. 2014). 86 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 87 Photo: Lindsay Richards When faced with extreme heat, pregnant women can be subject to preterm labor, and their babies may be smaller and/or more prone to Sudden Infant Death Syndrome/Sudden Unexpected Infant Death Syndrome (SIDS/SUIDS; also see Section 3). Women are less tolerant of extreme heat during pregnancy. They are more sensitive to dehydration and acute kidney damage. What we know in Montana.—In 2018, according to the Montana Public Health Information System, Montana had 11,515 births (MPHIS undated). In the same year. 5.9% of children in Montana were younger than 5 yr old, similar to the US average. Montanans 65 yr and older made up 18.7% of the population, compared to 16.0% nationwide. The proportion of people 65 yr and older is even higher in rural counties, where they are at risk due to limited access to healthcare (see below). In the six most populous counties, 16.8% of residents are 65 yr and older, while in rural counties, 21.7% are 65 and older (US Census Bureau 2019). People with limited access to healthcare services Why it matters.—Extreme weather events and natural disasters limit access to medical care. It is all too common for Montanans to be snowed in at their rural homes, with days passing before plows can get through. In February 2018, for example, 20-ft snow drifts were reported on the Blackfeet Reservation, and a state of emergency was declared by the Tribal Council and Montana Governor Bullock (Great Falls Tribune 2018; Spokesman-Review 2018). Likewise, rapid spring flooding, sometimes combined with major precipitation events, can cut communication lines, block access to roads, and limit availability of medical services to those in remote areas. The town of Roundup experienced such flooding of the Musselshell River in the spring of 2011, resulting in closed roads and disruptions to potable water supply (City of Roundup undated). The inability to access medical providers following such extreme events is particularly Figure 4-5. Location and type of healthcare facilities in Montana (RHIhubb 2018). consequential for those who already have compromised health (MTDPHHS 2020a). In rural Montana, assistance can be greatly delayed, given lack of nearby community health services and/ or the transportation infrastructure needed to reach medical attention. What we know in Montana.—As of January 2020, Montana had 49 critical-access hospitals, 58 rural health clinics, and 52 federally qualified health centers located outside of urban areas (Figure 4-5) (RHIhubb 2018). Even with these facilities, annual survey studies of Montana community members by the Montana Office of Rural Health show that access to healthcare is a major concern (MORHAHEC 2017). The Federal Health Resources and Services Administration designates 23 of Montana’s 56 counties as Health Provider Shortage Areas, meaning residents have limited access to primary care providers (HRSA undated). Such a designation is based on provider-to-patient ratio, percentage of the population living in poverty, and travel time to the nearest health facility. In 2019, residents of rural counties had a mortality rate 1.5 times higher due to unintentional injury compared with residents of more urban counties. Rural-county residents also had higher death rates due to chronic liver disease and cirrhosis, heart disease, diabetes, and suicide compared with residents of more urban counties, in part due to lack of immediate access to healthcare providers (MTDPHHS 2020a). The impact of climate change—whether on disease outcomes or transportation infrastructure—will only exacerbate the existing challenge of Choteau County Public Health in Fort Benton providing adequate access to health services for rural Montanans. Photo courtesy of Scott Bischke 88 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 89 People living in poverty American Indians Why it matters.—To save money, families with low incomes often must make lifestyle choices Why it matters.—American Indians are among the most vulnerable groups to climate change that subject them to impacts of climate change. These tough choices can result in poor diet, (Ford 2012; Bennett et al. 2014; Gamble et al. 2016; Ebi 2018). As the Third National Climate inadequate shelter, delayed medical care, unhealthy housing with leaks and mold, and no funds Assessment’s section on Indigenous Peoples explains (Bennett et al. 2014): for electric fans or air conditioners. People in poverty often live in substandard housing or in mobile homes and are more vulnerable to heat-related illnesses and extreme weather events Native cultures are directly tied to Native places and homelands, and many indigenous peoples (Headwaters Economics 2019). Displaced communities are also at risk. Planning is especially regard all people, plants, and animals that share our world as relatives rather than resources. critical for counties and communities already suffering from the loss of coal jobs and coal tax Language, ceremonies, cultures, practices, and food sources evolved in concert with the revenue, who need to diversify their economies in addition to planning for impacts described in inhabitants, human and non-human, of specific homelands. this report. Hence, in addition to coping with long-standing economic, social, and political inequities, tribes What we know in Montana.—The poverty rate in Montana is similar to the US average. In 2017, are stressed by climate changes that threaten ways of life they have practiced for thousands of 14.4% of Montana residents lived below the federally defined poverty level compared to 14.6% years. Native communities’ cultural and spiritual reliance on local ecosystems, water sources, nationally. However, a mean of 17.6% of young Montana residents under 18 yr lived in poverty, and subsistence foods contributes to an increased vulnerability during extreme climate events with highest percentages in more rural and reservation regions. The poverty rate for Montana (Cozetto et al. 2013; Gamble et al. 2016). The US Global Change Research Program’s 2016 report residents 65 yr and older was 8.3% (US Census Bureau 2018e; Givens et al. 2019), and 9.2% for the summarizes climate impacts to the health of Native peoples under the themes of loss of cultural US residents over 65 (CRS 2019). identity, water insecurity, decreased food safety and security, and degraded infrastructure (Gamble et al. 2016). What we know in Montana.—Interviews with Crow Tribal Elders reveal that climate change impacts to wild foods, water quality, and traditional spiritual practices are already being observed (Doyle et al. 2013; Doyle and Eggers 2017; also see sidebar next page). Crow Elders express a widespread sense of environmental-cultural-health loss, along with despair at their inability to address root causes of these local impacts of climate change (Martin et al. 2020). On the Flathead Indian Reservation, more than a quarter of low-income residents surveyed (both Native and non-Native) increase their food security by harvesting wild foods. They perceive that these wild foods are already adversely impacted by climate changes, such as increased wildfires, increased drought, and weather variability (Smith et al. 2019). Communities nationwide face threats to water security from droughts, floods, and other extreme climate events. Those threats are uniquely serious for tribes as many aquatic species are culturally and nutritionally vital to their well-being (Donatuto et al. 2011; Cozetto et al. 2013; Doyle et al. 2013). As an example, for many Crow families, increased microbial contamination means that rivers have been lost as a source of trusted water for ceremonial drinking and bathing (Doyle et al. 2013). Addressing degraded water and wastewater infrastructure is always challenging (Ferguson et al. 2011; Ojima et al. 2013; Redsteer et al. 2011), but the maze of jurisdictional and legal complexities—for example, the lack of authority to create water districts as described by the Apsaalooke Water and Wastewater Authority (Crow Reservation, Montana)—makes it more difficult for tribes (Doyle et al. 2018). In response, several Montana tribes are proactively assessing current and projected climate change impacts, developing resiliency plans, and implementing adaptation strategies (see sidebar in Section 5). Crossing the Little Bighorn River in August Photo courtesy of John Doyle 90 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 91 Changes Rippling Through Our Waters and Our Lives People lacking adequate health insurance C. Martin, J. Doyle, J. LaFrance, M.J. Lefthand, S.L. Young, E. Three Irons, and M. Eggers Why it matters.—Access to health insurance is directly related to a person’s ability to respond to health emergencies. People with chronic health conditions but no health insurance are less likely The Crow Reservation is located in south central Montana, in the heart of our traditional homelands. to be able to manage their illnesses, putting them at greater risk should an emergency arise As we live in a wide-open landscape and are tied to a different time than the fast pace of western (Sommers et al. 2017). Those without health insurance, for example, suffer more consequences life, our understanding of nature and observations of the seasons comes from the eye instead of a from air pollution compared to those with health insurance (Cooley et al. 2012). Likewise, other calendar or watch. climate-related concerns such as water-borne disease will be more difficult to treat for those without health insurance. Climate change is already impacting our lands, our waters, our health and well-being. To better understand these impacts, we interviewed 26 Crow Elders about their perceptions of changes in local What we know in Montana.—In 2017, 91.5% of Montana residents had either private or public weather patterns and ecosystems throughout their lifetime, and how they are being affected. We health insurance, close to the national average of 93.1% (Table 4-4). However, the proportion conducted a thematic analysis of the interviews. of Montana residents with health insurance varies both by age and between rural and urban places. Almost all residents old enough to qualify for Medicare have health insurance. The percent Interviewees’ observations paralleled and elaborated on instrumental climate data: we are of residents with health insurance is higher in urban counties than in rural counties. However, experiencing far less snowfall and milder winters, increased spring flooding, hotter summers, and private insurance prices vary, and coverage may be costly with plans paying for 60-90% of medical more severe wildfire seasons. Additionally, many Elders commented on extreme, unusual, and expenses. This variability may leave some individuals and families with substantial out-of-pocket unpredictable weather events, compared to earlier times when the seasons were consistent year costs depending on their plan (HealthCareInsider 2020). after year. Interviews notably identified declines in Table 4-4. Percentage of Montana residents with health insurance in wild foods, which have not been recorded 2017 (US Census Bureau undated) by scientists; wild game, fish, berries, and medicinal plants are being detrimentally Residency Age Group affected in diverse ways (Martin 2020). 18 yr and under 19-64 yr 65 yr and older All Our homes and infrastructure have been All counties 94.2% 88.1% 99.4% 91.5% hit time after time by high floods; we have Six most populous few resources to repair the damage, so counties 96.1% 90.0% 99.4% 92.9% this is taking a toll on families, including All other counties 91.5% 84.9% 99.4% 89.5% on our health and well-being. In addition to ecosystem resource losses and changes, we are devastated by the People with mental health issues loss of coal jobs and coal tax revenue. More than 1200 coal mining and tax- Why it matters.—People living with and learning about the consequences of climate change can funded jobs have been lost in the past experience stress, anxiety, and deep feelings of loss (Clayton et al. 2017). A 2019 Yale report couple years, in a community of about Bill Lincoln picking chokecherries on the Crow found that 62% of Americans were "somewhat worried” and 23% were “very worried” about 8000 people. Without that income and lacking any Reservation. Photo courtesy of John Doyle. global warming (Leiserowitz et al. 2019). The Yale Program on Climate Change Communications other tax structure, we cannot adequately fund (YPCCC 2019) estimates that 60% of Montanans worry about climate change. our government nor maintain our infrastructure. Chronic conditions like depression and anxiety can be worsened by climate change, with Through the research we have been conducting on climate change and with our Tribal Elders, we are consequences ranging from minimal stress to clinical conditions such as post-traumatic stress able to better understand what has been happening and anticipate what is to come. Although we are disorder and suicidal thoughts (USGCRP 2016). Feelings of hopelessness, helplessness, fatalism, enduring unprecedented environmental change and extreme economic conditions, we are looking apathy, and denial associated with environmental change have become so prevalent as to have for solutions we can implement ourselves. earned their own descriptive terms, including climate grief, eco-anxiety, and solastalgia (Albrecht et al. 2007; Clayton et al. 2017; NBC News 2018; Time 2019). (For more detail, see Martin et al. [2020]) 92 | WHOSE HEALTH IS MOST VULNERABLE TO CLIMATE CHANGE IMPACTS? 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 93 Such mental strife can be heightened further for those whose economic livelihoods or traditional ways What we know in Montana.—From 2011–2015, Montana’s suicide rate, at 240 suicides each year, are closely tied to the land or environment, as well as those who hunt, fish, and gather wild foods. was nearly twice the US average (MTDPHHS 2019b). Alarmingly, the suicide rate in Montana rose That group includes people working in natural resource-related industries, for example agriculture, 38 percent from 1999 to 2016. In 2017, Montana had the highest suicide rate in the US, but in forestry, and tourism, as well as coal, oil, or natural gas extraction (Clayton et al. 2017; also see 2018 the state dropped to the fourth highest (AAS 2020a,b). Montana regularly registers one of sidebars—below and Section 3 sidebar titled Climate Change and Mental Well-being—Perspectives from the highest suicide rates in the country, with an age-adjusted suicide rate of 25.9 per 100,000 Montana Farmers and Ranchers). people in 2016 compared to almost half that rate for the US. Males are 3.5 times more likely to die by suicide than females. Others at risk are veterans, American Indians, and residents of rural counties. Mental Health Impacts on Substance use is a risk factor for suicide, with toxicology screenings revealing that over 40% of suicides involve alcohol use. Resource-depend ent Communities Attempted suicide in Montana is also alarming. One in 10 of all Montana high school students Dr. Julia Haggerty, Associate Professor attempted suicide in 2019. For American Indian high school students alone, 1.5 in 10 attempted Department of Earth Sciences, Montana State University suicide in 2019 (MOPI 2019). Governor Bullock of Montana, reacting at least in part to these grave realities, invested $80 million over five years to address mental health services (MTDPHHS 2020b). Decarbonizing at national and global scales has profound social, economic, and, by Along with the mental health issues shared by many across Montana, tribal members may suffer extension, health implications for local places that have developed as key nodes in the a unique type of personal anguish, one tied to tribal history, which changes brought by climate current energy system. In Montana, these sites include the communities in which energy change can exacerbate. In a study conducted primarily by Crow tribal members, 26 Tribal Elders extraction, processing, and/or distribution constitute the area’s primary source of public were interviewed about the impacts of climate change on local ecosystems and community health. revenue and private income. Nearly all participants described a sense of loss in relation to the impacts from changing climate and environmental conditions on their land. They write (Martin et al. 2020): Resource-dependent communities are at risk of acute mental-health concerns in the event For us, and perhaps for many other indigenous people, the changes aren’t simply unfamiliar of mass layoffs associated with plant closures alterations in our home environment causing discomfort—they are direct threats to our ability and other events in the contraction of energy to carry on the traditional practices which define us as a people. It is history repeating itself in an economies. Research shows that negative even more insidious way. We lost the majority of our lands through treaties and Congressional psychological outcomes associated with such acts. We lost generations of raising and educating our own children through federal boarding events derive primarily through economic schools starting in the 1880s. We have since lost the upper Bighorn River to Yellowtail Dam, hardship (Broman et al. 1990), and secondarily agricultural and recreational lands to non-tribal members, much of our traditional diet—the through the loss of occupational identity (Carley list goes on. Now, even though we live in our traditional territory, the changes in climate are et al. 2018). Given that Montana’s remote and changing our homelands all around us, and this time there is no single enemy to fight. rural areas are chronically underserved across a variety of critical healthcare services, available resources may prove inadequate in the face of abrupt economic transitions. What ConCLusions Can We draW? Where local government revenue depends heavily on fossil fuel extraction—as in the As described in Section 2, Montana will experience more 90 oF+ (32oC+) heat days, increased case of several American Indian reservations as well as some rural communities—the wildfires, more spring flooding, and less water available with more drought during the late very services necessary to build community resilience in the face of economic shocks are growing season (Whitlock et al. 2017). Given this knowledge, communities need to take action at risk (Besser 2013; Haggerty et al. 2018). In the very worst cases in recent history in the now to protect the health of Montana residents most vulnerable to impacts of climate change. US, abandonment of resource-dependent regions can create a host of chronic health Climate change will amplify vulnerability, exacerbating pre-existing health disparities. 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CLIMATE HEALTH ACTIONS Margaret Eggers, Alexandra Adams, and Susan Higgins, with contributing authors Robert Byron, Amy Cilimburg, Angelina Gonzalez-Aller, Paul Lachapelle, Miranda Margetts, Jennifer Robohm, and Nick Silverman Planning, preparation, and collaboration across all sectors, both at the state and community levels, are critical to reducing the broad impacts of climate change on public health. This section describes planning guides, action strategies, and information sources1 for 1) communities, 2) healthcare practitioners and institutions, and 3) individuals, organized for each sector by the key health issues described in Section 3. These tools help communities and individuals access local climate and health data, assess the greatest threats to local well-being, prioritize goals and objectives, and prepare accordingly. 1 The authors recognize that the recommendations herein are not exhaustive, and that some of the actions and/or resources described are not available to every person. Similarly, some of the actions we describe may require local and/or statewide policy change, which is beyond the scope of this document, but is detailed in the recently released Governor’s Climate Solutions Plan (State of Montana 2020). 108 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 109 Planning, preparation, and collaboration across all sectors, CoMMunity aCtions: teaMinG up for suCCess both at the state and community levels, are critical to reducing A fall 2019 statewide survey of 222 Montana public-health and environmental-health professionals the broad impacts of climate change on public health. asked their concern regarding climate change. Almost three-fourths of respondents said that health departments should be preparing to deal with the public and environmental health effects of climate change, although less than 30% of the departments were currently doing so (Byron While the risks and outcomes of climate change may seem beyond anyone’s direct control, many 2019; see sidebar Montanans and Climate Concerns in Section 2). Almost all respondents indicated manageable actions exist for protecting our communities, our families, and ourselves. The goal of that multiple entities should work together in this effort. this section is to provide information that helps Montanans maintain optimal health in the face of climate change. Building resilience to climate change impacts on public health requires collaboration across all sectors: state, tribal, county, and municipal governments. It includes elected leadership; Tackling problems of climate-induced environmental issues—e.g., warmer temperatures, increased emergency management teams; public healthcare systems and practitioners; and local forest disease and fire, or changing water quality and availability—often involves discussions of organizations, businesses, and community members (UNDRR and WHO 2020). A wealth of online mitigation and adaptation. Mitigation is the work to reduce or stabilize the climate changes already materials is available to help build our resilience to climate change impacts. Developed by federal taking place. Adaptation involves efforts to adjust to life in a changing climate. Mitigation and agencies and professional and non-profit organizations, these materials provide many examples adaptation efforts also apply to tackling climate-induced human health issues. Citizen involvement from successful communities. In addition, many useful tools can be found in the Institute on in climate change adaptation and mitigation planning and action is already underway in some Ecosystems’ Climate Smart Montana Program2 and in the subsections that follow. Our list of top Montana counties, and several case studies are provided below. actions for communities is presented below. For some, tackling climate change may seem like too great a challenge, but even small efforts to improve health, well-being, and resilience make a difference for climate change mitigation and adaptation. It is time to work on building relationships, developing collaborations, and understanding who around you are most vulnerable to climate change, and who are best Top Actions for Communities positioned to provide support. Join or create a broad community coalition, optimally including your local health department, and start working together across sectors to create and implement a Mitigation is the work to reduce or stabilize the climate changes already taking community resilience plan that includes climate change mitigation and adaptation. place. Adaptation involves efforts to adjust to life in a changing climate. о Identify human, organizational, financial, and other resources for conducting your work. о Assess local climate change concerns such as extreme heat, poor air quality, drought/floods, food and water insecurity, vector borne diseases, and more. о Gather the local/county epidemiological (health) and climate data needed for your work. о Recognize that public health and economic well-being are inseparable— planning for climate change impacts will protect both. о Assure that more vulnerable groups, including those with mental health, concerns, are incorporated into all planning efforts. White Sulphur Springs 2 http://www.msucommunitydevelopment.org/ClimateSmartMontana.html 110 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 111 Steps to create a community climate action plan It is possible, and perhaps likely, that a community’s first step will be As the National League of Cities The Centers for Disease Control’s Climate and Health’s Building Resilience Against Climate Effects to implement a well-thought-out advises…, “Start with people, stay (BRACE) plan provides an excellent guide for creating a community climate action plan. This plan engagement and education campaign with people: build an inclusive, broad describes a five-step program to assist health officials and communities in preparing for health or initiate some actions that will excite effects resulting from, or worsened by, climate change (Figure 5-1) (CDC 2019). and galvanize a multi-sector coalition. public engagement program with As the National League of Cities advises local partners to grow public support in its multi-faceted guide to local actions and political will for climate action.” to address climate change, “Start with people, stay with people: build an inclusive, broad public engagement program with local partners to grow public support and political will for climate action” (NLCI undated). Including the public in initial planning leads to more public participation in plan implementation, and better understanding of community vulnerabilities (van Aalst et. al 2008; IPCC 2014; Di Matteo et al 2018). Implementing a BRACE plan in Montana ideally requires access to county-level climate and air quality data, updated climate projections, and current and projected disease burden related to climate, as well as a better understanding of climate-vulnerable populations. With these data and the BRACE framework, state, tribal, and local leaders can collaborate across sectors more effectively to prepare for, manage, and reduce the health and economic impacts of climate changes (UNDDR 2020; UNDDR and WHO 2020). Data availability and access challenges—some of which are detailed below—exist in every community but should not impede planning and taking action. Data gaps and missing analyses that are consistently identified can become work mandates for state agencies and academic institutions. The next step in creating a climate action plan is to assess sensitivity, exposure, and risk for your community. This assessment will form the basis for your community’s plan, and outline how it will address human health issues that result from climate change. Include local leaders, health professionals, a diverse stakeholder group representing your community, and people experienced in creating climate change plans. Explore the following questions: о What are the major climate- and health-related risks facing your community now and expected in the coming decades? The impacts of climate change on health may also vary widely among community members (Islam and Winkel 2017; National Geographic Figure 5-1. The CDC’s Climate-Ready States and Cities Initiative (see https://www.cdc.gov/ 2019). Develop a climate action plan that is equitable, feasible, and tailored to climateandhealth/climate_ready.htm) competitively funds states and large cities to implement community demographics (e.g., age and income distributions), exposures (e.g., climate the five-step BRACE framework shown here and described in the text. components like increasing temperatures), and risks (e.g., the likelihood that exposure events like major wildfires or flooding will occur). Initiating the BRACE (or other) planning framework requires broad community engagement о Carefully consider the needs of each community’s unique vulnerable populations, and one or more government agencies, citizen groups, or organizations committed to leading as described in Section 4. Who are the most vulnerable? Why? What can be done to the effort. Join with others in your community who are already addressing or are beginning to increase their resilience? address the impacts of climate change on local health. As a team, carefully consider the support о Are any stakeholder groups underrepresented on your team? If so, how can you of your citizens and leaders. Assess your community’s capacity to develop a health and climate engage them? action plan. Is the CDC’s BRACE framework, or some other process, best suited to address your community’s capacity and needs? 112 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 113 о Beyond applying to the CDC’s Climate-Ready States and Cities Initiative3 for funding, Act on climate change not only for public health, but also economic what financial resources are available for this process and for outside facilitation to well-being help guide discussions and actions? As we are learning during the current COVID-19 pandemic, public health and economic well- о What kind of community outreach will your team need to implement before, during, being are inseparable. The same concept applies to climate-driven increases in wildfire, flood, and after development of your climate action plan? and drought, which not only directly affect our health and our economy, but are also starting to о Could first-step targeted activities be initiated in your community before conducting a influence state and local government credit ratings. Broad collaboration and planning will reduce full climate and health assessment plan? If so, what steps? Getting started is one way the intertwined health and economic impacts of climate change. to build support for further action, plus it can help develop climate and health literacy. Climate surprises—such as heat waves, drought, flooding, or other disasters—can trigger an With persistence and patience, capable facilitation, and access to health- and climate-science exodus of residents, resulting in declining tax revenue, or bring a flood of new immigrants to the expertise, your community can assess its health vulnerabilities to climate change, identify the state from regions that are experiencing worse conditions. Damage to municipal infrastructure most suitable and highest priority interventions, and then create and continuously improve your from severe storms, floods, wildfires, or other disasters can incur major expenses for community climate action plan. That plan will describe mitigation or adaptation actions that fit communities. For instance, a major wildfire may result in runoff water of such poor quality that a your local conditions. For example, the Blackfeet Tribe, the Confederated Salish and Kootenai community’s current water plant can no longer adequately treat it. Such occurrences add to the Tribes, and the community of Missoula have actively responded to climate-related changes faced risks that rating agencies assess. As a result, they might lower a government’s credit rating and by their people and landscapes (see sidebars, coming pages). ultimately increase its cost of borrowing money via bonds (Fitch Ratings 2018; Pew 2019; DeFries Moody’s Analytics: “Cities and 3 https://www.cdc.gov/climateandhealth/climate_ready.htm et al. 2019; Janney Investment Strategy Group 2019; New York Times 2019). counties with plans for reducing their exposure to climate risks... could To better assess climate change risks, the rating see their credit ratings improve as a agency Moody’s recently bought a controlling share of a company that specializes in climate result, or at least not deteriorate.” change risk assessment. According to the New York Times, several major rating agencies, including S&P Global and Moody’s (Moody’s Investor Services 2017), have issued reports “…warning state and local governments that their exposure to climate risk could affect their credit rating. Moody’s has said that cities and counties with plans for reducing their exposure to climate risks, by updating their infrastructure for example, could see their ratings improve as a result, or at least not deteriorate” (New York Times 2019). Communities need climate and health data for planning and action One challenge facing Montana’s communities is that the climate and epidemiologic data necessary for planning are not currently collected for and shared with all counties in Montana. The coverage of NOAA/National Weather Service (NWS) meteorological stations is uneven in Montana, such that some parts of the state have limited direct information (NOAA-NCEIa undated). Additionally, only a small number of the meteorological stations have operated long enough to characterize long-term trends in climate variables (NOAA-NCEIb undated). Several programs seek to fill the gap. First, NOAA/NWS improves the coverage of recording sites by using participating cooperative observer information (NWSb undated) to provide a network of minimum/maximum temperatures, precipitation, snowfall, and snow depth. However, parts of Montana have relatively few of these sites and the time span of records is variable. Second, the Montana Climate Office is a partner in Missoula, in fine air NOAA’s Mesonet program, set up to deploy automated weather and environmental monitoring Photo courtesy of Philip Higuera stations at 74 sites across the state, and thus increase the spatial coverage of weather data and improve services (MCO 2020). 114 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 115 Stories of Climate Change, Health, and Indigenous Ways Confederated Salish and Kootenai Tribes (CSKT) of the Flathead Indian Reservation Mike Durglo, Jr., Environmental Director, CSKT Natural Resources Blackfeet Nation Gerald Wagner and Termaine Edmo, Blackfeet Environmental Office The Flathead Indian Reservation is home to approximately 28,000 people, of which about 9000 identify as Native American. CSKT has approximately 6800 enrolled tribal members, 4000 of whom live on the In 2018, Blackfeet Nation released a climate adaptation plan that works to protect our diverse reservation. On the Flathead Indian Reservation, climate change threatens our treasured landscapes, our ecosystems from the impacts of a rapidly changing climate. Underlying this plan is the Blackfeet people, and the traditional customs and practices that sustain our way of life. Climate change is the result understanding that people and nature are one, and that people can only be healthy if we ensure the of the worldwide establishment of a way of life that is fundamentally at odds with the traditional ways of health of the environment we depend on. Blackfeet Nation borders Glacier National Park to the east and tribal people here. This establishment, and its disregard for the environment, pose serious risks to the b Canada to the north. The Blackfeet Nation is not only our home, it’s our place of origin. From the soil we S’elish, Qlispe, and Ktunaxa peoples that call the reservation home. walk on, to the water and land we protect, the Amskapii Pikunii people have worked hard to preserve our language, customs, traditions, and practices throughout the 10,000 years we have called this region Climate change is already impacting the health and well-being of our people. Wildfires have caused home. We understand deeply that what happens to the Earth happens to us, and that we protect hazardous air quality conditions, and extreme weather events create dangerous conditions and limit ourselves by honoring our traditional principles and values of stewardship. access to healthcare and other critical services. The climate crisis and the ecological changes that it brings threaten traditional customs, including our access to first foods through hunting, fishing, and gathering, Climate change threatens all we hold sacred, and the impacts of a changing climate are visible and our ability to conduct ceremonies everywhere. For example, more extreme weather events are starting to disrupt power and water and spiritual practices. Many foods supplies, communication systems, and transportation, making it difficult to maintain critical services. and medicinal plants grow on the During winter storm emergencies, people have become stranded in their homes with insufficient food or reservation and aboriginal lands. As a medicine, jeopardizing their health and well-being. Similarly, more intense flooding can negatively impact result, climate change threatens our services. cultural survival, which directly affects both our physical and mental health. In 2019 alone, we experienced several winter storm emergencies and a flood disaster. During such To address these risks, CSKT released c events our communities demonstrate exceptional resilience, compassion, and creativity. Neighbors help our first Climate Change Strategic Plan each other free vehicles from mud or snow, we drive miles out of our way to check on Elders, and we in 2013 and is taking deliberate actions continue to work on ways to be better prepared for the next emergency. to address climate impacts wherever possible. Our tribal values affirm that Our climate adaptation plana works to protect the health and well-being of our people. We want our everything is connected and that people to understand the connection between climate change and health, so our adaptation plan is the human beings have a responsibility to foundation from which we iikakimaat (try hard) to care for the environment and thereby our people, and care for the things that were placed our ways of life. here, before the human beings. As with all things, the CSKT follow the circle pathway worldview. Our Elders teach that all things are connected and that any impact or action on one resource will impact all. The diagram shown illustrates a tribal way of thinking as also expressed during our recent climate planning session. Graphic design by Ron Oden of Ron Oden Designs and the Native Waters on Arid Lands Project Climate-related disturbances including flood, drought, wind events, and wildfires impact our tribal resources, and will therefore impact our culture, traditions, and our foods and spirituality—without which our lifeways cannot survive. Impacts are also expected to be place-based. Impacts in the high-elevation region will be different from impacts to resources in the dry-grass and sage-steppe ecoregions of the reservation. The climate crisis requires Photos, courtesy of Jacob LeVitus, from September 29 and 30, 2019. immediate and sustained action to protect human health and well-being. For the people of CSKT, this requires protecting the ways of life that define us as a people. _______ _______ a blackfeetclimatechange.com b The Tribes which in English are called the Salish, Pend d’Oreille, and Kootenai. c http://csktclimate.org/ 116 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 117 County-level epidemiologic data are also required for the CDC’s BRACE framework (CDC 2019), * We understand deeply that what happens to the Earth reviewed above. Statewide epidemiological data are collected by the Montana Department of Public Health and Human Services, but for a variety of reasons are not easily accessible at the happens to us, and that we protect ourselves by honoring county or commmunity level. We need shared, statewide monitoring of health-facility visits related our traditional principles and values of stewardship. to climate change, especially county-level data about visits related to smoke, heat, or home-mold exposure; vector- or water-borne illnesses; and mental health concerns.6 In sum, data are a critical need for climate monitoring agencies and communities—particularly for state and county public health departments and their collaborators—to address the impacts of climate change on health. * Climate change is the result of the worldwide establishment To meet that need the state of Montana, in collaboration with relevant federal agencies, should: of a way of life that is fundamentally at odds with the traditional ways of tribal people here. This establishment, and о increase the network of meteorological stations in the state to fill in geographic gaps; its disregard for the environment, poses serious risks …. о add to the network of air quality stations monitoring for particulate matter to fill in geographic gaps; о increase funding to the Montana Climate Office for historical and current analysis of Further, the Montana Climate Office is working with US Army Corp of Engineers and NOAA to climate and human health trends and patterns at the state, county, and community establish and maintain upwards of 220 additional monitoring stations across the state over scales; the next 5-7 yr.4 The US Army Corp of Engineers and NOAA federal funding will support better о improve the spatial resolution of climate projections to provide county-level soil moisture and snowpack monitoring for flood forecasts and drought assessment. However, information; and little funding exists for updating and analyzing historical and recent climate trends, or local climate projections. Other funding will be necessary to add air-quality monitoring sensors to о create a shared, statewide monitoring process of health-facility visits related to climate these stations, as presently there are only 20 air-quality monitoring stations managed by the change, with county-level data available to communities. Montana Department of Environmental Quality. Although the department posts current air quality conditions online, 20 stations provide only limited coverage and historical data are not provided.5 6 The authors recognize that privacy issues might exist if county-level data on rarer health conditions were released. MCA provides climate projections for Montana, focused on the seven NOAA climate divisions in the state (Whitlock et al. 2017; Section 2). However, projections at the climate division level are too coarse to assess climate trends for particular counties or communities. Each division covers a large area and their boundaries are not defined by physical geography. Local experience suggests this may be particularly true for changes in precipitation patterns (Doyle et al. 2013; Martin et al. 2020). The spatial resolution of climate projections will improve in future Montana climate assessments, with a scale that will be even more useful for community-level planning. Installing a weather station Photo courtesy of John Doyle 4 Jencso K, Montana Climate Office, personal communication, 3 May 3 2020; unreferenced. Also see https:// Medical lab work in Glasgow www.nwo.usace.army.mil/Media/News-Releases/Article/2369091/contracts-awarded-for-establishment-of- Photo courtesy of Alexandra Adams upper-missouri-basin-monitoring-network/. 5 https://svc.mt.gov/deq/todaysair/ 118 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 119 Strategies and actions for communities Community Climate Action Planning for Health The remainder of this section highlights some strategies your community will want to consider in planning and preparing for health-related impacts from climate change. How you prioritize Resilience—Tips from Missoula these categories will depend on your review of the data and discussions across your multi- sector collaboration. Appendix B provides a tabularized list of resources for communities, Amy Cilimburg, Executive Director, Climate Smart Missoula including public and environmental health agencies and organizations, to develop climate change assessments and action plans. More wildfire smoke combined with extreme heat is a challenge to physical and mental health— what can we possibly do? That was a question our newly formed non-profit, Climate Smart Missoula, Appendix B provides a tabularized list of resources for communities, asked a few years back as we recognized Missoulians were not prepared to “weather the changing including public and environmental health agencies and organizations, weather.” Via our Summer Smart program, we started working on a handful of initiatives, from to develop climate change assessments and action plans. planting shade trees to donating indoor high-efficiency particulate air (HEPA) filters to homebound seniors. Because we were already working with our City-County Health Department, in 2017, when hazardous smoke filled our valley, we were able to rapidly grow this program, providing HEPA Heat filters—and thus clean indoor air—to those most at risk, from babies to people with asthma to the elderly. Two strategies communities can use to address heat-related impacts to health are to: 1) inform citizens about dangers of overheating in extreme temperatures; and 2) provide cool or cooler This early effort helped us learn that although it may be difficult to spaces both inside and outside. Examples include: address the intersection of health and climate change, it can be done. And there’s more to do! о Encourage employers to improve the workplace environment and policies to reduce heat exposure. During extremely hot weather employers should, for example, provide Our Summer Smart efforts gave us the confidence and motivation to outdoor workers ready access to shade, drinking water, and restroom facilities, plus broaden this work. We are now partnering with Missoula County and allow break time for workers to cool off. the City to craft and implement Missoula’s first-ever resiliency plan: Climate Ready Missoulaa. We first partnered with scientists to understand climate projections and о Inform those working, playing, or otherwise spending extended time outdoors about then, given these, worked with hundreds of county residents to identify who and what is most at risk the importance of resting, hydrating, and seeking shade to avoid potentially life and what adaptation goals and strategies would best address these risks. We highly recommend the threatening, heat-related health issues. Climate Ready Communities guideb or other similar (and free) planning resources available to help any о Designate (or create) a cooling facility for your community or workplace where people Montana community get started. can go during a heat emergency. Such a facility might be an air-conditioned school or community center, or a deeply shaded park, perhaps near a community swimming By bringing people together to understand how we can best look ahead to the challenges coming pool, lake, or river. our way and “bounce forward,” we can build social equity and strengthen a can-do attitude in the face of change. And community members will no doubt be healthier as a result of these efforts. A о Ensure vulnerable populations (see Section 4) understand heat-related health issues few things we’ve learned along the way: and have a plan for staying cool. For example, develop programs to ensure access to cool community spaces. Likewise, ensure that those most vulnerable to extreme heat о Partner with community health professionals—they are trusted community members. have window fans or air conditioners. о Initiate conversations about who is most at risk in your area. о Create incentives and programs to address the rising urban heat-island effect (USEPAd о Consider starting with a focused initiative, then expand as capacity and buy-in grows. undated). Examples include substituting lighter colored materials in place of black о Connect with neighboring communities when and where you can. asphalt and tar on roads and driveways, and encouraging more environmentally friendly building practices, including cool roofs, constructed with light colors and heat- о Take care of your own personal health and go forth armed with compassion and hope. reflecting materials. _______ о Create incentives, programs, and/or campaigns to plant and care for trees and other a https://www.climatereadymissoula.org/ vegetation to create shade (USEPAe undated). b https://climatereadycommunities.org/learn-more/about-guidebook/ 120 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 121 Air quality о Inform homeowners about options to create safe indoor air using HEPA portable air cleaners, MERV 13 air filters, or HVAC (heating, ventilation, and air conditioning) While it might be possible to mitigate some of the health effects of wildfire and smoke through systems. See the Personal/Air Quality/Indoor Air subsection below and the Climate forest management practices, local communities do not generally carry out such efforts. Smart Missoula guide to filtration systems.8 However, every Montana community can focus on adaptation strategies for dealing with wildfire by increasing their community’s fire resilience and, during wildfire season, improving air quality о Consider funding air filtration in public spaces, for example in schools, daycare indoors and outside. centers, senior centers, municipal buildings, evacuation shelters, houses of worship, and gyms and recreational facilities. Such work is underway in Montana: the team at Climate Smart Missoula donated portable HEPA air cleaners to those who were most Actions your community can take include: vulnerable. о Implement sustainable construction and encourage new housing in more sustainable о Encourage employers to reduce workers’ exposure to smoke and particulate matter. and fire-safe areas (Zakaria 2020). Learn more about building fire resilience in your For example, employers could halt or limit outdoor work during periods of poor community through an excellent online resource titled “The science of firescapes: air quality, schedule (if possible) employees to work at alternative sites having less achieving fire-resilient communities.”7 The Federal Emergency Management hazardous air quality, or provide protective breathing masks appropriate to the Administration provides relevant checklists for homeowners (FEMAb undated) and conditions. communities (FEMAc undated). о Encourage schools, organizations and employers to implement the federal Air Quality о Educate homeowners about assessing fire risks to their homes, checking with their Flag Program.9 insurance company on the terms of their homeowner’s wildfire coverage, and, if needed, reducing fuels around their home. о Work with the Montana Climate Office and Department of Environmental Quality to ensure a) your community has a weather station with added sensors for particulate о Develop or enhance emergency response plans for forest and grassland wildfires. matter (PM2.5 and PM10); and b) that the public has online access to both real-time and Create a community database of people who would need physical assistance to historical data. evacuate if required, and determine who will help those people in such emergencies. 8 https://www.missoulaclimate.org/hepa-air-filtration.html 7 https://www.fs.fed.us/rm/pubs_journals/2016/rmrs_2016_smith_a001.pdf 9 https://www.airnow.gov/air-quality-flag-program/ Lolo Fire near Missoula, 2017 Photo courtesy of Philip Higuera 122 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 123 Flooding and water-related illness to humans and other animals—into the water (see Section 3, Water-Related Illnesses subsection). Best management practices such as creating vegetative buffers for water Flooding can impact human health in a number of ways, including by increasing exposure to bodies and limiting excessive use of fertilizers are effective mitigation measures vector-borne diseases. (USEPA 2020). Actions to counteract or minimize exposure include: о Assess water and wastewater infrastructure needs and vulnerabilities to flooding, drought, and sediment runoff following wildfire. Does your infrastructure need о Protect wetlands and restrict new development in flood-prone areas in and adjacent upgrading to handle such events? Assure that an emergency response plan is in place to your community. Wetlands retain water, slowly filtering and releasing it to surface in the event of an extreme weather event. The Montana Department of Environmental waters, thereby improving surface water quality. Wetlands also serve as recharge Quality provides a useful two-page flier11 that includes guidelines on training, areas for groundwater. Hence, wetlands protection and open space planning not development of local emergency planning committees, core elements of an Emergency only conserve habitat and local amenities, they also help protect water quality and Response Plan, and compliance with the National Incident Management System. quantity. For these reasons, identify and protect wetlands and other such groundwater о Ensure that emergency service providers have appropriate training, adequate supplies, recharge areas from development. If impermeable parking lots are built, design and tested plans and systems ready to help those in need during flooding (and other adjacent landscaping to capture and filter runoff. Note that if wetlands are destroyed emergency) events. Three critical items to prepare in advance are methods and by development, Montana law requires that alternate wetlands be created nearby.10 logistics a) for emergency communications and outreach; b) for evacuation, including о One major way floods can impact health is by contaminating lakes and ponds with strategies, routes, and safety zones; and c) for accessing medical care. The Montana nutrient and sediment runoff. Excessive nutrient enrichment, termed eutrophication, Primary Care Association12 and two Montana Department of Public Health and Human can result in deaths of fish and other aquatic organisms from depleted oxygen Services programs—Ready and Safe13 and EMS and Trauma Systems14—are good levels (National Ocean Service, NOAA undated), and trigger hazardous algal blooms resources to consult. (MTDPHHS 2019). During hazardous algal blooms, algae release toxins—poisonous 10 https://www.blr.com/Environmental/Water/Wetlands-in-Montana 11 https://deq.mt.gov/Portals/112/Water/PWSUB/Documents/docs/EmergencyResponseFactSheet.pdf 12 https://www.mtpca.org/programs-and-services/emergency-preparedness/ 13 http://readyandsafe.mt.gov 14 https://dphhs.mt.gov/publichealth/emsts Horses in a flooded pasture Flood near Crow Agengy, 2011 Photo courtesy of Larry Mayer, Billings Gazette Photo courtesy of Larry Mayer, Billings Gazette 124 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 125 Food security Vector-borne and zoonotic diseases Drought and extreme weather events impact local food security (see related sidebar in Section Paying attention to outbreaks of vector-borne, zoonotic, and other infectious diseases belongs 3), for example, when hail damages crops. But while some Montanans source their food close to on a community’s planning radar. Climate change is a key contributor to the emergence of these home, most rely heavily on food produced long distances away and trucked to grocery stores. diseases (see Section 3), and warming temperatures promote mosquito, tick, and other arthropod Climate change in other parts of the world can impact our food security. Crop destruction or reproduction and range extension. Having good drainage near homes and mosquito control failure and transportation interruption—potential outcomes from climate “surprises” (see Section programs (e.g., municipalities that spray for mosquitoes) are two ways to reduce vectors at the 2) or pandemics—may result in pricing increases or interruptions to Montana’s food supply. A community level. Community education on vector-borne diseases is essential (see Actions for vibrant local food system can build resilience in the face of such challenges, as well as support Individuals subsection below). Medical practitioners and those involved in public health should local economies (State of Montana 2020). stay current on issues of vector-borne disease epidemiology and symptoms, as provided by the Centers for Disease Control17, the US Department of Agriculture Animal and Plant Health A few examples of community actions that can help protect food security in the face of climate Inspection Service18, and Montana’s Department of Public Health and Human Services19. change are: о Incorporate the complexities of food security into community climate action plans. Mental health Identify those who most rely on food from outside sources, with particular attention to Extreme weather events, prolonged heat and smoke, and environmental and societal change all vulnerable people. affect mental health, including increasing feelings of disconnectedness and despair. Build a plan о Develop forums to discuss how much and what kinds of foods can be stored for for community well-being. Actions include: emergencies. Information on types and amounts of foods, as well as sanitation, cooking without power, and more can be found in the Federal Emergency Management о Plan for increased mental health Act15 and Ready.gov16. impacts of climate change by working Extreme weather events, prolonged with local hospitals, clinics, health heat and smoke, and environmental о Encourage personal, small-scale agriculture, local farmers’ markets, and farm-share departments, schools, and faith and programs to support and diversify local food supply and empower individuals with the service organizations to build mental and societal change all affect mental knowledge and skills to grow their own food. health services that connect across health, including increasing feelings о Tap resources offered by County Extension and Natural Resources Conservation jurisdictions in your county and of disconnectedness and despair. Service offices to understand sustainable practices, irrigation efficiencies, and community. integrated pest management. о Inform healthcare providers and the о Enhance and incentivize more effective, multi-stakeholder approaches to drought public about the mental health impacts related to climate-induced extreme weather response planning through local watershed groups and public works departments. events, poor air quality, rising heat, flooding, drought, and more. Discuss and plan for the potential community disruption (e.g., to healthcare access and food and water availability) that can be caused by extreme events, and how that disruption can impact the mental health of individuals and communities. Climate change in other parts of the world can impact our food о Build in-school capacity to address mental health issues in youth related to climate security. …. [Thus] encourage personal, small-scale agriculture, change. Acknowledge the anxiety some students feel around mounting climate change local farmers’ markets, and farm-share programs to support impacts (Burke et al. 2018), by opening discussion among teachers, students, parents, and friends. Consider also setting up mentoring programs with community members and diversify local food supply and empower individuals like the Child Advancement Project established by Thrive.20 with the knowledge and skills to grow their own food. 17 https://www.cdc.gov/nceh/information/state_factsheets/montana.htm 18 https://www.aphis.usda.gov/aphis/home/ 15 https://www.fema.gov/pdf/library/f&web.pdf 19 https://dphhs.mt.gov/HealthInThe406/HealthInThe406Archive/CommunicableDisease 16 https://www.ready.gov/food 20 https://allthrive.org/programs/child-advancement-project/ 126 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 127 strateGies and aCtions for heaLthCare praCtitioners and institutions Top Actions for Practitioners Medical practitioners, clinics, and hospitals have critical roles to play in preparing for and coping with health issues resulting from climate change. All in the medical field must become fluent in the о Get informed about the effects of climate change on health, language of climate change and its health impacts, and knowledgeable of the treatment methods including mental health, so you can recognize concerns and treat they will be required to apply—be those currently used methods or new skills they can obtain. your patients accordingly. Be especially vigilant during climate- related extreme-events, including droughts, floods, wildfires, and This subsection describes strategies and actions applicable to individual practitioners and other disasters. healthcare facilities. We also recognize the many online resources on the intersection of human health and climate change available for both groups. Table 5-1 provides a number of these о Educate your patients about the effects of climate change on health. resources, with an emphasis on information for Montana providers. о Provide educational materials about the effects of climate change on physical and mental health in your clinic and on your organizations Practitioners websites. Clinicians—primary care, subspecialty, or mental health professionals—are generally trusted о Become involved with professional or public organizations by their patients. Thus, healthcare practitioners trained to detect potential health impacts of advocating for climate action based on health impacts (Table 5-1). climate change can not only assess and treat those health impacts, they can also inform their о Provide primary care, behavioral health, and crisis treatments that patients. Groups like the American College of Physicians, American Academy of Pediatrics, and ameliorate the physical and mental health impacts of climate change Climate Psychiatry Alliance provide tools and guidelines for integrating climate- and health- (Anderson et al. 2017). The resources provided in Community related questions and discussions into routine patient visits (Table 5-1). Providers have many Actions subsection above include checklists for health-related opportunities for productive, climate-related actions when interacting with patients, the medical impacts, such as those from mold, overheating, wildfire smoke, community, or the community-at-large, as enumerated here. vector-borne disease, lack of nourishing foods, and the mental health distresses from major storm and other climate-induced weather events. о Consider providing patient-specific information related to climate change and ways to protect yourself, both in your clinic and on your organization’s websites. о Be an advocate in your community providing trusted guidance and information. Become involved with professional or public organizations advocating for climate action based on health impacts (Table 5-1). Dr. Lori Byron Photo courtesy of Dr. Robert Byron 128 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 129 Table 5-1. Information sources useful for healthcare providers, be they individuals or facilities.a Healthcare institutions In addition to the actions of individual practitioners, hospitals, clinics, and other healthcare Source Resource description Website facilities can make a substantial difference to their patients and communities dealing with climate- American Climate change toolkit for physicians, including ACP https://www.acponline.org/ related health issues, as enumerated below. College of position paper, educational materials, greening the advocacy/advocacy-in-action/ Physicians healthcare sector documents and other resources climate-change-toolkit American Academy of AAP policy statement on Global Climate Change and https://pediatrics. Pediatrics Children’s Health aappublications.org/ content/136/5/992 Top Actions for Healthcare Institutions Climate What psychiatrists can do about impacts of climate Psychiatry change on mental health, in terms of patient care, https://www.climatepsychiatry. о Work on mitigation efforts, for example instituting energy savings programs, Alliance systems of care and public health advocacy. org/what-to-do upgrades to HvAC systems, development or improvement of recycling programs, American and more. Choose one and start! Psychological APA 2017 Publication “Mental health and our changing http://ecoamerica.org/wp- Association climate: Impacts, implications and guidance,” 69 pp. content/uploads/2017/03/ea- apa-psych-report-web.pdf о Work within your organization and with community public health, community, American APHA’s declared mission is to “Improve the health of the public and achieve equity in health status,” including https://www.apha.org/~/media/ academic leaders, and other groups to create a community plan for management of Public Health files/pdf/topics/climate/ climate surprises, disasters, and pandemics. Association improving mental healthcare. This brief publication (APHA) referenced describes immediate, gradual and indirect climate_changes_mental_ impacts of climate change on mental health. health.ashx о Add climate health effects to electronic records for both physical and mental health. о Contribute to climate and health trainings for health professionals, including Medical Society psychological first aid. Consortium https://medsocietiesfor for Climate climatehealth.org/ and Health Groups that, among many functions, advocate for climate change action based on health impacts. MTHPHC welcomes all health professionals and health profession Here are additional actions for healthcare institutions: Montana Health students to join as members. Professionals for a Healthy https://www.montanahphc.org о Improve and model sustainable practices and processes, including capturing Climate anesthesia gases, decreasing use of disposables, shifting to renewable energy, and (MTHPHC) sourcing food locally. Tell your community that you are taking such steps, and hence The ALA advocates for climate action and preparedness by elected officials as well as professional and public helping mitigate climate change. Table 5-1 provides links to two programs—Health American Lung organizations. Resources on climate change impacts https://www.lung.org/clean-air/ Care Without Harm and MyGreenDoctor.org—scoped to meet such goals (also see Association on air pollution and lung health, as well as ways to fight climate-change next page). climate change. An evidence-based practice management tool for https://www.mygreendoctor. о Conduct climate adaptation and resilience planning with communities and local and MyGreenDoctor individual practitioners, clinics, and hospitals to save org state public health systems. money by becoming environmentally sustainable. • Consider addressing HVAC/HEPA retrofits to maintain facility indoor air quality, Works to transform healthcare worldwide. Their Climate particularly for hospital inpatients. and Health program supports the healthcare sector in Health Care reducing its carbon footprint, building climate-smart • Develop defined steps for meeting the needs of distressed communities, including Without and resilient hospitals and communities, and mobilizing https://noharm-uscanada.org/ Harm healthcare’s ethical, economic, and political influence climateandhealth not only physical ailments and distress, but also the needs of those who are to advance the transition to a low-carbon future that mentally traumatized or have severe mental illness (Rao 2006). The Centers for supports healthy people living on a healthy planet. Disease Control and Prevention has created a five-step plan titled Building Resilience Alliance of The Mission of ANHE: Promoting healthy people and https://envirn.org/ Against Climate Effects that health officials can follow to help your community Nurses for healthy environments by educating and leading the prepare for the health effects from or exacerbated by climate change (see the Healthy nursing profession, advancing research, incorporating Environments evidence-based practice, and influencing policy. Community Actions subsection above for more information). a Websites shown were active as of December 2020. For the latest resources and web links, go online to the • Assess impacts on the public health, medical, and mental healthcare systems due Climate Change and Human Health link at the Montana Climate Assessment website (montanaclimate. to shifting priorities, budget cuts, and budget diversion (e.g., to fire suppression) org). related to climate change. 130 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 131 Greener Healthcare Ideas о Work with universities, insurance providers, other healthcare systems, and local and state public health agencies to acquire critical data on the mental health consequences Julia Ryder BSN, RN, CEN of climate-related extreme weather events and disasters. Those data should include (Founding Board Member of Montana Health Professionals for a Healthy Climatea) prevalence and severity of climate-related health conditions, hospital admissions, suicide attempts, and episodes of violence. According to the World Health Organization, the US healthcare system contributes 8% of our • Recognize that overarching psychosocial consequences of global climate change, greenhouse gas emissions (WHO undated). Climate change is a threat to human health, and hospitals termed climate anxiety, stem from awareness of the looming threats and current especially must do all they can to model best-available environmental practices. risks of climate change. To reduce energy usage, a healthcare facility must first know how much • Prepare for disruptions to mental healthcare (including availability of psychotropic natural gas and fuel it uses, energy and water it consumes, and waste it medications) due to climate-related weather events and unexpected disasters that produces. Once familiar with these measures, a facility can set goals to may interrupt supplies. reduce them. Programs such as Practice Green Health and Health Care Without Harm help hospitals set goals and lead the way in sustainability. For • Educate decision makers—be they in public health, healthcare systems, emergency example, healthcare facilities can: response, the medical insurance industry, or local or state government—to increase understanding of where and how to invest in medical and public health о improve local air quality by creating no idling zones on their infrastructure and resources. campuses; о Implement, support, or participate in training programs for clinicians, as well as о reduce toxic emissions from incinerators with clear guidelines and healthcare, public health, and environmental health students and professionals on education for all employees regarding materials that can and cannot the health effects of climate change. (Healthcare training is a component of healthcare be processed in biohazard waste dispensers; systems.) о reduce laundry energy requirements by reducing the use of hot water • Curriculum development.—Address the physical and mental health impacts of and electricity; climate change in educational curricula for graduate and professional students in о switch to LED light bulbs (which also saves a hospital thousands of clinical health and social work training programs in Montana. Review availability dollars); and of pre-professional courses and course components on a) the physical and mental health impacts of climate change; and b) community-level climate change о update and improve maintenance of HvAC systems that consume an adaptation planning. Such courses are scoped for undergraduates in healthcare, enormous amount of energy. public health, and environmental health degree programs at institutions of higher Proper waste distribution and management must be demonstrated on every level in the hospital. education across Montana. The average hospital creates 29 lb (13.2 kg) of waste per patient bed per day (Eckelman and Sherman • Continuing education.—Provide climate health certification/training programs, 2016). Accessibility to well-placed recycling, compost, and trash bins is important; they should be placed continuing medical education credits, continuing education workshops, and online anywhere food is offered. To assist patients and staff, clear signage and instructions should be placed medical training modules for primary care, nursing, pharmacy, mental health, near every bin to ensure people properly segregate their waste. and public health professionals that highlight potential health and mental health impacts of climate change, and interventions to address those impacts. Examples Above all, if a healthcare facility wants to reduce its carbon footprint, it must build a culture of of such efforts include the Climate Change and Health Certificate offered at the awareness by encouraging employees to turn off lights, shut down computers, utilize natural lighting, Yale School of Public Health21, and the Climate Change and Health Training Module and not open materials until needed. It can reward employees who walk, bike, or carpool to work, and Series offered by the Minnesota Department of Health22. offer online meeting options rather than having employees drive to work for short time frames. A hospital can also help patients become healthier by offering more vegetable-based, locally sourced 21 https://publichealth.yale.edu/cchcert/ meals in the cafeteria, and cooking classes on how to prepare these foods at home. Last of all, hospitals 22 https://www.health.state.mn.us/communities/environment/climate/resources.html can invest in growing trees and other plants around campus. Such efforts not only improve air quality, but also provide shade and emotional support for patients and families. _______ a More information at https://www.montanahphc.org/index.php 132 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 133 • Psychological First Aid.—Ensure that first responders in Montana have training to respond to the psychological impacts of climate-related weather events and strateGies and aCtions for individuaLs disasters. Psychological First Aid is an evidence-informed modular approach to help children, adolescents, adults, and families in the immediate aftermath of Protecting your health in a changing climate takes work, but many actions are possible for disaster and terrorism.23 individuals to prepare for and minimize health risks associated with climate change. The recommendations that follow are broken into climate concerns similar to those addressed in о Join local, regional and national networks of health professionals working on climate Section 3 (Climate-related Health Impacts). change and health. • Encourage members to become involved in climate change mitigation and adaptation efforts through Montana Health Professionals for a Healthy Climate (Table 5-1). Top Actions for Individuals о Be familiar with your own (and your children’s) medical conditions and have regular checkups with a trusted healthcare professional. о Stay informed about climate change impacts on health. 23 https://www.nctsn.org/treatments-and-practices/psychological-first-aid-and-skills-for-psychological- recovery/about-pfa о Explore what you can do to become involved in community climate change and public health initiatives. о Become aware of local sources of mental health counseling. о Prepare your home now for extreme weather events. Have extras of essential medications, blankets, potable water, respiratory masks, and cleaning and food supplies on hand, and check your home insurance policies for flood and wildfire coverage. о Learn the signs of and remedies for heat exhaustion and heat stroke; and learn how to help yourself in extreme heat with adequate water, shade, home insulation, and salt replacements. о Consider installing high-efficiency particulate air (HEPA) filters or activated carbon filters in your home or business to remove dust, pollen, and smoke particles, especially for those living in areas threatened by wildfire. о Check current air quality at http://airnow.gov, or go directly to https:// fire.airnow.gov for fire, wildfire smoke, and air quality data. Historical, current, and forecast air-quality data are available from a national to regional (if not local) scale. Where monitors in Montana exist, clicking on the small circles on the map retrieves data from those particular locations. о Become aware of, utilize, and support local foods and renewable energy resources. 134 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 135 Photo facing page: Anna Shvets / Pexel Extreme events and disaster planning Here’s what you can do: Montana is expected to experience more climate-driven weather extremes, from intense heat о Ensure that you have curtains or shades on windows during the summer, as well as waves to spring flooding to late-summer drought to, potentially, more intense and more frequent adequate ventilation or air conditioning, to help keep your living space cool during high storms (Whitlock et al. 2017; Section 2). temperatures. If wildfire is not a risk where you live, consider planting trees near your home to provide shade. Here’s what you can do: о Explore retrofit options to help keep your home cooler, including white roofing and о Create a family emergency plan to encompass issues that are relevant to your region. added insulation and ventilation. Resources are available to help finance retrofits, 28 29 Resources are available from the US Department of Homeland Security24 and the including those from Northwestern Energy , the Montana’s electric cooperatives , the 30 31 National Safety Council25. Consider installing the Federal Emergency Management app Montana Department of Health and Human Services , the US Department of Energy , 32 on your phone.26 Plan so that you can comfortably stay in your home during extreme and the US Department of Housing and Urban Development . events, including, for example, being snowed-in for extended periods. Have at least о Know the locations of cooling centers—e.g., malls, libraries, movie theaters, civic three days of medications, water, and food safely stored in the home. The rule of centers, and shaded parks—in your community where you can seek shelter in extreme thumb is one gallon of water per person per day for three days. Make sure you have heat events. adequate blankets or sleeping bags to stay warm during low temperatures and/or power outages. о Never leave infants, children, or pets unattended in a hot car, even with the windows cracked. о Install a functional carbon monoxide (CO) detector in your home, especially important during cold temperatures. If you use a furnace system, check and change the furnace о Limit your outdoor exposure on hot days, and follow these recommendations (CDC filter regularly. 2017; NSC 2020; NIOSH undated): о Seek support from a healthcare professional should you experience a traumatic, • Air conditioning, if available, is the best way to cool down. climate-driven weather event, like flooding, drought, wildfires, and severe winter storms. Such events pose serious risks to mental health, particularly if they result • Stay well hydrated (drink before your get thirsty) and avoid alcohol. in displacement, or loss of property or life. They can bring increased risk of anxiety, • Wear loose, lightweight clothing and a hat. depression, post-traumatic stress disorder, suicidal thoughts, and suicide (USGCRP 2016; Guardian 2019). • Replace water or salt lost from sweating by drinking fruit juices or sports drinks. о Check with your insurance provider if your home is prone to flooding and/or • Avoid spending time outdoors during the hottest part of the day (11 AM to 3 PM). mud slides, as you may need to purchase separate coverage from the National Flood Insurance Program (FEMAa undated) or elsewhere. Also, check flood risk for • Wear sunscreen; sunburn affects the body’s ability to cool itself. your home address at https://floodfactor.com/, a website created by First Street • Pace yourself when you work, run, or otherwise exert yourself. Take breaks to rest Foundation, a group of independent experts who have modelled flood risk to include and cool down. climate change impacts. о Avoid losing too much water and salt, typically from excessive sweating, which can Heat lead to heat exhaustion, rhabdomyolysis (breakdown and death of muscles), health syncope (fainting), heat cramps, heat rash, or life-threatening heat stroke. Learn MCA notes that with climate change the number of days when temperature exceeds 90oF (32oC) the signs of these conditions33 and pay attention to your own and your colleagues’ in Montana is increasing (Whitlock et al. 2017). The National Integrated Heat Health Information condition in hot weather. System27 is a good resource on heat and health-related issues. 28 https://www.northwesternenergy.com/docs/default-source/documents/e-programs/3490_energyassistance 29 https://www.montanaco-ops.com/ 24 https://www.ready.gov/plan 30 https://dphhs.mt.gov/hcsd/energyassistance.aspx 25 https://www.nsc.org/home-safety/safety-topics/emergency-preparedness 31 https://www.energy.gov/eere/wipo/weatherization-assistance-program 26 https://www.fema.gov/mobile-app 32 https://www.hud.gov/states/montana/renting 27 https://nihhis.cpo.noaa.gov 33 https://www.cdc.gov/niosh/topics/heatstress/heatrelillness.html 136 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 137 о Avoid extended periods outside when smoke is present. Wildfire smoke creates a Air quality fine particulate matter that cannot be filtered by dust masks or bandanas. Those with Climate change can affect respiratory health through increased air pollution, including wildfire respiratory conditions and children under 18 are especially vulnerable to wildfire smoke and longer dust and pollen seasons (see Section 3). People with pollen sensitivities may smoke. Those over 65 yr are at increased risk of heart attack or stroke (Wettstein et al. experience more severe reactions, and those with respiratory conditions, such as asthma, may be 2018) (also see Section 3). especially at risk of their symptoms intensifying (e.g., coughing, shortness of breath) (Wellbery and о Do not hold or participate in outdoor activities, especially rigorous outdoor activities Sarfaty 2017). like running and other sports, when wildfire smoke or haze is visible. Check with your local health department for air quality advisories for outdoor sports events. Ask your Here’s what you can do: children’s schools if they receive air quality advisories and if so, if they abide by them. (Health departments can only provide advice; schools decide whether to cancel sports Outdoor air quality events). о Learn more about health risks from wildfire smoke, as well as how to reduce those о Monitor pollen conditions, develop a treatment plan with your doctor, and have the risks, on the Montana Wildfire Smoke website (montanawildfiresmoke.org). See also necessary medications on hand. The ragweed pollen season in central North America the Centers for Disease Control’s website on protecting yourself from wildfire smoke.34 is increasing in length as temperatures increase (Ziska et al. 2011). Periods of drought may also increase irritants, so limit your time outside during times of high pollen о Check current air quality anywhere in the country, including Montana, at AirNow.gov. and/or dust. Consider downloading one of the many phone apps—some free—for The website was created by the US Environmental Protection Agency, National Oceanic displaying and forecasting pollen counts and other allergens. and Atmospheric Administration, National Park Service, and tribal, state, and local agencies to provide the public understandable, easy-to-access national air quality Indoor air quality information. The website color coding system, from green to dark red, shows what level of health risk exists for your region. An Airnow app is available for iOS and о Protect air quality inside your home by using air filters and keeping doors and windows Android mobile devices. closed when outdoor air quality is poor. If you have central air, improve your indoor air quality by upgrading your system’s air filter. Filters are rated using the Minimum о Montana data on particulate matter (PM2.5) air pollution is available at https://www. Efficiency Reporting Value (MERV), ranging from 1-20. The higher the MERV, the more montanawildfiresmoke.org/todays-air.html, which also provides information on how effective the filter at removing small particles (USEPAa undated). The minimum MERV to estimate air quality based on visibility. On a clear day, establish pre-determined rating for removing the fine particulate in smoke is MERV 13. The more times air landmarks visible at various distances (1, 2, 5, 9, 13 and >13 miles), standing with passes through the MERV 13 filter, the cleaner the air becomes. Note that a higher- your back to the sun. When there is smoke in the air, check for the visibility of these rated MERV filter will likely need to be changed more frequently due to the amount of landmarks again. The more limited your visibility, the greater the PM2.5 levels. Consult material it accumulates. http://deq.mt.gov/Air/SF/breakpointsrevised to translate your visibility numbers into health risks. о Remove trees, dead brush, or other flammable materials near your home’s exterior to protect against wildfire. The National Fire Protection Agency provides a set of guidelines for protecting your home35, plus check with your local fire department for advice applicable to your local conditions. о As mentioned previously, check your home insurance to understand—and establish or increase if needed—your wildfire coverage. о Carefully monitor the status of wildfires in your region. If you live in a high-fire-risk area, have an evacuation plan and be prepared to leave your home quickly. 34 https://www.cdc.gov/air/wildfire-smoke/default.htm 35 https://www.nfpa.org/Public-Education/Fire-causes-and-risks/Wildfire/Preparing-homes-for-wildfire 138 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 139 Photo: CDC / Upsplash Not all central air systems can handle the pressure drop associated with higher MERv Flood and drought filters. Check with the manufacturer to find out what filters will work with your furnace, or have an HvAC technician check your system before installing. Note that your air is Flooding can contaminate surface water and groundwater, and harmful algal and bacterial cleaned only while it is moving through the filter, so keep your furnace fan running blooms are expected to become more frequent in a warming climate. The trends of early-season when air quality is poor. You may wish to upgrade to a higher MERV filter only during runoff and late-season drought described in the MCA (Whitlock et al. 2017) can also impact food poor air quality events; discuss the wear and tear on your furnace and the potential for security and the incidence of vector-borne disease (also see Section 2). higher utility bills with your furnace manufacturer’s local representative. Here’s what you can do: Another option is portable air cleaners with true HEPA filtration, which can dramatically improve indoor air quality. These standalone units use a fan to pull air through a о Protect your home from the risk of mold by checking for piping leaks or water true HEPA filter (MERV rating 17-20), which mechanically removes the fine particles in accumulation under sinks, crawl spaces, attics and basements. Install drainage smoke. Costs for portable air cleaners increase with room size. However, you should systems to prevent rainwater or saturated grounds from damaging your home, be able to find a good portable air cleaner with a true HEPA filter for under $200, including providing a foothold for mold and rot. suitable for most living rooms or bedrooms. Use the portable air cleaners in the room where you spend the most time; it is a good idea to run one in your bedroom while you о Act quickly if you find mold in your home. Along with the health effects that result sleep. Try to keep windows and doors to the room with the portable air cleaners closed from mold exposure—e.g., allergies, stuffy nose, wheezing—the longer mold grows to allow the machine to recirculate air through its filter. Make sure the portable air the more damage it will cause to your home. You must both eliminate the water cleaner is sized appropriately for the room. Caution: mechanical portable air cleaners source and remove the mold. EPA’s A Brief Guide to Mold, Moisture, and Your Home are reliable, while some that are electronic produce hazardous ozone (a gas) and/or provides a useful guide, including the tradeoffs between cleaning your home yourself other hazardous chemicals, and hence should be avoided (USEPAa undated, 2018a, versus employing a professional (USEPA 2012). 2018b, 2019). о Monitor your water supply if you have a well, and make your home as water-efficient For a lower-cost solution, you can put together a do-it-yourself fan/filter. Use a newer as possible. These are good practices anytime, and potentially critical during times of box fan (manufactured in the past five years), and a MERV 13 furnace filter attached drought. Store spare water in case of an emergency. to the back of the fan with the airflow arrow pointing toward the fan. Duct tape or a bungee cord will do the trick. Do not leave such a set up unattended, and change the filter when it becomes visibly dirty. These do-it-yourself air cleaners can be quite effective in rooms around 250 square feet. More information, including how-to videos, is available at montanawildfiresmoke.org. о Reduce sources of air pollution indoors when poor outdoor air quality requires staying inside. For example, avoid burning candles, smoking tobacco, using aerosol sprays, or burning your woodstove or fireplace. о Upgrade your woodstove or fireplace, as needed and if possible, to one that is tighter and cleaner burning, thereby helping improve both indoor and outdoor air quality. See the US EPA’s Burn Wise website36 for tips on woodstove use and for links to the US EPA’s database of certified woodstoves. о Support transitioning to clean, renewable sources of energy. As the American Lung Association states in its Lung Health Brief (American Lung Association 2016): “Switching to clean, renewable energy will allow the US to generate electricity without adding pollution that harms Americans’ health… Decades of research shows that these pollutants trigger asthma attacks and heart attacks, cause cancer, and shorten lives, among many other health impacts.” Flood of 2007, I-90 bridges at Crow Agency Photo courtesy of John Doyle 36 https://www.epa.gov/burnwise 140 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 141 о Ensure your wellhead has a watertight sanitary cap, rather than an old-style cap with Food security no gasket. The casing for a well must extend at least 18 inches (46 cm) above the natural ground surface; casing extensions can be added if needed (USEPAb undated). The growing-season drought and limitation on agricultural irrigation water projected in MCA These features protect your home well water from contamination year-round, and (Whitlock et al. 2017) will likely result in crop losses, lower yields, higher anxiety among producers, especially in the event of a flood. higher food prices, and higher risk of food-borne disease. Commodity crop and livestock producers can be challenged by a wide range of climate change factors, many of which are not о Be prepared to boil, filter, or chemically purify your water before drinking in the event local, but impact global food security. On a local scale, community food enterprises are taking an of flood contamination. Such treatments can eliminate most organic contaminants and active role in growing, marketing, processing, distributing, and retailing food to decrease reliance microbes (USEPAc undated). Organic compounds can be the biggest concern during a on food vulnerability of global food systems. Building local food availability creates local jobs, flood due to sewage (human and/or livestock) runoff. However, those with wells should improves the community economy, in some cases lowers emissions from transportation and know—in advance via testing—if their water contains such inorganic contaminants storage, and benefits human health by providing more fresh and nutritious food (Norberg-Hodge as uranium, arsenic, manganese, or other hazardous metals or nitrates. In the case et al. 2002; Borelli et al. 2020). of flood, such contaminants might make boiling your water a poor idea as boiling will likely concentrate these inorganic contaminants, resulting in increased health danger. Here’s what you can do: Uranium, arsenic, and some other hazardous contaminants have no taste, smell, or color—thus, you won’t know they are present until you have your water tested. о Buy from local sources whenever possible, including farmers markets, community Montana State University’s Montana Well Educated Program37 is an excellent resource supported agriculture (often called “CSAs”), food hubs39, and growers’ coops.40,41 for accessing discounted, EPA-certified, well-water testing for microbial, organic and inorganic contaminants, plus for learning more about drinking water quality and safety. о Diversify food supplies and crop types. Plant and eat from a variety of food sources and eat more seasonal foods. о Never swim in, nor drink from, water where blue-green algae (cyanobacteria) are visible or where harmful algal blooms have been reported (MTDPHHS undated). о Purchase less processed and highly packaged food. Similarly, keep pets and livestock away from waters where such hazards are present. If you are camping, understand that boiling, filtering, or adding purifying tablets to о Learn how to prepare and store more foods for later use. Store non-perishable foods water will not remove these toxins. Public drinking water supplies in Montana are not in a location expected to be safe and accessible in emergencies. MSU Extension is an 42 required to monitor or test for cyanobacterial toxins (MTDPHHS undated). For further excellent resource for helpful guides on food preservation and storage. information, see Section 3 and the Harmful Algal Bloom Guidance Document for Montana о Plant and grow your own vegetables using organic fertilizer and an efficient irrigation (MTDPHHS 2019). system. о Conserve water and reduce your water bill by upgrading to high efficiency о Advocate for local foods—fruits, vegetables, grains, legumes, or meat—sourced and showerheads, toilets, and washing machines, plus fixing faucet and shower leaks. Keep processed in Montana. your grass at least 3 inches (7.6 cm) high, mulch your plants, landscape with drought- tolerant plants, and learn best watering practices. Know how to operate and maintain о Decrease waste, both your own and your community’s, by supporting community your in-ground sprinkler system most efficiently. You can find great tips and water compost collection. conservation resources on the city of Bozeman website.38 о Support farm-to-table restaurants that use locally grown foods and ask others (including hospital cafeterias) to do so, as well. 37 http://waterquality.montana.edu/well-ed/ о Encourage Montana’s farm-to-school program43 and the FoodCorps program44 to 38 https://www.bozeman.net/government/water-conservation/resources inform our teachers and youth about local food sources. 39 The US Department of Agriculture defines a food hub as, “A centrally located facility with a business management structure facilitating the aggregation, storage, processing, distribution, and/or marketing of locally/regionally produced food products” (USDA undated). 40 https://www.farmersmarketplaces.com/ 41 https://www.wmgcoop.com/about.us 42 https://store.msuextension.org/Departments/MontGuides-by-Category/HR/Nutrition-and-Health.aspx 43 http://www.farmtoschool.org/our-network/Montana 44 htpps://foodcorps.org/apply/where-youll-serve/montana/ 142 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 143 Photo facing page: Charl van Rooy / Upsplash Vector-borne disease Changing temperatures and water regimes are expected to expand the range of illnesses spread Epidemics, Pandemics, and Climate Change by vectors such as mosquitoes, ticks, and fleas (see Section 3). Epidemics and pandemics have ravaged human societies throughout history. However, Here’s what you can do: studies suggest that the number of infectious disease outbreaks from all causes has increased significantly since 1980 (Smith et al. 2014). Up to 75% of newly emerging о Mount (or repair) screens on windows and doors to prevent mosquitoes from entering diseases originate in animals (referred to as zoonotic diseases) (USAID undated). your home. Limit pools of water around your home, where mosquitoes breed.45 To protect yourself outside use insect repellent and wear long-sleeved shirts and pants. As the world combats the ongoing COVID-19 pandemic, questions arise about the Stay inside or take extra precautions especially at dusk and dawn, when mosquitoes contribution of climate change to the emergence of new infectious diseases and are most active. pandemics, in general. Many of the same factors contributing to climate change also о Monitor outbreaks of vector-borne illnesses—e.g., West Nile virus, Rocky Mountain increase the risk of new diseases. Deforestation—for agriculture, urbanization, and Spotted Fever, and Q fever—through your local health department or the Montana mining—is a leading contributor to climate change due to the burning of trees and Department of Public Health and Human Services website46 (Figure 5-2). subsequent loss of carbon sequestration from photosynthesis, which further increases atmospheric carbon dioxide. In addition, deforestation forces humans and wild animals о Tuck your pants into into more frequent and closer interactions through loss of habitat and increased numbers your socks when of people living at the forest edge (Faust et al. 2018; Bloomfield et al. 2020). This proximity walking through increases the opportunities for disease transmission to humans. Deforestation, coupled grasses or areas where ticks are common. with economic disparities and food insecurity, can also lead to more people hunting wild Check yourself for ticks animals for food in many parts of the world. It also forces animal species that would when you return home. normally occupy different habitats into close proximity to each other, yielding yet another visit the Centers for opportunity for disease pathogens to cross species boundaries. Disease Control and Prevention website for Warmer temperatures globally drive animals and plants to shift their range from further information on unsuitable areas to places with conditions more conducive to their survival. This report preventing tick bites, discusses such shifts relative to disease vectors such as mosquitoes and ticks, but removing ticks, what research suggests that similar movement is occurring with mammals, such as bats, to do after a tick bite, bringing them into new areas and increasing risk of disease transmission to humans where different types (Plowright et al. 2015). of ticks live, and more.47 о Watch for potential Along with potentially contributing to the emergence of infectious diseases, the burning emergence of zoonotic of fossil fuels also causes air pollution, which worsens the effects of certain epidemics disease by monitoring the Figure 5-2. An example of vector-borne disease tracking that and pandemics among people with chronic medical conditions. During the 2003 SARS citizens can access from the Montana Department of Public Montana Department of Health and Human Services website (start at https://dphhs. outbreak (Cui et al. 2003) and recent SARS-CoV-2 outbreak and resultant COVID-19 Public Health and Human mt.gov/publichealth/cdepi/surveillance). pandemic (Wu et al. 2020), virus-related mortality was highest in areas with high levels of Services website (also see air pollution. Section 3).48 Although there are many illnesses that can potentially be transferred from animals to people, there Thus, climate change does not cause the diseases that result in epidemics or pandemics. is currently no research showing that climate changes are directly increasing these Climate change can, however, amplify the impacts on human health, and even some health risks in Montana. Still, new zoonotic diseases that emerge in other parts of the of the factors that make pandemics more likely. Further, many of the drivers of climate world can reach Montana, as COVID-19, from the SARS-CoV-2 virus, demonstrated (see change also contribute to emergence of new zoonotic diseases in humans. By addressing facing page). those forces, we not only lessen the chances of new diseases, but mitigate climate change, as well. 45 https://dphhs.mt.gov/aboutus/news/2019/preventwestnilevirus 46 https://dphhs.mt.gov/publichealth/cdepi/surveillance 47 https://www.cdc.gov/ticks/index.html 48 https://dphhs.mt.gov/publichealth/cdepi/diseases/zoonotic 144 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 145 Mental health: getting involved and finding support о Build a sense of community and become involved in civic action, such as volunteering, polling, voting, or advocacy. Working on climate change adaptation or mitigation has The stress of climate change can greatly influence our mental health. Recognizing that you need been shown to have mental health benefits (Reser et al. 2012), so find a group or help and taking the first steps to process hard times are often the most difficult. Approaches to organization that is active on climate change issues and get involved (see Table 5-1 protecting mental health include crisis counseling, primary care intervention, individual and group and sidebars in this section). therapy, and practices that increase emotional coping abilities (Hayes et al. 2018). о Foster optimism by maintaining connectedness to family, place, culture, and Here’s what you can do: community (Clayton et al. 2017). о Talk with others about climate-related distress (NBC News 2018; Ozy 2019). Consider о Learn more about coping skills. If you can, seek advice from a mental health counselor, therapist, or another trusted support person. involvement in such groups as The Good Grief Network 49, who describe themselves as “…a nonprofit dedicated to bringing people together to help metabolize collective о Get involved with art, literature, nature, and spirituality; spend time with friends; get grief. Using a 10-step approach, we help build personal resilience while strengthening outside; exercise; garden—all will increase emotional resilience (Koger et al. 2011; community ties to help combat despair, inaction, eco-anxiety, and other heavy Hayes et al. 2018; Guardian 2019) (Figure 5-3). emotions in the face of daunting systemic predicaments.” о Seek solace in nature as a way help overcome feelings of anxiety, hopelessness, and powerlessness over the future (Koger et al. 2011). о Finally, realize that we all have a role to play in the mitigation and adaptation to climate change and we can be inspired by the many communities, healthcare settings, and individuals in Montana who are working for a better future. What professionaL orGanizations are sayinG A number of professional organizations, health-focused and otherwise, have developed policies or position statements regarding the impacts of climate change on human health. Following is a collection of quotes from a number of these trusted resources. о Montana Farmer’s Union.—“As the impacts of climate change mount, producers will need to be armed with the latest research, information and tools to mitigate the adverse effects, adapt to the changing conditions and continue providing a safe, reliable and healthy food source for the world.” 50 о Montana Climate Change Advisory Committee.—“Explicitly articulated public education and outreach can support GHG emissions reduction efforts at all levels in the context of emissions reduction programs, policies, or goals. Public education and outreach is vital to fostering a broad awareness of climate change issues and effects (including co- benefits, such as clean air and public health) among the state’s citizens.” 51 о US Department of Health and Human Services.—“The US Department of Health and Human Services considers climate change to be one of the top public health challenges of our time.” 52 Figure 5-3. Creating art of all kinds—painting, drawing, sculpture, poetry, literature, photography, and more—can help increase emotional resilience during times of stress, including that related to climate 49 https://www.goodgriefnetwork.org/ change. Art provides anyone, young or old, a place to express his or her fears or hopes, or to encapsulate an idea or a moment in time. Here, for example, environmental engineer and painter Katie Lindberg has 50 https://montanafarmersunion.com/wp-content/uploads/2016/01/MFU_Climate_Final.pdf captured the essence of this report on climate change and human health in Montana. 51 https://deq.mt.gov/Portals/112/Energy/ClimateChange/Documents/FinalReportChapters.pdf 52 https://www.hhs.gov/climate/index.html 146 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 147 Younger Montanans Taking Action for Their Health Protecting the health of Montana youth, one of the most vulnerable populations to climate change, is a major action о National Institute of Environmental Health Sciences.—“While climate change is a global motivator for young people across Montana. Supporting this idea, a recent study of 47 students in the health field process, it has very local impacts that can profoundly affect communities. It can affect in Montana showed 100% agreement in the science of climate change, and 89% felt their health was at stake due to people’s health and well-being in many ways, some of which are already occurring.” 53 climate change (Byron 2019). о National Indian Health Board.—“Tribal communities can be particularly vulnerable to Sarah Lorch, a 21-year-old honors nursing student at Montana State University, is one the health effects associated with climate change for a variety of reasons. There are such active participant in the climate and health conversation. Sarah says, already existing and pronounced health disparities in Native communities that can lead to the health impacts from environmental damage being much more severe.” 54 Understanding how climate change affects my health and the health of my о Medical Society Consortium on Climate and Health’s Climate, Health, and Equity Policy generation is a deep passion as I pursue a profession in public health nursing. I Action Agenda.—“Climate change is a public health emergency. We call on our nation’s often find it puzzling that climate change has become such a political issue. I think leaders to act now by mobilizing climate actions for our health, and health actions for many youth are confused by this phenomenon. I want people from all walks of life our climate. With the right policies and investments today, we have the opportunity to to feel that climate change is relatable and to understand that their own personal realize our vision of healthy people in healthy places on a healthy planet.” 55 (Note: This well-being is affected by it. Widespread hesitations around climate change place statement was signed by over 100 health organizations.) us in a pressure cooker, and addressing climate change needs to be an emergency response accomplished through powerful and personal storytelling that sparks о National Academy of Medicine.—“The negative impacts of climate change immediate action. We also need to assure that climate change and human health disproportionately affect the very young and the very old, people who are ill, studies are integrated into every medical curriculum as a required standard. impoverished or homeless individuals, and populations that depend on the natural environment for survival. Urgent action is needed to mitigate the health consequences To move forward in this work, Sarah has contributed to several blogs and newsletters, of climate change for these populations, among others. … Climate change represents completed leadership training with the Sunrise Movement, is an active member of the one of the most significant threats to human health in the 21st century.” 56 Alliance of Nurses for Healthy Environments, and is the newest board member of the Montana Health Professionals for a Healthy Climate. These and other climate action and health groups, described о Lancet Commission Report on Health and Climate Change: Policy Responses to Protect below, draw on the innovation and leadership of Montana’s young people: Public Health, 2015.—“Climate change...threatens to undermine the last half century of gains in development and global health. … Tackling climate change could be the о The Sunrise Movementa is a global connection, with chapters in Montana, of “ordinary young people greatest global health opportunity of the 21st century.” 57 who are scared about what the climate crisis means for the people and places we love. We are gathering in classrooms, living rooms, and worship halls across the country … We are not looking to the right or left. We look forward. Together, we will change this country and this world, sure as the sun rises each Literature Cited morning.” Montana Sunrise helped organize the Global Climate Strike marches on September 20, 2019, in many cities across Montana for an historic call-to-action and strike for a livable future. The Sunrise American Lung Association. 2016. Lung health policy brief: clean energy and health. 2 p. Available as Movement offers national trainings in leadership and action. download at online https://www.lung.org/getmedia/e310efd8-b189-4411-b3a3-7db31dc54baa/clean- о Alliance of Nurses for Healthy Environmentsb believes that “changes to climate patterns lead to current energy-policy-brief_.pdf. Accessed 22 Apr 2020. and imminent threats to public and environmental health with growing evidence and concern about impacts on human health noted if action is not taken.” Anderson H, Brown C, Cameron LL, Christenson M, Conlon KC, Dorevitch S, plus 23 more. 2017. Climate and health intervention assessment: evidence on public health interventions to prevent the negative health о Student chapters in high schools and university campuses of 350.orgc, Citizens’ Climate Lobbyd, and effects of climate change. Climate and health technical report series. Atlanta GA: Centers for Disease Protect Our Winterse are active throughout Montana. Control and Prevention, Climate and Health Program. 96 p. Available online https://www.cdc.gov/ о 4-H, the USDA Extension Service’s youth development program, has a new national climate curriculum, climateandhealth/docs/ClimateAndHealthInterventionAssessment_508.pdf. Accessed 14 May 2020. initiated at Montana State University.f о On March 13th, 2020, a group of Montana’s youth filed a complaint in the First Judicial District Court 53 https://www.niehs.nih.gov/health/topics/agents/climate-change/index.cfm against the State of Montana arguing they are harmed by the “dangerous impacts of fossil fuels and the 54 https://www.nihb.org/docs/10102019/Climate%20Change%20&%20Tribes%20Article.pdf climate crisis.” The law firms representing the youth maintain that Montana’s fossil-fuel based energy 55 https://climatehealthaction.org/cta/climate-health-equity-policy/ system and the Climate Change Exception within the Montana’s Environmental Policy Act violates their 56 https://nam.edu/programs/climate-change-and-human-health/ state constitutional rights. 57 https://www.ncbi.nlm.nih.gov/pubmed/26111439 _______ a https://www.sunrisemovement.org; b https://envirn.org/; c https://350.org/; d https://citizensclimatelobby.org/; e https:// protectourwinters.org/; f https://shop4-h.org/products/4-h-weather-and-climate-learning-lab-leader-s-guide 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 149 Bloomfield LSP, McIntosh TL, Lambin EF. 2020. 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Fleetwood P, Hovanky KT, Kavanaugh T, Fulford G, vrtis RF, Patz JA, Portnoy J, Coates F, Bielory L, Frenz D. 2011. Recent warming by latitude associated with increased length of ragweed pollen season in Wellbery C, Sarfaty M. 2017. The health hazards of air pollution—implications for your patients. American central North America. Proceedings of the National Academy of Sciences 108(10):4248-51. https://doi. Family Physician 95(3):146-8. org/10.1073/pnas.1014107108 Paradise Valley south of Livingston Photo courtesy of Violeta Corpron 156 | CLIMATE HEALTH ACTIONS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 157 06. MOVING FORWARD Alexandra Adams This is the first report produced specifically for Montanans and Montana that focuses on human health impacts from climate change. As a special report of the 2017 Montana Climate Assessment, it is intended to foster greater awareness of public health impacts from climate change in communities across Montana, and thus spur action. The authors and their organizations—Montana Institute on Ecosystems, Center for American Indian and Rural Health Equity, and Montana Health Professionals for a Healthy Climate—support implementation of the key messages and recommendations herein to mitigate significant climate- related human health impacts in Montana. They extend their gratitude to many contributing experts, as noted in the Acknowledgments section, for their input to the development of this report. The recommendations promote establishment of a key climate action network that ensures the impacts of climate change on public health can be assessed, prepared for, and mitigated in Montana. Given the many efforts related to climate and health already occurring in Montana, the current lack of a collaborative network connecting these organizations and issues must be addressed. The creation of a statewide public health-climate science network comprising key stakeholders will improve climate and health data collection and sharing across Montana. Easier access to relevant data and capacity building will better inform and strengthen collective climate change adaptation planning, decision-making, and implementation, from state-level to personal health. This report presents the best available science and resources at the time of publication. Many interconnections exist between climate change and human health, and these relationships are likely to evolve in the coming years. As access to better data becomes available on the climate impacts on Montanans’ health, new knowledge will inevitably expand the foundation this report offers. Thus, while this effort fills a key gap, this work will need to be sustained, updated, and expanded on a regular basis as part of the overall MCA program. Continuing focus and collaborations on these issues will assure Montanans are informed about the impacts of climate change on their health, and are also prepared to respond to those impacts in the coming decades. This report provides an important and valuable first step in raising awareness of the topic of climate change and its impacts on human health in Montana. We hope that everyone will recognize their role to mitigate and adapt to climate change, both for our own health and for those most vulnerable among us. Foraging horse Photo courtesy of Alexandra Adams 158 | MOVING FORWARD 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 159 APPENDIX A. ANALYSIS OF VULNERABILITY TO HEAT BASED ON HISTORIC AND FUTURE TEMPERATURE, AS WELL AS SOCIOECONOMIC FACTORS Nick Silverman, Bruce Maxwell, and Robert Byron MuLti-Criteria deCision anaLysis We used Multi-criteria decision analysis (MCDA) to categorize vulnerability to heat across the state of Montana. MCDA is a statistical method of weighting different layers of contributing information to provide a qualitative description of risk. The method has been applied to a wide range of topics in risk analysis (Chi 2010, Ho et al. 2014). Several studies have used MCDA to better understand the relationship between land surface temperature (heat) and human health (Ho et al. 2015, Reid et al. 2009, Morabito et al. 2015). More locally, MCDA was used to map heat vulnerability across the city of Missoula, Montana (Thompkins 2018). The term decision analysis in the name comes from the original intent of the method to help inform decision-making by allowing decision makers with local knowledge to weigh different factors based on their intuitive sense of which factors may be most strongly associated with a response. In our case, how heat may associate with socioeconomic factors with different weightings to determine human health impact. We used this method to determine which counties in Montana may be most vulnerable to heat effects from Happiness in the Clark Fork River! climate change. Photo courtesy of Nick Silverman 160 | APPENDIx A 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 161 Table A-1. County rankings based on socioeconomic variables that are sensitive to heat using 2013-2017 data (closeness not used for ranking, but ranking associated with vulnerability so median income and percent exposure CaLCuLations professional jobs are ranked high if values are low and all other variables ranked from low to high). Two notes associated with the socioeconomic column: a) If average median household income was low for a county relative to the other counties in Montana then the rank would be high (i.e., more sensitive to heat); b) If the percentage of In our analysis, we define vulnerability as having three main components: 1) heat exposure; professional jobs in the county was low relative to other Montana counties then the rank would be high (i.e., more 2) heat sensitivity; and 3) adaptive capacity. Exposure is the direct effect of heat based sensitive to heat). on temperature and humidity; sensitivity and adaptive capacity are combined through socioeconomic factors that make humans more susceptible to heat-related illness. We refer to these socioeconomic factors as sensitivity for this analysis. Exposure is further broken down Socio- Counties with low Counties with Counties with medium-low medium-high Counties with high into historical conditions and future change. Historical heat conditions for each county1 were economic sensitivity rank variable (1-14) sensitivity rank sensitivity rank sensitivity rank estimated using the Moderate Resolution Imaging Spectroradiometer (MODIS) Land Surface (15-28) (29-43) (44-56) Temperature (daily average) and Emissivity (MOD11) approximately 1-km resolution satellite Rosebud, Broadwater, Sweet Grass, Garfield, th Custer, Richland, Pondera, Carter, Liberty, Ravalli, Musselshell, Chouteau, Meagher, product (Wan et al. 2015). We calculated the 95 percentile land surface temperatures from 2000- Fergus, Big Horn, Granite, Valley, Daniels, Fallon, Petroleum, Beaverhead, Sanders, Lincoln, Wheatland, 2019 for each grid-cell and then averaged those by county creating an estimate of the historical Median household Wibaux, Sheridan, Prairie, Stillwater, Dawson, Toole, Judith Basin, Powell, Phillips, Blaine, Roosevelt, income Madison, Teton, Powder land surface temperature for each county during the hottest climate events (i.e., falling within the Yellowstone, Carbon, Park, McCone, Lake, Hill, Glacier, Mineral, Deer Lodge, River, Cascade, Flathead, Gallatin, Lewis and Treasure, Golden Valley Silver Bow top 95th quantile) during the study period. For future changes in heat projections, we used the MissoulaClark, Jefferson heat index values by UCS (2019) for the 100°F threshold at mid century with the RCP8.5 scenario. Broadwater, Custer, Dawson, Yellowstone, Fergus, Missoula, Liberty, The heat indices for each county were generated based on an ensemble of general circulation Richland, Valley, Gallatin, Lewis and Ravalli, Beaverhead, Toole, Rosebud, Big Horn, Pondera, models and include a combination of temperature and humidity estimates to create a “feels like” Daniels, Fallon, Clark, Sweet Grass, Judith Basin, Powell, Lake, Hill, Chouteau, Sanders, % poverty Stillwater, Carbon, Wibaux, Sheridan, Prairie, temperature rating commonly used when estimating heat impacts on humans. Treasure, Golden Valley, Wheatland, Blaine, Roosevelt, Jefferson, Garfield, Madison, Cascade, Musselshell, Meagher, Glacier, Mineral, Silver Bow Granite, Teton, Powder Flathead, Carter, Lincoln, Phillips, Deer Lodge River, McCone Petroleum, Park s C Broadwater, Custer, Carbon, Jefferson, Granite, ensitivity aLCuLations Richland, Valley, Yellowstone, Lewis and Dawson, Flathead, Carter, Golden Valley, Rosebud, Daniels, Fallon, Clark, Sweet Grass, Fergus, Liberty, Ravalli, Toole, Big Horn, Pondera, Lake, % child poverty Stillwater, Garfield, Sheridan, Prairie, Powell, Treasure, Musselshell, Hill, Chouteau, Sanders, We based our calculation of sensitivity on socioeconomic factors from the US Census Bureau, Teton, Powder River, Madison, Cascade, Meagher, Lincoln, Phillips, Wheatland, Blaine, Roosevelt, 2013-2017 American Community Survey 5-Year Estimates. We used county estimates of median McCone, Gallatin, Petroleum, Park, Deer Lodge, Silver Bow Glacier, Mineral Wibaux, Beaverhead Missoula, Judith Basin household income assuming that if income was low the county population would have less ability Custer, Gallatin, Jefferson, to mitigate extreme heat. Percent of the county in poverty, percent of children in poverty, and Broadwater, Stillwater, Garfield, Granite, Yellowstone, Valley, Daniels, Beaverhead, Richland, Fallon, Powder River, percent of population unemployed for a county were assumed to increase the likelihood of Teton, McCone, Wibaux, Lewis and Clark, Carbon, Sheridan, Park, Sweet Grass, Petroleum, % construction Prairie, Madison, Dawson, negative health impacts from heat. The percent of construction and production (those employed Cascade, Missoula, Ravalli, Toole, Deer Lodge, Judith Basin, Liberty, Treasure, jobs Carter, Powell, Musselshell, Flathead, Fergus, Silver Big Horn, Pondera, Lake, Phillips, Golden Valley, in production, transportation, and material movement) jobs were assumed to be related to Meagher, Lincoln, Sanders, Bow, Hill, Chouteau, Roosevelt, Glacier Rosebud, Wheatland Blaine increased exposure to heat because most of these jobs are outside or have little access to air Mineral conditioning. Percent of professional jobs, like household income, is thought to increase the Jefferson, Lewis and potential for the population to survive extreme heat. In the cases of median household income Clark, Missoula, Daniels, Yellowstone, Chouteau, Custer, Gallatin, Cascade, Granite, Silver Bow, Hill, Mineral, Carbon, Sheridan, Beaverhead, Ravalli, Deer and percent of professional jobs, the inverse ranking was used to associate with heat vulnerability. Flathead, Fergus, Valley, Roosevelt, Stillwater, Dawson, Big Horn, Glacier, Lodge, Pondera, Lake, % production jobs Park, Toole, Powell, Musselshell, Meagher, These mapped layers of information were selected by a panel of Montana healthcare experts as Garfield, McCone, Broadwater, Teton, Wibaux, Blaine, Powder River, Sanders, Richland, Fallon, Prairie, Madison, Carter, Lincoln, Phillips, Golden best indicators of heat vulnerability from the list available (Table A-1).2 Wheatland Sweet GrassPetroleum, Judith Valley, Rosebud Basin, Liberty, Treasure Lewis and Clark, Sheridan, Daniels, Garfield, McCone, Jefferson, Missoula, Carbon, Prairie, Madison, Carter, Liberty, Treasure, Petroleum, Gallatin, Cascade, Big Horn, Glacier, Blaine, Judith Basin, Fergus, % Custer, Toole, Powell, Flathead, Valley, Beaverhead, Ravalli, Lake, Lincoln, Phillips, Park, Powder River, unemployment Deer Lodge, Teton, Pondera, Broadwater, Rosebud, Granite, Hill, Mineral, Wheatland, Yellowstone, Wibaux, Dawson, Golden Valley, Silver Bow, Roosevelt, Sanders Chouteau, Meagher, Fallon, Sweet Grass Stillwater, Musselshell Richland 1 See Figure 2-1 for a map naming Montana’s 56 counties. Garfield, Carter, Wibaux, 2 It is important to recognize that data and discussion on percent employment, as presented in this analysis, Chouteau, Meagher, Fergus, Rosebud, Pondera, Big Petroleum, Daniels, Musselshell, Sweet Grass, Broadwater, Valley, Horn, Granite, Custer, are from well before the 2020 COVID-19 pandemic. Prairie, Judith Basin, Liberty, Sanders, Lincoln, % professional Sheridan, Blaine, Teton, Ravalli, Phillips, Madison, Powell, McCone, Richland, Wheatland, Toole, jobs Glacier, Hill, Treasure, Beaverhead, Park, Dawson, Powder River, Gallatin, Roosevelt, Fallon, Stillwater, Golden Valley, Carbon, Lake, Yellowstone, Flathead, Lewis and Clark, Mineral, Deer Lodge Cascade Silver Bow Jefferson, Missoula 162 | APPENDIx A WeiGhtinG sCheMe We weighted historical land surface temperatures and projected heat index by 0.255 and each socioeconomic factor by 0.07 so that the cumulative exposure layers and cumulative sensitivity layers were equally weighted (0.255 + 0.255 + 7*0.07 = 1.0). Income and percent of professional jobs were maximized while all other layers were minimized in the MCDA algorithm to minimize vulnerability. We used the closeness values calculated from the “skcriteria” Python library to calculate county vulnerability using the Technique for Order of Preference by Similarity to Ideal Solutions (TOPSIS) method (Sevachandran et al. 2018). Closeness represents how far each county’s subset of socioeconomic variables, chosen to represent vulnerability, depart from the ideal set (Hwang and Yoon, 1981). Closeness values are normalized to be between 0 and 1. We grouped counties with closeness values below 0.25, between 0.25 and 0.50, above 0.50 and below 0.75 and above 0.75 into low, medium-low, medium-high and high vulnerability ratings, respectively. In the absence of additional information, we assumed that each of the socioeconomic factors were equally weighted to represent sensitivity to heat. We know that certain factors are likely to have a stronger influence in some counties, but equal weighting was the best assumption without a detailed investigation into the variation in epidemiology of heat-related illness in Montana. To assess the uncertainty in our assumption, we performed a Monte-Carlo analysis on our weighting scheme for the different variables. We ran 10,000 simulations where socioeconomic variables were randomly assigned a weight using a Dirichlet distribution (a family of continuous multivariate probability distributions representing the socioeconomic variables) and then forced the sum of the weights corresponding to the 7 socioeconomic variables to equal 0.49. We kept the exposure weights constant at 0.255 for both historical and future predicted heat. Figure A-1. Montana heat vulnerability ratings from the multi-criteria decision analysis. resuLts The higher the rank values the more vulnerable a county’s population is to heat. One county in Montana has a high vulnerability rating, while 17 have a medium-high rating, 12 have a medium- low rating, and 26 have a low rating (Figure A-1). There is a strong west-to-east increasing trend The uncertainty analysis shows that there is variability in the sensitivity of the county ratings to the in vulnerability that mostly results from the patterns of exposure (i.e., land surface temperatures socioeconomic weights (Figure A-2). In some counties, such as Madison and Carbon, the closeness and projected heat are highest in eastern Montana). Roosevelt County ranked 29 for historical values were less sensitive to the weights, while in other counties, such as Richland and Fallon, heat and 51 for future predicted heat relative to the other 56 counties, making it one of the top there was larger variability. In general, the uncertainty results suggest that when clumped into the five counties for projected extreme heat in Montana. Roosevelt’s high heat ranking coupled with a four categories (low, medium-low, medium-high, and high) the results are robust and that most number of other factors—a) relatively high unemployment; b) low median income; c) low number of the ratings are stay the same irrespective of the weighting scheme. This finding increases our of professional jobs; d) high poverty levels; and e) high number of agricultural production jobs— confidence in the general relative vulnerability prediction. make it highly vulnerable to human health impacts from heat. While Roosevelt County is the only county with a “high” vulnerability rating, it is important to remember the uncertainty in the socioeconomic weight assignments when evaluating these results. 164 | APPENDIx A 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 165 Literature Cited Chi G. 2010. Land developability: developing an index of land use and development for population research. Journal of Maps 2010(1):609-17. Ho HC, Mylroie J, Infante L, Rodgers III J. 2014. Fuzzy-based spatial modeling approach to predict island karst distribution. Environmental Earth Sciences 71:1369–77 Ho HC, Knudby A, Huang W. 2015. A spatial framework to map heat health risks at multiple scales. International Journal of Environmental Research and Public Health 12:16110–23. doi:10.3390/ ijerph121215046. Hwang CL, Yoon K. 1981. Methods for multiple attribute decision-making [chapter]. In: Multiple attribute decision-making. Berlin GDR: Springer. p 58-191. Morabito M, Crisci A, Gioli B, Gualtieri G, Toscano P, di Stefano V, Orlandini S, Gensini GF. 2015. Urban- hazard risk analysis: mapping of heat-related risks in the elderly in major Italian cities. PLOS ONE 10(5):e0127277. https://doi.org/10.1371/journal.pone.0127277. Reid CE, O’Neill MS, Gronlund CJ, Brines SJ, Brown DG, Diez-Roux AV, Schwartz J. 2009. Mapping community determinants of heat vulnerability. Environmental Health Perspectives 117:1730-6. Sevachandran G, Quek SG, Smarandache F, Broumi S. 2018. An extended technique for order preference by similarity to an ideal solution (TOPSIS) with maximizing deviation method based on integrates weight measure for single-valued neutrosophic sets. Symmetry 10:236. doi:10.3390/sym10070236. Thompkins J. 2018. Just open a window: understanding the vulnerability to summer heat of a mountain community in the western United States, Missoula, MT [master’s thesis]. Missoula MT: University of Montana. 53 p. Available online https://pdfs.semanticscholar. org/889e/1883fe683f37bac12602f944314bd0a31708.pdf?_ga=2.100382622.1055626674.1589500024- 1171419070.1589500024. Accessed 14 May 2020. [UCS] Union of Concerned Scientists. 2019. Killer heat in the United States; climate choices and the future of dangerously hot days [report]. Dahl K, Spanger-Siegfried E, Licker R, Caldas A, Abatzoglou J, Mailloux N, Cleetus R, Udvardy S, Declet-Barreto J, Worth P, authors. Available online https://www.ucsusa.org/sites/ default/files/attach/2019/07/killer-heat-analysis-full-report.pdf. Accessed 15 Sep 2019. Wan Z, Hook S, Hulley G. 2015. MYD11A1 MODIS/Terra Land Surface Temperature/Emissivity Daily L3 Global 1km SIN Grid V006 [data set]. NASA EOSDIS Land Processes DAAC. Available online https://doi. org/10.5067/MODIS/MOD11A1.006. Accessed 26 Jun 2019. Figure A-2. Monte-Carlo analysis of socioeconomic weights to predict closeness to ideal (not vulnerable) is used as the metric of human health vulnerability. 166 | APPENDIx A 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 167 APPENDIX B. COMMUNITY TOOLS AND Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and RESOURCES teachers to help plan for, address, and inform about climate change impacts.a Source Resource description National Center NCAT aims to help people to build resilient communities through local and Table B-1 provides a list of resources for communities, including public and environmental health for Appropriate sustainable solutions that reduce poverty, strengthen self-reliance, and protect Technology (NCAT) natural resources. See https://www.ncat.org/. agencies and organizations, to develop climate change assessments and action plans. The Geos Institute helps small to mid-sized communities plan for and build climate resilience. Climate Ready Communities is an affordable “assisted do-it-yourself” program, which includes: a) A free, downloadable, comprehensive Practical Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and Guide to Building Climate Resilience; b) Annual support for assistance utilizing teachers to help plan for, address, and inform about climate change impacts.a Geos Institute’s the Guide; c) Other services. See www.climatereadycommunities.org; https://Climate Ready climatereadycommunities.org/learn-more/about-guidebook/. Communities Geos’ Climate Wise Initiative: The Geos team supports community leaders in Source Resource description understanding likely future conditions, building resilience in ways that are effective and beneficial over the long term for people and nature, and developing locally NATIONAL: Comprehensive Planning for Climate Change Resilience and Adaptation appropriate solutions. See climatewise.org. Working Waters: A science-based initiative to ensure safe water for ecosystems, National Oceanic A comprehensive, nationwide, online climate toolkit to help communities a) explore Geos Institute’s including people. Helps water managers and other stakeholders to research, plan, and Atmospheric hazards; b) assess vulnerability and risks; c) investigate options to reduce risks and Working Waters incentivize, and implement actionable strategies to heal damaged habitat and Administration, protect assets; d) prioritize and plan; e) take actions to build resilience. At this site: protect healthy landscapes. See https://www.workingwatersgeos.org/. US find climate projections for every US county, funding opportunities to plan for climate impacts and training options. See https://toolkit.climate.gov/. UNDRR/WHO training webinar available: Resilience of local governments: A multi- United Nations sectoral approach to integrate public health and disaster risk management. The Moving Forward: A Guide to Building Momentum on Climate Solutions in Your Office for Disaster UNDRR’s Public Health Addendum to the Disaster Resilience Scorecard for Cities is Community. A guide for civic leaders in smaller and mid-size communities who Risk Reduction a useful tool for integrating relevant aspects of public health with disaster planning, want to lead on climate and sustainability but may lack full-time sustainability staff. (UNDRR) and mitigation and response. Examples include sanitation, disease prevention, nutrition, Provides resources and ideas to embed local climate solutions into planning and the World Health care for those who are already sick or disabled as a disaster happens, those who management activities, to achieve benefits with little or no additional costs. Create Organization are injured or become sick as a result of the disaster, mental health issues, health healthier communities, protect vulnerable residents, save money by reducing waste, (WHO) logistics, more. Training webinar and links to many resources for disaster resilience spur economic development, build property values, improve public safety and are available online. See https://www.unisdr.org/campaign/resilientcities/toolkit/ National League of restore natural assets. Engage residents using clear, positive, inclusive and relevant article/public-health-system-resilience-scorecard. Cities, Climate for messages. See https://www.nlc.org/topics/environment-sustainability/climate; https:// www.nlc.org/resource/moving-forward-a-guide-to-building-momentum-on-climate- NATIONAL: Planning for Climate Change and HealthHealth and many other partner solutions-in-your-community. The NIHHIS is an integrated system that builds understanding of the problem organizations Local Actions to Mitigate and Build Resilience to Climate Change: A list of some of the of extreme heat, defines demand for climate services that enhance societal many steps you can take locally to prepare your community, help mitigate impacts, National Integrated resilience, develops science-based products and services from a sustained climate- and build a cleaner future for your residents. See https://pathtopositive.org/wp- Heat Health science research program, and improves capacity, communication, and societal content/uploads/2019/09/P2P-checklist-Sep13-Final.pdf. Information System understanding of the problem in order to reduce morbidity and mortality due to extreme heat. The NIHHIS is a jointly developed system by the Centers for Additional resources from National League of Cities and ecoAmerica are available. Disease Control and Prevention (CDC) and the National Oceanic and Atmospheric See https://www.nlc.org/program-initiative/nlc-ecoamerica-elevating-local-climate- Administration. See https://nihhis.cpo.noaa.gov. action; https://www.neha.org/eh-topics/climate-change-0. Moving Forward: A Guide for Health Professionals to Building Momentum on Climate Widely used source of climate adaptation case studies, resources and opportunities, National League of Action. Guidance and tools to reduce energy use, build resilient clinics and health Climate Adaptation Knowledge to support managers, planners and practitioners in preparing for and responding to Cities, Climate for departments, and support policies, which better integrate health into climate climate change. Resources can be searched by adaptation phase, region and topic. Health, et al. solutions. See https://climateforhealth.org/wp-content/uploads/sites/2/2020/01/Exchange See www.cakex.org. CFHMFG-web.pdf. Association of State and Territorial Health Officials’ (ASTHO) Extreme Weather and The Impacts of Climate Change on Human Health in the United States: A Scientific Climate Readiness: Toolkit for State and Territorial Health Departments. Developed US Global Change Assessment. Climate change is a significant threat to the health of the American by the US Association of State and Territorial Health Officers for state-level health Research Program people. This scientific assessment examines how climate change is already affecting ASTHOs Climate departments in the US. It provides some practical steps, forms, and guidance for human health and the changes that may occur in the future. See https://health2016. Change climate readiness planning within your public health agency. The toolkit describes globalchange.gov/. Collaborative a comprehensive approach to integrating climate readiness into seven key public health programs. See https://www.astho.org/Programs/Environmental-Health/ Natural-Environment/Climate-Change/Extreme-Weather-and-Climate-Readiness- Toolkit-for-State-and-Territorial-Health-Departments/. 168 | APPENDIX B 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 169 Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and teachers to help plan for, address, and inform about climate change impacts.a teachers to help plan for, address, and inform about climate change impacts.a Source Resource description Source Resource description Climate Changes Health. A wealth of resources, including their Climate Change and ECONOMICS American Public Health Needs Assessment and their Climate Change and Health Strategic Plan. Health Association Understand and plan for the effects of climate change on health. See https://www. Moody’s Report: Environmental Risks—Evaluating the impact of climate change on apha.org/topics-and-issues/climate-change. Moody’s Investor US state and local issuers. “Climate change is forecast to heighten US exposure Services to economic loss… This will be a growing negative credit factor for issuers without PHI’s Center for Climate Change and Health’s report explores the many ways in sufficient adaptation and mitigation strategies.” See http://www.moodys.com/ Public Health which climate change, health, and equity are connected. Presents a conceptual researchdocumentcontentpage.aspx?docid=PBM_1071949. Institute (PHI) framework to show how these issues are linked, and to identify opportunities and recommendations for action. See https://www.phi.org/resources/?resource=climate- “Moody’s Buys Climate Data Firm, Signaling New Scrutiny of Climate Risks.” See change-health-and-equity-opportunities-for-action. New York Times https://www.nytimes.com/2019/07/24/climate/moodys-ratings-climate-change-data.html. Neighborhoods at See where flooding, urban heat, and hurricanes impact the most vulnerable people. Risk Tool Map and explore information at the neighborhood level for every community in the Muni Report, 10/22/19: Climate Change and Potential Impact on State and Local US. See https://headwaterseconomics.org/tools/neighborhoods-at-risk/tool-about/ Janney Investment Government Credit Analysis. See https://www.janney.com/docs/default-source/latest-Strategy Group articles-insights/isg/municipal-market-monthly/climate-change-and-munis-(oct-22). Climate and Health: Resources for Public Health Professionals. Resources include pdf. guidance, trainings, webinars, data, tools and videos for the range of essential public health services around climate and health. See https://www.cdc.gov/ “Climate Change Could Make Borrowing Costlier for States and Cities… now is the climateandhealth/default.htm; https://www.cdc.gov/climateandhealth/climate_ready. time for communities to make serious investments in climate resilience — or risk htm. Pew Trust being punished by the financial sector in the future.” See https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/10/01/climate-change-could-make- Assessing Health Vulnerability to Climate Change: A Guide for Health Departments. borrowing-costlier-for-states-and-cities. Provides a suggested sequence of steps that health departments can undertake to assess local health vulnerabilities associated with climate change. See https://stacks. 2019 Report: The Missing Economic Risks in Assessments of Climate Change Impacts. cdc.gov/view/cdc/24906. London School of Additional sponsors: Potsdam Institute for Climate Impact Research; Earth Institute Economics and at Columbia University. See http://www.lse.ac.uk/GranthamInstitute/wp-content/ Climate and Health Intervention Assessment. Outlines evidence of effectiveness of Political Science uploads/2019/09/The-missing-economic-risks-in-assessments-of-climate-change- various interventions for reducing the negative health impacts of climate change. impacts-2.pdf. Ninety pages of thoroughly cited, very helpful information. See https://www.cdc.gov/ Centers for Disease climateandhealth/docs/ClimateAndHealthInterventionAssessment_508.pdf. Environmental Risks in US State and Local Government Ratings (report available Control and Fitch Ratings to Fitch Ratings Research subscribers). See https://www.fitchratings.com/site/ Prevention (CDC) Information on the health effects of climate change, excerpted from the Third re/10031874. National Climate Assessment. Some existing health threats will intensify and new health threats will emerge. See https://www.cdc.gov/climateandhealth/effects/ MONTANA default.htm. MT Climate Solutions This Governor’s Council developed a Montana Climate Solutions Plan (June 2020), The Building Resilience Against Climate Effects (BRACE) framework is a five- Council which provides recommendations and strategies aimed at preparing Montanans for step process that allows health officials to develop strategies and programs to climate impacts. See https://deq.mt.gov/DEQAdmin/dir/Climate. help communities prepare for the health effects of climate change. Combining MT Dept. of Environ. Daily air quality updates for Montana. See svc.mt.gov/deq/todaysair/smokereport/ atmospheric data and climate projections with epidemiologic analysis allows health Quality mostrecentupdate.aspx. officials to more effectively anticipate, prepare for, and respond to a range of climate sensitive health impacts. See https://www.cdc.gov/climateandhealth/BRACE.htm. A non-partisan, non-profit network sharing information and resources to better coordinate community-based climate solutions and resiliency efforts in Montana. CDC’s Climate-Ready States and Cities Initiative (CRSCI) funds states and cities to Climate Smart Access existing and proposed community resiliency plans in Montana. Join their use the five-step Building Resilience Against Climate Effects (BRACE) framework Montana listserve. See http://www.msucommunitydevelopment.org/ClimateSmartMontana. (described above). See https://www.cdc.gov/climateandhealth/climate_ready.htm. html. Protecting the Health and Well-Being of Communities in a Changing Climate: A listserve for Montana citizens and educators who want to share information on National Academies Proceedings of a Workshop. Presentations and discussions about regional, state, and Montana State climate science and policy. Press local efforts to mitigate and adapt to health challenges arising from climate change. University See https://www.nap.edu/download/24797. Extension See https://www.montana.edu/communitydevelopment/csm/index.html. Water infrastructure: Technical Assistance and Climate Resilience Planning Could Bozeman’s Climate Planning Framework provides summaries of 17 separate Bozeman US Government Help Utilities Prepare for Potential Climate Change Impacts. This report examines City of Bozeman plans related to climate and climate change impacts. See https://www.bozeman.net/ Accountability federal technical and financial assistance to utilities for enhancing climate resilience, home/showdocument?id=9681. Office and options experts identified for providing additional assistance, among other things. See https://www.gao.gov/products/gao-20-24. 170 | APPENDIx B 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 171 Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and Table B-1. Resources for state and local governments, communities, tribes, faith organizations, and teachers to help plan for, address, and inform about climate change impacts.a teachers to help plan for, address, and inform about climate change impacts.a Source Resource description Source Resource description TRIBAL FAITH COMMUNITIES Northern Arizona University’s ITEP’s Tribal Climate Change Program offers training, Healthy Landscapes, Healthy People: A Guidebook for Montana Communities The Institute for Tribal technical assistance, educational resources, and tools to build the capacity of Preparing for a Changing Climate. A guide for people who are concerned about Environmental tribes to address climate change impacts. Resources include the ITEP Adaptation The Center for human health and climate change, with a specific focus on faith communities. Professionals Planning Toolkit. See http://toolkit.climate.gov/tool/tribal-climate-change- Large Landscape Addresses impacts of climate change to landscapes and human health; how to adaptation-planning-toolkit. Conservation protect landscapes to protect human health; things our communities can do; tools BIA Tribal Resilience Program. Provides resources to tribes to build capacity and for planning and acting now to protect our future. See https://largelandscapes.org/ resilience through leadership engagement, delivery of data and tools, training wp-content/uploads/2019/03/Climate_Landscapes__Health_Guidebook_10.9.18.pdf. and tribal capacity building. Competitive funding supports tribes and authorized tribal organizations to build resilience through tribally designed resilience training, Faith and Climate Educates individuals in faith communities about climate change and creates Action Montana space for spiritual reflection on social and environmental issues. See adaptation planning, vulnerability assessments, supplemental monitoring, capacity faithandclimateactionmontana.weebly.com. building, and youth engagement. See https://www.bia.gov/bia/ots/tribal-resilience- Bureau of Indian program. The FSCA Conferences provide a supportive community learning environment Affairs: Tribal Faith, Science and for participants to discuss climate change and our moral obligations to families, Resilience Program US Climate Resilience Toolkit: Tribal Nations. Tribal Nations often integrate traditional Climate Action MT neighbors, future generations, and vulnerable populations, and, fundamentally, to knowledges with technology and diverse research methods to effectively address our planet. See fscaconference.org. climate change and related impacts in a culturally appropriate community context. See https://toolkit.climate.gov/topics/tribal-nations. Seeks to deepen the connection between ecology and faith. IPL has mobilized MT Interfaith Power religious communities to be faithful stewards of creation through the promotion Tribal Resilience Resource Guide: Training. A wealth of training resources listed by the six strategies/subtopics described in the US Resilience Toolkit, Tribal Nations Topic. and Light of energy conservation, energy efficiency, and renewable energy. See http:// blessedtrinitymissoula.org/outreach/social-concerns-parish-team/interfaith-power- See https://biamaps.doi.gov/tribalresilience/resourceguide/training/index.html and-light/. The Climate Ready Tribes Initiative: 1) Funds tribes to conduct local climate health Blessed Tomorrow: Caring for Creation Today. Blessed Tomorrow is a coalition of work or research; 2) Hosts an Environmental Health and Climate Track at the Annual National Indian National Tribal Public Health Summit; 3) Shares materials including resources, ecoAmerica diverse religious partners working to advance climate solutions in faithful service to God. Living our faith means leading on climate change as stewards of God’s creation. Health Board information and opportunities, largely through the Climate and Health Learning See https://blessedtomorrow.org/. Community. See https://www.nihb.org/public_health/climate_ready_tribes.php; https://www.nihb.org/public_health/climate_resources.php. LOCAL FOOD SYSTEMS AND AGRICULTURE The Blackfeet Nation is building resilience to climate change. They are planning Northern Plains Northern Plains is a grassroots conservation and family agriculture group that ahead, engaging young people, and sharing information about climate change and: Resource Council organizes Montanans to protect our water quality, family farms and ranches, and air quality, extreme weather events, cancer, food safety and nutrition, heat-related unique quality of life. See https://northernplains.org/about-us/. Blackfeet Nation illnesses, pregnant women, mental health and well-being, vector-borne diseases and water-related illnesses. Check out their Blackfeet Climate Change Adaptation Montana Farmers Union is a statewide grassroots organization working for family Plan. See https://blackfeetclimatechange.com; https://bcapwebsite.files.wordpress. Montana Farmers farmers, ranchers and rural communities through conferences, scholarships and com/2018/04/bcap_final_4-11.pdf. Union other educational opportunities as well as legislative representation and support for producer-owned co-ops. See https://montanafarmersunion.com/. TEACHERS Montana Organic The MOA brings together people, businesses, organizations, and agencies working Toolbox for Teaching Climate and Energy. Downloadable scientifically and Association to develop Montana’s organic sector and building its community. See https:// pedagogically reviewed digital resources for teaching about climate’s influence montanaorganicassociation.org/. on us and our influence on climate. Prepare to teach the science and engineering called for in the new standards, which address major world challenges and WSE conserves the abundance of the Northern Rockies including its open spaces; National Oceanic opportunities, such as generating sufficient clean energy, building climate resilience Western wildlife habitats; soil, air, and water resources; rural communities; and agricultural and Atmospheric for businesses and communities, maintaining supplies of food and clean water, and Sustainability land and heritage. WSE consists of local, regional, national, and international Administration, US solving the problems of global environmental change. See https://www.climate.gov/ Exchange (WSE) partners working cooperatively to resolve problems facing the rural West. See teaching. https://www.westernsustainabilityexchange.org/about-wse. There are many communities and county based groups as well – look into what is happening in your area. a Websites shown were active as of December 2020. For the latest resources and web links, go online to the Climate Change and Human Health link at the Montana Climate Assessment website (montanaclimate.org). 172 | APPENDIx B 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 173 GLOSSARY adaptation — Actions taken to help communities and ecosystems better cope with potential negative effects of climate change or take advantage of potential opportunities. adaptive capacity — Ability of a person (or society) to cope with climate change. Used to calculate vulnerability. adverse childhood experiences — Potentially traumatic events that occur in childhood. Sometimes referred to as ACEs. These events can include violence, abuse, neglect, separation, substance abuse, mental health problems, or witnessing a family suicide. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. ACEs can also negatively impact education and job opportunities. ACEs can be prevented. anthropogenic — Originating in human activity; human caused. aquifer — A body of permeable rock that can contain or transmit groundwater. atmospheric carbon dioxide (CO2) — The amount of carbon dioxide in Earth’s atmosphere. Although the proportion of Earth’s atmosphere made up by CO2 is small, CO2 is one of the most potent greenhouse gases and directly related to the burning of fossil fuels. Atmospheric carbon dioxide levels in Earth’s atmosphere are at the highest levels in an estimated 3 million yr and these levels are projected to increase global average temperatures through the greenhouse effect. attribution — Identifies a source or cause of something. basin — A drainage basin or catchment basin is an extent or an area of land where all surface water from rain, melting snow, or ice converges to a single point at a lower elevation, usually the exit of the basin, where the waters join another body of water, such as a river, lake, reservoir, estuary, wetland, sea, or ocean. biodiversity — The variety of all native living organisms and their various forms and interrelationships. chronic disease — A disease or health condition lasting for a long time, usually more than Montana State University, Bozeman 3 months. Examples include high blood pressure, chronic obstructive lung/pulmonary disease Photo courtesy of Scott Bischke (COLD/COPD), cancer and diabetes. 174 | GLOSSARY 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 175 climate change — Changes in average weather conditions that persist over multiple ensemble of general circulation models (GCMs) — Succinctly: When many decades or longer. Climate change encompasses both increases and decreases in temperature, as different forecast models are used to generate a projection, and outputs are synthesized into well as shifts in precipitation, changing risk of certain types of severe weather events, and changes a single score or average. This type of forecast significantly reduces errors in model output and to other features of the climate system. enables a level of certainty to be placed on the projections. More broadly: Rather than relying on the outcome of a single climate model, scientists run ensembles of many models. Each climate pressures — Events or processes either caused by or made more frequent due to model in the ensemble plausibly represents the real world, but as the models differ somewhat climate change, including increased temperatures, sea-level rise, extreme precipitation events, they produce different outcomes. Scientists analyze the outputs (e.g., projected average daily and more extreme weather, such as storms. temperature at mid century) over the entire ensemble. Those analyses provide both the projection of the future resulting from the ensemble of models, and define the level of certainty that should climate variables — Essential information for understanding the Earth’s climate, including be placed on that projection. average annual and season temperature and precipitation. evaporation — The change of a liquid into a vapor at a temperature below the boiling point. climate versus weather — The difference between weather and climate is a measure of Evaporation takes place at the surface of a liquid, where molecules with the highest kinetic energy time. Weather is what conditions of the atmosphere are over a short period of time, and climate is are able to escape. When this happens, the average kinetic energy of the liquid is lowered and its how the atmosphere “behaves” over relatively long periods of time (i.e., multiple decades). temperature decreases. commodity futures — Buying or selling of a set amount of a commodity at a exposure — The type and magnitude of a climate change. Used to calculate vulnerability. predetermined price and date. fire regime — The frequency, severity, and pattern of wildfire. COVID-19 — Respiratory illness and associated complications caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) that was first detected in humans in late 2019. fire risk — The likelihood of a fire ignition. direct effect — A primary impact to a system from shifts in climate conditions (e.g., fire severity — The magnitude of effects from a fire, usually measured by the level of temperature and precipitation), such as direct mortality to species from increased heat extremes. vegetation or biomass mortality or the area burned. displacement — Forced migration due to conditions that prevent individuals, families, or flood — An overflowing of a large amount of water beyond its normal confines, especially over communities from sustaining themselves in traditional locations. Those conditions might result what is normally dry land. from climate change—e.g., sea-level rise, floods, or drought—or social upheaval such as violence, persecution, or economic distress. flood plain — An area of low-lying ground adjacent to a river, formed mainly of river sediments and subject to flooding. downscaling — A general term for procedures that take information known at large scales to make predictions at local scales. food security / insecurity — Describes an individual’s or community’s ability to reliably access a sufficient quantity of affordable, nutritious food. The USDA defines food security into four drought — Drought is generally categorized in three ways: 1) meteorological drought, defined categories: 1) high food security means having no food-access problems or limitations; 2) marginal as a deficit in precipitation, 2) agricultural drought, commonly understood as a deficit in soil food security means having some anxiety over food sufficiency, but little change in diets or food moisture, and 3) hydrological drought, characterized by reduced water levels in streams, lakes, and intake; 3) low food security (i.e., food insecurity) means reduced quality, variety, or desirability aquifers. of diet, though little or no reduction in food intake; and 4) very low food security (again, food insecurity) means disrupted eating patterns and reduced food intake. El Niño-Southern Oscillation (ENSO) — A periodic variation in wind and sea-surface temperature patterns that affects global weather; El Niño (warming phase where sea-surface frost days — The annual count of days where daily minimum temperature drops below 32°F temperatures in the eastern Pacific Ocean warm) generally means warmer (and sometimes (0°C). slightly drier) winter conditions in Montana. In contrast, La Niña (cooling phase) generally means cooler (and sometimes wetter) winters for Montanans. The two phases each last approximately general circulation models (GCMs) — Numerical models representing physical 6-18 months, and oscillate between the two phases approximately every 3-4 yr. processes in the atmosphere, ocean, cryosphere, and land surface. They are the most advanced tools currently available for simulating the response of the global climate system to increasing greenhouse gas concentrations. 176 | GLOSSARY 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 177 greenhouse gas — A gas in Earth’s atmosphere that absorbs and then re-radiates heat interpolation — The process of using points with known values to estimate values at other from the Earth and thereby raises global average temperatures. The primary greenhouse gases unknown points. in Earth’s atmosphere are water vapor, carbon dioxide, methane, nitrous oxide, and ozone. Earth relies on the warming effect of greenhouse gases to sustain life, but increases in greenhouse intervention — The act of interfering or interceding with the intent of modifying the gases, particularly carbon dioxide from the burning of fossil fuels, can increase average global outcome. In medicine, an intervention is generally undertaken to help treat or cure a condition. temperatures over historical norms. irrigation — Application of water to soil for the purpose of plant production. greenhouse gas emissions — The discharge of greenhouse gases, such as carbon dioxide, methane, nitrous oxide and various halogenated hydrocarbons, into the atmosphere. legume — Any of a large family (Leguminsoae syn. Fabaceae, the legume family) of Combustion of fossil fuels, agricultural activities, and industrial practices contribute to the dicotyledonous herbs, shrubs, and trees having fruits that are legumes or loments, bearing emissions of greenhouse gases. nodules on the roots that contain nitrogen-fixing bacteria, and including important food and forage plants (as peas, beans, or clovers). global warming — The increase in Earth’s surface air temperatures, on average, across the globe and over decades. Because climate systems are complex, increases in global average mental health — The condition of being sound mentally and emotionally that is temperatures do not mean increased temperatures everywhere on Earth, nor that temperatures characterized by the absence of mental illness and by adequate adjustment, especially as reflected in a given year will be warmer than the year before (which represents weather, not climate). More in feeling comfortable about oneself, positive feelings about others, and the ability to meet the simply: Gobal warming is used to describe a gradual increase in the average temperature of the demands of daily life. Earth’s atmosphere and its oceans, a change that is believed to be permanently changing the Earth’s climate. metrics — Quantifiable measures of observed or projected climate conditions, including both primary metrics (for example, temperature and precipitation) and derived metrics (e.g., projected groundwater — Water held underground in the soil or in pores and crevices in rock. days over 90°F [32°C ] or number of consecutive dry days). health factors — Factors that drive how long and how well people live including, for metropolitan areas — Areas having at least one urbanized area of 50,000 or more example, personal behaviors, socioeconomic factors, and the physical environment. population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties. heat index — A measure of perceived heat when humidity, which can make it feel much hotter, is factored in with the actual measured air temperature. (A similar and more familiar term microclimate — The local climate of a given site or habitat varying in size from a tiny crevice is wind chill factor, a measure of how cold it feels when wind, which can make it feel much colder, to a large land area. Microclimate is usually, however, characterized by considerable uniformity of is factored in with the actual measured air temperature.) climate over the site involved and relatively local when compared to its enveloping macroclimate. The differences generally stem from local climate factors such as elevation and exposure. heat stress — A buildup of body heat generated either internally by muscle use or externally by the environment. Heat exhaustion and heat stroke result when the body is overwhelmed by micropolitan areas — Areas having at least one urban cluster of at least 10,000 but less heat . As the heat increases, body temperature and the heart rate rise. than 50,000 population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties. HEPA — high-efficiency particulate air (filters) mitigation — Efforts to reduce greenhouse gas emissions to, or increase carbon storage hydrograph — A hydrograph is a graph showing the rate of flow (discharge) versus time past from, the atmosphere as a means to reduce the magnitude and speed of onset of climate change a specific point in a river, or other channel or conduit carrying flow. The rate of flow is typically expressed as cubic feet per second, CFS, or ft3/s (the metric unit is m3/s). model — A physical or mathematical representation of a process that can be used to predict some aspect of the process. hydrologic cycle — The sequence of conditions through which water passes from vapor in the atmosphere through precipitation upon land or water surfaces and ultimately back into the organic — A crop that is produced without: antibiotics; growth hormones; most conventional atmosphere as a result of evaporation and transpiration. pesticides; petroleum-based fertilizers or sewage sludge-based fertilizers; bioengineering; or ionizing radiation. USDA certification is required before a product can be labeled organic. hydrology — The study of water. Hydrology generally focuses on the distribution of water and interaction with the land surface and underlying soils and rocks. 178 | GLOSSARY 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 179 oscillation — A recurring cyclical pattern in global or regional climate that often occurs on runoff — Surface runoff (also known as overland flow) is the flow of water that occurs when decadal to sub-decadal timescales. Climate oscillations that have a particularly strong influence on excess stormwater, meltwater, or other sources flows over the Earth’s surface. Montana’s climate are the El Niño-Southern Oscillation (ENSO) and the Pacific Decadal Oscillation (PDO). scenario — Climate change scenarios are based on projections of future greenhouse gas (particularly carbon dioxide) emissions and resulting atmospheric concentrations given various Pacific Decadal Oscillation (PDO) — A periodic variation in sea-surface temperatures plausible but imagined combinations of how governments, societies, economies, and technologies that is similar to El Niño-Southern Oscillation, but has a much longer duration (approximately will change in the future. This analysis considers two plausible greenhouse gas concentration 20-30 yr). When the PDO is in the same phase as El Niño-Southern Oscillation, weather effects scenarios: a moderate (stabilized) and more severe (upper-bound) scenario, referred to as RCP4.5 are more pronounced. For example, when both are in the warming phase, Montanans may and RCP8.5, respectively. experience an extremely warm winter, whereas if PDO is in a cooling phase, a warm phase El Niño-Southern Oscillation may have a reduced impact. sensitivity — How sensitive a person is to climate change. Used to calculate vulnerability. pandemic — An epidemic of a disease that has spread across a wide geographic region, either Snow Water Equivalent (SWE) — A common snowpack measurement that is the multiple continents or worldwide. (Contrast with an epidemic, which is a disease that is actively amount of water contained within the snowpack. It can be thought of as the depth of water that spreading. Thus, a pandemic is a specific type of epidemic that has spread more widely.) would theoretically result if you melted the entire snowpack instantaneously. parameter — A variable, in a general model, whose value is adjusted to make the model soil moisture — A measure of the quantity of water contained in soil. Soil moisture is a specific to a given situation. key variable in controlling the exchange of water and energy between the land surface and the atmosphere through evaporation and plant transpiration. pathogen — Microorganisms, viruses, and parasites that can cause disease. Sudden Infant Death / Sudden Unexpected Infant Death syndromes peak flow — The point of the hydrograph that has the highest flow. (SIDS / SUIDS) — unexplained death, usually during sleep, of a seemingly healthy baby less than a year old. permeability — A measure of the ability of a porous material (often, a rock or an unconsolidated material) to allow fluids to pass through it. transpiration — The passage of water through a plant from the roots through the vascular system to the atmosphere. pulse crop — Annual leguminous crops yielding from 1-12 grains or seeds of variable size, shape, and color within a pod. Limited to crops harvested solely for dry grain, thereby excluding vulnerability — The extent to which a person is susceptible to the impacts of climate change. crops harvested green for food, oil extraction, and those that are used exclusively for sowing purposes. warm days — Percentage of time when daily maximum temperature >90th percentile. RCP (representative concentration pathways) — Imagined plausible trends warm nights — Percentage of time when daily minimum temperature >90th percentile. in greenhouse gas emissions and resulting concentrations in the atmosphere used in climate projection models. This analysis uses the relatively moderate and more severe scenarios of water quality — The chemical, physical, biological, and radiological characteristics of water. RCP4.5 and 8.5. These scenarios represent a future with an increase in radiative forcing of 4.5 or It is a measure of the condition of water relative to the requirements of one or more biotic species 8.5 watts/m2, respectively. The RCP4.5 scenario assumes greenhouse gas emissions peak mid and/or to any human need or purpose. century, and then decline, while the RCP8.5 scenario assumes continued high greenhouse gas emissions through the end of the century. watershed — An area characterized by all direct runoff being conveyed to the same outlet. Similar terms include basin, sub-watershed, drainage basin, catchment, and catch basin. resilience — In ecology, the capacity of an ecosystem to respond to a disturbance or perturbation by resisting damage and recovering quickly. weather versus climate — See climate versus weather. resistance — In ecology, the property of populations or communities to remain essentially zoonosis (plural, zoonoses) — An infectious disease caused by a bacterium, virus, unchanged when subject to disturbance. Sensitivity is the inverse of resistance. fungus, or other agent that has moved from non-human animals to humans. Recent examples include Ebola, HIv, and SARS-Cov2. 180 | GLOSSARY 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 181 Pelicans on the Jefferson River Photo courtesy of Scott Bischke LIST OF CONTRIBUTORS Alexandra Adams MD, PhD is the Professor and Director of the Center for American Indian and Rural Health Equity (CAIRHE), a phase II COBRE at Montana State University, and she was the founding director of the Collaborative Center for Health Equity, an NIH P60 center at the University of Wisconsin (UW) School of Medicine and Public Health. She has an international reputation as a highly respected health equity researcher based on her work in community-based participatory research, working in partnership with communities to understand and solve health challenges using both scientific rigor and crucial community knowledge. At UW, she also practiced in family medicine and pediatric obesity clinics for 17 years. She has directed multiple NIH-funded clinical trials, including the Healthy Children Strong Families 2 trial in five Native communities nationally, and has over 60 peer-reviewed publications. Her work also includes leading a large collective impact project on statewide obesity prevention and health promotion with over 3000 community, public health, and academic partners in Wisconsin. Scott Bischke of MountainWorks Inc. served as Science Writer for this report, as well as for the 2017 Montana Climate Assessment. Scott is a BS (Montana State University), MS (University of Colorado) chemical engineer who has worked as an engineering researcher at three national laboratories: the National Bureau of Standards (now National Institute of Science and Technology), Sandia, and Los Alamos. He worked for roughly 11 years as lead environmental engineer for a Hewlett-Packard business unit. Scott has authored, co-authored, or edited two environmental impact statements, book chapters, technical papers, five popular press books, and successful proposals totaling tens of millions of dollars. 182 | LIST OF CONTRIBUTORS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 183 Madison Boone is the Program and Communications Manager for the Montana Institute on Angelina Gonzalez-Aller PhD is a researcher, educator, and organizer working at the Ecosystems (IoE) at Montana State University, a position she has held since 2017. Prior to joining intersections of health, climate change, and social justice. Angelina holds a PhD in political science, the IoE, she served for two years with the non-profit One Montana and MSU-Extension Service specializing in racial and ethnic studies, health disparities, and US policymaking. Angelina currently in Gallatin County through the Big Sky Watershed Corps program, during which she worked on works at the Center for Large Landscape Conservation as the Community Resilience Program projects related to climate, agriculture, and water. Boone graduated magna cum laude in 2014 Manager where she strives to support communities in their efforts to achieve conservation goals from Hendrix College with a BA in Biology and a BA in Environmental Studies. and prepare for a changing world. Lori G. Byron MD, MS, of Hardin Montana, received a BS and BA from Kentucky Wesleyan Philip Higuera PhD is an Associate Professor of fire ecology in the Department of Ecosystem College, her MD from University of Louisville, and completed a pediatric residency. She practiced and Conservation Sciences at the University of Montana. He directs the PaleoEcology and Fire pediatrics for 27 years on the Crow Indian Reservation. She is a past-president of the Montana Ecology Lab, funded largely from the National Science Foundation and Joint Fire Science Program, Academy of Pediatrics. She co-chairs the Citizen’s Climate Lobby Health Team and chairs Montana and he teaches undergraduate and graduate courses in fire and disturbance ecology. Work from Health Professionals for a Healthy Climate. Lori is on the Children’s Health Advisory Committee his lab spans western North America and reveals how fire activity and forest ecosystems vary with to USEPA and the Executive Committee of the Environmental Health Council at the American climate change, in recent decades and the distant past. Academy of Pediatrics. She recently earned a MS in Energy Policy and Climate from Johns Hopkins. Susan Higgins MS is an Associate with the Center for American Indian and Rural Health Equity Robert Byron MD, MPH, is an internist from Hardin, Montana. After receiving his and Montana INBRE at MSU. Prior, Sue was water planner for the State of Montana, and facilitated undergraduate degree from vanderbilt University, he served in the US Navy. Obtaining his research exchanges for The Tributary Fund in Mongolia and Montana. She was also director for medical degree from the University of Louisville School of Medicine, he then completed an water research communications at MUS Water Center and a founding director for the Montana internal medicine residency, later earning a master’s in public health through the University of Watercourse. A trained facilitator, Sue has authored guides on topics such as streambank Washington. Dr. Byron worked on the Crow Indian Reservation for over 20 years, then later helped stabilization and wetlands management. She was consultant for the Roundtable on the Crown of start Bighorn valley Health Center in Hardin. A former governor of the Montana Chapter of the the Continent and the National Drought Resiliency Project and has co-developed best practices for American College of Physicians, he also served on the Montana Board of Environmental Review. scientists engaging globally with faith and indigenous communities. He is vice-chair of the Montana Health Professionals for a Healthy Climate and co-chairs the Citizen’s Climate Lobby Health Team. Paul Lachapelle PhD is Professor in the Department of Political Science at Montana State University-Bozeman. His teaching and research spans many disciplines and practices, including Amy Cilimburg is the Executive Director of Climate Smart Missoula where she develops local community climate-change resiliency, diversity and inclusion, and social justice topics. His climate solutions and works to build networks and community resiliency. Amy helped launch publications include the edited book, Addressing Climate Change at the Community Level (Routledge Climate Smart in 2015 following efforts to develop Missoula’s municipal and community Climate 2019), as well as journal articles on energy impacts in communities, democratic practice, and Action Plans. Based in Missoula, she has worked on climate and energy policy and conservation local governance. He earned a PhD (Forestry) at the University of Montana’s College of Forestry for over a decade. Amy has a MS degree in Wildlife Biology from the University of Montana. She is and Conservation and serves as a member of the Board of Directors (and past-President) of the on the Board of the Missoula’s Mountain Line Transit System and is a member of the Governor’s International Association for Community Development. Climate Solutions Council. Miranda Margetts PhD is an instructor (Department of Land Resources and Environmental Margaret (Mari) Eggers PhD is a research assistant professor in environmental health Science) and research assistant (Center for American Indian and Rural Health Equity) at Montana at Montana State University Bozeman (MSU). She previously lived in Crow and taught science at State University. She received her legal qualifications and worked as a health lawyer in Australia Little Big Horn College for a decade. Since 2005 Eggers has been working with Crow colleagues before moving into health research in the US. Miranda also holds a research affiliate position with and others on community-engaged research and mitigation to reduce exposure to waterborne the Department of Obstetrics, Gynecology and Reproductive Sciences at Yale University, for her contaminants, improve access to safe drinking water and understand the impacts of climate role on an international women’s reproductive health study. She also serves as a member of the change on water resources and community health. Eggers teaches environmental and global Board of Trustees for the Community Memorial Health System in ventura County, California. health, is the Associate Director for MSU’s accredited Environmental Heath degree program and serves on the local Board of Health. Eggers has a BA and MA (Stanford), an MS in Ecology and a PhD in environmental health (MSU). 184 | LIST OF CONTRIBUTORS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 185 Bruce Maxwell PhD is Professor of Agroecology and Applied Plant Ecology in the Department Jennifer Robohm PhD is a clinical psychologist on the faculty of the University of Montana of Land Resources and Environmental Science (LRES) at Montana State University. Maxwell was Family Medicine Residency of Western Montana. She is part of the 2020 class for the Bloomberg instrumental in the formation of the Department of LRES and has received national awards for Fellowship Program at the Bloomberg Johns Hopkins School of Public Health, where she will be outstanding teaching, best peer reviewed papers and outstanding graduate student from the working on the physical and mental health impacts of climate change in Montana. Dr. Robohm Weed Science Society of America. He has published over 100 scientific journal articles and book and Hayley Blackburn, PharmD, recently received a planning grant from the Montana Healthcare chapters, chaired and been a member of numerous agricultural and ecological research grant Foundation to develop “climate change and health” curriculum and continuing education review panels and been a member of two National Academy of Sciences National Research programming for health care trainees and practicing health professionals in our state. Council Committees on Agriculture. He was a Fulbright Fellow in Argentina in 2007. His research has historically straddled the disciplines of invasion biology and agroecology. Nick Silverman PhD, PE is a Faculty Affiliate and Adjunct Professor at the University of Montana in Geosciences and the College of Forestry. His academic research focuses on identifying David McWethy PhD is an Assistant Professor in the Department of Earth Sciences at hydroclimatic trends in mountainous landscapes and the interactions between water, climate, Montana State University. His research focuses on understanding how changes in climate and vegetation. Nick has a background in Physics and Engineering and is a licensed Civil and and human and natural disturbances shape the structure and function of ecosystems in the Water Resources Engineer in the State of Montana. He received a PhD in Hydroclimatology from western US, Australia, the Pacific Basin, and South America. His research utilizes fossil pollen, the University of Montana in 2014 and led the climate analysis for the 2017 Montana State Climate charcoal, plant remains, and the geochemical fingerprint found in lake-sediment and ice cores to Assessment. Currently, Nick works around Montana and the greater Pacific Northwest on projects reconstruct past changes in climate, vegetation, fire, and human activity. that help land managers build adaptive capacity to solve food, water, and energy challenges related to climate change. Sally Moyce RN, PhD is an assistant professor in the College of Nursing at Montana State University. Her research interests focus on occupational exposures to extreme heat for outdoor Eliza Webber MPH is a Research Project Manager at the Center for American Indian and Rural workers. She studies the intersection of occupational policy and human health, with an emphasis Health Equity at Montana State University. She graduated with an MPH from Yale School of Public on immigrant workers. Sally teaches nursing research and population-focused nursing courses. Health in 2015, specializing in chronic disease epidemiology and social and behavioral science. Since then, she has worked in program evaluation, assessing community-wide diabetes prevention Richard Ready PhD is a professor of environmental and resource economics at Montana interventions, and in clinical health outcomes research, using state and nation-wide datasets to State University. Dr. Ready has a bachelor’s degree in Natural Resources from Cornell University explore indicators and trends in pediatric cardiac disease. Eliza’s work is driven by her passion for and master’s degree and PhD in Agricultural and Resource Economics from the University of eliminating health disparities. Wisconsin. Previously, he was on the faculty at University of Kentucky, The Norwegian University of Life Sciences, and Pennsylvania State University. His research addresses topics including Cathy Whitlock PhD is a Regents Professor in Earth Sciences and Fellow of the Montana environmental health, climate change, invasive species, landscape change, and outdoor Institute on Ecosystems at Montana State University. She is recognized nationally and recreation. He has served on several editorial boards of professional journals and on the EPA internationally for her scholarly contributions and leadership activities in the area of long-term Science Advisory Board’s Environmental Economics Advisory Committee. environmental and climate change, with much of her research focused on Montana. Whitlock has published over 200 scientific papers on this topic. She is a member of the National Academy of Lisa Richidt MPH is a Senior Epidemiologist for the Montana Department of Public Health Sciences, a Fellow of the American Association for the Advancement of Science, and a Fellow of the and Human Services. She works in the Chronic Disease Bureau where she analyzes data from Geological Society of America. Whitlock is lead author of the 2017 Montana Climate Assessment. multiple surveillance systems, develops program goals and objectives, and conducts program evaluation. Before moving to Montana in 2011, Lisa spent two years working for the Centers for Disease Control and Prevention and attending Emory University in Atlanta, Georgia. Prior to that, she served as a Peace Corps volunteer in Mozambique where she taught high school biology and coordinated a variety of health/HIV-related projects. 186 | LIST OF CONTRIBUTORS 2021 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA | 187 What Professional Organizations are Saying Get involved and be part of the solution! A number of professional organizations, health-focused and otherwise, have developed policies or position statements regarding the impacts of climate change on human health. Following are a collection of quotes from a number of these trusted resources. Use the information in this report to help о Montana Farmer’s Union.—“As the impacts of climate change mount, producers will need to be armed with the latest research, information and tools to mitigate the adverse effects, adapt to the changing yourself, your community, and Montana conditions and continue providing a safe, reliable and healthy food source for the world.” 1 address climate change. о Montana Climate Change Advisory Committee.—“Explicitly articulated public education and outreach can support GHG emissions reduction efforts at all levels in the context of emissions reduction programs, policies, or goals. Public education and outreach is vital to fostering a broad awareness of Everyone has a role to play! climate change issues and effects (including co-benefits, such as clean air and public health) among the state’s citizens.” 2 о US Department of Health and Human Services.—“The US Department of Health and Human Services considers climate change to be one of the top public health challenges of our time.” 3 о National Institute of Environmental Health Sciences.—“While climate change is a global process, it has very local impacts that can profoundly affect communities. It can affect people’s health and well- being in many ways, some of which are already occurring.” 4 о National Indian Health Board.—“Tribal communities can be particularly vulnerable to the health effects associated with climate change for a variety of reasons. There are already existing and pronounced health disparities in Native communities that can lead to the health impacts from environmental damage being much more severe.” 5 о Medical Society Consortium on Climate and Health’s Climate, Health, and Equity Policy Action Agenda.— “Climate change is a public health emergency. We call on our nation’s leaders to act now by mobilizing climate actions for our health, and health actions for our climate. With the right policies and investments today, we have the opportunity to realize our vision of healthy people in healthy places on a healthy planet.” 6 (Note: This statement was signed by over 100 health organizations.) о National Academy of Medicine.—“The negative impacts of climate change disproportionately affect the very young and the very old, people who are ill, impoverished or homeless individuals, and populations that depend on the natural environment for survival. Urgent action is needed to mitigate the health consequences of climate change for these populations, among others. … Climate change represents one of the most significant threats to human health in the 21st century.” 7 о Lancet Commission Report on Health and Climate Change: Policy Responses to Protect Public Health, 2015.—“Climate change...threatens to undermine the last half century of gains in development and global health. … Tackling climate change could be the greatest global health opportunity of the 21st century.” 8 Two views from Wild Horse Island in Flathead Lake: * Smoke-covered Melita Island, August 2020 1 https://montanafarmersunion.com/wp-content/uploads/2016/01/MFU_Climate_Final.pdf * Normal view of Mission Mountains, inset Photos courtesy of Bruce Maxwell 2 https://deq.mt.gov/Portals/112/Energy/ClimateChange/Documents/FinalReportChapters.pdf 3 https://www.hhs.gov/climate/index.html 4 https://www.niehs.nih.gov/health/topics/agents/climate-change/index.cfm 5 https://www.nihb.org/docs/10102019/Climate%20Change%20&%20Tribes%20Article.pdf Back cover: Tipi, mountain fires, and the Milky Way 6 https://climatehealthaction.org/cta/climate-health-equity-policy/ Photo courtesy of Chema Domenech (copyright 2018) 7 https://nam.edu/programs/climate-change-and-human-health/ 8 https://www.ncbi.nlm.nih.gov/pubmed/26111439 CLIMATE CHANGE AND HUMAN HEALTH IN MONTANA A Special Report of the Montana Climate Assessment www.montanaclimate.org Printed in Montana on recycled paper