Medical Justice is Drowning:
The Need to Address Medical Infrastructure Vulnerability
through Climate Reparations

During the 2022 US-Pacific Island Country Summit, the US pledged to provide $810 million in funding to Pacific Island Countries (PICs), from which $130 million would address the consequences of climate change, including the fragilization of health systems. Indeed, climate change disproportionately affects PICs due to their littoralisation, and with limited agency in mitigation efforts (e.g: the global reduction of greenhouse gas emissions), the Pacific islands can only turn to adaptation (i.e “the process of adjustment to actual or expected climate and its effects”). However, adaptation is strictly contingent upon foreign aid: a dependency which seems absurd knowing that the actors to which PICs beg and compete for funding are often the biggest environmental saboteurs. To break out from this geopolitical Stockholm Syndrome we urgently need a binding and just transnational environmental loss and damage mechanism.

Medical infrastructure under threat: a confluence of geographic, demographic and socioeconomic factors in the Pacific

The vulnerability of PICs can be explained by a confluence of geographic, demographic and socioeconomic factors. Indeed, the islands are characterized by a high ratio of shoreline to land area, they are particularly low-lying (as atolls rarely exceed two meters above sea level) and are peppered across a vast area of ocean. This creates a high susceptibility to the effects of sea level rise (e.g: flooding, shoreline erosion/retreat, groundwater salinization) as well as extreme weather events. In addition, the insular economic model and climate migration have resulted in a coastal location of major urban centers, with their critical infrastructure and large majorities of insular populations, which magnifies the geographical risks.  Under these circumstances, health infrastructures are of utmost concern (61.5% of medical facilities in the 14 PICs are located within 500 m of the coast) and are thus acutely vulnerable to sea level rise and extreme weather events (e.g: the 2016 tropical cyclone Winston destroying 88 health facilities in Fiji). The states with one hospital serving their entire population (Palau, Nauru, Tuvalu, Niue), or a single hospital providing services for vast archipelagos (e.g: the National Referral Hospital of Solomon Islands providing care for 900+ islands) are the most critically vulnerable. 

A poly-pressured health system: the multiplication of climate-sensitive health risks in the Pacific

Apart from threatening the physical integrity of medical infrastructure, climate change has also multiplied the health risks PIC populations are subject to. These threats can be classified as primary effects, which are directly induced by extreme weather events (e.g: increased of diarrhoeal disease outbreaks during extreme weather events), secondary effects, which are mediated by changes in biophysical and ecological systems (e.g: the increase of the spread of Malaria with increasing temperatures in Solomon Islands) and tertiary effects, which are diffused and often prolonged in time (e.g: mental health effects on displaced groups).  This multiplication of health risks heightens the pressure on health services and infrastructure, which are themselves increasingly vulnerable to climate change, which calls for an urgent adaptation of the medical paradigm in the Pacific

National Adaptation Plans: how the centrality of international resource mobilization curtails PICs resilience capacity

Amongst the PICs, several have started to address their climate-health insecurity through National Adaptation Plans, which imply medical facility relocation, or remodeling when options to move are limited. For example, Tuvalu implemented the Tuvalu Coastal Adaptation Project (2017) to remodel the Princess Margaret Hospital (30 meters from the coastline ; 5 meter high elevation). The quasi totality of the plan is funded by the Green Climate Fund. Kiribati implemented the Kiribati Health Infrastructure Strengthening Program (2021) to relocate the Beito Hospital (5 meters from the coastline ; 6 meter high elevation). The project is vastly funded by the New Zealand Ministry of Foreign Affairs and Trade and the World Bank. However, whilst some countries are able to mobilize the resources for their National Adaptation Plans, others, often those with the most vulnerable facilities, struggle to find adequate funding (e.g: Tungaru Central Hospital of Kiribati does not even have the means to build a seawall). Indeed, as the implementation of national resilience strategies in the Pacific is highly contingent upon the appeal to and mobilization of international actors and funding, this creates great inequality amongst and within states (as funding is predominantly channeled to the main islands within archipelagoes), cut-throat competition for funding, dependencies and investment inefficiencies ( in the absence of thorough National Adaptation Plans, ad hoc and untenable remending investments are made, which on the long term waste resources). 

The need for a new funding model for adaptation in the Pacific Islands

The urgency of health-climate insecurity in the Pacific calls for a radical change in the territorialized funding paradigm of climate adaptation projects. Indeed, the transnational nature and inequality of effects of human-induced climate change, legitimately demand transnational obligations of reparations and national responsibilization. During the COP27, an agreement on climate reparations for loss and damage to poor countries harmed by impacts from climate change was reached. The terminology might be discriminatory towards PICs which may not be economically stratified as poor, yet are disproportionately vulnerable. First, we urgently need to reform the current qualification metric centered solely on the Gross National Index (GNI), and instead employ the UN Multi-dimensional Vulnerability Index (MVI) which recognizes loss and damage of Pacific Islands. Then, we must ensure the fund is kaleidoscopic, including technological transfers, assistance in data collection, etc., alongside economic assistance. Lastly, we must ensure that the operability of the fund does not rely on ‘pledges’, but legally binding obligations, computed proportionally to emissions, in order to justly redistribute the burden of climate reparations. 

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