Personal View

Framing climate change as a human health issue: enough to

tip the scale in climate policy?
Verena Rossa-Roccor, Amanda Giang, Paul Kershaw

Almost four decades of climate science have not yet led to transformative policy change at the pace and scale required Lancet Planet Health 2021;
to confront the climate crisis. Colleagues in the planetary health community attribute much potential to framing 5: e553–59

climate change as human health issue in order to create greater impact on policy makers. In this Personal View, we Institute for Resources,
Environment and
discuss the promise and limitations of this approach by drawing on insights from political science and public policy
Sustainability
with regards to the complexity of these contentious policy issues. We argue that we, as academics, have a moral (V Rossa-Roccor MD,
obligation to embrace an active role in the knowledge-to-action (KTA) sphere and that we would be well advised to A Giang PhD) and School of
expand our KTA approach to include evidence-based strategies, such as lobbying or civil resistance. As scientists, we Population and Public Health
(P Kershaw PhD), University of
can no longer wait to embrace the realpolitik insights of political science to move our evidence into policy action. British Columbia, Vancouver,
BC, Canada; Generation
Introduction The wickedness of climate policy Squeeze, Vancouver, BC,
Our planetary health community experienced a magical The answer lies, partly, in the complexity of climate change Canada (P Kershaw)

moment at the 2017 Inaugural Global Meeting of the
Planetary Health Alliance. In a plenary session titled
Making Change, Eriel Tchekwie Deranger, a member of
the Athabasca Chipewyan First Nation and Executive
Director of Indigenous Climate Action, achieved
something we had never seen before in such a setting.
When she finished her talk about the devastating impact
of the Alberta oil sands, one of the world’s largest and
most destructive industrial projects, on the lives of her
people, we looked around the audience: everyone had
tears in their eyes and offered standing ovations.
This moment of collective emotional response
strengthened our impression of the community as being
one of highly engaged and motivated individuals who care
deeply about the natural environment and whose
professional lives are dedicated to protecting it. We work
very hard to produce high-quality, impactful evidence, in
the hopes that this evidence will be useful to policy makers.
We issue countless calls to action and provide suggestions
for policies that could mitigate the impact of environ­
mental destruction on human health.1,2 Because of its
global scale, the expected increase of its severity, and its
inequitable impact, we have identified climate change as
the biggest global health threat of the 21st century.3
The evidence on the health impacts of climate change is
clear—the effects are “large, increasing, and inequitably
distributed”.4 Climate change also contributes to and
exacerbates other severe environmental health issues such
as air pollution, which causes almost 7 million deaths
annually.5 Not least because of the vast co-benefits of its
mitigation, tackling climate change has been discussed as
the greatest global health opportunity of our times.2
And yet, the response by governments remains
inadequate to the urgency and scale of the problem that
the evidence suggests. Indeed, carbon emissions continue
to rise and the world largely seems to be following the
“business as usual” pathway.2 Almost four decades of
ever-progressing climate science have not led to
transformative policy change at the pace or scale required
to confront this crisis. Why is that?
as a policy issue. Climate change ticks all the boxes of a Correspondence to:
Dr Verena Rossa-Roccor, Institute
so-called super-wicked problem. These problems are
for Resources, Environment and
characterised by enormous interdependencies, uncertain­ Sustainability, University of
ties, circularities, conflicting stakeholder interests, absence British Columbia, Vancouver
of institutional governance, inequitable distribution of V6T1Z4, BC, Canada
verena.rossa-roccor@ubc.ca
responsibility and burden, and urgency.6,7 This perfect
storm of challenges renders simplistic policy solutions
short-sighted and inevitably opens doors for diverging
ideologies, contention, and competing interests.
Although climate change is a global challenge, the
implementation of global climate agreements remains
grossly inadequate and leaves the responsibility up to
individual nations and regions. Ironically, the nations
who contribute the most to the problem, and whose
actions would, therefore, have the most impact, are those
who have been least affected by climate change in the
past. In turn, countries with the most interest in
mitigation are the least powerful in terms of effecting
change.6,8
There is also a temporal challenge that complicates the
synchronisation of policy and climate change. Climate
change requires us to fully address the long-term costs we
have created so that these are not unfairly left to future
generations, something that policy makers who operate
in short election cycles are generally reluctant to do.7,9 To
add to the complexity, even if a government succeeds in
implementing climate policies, these policies can be
reversed long before they have an effect because of
fluctuations in political leadership, interests, and goals.6
Finally, the climate change movement has been faced
with a very powerful countermovement, whose influence
on the public, and political opinion and action, cannot be
overstated. Energy-intensive industries, certain political
parties, and other affiliated organisations have been
incredibly successful in dispersing doubt about the issue
despite strong evidence linking fossil fuel activities to the
global burden of mortality and disease.10 By leveraging
the inherent uncertainties in climate science, these
players continue to promote climate change denial
and scepticism.11–14 As a result, many individuals do not

www.thelancet.com/planetary-health Vol 5 August 2021 e553

 Personal View
understand climate change as an urgent issue of today
but rather see it as an abstract, environmental issue that
hardly affects their everyday lives. Conversely, these
individuals feel very strongly about the immediate impact
of policies that aim to mitigate climate change, often
perceiving them as constraints on their freedom or their
wallets. We need to be most aware that this framing of
the economy versus climate action has been intentionally
created and pushed by very powerful players who have a
vested interest in continued economic growth and are
largely responsible for the climate crisis to begin with.15,16
Against such powerful interests, evidence alone stands
little chance.17
Does the solution lie in framing climate change
as an issue of human health?
To counter these challenges, many health researchers and
practitioners argue that framing climate change as a
human health issue as well as an environ­mental issue has
much potential to prompt transformative policy change.2,4
Framing has been described as selecting “some aspects of
a perceived reality and make them more salient in a
communicating text, in such a way as to promote a
particular problem definition, causal interpretation, moral
evaluation, and/or treatment recom­ mendation for the
item described”.18 In other words, it is an emphasis on
different aspects of an issue with the goal of shaping
people’s opinion about the issue. Framing is an inevitable
part of human interaction that has been found to influence
individual decision making and, as such, is used
intentionally in politics and the media.19
Perhaps the biggest hypothesised advantage of framing
climate change as a human health issue is that people
across the political spectrum, including politicians,
generally care about their health and that of their loved
ones (or constituents). Therefore, we hope that, by
focusing on the impact of climate change on human
health in our research and science communication
efforts, we can take the issue out of the contentious and
ideology-driven context in which climate change policy
finds itself.20 This shift would allow for more substantive
support across the political spectrum and would
ultimately lead to more impactful policies than have been
achieved previously.21
However, health itself is not free from values or
ideology. Neoliberal ideologies in countries such as
Canada, the USA, or the UK often portray health as an
economic commodity where health inequities are
“accepted as inevitable results of individual differences”
rather than as something that should be tackled by state
interventions.22,23 As such, health, like climate change, is
a concept that is rather entrenched with one’s value
system.24,25 The powerful and strategic climate change
countermovement has long understood the importance
of emotions, beliefs, and group identities in the creation
of meaning or in undermining acceptance of the
evidence, and it has used this knowledge to its advantage
e554
very successfully. For example, one study showed that
framing the climate crisis in terms of public health did
not affect the beliefs of people in the USA about the
positive effects of climate policies. Additionally, when
presented with a climate change denial counter-frame,
both the belief in the reality of anthropogenic climate
change and support of mitigating policies dropped
substantially.26 It can be expected that, once the health
framing gets more traction in the public discourse, the
countermovement will undoubtedly ramp up its efforts
to denounce the message.
Another advantage might be that, rather than speaking
of uncertain future events and an abstract and global
concept, the health framing brings climate change close
to home by making it local, short-term, and personal.2,4,27,28
We believe that, by making climate change more of a
personal problem, the public will be motivated to put
pressure on policy makers to safeguard their health
through climate policy. However, some research points at
a paradox that questions this strategy. Due to the
perception of climate change as a global problem, there
is scepticism that local efforts to reduce the carbon
footprint can meaningfully reduce risks that have global,
rather than local, sources. As a result, there is less
support for local climate mitigation actions.29
A lot of work remains to be done in creating a general
awareness among the public about the health impacts of
climate change. Many people are not aware of the
concrete pathways through which these effects occur, nor
are they aware that they themselves may be directly
affected rather than people living in regions of the world
that are perceived as more vulnerable to climate change.30
As a result, there is currently only moderate support for
more pronounced climate policy action as a public health
measure.31 Moreover, we need to be cautious about the
assumption that, just because people are aware of the
immediate impacts on their own lives, they will act upon
this knowledge—either in terms of their own ecological
behaviour or their support for certain policy initiatives.
Decades of health promotion research and interventions
show that being aware of the threats to one’s health is not
necessarily an effective driver in changing behaviour.32
There is also another risk in making climate change
more personal: focusing on the individual distracts from
the responsibility of politicians and instead puts the
blame on the behaviour of the individual rather than on
the system as a whole. This focus on the individual is
predictably pushed by the heavy emitters in the industry,
who claim to be only reacting to market demand.17
Unfortunately, public health is not immune to this way
of thinking. Although it has been shown that public
policies considerably shape public health,33 the dominant
paradigm of the field understands health as a biomedical
concept under a pathogenic epistemology. Therefore,
social policies are rarely at the forefront of solutions to
population health challenges.23,34 If the public health
community were indeed to contribute to a shift in climate
www.thelancet.com/planetary-health Vol 5 August 2021

policy, it would first need to embrace its own field as one
that is profoundly political—arguably, a mammoth task
in and of itself.34
Health professionals are among the most trusted
members of society—more so than environmental
scientists.2,31,35 The question of who is trusted is crucial
because trust strongly correlates with the uptake of
public and private climate-friendly behaviour.36 The
health professions have historically embraced their role
as advocates and many influential professional asso­
ciations, such as the American Medical Association or
the Canadian Public Health Association, clearly include
their members’ mandate to advocate for climate change
mitigation.37 There is now even discussion on whether
the health community should take a planetary health
pledge based on the Declaration of Geneva that
“considers the vitality of the planet as a bedrock for
human wellbeing”.38 However, the public health
community is not yet living up to its potential. Most
progress has been made in conventional activities, such
as improving assessments and monitoring systems as
well as expanding the evidence base on the link between
climate change and health, which lie well within the
traditional role of public health and thus do not require
a paradigmatic change.39 The impact on climate
mitigation policy, on the other hand, has produced
mixed results at best. Fox and colleagues ascribe this
outcome to “vested economic interests and structural
political issues”.39 We would argue that it can also be
attributed to insuf­fi­ciently effective advocacy strategies.40
The public health community still largely operates
within a narrow aetiological framework concerning
climate change and health, and lacks the necessary
leadership to expand public health to become a leader in
climate policy advocacy.41,42
Finally, the health framing should be understood as
integrative with other emerging frames. The inequity
between climate change perpetrators and victims
establishes climate change as an ethical, social justice,
and human rights issue. The UN Special Rapporteur on
Human Rights and the Environment ascertains that:
“Climate change interacts with poverty, conflict, resource
depletion and other factors to cause or exacerbate food
insecurity, loss of livelihoods, infrastructure breakdown
and loss of access to essential services including
electricity, water, sanitation and health care. Poor people
are disproportionately affected by climate impacts, which
could push an additional 100 million people into extreme
poverty by 2030”.8 Importantly, this divide along socio­
economic status can be observed, not only across nations,
but also within nations, with marginalised populations
bearing higher risks of climate effects. The long-term
impacts of climate change reveal the intergenerational
injustice—as recognised by the Supreme Court of
Canada in a recent majority decision that concluded
climate change “poses a grave threat to humanity’s
future”.43 Synergies and collaborations between the
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Personal View
health community and the climate justice movement
could thus be highly effective, particularly in efforts that
leverage the judicial branch of government.44,45
Altogether, the health framing of climate change holds
some promise to win the hearts and minds of the public,
but there are many questions still to be answered about
its true potential. Yet the challenge does not end there.
Indeed, the complexity of climate policy is only part of the
problem. We believe the real crux of the matter lies
elsewhere; a change in framing alone will not be the
solution to overcoming the wickedness of climate policy.
The wider academic community, including public health,
will need to significantly expand its capacity in strategically
advocating for policy change. Our approach needs to take
into consideration the way that policy is made in the real
world, particularly in a political, contested, ideology-driven
environment that is stricken by complex power dynamics.
Here lies the biggest challenge for our community
because our current approaches, which are so entrenched
in our academic culture, currency, and self-image, are,
quite frankly, inadequate.
Beyond evidence and framing: what does
politics have to do with it?
We are keen to promote evidence-based policy, yet we
ignore the existing evidence on how to enact change. As
political scientist Paul Cairney states, “if you want to
inject more science into policymaking you need to know
the science of policymaking”.46 What does this science
tell us? It tells us that our idea of evidence-based policy
making is naive and not necessarily equal to good policy
making.47,48 Under its premise, the predominant belief is
that the policy making process follows a linear,
technocratic pathway in a policy cycle from agenda
setting and policy formulation to implementation and
evaluation.49 The role of science in this model is seen as
straightforward: scientific evidence is considered in the
different stages and steers the decisions of the policy
makers on the basis of comprehensive rationality—ie,
an ideal type of decision making in “which policymakers
are able to generate a clear sense of their preferences,
gather and understand all relevant information, and
make choices based on that information”.46 In other
words, we believe that the problem is an information
deficit among decision makers.50 There are many terms
in the literature that describe some aspect of the system,
whereby “knowledge in some form (ideas, innovation,
skills, policy) moves in some direction (laterally,
hierarchically, spreads, or exchanges) among various
stakeholders (knowledge producers, end users, or
intermediaries) and contexts (national, community, or
organisational) to achieve some outcomes (intended
benefits, unanticipated outcomes, or hijacked effects).”51
We chose to use the term knowledge-to-action (KTA) to
evoke an understanding of this work needing active
partici­pation rather than passive diffusion of knowledge
and evidence. Our KTA strategies, therefore, focus on
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 Personal View
reducing the uncertainty of evidence, by making it ever-
more precise and better (in the academic sense of a
hierarchy of evidence), and on more efficient ways to
concisely communicate the findings.52
The focus on reducing uncertainty and better science
communication has led to the rise of impressive advising
consortia, such as the Intergovernmental Panel on
Climate Change Working Groups, and public intellectuals
and academics who participate in the public realm via
contributions to science communication. We have also
started to understand that building relationships with
decision makers is important. We take an integrated
approach to our research and include so-called knowledge
users in the hopes of producing evidence that is relevant
to their work. These strategies are often celebrated as
innovative ways to bridge the science-to-policy gap. But
why is it that “co-produced, policy-relevant, adequately
communicated science fail[s] to influence policy
implementation?” As Cáceres and colleagues point out,
focusing on the “societal relevance of the research
questions and on the strategies to convey findings to the
political sphere…are necessary but not sufficient”.53
The approaches mentioned can indeed only be the first
step in our efforts to influence policy, which requires
academics to break new ground in terms of KTA strategies.
Instead of chasing after an ideal of evidence-based policy
making that does not align with the evidence about policy
making or retreating to lamentations about policy makers’
unwillingness to act upon the evidence, it is time for us to
acknowledge explicitly what is required to mobilise
knowledge in the world of politics. Policy making is not a
system in which rational, independent individuals have
the top-down power to make decisions. The game of
politics is rather one of so-called bounded rationality,
meaning that policy makers make decisions in non-ideal
settings (ie, with limited information, time, and resources)
on the basis of their inherent but unconscious value and
belief systems.54 These decisions are influenced by
external factors, such as social constructs,55 narratives,56
interest coalitions,57 and political and power dynamics.58,59
Therefore, the key strategies to change policy are ones
of persuasion, manipulation, coalition building, and
power-brokering.59,60
In the real world, politics is about power.23,61,62 In the
field of climate change, this becomes evident by the
multifarious ways in which a climate change denial
countermovement has been successful for decades.
Broadly speaking, there are two ways for the academic
community to engage with power: directly, by inside
lobbying, and indirectly, by leveraging power in numbers
through mobilising the public. Vital tools for both
approaches are high-quality evidence, communication
skills, framing, engaging with the media, and relationship
building. But these tools are a means to an end, not the
necessary strategy itself. We can learn important lessons
from our opponents and from history: in 1971, the US
Chamber of Commerce, a powerful business lobbying
e556
group, issued a confidential memorandum stating that
business must learn that “political power is necessary;
that such power must be assiduously cultivated; and that
when necessary, it must be used aggressively and with
determination—without embarrassment and without
reluctance”.63 This strategic thinking has led to an
extraordinary rise in corporate influence on government
of all levels over the past century64—and, although
financial resources dedicated to lobbying efforts play an
important part, such resources are not the only reason
why lobbying is successful. Lobbyists understand that
directly engaging with those in power, fully understanding
their points of view and their value systems, and then
using those to your advantage is the way to sway decisions
in your favour, rather than expecting facts to speak for
themselves or wanting to convince the other of the
importance of your own values. However, in most of us,
the term lobbying evokes a feeling of discomfort and “the
image of the fat-cat lobbyists shoving money in the
pockets of legislators”.65 But, really, the political science
literature makes clear that lobbying is a way to persuade
a decision maker to act on behalf of one’s interest or—in
the case of the academic community—on behalf of the
evidence (while acknowledging that all evidence is partial
and limited). It is time we embraced lobbying as an
expedient strategy to instill evidence in policy decisions.
The other pathway is to generate public support through
social movements and civil resistance. Influencing,
mobilising, and sustaining public opinion is key in
achieving political will and policy change.66,67 Historically,
this strategy has led to ground-breaking policy changes,
such as the Civil Rights Act in the USA, the end of
apartheid in South Africa, or, more recently, the capit­
ulation of regimes such as those in Sudan and Algeria
in 2019.68 Importantly, social movements have also played
a crucial part in the advancement of population health.69
For example, the AIDS Coalition to Unleash Power
achieved a number of health and social policy changes,
such as continued insurance coverage for people with
HIV.70 As academics, we should feel encouraged to make
common cause with activists and take on leadership roles
in social movements acting on behalf of our evidence.67
It is time to overcome the pseudo-dilemma of
being an academic activist
There is a dilemma that academics are faced with when
wanting to create change: what we are doing under the
current norms of our profession does not seem to be
enough, but what we would need to do is not in line with
our current professional culture. It seems as though there
are two kinds of barrier that we have yet to overcome. Even
though “positive impacts on policy and practice is
generally embraced as desirable by academic institutions”,71
many institutions currently lack the necessary support
systems for such activities.71,72 Among the most common
institutional barriers are money and time constraints,
absence of measurable targets for KTA strategies, or
www.thelancet.com/planetary-health Vol 5 August 2021

difficulty in communicating scientific findings.71 Even if
support for KTA exists, it has been found that researchers
do not leverage these resources and spend less than
10% of their time on KTA activities.72 It follows that
universities need to increase their capacity and that of
their faculty, with regards to impactful KTA work. In
particular, KTA activities should be valued in promotion
and tenure processes and funders could do their part by
increasing dedicated resources and support.72 Such
incentives are required, because the current lack of
cultural acceptance of activism among large parts of
academia presents a big barrier. Divided attitudes among
faculty reflect concerns about scientific credibility and the
idea that activism is incompatible with value-free science
and scientists.73,74 But there is little evidence to support this
concern, particularly when the advocacy effort is well
substantiated.75 Not to mention that it is a false truism that
science and scientists are value-free. Indeed, values, both
epistemic and non-epistemic, are instrumental to the
scientific endeavour. And yet, academics who engage in
activities such as civil disobedience run the risk of being
ousted from their academic community. They are often
seen as problematic and are met with depreciation, if not
hostility, among colleagues.76 These professional and
personal risks might be further magnified for those with
minoritised identities in academia.77 Why is that? While
we absolutely have a responsibility to be impartial about
reporting what the data reveal, this responsibility does not
imply impartiality about whether scientifically sound data
are implemented. Does the urgency and fundamental
threat to humanity posed by climate change not provide
an ethical imperative for our community to stand up?
If we begin to understand these activities as evidence-
based KTA strategies, maybe there is a way for us to
embrace this work on a larger scale and make it the new
norm for scholars to engage in activism for the evidence as
a third pillar of our work, besides research and teaching.
As such, many of us would possibly be able to shed the
feeling of discomfort and be better supported to embrace
these well accepted political science activities as part of our
professional mandate. Indeed, we are hopeful that such a
cultural shift in our community is underway. Health
researchers and professionals in particular have historically
been involved in civil resistance campaigns and are being
increasingly called upon to do so with regards to issues of
climate change and justice70,78–80—as Richard Horton,
Editor-in-Chief of The Lancet, states, we are “obliged to
protest”.81 Mary T Basset, Director of the FXB Center for
Health and Human Rights at Harvard University, adds
“the label ‘activist’ should be an honour, not a slur”.82 We
agree and would propose that this work falls within our
moral and professional duty as scholars because other
evidence dissemination strategies have had insufficient
impact and because climate change presents an urgent
injustice affecting fundamental human rights.8,78,83
Let us collectively acknowledge that we are all in this
field because we care deeply about our planet and its
www.thelancet.com/planetary-health Vol 5 August 2021
Personal View
inhabitants. Climate change is an urgent issue; it needs
all hands on deck, which includes us. We all felt it deeply
when Eriel Tchekwie Deranger closed her talk at the
Inaugural Meeting of the Planetary Health Alliance with
the words “we are all from the land”. When are we going
to stand up and act on behalf of the evidence, which
shows that this land upon which our lives depend is
severely under threat? As scientists, we can no longer
wait to embrace the realpolitik insights of political
science in order to move our evidence into policy action.
The time to rise is now.
Contributors
VR-R conceptualised this Personal View, did the associated literature
review and synthesis, and wrote the original draft. AG supported the
conceptualisation, provided supervision to the first author, and
significantly contributed to the review and editing of the revised
manuscript. PK supported to conceptualisation, provided supervision to
the first author, and significantly contributed to the review and editing of
the revised manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
We would like to thank David R Boyd for his thought-provoking input
and comments during the development of this manuscript. We are also
genuinely grateful to the four anonymous reviewers for their thoughtful
and encouraging feedback which was integral to the improvement of the
manuscript.
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