Health Policy Envisioning environmental equity: climate change, health, and racial justice Thilagawathi Abi Deivanayagam, Sonora English, Jason Hickel, Jon Bonifacio, Renzo R Guinto, Kyle X Hill, Mita Huq, Rita Issa, Hans Mulindwa, Heizal Patricia Nagginda, Priscila de Morais Sato, Sujitha Selvarajah, Chetna Sharma, Delan Devakumar Climate change has a broad range of health impacts and tackling climate change could be the greatest opportunity for Published Online improving global health this century. Yet conversations on climate change and health are often incomplete, giving May 29, 2023 https://doi.org/10.1016/ little attention to structural discrimination and the need for racial justice. Racism kills, and climate change kills. S0140-6736(23)00919-4 Together, racism and climate change interact and have disproportionate effects on the lives of minoritised people both Institute for Global Health, within countries and between the Global North and the Global South. This paper has three main aims. First, to survey University College London, the literature on the unequal health impacts of climate change due to racism, xenophobia, and discrimination through London, UK a scoping review. We found that racially minoritised groups, migrants, and Indigenous communities face a (T A Deivanayagam MPH, S English MSc, M Huq MSc, disproportionate burden of illness and mortality due to climate change in different contexts. Second, this paper aims R Issa MSc, S Selvarajah MBBS, to highlight inequalities in responsibility for climate change and the effects thereof. A geographical visualisation of C Sharma MSc, responsibility for climate change and projected mortality and disease risk attributable to climate change per Prof D Devakumar PhD); 100 000 people in 2050 was conducted. These maps visualise the disproportionate burden of illness and mortality due Lancaster Medical School, Faculty of Health and Medicine, to climate change faced by the Global South. Our third aim is to highlight the pathways through which climate Lancaster University, change, discrimination, and health interact in most affected areas. Case studies, testimony, and policy analysis drawn Lancaster, UK from multidisciplinary perspectives are presented throughout the paper to elucidate these pathways. The health (T A Deivanayagam); Institute community must urgently examine and repair the structural discrimination that drives the unequal impacts of for Environmental Science and Technology, Autonomous climate change to achieve rapid and equitable action. University of Barcelona, Barcelona, Spain Introduction the Global North (eg, the USA, Canada, and Australia).7 (Prof J Hickel PhD); International Climate change impacts the health of the planet and The majority of the responsibility for excess emissions Inequalities Institute, London School of Economics and people; however, the impacts fall disproportionately on lies with the states, corporations, and ruling classes of Political Science, London, UK groups that are already disadvantaged. Racism, the Global North, in a manner reminiscent of the (Prof J Hickel); Youth Advocates xenophobia, and discrimination are about division, damages inflicted on people, land, and biodiversity for Climate Action Philippines, control, and ultimately power, which are present in every during industrialisation and colonisation. In 2022, the Quezon City, Philippines (J Bonifacio BSc); Planetary and society.1 Racism kills,2 and climate change kills.3 Racism, Intergovernmental Panel on Climate Change explicitly Global Health Program, xenophobia, and discrimination interact with climate identified “historical and ongoing patterns of inequity St Luke’s Medical Center College change to worsen existing harm to health and widen such as colonialism” as a factor in vulnerability to climate of Medicine—William H Quasha inequities for minoritised people both within and change.8 Global North–South inequality in responsibility Memorial, Quezon City, Philippines (R R Guinto DrPH); between the Global North and Global South4 and impact are intrinsically linked to discriminatory Department of Indigenous (ie, individuals and populations who are denied equitable social and structural processes produced during Health, School of Medicine and access to resources, social standing, and power; see the colonialism. These processes continue today— Health Sciences, appendix pp 2–5 for a glossary of terms). This interaction eg, through the corporate destruction of land, excessive University of North Dakota, Grand Forks, ND, USA is facilitated through institutionalised discriminatory emissions, frequent exclusion of people from the (K X Hill PhD); School of policies and experiences of systemic oppressions by Global South and Indigenous Peoples from international International Development, individuals and communities.5 In this Health Policy, we climate-related decision making, and placing the burden University of East Anglia, Norwich, UK (R Issa); Climate explore how several different forms of structural on minoritised people to develop less, slowly, or restrict Operation, Kampala, Uganda discrimination (based on caste, skin colour, ethnicity, their population to mitigate climate change.9,10 (H Mulindwa BA, race, Indigeneity, migratory status, and religion) interact This Health Policy has three aims. The first is to show H P Nagginda LLB); School of with climate change and health. These distinct but the unequal health impacts of climate change due to Nutrition, Federal University of Bahia, Salvador, Brazil intersecting vectors of inequality often result in poor racism, xenophobia, and discrimination, achieved (P de Morais Sato PhD) health and underlying them are similar systems of through a scoping review of the literature. The second is Correspondence to categorisation, minoritisation, and oppression.6 The to highlight unequal responsibility for climate change Dr Thilagawathi Abi COVID-19 pandemic has highlighted the absence of historically between countries, achieved through a Deivanayagam, Lancaster global solidarity and willingness to redistribute resources geographical visualisation of secondary data, comparing Medical School, Faculty of Health and Medicine, Lancaster to secure a safe route out of the pandemic. The same is responsibility for and the health burden of climate change University, Lancaster LA1 4AT, UK true of climate change. with maps. Although Global North–South analysis can a.deivanayagam@lancaster. The most affected peoples and areas living in the illustrate inequalities in responsibility and health burden ac.uk Global South are often least responsible for climate between colonised countries and their ex-colonisers, and See Online for appendix change and yet bear its burden; but this also includes discrimination at the global level, they obscure inequities minoritised communities everywhere, such as within countries. We also cannot infer causal links Indigenous Peoples in the settler-colonial countries of between unequal responsibility and unequal health www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 1 Health Policy Further, per Crenshaw’s notion of intersectionality,11 Search strategy and selection criteria discrimination takes many forms and the lived experience This literature review addressed the question: how does of multiple forms of discrimination is greater than and climate change lead to health inequalities by race, ethnicity, distinct from the sum of each type of discrimination in caste, Indigeneity, religion, migratory status, or skin colour? isolation (see the appendix pp 2–4 for a glossary of We ran search terms (appendix p 11) through six databases: terms). Above all, we stress that these categories assigned MEDLINE, Embase, Web of Science, Scopus, Global Health, to people are socially constructed, born from colonial and GEOBASE, with no date restrictions on Dec 17, 2021. We histories linked to ongoing separation and subjugation. restricted papers to availability in an English version. We also Other characteristics such as age, disability, gender, used subject headings related to the search terms in running sexuality, and socioeconomic status (and the values the search, to ensure that no relevant literature was missed. placed on them) can exacerbate or mitigate experiences The literature search returned 830 titles. The title and of discrimination, compounding the impact of climate abstract of each paper were then independently screened change on health.12 Although this Health Policy focuses against the inclusion criteria (appendix p 12) by two authors on the forms of discrimination specified previously, lived (TAD, CS, JB, MH, PdMS, RI, or SE) and any conflicts were experiences are shaped by the relationship between resolved by a third author (SE or MH). Full-text screening was overlapping systems of power and social categorisation.13 then done for 96 papers. Each paper was screened We acknowledge the commonalities in the role of independently by two authors, and conflicts were resolved in coloniality, separation, and division in giving rise to discussion. 35 peer-reviewed articles met the inclusion discrimination based on social categorisations.14 Gender, criteria for this paper. All studies were published between disability, and income overlapping with racism are 2003 and 2021, and both qualitative (n=15) and explored in this paper to understand interactions between quantitative (n=20) studies were included. The studies were social stratifiers. from North America (USA=22; Canada=1), Australasia (n=4), There is no single definition of climate justice. Defini­ Africa (n=3), Asia (n=2), Pacific islands (n=2), and tions range from Western conceptions (eg, Robinson’s South America (n=1). A PRISMA diagram and checklist can be human-centred definition for activist spaces that found in the appendix (p 13). We extracted and charted data insists on a movement in solidarity with people and with the following headings: author, title, journal, year, communities most affected and sharing the impacts of country, location, population affected, life course stage, study climate change fairly15) to Global South conceptions type, aims, methods, climate indicator, health indicator, (eg, the 2002 Bali Principles that demand ecological unity inequity indicator, outcome, limitations, and summary. We of all species). The Bali Principles insist that “communities specifically sought data on climate, health, and inequity have the right to be free from climate change, its related indicators (variables) as identified by the included sources. impacts and other forms of ecological destruction”.16 We Definitions of all inequity indicators can be found in the acknowledge both definitions. We also recognise that glossary of terms.6 All data extraction was verified by a second climate justice must grapple with notions of climate debt author. and coloniality caused by centuries of ongoing oppression, felt deeply by generations of minoritised people,17,18 and that populations already facing human rights violations burdens from solely Global North–South analysis. Thus, also face the greatest human rights consequences of the third aim is to show the pathways through which climate change.19 Environmental justice is also a relevant climate change, health, and discrimination interact in the but distinct movement, which can largely be traced back most affected areas across the world. These pathways are to resistance to toxic waste dumping in poor, Black shown through case studies, testimonies, and policy communities in the USA in the 1980s. This movement analyses from multidisciplinary perspectives throughout brought the civil rights, racial justice, and environ­ the paper. This is a novel paper that presents the first mentalism movements together.20 academic review of literature on the interaction between climate change and discrimination leading to health Methods inequalities, with quantitative geographical visualisations, We used a multimethod approach to tackle our three qualitative case studies, and policy analysis to produce an central aims. The first section of the paper presents the encompassing analysis on this topic. We hope this can findings of a scoping review on the health impacts of provide a robust platform for academics and practitioners climate change, related to racism, xenophobia, and to build discourse and justice-led action. discrimination. The findings of the scoping review are presented according to the form of categorisation that Definitions they relate to. This section highlights health inequalities We define discrimination as unequal access to resources, within countries. political representation, and social treatment on the basis The second section presents a geographical of caste, ethnicity, Indigeneity, migratory status, race, visualisation, highlighting inequalities in responsibility religion, or skin colour, unless otherwise specified.6 for climate change and the distribution of illness and 2 www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 Health Policy mortality burden due to climate change between dimensions of the interaction between climate change, countries. In this section, national responsibility for health, and discrimination at each level. Specific examples climate breakdown is defined according to the fair-share are included throughout figure 1 to highlight how these approach.21 The fair-share approach rests on the principle interactions manifest across contexts and from the that all people are entitled to use an equal share of the structural to individual level. A fully referenced version of atmosphere within the safe planetary boundary of figure 1 can be found in the appendix (pp 17–18). 350 parts per million concentration of carbon dioxide in the atmosphere.22 The maps visually represent the burden Race and ethnicity of illness and mortality attributable to climate change for 17 studies from the USA and one from Canada addressed climate-sensitive health outcomes in 2050.23 Indicators the relationship between climate change, health, and were chosen due to the availability of climate-related race or ethnicity (or both). Although the effects of race health data at the global level. Mortality and at-risk and ethnicity were searched separately, we summarise estimates were drawn from WHO,23 and population the findings together due to their overlap in the estimates from the UN World Population Prospects.24 literature. The third aim of this paper is to show the pathways 13 studies focused on heat exposure, heat sensitive through which climate change, health, and discrimination illness, and mortality in the context of a warming climate. interact. This is addressed throughout the paper with In the USA, census block groups (geographical units) case studies, testimony, and policy analysis (presented in with greater proportions of Black, Hispanic, and non- panels), as these methods are better suited than White residents have been found to be hotter on average quantitative methods for analysing injustice in depth.25 than block groups with higher proportions of White These panels draw on perspectives from health workers, residents within the same cities.26,27 Areas with greater activists, youth (people aged 15–24 years), climate proportions of non-White residents also have heat-risk educators, anthropologists, and economists, integrating related land cover conditions (eg, little tree cover and high insights from community engagement activities, publicly proportions of impervious surfaces), contributing to accessible video testimony, and diverse bodies of urban heat inequalities.28 Further, Black and Hispanic collective knowledge from climate justice movement people are less likely to have air conditioning at home, spaces with peer-reviewed literature. The topic of each after adjusting for household income, than White panel was collaboratively decided by the authors and people.29,30 In contrast, a study in Canada found no each panel was written or reviewed (or both) by correlation between area level temperatures and individuals with localised expertise. The panels highlight proportion of visible minorities in Montreal, potentially the complex nature of the interactions between climate due to rapid gentrification and lower levels of segregation change, discrimination, and health, supplementing the than in the USA.31 The continued legacy of redlining, a overarching analysis presented in the scoping review and policy of systematic disinvestment in minority and low- geographical visualisation sections. income neighbourhoods, could contribute to the inequitable distribution of heat exposure and heat- Climate change, health, and discrimination: sensitive illness in the USA. Land surface temperatures a scoping review of the literature and hospital admissions for heat-sensitive illnesses were This section identifies and analyses literature from a higher in areas of cities previously targeted by this racist scoping review we conducted to identify the breadth of policy than areas not targeted.32,33 available evidence on the impact of climate change on Reflecting exposure patterns, heat-related asthma and health inequalities by race, ethnicity, caste, Indigeneity, acute myocardial infarctions are more common in Black religion, migratory status, and skin colour. The findings and Hispanic people than White people in the USA.29,34,35 were limited to race, ethnicity, migratory status, and Further, hospital admissions for asthma, and Indigeneity as no evidence was elicited in the search on cardiorespiratory and non-injury mortality, are more caste, religion, or skin colour. Findings are summarised temperature-dependent in Black and Hispanic people according to the form of categorisation that they relate to, than White people.34–37 Climate-sensitive health risks can with detailed findings in the appendix (pp 6–10). have intergenerational effects on racially minoritised Key themes from the scoping review are displayed in families: Black women have a higher relative risk of figure 1 with the use of Devakumar and colleagues’ preterm birth after exposure to heatwaves than White and conceptual model from The Lancet Series on racism, Hispanic women, and exposure to extreme heat increases xenophobia, discrimination, and health.6 This conceptual the risk of maternal hospitalisation more for Black women model highlights that health inequities are determined by than White women.38,39 active processes that occur within power structures, affect Beyond heat-sensitive morbidity and mortality, racially different levels of society, and impact biology across the minoritised groups are also more vulnerable to the life course. In figure 1, layers of society from the structural physical and mental health impacts of extreme weather to individual level are represented by the layers from the events and less likely to have their health-care needs met. core to the surface of the earth, illustrating the numerous For example, following the 2017 Hurricane Harvey, Black www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 3 Health Policy Individual health outcomes • Climate change increases food insecurity and undernutrition, including for Batwa Indigenous communities in Uganda • Following Hurricane Harvey, Black Texas residents had a four times higher risk of post-traumatic stress disorder than White residents • Racially minoritised individuals face a disproportionate burden of occupational health risks such as heat-related illness Communities and spatial determination • Previously colonised countries are disproportionately located in the areas most affected by climate change • Within US cities, areas with greater proportions of Black, Hispanic, and Asian Communities Spatial determination residents are hotter on average than areas with more White residents • Rural–urban migrants in Dhaka (Bangladesh) are more likely to end up in areas of the city that are prone to flooding than non-migrants Individuals • In Pakistan, exposure to flooding increased the proximity between people displaced to zoonotic and vector-borne diseases Health systems Health systems • Previously colonised countries have less economic resources to adapt their health systems in response to climate change, contributing to a disproportionate burden of deaths in the Global South • Without legal recognition or protection, climate refugees are excluded from Institutions and systems accessing health systems in receiving countries • Climate change is a cause of ill health, as seen in the tragic death of Ella Addo-Kissi n Debrah sio res • Health systems must tackle the interwoven roots of discrimination that exist pp alongside their carbon emitting processes fo so tem Institutions and systems Structural sys • The harmful health impacts of the fossil fuel industry affect minoritised discrimination: ing separation and ect populations even before reaching the high emissions stage by polluting land hierarchical power ers and water (eg, the oil spills in the Niger Delta) Int • Health institutions must support the dismantling of extractive industries that create health inequalities Intersecting systems of oppression • Racially minoritised people with disabilities face unique challenges to disaster and extreme weather-related evacuation, exacerbating health inequalities • Climate change compounds racialised and gendered health harms, including increasing prenatal hospitalisation and preterm birth in racially minoritised women • Racially minoritised people are over-represented in low income groups who have limited financial capacity to mitigate climate-related health risks, including access to air conditioning Structural discrimination • Global capitalism has an extractive relationship with the Global South, shaping local inequalities especially for Indigenous and rural communities • Settler-colonialism institutionalises manufactured difference, creating political, social, and economic implications for those in the margins (eg, the life expectancy gap between Aboriginal and White Australians that is exacerbated by climate change) • Within a capitalist system, individuals and institutions are incentivised to project an image of tackling climate change or racial equity, which is tokenistic and performative Figure 1: Devakumar and colleagues’6 conceptual model on racism, xenophobia, discrimination, and health applied to climate change and health Reproduced with permission of Devakumar and colleagues.6 Texas residents were four times more likely to have high study highlights the complex and cascading risks linking post-traumatic stress (scoring above 40 on the Post- discrimination, climate change, and health, showing Traumatic Stress Disorder Checklist–Specific).40 Racially relevant pathways not captured by the scoping review and ethnically minoritised respondents were also more findings presented previously. likely to report poor access to health care due to the hurricane than their White counterparts.40 Panel 1 Migratory status presents a case study from Brazil on the interaction Ten studies from the USA (n=3), New Zealand (n=2), between racism against Quilombola people, climate Australia (n=1), Austria (n=1), Bangladesh (n=1), Fiji (n=1), change and deforestation, and their health. The case and Pakistan (n=1) highlighted the increased vulnerability 4 www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 Health Policy of migrants to environmental hazards related to climate change. In Bangladesh, poor rural-to-urban migrants Panel 1: Justice for Quilombolas in Brazil often migrate to low elevation coastal zones, increasing In Brazil, Quilombola communities, composed of descendants of enslaved African people their risk from coastal flooding.50,51 Internal migrants in with specific forms of communal social organisation, rely on the land and natural Pakistan and Fiji face increased vulnerability to zoonotic resources for their cultural, social, religious, ancestral, and economic reproduction. diseases and non-communicable diseases due to dietary Under the Brazilian settler-colonial state, Quilombolas experience legal instability to their change, respectively.52–55 In the USA, non-citizens are territorial rights, which (combined with poor access to health care, education, and other more likely to live in previously redlined areas where land rights) reveals how historical disadvantages and institutional racism restricts the dignified surface temperatures are higher; are over-represented in survival of these populations.41 In several regions of the country, as in the Brazilian flood-zones; and face greater exposure to harms associated Amazon, land disputes of Quilombola and other traditional populations are intensified by with wildfires due to precarious work conditions and poor mining and agribusiness. Brazil’s previous governmental response reinforces threats to accessibility of disaster risk information.32,56,57 In Australia, traditional communities and the Amazon rainforest, with the reduction of law migrant families reported higher perceived risk of heat- enforcement and increased amnesty for deforesters.42 From August, 2020, to July, 2021, related health effects and decreased access to cooled 13 235 km² were deforested in the Brazilian Amazon region.43 A study in the region has public spaces.50 In addition to increased exposure to shown that increases in deforestation combined with the intensification of the dry season environmental hazards, people who have experienced worsens carbon emissions, risk of fire, and ecosystem stress.44 international climate-induced migration face restricted In addition to contributing to climate change, deforestation drastically impacts access to health care, further increasing their vulnerability Quilombola communities. Residents of the Médio Itacuruçá community located in to climate-related health problems, highlighting the need Abaetetuba, a city in the Brazilian Amazon, have reported the effects of weather for universal health care.50,52,53,58 unpredictability leading to crop failures and reduced food production in family farming. Older residents also reported that extreme heat has shortened the length of working Indigeneity days. These situations are aggravated by other forms of discrimination that leave Eight studies discussed Indigenous communities in Quilombolas more economically vulnerable to the delay in planting and the smaller Uganda (n=3), the USA (n=2), Australia (n=1), Peru (n=1), harvests, creating susceptibility to food insecurity; almost half of Quilombolas are highly and Tuvalu (n=1). Climate-related health concerns food insecure.45 Climate change threatens food security in communities around the for Indigenous communities included malnutrition, world.46 Negative health outcomes associated with food insecurity include anaemia, malaria,59,60 negative reproductive health outcomes,61 asthma, cognitive problems, aggression and anxiety, depression, and suicide among declining infant health,60 poor mental health,62 and children and poor mental health, diabetes, hypertension, hyperlipidaemia, and poor sleep respiratory distress.63 These outcomes were linked to among adults.47 colonialism’s role in marginalising Indigenous com­ munities, encroaching on land rights, and the impact The vulnerability of Quilombola communities to the health impacts of climate change that this has on their way of life.64,65 is multidimensional, extending beyond the impacts of food insecurity while also In Batwa (Uganda) and Shawi (Peru) communities, aggravating it. Severe storms endanger housing of Quilombolas, as observed between malnutrition was driven by unusually extended rainy and December, 2021, and January, 2022, in several regions of Brazil. For example, in the state dry seasons that negatively affected their primary food of Minas Gerais at least 72 communities across 20 municipalities were affected, leaving sources and added financial hardships that shaped food more than 7000 families in need of assistance, without food or water.48 The storms insecurity.59,64 In Batwa communities, food insecurity was further hampered access to already marginalised communities, leaving populations also linked to worse birth outcomes, such as smaller without access to health care. Loss of biodiversity is a serious problem in the Amazon babies and a higher frequency of infant illness.60 In the rainforest as it diminishes ecological niches occupied by predators of vector species and same community, increased rainfall led to higher rates of also creates new niches to alternative vectors, hosts, and pathogens. Moreover, malaria by increasing the amount of contaminated, deforestation and habitat loss are often accompanied by psychological aggressions stagnant water present in the community, whereas the (stress, malnutrition, and increased contact with pollutants), which can affect the dust of extended dry seasons led to respiratory problems.59 immune system chronically and increase susceptibility to pathogens.49 In Houma Nation (USA), women observed an increase Although protecting the environment is necessary for the existence of Quilombola in reproductive health concerns including eclampsia, communities, Quilombolas are also essential in ensuring the preservation of the gynaecological cancers, and preterm birth.61 Sociopolitical environment and limiting the greenhouse effect. In Quilombola territories, nature is well exclusion and socioeconomic hardship amplified the conserved and highly valued, as their way of living centres around the rational and health impacts of climate change faced by Indigenous sustainable use of available natural resources. Therefore, assuring Quilombolas’ rights and communities. For example, land insecurity restricts facilitating community leadership before measures that could affect the territory are Batwa communities’ socioeconomic mobility and low necessary to achieving both historical reparation to the Quilombola population and socioeconomic status restricts their access to household reductions in greenhouse gas emissions. goods for infection prevention (eg, boiling contaminated water)59 and financial access to education.64 interacting power structures.14 Two intersecting systems Intersecting systems of oppression of oppression are addressed in the findings of our An intersectional approach is necessary to understand scoping review: gender and race; and income and race. and respond to health inequalities resulting from None of the papers reviewed presented findings on age www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 5 Health Policy or sexuality. Visually, intersectionality is represented in minoritisation and discrimination result from multiple Devakumar and colleagues’ model as an arrow cutting systems of power operating within their own historical across various strata of society, representing how and structural contexts (figure 1). Gender and race Panel 2: Comparative policy analysis of gender mainstreaming in the climate– Two studies focused on the environmental determinants agriculture–health policy nexus in the Philippines and Uganda of racial inequalities in maternal health; in addressing Gender mainstreaming has been integrated into climate policies in many countries, gendered health issues, they highlighted that women face including the Philippines and Uganda, to address the health inequities faced by women additional climate-related health vulnerabilities and that agriculturalists due to a changing climate. Mainstreaming is a policy approach that racially minoritised women are doubly disadvan­taged.38,39 integrates elements across distinct issue areas towards one policy agenda. Gender However, none of the studies applied intersectionality to mainstreaming can redress structural inequalities that result from colonial legacies, analyse the role of gender in shaping inequalities faced by including gender inequity. Such structural inequalities shape the uneven distribution of minoritised people or addressed the health burden faced climate change’s impact on health, causing women and minoritised groups to be by people of other marginalised genders (ie, other than disproportionately affected. cisgender women). Nevertheless, there is a large body of work on gendered climate-related health inequalities.66,67 Under Spanish, American, and British occupation, the Philippines and Uganda Panel 2 shows the interaction between colonialism, experienced colonial histories that continue to diminish the role of women in society gender, and health in the Philippines and Uganda through compared with pre-colonial times. For instance, in pre-colonial Philippine society, women a comparative policy analysis. held leadership roles in spiritual and scientific affairs;68 in Uganda, the value system introduced by colonialism devalued the role of women in society by depicting their work Income and race as traditional and backwards.69 Colonial structures still shape how both Filipino and Income and race are two axes of oppression that closely Ugandan women experience health, economic, and social deprivations. interact.14 Many of the papers (n=16) addressing race and The nexus of agriculture, climate change, and health exemplifies the lasting impacts of ethnicity in our scoping review also highlighted the colonially driven gender inequity. Climate change will devastate the health of small scale importance of income in mediating climate-related racial and subsistence farmers, particularly through reducing food security and nutrition. health inequalities. For example, the literature highlighted In both the Philippines and Uganda, these health implications will be felt more acutely by the disproportionate burden of extreme heat and heat- women. In Uganda, women constitute 76% of the agricultural labour force70 and are sensitive illnesses faced by people and areas with low- disproportionately represented in subsistence-oriented farming of low-value crops. income,27,31,34 their poor access to cooling facilities and Women are less represented in the Philippine agricultural labour force, but consistently resources, and their exclusion from green infrastructure have lower wage rates and purchasing power relative to men.71 The marginalisation of initiatives,26,29,30 demonstrating structural racism.1,81 None women increases their vulnerability to climate change-related agricultural shocks of the studies examined how race or ethnicity intersect including drought, flooding, and crop failures. Women additionally face unique climate with socioeconomic status to compound health impacts on maternal, reproductive, and sexual health.72,73 For instance, following the inequalities related to climate change. Further, the 2013 Typhoon Haiyan in the Philippines, pregnant women were more vulnerable to reviewed literature failed to highlight that poorer and undernutrition and miscarriage and adolescent girls to sexual-based violence.74 marginalised people who experience the greatest impacts The Philippine Magna Carta for Women75 protects women affected by disasters and of climate change have contributed to it the least, as calamities, empowers women farmers, and ensures access to healthy food for women and shown in a large body of work.82–84 girls. Further, the Climate Change Act76 of 2009 and the People’s Survival Fund Act77 of 2012 both promote gender mainstreaming in climate adaptation and disaster risk reduction. Summary Meanwhile, the Ugandan National Climate Change Act78 2021 includes valuable Overall, the findings indicate an unequal distribution of considerations of gender and food security, showing attention to the specific needs of the health impacts of climate change, disproportionately women agriculturalists. Nevertheless, gender mainstreaming efforts have not substantially burdening racially and ethnically minoritised groups, mitigated the risks faced by Filipino and Ugandan women. In Uganda, gender and food migrants, and Indigenous Peoples. These findings are security are unsystematically integrated into climate and food security policies79 and in the supported by the Intergovernmental Panel on Climate Philippines, community-level implementation of climate disaster risk management policies Change, which has highlighted that people who face are insufficient and devoid of gender considerations.80,69 Addressing the implementation social marginalisation due to ethnicity and Indigeneity challenges of gender mainstreaming is key to ensuring effective and sustainable policy are among those most vulnerable to the impacts of responses. Although gender mainstreaming might be frequently advocated by international climate change.8 The numerous dimensions of the organisations, the design and implementation of such policies must consider the interaction between climate change, health, and idiosyncrasies of local contexts (including colonial histories) and incorporate grassroots, discrimination at each level of society are presented community-led interventions. In addition to embedding gender mainstreaming in domestic through application of Devakumar and colleagues’ climate policy, it must be integrated across other sectoral policy areas, given the climate’s conceptual model in figure 1.6 The evidence is overarching impact on society and government. Finally, gender mainstreaming must also concentrated in high-income settings, but low-income incorporate a broader anti-colonial and anti-imperialist approach to address all forms of settings are also represented. Although the evidence inequality—eg, racial discrimination, which oftentimes overlaps with gender inequality. summarised here points towards an unequal distribution of health impacts of climate change, unequal 6 www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 Health Policy responsibility for climate change was not highlighted in section of this paper analyses inequalities in responsibility the body of literature reviewed here, suggesting a gap in and health impacts of climate change through presen­ research linking unequal responsibility with health tation of a geographical visualisation. effects. Yet, inequities in responsibility and burden are visible within and between countries. Discussion of Inequalities in responsibility and health impact: unequal responsibility alongside the health inequalities a geographical visualisation identified in this scoping review is essential to identifying Unequal responsibility for climate change and dismantling the power structures at the root of There is a tendency to refer to climate change in the climate-related health inequities. As such, the next language of the so-called Anthropocene. This A CO2 emissions in excess of planetary boundary fair shares (350 ppm) 0 High B C Diarrhoeal deaths At risk of malaria per 100 000 per 100 000 01 2345678 0 37 108 D E Deaths related to undernutrition Heat-related deaths per 100 000 per 100 000 0 83 7 40 Figure 2: Unequal responsibility for climate breakdown and unequal health outcomes between countries (A) Responsibility for climate breakdown across countries based on cumulative CO2 emissions from 1850–2015; countries in green were still within their fair share of the 350 ppm boundary as of 2015. (B) Projected climate-change attributable diarrhoeal mortality in people aged younger than 15 years; countries in light grey have mortality less than 0·01. (C) Projected climate-change attributable population at risk of malaria; countries in light grey have a risk of 0, the USA and Canada have a risk of 27. (D) Projected climate-change attributable heat-related mortality in people older than 65 years. (E) Projected climate-change attributable mortality due to undernutrition in children younger than 5 years; grey indicates no data. Projected climate change-attributable mortality and disease risk maps were created using Microsoft Excel and Datawrapper software to visually display mortality rates and population at risk per 100 000. Rates were calculated with the estimated number of deaths and population at risk per region in 2050 and medium population growth estimates for 2050 from the World Population Prospects 2010 revision.23,24 PPM=parts per million. www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 7 Health Policy terminology is useful to the extent that it highlights the the bottom 50% of emitters.84 Corporations bear a specific anthropogenic causes of the crisis; however, not all respon­sibility here, and have long exploited racial humans are equally responsible for the problem. divisions—eg, through damaging the territories of Climate change is ultimately an effect of the economic minoritised groups, exemplified by the case study of system: capitalism, which seeks to cheapen labour and Quilombolas. In all settings, groups who are minoritised resource inputs, often through processes of extraction experience the health impacts in their settings while and exploitation, including through historical and consumption occurs in global centres of wealth.89,90 ongoing processes of colonisation, dispossession, and coercion.85 Ideologies of race and other forms of Health inequalities between countries categorisation have long been used to justify these According to the Climate Vulnerability Monitor, of the processes (figure 1).86 Capitalist dynamics have produced estimated 400 000 deaths caused by climate change severe global inequalities, with centres of wealth and globally in 2010, 98% occurred within the Global South.91 capital accumulation characterised by high amounts of Figure 2 displays the unequal global burden of mortality consumption and energy use, hindering the ability of attributable to climate change from heat-related mortality, some populations to meet their basic needs. undernutrition, and diarrhoea, and the population at risk Centres of accumulation in the Global North are of malaria in 2050. The data used in each map accounts overwhelmingly responsible for greenhouse gas emissions for base case economic growth and an emissions scenario that exceed the safe planetary boundary, whereas the consistent with A1b (see appendix p 19 for descriptions of Global South suffers the effects dispropor­tionately. With emissions scenarios).23 The responsibility for the climate the fair-share approach, described in the methods section, breakdown map92 is based on overshoot emissions beyond it is possible to determine the extent to which nations have the 350 parts per million planetary boundary.21 exceeded their fair share of the safe emissions budget and Geographically uneven patterns of climate-related thus how much they have contributed to pushing global health impacts are apparent, with risk of exposure to emissions beyond the safe planetary boundary. Cumulative deadly heat and heat-related mortality93–96 and food emissions exceeded this level in the late 1980s, driving the insecurity97,98 concentrated in the Global South. Multi­ crisis of climate breakdown that is evident today. dimensional climate vulnerability, which assesses Assessing cumulative emissions over the period vulnerability indicators related to food, water, health, 1850–2015, countries of the Global North, which represent ecosystem services, human habitat, and infrastructure, is 14% of the world’s population, are responsible for likewise higher in the Global South than the Global North.99 92% of historical carbon dioxide emissions in excess of The vulnerability of Global South countries to climate the safe planetary boundary.21 Most countries in the change is due in part to the concentration of negative Global South (including large, populous countries like biophysical effects in tropical zones, but also to colonial India, Indonesia, and Nigeria) are still well within their histories and persistent structures, including trade fair share of the planetary boundary (figure 2). This liberalisation, predatory financing arrangements, and dynamic can be understood as a process of atmospheric debt accrual by the International Monetary Fund and colonisation.87 Just as land and territories have been World Bank beginning in the 1980s.100,101 Countries colonised in the past, so too have the atmospheric affected by these measures often do not have the capacity commons been appropriated by wealthy countries for to respond and adapt to climate-related health impacts, their own enrichment, through forms of industrialisation and benefits of adaptation will thus be concentrated in and growth that have relied on colonial patterns of countries with the economic power necessary to invest in appropriation, with devastating consequences for all life adaptive technologies and behaviours.94 Panel 3 is a case on Earth.88 In this way, climate change showcases study from the Marshall Islands, a nation that still colonialism as a historically rooted, yet ongoing structure, remains well within its fair share of the planetary that governs and shapes our lives, “which are co- boundary but is highly vulnerable to climate-related constitutive of processes of capitalism, imperialism, and health inequalities driven by racial injustice. international development”.18 This visualisation shows not only where economic, social, and political dominance Health inequalities within countries lies, but also which economies are more responsible for Climate change and other human-induced environmental repairing damage. changes, such as loss of biodiversity and air pollution, Not all people in the Global North are responsible for disproportionately affect the health of minoritised people excessive emissions, just as not everyone in the globally. Indigenous Peoples live in different contexts, Global South is less responsible. Here, class inequalities affected by different histories, and according to different prevail; wealthy individuals are disproportionately respon­ lifeways. Despite these differences, Indigenous Peoples sible for excess emissions given their dispro­portionate around the world bear an extraordinary burden of the influence over production and legislation, but also in health threats of climate change.113 This burden is due to terms of their personal consumption. The average carbon a legacy of colonial subjugation, responsible for footprint of the top 1% of emitters is 75 times higher than catastrophic loss of life, loss of lands, and ethnocide.114 In 8 www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 Health Policy efforts to recognise the scope of land dispossession and forced removals in the USA, an investigation found that Panel 3: Climate, health, and racial apathy in the Marshall Islands Indigenous communities have experienced near total Despite being well within their fair share of the planetary boundary and facing loss of historical coextensive territorial homelands geographical isolation from the financial benefits of a fossil fuel-driven global economy, (98·9%), an average forced removal from territorial large ocean states are uniquely vulnerable to climate change.102 The Marshall Islands is homelands of 239 km, and contemporary lands that have among the most climate-vulnerable countries in the world due to the risks associated more heat days (ie, days when the maximum temperature with sea level rise, given its low altitude (averaging less than 2 metres above sea level), surpasses approximately 38·8°C), less precipitation, and densely populated coastlines, and concentration of more than 95% of its infrastructure in decreased mineral value potential than historical lands.115 the Low Elevation Coastal Zone.8,103 Under a high emissions scenario, the Marshall Islands Indigenous Peoples are also minoritised through is projected to have annual wave-driven flooding over its entire surface by 2060–2070.104 evictions with no compensation for their relocation,59 For this atoll nation, climate change is a current reality already affecting the Marshallese subsequent financial burdens associated with housing and the survival of their nation. insecurity and displacement,59,64 and isolation and stress Marshall Islands faces a triple burden of disease: communicable disease, stemming from a disrupted spiritual and cultural non-communicable diseases, and the health impacts of climate change.8,105 High-priority, relationship with their land.62,65 Indigenous communities climate-sensitive health risks in the Marshall Islands span insufficient food and water; have been stewards of land and ecosystems, defending it vector-borne, non-communicable, and respiratory diseases; mental health stress; and against ongoing extraction from industry and managing extreme weather events.106 The health impacts of extreme weather events alone have the an estimated 20–25% of the Earth’s land and potential to be widespread and devastating, resulting in reduced drinking water and food 80% of biodiversity, all while comprising only 5% of the availability, increased communicable diseases, and diminished mental health and world’s population.116 wellbeing.8,107 Despite relevant evidence showing the health risks associated with climate effects in the Marshall Islands, crucial gaps in research and evidence exist. Very little Discussion research has been conducted within the Marshall Islands, or the Pacific Islands more Interaction between climate change, health, and broadly.105,108 As a result, there are no granular data on the health impacts of climate discrimination change experienced by minoritised people in the Marshall Islands, mirroring global This is the first scoping review that has summarised epistemic injustice in this area. Research must identify climate-attributable changes to current evidence on how structural discrimination health indicators over time; no data of this nature currently exist for the Marshall Islands interacts with climate change to cause profound damage and are limited across the Pacific Islands.105 Research in these areas is crucial for guiding to minoritised people’s health globally. The geographical climate action and health policy. visualisation has illustrated geopolitical inequities in responsibility for emissions: Global South countries (and Adaptation is also essential to addressing the health impacts of climate change. However, minoritised people in any region) have contributed the Marshallese adaptive capacity has been diminished by colonialism, creating an economy least to the problem, yet experience the health impacts of dependency and limiting Marshallese sovereignty over adaptative planning due to most acutely. Climate breakdown is being driven by power differentials.109 From the beginning of the 19th century, the Marshall Islands passed processes of atmospheric colonisation and its conse­ under colonial rule of Spain, Germany, Japan, and finally the USA. While under American quences unfold along colonial lines. The case studies and occupation, the Marshall Islands additionally faced nuclear colonisation: the USA tested policy analysis have elucidated the relationship between more than 65 nuclear weapons on the Bikini and Enewetak atolls, contaminating water climate change, health, and discrimination, manifesting and soil with long lasting implications for food access, forcibly displacing Indigenous through extractive behaviours of powerful industries, communities and rendering 20% of the Marshall Islands uninhabitable.107,110,111 Racism was often facilitated by governments. For example, government central to the justification of such violence.6 This same racist logic has facilitated subsidies for fossil fuels exceed national health spending atmospheric colonisation,21 causing the Marshall Islands to now face the existential threat in some countries and totals US$400 billion globally.3 posed by climate change. Prominent Marshallese climate activist and poet Applying racial justice to climate change and health Kathy Jetnil-Kijiner has powerfully drawn this parallel between nuclear testing and climate reveals opportunities for the health community to redress change: “We’re seen as disposable in both situations. We’re disposable. Our lives don’t unequal power dynamics between minoritised com­ matter, the war matters, nuclear bombs matter. Our lives don’t matter, oil matters, munities and the geopolitical and commercial factions money matters, gas matters, profits matter.”112 that dominate the world economy and directly affect In the face of climate change and an apathetic global system, the Marshallese are not health. Racial justice necessitates repairing the harm passive. They are spearheading global action on climate change through the Climate through equitable distribution of the costs of adverse Vulnerable Forum and the High Ambition Coalition. As articulated by the Paris Agreement effects of climate change and resources to address climate and Glasgow Pact, staying within 1·5°C of warming (which would still result in some change. damage) is paramount to the survival of the Marshall Islands and Large ocean states and Our analysis of climate-related health inequities, and require drastic emissions reduction. As the Marshallese are fighting for survival, the rich the parameters defining evidence-based solutions, are nations of the world, including Marshall Islands’ former colonisers, must take shaped by a research lens informed by data, policies, and responsibility for their actions by repairing past and ongoing harm. practices produced by systems of colonialism and discrimination. For example, our understanding of climate change, health, and discrimination is limited by the concentration of studies on racial and ethnic health www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 9 Health Policy inequalities in North America, enacting epistemic injus­ and appropriately resourcing movements to decolonise tice through both hypervisibility of some characteristics and reclaim Indigenous cultures, lifeways, and traditional and erasure of those not accounted for. Geographical practices.121 Ultimately, allies and global health movements inequalities between countries are better documented must recognise the crucial relationship and kinship of due to greater data availability and policy attention. Indigenous communities with local ecosystems and Colonial legacies of profit and power are ever present associated ecological knowledge systems as a solution to today. As shown in the case studies and geographical climate change and representative of model sustainability visualisation, reliance on oil, gas, and other extractive practices. industries that drive excessive emissions is a matter of life and death for minoritised people. Although Reparative justice and human rights legal interventions millions of people in Europe face fuel poverty and The evidence in this Health Policy shows the unequal residents in the Niger Delta are poisoned by oil spills, the distribution of responsibility for damage between companies responsible report soaring profits.117 Health countries, whereby the Global North is disproportionately institutions’ investment in fossil companies continues responsible for damage and the Global South is least despite overwhelming evidence that such companies are responsible. The Global North nations have colonised the actively blocking climate justice and harming the health atmospheric commons for their own enrichment through of minoritised people. A fair and just transition to forms of industrialisation and growth that have relied on renewable energy to meet the 1·5°C climate target colonial patterns of appropriation.88 Across all countries, requires transdisciplinary solidarity between movements responsibility lies primarily with the affluent and ruling fighting colonialism, racism, and health inequities. classes, due to their high levels of emissions83 and disproportionate control over energy systems and national Relational Indigenous lifeways and health legislation. In many settings, extraction lies more with Indigenous communities continue to contend with the corporations with substantial economic influence.89 ontological and epistemic assault of colonialism on Alternative economic paradigms such as degrowth, Indigenous lifeways, cultures, languages, and spirituality, wellbeing economy, and doughnut economics—all rooted resulting in a profound cultural discontinuity that in ecological economics—offer opportunities to make the challenges the capacity to engage Indigenous Traditional transition to an economic system that is designed to Ecological Knowledges towards adaptation or mitigation promote human and planetary health from the outset, efforts (or both).118–120 Meanwhile, the interdependence rather than one where social and environmental damage and kinship shared between local ecosystems, sacred must be constantly corrected afterwards.123 places, and Indigenous Traditional Ecological Know­ In light of the evidence discussed here, there is a clear ledges are persistently threatened by climate change, health case for supporting climate reparations.124 Those undermining community health. countries, companies, and ruling classes who are most Unequal health outcomes highlighted by existing responsible both historically and currently should pay evidence in the scoping review are perpetuated by political monetarily to the most affected peoples and areas and exclusion and under-representation of minoritised voices repair harm holistically.125 The health community must from decision-making spaces. Indigenous communities not only lobby to ensure that loss and damage funds are are continuously excluded from policy-making pro­ rapidly implemented, it must also demand more to heal cesses,60,64 an enactment of colonial violence,64 and have and repair harm, grounded in principles of reparative few protections against intrusive developments by fossil justice.126 Reparative justice can take many forms: debt fuel companies.61 Despite increasing recognition of cancellation; giving land back to communities; Traditional Knowledges in climate adaptation and unconditional grants; a Global Climate Stabilisation Fund mitigation plans, these have been symbolic rather than according to responsibility; divestment from extractive applied practically on a global scale.121 Non-tokenistic industries; and transfer of technology, wealth, and representation of Indigenous voices in decision-making resources.127 Scholars urge that reparations involve not spaces is an important solution to alleviating these health only addressing past harm but a transformative inequalities, but is severely scarce.60,64 worldbuilding project for ecological futures.125 In efforts to mitigate the intersecting and persistent As discriminatory policies are enabled by our current threats of settler-colonialism, white supremacy, and political and legal landscapes, a legal approach that structural discrimination, Indigenous communities have employs human rights frameworks can provide grounds spearheaded movements to decolonise the Anthropocene for the structural change that is necessary to address the across multiple sectors, namely public health policy, land deep health inequities outlined throughout this Health rights, maternal and child health, and environmental Policy. International human rights legal interventions can health policy.122 Planetary health recognises the need to be a tool for challenging racist and discriminatory policies, pursue mechanisms that confront the enduring impacts through setting shared visions and com­mitments around of structural discrimination while advancing the often- the human right to health and enshrining mechanisms cited adaptive capacity of Indigenous Knowledge systems, for public and private actors to be held accountable for 10 www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 Health Policy violating equality frameworks.128 For example, health probably an under-estimation as they only cover a select organisations can support the increasingly popular number of climate-related causes of death and do not method of litigation against the fossil fuel industry to stop include the health impacts of economic damage, major racist and discriminatory practices deployed by the heat waves, river flooding, water scarcity, or conflict. industry to harm the health of minoritised groups. When international judicial systems fail communities, initiatives Towards just futures such as the People’s Health Tribunal provides space for We conclude that a holistic approach to climate change testimonies from the front lines of climate violence caused and health requires not only addressing the web of social, by extractive industry giants based in the Global North.129 commercial, and political determinants of health (eg, the This initiative is an example of the health community in built environment, education, and income) but going the Global North practising solidarity-driven work with one step further into the oppressive structures that communities across the African continent and diaspora. underpin all these conditions. Colleagues must strive to incorporate anti-racism, anti-xenophobia, and anti- Strengths and limitations discrimination in their work, centring voices of the most A key strength of this paper lies in its multiple methods, affected peoples and communities resisting the root employing a scoping review, geographical visualisations, causes of the health inequalities. As such, we have set out case studies from most affected peoples and com­ guiding principles to approach research and action at munities, testimonies, and policy analysis. The this intersection of climate change, health, and geographical visualisation draws together a robust body discrimination, at differing levels of society. of literature, visually complemented by original maps. We invite scholars to pursue research that interrogates These maps are the first to present unequal responsibility and repairs structural discrimination. The nexus of for climate change and health outcomes in this way. The climate change, health, and discrimination offers a wealth inclusion of case studies and policy analysis sheds light of opportunities to engage with research that is justice- on the complex pathways through which unequal driven, has hyperlocal to international reper­cussions, and responsibility leads to unequal impact, exacerbated by harnesses the potential in inter­disciplinary collaborations discrimination. Through these methods, we respond to to create policies and practices for equitable health calls for consideration of the multiple injustices and outcomes and flourishing ecosystems. We present a non- their health implications in climate and health.130 We encountered several methodological challenges highlighting the difficulty of analysing injustice with existing climate and health indicators.25 The literature Centre the voices and solutions of MAPA, represents scholarship on the unequal health impacts of with measures of success climate change, a topic that is grossly underexamined due and accountability processes to the skewing of global research efforts towards the health determined by MAPA needs of high-income countries. Additionally, focusing on Employ transformative Quantitative research that papers written in English narrows the reach of our analysis mixed method designs to explicitly includes and analyses advance critical and discrimination based on race, and excludes non-English-speaking research communities. emancipatory research ethnicity, and other categories Further, the search strategy was limited to describing health inequities due to climate change but not the effects of drivers of climate change, such as consumerism and extractivism, or more broadly conceived health effects, such as wellbeing and social health. The scoping review Research priorities did not capture the complexity of pathways linking climate Practise a decolonial Qualitative studies of change, discrimination, and health impacts, especially approach that acknowledges perspectives and experiences when either climate change or health were not explicitly contemporary of minoritised people and historical harms discussed. For the geographical visualisation, the availability of data for map creation were limited overall, as existing data initiatives do not capture information on variables that reflect different forms of discrimination and as a Existing and emerging climate Interdisciplinary collaborations change and health funders to result are not presented in a granular and disaggregated between climate change, fund research at the intersection racial justice, and health manner to allow a more complete examination of equity scholars of climate change, health, and discrimination climate, health, and discrimination. Different forms of inequality and discrimination could not be captured beyond the traditional geographical or economic and income inequalities. As such, the maps represent only Figure 3: Research priorities at the nexus of climate change, health, and discrimination regional-level inequalities. Further, existing data are MAPA=most affected people and areas. www.thelancet.com Published online May 29, 2023 https://doi.org/10.1016/S0140-6736(23)00919-4 11 Health Policy exhaustive list of research priorities (figure 3). For complex research context. Publications from a diversity of example, we highlight the possibility for transformative epistemologies and onto­logies using alternative methods mixed methods to address structural issues, including carry the opportunity for producing emancipatory racism and inequity. Study designs that use participatory research outcomes.131 action research and restorative practices have been shown We urge the health community, including everyone to be effective in flattening hierarchies when conducting whose work affects health, to engage in the principles set research with minoritised populations, legitimising and out here (panel 4), based on Abubakar and colleagues’128 contextualising perspectives, and promoting critical six principles for confronting the impact of discrimination conscious­ness. Hegemonic research involving on health from The Lancet Series on racism, xenophobia, randomised controlled trials and epidemio­logical methods discrimination, and health. Our values were developed need valid critique over their appropriateness in this from the findings of this paper and the expertise of the authors (see appendix p 20 for the process of developing the principles). We urge the health community to tackle Panel 4: Principles to guide research and action on climate root causes of historical and ongoing harm and trauma change, health, and racial justice brought about when climate change interacts with The health community can offer skills, solidarity, research, and structural discrimination. organising power and be a strong voice for justice. The health Contributors community’s role in dismantling power structures to achieve TAD conceived and designed the outline of the paper, with input from all the authors. TAD, SE, and CS designed the literature search question and health equity should be embraced at each level of society, TAD and DD defined the search terms. SE ran the searches, and TAD, CS, aligned with Devakumar and colleagues’6 conceptual model JB, MH, PdMS, RI, and SE undertook initial screening. Data extraction was from The Lancet Series on racism, xenophobia, discrimination, completed by CS, JB, MH, and SE and the critical analysis was drafted by and health—ie, the individual, community, institutional, JB, MH, and SE. JH and SE created the maps. JH, TAD, and SE wrote the narrative review section. KXH contributed to the sections on Indigenous health system, and structural level (figure 1). In taking up health. SS and TAD created figure 1. TAD coordinated the collaborative these values, we urge the health community to be mindful of structuring, writing, and editing of the manuscript. PdMS wrote panel 1; context and to be guided by communities taking action. HPN, HM, JB, and RRG wrote panel 2; and SE and RRG wrote panel 3. TAD and CS wrote the discussion. The recommendations were co-created Individual by all the authors. All authors edited and critically revised the draft. • Centre the voices and solutions of the most affected Declaration of interests people and areas in policy, education, advocacy, and TAD, SS, PdMS, JB, SE, MH, RI, HM, HPN, CS, and DD report grants action to practise a decolonial approach from the Wellcome Trust (224687/Z/21/Z) paid to University College London and for which DD is the principal investigator. The other • Accountability for measures of success in policy and authors declare no competing interests. action should lie with the most affected people and areas Acknowledgments Communities We thank Mark Stege for his expert review of panel 3. JH acknowledges support by the María de Maeztu Unit of Excellence grant from the • Global North communities must practise allyship by Spanish Ministry of Science and Innovation (CEX2019-000940-M). creating space for Global South voices in decision making Editorial note: The Lancet Group takes a neutral position with respect to through non-tokenistic means territorial claims in published maps. • Diverse forms of knowledge, including Indigenous References Knowledges, should be embraced during decision making 1 Selvarajah S, Corona Maioli S, Deivanayagam TA, et al. Racism, xenophobia, and discrimination: mapping pathways to health Institutions and health systems outcomes. Lancet 2022; 400: 2109–24. • Education institutions should raise critical consciousness 2 Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public about power imbalances and discrimination related to health crisis we can no longer ignore. 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