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As part of a Congressionally mandated national study of the impacts of climate variability and change in the United States, a team of 12 experts from universities and government agencies across the country assessed the potential impacts that climate change could cause by 2030 and 2100. However, before dealing with each of the five groups of potential adverse health effects, a caveat is in order. The Committee, headed by Professor J. A. Patz, of the Johns Hopkins University School of Hygiene and Public Health, concluded that "the levels of uncertainty preclude any definitive statement on outcomes," which is worth bearing in mind as the potential impacts of climate change on health are rendered [44] .

More than likely the direct effects of heat, which currently cause substantial numbers of deaths among vulnerable populations in summer, will increase. From the numbers of deaths in Europe and England in 2003, there is less uncertainty here than with other conditions. In 2003, France suffered the hottest summer of the last 50 years. By the end of the heat wave, the French Institute of Health and Medical research reported that there had been 14,802 deaths related to heat in just 2 weeks. Failure to grasp the severity of the crisis delayed timely decisionmaking by public officials [44]. This lamentable event offers a cautionary tale. During August 2003, France was in the grip of the Tour de France. Total concern was focused on the hardship of the heat on the cyclists. The health services paid little attention to the elderly and the fact that heat leads to fluid loss and exhaustion with consequent heat stroke. Advanced age, excessive sweating, vomiting, and diarrhea (additional fluid loss) predis poses the body to heat stroke; high humidity, exertion, poor ventilation, and heavy clothing contribute to dehydration and exhaustion. Heat stroke occurs when the body' s thermoregulatory system ceases functioning and sweating stops. During this sequence of events the person is unaware of what is happening. The skin becomes dry and hot and reddens dramatically; body temperature is up to 104°F, and rising, which can trigger mental confusion. If at this point, a person is not quickly cooled, the progression is usually delirium, convulsions, unconsciousness, and death. Too often these people are alone, so that no one can help or call 911. If the country is ill-prepared for increased numbers of heat waves, which are clearly in the scenario, the death rate can be expected to climb and hospital facilities sorely taxed.

Computer models indicate an increased frequency and intensity of storms and hurricanes. After Hurricane Andrew roared through south Florida, posttraumatic stress syndrome increased dramatically in the area. How the thousands of refugees from Katrina will fare is yet to be seen. Anger at the failure of government at local, state, and federal levels may not have a lasting effect, but it surely will be translated into future preventive modalities as lessons will undoubtedly be learned.

With water purification and sewage treatment systems rendered inoperable, microbial diseases are always anticipated. During Katrina' s ravagings, none appeared. Why? It must be borne in mind that for waterborne diseases to spread, individuals in the besieged areas must shed bacteria into the water, which means that they must either be frankly ill with a disease that can be transmitted by water, or they must be healthy, asymptomatic carriers; otherwise the fecally polluted water will be no more than of aesthetic concern. Boiling water to kill potential pathogenic bacteria is widely recommended, as no one knows if anyone is ill, or a carrier.

Walking through floodwaters can be a real concern. Although leptospirosis occurs around the world, 10% of cases occur in the United States. Symptoms of leptospirosis include fever, jaundice, hemorrhage, and liver and renal failure contracted by picking up the spirochetes of the genus Leptospira, deposited in water in the urine of animals and rodents. Leptospires gain entry into the body via breaks in skin as well as orally through mucous membranes when contaminated water is accidentally swallowed. Person-to-person spread is uncommon. Fortunately, leptospirosis does not seem to have been one of Katrina ' s byproducts.

Excessive water can cut both ways. Rainfall can increase mosquito populations by offering puddles, breeding sites. On the other hand, heavy rains and flooding can flush such sites, destroying mosquitoes in their larval stages.

Although not widely known, malaria was prevalent in the American colonies, and by 1850, had spread north to the territories now occupied by Minnesota, Wisconsin, and Michigan. By the 1930s, malaria had disappeared from the north, but was still active in Louisiana, Mississippi, and Alabama, and was considered eradicated in the United States early in the 1970s. Ergo, a warmer world with increased rainfall could see malaria revisiting its previous habitats. However, current public health infrastructure and policies suggest that this is unlikely.

A cluster of enteric diseases appear to exhibit a seasonal pattern suggesting sensitivity to climate. In the tropics, diarrheal diseases usually rise during the rainy season. Both floods and droughts are associated with increased risk of these illnesses as heavy rainfalls can wash fecal matter into the water supply, while arid conditions that reduce availability of freshwater can lead to an increase in hygiene-related diseases. Transmission of enteric diseases may be increased by higher temperatures because of direct effects on the growth of pathogens in the surrounding environment. But again, the uncertainty factor is high, and developed countries will have responses markedly different from those of undeveloped countries.

Yet another question must be; What of animals—not just pet cats and dogs, but cattle, sheep, swine, and poultry—our major food animals and protein sources? How will they respond to a warmer world? Surely widespread drought would result in great losses. Increased heat could adversely affect animals physiologically, impairing reproductive capacity, and egg-laying among poultry could well be compromised. Insect pests could proliferate and could so irritate cattle as to cause loss of appetite and malnourishment with its loss of weight and meat supply. The possibilities are there and require consideration and evaluation before temperature increases occur—i f we should fail to act in curtailing CO2 emissions.

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