Today few scientists doubt the atmosphere is warming. Most also agree that the rate of heating is accelerating and that the consequences of this temperature change could become increasingly disruptive. Even high school students can reel off some projected outcomes: the oceans will warm, and glaciers will melt, causing sea levels to rise and salt water to inundate settlements along many low-lying coasts. Meanwhile the regions suitable for farming will shift. Weather patterns should also become more erratic and storms more severe.

Yet less familiar effects could be equally detrimental. Notably, computer models predict that global warming, and other climate alterations it induces, will expand the incidence and distribution of many serious medical disorders. Disturbingly, these forecasts seem to be coming true.

Heating of the atmosphere can influence health through several routes. Most directly, it can generate more, stronger and hotter heat waves, which will become especially treacherous if the evenings fail to bring cooling relief. Unfortunately, a lack of nighttime cooling seems to be in the cards; the atmosphere is heating unevenly and is showing the biggest rises at night, in winter and at latitudes higher than about 50 degrees. In some places, the number of deaths related to heat waves is projected to double by 2020. Prolonged heat can, moreover, enhance production of smog and the dispersal of allergens. Both effects have been linked to respiratory symptoms.

Global warming can also threaten human well-being profoundly, if somewhat less directly, by revising weather patterns-particularly by pumping up the frequency and intensity of floods and droughts and by causing rapid swings in the weather. As the atmosphere has warmed over the past century, droughts in arid areas have persisted longer, and massive bursts of precipitation have become more common. Aside from causing death by drowning or starvation, these disasters promote by various means the emergence, resurgence and spread of infectious disease.

That prospect is deeply troubling, because infectious illness is a genie that can be very hard to put back into its bottle. It may kill fewer people in one fell swoop than a raging flood or an extended drought, but once it takes root in a community, it often defies eradication and can invade other areas.

The control issue looms largest in the developing world, where resources for prevention and treatment can be scarce. But the technologically advanced nations, too, can fall victim to surprise attacks-as happened last year when the West Nile virus broke out for the first time in North America, killing seven New Yorkers. In these days of international commerce and travel, an infectious disorder that appears in one part of the world can quickly become a problem continents away if the disease-causing agent, or pathogen, finds itself in a hospitable environment.

Floods and droughts associated with global climate change could undermine health in other ways as well. They could damage crops and make them vulnerable to infection and infestations by pests and choking weeds, thereby reducing food supplies and potentially contributing to malnutrition. And they could permanently or semipermanently displace entire populations in developing countries, leading to overcrowding and the diseases connected with it, such as tuberculosis.

Weather becomes more extreme and variable with atmospheric heating in part because the warming accelerates the water cycle: the process in which water vapor, mainly from the oceans, rises into the atmosphere before condensing out as precipitation. A warmed atmosphere heats the oceans (leading to faster evaporation), and it holds more moisture than a cool one. When the extra water condenses, it more frequently drops from the sky as larger downpours. While the oceans are being heated, so is the land, which can become highly parched in dry areas. Parching enlarges the pressure gradients that cause winds to develop, leading to turbulent winds, tornadoes and other powerful storms. In addition, the altered pressure and temperature gradients that accompany global warming can shift the distribution of when and where storms, floods and droughts occur.

I will address the worrisome health effects of global warming and disrupted climate patterns in greater detail, but I should note that the consequences may not all be bad. Very high temperatures in hot regions may reduce snail populations, which have a role in transmitting schistosomiasis, a parasitic disease. High winds may at times disperse pollution. Hotter winters in normally chilly areas may reduce cold-related heart attacks and respiratory ailments. Yet overall, the undesirable effects of more variable weather are likely to include new stresses and nasty surprises that will overshadow any benefits.

Diseases relayed by mosquitoes-such as malaria, dengue fever, yellow fever and several kinds of encephalitis-are among those eliciting the greatest concern as the world warms. Mosquitoes acquire disease-causing microorganisms when they take a blood meal from an infected animal or person. Then the pathogen reproduces inside the insects, which may deliver disease-causing doses to the next individuals they bite.

Mosquito-borne disorders are projected to become increasingly prevalent because their insect carriers, or "vectors," are very sensitive to meteorological conditions. Cold can be a friend to humans, because it limits mosquitoes to seasons and regions where temperatures stay above certain minimums. Winter freezing kills many eggs, larvae and adults outright. Anopheles mosquitoes, which transmit malaria parasites (such as Plasmodium falciparum), cause sustained outbreaks of malaria only where temperatures routinely exceed 60 degrees Fahrenheit. Similarly, Aedes aegypti mosquitoes, responsible for yellow fever and dengue fever, convey virus only where temperatures rarely fall below 50 degrees F.

Excessive heat kills insects as effectively as cold does. Nevertheless, within their survivable range of temperatures, mosquitoes proliferate faster and bite more as the air becomes warmer. At the same time, greater heat speeds the rate at which pathogens inside them reproduce and mature. At 68 degrees F, the immature P. falciparum parasite takes 26 days to develop fully, but at 77 degrees F, it takes only 13 days. The Anopheles mosquitoes that spread this malaria parasite live only several weeks; warmer temperatures raise the odds that the parasites will mature in time for the mosquitoes to transfer the infection. As whole areas heat up, then, mosquitoes could expand into formerly forbidden territories, bringing illness with them. Further, warmer nighttime and winter temperatures may enable them to cause more disease for longer periods in the areas they already inhabit.

The extra heat is not alone in encouraging a rise in mosquito-borne infections. Intensifying floods and droughts resulting from global warming can each help trigger outbreaks by creating breeding grounds for insects whose desiccated eggs remain viable and hatch in still water. As floods recede, they leave puddles. In times of drought, streams can become stagnant pools, and people may put out containers to catch water; these pools and pots, too, can become incubators for new mosquitoes. And the insects can gain another boost if climate change or other processes (such as alterations of habitats by humans) reduce the populations of predators that normally keep mosquitoes in check.

Malaria and dengue fever are two of the mosquito-borne diseases most likely to spread dramatically as global temperatures head upward. Malaria (marked by chills, fever, aches and anemia) already kills 3,000 people, mostly children, every day. Some models project that by the end of the 21st century, ongoing warming will have enlarged the zone of potential malaria transmission from an area containing 45 percent of the world's population to an area containing about 60 percent. That news is bad indeed, considering that no vaccine is available and that the causative parasites are becoming resistant to standard drugs.

True to the models, malaria is reappearing north and south of the tropics. The U.S. has long been home to Anopheles mosquitoes, and malaria circulated here decades ago. By the 1980s mosquito-control programs and other public health measures had restricted the disorder to California. Since 1990, however, when the hottest decade on record began, outbreaks of locally transmitted malaria have occurred during hot spells in Texas, Florida, Georgia, Michigan, New Jersey and New York (as well as in Toronto). These episodes undoubtedly started with a traveler or stowaway mosquito carrying malaria parasites. But the parasites clearly found friendly conditions in the U.S.-enough warmth and humidity, and plenty of mosquitoes able to transport them to victims who had not traveled. Malaria has returned to the Korean peninsula, parts of southern Europe and the former Soviet Union and to the coast of South Africa along the Indian Ocean.

Dengue, or "breakbone," fever (a severe flu-like viral illness that sometimes causes fatal internal bleeding) is spreading as well. Today it afflicts an estimated 50 million to 100 million in the tropics and subtropics (mainly in urban areas and their surroundings). It has broadened its range in the Americas over the past 10 years and had reached down to Buenos Aires by the end of the 1990s. It has also found its way to northern Australia. Neither a vaccine nor a specific drug treatment is yet available.

Although these expansions of malaria and dengue fever certainly fit the predictions, the cause of that growth cannot be traced conclusively to global warming. Other factors could have been involved as well-for instance, disruption of the environment in ways that favor mosquito proliferation, declines in mosquito-control and other public health programs, and rises in drug and pesticide resistance. The case for a climatic contribution becomes stronger, however, when other projected consequences of global warming appear in concert with disease outbreaks.

Such is the case in highlands around the world. There, as anticipated, warmth is climbing up many mountains, along with plants and butterflies, and summit glaciers are melting. Since 1970 the elevation at which temperatures are always below freezing has ascended almost 500 feet in the tropics. Marching upward, too, are mosquitoes and mosquito-borne diseases.

In the 19th century, European colonists in Africa settled in the cooler mountains to escape the dangerous swamp air ("mal aria") that fostered disease in the lowlands. Today many of those havens are compromised. Insects and insect-borne infections are being reported at high elevations in South and Central America, Asia, and east and central Africa. Since 1980 Ae. aegypti mosquitoes, once limited by temperature thresholds to low altitudes, have been found above one mile in the highlands of northern India and at 1.3 miles in the Colombian Andes. Their presence magnifies the risk that dengue and yellow fever may follow. Dengue fever itself has struck at the mile mark in Taxco, Mexico. Patterns of insect migration change faster in the mountains than they do at sea level. Those alterations can thus serve as indicators of climate change and of diseases likely to expand their range.

The increased climate variability accompanying warming will probably be more important than the rising heat itself in fueling unwelcome outbreaks of certain vector-borne illnesses. For instance, warm winters followed by hot, dry summers (a pattern that could become all too familiar as the atmosphere heats up) favor the transmission of St. Louis encephalitis and other infections that cycle among birds, urban mosquitoes and humans.

This sequence seems to have abetted the surprise emergence of the West Nile virus in New York City last year. No one knows how this virus found its way into the U.S. But one reasonable explanation for its persistence and amplification here centers on the weather's effects on Culex pipiens mosquitoes, which accounted for the bulk of the transmission. These urban dwellers typically lay their eggs in damp basements, gutters, sewers and polluted pools of water.

The interaction between the weather, the mosquitoes and the virus probably went something like this: The mild winter of 1998-99 enabled many of the mosquitoes to survive into the spring, which arrived early. Drought in spring and summer concentrated nourishing organic matter in their breeding areas and simultaneously killed off mosquito predators, such as lacewings and ladybugs, that would otherwise have helped limit mosquito populations. Drought would also have led birds to congregate more, as they shared fewer and smaller watering holes, many of which were frequented, naturally, by mosquitoes.

Once mosquitoes acquired the virus, the heat wave that accompanied the drought would speed up viral maturation inside the insects. Consequently, as infected mosquitoes sought blood meals, they could spread the virus to birds at a rapid clip. As bird after bird became infected, so did more mosquitoes, which ultimately fanned out to infect human beings. Torrential rains toward the end of August provided new puddles for the breeding of C. pipiens and other mosquitoes, unleashing an added crop of potential virus carriers.

Like mosquitoes, other disease-conveying vectors tend to be "pests"-opportunists that reproduce quickly and thrive under disturbed conditions unfavorable to species with more specialized needs. In the 1990s climate variability contributed to the appearance in humans of a new rodent-borne ailment: the hantavirus pulmonary syndrome, a highly lethal infection of the lungs. This infection can jump from animals to humans when people inhale viral particles hiding in the secretions and excretions of rodents. The sequential weather extremes that set the stage for the first human eruption, in the U.S. Southwest in 1993, were long-lasting drought interrupted by intense rains.

First, a regional drought helped to reduce the pool of animals that prey on rodents-raptors (owls, eagles, prairie falcons, red-tailed hawks and kestrels), coyotes and snakes. Then, as drought yielded to unusually heavy rains early in 1993, the rodents found a bounty of food, in the form of grasshoppers and pinon nuts. The resulting population explosion enabled a virus that had been either inactive or isolated in a small group to take hold in many rodents. When drought returned in summer, the animals sought food in human dwellings and brought the disease to people. By fall 1993, rodent numbers had fallen, and the outbreak abated.

Subsequent episodes of hantavirus pulmonary syndrome in the U.S. have been limited, in part because early-warning systems now indicate when rodent-control efforts have to be stepped up and because people have learned to be more careful about avoiding the animals' droppings. But the disease has appeared in Latin America, where some ominous evidence suggests that it may be passed from one person to another.

As the natural ending of the first hantavirus episode demonstrates, ecosystems can usually survive occasional extremes. They are even strengthened by seasonal changes in weather conditions, because the species that live in changeable climates have to evolve an ability to cope with a broad range of conditions. But long-lasting extremes and very wide fluctuations in weather can overwhelm ecosystem resilience. (Persistent ocean heating, for instance, is menacing coral reef systems, and drought-driven forest fires are threatening forest habitats.) And ecosystem upheaval is one of the most profound ways in which climate change can affect human health. Pest control is one of nature's underappreciated services to people; well-functioning ecosystems that include diverse species help to keep nuisance organisms in check. If increased warming and weather extremes result in more ecosystem disturbance, that disruption may foster the growth of opportunist populations and enhance the spread of disease.

Beyond exacerbating the vector-borne illnesses mentioned above, global warming will probably elevate the incidence of waterborne diseases, including cholera (a cause of severe diarrhea). Warming itself can contribute to the change, as can a heightened frequency and extent of droughts and floods. It may seem strange that droughts would favor waterborne disease, but they can wipe out supplies of safe drinking water and concentrate contaminants that might otherwise remain dilute. Further, the lack of clean water during a drought interferes with good hygiene and safe rehydration of those who have lost large amounts of water because of diarrhea or fever.

Floods favor waterborne ills in different ways. They wash sewage and other sources of pathogens (such as Cryptosporidium) into supplies of drinking water. They also flush fertilizer into water supplies. Fertilizer and sewage can each combine with warmed water to trigger expansive blooms of harmful algae. Some of these blooms are directly toxic to humans who inhale their vapors; others contaminate fish and shellfish, which, when eaten, sicken the consumers. Recent discoveries have revealed that algal blooms can threaten human health in yet another way. As they grow bigger, they support the proliferation of various pathogens, among them Vibrio cholerae, the causative agent of cholera.

Drenching rains brought by a warmed Indian Ocean to the Horn of Africa in 1997 and 1998 offer an example of how people will be affected as global warming spawns added flooding. The downpours set off epidemics of cholera as well as two mosquito-borne infections: malaria and Rift Valley fever (a flu-like disease that can be lethal to livestock and people alike).

To the west, Hurricane Mitch stalled over Central America in October 1998 for three days. Fueled by a heated Caribbean, the storm unleashed torrents that killed at least 11,000 people. But that was only the beginning of its havoc. In the aftermath, Honduras reported thousands of cases of cholera, malaria and dengue fever. Beginning in February of this year, unprecedented rains and a series of cyclones inundated large parts of southern Africa. Floods in Mozambique and Madagascar killed hundreds, displaced thousands and spread both cholera and malaria. Such events can also greatly retard economic development, and its accompanying public health benefits, in affected areas for years.

The health toll taken by global warming will depend to a large extent on the steps taken to prepare for the dangers. The ideal defensive strategy would have multiple components.

One would include improved surveillance systems that would promptly spot the emergence or resurgence of infectious diseases or the vectors that carry them. Discovery could quickly trigger measures to control vector proliferation without harming the environment, to advise the public about self-protection, to provide vaccines (when available) for at-risk populations and to deliver prompt treatments.

This past spring, efforts to limit the West Nile virus in the northeastern U.S. followed this model. On seeing that the virus had survived the winter, public health officials warned people to clear their yards of receptacles that can hold stagnant water favorable to mosquito breeding. They also introduced fish that eat mosquito larvae into catch basins and put insecticide pellets into sewers.

Sadly, however, comprehensive surveillance plans are not yet realistic in much of the world. And even when vaccines or effective treatments exist, many regions have no means of obtaining and distributing them. Providing these preventive measures and treatments should be a global priority.

A second component would focus on predicting when climatological and other environmental conditions could become conducive to disease outbreaks, so that the risks could be minimized. If climate models indicate that floods are likely in a given region, officials might stock shelters with extra supplies. Or if satellite images and sampling of coastal waters indicate that algal blooms related to cholera outbreaks are beginning, officials could warn people to filter contaminated water and could advise medical facilities to arrange for additional staff, beds and treatment supplies.

Research reported in 1999 illustrates the benefits of satellite monitoring. It showed that satellite images detecting heated water in two specific ocean regions and lush vegetation in the Horn of Africa can predict outbreaks of Rift Valley fever in the Horn five months in advance. If such assessments led to vaccination campaigns in animals, they could potentially forestall epidemics in both livestock and people.

A third component of the strategy would attack global warming itself. Human activities that contribute to the heating or that exacerbate its effects must be limited. Little doubt remains that burning fossil fuels for energy is playing a significant role in global warming, by spewing carbon dioxide and other heat-absorbing, or "greenhouse," gases into the air. Cleaner energy sources must be put to use quickly and broadly, both in the energy-guzzling industrial world and in developing nations, which cannot be expected to cut back on their energy use. (Providing sanitation, housing, food, refrigeration and indoor fires for cooking takes energy, as do the pumping and purification of water and the desalination of seawater for irrigation.) In parallel, forests and wetlands need to be restored, to absorb carbon dioxide and floodwaters and to filter contaminants before they reach water supplies.

The world's leaders, if they are wise, will make it their business to find a way to pay for these solutions. Climate, ecological systems and society can all recoup after stress, but only if they are not exposed to prolonged challenge or to one disruption after another. The Intergovernmental Panel on Climate Change, established by the United Nations, calculates that halting the ongoing rise in atmospheric concentrations of greenhouse gases will require a whopping 60 to 70 percent reduction in emissions.

I worry that effective corrective measures will not be instituted soon enough. Climate does not necessarily change gradually. The multiple factors that are now destabilizing the global climate system could cause it to jump abruptly out of its current state. At any time, the world could suddenly become much hotter or even much colder. Such a sudden, catastrophic change is the ultimate health risk-one that must be avoided at all costs.

Scientists often gain insight into the workings of complicated systems by studying subsystems. In that spirit, investigators concerned about global warming's health effects are assessing outcomes of the El Nino Southern Oscillation (ENSO), a climate process that produces many of the same meteorological changes predicted for a warming world. The findings are not reassuring.

"El Nino" refers to an oceanic phenomenon that materializes every five years or so in the tropical Pacific. The ocean off Peru becomes unusually warm and stays that way for months before returning to normal or going to a cold extreme (La Nina). The name "Southern Oscillation" refers to atmospheric changes that happen in tandem with the Pacific's shifts to warmer or cooler conditions.

During an El Nino, evaporation from the heated eastern Pacific can lead to abnormally heavy rains in parts of South America and Africa and parts of Southeast Asia and Australia suffer droughts. Atmospheric pressure changes over the tropical Pacific also have ripple effects throughout the globe, generally yielding milder winters in some northern regions of the U.S. and western Canada. During a La Nina, weather patterns in the affected areas may go to opposite extremes.

The incidence of vector-borne and water-borne diseases climbs during El Nino and La Nina years, especially in areas hit by floods or droughts. Long-term studies in Colombia, Venezuela, India and Pakistan reveal, for instance, that malaria surges in the wake of El Ninos. And my colleagues and I at Harvard University have shown that regions stricken by flooding or drought during the El Nino of 1997-98 (the strongest of the century) often had to contend as well with a convergence of diseases borne by mosquitoes, rodents and water. Additionally, in many dry areas, fires raged out of control, polluting the air for miles around.

ENSO is not merely a warning of troubles to come; it is likely to be an engine for those troubles. Several climate models predict that as the atmosphere and oceans heat up, El Ninos themselves will become more common and severe--which means that the weather disasters they produce and the diseases they promote could become more prevalent as well.

Indeed, the ENSO pattern has already begun to change. Since 1976 the intensity, duration and pace of El Ninos have increased. And during the 1990s, every year was marked by an El Nino or La Nina extreme. Those trends bode ill for human health in the 21st century.

The Emergence of New Disease. Richard Levins, Tamara Auerbuch, Uwe Brinkmann, Irina Eckardt, Paul R. Epstein, Tim Ford, Najwa Makhoul, Christina dePossas, Charles Puccia, Andrew Spielman and Mary E. Wilson in American Scientist, Vol. 82, No. 1, pages 52-60; January/ February 1994.

Climate Change and Human Health. Edited by Anthony J. McMichael, Andrew Haines, Rudolf Slooff and Sari Kovats. World Health Organization, World Meteorological Organization, United Nations Environmental Program, 1996.

The Regional Impacts of Climate Change: An Assessment of Vulnerability, 1997. Edited by R. T. Watson, M. C. Zinyowera and R. H. Moss. Cambridge University Press, 1997.

Summary from the Intergovernmental Panel on Climate Change available at http://www.ipcc.ch/pub/reports.htm Biological and Physical Signs of Climate Change: Focus on Mosquito-Borne Diseases. Paul R. Epstein, Henry F. Diaz, Scott Elias, Georg Grabherr, Nicholas E. Graham, Willem J. M. Martens, Ellen Mosley-Thompson and Joel Susskind in Bulletin of the American Meteorological Society, Vol. 79, pages 409-417; 1998. Other Web sites of interest: www.heatisonline.org and www.med.harvard.edu/chge

Computer models have predicted that global warming would produce several changes in the highlands: summit glaciers (like North Polar sea ice) would begin to melt, and plants, mosquitoes and mosquito--borne diseases would migrate upward into regions formerly too cold for them. All these predictions are coming true. This convergence strongly suggests that the upward expansion of mosquitoes and mosquito-borne diseases documented in the past 15 years has stemmed, at least in part, from rising temperatures.

WHERE DISEASES OR THEIR CARRIERS HAVE REACHED HIGHER
ELEVATIONS

Malaria                  Dengue fever               Aedes aegypti
                                                  mosquitoes (can
                                              spread dengue fever
                                                and yellow fever)

Highlands of            San Jose, Costa            Eastern Andes
Ethiopia, Rwanda,        Rica, Taxco,         Mountains, Colombia
Uganda and Zimbabwe         Mexico             Northern Highlands
Usamabara Mountains,                                 of India
Tanzania Highlands of
Papua New Guinea and
West Papua (Iran Jaya)

MAP: RISK OF MALARIA TRANSMISSION will have risen in many parts of the world by 2020 (relative to the average risk in the years 1961 to 1990), according to projections assuming a temperature increase of about two degrees Fahrenheit. The analysis was based solely on temperature threshold and did not asses other factors that could influence malaria's spread.

MAP: Disease Outbreaks Accompanying Extreme Weather during the 1997-1998 El Nino

DIAGRAM: Changes Are Already Under Way

DIAGRAM: Weather and the West Nile Virus

PHOTO (COLOR): WOMAN RINSES RICE in floodwaters outside her hut in Madagascar. Heavy floods earlier this year there and to the west in Mozambique led to outbreaks of cholera (a waterborne disease) and malaria (transmitted by mosquitoes).

PHOTO (COLOR): A mother in Mozambique holds her child, who is feared to have malaria

PHOTO (COLOR): The body of a cholera victim in Madagascar is placed in a coffin. As global warming increases, it is expected to generate more frequent and devastating floods and droughts around the world--and more of the infectious diseases those conditions promote.

PHOTO (COLOR): SATELLITE IMAGE revealed that the sea-surface temperature of both the western equatorial Indian Ocean and the eastern Pacific was warm and that the Horn of Africa was lush with vegetation because of heavy rains. This pattern indicated that the Horn was at risk for an epidemic of Rift Valley fever in livestock and people. Satellite surveillance is being used increasingly to detect conditions conducive to disease outbreaks, so that preventive measures can be taken.

~~~~~~~~

By Paul R. Epstein

PAUL R. EPSTEIN, an M.D. trained in tropical public health, is associate director of the Center for Health and the Global Environment at Harvard Medical School. He has served in medical, teaching and research capacities in Africa, Asia and Latin America and has worked with the Intergovernmental Panel on Climate Change, the National Oceanic and Atmospheric Administration, and the National Aeronautics and Space Administration to assess the health effects of climate change and to develop health applications for climate forecasting and remote-sensing technologies.