| · Making the health-care system climate-resilient and ecologically sustainable are among the several innovative initiatives being taken to combat climate change and mitigate its impact. · Addressing environmental health and the factors affecting it are at the core of Maldives’ development policy. · Community awareness and involvement is one of the key aspects of the country’s strategic approach to a low carbon growth. |
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An inhabited atoll as seen from the air in the Maldives (Photo credit: WHO)
Climate change is the single biggest health threat facing humanity. It threatens to overwhelm the world’s health systems and the health of people. The health impacts of climate change will be felt by everyone, everywhere; however, the WHO South-East Asia Region, home to more than 2 billion people, is highly vulnerable and has the highest estimated number of deaths due to climate change.
While all countries of the Region have seen first-hand the devastating effects of climate change, in Maldives, where even a 1-metre rise in sea level can lead to submergence of over 80% of the country’s total land area, global warming poses an existential threat.
Climate change is already posing increasing challenges in Maldives, with more frequent soil erosion, loss of beaches and saltwater intrusion into land and freshwater sources. Rising ocean temperatures are leading to reduced tuna catches. With a high population density and more than 50% of the housing structures on 121 islands within 100 meters of the coastline, more frequent extreme weather events, including storm surges, floods and cyclones, are directly and indirectly impacting the health and well-being of the people.
Acutely aware that time is running out and inaction to combat climate change and prepare for the effects of global warming is not an option, the country has been leading by example. It has a low carbon growth, environmentally sustainable and resilient smart health-care services, and addressing factors affecting environmental health is at the core of its development policy.
Ahmed Naseem, Minister of Health, Maldives at the World Health Assembly, May 2022 (Photo credit: WHO)
Maldives is constantly battling the ravages of nature for our very survival as a nation. Global warming and rising sea levels are causing warming of the seas and more severe frequent tidal waves and flooding in Maldives. Tidal waves and flooding often contaminate groundwater and sewerage systems leading to disease outbreaks in the country.- Ahmed Naseem, Minister of Health, Maldives at the World Health Assembly, May 2022
Combating these adversities and challenges have provided Maldives with a unique perspective, knowledge and insight into the strategies and best practices to address these multiple and complex challenges.
Making health systems climate-resilient and ecologically sustainable
While Member States of the WHO South-East (SE) Asia Region have been making concerted efforts to strengthen and make health systems more climate-resilient and ecologically sustainable, in 2017, they reaffirmed their high-level political commitment to make health systems more resilient to climate change through the Malé Declaration adopted at the Seventieth Regional Committee meeting of the Region in Maldives.
Health national adaptation plans and Green Climate Smart Hospital Policy and Strategy
One of the key action points of the Malé Declaration is the development of individual national adaptation plans for
health. In 2020, with technical and financial support from WHO, Maldives developed its Health National Adaptation
Plan (HNAP). The Plan aims to build the climate resilience of health facilities, mainstream management of risk to health
and health facilities from climate change, protect human
health from the effects of climate change through a multisectoral response, build health workforce capacity and raise public awareness of the impact on health from climate change and ensure sustainable financing.
The country has also conducted climate vulnerability assessments in health facilities and has developed the “Green Climate Smart Hospital Policy and Strategy”. In 2018, Greater Malé became the first city in the WHO SE Asia Region to join the BreathLife campaign.
Waste management
Solid waste management is a growing problem in Maldives. With the islands remote and dispersed over a wide geographical area, the collection, management and transportation of waste for disposal at facilities comes with its own complexities and difficulties. Extreme weather events, including intense rainfall and tidal waves, further adversely impact the system of collection, management and disposal of garbage.
For almost 30 years, garbage generated by Malé and neighbouring atolls used to be sent to the Thilafushi island, nicknamed the garbage island. While some waste was burnt, most of it ended up in a landfill in a lagoon on the island. This was not only causing water and air pollution but burning of waste is also responsible for 15% of Maldives’ carbon emissions.
As part of a larger sustainable waste management strategy, Maldives in 2021 launched the Greater Malé Waste to Energy Project, the largest integrated waste management initiative in the country located at the waste management facility on Thilafushi Island.
As part of the Waste to Energy Project, a regional solid waste treatment system is being set up from the Greater Malé region to the Ari and Vaavu Atolls for the proper collection, storage, management and transportation of waste to the regional waste management facility on Thilafushi Island. A 500-tonne per day waste-to-energy plant is also being set up.
Maldives aims to stop incineration and open burning in all health facilities of the country and has been working to strengthen safe and environment-friendly health-care waste management with WHO support. As part of this:
WHO provided technical assistance to the Ministry of Health (MoH) to develop the National Health Care Waste Management Policy (2016) and Strategy (2016–2021).
A pilot Health Care Waste Management Project has been implemented in Laamu Atoll on all inhabited islands (through the Low Emission Climate Resilient Development Programme [LECReD]). Autoclaves were installed and autoclave consumables were provided for three months. Health-care workers of all the islands were trained on health-care waste management.
Eighteen additional autoclaves and consumables were handed over to the MoH. Five of these autoclaves were bought through emergency funds. Some of the autoclaves are being used for waste management in COVID-19 treatment and isolation facilities.
The purchase of 10 additional autoclaves using emergency funds is under process.
WHO is also supporting the MoH to install autoclaves in 40 islands under the Canada Grant.
Community sensitization to minimize single-use plastic
Single-use plastic is a real challenge on the islands. Most of it is disposed of by burning at garbage dumps. This releases toxic fumes into the air and contaminates the ground and water.
In 2018, a nationwide ban on single-use plastics was implemented in schools. This was followed up with a ban in 2021 on the import of eight types of single-use plastics – single-use plastic-based drinking straws, single-use plastic-based plates, cutlery and stirrers, plastic shopping bags below 30×30 cm; single-use plastic drinking cups below 250 mL; cotton buds with plastic stems and shampoo, soap, conditioner and lotion bottles in plastic packaging that were 50 mL and below. From June 2022, the country also banned the production and sales of these and more single-use plastic products.
To build community participation and encourage the use of reusable bottles and bags, the islands roped in children as the main drivers of campaigns to promote reusable bottles in workplaces and at social gatherings. Community members are also encouraged to make use of reusable carry bags for all shopping and other needs.
In 2022, as part of WHOs “Our Planet, Our Health” theme for World Health Day and the year-long campaign, the MoH and Ministry of Education in Maldives held a national recycled art and short story competition. Open to students from grades 1 to 9 from all schools nationwide, students were required to create original artwork using only recycled materials, including plastic, rope, paper, glass, electronic waste, foam, etc. The contest generated enthusiastic responses and helped engage children and local communities to focus on the environmental impacts on health and solutions for a healthier and sustainable future.
Artworks using recycled material by schoolchildren in Maldives, 2022 (Source: WHO Maldives)
Green Smart Island’ – leading by innovation
Maldives consists of about 1192 islands with the population mainly distributed on 187 inhabited islands. While each island varies in size, they all have similar problems and challenges when it comes to the health risks of climate change and environmental health.
To calibrate a successful strategy, address challenges and protect human health, Maldives has drafted a “Green Smart Island initiative” as part of the HNAP. A pilot project across four islands aims to create green cities and islands that are environmentally friendly. They will provide clean air, water, land and green spaces to educate and create awareness among and empower communities to practise environment-friendly habits.
The Initiative aims to do this by integrating the management of infrastructure and natural resources, including energy, transport and mobility, wastewater and sanitation, and promoting the use of innovative and socially inclusive governance and financing schemes.
Green technology, transport and infrastructure
Transport is one of the biggest consumers of energy in Maldives and is estimated to be responsible for 25% of the country’s greenhouse emissions. Usage of vehicles is being controlled on some islands to encourage walking and cycling.
To accelerate the transition towards sustainable transport, the Smart Island initiative aims to encourage the use of bicycles and switch to walking to schools, places of work, and other destinations on the islands. The aim is to achieve a 90% reduction in motorized transport by 2023 on the four islands to start with. The Integrated National Public Ferry Network through high-speed ferry services was launched by the government in 2021 to strategically address the sea transport demands of the nation.
Green agriculture and living
To reduce the use of chemical-based fertilizer and pesticides and prevent soil and groundwater contamination, Maldives is working to minimize the use of pesticides and fertilizers and promote the use of organic fertilizers.
The Green Smart Islands pilot project aims, by 2024, to reduce pesticide use by 35% and enhance public knowledge and awareness about the use of organic fertilizers.
Men playing a game of football on a beach playground, Maldives (Photo credit: WHO)
To improve mental, physical and social well-being and quality of life, green spaces, including parks and outdoor recreational areas, have been planned in all of the four islands by 2024.
Green power and infrastructure
Most of the power in Maldives comes from diesel generators. According to a 2020 Asian Development Bank (ADB) report, about 290-megawatt (MW) diesel generators are installed in 186 inhabited islands. Islands with resorts have an additional 144 MW in diesel generators and islands with industries about 20 MW.
The use of diesel fuel is polluting, expensive and produces greenhouse gasses. Instillation of solar panels in the greater Malé region has increased in the past few years and, by 2020, had reached a peak of 3000 kilowatt (KW).
With an aim to turn diesel-based energy systems into hybrid solar–diesel systems in at least 160 islands, Maldives established the Preparing Outer Islands for Sustainable Energy Development (POISED) project in 2014. This Project aims to instal a minimum of 21 megawatt-peak (MWp) in photovoltaic (PV) installations with the support of ADB. The concept design of hybrid systems (combining efficient diesel generator sets + solar energy + energy storage) has resulted in an average fuel saving of 25%.
An aerial view of a solar powered hospital in Maldives (Source: WHO Maldives)
Buildings and houses account for a large share of energy use in Maldives. To ensure that houses, offices and other public buildings have adequate natural lighting and ventilation, the Green Smart Island project aims to engage with planners and architects, and encourage them to adopt designs that reduce the need for lighting and cooling of homes, schools and workplaces.
The plan is to install solar panels in all government buildings by 2024. To make homes healthier and safer, only lead-free paint is being used on the four islands.
Health emergency preparedness
As first responders, medical systems are particularly vulnerable to the impacts of climate change. As with other coastal communities, extreme weather along with sea-level rise can generate storm surges, which could flood and quickly overwhelm the island’s infrastructure and significantly impact health-care service delivery during and after emergencies.
To ensure that hospitals and health systems can withstand climate-related natural hazards and mitigate the impacts of climate change by reducing their own ecological footprint, an on-the-ground assessment of several existing health-care facilities was commissioned by WHO and carried out by Health Care Without Harm (HCHW) in 2018. The Maldives Health Protection Agency (HPA) requested this technical assistance to facilitate HPA’s initiative to pilot a green, climate-smart health facilities programme in Maldives.
The assessment focused on a review of the existing policies in Maldives and related national and international documents and studies, on-site visits of seven typical Maldivian health-care facilities, meetings with WHO, MoH, HPA, Ministry of Environment and Energy and key stakeholders.
To assess the vulnerability of the health facilities, the WHO model for climate-resilient health systems, the World Bank Climate-Smart Healthcare, Low-Carbon and Resilience Strategies for the Health Sector8 and HCWH’s Global Green and Health Hospitals (GGHH) Agenda were used to examine 10 sustainability goal areas. These include the following:
leadership for prioritizing environmental health;
substituting harmful chemicals with safer alternatives;
reducing and safely disposing of health-care waste;
implementing energy efficiency and clean renewable energy generation;
reducing water consumption and increasing provision of potable water;
improving transportation for patients and staff;
purchasing and serving sustainably grown healthy food;
safely managing and disposing of pharmaceuticals;
supporting green and healthy hospital design and construction; and
buying safer and more sustainable products, materials and services.
Stakeholders also identified ongoing activities and priorities for the future, which include improving natural lighting and ventilation, planting more trees to reduce the heat island effect, installing solar panels, minimizing and better managing waste, exploring zero waste hospitals, reducing water consumption and wastage in health-care facilities, substituting outdated mercury-containing medical devices in a phased manner starting with the main regional/atoll hospitals followed by island health centers and making sure all X-ray systems are digital and chemical free, among others.
Daylight from windows reduces the need for electrical lighting at ADK hospital, Maldives (Source: Maldives: Green Climate Smart Hospitals, Hospitality Vulnerability Analysis and Report https://apps.who.int/iris/bitstream/handle/10665/312045/9789290226994-eng.pdf?sequence=1&isAllowed=y)
Following the assessment, a health emergency operations plan was endorsed to ensure an efficient and effective response and to strengthen health sector emergency preparedness. To build capacity among the health workforce and relevant organizations, hospital emergency drills were also conducted among 13 islands in Maldives.
Challenges and the road ahead
There is growing evidence globally that climate change is adversely affecting human health. With climate-induced weather events becoming more intense, along with health-care facilities, there is a need to make other key infrastructure more climate-resilient, including water supply, waste disposal and sanitation, telecommunication, energy supply and transport. There is also an urgent need to scale up the medical workforce to take care of the expected increase in demand.
More research is needed to better understand the impact and effects of climate change to tailor strategies and adapt measures to ensure that these are the most cost effective and efficient. Despite the challenges, Maldives, by “walking the talk” on climate action, has built a track record of leadership in combating climate change through mitigation, adaptation and building health-care resilience.