The Lancet Countdown on Health and Climate Change Policy brief for Costa Rica 2022 Introduction Climate change poses a significant threat to human health in Costa Rica and around the world. Urgent action is needed to reduce greenhouse gas emissions and adapt to climate impacts. In recent years, Costa Rica has positioned itself internationally as a ‘green’ country that embraces nature-based solutions and sustainable development. Costa Rica has also made clear efforts to address climate change through its Decarbon- ization Plan1 and a National Adaptation Plan;2 however, these plans do not include specific measures to protect and improve health through climate change action. Health is affected by climate change through, for example, heat stress, floods, droughts, storm damage and changes in the spread of vector- and water-borne diseases.3 Coastal areas, frequently occupied by marginalized communities, are vulnerable to the impacts of flooding, sea level rise and coastal erosion. The agricultural sector is also affected, with changing weather patterns affecting crops and food security. Increasingly, Costa Rica's health system will need to adapt to climate impacts which could lead to increased healthcare costs.4 Key issues for Costa Rica include the impact of climate change on food security and the need for stronger environmental governance, all of which are compounded by scarce understanding and data on the links between climate change and health. For example, Costa Rica’s health surveillance systems for airborne, vector- and water-borne diseases are not climate-informed to include meteorological information, nor do they have any climate-informed health early warning system in place (Lancet Countdown global report, indicator 2.2.1). This policy brief draws on further evidence from the 2022 global Lancet Countdown report to explore these issues. 2 1 Improve data flow between climate agencies, government, and local producers to antici- pate and respond to climate effects on local agricultural production. The Climate Change Directorate of the Environment and Energy Ministry (MINAE) should provide annual updates to the government council, local governments and local agricultural producers of a National System of Climate Change Metrics (SINAMECC). The update should overlay fore- casts of El Niño and La Niña with data on impacts on crop yield. This will help inform plans to strengthen food security. Declare food insecurity as a public health priority in order to direct efforts and resources toward adaptation as the climate changes, including reactivating the National Information System for food security and nutrition. Ministers for Health, the Environment, and for Agricul- ture and the Caja Costarricense del Seguro Social (CCSS) should frame the current situation as a public health priority. In order to develop data-informed and evidence-based policies, it is recommended that the National Information System for food security and nutrition be reactivated. Recommendations 3 Secure long-term funding of the climate change functions of the Environment and Energy Ministry (MINAE) to lead climate governance for an effective inter-institutional climate change approach. Guarantee the financing of the Environment and Energy Ministry (MINAE), particularly the Climate Change Directorate, so that it can coordinate inter-institu- tional actions with CCSS, the health ministry, parliament, and local governments to evaluate the implementation of climate change policies, using data and scientific evidence to improve climate governance. Climate Change Impacts on Crop Growth Costa Rica’s climate is strongly influenced by El Niño and La Niña. Climate change affects the frequency and intensity of these weather patterns which bring warmer and cooler conditions that correlate with changes in rainfall extremes, driving drought and floods.1,5 Consequently, changes in climate will impact national food production by affecting the yield of certain crops and may exacerbate food insecurity. According to the 2022 global Lancet Countdown report, higher temperatures shortened crop growth seasons globally (indicator 1.4). Moreover, the increase in number of heatwave days during crop growth season were associated with 98 million more people reporting moderate to severe food insecurity in 2020 (indicator 1.4). Data for Costa Rica show that the crop growth season for maize and rice has shortened since 2001. Annual time series show declining crop growth duration for the period 1981-2010 baseline, year to year and over the decades. The impact of changing weather patterns on the agricultural sector is significant. Climate and crop models predict reductions in the yield of crops of particular relevance for Costa Rica, such as sugar cane and coffee. The reduction of crop yields can have profound effects in Costa Rica. For example, during 2000 - 2013, the yield of rice and beans, which are important food staples for Costa Rica's population, stagnated.6 During the same period, the yield of pineapples, sugarcane, and coffee also declined.6 This resulted in reduced revenue for farmers which was further exacerbated by a lack of economic support for small, local producers. While the government should continue its policy of pursuing carbon neutrality and environmentally-friendly production practices, which allow the country to differentiate itself in tourism and agricultural production, it should also allocate more resources towards adaptation to the consequences of climate change, particularly in the case of small farmers producing basic food staples and those located in areas particularly vulnerable to extreme climate events.7 Climate monitoring and projection models are needed to provide clear communication of climate risks for producers, and to inform the implementation of adaptation measures and response mechanisms to minimise the impacts on the health, wellbeing and livelihoods of local populations. Improvements are needed in data collection and quality at all levels (e.g. database management, analysis, access) alongside better collaboration between different sectors to understand how climate change is leading to cascading effects on crops, food security and human health. To achieve this, it is recommended that the Climate Change Directorate of the Environment and Energy Ministry (MINAE) provide annual updates to the government council, local governments and local agricultural producers of a National System of Climate Change Metrics (SINAMECC). The update should overlay forecasts of El Niño and La Niña with impacts on crop yield. This will help inform planning to strengthen food security. Food Security as a Public Health Issue Despite Costa Rica’s goal of eradicating hunger as part of its National Food Security and Nutrition Plan, political and economic decisions during the last two decades have steered food production towards monocultures for export to increase gross domestic income (GDI).8,9 This economic policy has put Costa Rica in an extremely vulnerable situation regarding food security.10,11 In Costa Rica,16% of households are food insecure in a moderate to severe degree and 2% are severely food insecure.12 Climate change threatens to aggravate this situation because of its impact on crop production, locally and globally. Costa Rica is highly dependent on basic grains imports, even though the country is a net exporter of food products. This makes the country susceptible to volatile international food markets, which can also be affected by climate change-related shocks to crop yields and disruption of supply chains.10 As with many countries around the world, food insecurity is also being driven by high food prices. Most families have experienced changes in their diets due to inflation and loss of purchasing power.13 In Costa Rica, there is a growing reliance on highly processed meat products instead of fresh, good quality meat and dairy.7,14 According to the 2022 global Lancet Countdown report, in 2019, over 5,500 deaths among adults in Costa Rica were attributable to imbalanced diets (indicator 3.5.2). From 2010 to 2019, overall deaths due to high intake of red meat, processed meat and dairy products in Costa Rica increased by 35% from 801 to 1080 total deaths (Fig. 1). The impact of animal-derived products on health is driven not only by intake, but also by quality.15,16,17 Highly processed meats rich in fat, nitrites, sugar, salt, and additives, are significantly cheaper than quality meat and dairy products. In parallel, diets high in red meat contribute to greenhouse gas emissions from the agricultural sector. Data from the Lancet Countdown shows that, in Costa Rica, red meat and dairy products contribute to 67% of all emissions from the consumption of agricultural products, representing a substantial proportion of the country’s greenhouse gas emissions (indicator 3.5.1). Considering the effect that unhealthy diets pose to the health of the population, and their associated environmental impact, authorities should comply with their duties regarding food insecurity and frame the current situation as a public health priority.4 Under current growing unemployment, high inflation and lack of government support for families in poverty, there is an increased risk of food insecurity that needs quick state intervention. Nevertheless, lack of current data is a barrier for developing evidence-based public policy for both food security and climate change. Consequently, it is strongly recommended that the National Information System for food security and nutrition be reactivated.18 The main purpose of this system is to detect the level of household food insecurity, in order to guide interventions to protect individuals’ human right to food. Without data that provides a clearer picture of food and nutritional insecurity, public policy will continue to be limited to lowering prices without considering quality and a broad understanding of the food system.19 Costa Rica should support a model that values locally grown food as it has a lower carbon footprint and is linked to the creation of local jobs and the preservation of local systems of knowledge. Research developed at the University of Costa Rica (UCR) could inform national policy in food security and agro-industrial production.20 Fig 1: Lancet Countdown Indicator 3.5.2. Diet and Health Co-Benefits Climate Governance for An Effective Inter-Institutional Climate Change Approach Adaptation to climate change is key for Costa Rica. The country has developed a National Adaptation Plan and National Adaptation Policy to inform action. In a recent analysis of the country’s Nationally Determined Contribution document, in which countries state their efforts towards meeting the goals of the Paris Agreement, Costa Rica ranked #4 out of 94 in their consideration of climate commitments to protect health.21 Costa Rica also has a decarbonization plan, as well as a National Risk Management Policy which emphasises preparedness and interinstitutional actions for different risks, including climate-related events. However, Costa Rica’s most recent State of the Nation Report7 indicates that the strength of public institutions in the country is weakening, given the budget cuts to various institutions including environmental protection through MINAE. Inter-institutional responses are needed to ensure the coordination and adequate funding of climate change policies, especially where it impacts health.7,19,22 Long term funding must be secured for the climate change functions of MINAE to lead climate governance for an effective inter-institutional climate change approach. For instance, the Climate Change Directorate of the MINAE could coordinate actions and communications with various departments, including the health sector. This would entail promoting inclusion and leadership within local clinics (EBAIS), CCSS, local governments and communities. Additionally, MINAE could coordinate communication to non-governmental organisations, local governments, and community organisations, with an emphasis on bringing awareness to the impacts of climate change on health. Conclusion Costa Rica is vulnerable to climate change impacts on public health due to its geographical location, socioeconomic and environmental factors. The impact of climate change on food security is of particular concern and local governments and agricultural producers need to be better informed and prepared. Although Costa Rica has developed a series of climate plans, long term funding for climate governance through MINAE must be secured to ensure coordinated action between relevant government departments. References 1. Rica G de C. Plan nacional de Descarbonización 2018-2050. 2018. 2. Dirección de cambio climático, Ministerio de ambiente y energía. Plan Nacional de Adaptación al Cambio Climático de Costa Rica, 2022 - 2026. San José, 2022. 3. Barboza LA, Chou-Chen S-W, Vásquez P, et al. Assessing dengue fever risk in Costa Rica by using climate variables and machine learning techniques. PLoS Negl Trop Dis 2023; 17: e0011047 4. Chacón Araya K. Informe Estado de la Nación en Desarrollo Humano Sostenible 2018. Agricultura y sostenibilidad ambiental en Costa Rica. San José, 2018. 5. Hidalgo HG, Alfaro EJ, Quesada-Montano B. Observed (1970–1999) climate variability in Central America using a high-resolution meteorological dataset with implication to climate change studies. Clim Change 2017; 141: 13–28. 6. Research Institute (IFPRI) IFP. Climate change, agriculture, and adaptation options for Costa Rica. 2019 DOI:10.2499/p15738coll2.133209. 7. Programa Estado de la Nación, Consejo Nacional de Rectores. Estado de la Nación 2022. San José, 2022. 8. Fallas H, Molina ML. Desde inundaciones en Turrialba hasta sequía en Guanacaste, el cambio climático marca huella en Costa Rica. La Data cuenta. 2021. https://ladatacuenta.com/2021/11/24/ desde-inundaciones-en-turrialba-hasta-sequia-en-guanacaste-el-cambio-climatico-marca-huel- la-en-costa-rica/ (accessed Nov 7, 2022). 9. Molina L. Alza en precios de los granos liberalizados es un mal presagio para el futuro del arroz. Semanario Universidad. 2022; published online Aug 3. https://semanariouniversidad.com/pais/ alza-en-precios-de-granos-liberalizados-es-un-mal-presagio-para-el-futuro-del-arroz/ (accessed Nov 7, 2022). 10. Retana Barrantes JA, Villalobos Flores R, Alvarado Gamboa LF, Sanabria Valverde N, Córdoba Peraza J. Tercera Comunicación Nacional. Seguridad alimentaria y el cambio climático en Costa Rica: granos básicos. 2014. 11. Valerín Román J. Informe situacional granos básicos 2012-2019: frijol y maíz. San José, 2019. 12. Caravaca Rodríguez I, Ugalde Montero F. Prevalencias de inseguridad alimentaria en Costa Rica. San José, 2020. 13. Chung A, Westerman L, Martin J, Friel S. The commercial determinants of unhealthy diets. Public Health Res Pract 2022; 32. https://www.phrp.com.au/issues/october-2022-volume-32-issue-3/ commercial-determinants-of-unhealthy-diets/. 14. Instituto Nacional de Estadística y Censo. Boletín mensual. Costo de la canasta básica alimentaria. 1 2011. 15. Carroll AE, Doherty TS. Meat consumption and health: Food for thought. Ann Intern Med 2019; 171: 767–8. 16. Sun Y, Liu B, Snetselaar LG, et al. Association of major dietary protein sources with all-cause and cause-specific mortality: Prospective cohort study. J Am Heart Assoc 2021; 10: 1–24. 17. Zhong VW, Allen NB, Greenland P, et al. Protein foods from animal sources, incident cardiovascular disease and all-cause mortality: a substitution analysis. Int J Epidemiol 2021; 50: 223–33. 18. Sanchez Solis A, Bonilla Vargas A. Plan Nacional para la Seguridad Alimentaria, Nutrición y Erradi- cación del Hambre 2025: Plan SAN-CELAC Costa Rica I Quinquenio. San José, 2016. 19. Arnaboldi M, Azzone G. Data science in the design of public policies: dispelling the obscurity in matching policy demand and data offer. Heliyon 2020; 6: e04300. 20. O´Neal Coto K, Izaguirre Cedeño M del M. En nuestra diversidad agrícola está la clave para combatir el hambre oculta. https://www.ucr.ac.cr/noticias/2022/07/11/en-nuestra-diversidad-agricola-es- ta-la-clave-para-combatir-el-hambre-oculta.html. 2022; published online July. 21. NDC Scorecards - The Global Climate and Health Alliance. https://climateandhealthalliance.org/ initiatives/healthy-ndcs/ndc-scorecards/ (accessed Sept 13, 2022). 22. van Veenstra AF, Kotterink B. Data-driven policy making: The policy lab approach. Lecture Notes in Computer Science (including subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics) 2017; 10429 LNCS: 100–11. Organisations and acknowledgements This brief was written by: Zaray Miranda Chacón, MD, PhD; Eric Alfaro Martínez, PhD; Hugo Hidalgo León, PhD; Gabriela Arguedas Ramírez, MPharm and PhD(c); and Ana Leonor Rivera Chavarría, MD, MSc. The review was carried out by Michelle Soto, Licda. Review on behalf of the Lancet Countdown was provided by Marisol Yglesias-González, MScIH; Frances MacGuire, PhD MPH; Marina Romanello, PhD; and Camile Oliveira. THE LANCET COUNTDOWN The Lancet Countdown: Tracking Progress on Health and Climate Change is a multi-disciplinary collaboration monitoring the links between health and climate change. It brings togethers lead researchers from 43 academic institutions and UN agencies in every continent, publishing annual updates of its findings to provide decision-makers with high-quality evidence-based recommendations. For its 2022 assessment visit https://www.lancetcountdown.org/2022-report/ THE LANCET COUNTDOWN SOUTH AMERICA The Lancet Countdown South America exists to promote research on health and climate change in the region, to encourage regional engagement on how climate change is affecting health across the continent, and challenge countries to respond in line with the evidence. It is the only academic centre in South America specifically researching climate change and health and is based at the Clima centre at Universidad Peruana Cayetano Heredia (UPCH) in Lima, Peru. SCHOOL OF MEDICINE, UNIVERSITY OF COSTA RICA The School of Medicine of the University of Costa Rica is the first training house for medical and surgical professionals in Costa Rica, with countless contributions to the public health of our country. Its purpose is to train medical professionals with solid scientific, ethical, and humanistic bases that respond to their social and professional context. SCHOOL OF PHILOSOPHY, UNIVERSITY OF COSTA RICA Since 1974, the School of Philosophy has been dedicated to the promotion of philosophical thinking in the University of Costa Rica. With an interdisciplinary approach and a variety of perspectives, the school of philosophy develops an ample range of research, contributing to an analytical perspective of different issues of national interest. COSTA RICAN INSTITUTE FOR RESEARCH AND EDUCATION ON NUTRITION AND HEALTH (INCIENSA) The activities of the Costa Rican Institute for Research and Education on Nutrition and Health (INCIENSA) (https://www.inciensa.sa.cr/) are oriented to public health research, epidemiological surveillance, and teaching and quality assurance. Epidemiological surveillance actions support the identification, measurement, follow-up, and treatment of priority health events. RESEARCH CENTER IN GEOPHYSICS, UNIVERSITY OF COSTA RICA (CIGEFI – UCR) The Research Center in Geophysics of the University of Costa Rica (CIGEFI - UCR, http://cigefi.ucr.ac.cr/) was created in February 1979; it is attached to the Vice Rector's Office of Research of the University of Costa Rica. It is dedicated to the study of meteorology, climatology, and hydrology of Central America.