Di Napoli et al. BMC Public Health (2022) 22:663 https://doi.org/10.1186/s12889-022-13055-6 RESEARCH IN PRACTICE Open Access Tracking the impacts of climate change on human health via indicators: lessons from the Lancet Countdown Claudia Di Napoli1,2* , Alice McGushin3, Marina Romanello3, Sonja Ayeb‑Karlsson4,5,6, Wenjia Cai7, Jonathan Chambers8, Shouro Dasgupta9,10,11, Luis E. Escobar12, Ilan Kelman3,4,13, Tord Kjellstrom14, Dominic Kniveton5, Yang Liu15, Zhao Liu7, Rachel Lowe16,17,18, Jaime Martinez‑Urtaza19, Celia McMichael20, Maziar Moradi‑Lakeh21, Kris A. Murray22,23, Mahnaz Rabbaniha24, Jan C. Semenza25, Liuhua Shi15, Meisam Tabatabaei26,27, Joaquin A. Trinanes28, Bryan N. Vu15, Chloe Brimicombe2 and Elizabeth J. Robinson9 Abstract Background: In the past decades, climate change has been impacting human lives and health via extreme weather and climate events and alterations in labour capacity, food security, and the prevalence and geographical distribution of infectious diseases across the globe. Climate change and health indicators (CCHIs) are workable tools designed to capture the complex set of interdependent interactions through which climate change is affecting human health. Since 2015, a novel sub-set of CCHIs, focusing on climate change impacts, exposures, and vulnerability indicators (CCIEVIs) has been developed, refined, and integrated by Working Group 1 of the “Lancet Countdown: Tracking Progress on Health and Climate Change”, an international collaboration across disciplines that include climate, geogra‑ phy, epidemiology, occupation health, and economics. Discussion: This research in practice article is a reflective narrative documenting how we have developed CCIEVIs as a discrete set of quantifiable indicators that are updated annually to provide the most recent picture of climate change’s impacts on human health. In our experience, the main challenge was to define globally relevant indica‑ tors that also have local relevance and as such can support decision making across multiple spatial scales. We found a hazard, exposure, and vulnerability framework to be effective in this regard. We here describe how we used such a framework to define CCIEVIs based on both data availability and the indicators’ relevance to climate change and human health. We also report on how CCIEVIs have been improved and added to, detailing the underlying data and methods, and in doing so provide the defining quality criteria for Lancet Countdown CCIEVIs. Conclusions: Our experience shows that CCIEVIs can effectively contribute to a world-wide monitoring system that aims to track, communicate, and harness evidence on climate-induced health impacts towards effective intervention strategies. An ongoing challenge is how to improve CCIEVIs so that the description of the linkages between climate change and human health can become more and more comprehensive. Keywords: Climate change, Public health, Indicators, Climate data, Policy making *Correspondence: c.dinapoli@reading.ac.uk 1 School of Agriculture, Policy and Development, University of Reading, Reading, UK Full list of author information is available at the end of the article © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Di Napoli et al. BMC Public Health (2022) 22:663 Page 2 of 8 Background Countdown has been providing a global monitoring sys- Climate change affects global health via multiple direct tem that tracks the complex, reflective ways in which cli- and indirect pathways [1, 2]. Every year, disasters involv- mate change affects health [27–32]. It accomplishes this ing weather- and climate-related hazards result in thou- through a set of CCHIs spanning five domains of the cli- sands of deaths worldwide and contribute to the global mate-health system: climate change impacts, exposures, burden of disease [3, 4]. Direct health consequences may and vulnerability; adaptation planning and resilience for derive from changes in temperature and precipitation, health; mitigation actions and health co-benefits; eco- and human exposure to heatwaves, wildfires, floods, and nomics and finance; and public and political engagement. droughts [5–9]. These include an increase in cardiovas- One of the five Lancet Countdown thematic working cular mortality during events of extreme heat; a higher groups, namely Working Group 1 (WG1), is tasked with incidence of chronic kidney disease among outdoor identifying and tracking indicators that trace the links workers in hot areas; and fatalities and multiple nega- across “climate change impacts, exposures, and vulner- tive health consequences of fire smoke inhalation dur- ability”. This research in practice article aims to provide ing wildfires [10–13]. Indirect impacts may be triggered guidance for the development and tracking of CCHIs by climate change-induced environmental and ecosys- through a detailed case study of how WG1 authors devel- tem alterations, such as crop failures, reduced marine oped these indicators, referred to from here on as climate food capture, geographic range expansion of disease vec- change impacts, exposures, and vulnerability indicators tors, and reduced labour capacity [14–17]. Other indi- (CCIEVIs), that contribute to the Lancet Countdown’s rect effects may be mediated through social systems and overall objectives. As such, this article is equally rel- responses to climate change. Examples include reduced evant for those individuals and policy makers wanting labour capacity in vulnerable occupations due to increas- to develop their own climate change and health indica- ing heat, migration of populations related to sea-level rise tors specific to a country or region, and those wanting a and food insecurity, as well as other drivers of human more detailed understanding of specific indicators used mobility [18–20]. in the Lancet Countdown, and particularly WG1. Here- As understanding and awareness grow regarding the after, we describe (i) the aim, design, and characteristics health dimension of climate change, there is an increased of CCIEVIs, as employed in the Lancet Countdown, (ii) demand for feasible and efficient tools that can inform their main components, (iii) underlying data and meth- climate change mitigation and adaptation strategies to ods, and (iv) plans for future improvements. deliver benefits to human health at all levels. Climate- health linkages are complex, with multiple interactions, Climate change impacts, exposures, synergies, and feedback loops. Understanding their char- and vulnerability indicators acteristics and relationships is challenging and poses a Designing CCIEVIs level of complexity that could render the development of Lancet Countdown CCIEVIs have been developed to such tools unfeasible. A reasonable alternative is to deploy monitor the health impacts related to anthropogenic a subset of measures describing the key aspects of the climate change, their trends to date, and the extent to state, extent and change of the climate-health system [21]. which progress (or backsliding) is occurring over time. Climate change and health indicators (CCHIs) are They are presented from a historical starting date up to summary measures, often quantitative, that represent the year for which the most recent complete data are the heterogeneous set of factors and relationships link- available. The indicators provide evidence along differ- ing climate change with health [22–26]. Their purpose is ent dimensions – some indicators are positioned closer three-fold. First, to assess long-term trends and changes to the climate change hazard and some closer to the in climate-induced impacts on population health. Second, health impact – as to whether, and to what extent, cli- to effectively communicate relevant evidence to research- mate change is affecting health, for better or for worse. In ers, health professionals, policymakers, and the general the Lancet Countdown, CCIEVIs start tracking climate public. Third, to support and monitor decision making for change-health linkages from the 1980s, and are grouped successful intervention strategies and plans that address into five thematic clusters: heat; weather and climate the human health consequences of climate change. extremes; infectious diseases; food security of terrestrial In the past decade, CCHIs have represented the build- and marine assets; global mean sea-level rise. ing blocks for a variety of initiatives tracking the cli- To ensure that CCIEVIs are reproducible, relevant, and mate-health system across multiple spatial and temporal useful to scientific and policy-making communities, they scales [24, 25]. One high profile and current CCHI ini- must satisfy five quality criteria that mirror the World tiative is the “Lancet Countdown: Tracking Progress Meteorological Organisation guidelines for climate indi- on Health and Climate Change”. Since 2015 the Lancet cators [33]: Di Napoli et al. BMC Public Health (2022) 22:663 Page 3 of 8 1. Representativeness: a CCIEVI should track an aspect the Intergovernmental Panel on Climate Change [34, 35]. of both climate change and health, particularly focus- Specifically: ing on the relationship between the two; it should do this across a timescale and geographical coverage • Hazard is any physical event with the potential sufficient for long-term global trends to be observed. to cause disruption or damage in vulnerable and 2. Relevance: a CCIEVI should be clear and understand- exposed elements; able to a broad range of audiences; global CCIEVIs • Exposure is who or what is present in the area where may also have value at local (i.e. national, regional) a hazard may occur; level for policy and decision makers. • Vulnerability is the factors or constraints of an eco- 3. Robustness: a CCIEVI should use data and meth- nomic, social, physical, or geographic nature, which ods that are robust, reliable, and valid to track the reduce the ability of exposed elements to prepare for relevant aspect of climate change and health; data and cope with the impact of the hazard. from publicly available databases, and especially those developed by international organisations, In Lancet Countdown CCIEVIs, each of these com- governmental bodies, or academic institutions, are ponents represents a dimension or layer of the multi- preferred; methods should be supported by a high facet climate-health system. For the hazards, the Lancet standard of evidence from the scientific literature. Countdown CCIEVIs target extremes in temperature and 4. Reproducibility: a CCIEVI should be calculated precipitation, namely heatwaves, drought, and floods, as using an internationally agreed and published sci- well as phenomena mediated by these two environmen- entific method as well as open-access and quality- tal variables, i.e. wildfires and suitability of vector-borne controlled data; the methodology underlying an indi- diseases (malaria, dengue). Similarly, health hazards in cator should be clearly laid out, including details of the ocean system are identified in changes of global mean the process of data collection and processing, which sea level as well as sea surface temperature and salinity. must be done in a systematic and unbiased way; sta- The second layer tracks the exposure of populations, cul- tistical analysis of the data should be carried out to tivated areas, and health systems to hazards. This reflects support the interpretation of the data. the purpose of representing climate change-health path- 5. Timeliness: a CCIEVI should be calculated regularly, with ways that are both direct (e.g. on people) and indirect a short lag between the end of the period under consider- (e.g. food mediated). Lancet Countdown CCIEVIs also ation and the publication of the data; the calculation must track vulnerabilities to extreme heat, incorporating the be practicable with existing and future resources. proportion of the population over 65 years of age, the prevalence of predisposing chronic diseases (i.e. diabe- WG1 indicators have evolved over the five years that tes and cardiovascular, respiratory, and renal disease), they have been reported in the annual Lancet Countdown the proportion of the population living in urban areas, publications so to fulfil above-listed criteria. For exam- and the number of outdoor workers. In the 2021 report, ple, in 2020, there were twelve WG1 Lancet Countdown the vulnerability of children younger than 1 year to life- CCIEVIs, almost double the number of when they first threatening heatwaves was added [36]. Lancet Count- appeared in 2016 [28, 32]. As well as new indicators being down CCIEVIs also consider vulnerability linked to the introduced each year, established indicators are revised capacity of local health services to respond to public to reflect the latest evidence in the scientific literature health risks and emergencies. and the needs of new and emerging stakeholders [30, 31]. The revision of Lancet Countdown CCIEVIs occurs Data and methods for developing CCIEVIs annually by experts across a broad range of relevant dis- Hazards, exposures, and vulnerabilities change over ciplines, including climate, geography, epidemiology, time and across space as do their interactions as a result and occupation health. The publication of an appendix of changes in the climate. Consequently, climate change alongside each Lancet Countdown annual report ensures amplifies or diminishes existing health impacts, and that the data and methods underlying every CCIEVI are induces or suppresses new ones with a high degree of explicitly cited and described along with possible caveats. spatial and temporal variability. Geographic information systems, and more specifically geospatial data, have long Main components of CCIEVIs been identified as useful analytical tools for monitoring Lancet Countdown CCIEVIs focus on three main com- the health-climate system at all spatial levels, from local ponents: hazard, exposure, and vulnerability. These are to global [37]. defined according to the terminology provided by the Many relevant sources for CCIEVIs provide the data as United Nations Office for Disaster Risk Reduction and rasters, i.e. grids of cells. This allows information, such Di Napoli et al. BMC Public Health (2022) 22:663 Page 4 of 8 as variations in climate-relevant variables like air tem- ship can also foster the development of CCIEVI- perature, to be represented in a spatially continuous and based initiatives in locations where these are cur- consistent way across the Earth’s surface. Usefully, rasters rently missing but are perceived as useful [42–46]. can be stacked to assess cumulative hazards in a given Over the long term, partnerships can expand the region or to produce spatially resolved time series of a areas where CCIEVIs drive decision-making as well given variable. as increase workforce preparedness via the inclusion Environmental data are nowadays available as rasters of climate change curriculum into health professional across a wide range of spatial and temporal scales. This education [47–50]. makes them an ideal tool for constructing relationships 2. Iterative process: To satisfy the timeliness criteria of between hazards, exposed elements, and associated vul- CCIEVIs, their design and utility must be revised nerability anywhere in the world, low and middle income periodically [21]. Every year, Lancet Countdown countries included [38]. For instance, one of the Lancet CCIEVIs indicators undergo a thorough quality Countdown CCIEVIs tracks the climatic suitability for check and improvement process before being con- the transmission of Plasmodium falciparum, the parasite sidered for the annual report. In this process, inde- causing malaria. Following the work by Grover-Kopec pendent experts assess the quality and suitability of and colleagues [39], the indicator tracks the number of each indicator and provide constructive feedback to months per year suitable for malaria transmission as the aid their development and improvement. Addition- coincidence of precipitation accumulation greater than ally, new CCIEVIs can be developed and added to the 80 mm, average temperature between 18 °C and 32 °C, original indicators suite to provide a more complete and relative humidity greater than 60%. The number of description of the climate-health system. suitable months in a year is calculated for each grid cell 3. Going local: Because CCIEVIs are provided as geo- by overlaying precipitation, temperature, and humidity spatial data, they are down-scalable and able to raster layers across twelve months. Year-by-year changes identify priority areas for public health intervention in the number of suitable months generate a time series, across the globe. Location-specific CCIEVIs can which can be spatially aggregated (e.g. for highland vs assist local health departments in tracking varia- lowland areas). tions in community exposure and vulnerability to cli- CCIEVIs can be explored via an online visualization mate change, uncovering health impacts at regional platform. For example, maps represent a powerful way to or sub-regional level (including their linkages to the visualise and communicate climate information, and har- surrounding urban/natural environment), designing ness the latter for action [40]. CCIEVIs can be displayed interventions to enhance community resilience and as a set of world-wide maps that can be navigated via an evaluating the effectiveness of implemented inter- interactive, user-friendly interface to show year-specific ventions [51, 52]. With this motivation, the Lancet data or to highlight countries or geographical areas of Countdown CCIEVIs structure has been replicated interest, as has been done by the Lancet Countdown [41]. to produce the Australia and China reports with indicators being provided at national to regional and Perspectives and improvements for CCIEVIs city scales [53, 54]. These local reports may serve as Climate change is an evolving phenomenon and our a guidance for disseminating progress on CCIEVIs understanding of it is also evolving. Only with the most from other countries in a uniform format. Every year, up-to-date data, methodologies, and expertise, CCIEVIs the Lancet Countdown report is also followed by a can provide the quantitative underpinnings of a compel- range of resources, such as briefs for policymakers ling narrative on the health impacts that climate change and translations of the executive summaries, tailored imposes across the globe. Based on our experience from to specific cities, countries and geographical areas the Lancet Countdown, we here report the main points [55–57]. CCIEVIs might consider to be meaningful and useful in 4. Data: CCIEVIs typically have to rely on differ- their purpose. ent sources for the provision of health, climate, and demographics data. They therefore may well differ 1. Partnership: The cross-cutting nature of CCIEVIs in the spatial resolution, the time period covered, demands a combination of skills, knowledge and data and the reference baseline used for the definition that span across institutions, disciplines, countries, of extreme events. Notwithstanding this, consist- and geographical regions. Creating and maintaining ency in climate data and demographics among Lan- a long-term collaboration among a group of diverse cet Countdown CCIEVIs has been attempted and experts is crucial to guaranteeing the robustness and achieved wherever possible so that indicators are reliability of developed CCIEVIs over time. Partner- compatible and comparable with each other. It is Di Napoli et al. BMC Public Health (2022) 22:663 Page 5 of 8 worth noting that protocols are in place for the effec- ers of hazard, exposure and vulnerability. It can also tive archival, management, analysis, delivery, and use be applied to different CCIEVIs to assess multiple cli- of climate data, whereas health data standardisation mate change impacts in a single location. This could is an open topic [58, 59]. The collection and reporting allow for a one health perspective if CCIEVIs at the of public health data, for instance, vary greatly across human–animal–environment interface are imple- nations and healthcare organizations [60]. Data mon- mented [67, 68]. For instance, concerning food secu- itoring on disease incidence or health outcomes that rity of terrestrial assets, a CCIEVI tracking changes are standardised at a global level is in general lacking. in crop yield potential due to rising temperatures In most cases, health impacts are therefore tracked could be overlayed with CCIEVIs monitoring ani- using epidemiological models rather than measured mal-source foods and/or the effects of environmental records. Furthermore, their geographical resolu- changes on diseases of livestock and crops. In either tion is generally lower than climate data (i.e. country case, the identification and tracking of climate-health level rather than at raster cell level). Unlike climate hotspots and incorporation into a monitoring sys- data, health records are generally not publicly avail- tem, could improve further public health action, par- able. Creating open-access online databases for pub- ticularly in the context of reducing the likelihood of lic health data would help foster knowledge exchange systemic health crises [69]. between the climate and the public health commu- 3. Inequality and inequity: Global indicators generally nity, as well as promote its applicability at all scales. do not provide a nuanced picture of the differenti- ated impacts of climate change on health by country CCIEVIs can be used as a starting point for broader and region, or across populations within countries. explorations of the linkages between climate change and Disaggregating indicators by relevant socioeconomic health that have relevance for policy making. Here we and occupational characteristics (e.g. income, gen- suggest six specific areas for future research, many of der, race or ethnicity, disability, occupation, and age) which are currently being pursued by WG1 authors. is necessary to measure inequalities in exposure to climatic risk factors and health outcomes attribut- 1. Looking to the future: In the Lancet Countdown, able to these exposures. For heatwaves, for instance, CCIEVIs are used to track the current health impacts these may consider pregnancy and mental health [70, of climate change, and contextualise them with 71]. With this approach, climate change and climate- respect to the recent past. These indicators there- related risk factors are positioned as both environ- fore hint at how the future will likely evolve without mental and social determinants of health. efforts to mitigate and adapt to climate change. How- 4. Mental health: Mental health issues are closely inter- ever, the methodology described in this research in twined with people’s geographical, social, environ- practice article is time-agnostic and can be applied mental, financial, and political context, and any cli- to indicators predictive of the future. Designing, mate-induced impact on physical health is also a risk developing and implementing future projections of factor for mental health [72]. As such, factors linking CCIEVIs presents additional research challenges, climate change to health may affect mental health such as the choice of the climate prediction model and underlying mental health status can affect the and its verification, but has the potential to provide capacity to adapt to (or to mitigate) climate change. actionable information to support policymaking [61]. The description of the climate-health system, there- 2. Identifying hotspots: Climate change often affects fore, requires the inclusion of CCIEVIs that address people and places in multiple ways. We define cli- the mental health consequences of climate change. mate-health hotspots as locations where climate A growing body of literature is currently examining affects people negatively through multiple pathways. these linkages [73–79], inspiring the development of This definition builds upon work already established future CCIEVIS on the topic. in the climatology field on mapping hotspots, i.e. 5. Attribution: In recent years, formal methods have geographical areas where the combined occurrence been developed to identify changes in the occur- of multiple weather extremes (compound events) is rence of adverse health outcomes, and to determine observed [62, 63]. As adverse health effects occur the extent to which those changes may be attrib- in populations that are already at risk from climate uted to climate change [80]. Multi-step attribution, extremes and lack adequate health infrastructure for instance, consists of a) attributing an observed [64–66], the overlay method described in this work change in a variable of interest to a change in cli- can be adapted to identify climate-health hotspots mate or other environmental variable and b) attrib- and trace them overtime by overlapping multiple lay- uting the change in climate to external drivers such Di Napoli et al. BMC Public Health (2022) 22:663 Page 6 of 8 as greenhouse gas emissions [81]. The 2020 Lancet to which individuals and countries are able to adapt and Countdown report showcased the attribution of build resilience. By unveiling the challenges underpin- 76 extreme weather events to climate change, and ning the evolution of the climate-health system in time the effects that a selection of these have had on the and in space, CCIEVIs can be the pillars of a new public health of the population [32]. Future CCIEVIs could health that safeguards and advances global wellbeing in be based on attribution to quantitatively understand the decades to come. how climate change makes extreme events associated Acknowledgments with health outcomes more likely. The authors are grateful to the three anonymous reviewers and the editor for 6. Embracing the unquantifiable: There are important their constructive comments. aspects of the relationship between climate change Authors’ contributions and health that cannot be quantified or are very dif- CDN, AM, MR, SAK, WC, JC, SD, LEE, IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM, ficult to quantify meaningfully. One example of this is MR2, JCS, LS, MT, JAT, BNV, CB, and EJR authors planned and designed this human migration [18]. Local-level studies find wors- manuscript. CDN prepared the first draft; CDN, AM, MR, SAK, WC, JC, SD, LEE, IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM, MR2, JCS, LS, MT, JAT, BNV, CB, and ening food security where people move away from EJR provided input into subsequent drafts. CDN, AM, MR, SAK, WC, JC, SD, LEE, places affected by sea level rise and saltwater intru- IK, TK, DK, YL, ZL, RL, JMU, CM, MML, KAM, MR2, JCS, LS, MT, JAT, BNV, CB, and sion, or adverse psychosocial impacts of disrupted EJR authors read and approved the final manuscript. lives, social networks and livelihoods for those on the Funding move in a changing climate. It is extremely challeng- This work is supported by an unrestricted grant from the Wellcome Trust ing, however, to attribute human mobility to climate (209734/Z/17/Z). change (and quantify its magnitude), or to develop a Availability of data and materials global CCIEVI that can quantify links between cli- Not applicable. mate impacts, human mobility, and health. Declarations Ethics approval and consent to participate Conclusions Not applicable. In developing climate change impacts, exposures, and Consent for publication vulnerability indicators (CCIEVIs), several key challenges Not applicable. have to be addressed around the idea of representing Competing interests highly complex systems by a discrete set of quantifiable The authors declare that they have no competing interests. indicators that are updated annually. One challenge is to find globally relevant indicators, with data available Author details 1 School of Agriculture, Policy and Development, University of Reading, Read‑ across a sufficiently large number of countries, that also ing, UK. 2 Department of Geography and Environmental Science, University have local relevance. of Reading, Reading, UK. 3 Institute for Global Health, University College A hazard, exposure, and vulnerability framework London, London, UK. 4 Institute for Risk and Disaster Reduction, University College London, London, UK. 5 School of Global Studies, University of Sussex, has proven to be an effective structure within the Brighton Falmer, UK. 6 United Nations University, Institute for Environment Lancet Countdown initiative. Around such a frame- and Human Security, Bonn, Germany. 7 Ministry of Education Key Laboratory work, Lancet Countdown CCIEVIs have been crafted, for Earth System modeling, Department of Earth System Science, Tsinghua University, Beijing 100084, China. 8 Institute for Environmental Science, Univer‑ based on both data availability and the indicators’ sity of Geneva, Geneva, Switzerland. 9 Grantham Research Institute on Climate relevance to climate change and human health. Over Change and the Environment, London School of Economics and Political time these indicators have been improved and added Science (LSE), London, UK. 10 Centro Euro-Mediterraneo sui Cambiamenti Climatici (CMCC), Venice, Italy. 11 Università Ca’ Foscari, Venice, Italy. 12 Depart‑ to, as data become available and methodologies are ment of Fish and Wildlife Conservation, Virginia Tech, Blacksburg, VA, USA. refined. An ongoing challenge is how to incorporate 13 University of Agder, Kristiansand, Norway. 14 Health and Environment Inter‑ those linkages between climate change and health national Trust, Nelson, New Zealand. 15 Rollins School of Public Health, Emory University, Atlanta, USA. 16 Barcelona Supercomputing Center, Barcelona, Spain. that are clear and well documented but at the same 17 Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, time difficult to measure, quantify, and fit within this Spain. 18 Centre on Climate Change & Planetary Health and Centre for Mathe‑ framework. matical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK. 19 Department of Genetics and Microbiology, Univer‑ Together, Lancet Countdown CCIEVIs present a com- sitat Autònoma de Barcelona (UAB), Barcelona, Spain. 20 School of Geography, pelling visualisation of how climate change is increasingly Earth and Atmospheric Sciences, The University of Melbourne, Melbourne, exposing people to the negative health impacts of climate Australia. 21 Preventive Medicine and Public Health Research Center, Psycho‑ social Health Research Institute, Iran University of Medical Sciences, Tehran, change, both direct and indirect, across land and water. 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