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In 2015, an estimated 429,000 deaths and 212 million cases of malaria occurred worldwide, while 70% of the deaths occurred in children under five years old. Changes in climatic exposure such as temperature and precipitation makes malaria one of the most climate sensitive outcomes. Using a global malaria mortality dataset for 105 countries between 1980 and 2010, we estimate that the global optimal temperature maximizing all-age malaria mortality is 20.6, lower than previously predicted in the literature. While in the case of child mortality, a significantly lower optimum temperature of 19.3° is estimated. Our results also suggest that in Africa and Asia, the continents where malaria is most prevalent malaria, mortality is maximized at 28.4 and 26.3, respectively. Furthermore, we estimate that child mortality (ages 0-4) is likely to increase by up to 20 percent in some areas due to climate change by the end of the 21st century.

I read with interest the commentary article by Bongaarts and Sitruk-Ware.1 I think this commentary is very timely, and I am so glad to see this topic being discussed. However, I wondered whether there could have been more of a focus on the impact of population in developed countries, particularly on the impact of having a child if you are in the most socioeconomically developed subgroup of the population? I would be really interested to hear the commentary authors' views on this. Although …

The Pan-African Consortium for the Evaluation of Anti-Tuberculosis Antibiotics (PanACEA) was designed to build tuberculosis (TB) trial capacity whilst conducting clinical trials on novel and existing agents to shorten and simplify TB treatment. PanACEA has now established a dynamic network of 11 sub-Saharan clinical trial sites and four European research institutions.In 2011, a capacity development program, funded by the European & Developing Countries Clinical Trials Partnership (EDCTP), was launched with four objectives, aiming at strengthening collaborating TB research sites to reach the ultimate goal of becoming self-sustainable institutions: networking; training; conducting clinical trials; and infrastructure scaling-up of sites.Assessment in six sub-Saharan TB-endemic countries (Gabon, Kenya, South Africa, Tanzania, Uganda and Zambia) were performed through a structured questionnaire, site visits, discussion with the PanACEA consortium, setting of milestones and identification of priorities and followed-up with evaluations of each site. The results of this needs-based assessment was then translated into capacity development measures.In the initial phase, over a four-year period (March 2011 - June 2014), the programme scaled-up six sites; conducted a monitoring training program for 11 participants; funded five MSc and four PhD students, fostering gender balance; conducted four epidemiological studies; supported sites to conduct five Phase II studies and formed a sustainable platform for TB research (panacea-tb.net).Our experience of conducting TB clinical trials within the PanACEA programme environment of mentoring, networking and training has provided a sound platform for establishing future sustainable research centres. Our goal of facilitating emergent clinical TB trial sites to better initiate and lead research activities has been mostly successful.

As several contributions in this issue of International Journal of Public Health suggest (in particular that from Kjellstrom 2009), there is a wide range of potential—direct and indirect—health consequences of climate change. However, the science of such effects is still in its infancy and faces considerable challenges, as we try to suggest in our contribution (Xun et al. 2009). Possible events attributable to climate change range from rapid and catastrophic to slow and mild. For example, IPCC does not rule out (though it is very unlikely) a cascade of events leading to Bangladesh being swept away because of rapid Himalayan glacier melting. Apart from extreme and unlikely effects, some of the direct consequences of climate change are rather obvious and can be easily perceived, such as the deaths related to heat waves in Europe in 2003. The causal pathway in these cases is clear, and does not require any particularly sophisticated epidemiological technique. Confounding is irrelevant as far as we consider the causal association between the climate event (heat wave) and its direct health consequences. But still: were all heat waves in the recent past due to what we call climate change, i.e. a man-made trend in temperature and its related epiphenomena? Was the flood in Bangladesh in 1974 the first attributable to climate change, or the last not due to it? And what about the one in 1998? Clearly borders are fuzzy, and causal chains intricate. Uncertain inferences on the causal nature of events also concern the attribution to climate change of indirect health effects, such as infectious disease outbreaks, changes in food quality and availability, water salinization and the ensuing epidemic of hypertension (Xun et al. 2009). Even wars and conflicts (like in Darfur), mass migrations and effects on mental health have been attributed to climate change. In a survey conducted among children aged between 2 and 9 in Bangladesh, Durkin et al. (1993) found post-flood changes in behaviour and bedwetting. Children were reported to have ‘‘very aggressive behaviour’’ after floods, with a significant increase compared to the preflood situation. A qualitative study explored the experiences of female adolescents during the 1998 floods in Bangladesh, focusing on the implications of sociocultural norms related to notions of honour, shame, purity and pollution. A number of the girls were vulnerable to sexual and mental harassment through exposure to unfamiliar environment of flood shelters and relief camps. Common mental health disorders following climate-induced displacement include anxiety, depression, post-traumatic stress disorder, irritability, sleeplessness and suicide. Moreover, conflict situations that may arise among farmers in times of climate-induced natural disasters like droughts and floods need to be addressed. Is all of this attributable to what we call climate change? Where are the borders between the burden of events that would occur anyhow, particularly in low-income countries, even in the absence of climate change, and those attributable to the latter? How can we identify the chain of events that eventually explains the local outbreak? Again, fuzzy borders have to be acknowledged. It should be noted that the effects we have described are mainly occurring or Paolo Vineis is Chair of Environmental Epidemiology at Imperial College, London. His main interests are in the field of molecular epidemiology and gene–environment interactions. He also works on climate change with the Grantham Institute for Climate Change in London.

IntroductionNigeria faces enormous challenges to meet the growing demands for maternal healthcare. This has necessitated the need for digital technologies such as mobile health, to supplement existing maternal healthcare services. However, mobile health programs are tempered with gender blind spots that continue to push women and girls to the margins of society. Failure to address underlying gender inequalities and unintended consequences of mobile health programs limits its benefits and ultimately its sustainability. The importance of understanding existing gender dynamics in mobile health interventions for maternal health cannot be overstated.ObjectiveThis study explores the gender dimensions of Text4Life, a mobile health intervention for maternal healthcare in Edo State, Nigeria by capturing the unique perspectives of women who are the primary beneficiaries, their spouses who are all men, and community leaders who oversaw the implementation and delivery of the intervention.MethodThis qualitative study used criterion-based purposive sampling to recruit a total of 66 participants: 39 women, 25 men, and two ward development committee chairpersons. Data collection involved 8 age and sex desegregated focus group discussions with women and men and in-depth interviews with ward development committee chairpersons in English or Pidgin English. Translated and transcribed data were exported to NVivo 1.6 and data analysis followed a conventional approach to thematic analysis.ResultsWomen had some of the necessary resources to participate in the Text4Life program, but they were generally insufficient thereby derailing their participation. The program enhanced women's status and decision-making capacity but with men positioned as heads of households and major decision-makers in maternal healthcare, there remained the possibility of deprioritizing maternal healthcare. Finally, while Text4Life prioritized women's safety in various contexts, it entrenched systems of power that allow men's control over women's reproductive lives.ConclusionAs communities across sub-Saharan Africa continue to leverage the use of mHealth for maternal health, this study provides insights into the gender implications of women's use of mHealth technologies. While mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's access to resources and their reproductive and social lives.

As the effects of climate change become more visible, extreme weather events are becoming more common. The effects of flooding on health are understood but the long-term impact on the well-being of those affected need to be considered. This mixed methods secondary analysis of a cross-sectional survey examined the extent to which being flooded in the past is associated with ongoing concerns about flooding. Survey data were collected from residents in Hull 11 years after the initial flooding event. Respondents were asked about the floods in 2007 and their current level of concern about flooding. Ordinal logistic regression explored the effect of age and tenancy status as predictors of current concern. Textual data were analyzed using thematic content analysis. Responses were received from 457 households, of whom 202 (48%) were affected by flooding in 2007. A fifth of respondents were very concerned about future flooding. Those who were not flooded were significantly less concerned about the risk of future flooding (U = 33391.0, z = 5.89, p < 0.001). Those who reported negative health and wellbeing effects from the floods were significantly more concerned about future flooding than those whose health was not affected (U = 7830.5, z = 4.43, p < 0.001). Whilst some residents were reassured by the introduction of new flood alleviation schemes, others did not feel these were adequate, and worried about the impact of climate change. The financial and emotional impacts of the floods still resonated with families 11 years after the event, with many fearing they would not cope if it happened again. Despite the 2007 floods in Hull happening over a decade ago, many of those affected continue to experience high levels of anxiety when storms are forecast. Residents feel powerless to protect themselves, and many remain unconvinced by the presence of new flood alleviation schemes. However, with the ongoing threat of climate change, it may be that other residents are unrealistic in their expectation to be ‘protected’ from flood events. Therefore, public health agencies need to be able to mobilize organizations to come together to pro-actively support families affected by flooding, to ensure those in need do not fall through the gaps of public healthcare delivery.

There is growing evidence on the observed and expected consequences of climate change on population health worldwide. There is limited understanding of its consequences for child health inequalities, between and within countries. To examine these consequences and categorize the state of knowledge in this area, we conducted a review of reviews indexed in five databases (Medline, Embase, Web of Science, PsycInfo, Sociological Abstracts). Reviews that reported the effect of climate change on child health inequalities between low- and high-income children, within or between countries (high- vs low–middle-income countries; HICs and LMICs), were included. Twenty-three reviews, published between 2007 and January 2021, were included for full-text analyses. Using thematic synthesis, we identified strong descriptive, but limited quantitative, evidence that climate change exacerbates child health inequalities. Explanatory mechanisms relating climate change to child health inequalities were proposed in some reviews; for example, children in LMICs are more susceptible to the consequences of climate change than children in HICs due to limited structural and economic resources. Geographic and intergenerational inequalities emerged as additional themes from the review. Further research with an equity focus should address the effects of climate change on adolescents/youth, mental health and inequalities within countries.