PCLM-D-22-00178

Informing adaptation strategy through mapping the dynamics linking climate change, health, and other human systems: Case studies from Georgia, Lebanon, Mozambique and Costa Rica

PLOS Climate

Dear Dr. Ager,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please play particular attention to comments on country profiles, connection to climate and health policies, and expanding the discussion section. 

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We look forward to receiving your revised manuscript.

Kind regards,

Shouro Dasgupta, PhD

Academic Editor

PLOS Climate

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The research article uses a case study approach to fulfil the research gaps in the emerging area of health and climate change in lower-income countries, ranging from Central Asia, Middle East and East Africa and Central America. The links between health and climate in these countries are well presented by using causal loop diagrams. It is quite impressive that the authors apply a system thinking approach to present the country-specific climate-related health challenges and adaptation strategies. This research findings provide valuable information for policymakers and researchers to factor in health considerations in the climate policymaking process.

I have a few comments and suggestions for your consideration please:

1. I would suggest that the authors may highlight the growing role of health in international climate negotiations. In the Introduction section, the authors have pointed out the international climate policy agenda at COP26 and COP27 with an increased focus on adaptation and resilience. It would also be helpful to highlight the importance of the establishment of a Loss and Damage fund at COP27 which was the first ever in the international climate negotiations. For example, as the health impacts of climate change are non-economic loss and damage, your research article is very timely to provide important policy implications for COP28 in Dubai.

2. I would also suggest clearer links between economic, health and climate in the country profiles of Georgia, Lebanon, Mozambique and Costa Rica. In the current structure, each country profile includes a broad overview of socio-economic development and public health-related risks and challenges, followed by climate change impacts and international climate commitments. The authors may present through a more integrated approach, reflecting on the extent to which the country may be affected by the growing impacts of climate change particularly on health, which will, in turn, weaken the economic growth outlook. Subsequently, the country's NDC commitments are a major step forward to improving health outcomes through the development and implementation of climate mitigation and adaptation strategies. For Lebanon, the authors may refer to the health and climate change country profile 2021 published by the World Health Organisation.

3. In the section on Integrative Analysis, Figure 7 could also incorporate the affordability of healthcare services in the health system resilience. Likewise, the authors may elaborate further on the quality of housing/infrastructure that needs to be low-carbon and climate-resilient, as a key part of adaptation strategy for urban planning.

4. In the Discussion section, it would be great to put more effort into explaining the importance of the WHO Operational Framework for building climate resilient health systems. Also, the authors may emphasise the role of renewable energy in strengthening the health systems resilient to climate change, while mitigating carbon emissions. For example, healthcare facilities with fossil fuels-based power supplies would experience a power shortage or blackout affected by the impact of climate-related extreme weather events (such as flooding). Solar energy can be a good example that can save the lives of critical patients who need an emergency power supply for surgeries and medical care during climate and weather shocks.

Reviewer #2: This study applies a dynamic systems approach, utilizing literature review and participatory workshops to develop casual loop diagrams representing the relationships between climate change and public health, with the aim of identifying entry points for the application of adaptation measures. While the idea and approach are interesting, the paper lacks many relevant details.

The Abstract and Introduction could be strengthened significantly by including more references to support claims being made (e.g., sentence on line 34, sentence on lines 57-59, sentence on lines 64-66, etc.), and an explanation on how this study relates to other published literature on this topic (e.g., have system dynamics and casual loop diagrams (CDLs) been used to assess the interlinkages between climate impacts and health or other sectors in previous studies?).

The Methods section could benefit from more explanation on how, or which information from the literature review fed into the seed model to create the CDLs. Additional information on the workshop methodology would also be useful - how were participants selected, how were workshops structured to collect and integrate feedback into CLDs, etc.? How were adaptation measures introduced to the discussion - did these come from the literature review, were they proposed by workshop participants, or by the leaders of the study? Was there a systematic presentation or consideration of adaptation? Furthermore, the integrative analysis should be introduced here since the results of that exercise are presented in the next section of the paper.

In the Results section, the Country profiles provide a lot of interesting and relevant information that was not collected during the literature review or workshop, and therefore might be better placed in the Discussions section to give context when interpreting results for each case study.

For Figures 3, 4, 5 and 6, it could be nice to show the benefit gained from the workshops by highlighting what additional information was included from these interactions with experts.

Note: Figures 4 and 5 are currently the same. It seems this should be Figure 5 and that Fig 4 is missing.

Also, Figure 7 is missing the “+” on the arrow from Extreme events to Population exposure to risk.

Finally, the Discussion and Conclusion sections could have a greater impact if more focused on the outcomes of the activities carried out in the study.

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Reviewer #1: Yes: Lei Bian

Reviewer #2: No

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Informing adaptation strategy through mapping the dynamics linking climate change, health, and other human systems: Case studies from Georgia, Lebanon, Mozambique and Costa Rica

PCLM-D-22-00178R1

Dear Dr. Ager,

We are pleased to inform you that your manuscript 'Informing adaptation strategy through mapping the dynamics linking climate change, health, and other human systems: Case studies from Georgia, Lebanon, Mozambique and Costa Rica' has been provisionally accepted for publication in PLOS Climate.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team. 

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Shouro Dasgupta, PhD

Academic Editor

PLOS Climate

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