ICSM CHC White Paper II: Impacts, vulnerability, and understanding risks of climate change for culture and heritage: Contribution of Impacts Group II to the International CoSponsored Meeting on Culture, Heritage and Climate Change

Climate change is already impacting multiple types of heritage across all regions of the world. Future climate change poses increased risks to heritage globally, including losses and damages to heritage of current and future generations and particularly severe impacts on the intangible cultural heritage of Indigenous communities. Climate change impacts on heritage are not being studied consistently nor systematically, which is reflected in heritage coverage in IPCC assessments and special reports. There is a global imbalance in the number of publications assessing the impact of climate change on heritage between different regions. Regional, national and sub-national disparities are also observed (example of Australia East vs. West). As a result, it is difficult to know if what we know about the impact of climate change on heritage is just a reflection of where the science is funded rather than where or when heritage is being affected by climate change. Impacts of climate change on the broader economic benefits (besides tourism), and social and cultural value of heritage are neither investigated nor reviewed globally and rarely explored regionally or locally. Disparities in climate change / heritage publications appear to be determined by research funding, income inequality (within and between countries), colonial legacy (research ties and relationships between former colonies and colonising countries), legal systems of heritage protection (imbalance between natural and cultural heritage depending on the country/region), local vs. international interest in heritage, the language of publication (focus on English excluding other significant scientific languages such as French, Spanish, or Japanese). Improvement of data reliability and resolution allows for more nuanced reconstructions of impacts of past climatic events, facilitating historically important factors of societal adaptation processes proportional to those changes. Yet they do not provide straightforward solutions for contemporary anthropogenic climate change as the scale of recent changes across the climate system are unprecedented over many centuries to many thousands of years. Alignment of climate change risk terms may facilitate collaboration between climate science and heritage research fields and enhance the likelihood of uptake by large climate change assessments like the IPCC. Innovative methods, especially those which are ideal for assessing social and cultural vulnerability, are needed to integrate the value of intangible cultural heritage with assessments of climate change risk. There is opportunity for climate change / heritage research to embrace transformational, inter- and transdisciplinary, and decolonial principles to address a range of the research and practice challenges as the field matures

Decolonizing climate change–heritage research

Climate change poses a threat to heritage globally. Decolonial approaches to climate change–heritage research and practice can begin to address systemic inequities, recognize the breadth of heritage and strengthen adaptation action globally.DATA AVAILABILITY STATEMENT: The underlying dataset for Fig. 1a is available open access from the supplemental material in ref. 5, and datasets for Fig. 1b,c from the UNESCO World Heritage List 2021 in ref. 32.The UK government’s Foreign, Commonwealth & Development Office and the International Development Research Centre, Ottawa, Canada; the FLAIR Fellowship Programme: a partnership between the African Academy of Sciences and the Royal Society funded by the UK government’s Global Challenges Research Fund; the Mapping Africa’s Endangered Archaeological Sites and Monuments project funded by Arcadia — a charitable fund of Lisbet Rausing and Peter Baldwin; the Leverhulme Trust Doctoral Training Scheme, hosted by Southampton Marine and Maritime Institute at the University of Southampton.https://www.nature.com/nclimatehj2023Historical and Heritage Studie

Research priorities for climate mobility

The escalating impacts of climate change on the movement and immobility of people, coupled with false but influential narratives of mobility, highlight an urgent need for nuanced and synthetic research around climate mobility. Synthesis of evidence and gaps across the Intergovernmental Panel on Climate Change (IPCC) Sixth Assessment Report highlight a need to clarify the understanding of what conditions make human mobility an effective adaptation option and its nuanced outcomes, including simultaneous losses, damages, and benefits. Priorities include integration of adaptation and development planning; involuntary immobility and vulnerability; gender; data for cities; risk from responses and maladaptation; public understanding of climate risk; transboundary, compound, and cascading risks; nature-based approaches; and planned retreat, relocation, and heritage. Cutting across these priorities, research modalities need to better position climate mobility as type of mobility, as process, and as praxis. Policies and practices need to reflect the diverse needs, priorities, and experiences of climate mobility, emphasizing capability, choice, and freedom of movement

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Interdisciplinary assessment of the risks and impacts associated with erosion, flooding, and sea-level rise in coastal natural world heritage sites

Natural World Heritage Sites (NWHS) are social-ecological systems of Outstanding Universal Value and are increasingly threatened by natural and anthropogenic pressures. 88 (42%) of 210 NWHS worldwide are coastal, and their risks from coastal hazards will change with climate change and sea-level rise. This thesis aims to analyse the risk from past, present and future erosion and flooding on coastal NWHS by adopting a multi-scalar interdisciplinary mixed quantitative and qualitative approach to respond to the wicked problem at hand. Using consistent remote sensing data, a global analysis of historical exposure to shoreline change from 1984 to 2016 was undertaken. Significant erosions and accretions occurred within 52 (59%) coastal NWHS, these being composed of low-lying unconsolidated sediments in vegetated tidal systems and inlets. The most stable soft coasts were associated with the natural protection of coral reef ecosystems. Significant shoreline changes were associated with a range of natural and human-induced drivers situated outside or within the sites’ boundaries, such as the redistribution of sediments, the opening of inlets, sand nourishment and sediment starvation due to dams. Interviews with a global sample of NWHS managers were conducted to assess their perceptions of shoreline change impacts on the sites, and the implemented adaptation measures. Managers perceived that present shoreline change adversely affects NWHS communities and that potential future exacerbation of erosion and flooding by sea-level rise and climate change threaten the natural values and human benefits of NWHS. Although some NWHS managers were aware of multi-decadal coastal changes, most lacked comprehensive and systematic data on erosion and flooding at their sites. Several adaptation measures have been implemented along coastlines prone to particularly adverse impacts of erosion and flooding in high-income countries. However, systematic preparation for the potential increase of coastal changes is lacking across most NWHS. A case study analysing shoreline change perceptions of Imraguen coastal communities in the Banc d’Arguin National Park NWHS (Mauritania, Africa) indicates that erosion and flooding presently impact the indigenous communities' livelihood and traditional practices through the breaching of barriers, creation of channels, flooding and submergence of low land. These impact their human capital (health and capacity to work), social capital (culture, shared values and behaviours), natural capital (coastal land) and physical capital (accessibility and transportation of goods and people). In the future, improved emergency preparedness and strategically planned retreats supported by managers and local authorities represent better adaptive responses for the communities than forced relocations and retreats experienced at present. There is currently no mechanism in place to propose those responses. Greater multi-scalar, interdisciplinary, and mixed-method approaches can help identify risks and integrated adaptation measures and emergency responses in NWHS. Further research to assess complex risks from different drivers will help develop and design these responses