DEEPENING INEQUITIES IN A WARMING WORLD: Record temperatures in 2020 resulted in a new high of 3·1 billion more person-days of heatwave exposure among people older than 65 years and 626 million more person-days affecting children younger than 1 year, compared with the annual average for the 1986–2005 baseline (indicator 1.1.2). Looking to 2021, people older than 65 years or younger than 1 year, along with people facing social disadvantages, were the most affected by the record-breaking temperatures of over 40°C in the Pacific Northwest areas of the USA and Canada in June, 2021—an event that would have been almost impossible without human-caused climate change. Although the exact number will not be known for several months, hundreds of people have died prematurely from the heat. Furthermore, populations in countries with low and medium levels of UN-defined human development index (HDI) have had the biggest increase in heat vulnerability during the past 30 years, with risks to their health further exacerbated by the low availability of cooling mechanisms and urban green space (indicators 1.1.1, 2.3.2, and 2.3.3). Agricultural workers in countries with low and medium HDI were among the worst affected by exposure to extreme temperatures, bearing almost half of the 295 billion potential work hours lost due to heat in 2020 (indicator 1.1.4). These lost work hours could have devastating economic consequences to these already vulnerable workers—data in this year’s report shows that the average potential earnings lost in countries in the low HDI group were equivalent to 4–8% of the national gross domestic product (indicator 4.1.3). Through these effects, rising average temperatures, and altered rainfall patterns, climate change is beginning to reverse years of progress in tackling the food and water insecurity that still affects the most underserved populations around the world, denying them an essential aspect of good health. During any given month in 2020, up to 19% of the global land surface was affected by extreme drought; a value that had not exceeded 13% between 1950 and 1999 (indicator 1.2.2). In parallel with drought, warm temperatures are affecting the yield potential of the world’s major staple crops—a 6·0% reduction for maize; 3·0% for winter wheat; 5·4% for soybean; and 1·8% for rice in 2020, relative to 1981–2010 (indicator 1.4.1)—exposing the rising risk of food insecurity. Adding to these health hazards, the changing environmental conditions are also increasing the suitability for the transmission of many water-borne, air-borne, food-borne, and vector-borne pathogens. Although socioeconomic development, public health interventions, and advances in medicine have reduced the global burden of infectious disease transmission, climate change could undermine eradication efforts. The number of months with environmentally suitable conditions for the transmission of malaria (Plasmodium falciparum) rose by 39% from 1950–59 to 2010–19 in densely populated highland areas in the low HDI group, threatening highly disadvantaged populations who were comparatively safer from this disease than those in the lowland areas (indicator 1.3.1). The epidemic potential for dengue virus, Zika virus, and chikungunya virus, which currently primarily affect populations in central America, South America, the Caribbean, Africa, and south Asia, increased globally, with a basic reproductive rate increase of 13% for transmission by Aedes aegypti and 7% for transmission by Aedes albopictus compared with the 1950s. The biggest relative increase in basic reproductive rate of these arboviruses was seen in countries in the very high HDI group (indicator 1.3.1); however, people in the low HDI group are confronted with the highest vulnerability to these arboviruses (indicator 1.3.2). Similar findings are observed in the environmental suitability for Vibrio cholerae, a pathogen estimated to cause almost 100 000 deaths annually, particularly among populations with poor access to safe water and sanitation. Between 2003 and 2019, the coastal areas suitable for V cholerae transmission increased substantially across all HDI country groups—although, with 98% of their coastline suitable to the transmission of V cholerae in 2020, it is people in the low HDI country group that have the highest environmental suitability for this disease (indicator 1.3.1). The concurrent and interconnecting risks posed by extreme weather events, infectious disease transmission, and food, water, and financial insecurity are over-burdening the most vulnerable populations. Through multiple simultaneous and interacting health risks, climate change is threatening to reverse years of progress in public health and sustainable development. Even with overwhelming evidence on the health impacts of climate change, countries are not delivering an adaptation response proportionate to the rising risks their populations face. In 2020, 104 (63%) of 166 countries did not have a high level of implementation of national health emergency frameworks, leaving them unprepared to respond to pandemics and climate-related health emergencies (indicator 2.3.1). Importantly, only 18 (55%) of 33 countries with a low HDI had reported at least a medium level of implementation of national health emergency frameworks, compared with 47 (89%) of 53 countries with a very high HDI. In addition, only 47 (52%) of 91 countries reported having a national adaptation plan for health, with insufficient human and financial resources identified as the main barrier for their implementation (indicator 2.1.1). With a world facing an unavoidable temperature rise, even with the most ambitious climate change mitigation, accelerated adaptation is essential to reduce the vulnerabilities of populations to climate change and protect the health of people around the world.

AN INEQUITABLE RESPONSE FAILS EVERYONE: 10 months into 2021, global and equitable access to the COVID-19 vaccine had not been delivered—more than 60% of people in high-income countries have received at least one dose of a COVID-19 vaccine compared with just 3·5% of people in low-income countries. Data in this report exposes similar inequities in the global climate change mitigation response. To meet the Paris Agreement goals and prevent catastrophic levels of global warming, global greenhouse gas emissions must reduce by half within a decade. However, at the current pace of reduction, it would take more than 150 years for the energy system to fully decarbonise (indicator 3.1), and the unequal response between countries is resulting in an uneven realisation of the health benefits of a low-carbon transition. The use of public funds to subsidise fossil fuels is partly responsible for the slow decarbonisation rate. Of the 84 countries reviewed, 65 were still providing an overall subsidy to fossil fuels in 2018 and, in many cases, subsidies were equivalent to substantial proportions of the national health budget and could have been redirected to deliver net benefits to health and wellbeing. Furthermore, all the 19 countries whose carbon pricing policies outweighed the effect of any fossil fuels subsidies came from the very high HDI group (indicator 4.2.4). Although countries in the very high HDI group have collectively made the most progress in the decarbonisation of the energy system, they are still the main contributors to CO2 emissions through the local production of goods and services, accounting for 45% of the global total (indicator 4.2.5). With a slower pace of decarbonisation and poorer air quality regulations than countries in the very high HDI group, the medium and high HDI country groups produce the most fine particle matter (PM2·5) emissions and have the highest rates of air pollution-related deaths, which are about 50% higher than the total deaths in the very high HDI group (indicator 3.3). The low HDI group, with comparatively lower amounts of industrial activity than in the other groups, has a local production that contributes to only 0·7% of global CO2 emissions, and has the lowest mortality rate from ambient air pollution. However, with only 12% of its inhabitants relying on clean fuels and technologies for cooking, the health of these populations is still at risk from dangerously high concentrations of household air pollution (indicator 3.2). Even in the most affluent countries, people in the most deprived areas over-whelmingly bear the burden of health effects from exposure to air pollution. These findings expose the health costs of the delayed and unequal mitigation response and underscore the millions of deaths to be prevented annually through a low-carbon transition that prioritises the health of all populations. However, the world is not on track to realising the health gains of the transition to a low-carbon economy. Current global decarbonisation commitments are insufficient to meet Paris Agreement ambitions and would lead to a roughly 2·4°C average global temperature increase by the end of the century. The current direction of post-COVID-19 spending is threatening to make this situation worse, with just 18% of all the funds committed for economic recovery from the COVID-19 pandemic by the end of 2020 expected to lead to a reduction of greenhouse gas emissions. Indeed, the economic recovery from the pandemic is already predicted to lead to an unprecedented 5% increase in greenhouse gas emissions in 2021, which will bring global anthropogenic emissions back to their peak amounts. In addition, the current economic recession is threatening to undermine the target of mobilising US$100 billion per year from 2020 onwards to promote low-carbon shifts and adaptation responses in the most underserved countries, even though this quantity is minute compared with the trillions allocated to COVID-19 recovery. The high amounts of borrowing that countries have had to resort to during the pandemic could erase their ability to deliver a green recovery and maximise the health gains to their population of a low-carbon transition.

THE IMPACTS OF CLIMATE CHANGE ON HUMAN HEALTH: The world has observed a 1°C temperature rise above pre-industrial levels, with feedback cycles and polar amplification resulting in a rise as high as 3°C in north western Canada., Eight of the ten hottest years on record have occurred in the past decade. Such rapid change is primarily driven by the combustion of fossil fuels, consumed at a rate of 171 000 kg of coal, 116 000 000 L of gas, and 186 000 L of oil per s.– Progress in mitigating this threat is intermittent at best, with carbon dioxide emissions continuing to rise in 2018. Importantly, many of the indicators contained in this report suggest the world is following this “business as usual” pathway. The carbon intensity of the energy system has remained unchanged since 1990 (indicator 3.1.1), and from 2016 to 2018, total primary energy supply from coal increased by 1·7%, reversing a previously recorded downward trend (indicator 3.1.2). Correspondingly, the health-care sector is responsible for about 4·6% of global emissions, a value which is steadily rising across most major economies (indicator 3.6). Global fossil fuel consumption subsidies increased by 50% over the past 3 years, reaching a peak of almost US$430 billion in 2018 (indicator 4.4.1). A child born today will experience a world that is more than four degrees warmer than the pre-industrial average, with climate change impacting human health from infancy and adolescence to adulthood and old age. Across the world, children are among the worst affected by climate change. Downward trends in global yield potential for all major crops tracked since 1960 threaten food production and food security, with infants often the worst affected by the potentially permanent effects of undernutrition (indicator 1.5.1). Children are among the most susceptible to diarrhoeal disease and experience the most severe effects of dengue fever. Trends in climate suitability for disease transmission are particularly concerning, with nine of the ten most suitable years for the transmission of dengue fever on record occurring since 2000 (indicator 1.4.1). Similarly, since an early 1980s baseline, the number of days suitable for Vibrio (a pathogen responsible for part of the burden of diarrhoeal disease) has doubled, and global suitability for coastal Vibrio cholerae has increased by 9·9% indicator 1.4.1). Through adolescence and beyond, air pollution—principally driven by fossil fuels, and exacerbated by climate change—damages the heart, lungs, and every other vital organ. These effects accumulate over time, and into adulthood, with global deaths attributable to ambient fine particulate matter (PM2·5) remaining at 2·9 million in 2016 (indicator 3.3.2) and total global air pollution deaths reaching 7 million. Later in life, families and livelihoods are put at risk from increases in the frequency and severity of extreme weather conditions, with women among the most vulnerable across a range of social and cultural contexts. Globally, 77% of countries experienced an increase in daily population exposure to wildfires from 2001–14 to 2015–18 (indicator 1.2.1). India and China sustained the largest increases, with an increase of over 21 million exposures in India and 17 million exposures in China over this time period. In low-income countries, almost all economic losses from extreme weather events are uninsured, placing a particularly high burden on individuals and households (indicator 4.1). Temperature rise and heatwaves are increasingly limiting the labour capacity of various populations. In 2018, 133·6 billion potential work hours were lost globally, 45 billion more than the 2000 baseline, and southern areas of the USA lost 15–20% of potential daylight work hours during the hottest month of 2018 (indicator 1.1.4). Populations aged 65 years and older are particularly vulnerable to the health effects of climate change, and especially to extremes of heat. From 1990 to 2018, populations in every region have become more vulnerable to heat and heatwaves, with Europe and the Eastern Mediterranean remaining the most vulnerable (indicator 1.1.1). In 2018, these vulnerable populations experienced 220 million heatwave exposures globally, breaking the previous record of 209 million set in 2015 (indicator 1.1.3). Already faced with the challenge of an ageing population, Japan had 32 million heatwave exposures affecting people aged 65 years and older in 2018, the equivalent of almost every person in this age group experiencing a heatwave. Finally, although difficult to quantify, the downstream risks of climate change, such as migration, poverty exacerbation, violent conflict, and mental illness, affect people of all ages and all nationalities. A business as usual trajectory will result in a fundamentally altered world, with the indicators described providing a glimpse of the implications of this pathway. The life of every child born today will be profoundly affected by climate change. Without accelerated intervention, this new era will come to define the health of people at every stage of their lives.

THE RISING HEALTH TOLL OF A CHANGING CLIMATE: In 2023, the world saw the highest global temperatures in over 100 000 years, and heat records were broken in all continents through 2022. Adults older than 65 years and infants younger than 1 year, for whom extreme heat can be particularly life-threatening, are now exposed to twice as many heatwave days as they would have experienced in 1986–2005 (indicator 1.1.2). Harnessing the rapidly advancing science of detection and attribution, new analysis shows that over 60% of the days that reached health-threatening high temperatures in 2020 were made more than twice as likely to occur due to anthropogenic climate change (indicator 1.1.5); and heat-related deaths of people older than 65 years increased by 85% compared with 1990–2000, substantially higher than the 38% increase that would have been expected had temperatures not changed (indicator 1.1.5). Simultaneously, climate change is damaging the natural and human systems on which people rely for good health. The global land area affected by extreme drought increased from 18% in 1951–60 to 47% in 2013–22 (indicator 1.2.2), jeopardising water security, sanitation, and food production. A higher frequency of heatwaves and droughts in 2021 was associated with 127 million more people experiencing moderate or severe food insecurity compared with 1981–2010 (indicator 1.4), putting millions of people at risk of malnutrition and potentially irreversible health effects. The changing climatic conditions are also putting more populations at risk of life-threatening infectious diseases, such as dengue, malaria, vibriosis, and West Nile virus (indicator 1.3). Compounding these direct health impacts, the economic losses associated with global heating increasingly harm livelihoods, limit resilience, and restrict the funds available to tackle climate change. Economic losses from extreme weather events increased by 23% between 2010–14 and 2018–22, amounting to US$264 billion in 2022 alone (indicator 4.1.1), whereas heat exposure led to global potential income losses worth $863 billion (indicators 1.1.4 and 4.1.3). Labour capacity loss resulting from heat exposure affected low and medium Human Development Index (HDI) countries the most, exacerbating global inequities, with potential income losses equivalent to 6·1% and 3·8% of their gross domestic product (GDP), respectively (indicator 4.1.3). The multiple and simultaneously rising risks of climate change are amplifying global health inequities and threatening the very foundations of human health. Health systems are increasingly strained, and 27% of surveyed cities declared concerns over their health systems being overwhelmed by the impacts of climate change (indicator 2.1.3). Often due to scarce financial resources and low technical and human capacity, the countries most vulnerable to climate impacts also face the most challenges in achieving adaptation progress, reflecting the human risks of an unjust transition. Only 44% of low HDI countries and 54% of medium HDI countries reported high implementation of health emergency management capacities in 2022, compared with 85% of very high HDI countries (indicator 2.2.5). Additionally, low and medium HDI countries had the highest proportion of cities not intending to undertake a climate change risk assessment in 2021 (12%; indicator 2.1.3). These inequalities are aggravated by the persistent failure of the wealthiest countries to deliver the promised modest annual sum of $100 billion to support climate action in those countries defined as developing within the UN Framework Convention on Climate Change. Consequently, those countries that have historically contributed the least to climate change are bearing the brunt of its health impacts—both a reflection and a direct consequence of the structural inequities that lie within the root causes of climate change.

THE HUMAN COSTS OF PERSISTENT INACTION: The growing threats experienced to date are early signs and symptoms of what a rapidly changing climate could mean for the health of the world’s populations. With 1337 tonnes of CO2 emitted each second, each moment of delay worsens the risks to people’s health and survival. In this year’s report, new projections reveal the dangers of further delays in action, with every tracked health dimension worsening as the climate changes. If global mean temperature continues to rise to just under 2°C, annual heat-related deaths are projected to increase by 370% by midcentury, assuming no substantial progress on adaptation (indicator 1.1.5). Under such a scenario, heat-related labour loss is projected to increase by 50% (indicator 1.1.4), and heatwaves alone could lead to 524·9 million additional people experiencing moderate-to-severe food insecurity by 2041–60, aggravating the global risk of malnutrition. Life-threatening infectious diseases are also projected to spread further, with the length of coastline suitable for Vibrio pathogens expanding by 17–25%, and the transmission potential for dengue increasing by 36–37% by midcentury. As risks rise, so will the costs and challenges of adaptation. These estimates provide some indication of what the future could hold. However, poor accounting for non-linear responses, tipping points, and cascading and synergistic interactions could render these projections conservative, disproportionately increasing the threat to the health of populations worldwide.

A WORLD ACCELERATING IN THE WRONG DIRECTION: The health risks of a 2°C hotter world underscore the health imperative of accelerating climate change action. With limits to adaptation drawing closer, ambitious mitigation is paramount to keep the magnitude of health hazards within the limits of the capacity of health systems to adapt. Yet years of scientific warnings of the threat to people’s lives have been met with grossly insufficient action, and policies to date have put the world on track to almost 3°C of heating. The 2022 Lancet Countdown report highlighted the opportunity to accelerate the transition away from health-harming fossil fuels in response to the global energy crisis. However, data this year show a world that is often moving in the wrong direction. Energy-related CO2 emissions increased by 0·9% to a record 36·8 Gt in 2022 (indicator 3.1.1), and still only 9·5% of global electricity comes from modern renewables (mainly solar and wind energy), despite their costs falling below that of fossil fuels. Concerningly, driven partly by record profits, oil and gas companies are further reducing their compliance with the Paris Agreement: the strategies of the world’s 20 largest oil and gas companies as of early 2023 will result in emissions surpassing levels consistent with the Paris Agreement goals by 173% in 2040—an increase of 61% from 2022 (indicator 4.2.6). Rather than pursuing accelerated development of renewable energy, fossil fuel companies allocated only 4% of their capital investment to renewables in 2022. Meanwhile, global fossil fuel investment increased by 10% in 2022, reaching over $1 trillion (indicator 4.2.1). The expansion of oil and gas extractive activities has been supported through both private and public financial flows. Across 2017–21, the 40 banks that lend most to the fossil fuel sector collectively invested $489 billion annually in fossil fuels (annual average), with 52% increasing their lending from 2010–16. Simultaneously, in 2020, 78% of the countries assessed, responsible for 93% of all global CO2 emissions, still provided net direct fossil fuels subsidies totalling $305 billion, further hindering fossil fuel phase-out (indicator 4.2.4). Without a rapid response to course correct, the persistent use and expansion of fossil fuels will ensure an increasingly inequitable future that threatens the lives of billions of people alive today.

THE OPPORTUNITY TO DELIVER A HEALTHY FUTURE FOR ALL: Despite the challenges, data also expose the transformative health benefits that could come from the transition to a zero-carbon future, with health professionals playing a crucial role in ensuring these gains are maximised. Globally, 775 million people still live without electricity, and close to 1 billion people are still served by health-care facilities without reliable energy. With structural global inequities in the development of, access to, and use of clean energy, only 2·3% of electricity in low HDI countries comes from modern renewables (against 11% in very high HDI countries), and 92% of households in low HDI countries still rely on biomass fuels to meet their energy needs (against 7·5% in very high HDI countries; indicators 3.1.1 and 3.1.2). In this context, the transition to renewables can enable access to decentralised clean energy and, coupled with interventions to increase energy efficiency, can reduce energy poverty and power high quality health-supportive services. By reducing the burning of dirty fuels (including fossil fuels and biomass), such interventions could help avoid a large proportion of the 1·9 million deaths that occur annually from dirty-fuel-derived, outdoor, airborne, fine particulate matter pollution (PM2·5; indicator 3.2.1), and a large proportion of the 78 deaths per 100 000 people associated with exposure to indoor air pollution (indicator 3.2.2). Additionally, the just development of renewable energy markets can generate net employment opportunities with safer, more locally available jobs. Ensuring countries, particularly those facing high levels of energy poverty, are supported in the safe development, deployment, and adoption of renewable energy is key to maximising health gains and preventing unjust extractive industrial practices that can harm the health and livelihoods of local populations and widen health inequities. With fossil fuels accounting for 95% of road transport energy (indicator 3.1.3), interventions to enable and promote safe active travel and zero-emission public transport can further deliver emissions reduction, promote health through physical activity, and avert many of the 460 000 deaths caused annually by transport-derived PM2·5 pollution (indicator 3.2.1), and some of the 3·2 million annual deaths related to physical inactivity. People-centred, climate-resilient urban redesign to improve building energy efficiency, increase green and blue spaces, and promote sustainable cooling, can additionally prevent heat-related health harms, avoid air-conditioning-derived emissions (indicator 2.2.2), and provide direct physical and mental health benefits. Additionally, food systems are responsible for 30% of global greenhouse gas (GHG) emissions, with 57% of agricultural emissions in 2020 being derived from the production of red meat and milk (indicator 3.3.1). Promoting and enabling equitable access to affordable, healthy, low-carbon diets that meet local nutritional and cultural requirements can contribute to mitigation, while preventing many of the 12·2 million deaths attributable to suboptimal diets (indicator 3.3.2). The health community could play a central role in securing these benefits, by delivering public health interventions to reduce air pollution, enabling and supporting active travel and healthier diets, and promoting improvements in the environmental conditions and commercial activities that define health outcomes. Importantly, the health sector can lead by example and transition to sustainable, resource-efficient, net-zero emission health systems, thereby preventing its 4·6% contribution to global GHG emissions, with cascading impacts ultimately affecting the broader economy (indicator 3.4). Some encouraging signs of progress offer a glimpse of the enormous human benefits that health-centred action could render. Deaths attributable to fossil-fuel-derived air pollution have decreased by 15·7% since 2005, with 80% of this reduction being the result of reduced coal-derived pollution. Meanwhile the renewable energy sector expanded to a historical high of 12·7 million employees in 2021 (indicator 4.2.2); and renewable energy accounted for 90% of the growth in electricity capacity in 2022 (indicator 3.1.1). Supporting this, global clean energy investment increased by 15% in 2022, to $1·6 trillion, exceeding fossil fuel investment by 61% (indicator 4.2.1); and lending to the green energy sector rose to $498 billion in 2021, approaching fossil fuel lending (indicator 4.2.7). Scientific understanding of the links between health and climate change is rapidly growing, and although coverage lags in some of the most affected regions, over 3000 scientific articles covered this topic in 2022 (indicators 5.3.1 and 5.3.2). Meanwhile, the health dimensions of climate change are increasingly acknowledged in the public discourse, with 24% of all climate change newspaper articles in 2022 referring to health, just short of the 26% in 2020 (indicator 5.1). Importantly, international organisations are increasingly engaging with the health co-benefits of climate change mitigation (indicator 5.4.2), and governments increasingly acknowledge this link, with 95% of updated Nationally Determined Contributions (NDCs) under the Paris Agreement now referring to health—up from 73% in 2020 (indicator 5.4.1). These trends signal what could be the start of a life-saving transition.

A DEBILITATED FIRST LINE OF DEFENCE: With the worsening health impacts of climate change compounding other coexisting crises, populations worldwide increasingly rely on health systems as their first line of defence. However, just as the need for healthcare rises, health systems worldwide are debilitated by the effects of the COVID-19 pandemic and the energy and cost-of-living crises. Urgent action is therefore needed to strengthen health-system resilience and to prevent a rapidly escalating loss of lives and to prevent suffering in a changing climate. However, only 48 (51%) of 95 countries reported having assessed their climate change adaptation needs (indicator 2.1.1) and, even after the profound impacts of COVID-19, only 60 (63%) countries reported a high to very high implementation status for health emergency management in 2021 (indicator 2.2.4). The scarcity of proactive adaptation is shown in the response to extreme heat. Despite the local cooling and overall health benefits of urban greenspaces, only 277 (27%) of 1038 global urban centres were at least moderately green in 2021 (indicator 2.2.3), and the number of households with air conditioning increased by 66% from 2000 to 2020, a maladaptive response that worsens the energy crisis and further increases urban heat, air pollution, and greenhouse gas emissions. As converging crises further threaten the world’s life-supporting systems, rapid, decisive, and coherent intersectoral action is essential to protect human health from the hazards of the rapidly changing climate.

HEALTH AT THE MERCY OF FOSSIL FUELS: The year 2022 marks the 30th anniversary of the signing of the UN Framework Convention on Climate Change, in which countries agreed to prevent dangerous anthropogenic climate change and its deleterious effects on human health and welfare. However, little meaningful action has since followed. The carbon intensity of the global energy system has decreased by less than 1% since the UNFCCC was established, and global electricity generation is still dominated by fossil fuels, with renewable energy contributing to only 8·2% of the global total (indicator 3.1). Simultaneously, the total energy demand has risen by 59%, increasing energy-related emissions to a historical high in 2021. Current policies put the world on track to a catastrophic 2·7°C increase by the end of the century. Even with the commitments that countries set in the Nationally Determined Contributions (NDCs) updated up until November 2021, global emissions could be 13·7% above 2010 levels by 2030—far from the 43% decrease from current levels required to meet Paris Agreement goals and keep temperatures within the limits of adaptation. Fossil fuel dependence is not only undermining global health through increased climate change impacts, but also affects human health and wellbeing directly, through volatile and unpredictable fossil fuel markets, frail supply chains, and geopolitical conflicts. As a result, millions of people do not have access to the energy needed to keep their homes at healthy temperatures, preserve food and medication, and meet the seventh Sustainable Development Goal (to ensure access to affordable, reliable, sustainable, and modern energy for all). Without sufficient support, access to clean energy has been particularly slow in low HDI countries, and only 1·4% of their electricity came from modern renewables (mostly wind and solar power) in 2020 (indicator 3.1). An estimated 59% of healthcare facilities in low and middle-income countries still do not have access to the reliable electricity needed to provide basic care. Meanwhile, biomass accounts for as much as 31% of the energy consumed in the domestic sector globally, mostly from traditional sources—a proportion that increases to 96% in low HDI countries (indicator 3.2). The associated burden of disease is substantial, with the air in people’s homes exceeding WHO guidelines for safe concentrations of small particulate air pollution (PM2·5) in 2020 by 30-fold on average in the 62 countries assessed (indicator 3.2). After 6 years of improvement, the number of people without access to electricity increased in 2020 as a result of the socioeconomic pressures of the COVID-19 pandemic. The current energy and cost-of-living crises now threaten to reverse progress toward affordable, reliable, and sustainable energy, further undermining the socioeconomic determinants of health. Simultaneously, oil and gas companies are registering record profits, while their production strategies continue to undermine people’s lives and wellbeing. An analysis of the production strategies of 15 of the world’s largest oil and gas companies, as of February 2022, revealed they exceed their share of emissions consistent with 1·5°C of global heating (indicator 4.2.6) by 37% in 2030 and 103% in 2040, continuing to undermine efforts to deliver a low carbon, healthy, liveable future. Aggravating this situation even further, governments continue to incentivise fossil fuel production and consumption: 69 (80%) of 86 countries reviewed had net-negative carbon prices (ie, provided a net subsidy to fossil fuels) for a net total of US$400 billion in 2019, allocating amounts often comparable with or even exceeding their total health budgets (indicator 4.2.4). Simultaneously, wealthier countries failed to meet their commitment of mobilising the considerably lower sum of $100 billion annually by 2020 as agreed at the 2009 Copenhagen Accord to support climate action in “developing countries”, and climate efforts are being undercut by a profound scarcity of funding (indicator 2.1.1). The impacts of climate change on global economies, together with the recession triggered by COVID-19 and worsened by geopolitical instability, could paradoxically further reduce the willingness of countries to allocate the funds needed to enable a just climate transition.

A HEALTH-CENTRED RESPONSE FOR A THRIVING FUTURE: The world is at a critical juncture. With countries facing concurrent crises, the implementation of long-term emissions-reduction policies risks being deflected or defeated by challenges wrongly perceived as more immediate. Addressing each of the concurrent crises in isolation risks alleviating one, while worsening another. Such a situation is emerging from the response to COVID-19, which has so far has not delivered the green recovery that the health community proposed, and, on the contrary, is aggravating climate change-related health risks. Less than one third of $3·11 trillion allocated to COVID-19 economic recovery is likely to reduce greenhouse gas emissions or air pollution, with the net effect likely to increase emissions. The COVID-19 pandemic affected climate action at the city level, and 239 (30%) of 798 cities reported that COVID-19 reduced financing available for climate action (indicator 2.1.3). As countries search for alternatives to Russian oil and gas, many continue to favour the burning of fossil fuels, with some even turning back to coal. Shifts in global energy supplies threaten to increase fossil fuel production. Even if implemented as a temporary transition, these responses could reverse progress on air quality improvement, irreversibly push the world off track from meeting the commitments set out in the Paris Agreement, and guarantee a future of accelerated climate change that threatens human survival. On the contrary, in this pivotal moment, a health-centred response to the current crises would still provide the opportunity for a low-carbon, resilient future, which not only avoids the health harms of accelerated climate change, but also delivers improved health and wellbeing through the associated co-benefits of climate action. Such response would see countries promptly shifting away from fossil fuels, reducing their dependence on fragile international oil and gas markets, and accelerating a just transition to clean energy sources. A health-centred response would reduce the likelihood of the most catastrophic climate change impacts, while improving energy security, creating an opportunity for economic recovery, and offering immediate health benefits. Improvements in air quality would help to prevent the 1·2 million deaths resulting from exposure to fossil fuel-derived ambient PM2·5 in 2020 alone (indicator 3.3), and a health-centred energy transition would enhance low-carbon travel and increase urban green spaces, promoting physical activity, and improving physical and mental health. In the food sector, an accelerated transition to balanced and more plant-based diets would not only help reduce the 55% of agricultural sector emissions coming from red meat and milk production (indicator 3.5.1), but also prevent up to 11·5 million diet-related deaths annually (indicator 3.5.2), and substantially reduce the risk of zoonotic diseases. These health-focused shifts would reduce the burden of communicable and non-communicable diseases, reducing the strain on overwhelmed health-care providers. Importantly, accelerating climate change adaptation would lead to more robust health systems, minimising the negative impacts of future infectious disease outbreaks and geopolitical conflicts, and restoring the first line of defence of global populations.

EMERGING GLIMMERS OF HOPE: Despite decades of insufficient action, emerging, albeit few, signs of change provide some hope that a health-centred response might be starting to emerge. Individual engagement with the health dimensions of climate change, essential to drive and enable an accelerated response, increased from 2020 to 2021 (indicator 5.2), and coverage of health and climate change in the media reached a new record high in 2021, with a 27% increase from 2020 (indicator 5.1). This engagement is also reflected by country leaders, with a record 60% of 194 countries focusing their attention on the links between climate change and health in the 2021 UN General Debate, and with 86% of national updated or new NDCs making references to health (indicator 5.4). At the city level, local authorities are progressively identifying risks of climate change on the health of their populations (indicator 2.1.3), a first step to delivering a tailored response that strengthens local health systems. Although the health sector is responsible for 5·2% of all global emissions (indicator 3.6), it has shown impressive climate leadership, and 60 countries had committed to transitioning to climate-resilient and/or low-carbon or net-zero carbon health systems as part of the COP26 Health Programme, as of July, 2022. Signs of change are also emerging in the energy sector. Although total clean energy generation remains grossly insufficient, record high levels were reached in 2020 (indicator 3.1). Zero-carbon sources accounted for 80% of investment in electricity generation in 2021 (indicator 4.2.1), and renewable energies have reached cost parity with fossil fuel energies. As some of the highest emitting countries attempt to cut their dependence on oil and gas in response to the war in Ukraine and soaring energy prices, many are focusing on increasing renewable energy generation, raising hopes for a health-centred response. However, increased awareness and commitments should be urgently translated into action for hope to turn into reality.