The health dimension of vulnerability to extreme events includes differential physical, physiological and mental health effects in different regions and on different social groups. It also includes the possible impact of extreme weather events on the provision of health services (e.g., infrastructure and facilities). Vulnerability can also be understood in terms of functionality related to communication, medical care, maintaining independence, supervision and transportation [5
]. The public health policies for adaptation to extreme climate events essentially require sound and effective preparedness for response to heat waves, cold spells, floods and droughts.
In particular, health policies that address the special needs of vulnerable groups must be identified, and where necessary, given special attention. In general, policy recommendations should address at least five areas: early detection of extreme weather events, preparedness of the health systems, monitoring of morbidity and mortality, public education and the living environment. These recommendations are grounded in the review of the literature presented in previous sections of this paper, along with our own insights into Israeli society and its policy development processes. In light of the space constraints of a journal article, these recommendations are perforce presented in general terms and could easily be elaborated in appropriate forums.
Early detection of extreme weather events
The meteorological services are responsible for the updated alerts on the possibility of extreme weather events. Thus, a prerequisite for any monitoring system for the early detection of extreme weather events is productive collaboration between the meteorological service and the health authorities. An action plan should be developed, containing definitions of "changes in the level of alertness and action" for the preparedness for heat waves and cold spells. Exercises on an annual basis should be carried out to evaluate the functioning and quality of the alert system.
Preparedness of the health system
Policy recommendations should address the emergency services’ delivery, governance and regulations, the health workforce, medical products, financing and assisting other countries in addressing the health effects of climate change. Special attention should be given to people with limited ability and who are unable to leave their homes independently. During heat waves and cold spells, all individuals in the high risk groups should be contacted personally by employees of the Ministry of Welfare, either by telephone or a home visit. In case of need, those individuals should be evacuated to hospitals or to air-conditioned public places. This should be done in addition to, and not instead of, the current recommendation that family members should visit individuals in risk groups, such as older persons, on hot days.
Moreover, the Israel Ministry of Health defined heat wave as sequentially three days or more with at least 32.2°C. According to their report, extreme heat wave occurs when the temperature is 30°C and the relative humidity is at least 70%, or when the relative humidity is lower but the temperatures are higher [64
]. Since these conditions exist in many parts of the country along the whole summer, we call for a more relevant new definition.
There is a need for a monitoring system for the health effects of climate change, including indices of total and cause-specific morbidity and mortality. As soon as a heat/cold wave begins, causes of morbidity and mortality should be reported to a central department in the Ministry of Health within 48 hours (Figure ). The data should be analyzed and reviewed on a daily basis. This applies to both hospitals and community health clinics. Registers of the demographic details and geographic location of vulnerable groups and individuals should be maintained and updated regularly; (elderly, children, chronically ill, people with special needs, outdoor workers) (Figure ). At the same time, it should be kept in mind that the experience in other countries suggests that the development of such registries can be challenging, but that these challenges can be overcome with adequate resources and ingenuity.
Recommended data needs for preparedness for extreme weather events.
Recommended registries of the demographic details and geographic location of vulnerable groups and individuals that should be maintained and updated regularly (older persons, children, chronically ill, people with special needs, outdoor workers).
There is a need for improved educational programs for the public and for health professionals on how to adapt to the changes in the climate. Guidelines for behavior in case of heat waves and cold spells for the general public, as well as guidelines for the proper treatment of heat and cold injuries in hospitals, have been published by the Israel Ministry of Health [63
]. These materials should be updated regularly and made more accessible to the public. They should be displayed clearly in emergency rooms and primary care clinics. In addition, these guidelines should be included in the teaching curriculum for medical students and other health professionals. No guidelines for public workers have been published regarding the identification of the onset of heat-related illness and the guidelines for prevention. Such guidelines should be developed and displayed.
The living environment
The potential impact of climate change requires a conceptual adjustment in the way buildings and cities can be adapted (shade, wind exposure, thermal comfort, adjustment to extreme events such as floods and sea level rise, etc.). Currently, health aspects are not given sufficient consideration in existing compulsory building regulations. It is important that the building codes will require new buildings to be designed to comply with green standards [98
] considering design strategies, such as improved insulation, window shading, thermal mass and natural ventilation. This is not only for mitigation and energy saving, but also to achieve indoor air quality and thermal comfort throughout the year and to ensure that they remain relatively cool in case of a heat wave. In addition, there is a need to reduce dependence on air conditioning (through shading and natural ventilation) which makes high and increasingly unsustainable demands on energy.
Special consideration should be given to existing buildings, offering incentives to perform green retrofit and to adapt them to updated green standards, improving the building envelope to reduce energy consumption and improve thermal comfort. The use of energy-efficient heating, ventilation and air-conditioning (HVAC) systems to achieve thermal comfort during extreme events should be encouraged.
Open areas, parks and streets can provide a vital space for public urban life throughout the entire year. The public’s successful use and enjoyment of this space depends heavily on microclimatic conditions that affect thermal comfort. Appropriate comprehensive planning should consider ways of bringing together the different urban components to make use of renewable energy sources for passive heating and cooling of buildings, to reduce the heat island effect (the built-up areas that are hotter than nearby rural areas) and to create open spaces that can provide enjoyment and sustain a healthy urban lifestyle.
The Israeli government has started taking steps toward the achievement of this goal, but has reduced its investment in the plan due to budgetary considerations [99
]. This plan should be updated and reactivated as it is likely to enhance both mitigation and adaptation efforts for climate change and to reduce the severity of its predicted health effects. Shelters should be continually maintained and improved so that they can be used for homeless people in case of a heat wave. Individuals from risk groups should be housed in buildings that are well-designed, properly insulated and equipped with air conditioning. All public spaces should be designed in accordance with green standards, including those proposed by the Israel Green Building Council, and should ensure the thermal comfort of users. Shading and ventilation should be provided in open spaces, particularly during the hot season [100