BACKGROUND:Food security is central to global nutrition improvement and public health goals, and healthy diets represent a higher-level aspiration beyond merely avoiding hunger. Climate change poses an increasing threat to food systems by affecting crop yields and food prices. Although climate change-driven risks to hunger have been widely studied, the extent to which climate change undermines the affordability of healthy diets while accounting for socioeconomic responses and regional inequalities remains insufficiently understood. This study aimed to quantify the effects of climate change on the future affordability of healthy diets under alternative socioeconomic and climate scenarios. METHODS:We developed an integrated modelling framework that explicitly couples multimodel crop-yield projections with an integrated assessment model (Global Change Analysis Model [GCAM]). Yield responses from six global gridded crop models driven by four climate models were integrated into GCAM, allowing endogenous socioeconomic adjustments such as land-use shifts, production reallocation, and price responses to emerge under shared socioeconomic pathways (SSPs). Diet affordability was then assessed using the Food and Agriculture Organization of the UN's Cost and Affordability of a Healthy Diet framework across three socioeconomic-climate scenarios (SSP1-2.6, SSP2-4.5, and SSP3-6.0). FINDINGS:Under a high-emissions pathway (ie, SSP3-6.0), climate change was projected to render healthy diets unaffordable for a model-mean of 119 million people globally by 2100, even when CO2 fertilisation effects are included, with the upper end of the model ensemble reaching about 1·6 billion people. In contrast, climate-induced affordability losses were found to be negligible under both a low-emissions pathway (ie, SSP1-2.6; -0·3 million) and a medium-emission pathway (SSP2-4.5; +0·2 million). Under a high-emission pathway, model-mean projections indicated that diet costs could increase by up to 12% in the most affected regions by the end of the century. Under medium emissions, cost increases were projected to remain below 4%, whereas under low emissions, affordability changes were projected to be minimum across regions (within approximately 0·5%). Substantial regional disparities emerged, with the largest and most consistent affordability losses concentrated in low-income regions that contributed least to historical greenhouse gas emissions. Under SSP3-6.0, these disparities persisted particularly in regions of Africa and Asia despite projected three-to-five-fold increases in income over the century, with climate-induced disruptions to food systems increasing the number of people unable to afford a healthy diet through mid-century. INTERPRETATION:Climate change is likely to exacerbate global nutritional inequalities by disproportionately increasing the affordability risks of healthy diets in regions that have contributed least to historical greenhouse gas emissions. Under high-warming scenarios, socioeconomic development alone is insufficient to fully offset these risks, highlighting the structural vulnerability of low-income food systems to climate-driven price shocks. These findings suggest that in the absence of targeted interventions, climate change could continue to undermine progress towards equitable and health-oriented nutrition outcomes. FUNDING:Ministry of Science and Technology of the People's Republic of China; National Natural Science Foundation of China; National Aeronautics and Space Administration Goddard Institute for Space Studies Climate Impacts Group; Future of Life Institute; and Global Alliance for Improved Nutrition.
BACKGROUND:Coccidioidomycosis is an emerging fungal disease caused by inhaling Coccidioides spp spores. As spores reside in soil, activities that disturb soil and generate dust can aerosolise and transport the pathogen. The oil and gas industry has been extensively developed in some regions that are endemic for Coccidioides spp and has been associated with dust emissions. Although several adverse health outcomes have previously been associated with oil and gas development, its impact on coccidioidomycosis risk has not been investigated. We aimed to estimate the association between exposure to oil and gas well development (ie, wells in preproduction) and risk of coccidioidomycosis among residents living near new wells. METHODS:In this case-crossover study, we obtained information on reported coccidioidomycosis cases and oil and gas well development between 2007 and 2022 in Kern County, CA, USA. We then compared exposure to preproduction wells within 5 km of each individual's place of residence during both hazard (ie, the 49-139 days before case onset) and control periods using conditional logistic regression. FINDINGS:During the study period, 658 108 (72·4%) of 909 282 of Kern County residents lived within 5 km of at least one preproduction well, and 116 020 (12·8%) lived within 5 km of 23 or more preproduction wells within a single 90-day period. We estimated that the odds of coccidiomycosis incidence were 12·5% (95% CI 5·8-19·6) higher in the 90 days following exposure to at least one preproduction well within 5 km of an individual's place of residence and that the odds of infection increased by 0·7% (0·4-0·9) for each additional preproduction well developed within this distance. INTERPRETATION:These findings support a previously-unrecognised association between the development of oil and gas wells and transmission of coccidioidomycosis, potentially driven by dust generation. Given the prevalence of oil and gas development in the study region, its impact on coccidioidomycosis incidence might be large. FUNDING:National Institutes of Health, National Science Foundation.
BACKGROUND:Health-system resilience serves as a key contributor in mitigating adverse health impacts during climate hazards. However, quantitative insights into resilience-associated health-care utilisation patterns and targeted adaptation policies remain scarce. We aimed to capture the spatiotemporal health impacts in disaster-exposed counties and their neighbouring counties in China during storms, floods, tropical cyclones, and blizzards or winter storms; understand the association between health-system resilience metrics and hazard-attributable hospitalisations; and develop evidence-based adaptation policies towards climate extremes. METHODS:In this retrospective, observational analysis of county-level aggregated hospitalisation data, we used a propensity score matching-difference-in-differences framework to assess the spatiotemporal changes of nine types of disease-specific hospitalisations in both disaster-exposed and neighbouring regions during storms, floods, tropical cyclones, and blizzards in China. We quantified the relative importance and health gains of health-system metrics during such hazards through random forest approach with interpretable partial dependence plots to derive evidence-based adaptation recommendations. FINDINGS:We included hospitalisation data from Jan 1, 2016 to Dec 31, 2023. In this period, 3241 county-hazard event combinations and 41 747 482 hospitalisations were recorded across 955 Chinese counties. The disaster-exposed regions experienced an initial decline in hospitalisation rates, followed by admission surges after disasters. For example, infectious disease admissions decreased by 11·92% (95% CI -10·53 to -13·31) during the flood-active period but increased by 7·68% (6·46-8·91) after 1-2 weeks of floods. Neighbouring zones were also affected through spillover effects, with infectious disease admissions increasing by 3·18% (1·76-4·61) after 1-2 weeks of the floods. Cardiovascular disease, injuries, infectious, respiratory, and mental disorders were more sensitive across all regions. Particularly for disaster-exposed counties, cardiovascular hospitalisations increased by 14·31% (7·34-21·29) during the tropical cyclone-active period. Notably, compared with low-resilience counties, high-resilience counties were associated with 19·48-30·03% smaller hazard-related relative changes in hospitalisation rates during the hazard-active period and 27·07-31·08% smaller hazard-related relative changes in hospitalisation rates in post-hazard periods. For instance, during the storm-active period, the increase in respiratory hospitalisations was 7·21% (0·67-13·75) in high-resilience counties versus 12·13% (5·20-19·05) in low-resilience counties. Health workforce (relative importance 14·58% during the hazard-active period and 13·80% during the post-hazard period) and service delivery (14·10% during the hazard-active period and 14·17% during the post-hazard period) were identified as key contributors of health-system resilience. Empirical synergistic effects were observed when combining interventions during the post-hazard period, with the combined effect of service delivery (individual contribution 8%) and workforce (individual contribution 4%) exceeding the sum of their individual contributions (16% reduction in cumulative excess admissions) by 33%. INTERPRETATION:Climate hazards are associated with substantial changes in hospitalisation rates in both disaster-exposed and neighbouring regions. Health-system resilience is essential in addressing disaster-health challenges. Targeted adaptation interventions should be context-appropriate and threshold-aware, thereby maximising the public health benefits relative to resilience-oriented investments in health systems. FUNDING:Gates Foundation and the National Natural Science Foundation of China.
BACKGROUND:Substantial improvements in air quality have been recorded following the implementation of China's Clean Air Act (CCAA) in 2013. However, the association between CCAA implementation and individual-level cardiovascular disease (CVD) risk remains unclear. We aimed to examine the long-term association between CCAA implementation and individual-level predicted CVD risk. METHODS:In this prospective, quasi-experimental study, we used data from the China Kadoorie Biobank, a prospective cohort study that recruited participants from five urban and five rural areas across China between 2004 and 2008, with three resurveys conducted after the baseline survey (in 2008, 2013-14, and 2020-21). We included 34 862 individuals (mean age 51·3 years) who participated in at least one resurvey and had no history of CVD at baseline. Participants were classified into intervention (n=25 497) and control (n=9365) groups based on the local government's targets for particulate matter reduction. We estimated the 10-year risk of incident CVD morbidity or mortality using a validated risk prediction model. We used a difference-in-difference model to assess the long-term association between CCAA implementation and predicted risk, with adjustments made for regional confounders and individual-level characteristics, including demographics, lifestyle factors, medical history, and indoor air pollution exposure. The relationship between changes in long-term exposure to PM2·5, PM10, and O3 and predicted risk after CCAA implementation was analysed using a linear model. The estimated risk differences associated with air pollutant changes were estimated based on the magnitude of changes and their corresponding effect sizes. FINDINGS:After the CCAA was implemented, PM2·5 and PM10 concentrations declined in both groups, but O3 concentrations increased. The intervention group showed a 3·95% (95% CI 3·18-4·72%) lower increase in predicted risk than the control group, with larger estimated differences under stricter enforcement. Between 2013 and 2021, each 10 μg/m3 change in PM2·5 concentration was positively associated with a 1·80 (1·34-2·27) percentage point change in predicted CVD risk, whereas each 10 μg/m3 change in PM10 concentration was associated with a 1·24 (0·84-1·63) percentage point change and each 10 μg/m3 change in O3 concentration with a 0·58 (0·33-0·83) percentage point change. Overall, the observed changes in air pollutants during the study period were associated with an average 6·6 percentage point reduction in predicted CVD risk. INTERPRETATION:The CCAA and improved air quality were associated with a slower increase in predicted CVD risk, supporting the necessity for stricter, multipollutant air quality policies to maximise public health benefits. FUNDING:National Natural Science Foundation of China, Kadoorie Charitable Foundation, Noncommunicable Chronic Diseases-National Science and Technology Major Project, National Key R&D Program of China, Chinese Ministry of Science and Technology, and UK Wellcome Trust.
Escalating heat extremes under climate change are imposing substantial health burdens, with 2023 and 2024 consecutively breaking global temperature records. Mounting evidence suggests that heatwaves elevate the risks of hospitalisation and mortality across multiple disease categories, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and acute kidney injury. Nonetheless, most existing heat-health warning systems remain primarily reliant on population-level predictions, and considering individual differences and disease-specific considerations when defining warning levels would benefit the effectiveness of early prevention for high-risk groups. In this Viewpoint, which is based on the framework of precision public health—delivering the right intervention to the right population at the right time—we propose a framework for personalised digital heat-health early warning tools comprising three dimensions: individualised, risk-stratified prediction models that generate tiered early warnings; personalised health prompts coupled with theory-informed behavioural interventions; and adaptive, equity-oriented alert delivery mechanisms tailored to diverse populations. Such tools have the potential to bridge precision disease prevention and climate adaptation, thereby helping to mitigate heat exposure risks and disease burdens, particularly among high-risk populations. Future implementation research will be essential to address substantial challenges related to feasibility, validation, and equity.
BACKGROUND:In a warming world, understanding where, when, and to what extent human heat tolerance limits will be breached has become increasingly important. Previous projections applied heat limits for healthy young adults to all age groups, overlooking greater vulnerability in older ages. With global ageing, this oversight could seriously underestimate future heat risks. In this study, we aimed to examine the extent to which accounting for age-specific heat tolerance alters global projections of heat limit exceedances. METHODS:We integrated experimentally derived heat limits for young (18-39 years), middle-aged (40-59 years), and older adults (≥60 years) with climate projections and age-stratified population projections to assess where and to what extent these limits could be breached across age groups under 1-4°C of global warming above preindustrial levels. The climate projections include bias-corrected projections of dry-bulb temperature and wet-bulb temperature from 14 Coupled Model Intercomparison Project Phase 6 climate models under the shared socioeconomic pathway 5-8·5 scenario. We also highlighted countries with high exposure risk and low adaptive capacity. FINDINGS:More widespread and imminent breaches of heat limits were estimated among older adult populations than among other populations. Older adults faced more frequent and spatially extensive exceedances under the 1·5°C global warming scenario relative to the preindustrial period than young adults did under 4°C. Using age-specific thresholds more than doubled the global population having 180 h or more of exceedance annually as compared with previous estimates. Older adults in south Asia and the Persian Gulf could face sustained, day-and-night exposure for three consecutive months at 3°C or more warming. We also identified 13 countries under 3°C global warming above the preindustrial period where poverty rates exceed 50% and either at least 10 million older adults or at least 80% of the older adult population experiences 180 h or more of heat limit exceedance annually. India, Pakistan, Bangladesh, Myanmar, and Niger exceed both the absolute (10 million older adults) and proportional (80% of older adults) exposure thresholds. INTERPRETATION:Our results suggest accounting for age stratified vulnerability, intolerable heat will be experienced at much larger scales and for longer durations, affecting far more people than previously estimated. By identifying who and where people are exposed, our findings can inform targeted heat action plans and guide resource allocation and response planning. FUNDING:US National Institutes of Health; US National Science Foundation; US National Aeronautics and Space Administration; Yale Institute for Biospheric Studies; The Rockefeller Foundation.
BACKGROUND:Natural spaces have the potential to improve mental health conditions such as depression and anxiety. Urban woodlands present an opportunity to provide local residents with nearby green and natural areas, when such areas are safe, inviting, and easy to access. We examined a broad programme of woodland improvements in Scotland that targeted less-advantaged communities to identify the effects improved woodland spaces could have on mental health outcomes. METHODS:Individual de-identified sociodemographic data from the Scottish Longitudinal Study were linked with residential histories and mental health prescription records from National Health Service (NHS) Scotland between 2012 and 2016. Geospatial data on the location of urban woodland improved under the Woods In And Around Town (WIAT) scheme funded by Scottish Forestry. We used longitudinal random-effects models to assess the association of between-individual and within-individual changes in improved woodland exposure with the risk of being prescribed antidepressant or anxiolytic medications over the 5-year period. FINDINGS:A total of 129 335 adults were included in the final sample. In the cross-sectional, between-individual analysis, we observed a greater risk (adjusted odds ratio [aOR] 1·10 [95% CI 1·03-1·20] p<0·05) of antidepressant prescription for those living within 800 m (approximately 10-min walk) of an improved woodland compared with those living further away, but no significant difference in the risk of anxiolytic prescription. In the longitudinal, within-individual analysis, we observed lower prescription use for antidepressants (aOR 0·90 [95% CI 0·87-0·93] p<0·01) and anxiolytics (aOR 0·94 [0·90-0·99] p<0·01) during periods spent living within 800 m of an improved woodland when compared with periods spent living beyond 800 m of an improved woodland. INTERPRETATION:We suggest that the greater risk of antidepressant use between individuals reflects the fact that the WIAT improvement programme targeted more socioeconomically deprived areas. However, the significantly reduced risk of mental health prescription for individuals moving from outside of a WIAT area into a WIAT area suggests that the intervention had a positive effect on individuals' mental health over time. These findings point to the value of environmental interventions, such as urban woodland investments, as a preventive public health strategy, especially in deprived areas that tend to have greater mental health burdens and less access to green space. FUNDING:Economic and Social Research Council; GroundsWell Consortium, a UK Prevention Research Partnership.
Achieving environmentally sustainable health systems represents a crucial objective for both planetary and human health. Integrating environmental measures into existing health-care quality measurement and improvement frameworks can greatly advance sustainability efforts. However, current environmental measures have not been evaluated for this purpose. In this Personal View, we evaluate commonly reported measures of environmentally sustainable health care against standard criteria and propose a minimum set of standard environmental sustainability measures compatible with quality reporting standards. Common measures of environmental sustainability were identified at the hospital and health-facility level through a literature review. We created generic, representative measures based on the environmental domain (eg, greenhouse gases, energy) and evaluated them using quality measure criteria established by the Partnership for Quality Measurement. Six generic measures were created and evaluated across the domains of greenhouse gas emissions, water use, energy use, travel, and solid waste. Although all six measures were considered of high importance, two (distance travelled by patients and staff and mass of total [scopes 1, 2, and 3] carbon dioxide-equivalent emissions per year) showed weaknesses in scientific acceptability and feasibility, and one (energy consumed per year) was highly correlated with and less informative than the others. No measures evaluated included a consistent method for standardisation. The proposed minimum set comprises measures of greenhouse gas emissions (scopes 1 and 2), water use, and solid waste production, standardised by adjusted patient-days. To our knowledge, this work presents the first proposed list of environmental measures for use in quality reporting and a pathway for integrating environmental sustainability measures into existing quality measurement frameworks.
Critiques of economic growth are receiving increased scientific and public attention. The post-growth literature discusses how wellbeing can be achieved for all within planetary boundaries. However, current welfare states, which play a crucial role in supporting health and wellbeing, are often seen as growth dependent. The drivers of welfare state growth dependencies and related policy responses remain poorly understood. In this Review, we address this gap and provide an overview of drivers and policy responses, by performing a semi-systematic literature review. The Review identified key drivers that the literature suggests, such as the growth dependence of employment and related welfare funds, rent extraction and for-profit provisioning, increasing inequality, ageing societies, political power of vested interests, and environmental impacts. Policies proposed as responses to these drivers include maintaining employment without growth, using less growth dependent revenues, restricting rent seeking and political power of vested interests, implementing predistributive and redistributive policies, implementing preventive health-care approaches, and mitigating climate change. We argue that a more holistic assessment of policies should consider the interaction between the supply of welfare funding and demand for welfare spending. Finally, we summarise views in the literature on whether welfare state growth independence can be achieved within a capitalist system.
All life on earth is affected by the intensifying impacts of climate change, biodiversity loss, and pollution. Planetary health science is emerging as a crucial framework to address the health of the planet and its inhabitants. Indigenous Peoples' knowledge systems have evolved over millennia and are grounded in principles such as interconnectedness of all living things. As a discipline, the tenets of planetary health draw upon Indigenous science and approaches; however, the extent of ethical engagement has not been examined. We conducted a systematic review of all articles published in The Lancet Planetary Health up to October 2025, to assess the recognition and integration of Indigenous knowledge systems. 1137 of 1172 articles reviewed contained no Indigenous research features or perspectives. Although the number of articles engaging with Indigenous knowledge systems has increased over time, these publications are predominantly commentaries, with relatively few original research articles. The Lancet Planetary Health was launched with the aim of informing a "radical civilisational transformation". Based on the findings of this systematic review, we suggest that decolonising planetary health science should be integrated into this civilisational transformation.
BACKGROUND:Coccidioides are fungi endemic to western USA and are estimated to cause more than 200 000 symptomatic cases of coccidioidomycosis, also known as Valley fever, annually. Endemicity is influenced by environmental conditions, including precipitation, temperature, and soil composition. As environmental conditions change in the future, the geographical distribution of the fungi can be altered. METHODS:In this modelling study, we used generalised additive models to construct two Coccidioides suitability models at the county and ZIP code tabulation area (ZCTA) scales. The county model used public health surveillance data from 2010 to 2019 provided by the US Centers for Disease Control and Prevention, whereas the ZCTA model was based on emergency department visit data. We compared predicted suitable areas to assess the utility of hospital data in estimating Coccidioides suitability and projected future suitability using data from 33 global climate models for 2050, 2075, and 2100. FINDINGS:The ZCTA model had better out-of-sample predictive performance for identifying endemic areas than the county model (area under the precision-recall curve: 0·81 vs 0·57), including higher specificity (0·84 vs 0·52). Both models identified potential suitable areas for the fungi beyond California and Arizona, including Texas, where coccidioidomycosis is currently not a notifiable disease. Additionally, both models projected a similar future northward and eastward shift in Coccidioides suitability, with these shifts exacerbating under higher levels of warming. Under Shared Socioeconomic Pathway 2-4.5, we estimated that non-endemic ZCTAs containing 23 million (95% uncertainty interval 8-34) people could become suitable for Coccidioides by 2050, rising to areas containing 30 million (21-43) by 2100. INTERPRETATION:Potential future expansion of Coccidioides into new regions highlights the need for increased surveillance in the USA. Hospital data can be used to estimate Valley fever risk wherever surveillance data are scarce. FUNDING:US National Institutes of Health.
BACKGROUND:Food systems are important drivers of planetary boundary transgressions at both global and local scales. Growing evidence shows that when multiple planetary boundaries are transgressed simultaneously, such transgression can amplify their negative consequences on Earth system processes. Therefore, it is essential to scrutinise global boundary transgressions at the local scale. METHODS:This study assessed future planetary boundary transgressions under different food system-transformation (EL2) and combined food system-transformation and climate mitigation (ELM) scenarios, both on global and local scales, by defining ten global and eight local boundary indicators and simulating them using the Integrated Model to Assess the Global Environment framework. FINDINGS:Our results identified hotspots of local boundary transgressions across scenarios. Policies addressing the food system (such as dietary change, productivity increase, and halving food loss and waste) can help to reduce future transgressions. Dietary change results in the largest reductions in the land-system change (70%) and biosphere integrity (69%) domains. Policies with a focus on agricultural productivity improve the biogeochemical flows (phosphorus) domain (92%), and mitigation measures drive most of the improvements in freshwater change (62% blue, 82% green), climate change (67%), and aerosol loading (75%). On a global scale, there are no trade-offs between the EL2 and ELM scenarios, but trade-offs can occur on a local level, with large regional differences in boundary transgressions. Grid cells with six or more local boundary transgressions account for 6·1% of the total land area under business-as-usual, 4·5% under EL2, and 3·1% under ELM, as compared with 4·9% in the historical reference period 2020. INTERPRETATION:Policies addressing both the food system and climate change can be effective in simultaneously reducing boundary transgressions across scenarios, although a multiscale approach can help to identify regional trade-offs that remain hidden at global scales. FUNDING:BrightSpace, EU's Horizon Europe - Research and Innovation Programme; PBL Netherlands Environmental Assessment Agency.
Ecological-collective-flourishing (e-co-flourishing) describes the interconnected flourishing of human and non-human natural entities. Despite existing conceptual frameworks, translation into practice remains inadequate owing to insufficient synthesis of empirically tested mechanisms driving change across human and ecological systems. We conducted an umbrella review of systematic reviews examining mechanisms at the e-co-flourishing interface. Searches of seven databases and four grey literature sources identified nine eligible reviews. Evidence supported several cross-domain mechanisms, including psychological (eg, attention restoration and reduced stress), social (eg, cohesion and contact), physical (eg, activity), and environmental pathways (eg, reduced stressors and enhanced environmental quality). Psychological mechanisms showed the most consistent support, whereas evidence for other mechanism domains was mixed. Evidence for causality was weak and largely derived from cross-sectional and qualitative studies, and no reviews examined reciprocal mechanisms influencing both human and non-human flourishing. Future research should prioritise rigorous designs, theory-driven testing, and replication to strengthen evidence for equitable and sustainable e-co-flourishing pathways.
