“It is time to treat the climate and nature crisis as a global health emergency,” says a call to action published in over 200 health journals in the run up to the 2023-24 COP meetings on climate change and biodiversity.

Dr Zulfiqar A. Bhutta, Founding Director of the Centre of Excellence in Women and Child Health and the Institute for Global Health and Development at the Aga Khan University (AKU), is all too familiar with how factors beyond the traditional sphere of health – whether in food security, conflict or climate – affect the most vulnerable. On World Children’s Day, he explores how to improve the situation of mothers and children.

Who bears the brunt?

“Some of the challenges around gender, particularly the heat effects of climate, are not well known. And even if they are recognised, there aren't many solutions in place.”

Women are more likely than men to work from home, and poorer-quality housing, lacking electricity to power fans, or running water, traps many in inescapable heat. Moreover, those without an indoor latrine may not drink water to avoid having to urinate during long days inside. In a heat wave, this significantly increases the risks of dehydration and death.

For pregnant women, extreme heat increases the risk of miscarriage, early labour and birth complications. Globally over 20 percent of children under five are stunted, but this is not all a consequence of inadequate nutrition:

“Heat exposure in pregnant women has an enormous impact on birth outcomes, potentially even intergenerational effects,” says Dr Bhutta. “In Pakistan, we've discovered that a lot of the childhood stunting in the last decade or two is actually related to potential exposure to environmental heat. Infant mortality rates may increase by a quarter due to the effects of climate change. But this is preventable. We hold the strings of solutions in our hands.”

Changing rainfall patterns are affecting crops and causing malnutrition, with women often particularly deprived when household resources are limited. When food is scarce, they eat less than men.

When floods or other climate-exacerbated disasters destroy or prevent access to healthcare provision, or even force community displacement, the health implications are significant. Climate change also increases the spread of vector- and water-borne illnesses like dengue fever and typhoid. “If you are water-insecure, you can well imagine the risk to agriculture and food security, and the consequences as diarrhoeal disorders go up.”

Dr Bhutta adds, “Some of the mental health stresses that climate change poses are disproportionately clustered amongst young people, because they don't see a future in the wake of climate change. They get impacted by this much more than somebody who's already in their 80s or 90s.”

How can health studies create change?

Dr Bhutta has been working in child and maternal health since the 1970s, saying “Women and children, particularly young children, need to be at the centre of the sustainable development goals for us to reach our human capital potential.”

One of his early studies found that in South Asia, over half of newborn and infant deaths occurred in village or rural settings, in the areas with fewest health service providers. He tested whether encouraging Pakistan’s Lady Health Workers to undertake outreach with groups of pregnant women could reduce neonatal mortality in rural Sindh and saw such a significant reduction of stillbirths and neonatal mortality that he sent his team to recheck their numbers. India would soon adopt this practice for its Asha health workers, demonstrating how large-scale implementation research can influence policy and affect entire populations.

As he nears the end of his four decades at AKU, with an array of awards and top-level positions to his name, Dr Bhutta is leading three international studies to improve child and adolescent health and nutrition, address women and children’s health in humanitarian and conflict settings, and tackle the challenges of climate change and health for women and children in at-risk populations in South Asia. How did he incorporate such varied factors when working to improve maternal and child health?

What else can protect the vulnerable?

When the 2010 floods displaced close to 10 million people in Pakistan, his research group at AKU established health camps that treated over a million people. “It became very clear to me at that time that there were several things outside of the mainstream health system that impacted the health, well-being and nutrition of women and children. One of those was climate change. Another was that problems in fragile populations such as conflicts or displacement also had a big influence on what we could or could not do. Almost 40 percent of the burden of deaths in children and women and newborns are in geographies affected by polycrises, not a single problem. So I started to think about what could be done in terms of building resilience.

“In Pakistan some eight years ago, there was an extreme heat event in Karachi that killed about one and a half thousand people in a single day, more than half of them children. And that happened because nobody was prepared for it. Nobody recognised the challenges of families and children living in urban slums which become like ovens in the heat of the summer.

“That led to governmental interventions like hotlines, emergency services and early warning systems. But communities also organised themselves to build in resilience with both water supply and volunteers who could protect those who were at greatest risk. We have had events since which have been just as severe. Yet the mortality was nowhere near as high. We think that we can further improve the organisation of rural communities around protecting women, children and the elderly from the consequences of climate.”

Dr Bhutta sees an advocacy role for paediatricians like himself. “We can’t just observe what is happening. We need to be in the frontline of the debate with politicians in terms of how important this is to address, and to make sure that strategies are evidence-based. You can’t give a pill for climate change. Nobody's going to wait 30 years for carbon emissions to come down and then the impact becoming visible downstream.

“You’ve got to impact lives and livelihoods. We need social protection, support for individuals impacted by climate change, which is not necessarily within the purview of health ministries. Working with our rural communities around agriculture, food security and biodiversity is going to be a very important part of the climate response. And building strategic collaborations with other partners and programmes is extremely important.

“The northern and southern hemispheres are not different worlds. Climate change impacts everybody and the consequences don't need passports or visas.”