WATER AND HEALTH: IMPACT OF CLIMATE CHANGE IN BANGLADESH DISCUSSION PAPER SEPTEMBER 2022 Wameq Azfar Raza Aneire Ehmar Khan / WATER AND HEALTH: IMPACT OF CLIMATE CHANGE IN BANGLADESH Wameq Azfar Raza, Aneire Ehmar Khan September 2022 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors, or to the countries they represent. Citation and the use of the material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jung-Hwan Choi at jchoi@worldbank.org or Erika Yanick at eyanick@worldbank.org. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages the dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © 2022 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. ii Health, Nutrition, and Population (HNP) Discussion Paper Water and Health: Impact of Climate Change in Bangladesh CCDR Bangladesh Delta Prosperity Plan Deep Dive Wameq Azfar Razaa Aneire Ehmar Khanb a Health, Nutrition and Population Global Practice, World Bank, Dhaka b Health, Nutrition and Population Global Practice, World Bank, Dhaka Abstract: The government of Bangladesh’s (GoB) Delta Plan 2100 (BDP 2100) disaggregates Bangladesh’s 64 districts into six ecological zones based on hydrological characteristics and climate risks and deems 58 districts to be “extremely vulnerable” to the effects of climate change. The heterogeneity in the water crisis across the different hotspots presents unique health challenges. This paper summarizes the effects of altered quantity and quality of water on human health for each of the ecological zones and provides recommendations based on the findings. Climate change continues to deteriorate the quality and quantity of water in Bangladesh and is one of the leading causes of morbidity and death. The consequences are particularly pronounced for pregnant women and children. There are substantial regional variations in the effects on health, driven by the country’s topological attributes, such as groundwater depletion in the Barind and drought-prone areas and salinity in drinking water in the coastal regions. To address these challenges, it is imperative for agencies such as the Institute of Epidemiology, Disease Control and Research (IEDCR) and the Ministry of Health and Family Welfare (MoHFW) to build research capacity and upscale comprehensive disease surveillance systems to monitor trends in existing and emerging communicable and noncommunicable diseases, and to rigorously evaluate the efficacy of disease prevention and control programs. A set of zone-specific health policies and actions needs to be formulated under the aegis of the MoHFW in collaboration with relevant GoB stakeholders (such as the Bangladesh Bureau of Statistics, academics, practitioners, and policy makers, underpinned by credible evidence. Keywords: Climate change, water, health, surveillance, disease prevention and control Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Wameq Azfar Raza, the World Bank, Plot E, 32 Syed Mahbub Morshed Avenue, Dhaka 1207; +8802556677777-4204; wraza@worldbank.org, www.worldbank.org. iii iv Table of Contents RIGHTS AND PERMISSIONS ...................................................................................... II ACKNOWLEDGMENTS .............................................................................................. VI ACRONYMS ................................................................................................................. VII INTRODUCTION............................................................................................................. 9 CLIMATE CHANGE, WATER QUALITY AND QUANTITY, AND HEALTH ..... 9 BANGLADESH DELTA PROSPERITY PLAN 2100 .............................................................. 11 METHODS ...................................................................................................................... 14 IMPACTS ON PHYSICAL AND MENTAL HEALTH IN CLIMATE- VULNERABLE HOTSPOTS IN BANGLADESH ...................................................... 14 BARIND AND DROUGHT-PRONE ZONE ............................................................................ 14 COASTAL ZONE .............................................................................................................. 17 HAOR AND FLASH FLOOD-PRONE ZONE ......................................................................... 19 URBAN ZONE .................................................................................................................. 22 RIVER SYSTEMS AND ESTUARIES ................................................................................... 26 CHATTOGRAM HILL TRACTS .......................................................................................... 27 CONCLUSION AND RECOMMENDATIONS .......................................................... 30 REFERENCES................................................................................................................ 35 ANNEX 1: SUMMARY OF CORE STUDIES INCLUDED ...................................... 44 v ACKNOWLEDGMENTS The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper. The authors acknowledge and are grateful for the insightful feedback from Keiko Inoue (Practice Manager, HSAED) and Shiyong Wang (Senior Health Specialist, HSAHP). The authors are also grateful to the Bangladesh CCDR and the CCDR Deep Dive on Delta Plan for Resilience and Prosperity teams for their feedback and support. vi ACRONYMS BBS Bangladesh Bureau of Statistics BDP Bangladesh Delta Plan CCDR Country Climate and Development Report CHT Chittagong Hill Tracts CR Climate refugee DHF Dengue hemorrhagic fever GBM Ganges-Brahmaputra-Meghna GBV Gender-based violence GOB Government of Bangladesh HNP Health, Nutrition, and Population IEDCR Institute of Epidemiology, Disease Control and Research IPCC Intergovernmental Panel on Climate Change MoHFW Ministry of Health and Family Welfare NCD Noncommunicable disease NWMP National Water Management Plan PTSD Post-traumatic stress disorder WHO World Health Organization vii viii INTRODUCTION Global temperature is expected to reach or exceed 1.5°C over the next 20 years (IPCC 2021). This is anticipated to increase the frequency and intensity of heatwaves; increase sea levels; and cause longer durations of hot seasons, erratic weather patterns, and a decline in air quality. Observational records and climate projections suggest that freshwater resources will be strongly impacted by climate change, with wide-ranging consequences on human health (Cisneros et al. 2014). The extent of the health impacts on individual regions will depend on the ability of different societal and environmental systems to mitigate or adapt to change. Bangladesh is currently considered one of the most vulnerable countries to the effects of climate change, primarily driven by its geographic location, flat and low-lying topography, high population density, high levels of poverty, and weak public health infrastructure. Over the past 44 years, the country has become hotter, with a 0.5°C increase in the mean temperature recorded between 1976 and 2019 (Mahmud, Raza, and Hossain 2021). Overall, summers are becoming hotter and longer, with the monsoon season being extended from February to October, while winters are also becoming warmer (Mahmud, Raza, and Hossain 2021). With these regional environmental changes, Bangladesh appears to be losing its distinct seasonal variations. Bangladesh is frequently confronted with cyclones, storm surges, droughts, floods, salinity intrusion, and coastal and riverine erosion. About 30 to 50 percent of the country is affected by floods every year, which affects about one million people annually (Mirza 2002). Climate change is projected to further increase water-related disasters, which may have a devastating impact on human health, mainly among the poorest populations around the country (Mirza 2002). Given the strong link between climate change and how it deleteriously affects the quality and quantity of water in Bangladesh, this study explores how these effects impact the physical and mental health of the population, and how exacerbating conditions can magnify diseases in the coming years. The analysis presented is disaggregated by six ecological zones as identified in the Bangladesh Delta Plan 2100 (Ministry of Planning 2018), given that the typological conditions and effects of climate change on the quantity and quality of water in these locations are uniquely affected and, as such, may affect human health in different ways. The paper is organized as follows—Section 2 outlines the relationship between climate change, water, and health and provides a broad overview of the Bangladesh Delta Plan 2100; Section 3 outlines the methodology used for the analysis; Section 4 analyzes the impact of climate change on the quality and quantity of water and, in turn, its impact on health; Section 5 provides concluding remarks and recommendations on the way forward. CLIMATE CHANGE, WATER QUALITY AND QUANTITY, AND HEALTH Climate change is tightly linked to issues related to water quantity (drought, flooding, extreme rainfall) as well as water quality. Approximately 74 percent of natural disasters 9 between 2001 and 2018 were water-related, including droughts and floods (UNICEF 2021). Natural disasters can destroy or contaminate entire water supplies, increasing the risk of diseases like cholera and typhoid to which children are especially vulnerable. Rising temperatures can lead to the release of dangerous pathogens in freshwater sources, making the water unsafe for people to drink. In parallel, rising sea levels lead to increased salinization of fresh water. Diseases brought on by poor water, sanitation, and hygiene conditions continue to be one of the leading causes of death in children under five years old (UNICEF 2021). Figure 1 shows the different pathways that link climate change to health impacts via water quality and availability. Figure 1. Pathways through Which Climate Change Affects Health via Water Quality and Quantity Source: Author’s rendition based on existing literature Globally, climate change causes an estimated 150,000 deaths every year (WHO 2021c). By 2050, climate change is expected to cause approximately 250,000 additional deaths per year due to malnutrition, malaria, diarrhea, and heat stress alone (WHO 2021a). These estimates include deaths as a result of extreme weather conditions, which may occur with increased frequency and intensity. Changes in temperature and rainfall conditions will influence transmission patterns for many diseases, including water-related diseases, such as diarrhea and vector-borne infections, including dengue and malaria (WHO 2021c). Climate change may also affect patterns of food production, which in turn can exacerbate rates of malnutrition, especially among the poorest populations (WHO 2021c). Further, extreme weather events such as storms, floods, and droughts may impair mental health, in particular leading to anxiety, depression, and post-traumatic stress disorder (PTSD), for example, through population displacement and food insecurity, and have long-term impacts on the well-being of affected populations (Clayton 2021). The World Health Organization (WHO) reports that every year about 525,000 children under five die from diarrhea, largely due to lack of access to clean water supply and poor 10 hygiene conditions, while approximately 60,000 people die in natural disasters (WHO 2017; Ritchie and Roser 2014). It is estimated that by 2040, almost one in four children will live in areas of “extremely high” water stress (UNICEF 2021). Climate change will have far-reaching impacts on water quality and availability, especially in water-scarce locations, and may even lead to conflict over water supplies. The health impacts of climate change are inequitable, with disproportionate effects on the most susceptible populations around the world, including people with low incomes, minority groups, women, children, older adults, people with chronic diseases and disabilities, and outdoor workers (Romanello et al. 2021). In 2020, during a six-month period, 84 disasters from floods, droughts, and storms affected 51.6 million people in countries already struggling with COVID-19, with the escalating effects of disasters reducing their ability to respond to health emergencies (Romanello et al. 2021). BANGLADESH DELTA PROSPERITY PLAN 2100 In Bangladesh, 58 out of 64 districts are considered extremely vulnerable to climate change. Water resources are closely linked with climatic factors, and the most damaging effects are predicted to be floods, salinity intrusion, groundwater depletion and contamination, and droughts. Deaths due to water scarcity and quality are widespread in Bangladesh, particularly among children. To address the long-term challenges of climate change and natural hazards, the government has formulated a long-term Bangladesh Delta Plan 2100 (BDP 2100), which identifies and prioritizes investable sectors for action to reduce climate risk and environmental losses in the vulnerable areas of the country (Ministry of Planning 2018). It is aligned with national goals and outlines policies that are focused on flood risk management and freshwater conservation. To support prioritization, the districts have been grouped into six hotspots based on ecological characteristics (Figure 2). The hotspots encompass almost all the districts of Bangladesh as they face numerous weather and climate change risks related to their location either around the sea, around major rivers, or in water-scarce zones. Only six districts are relatively less hazard-prone owing to their location away from the sea and active rivers. The hotspot grouping is useful in summarizing certain broad socioeconomic characteristics and common risk profiles. The hotspots, including Barind and Drought-Prone Zone, Coastal Zone, Haor and Flash Flood-Prone Zone, Urban Zone, River Systems and Estuaries, and Chittagong Hill Tracts (CHT) were proposed on the basis of analysis from hydrological regions identified in the National Water Management Plan 2004, and their hydrological characteristics and climate risks, which are summarized below: • The Barind and Drought-Prone Zone is situated in northwest Bangladesh, comprising Rajshahi and Rangpur Divisions, and in part Khulna Division. This location is typically characterized by seasonal drought, and future risks include rising temperature, reduced groundwater levels, and reducing wetlands. • The Coastal Zone is in the southern part of the country covering Khulna and Barisal Divisions and part of Chittagong Division. The common risks include tidal fluctuation, accelerated sea-level rise, salinity intrusion with sea-level rise, cyclones, and storm surges. • The Haor and Flash Flood-Prone Zone falls in the northeastern part of the country, comprising Sylhet Division and parts of Mymensingh and Dhaka Divisions. The zone is at risk of increased precipitation causing flash floods, 11 subsidence and decreased sediment supply, landfilling, encroachment, and land- use change. • The Urban Zone covers all the urban centers around the country including the megacity, Dhaka, and other secondary cities in Khulna, Rajshahi, Rangpur, Sylhet, and Chittagong. The risks include urban sprawl, unplanned settlements and development, falling groundwater levels, fecal sludge and industrial effluents, air and noise pollution, sea-level rise, and increase in precipitation. • The River System and Estuaries include areas near the river that are sprawled across the country. The zone is vulnerable to frequent riverine erosion and accretion, drought, river avulsion, sedimentation offtake, subsidence, tidal fluctuation, sea-level rise, flash floods in hilly terrain, and dry periods. • The Chittagong Hill Tracts (CHT) comprise the three hill districts of Rangamati, Bandarban, and Khagrachari in Chittagong Division in the southeast region of Bangladesh. The zone is geographically distinct from other parts of Bangladesh and is mainly characterized by very steep and rugged mountainous terrain. The climate-related risks include loss of forest and vegetation cover and flash floods in hilly terrain. 12 Figure 2: Ecological Zones in Bangladesh Source: Original figure for this publication, based on the Bangladesh Delta Prosperity Plan 2100 (Ministry of Planning 2018). Notes: Ecological zones: (1) Coastal Zone; (2) Barind and Drought-Prone Zone; (3) Haor and Flash Flood–Prone Areas; (4) Chittagong Hill Tracts; (5) River Systems and Estuaries; (6) Urban areas; (7) Less hazard-prone areas; (99) Not classified. 13 METHODS We identified 27 core and 119 related studies and reports on climate change and impacts on health and/or agriculture for the six ecological zones. The analysis was conducted between October 2020 and December 2020 and information was gathered through a review of peer-reviewed studies and reports by development organizations. The team scanned the peer-reviewed literature—including both qualitative and quantitative studies—using PubMed and Google Scholar databases. In addition, a more targeted search of research papers and reports focusing specifically on the districts that fall in the six ecological zones was carried out. IMPACTS ON PHYSICAL AND MENTAL HEALTH IN CLIMATE- VULNERABLE HOTSPOTS IN BANGLADESH BARIND AND DROUGHT-PRONE ZONE The drought-prone Barind tract located in northwest Bangladesh comprises 18 districts, covering an area of 22,848 square kilometers (sq. km) (Figure 3). Drought, Figure 3. Barind and Drought-Prone Areas defined as severe moisture deficit in the soil, has been a considerable problem in the Barind Region for many years (Dey et al. 2011). The National Water Management Plan (NWMP) considers occurrences of drought as a major risk to water deficiency in the area. Climate models indicate that droughts are occurring more frequently, are more severe, spatially broad, and last longer in duration because of rapid environmental change (Alam et al. 2021). Consequently, the local population is impacted by freshwater scarcity, flooding, waterlogging, and reduced groundwater levels (Ministry of Planning 2018). In Bangladesh, groundwater has been used as the primary source of drinking water and irrigation since the 1960s and has been the single most important driving force behind the steady expansion of agricultural output in the country (Zahid and Ahmed 2006). As such, in the mid- Source: Original figure for this publication, based on 1970s, due to population growth and the Bangladesh Delta Prosperity Plan 2100 (Ministry rising demand for food, both deep and of Planning 2018). shallow water tube wells were used for groundwater irrigation. However, overextraction of groundwater, along with decreasing rainfall and rising temperature, have now created a major crisis in the region. Not only 14 has the groundwater table receded significantly, the quality of groundwater in many areas of the Barind tract has also been impacted by exposure to pollution from agriculture, urbanized areas, and industrial sites and arsenic contamination in shallower groundwater aquifers, making it unfit for human consumption, and in some cases, even for irrigation purposes (Jahan, Mazumder, and Islam 2010; Zahid and Ahmed 2006). Rainfall, which plays a major role in recharging the groundwater aquifer in the Barind Region, has also reduced substantially over the past few decades (Bari et al. 2019; Aziz et al. 2015). Bari et al (2019) found that annual rainfall in Rajshahi District follows a decreasing trend in parallel to rising maximum and minimum temperature, adversely impacting the availability of water (Bari et al. 2019). Compared to a national average of 2,550 millimeters (mm), the average annual rainfall in the Barind Region is much lower— about 1,100 mm. Since the 1980s, the average rainfall has fallen by 24 to 31 percent during monsoons, 36 to 41 percent during summer, and 86 to 115 percent during winter (Chowdhury 2020). Surface water area has also reduced significantly at an average rate of 2.53 sq. km per year (Bari et al. 2019). Drought is often considered a hidden risk factor that has the potential to cause a silent public health disaster. Prolonged droughts affect several million people globally. Between 1960 and 2013, 612 drought events resulted in 2.19 million deaths and 2.14 billion affected persons (Sena 2014). Droughts have far-reaching and serious effects on water resources, agriculture, ecology, and population health. Many of the effects are diffused, indirect, and cumulative, and the impact on human health depends on the duration and severity of the drought, as well as the country’s economic, social, and structural capacity to deal with the fallout (Alam et al. 2021; Stanke et al. 2013). The biological mechanisms through which droughts affect human health are still unclear, but several distinct adverse health outcomes have been identified by Bellizzi et al. (2020) (see Table 1). Table 1. Summary of Health Conditions associated with Droughts Systems and services Human health Access to drinking water (quality and quantity, Acute gastrointestinal diseases unsafe water storage, limited water for Waterborne and food-borne diseases hygiene) Vector- and rodent-borne diseases, zoonoses Food and nutrition (limited water for food Waterborne and food-borne diseases hygiene, reduced or damaged crop yields, Malnutrition reduced health or death of animals and livestock) Air quality (dust, drought-related wildfires) Respiratory diseases (allergic rhinitis, asthma) Acute respiratory infections (bronchitis, sinusitis, pneumonia) Fungal infectious diseases (mycoses) Allergic reactions Basic sanitation and hygiene (limited water for Infectious and parasitic diseases personal hygiene) Skin infections Mental health and behavior Stress, anxiety, depression Behavioral changes, violence Health services Loss of medicines and personnel Health service interruption Source: Bellizzi et al. 2020. 15 The most studied impacts of droughts globally have been on nutritional deficiencies and mental health (Bellizzi et al. 2020; Stanke et al. 2013; Smith et al. 2015; Alpino, Sena, and Freitas 2016). Additionally, droughts have been associated with an increased risk of morbidity and mortality from diarrheal illness (Aziz et al. 1990); the transmission of some vector-borne diseases (Bellizzi et al. 2020; Bouma and Dye 1997; Menne and Bertollini 2000); waterborne diseases such as dysentery, diarrhea, and cholera (Umma, Rajib, and Yukiko 2011); and the risk of cardiovascular and upper respiratory diseases (Cohen et al. 2012). Studies have also shown how droughts increase the risk of suicide in farmers (Hanigan et al. 2012; Vins et al. 2015). Further, droughts may aggravate preexisting chronic pathological conditions that may continue even after the end of the crisis (Barreau et al. 2015; Edwards, Gray, and Hunter 2008). Very few studies have looked specifically at the impact of droughts on human health in Bangladesh’s Barind tract. Dey et al (2011) associated droughts with a significant reduction in freshwater availability, increasing the risk of diseases associated with poor hygiene. The study found that during the drought period, many tube wells turned dry or failed to supply the required quantity of water for household drinking and irrigation purposes. A substantial number of surface water bodies including rivers, stagnant ponds, ditches, canals, and streams also had a lower volume of water, with poor quality. In normal years, almost all households used tube wells as the major source of drinking water, while in the drought period, tube well use dropped significantly as a substantial proportion of tube wells turned dry. People in the Barind Region often have to collect drinking water from long distances to meet basic requirements. High temperatures and high prevalence of severe dust during drought periods compared to normal years caused outbreaks of dysentery and diarrhea among both adults and children in Kishoreganj (28 vs. 5 percent) and Badarganj (34 vs. 6 percent) Districts of northwest Bangladesh (Dey et al. 2011). Poor population health status, poor quality of water, and inadequate sanitation facilities or subpar practices often magnify these effects. Alam et al. (2021) found that severe and extreme drought in the short-term drought periods in Rangpur and Nilphamari were associated with mortality (Alam 2021). In Dinajpur, mild and moderate drought was associated with circulatory- and respiratory- related mortality (Alam et al. 2021). Droughts have the potential to severely compromise agricultural production and fish cultivation, increasing food insecurity and threatening the livelihoods of people in the Barind tract. A large proportion of the population is already living in extreme poverty in the region (Iqbal 2014). Reduced cropped land and food production exacerbate poverty rates by worsening food insecurity, especially during the summer months (Iqbal 2014). The northwestern region has recurrent poor food consumption scores compared to other regions of Bangladesh, and the per capita GDP is far below the national average (Zug 2006a, 2006b; Bangladesh Planning Commission 2012). During the period 1973–1987, about 2.18 million tons of rice were damaged due to drought, while the extent of crop loss was 2.38 million tons due to floods in the same period (Dey et al. 2011; Paul 1995). Rice contributes more than 80 percent to the total food supply of the country, with 95 percent of the population consuming it, providing 76 and 66 percent of calories and total protein requirement of daily food intake, respectively (Aziz et al. 2015). In Tanore, Godagari, Mohanpur, and Baghmara Upazilas of the Rajshahi District, which is located in severely drought-prone areas, the production of Boro rice during the dry season, is hugely impacted by depleting groundwater levels (Aziz et al. 2015). A crucial relationship exists between Boro rice production and 16 groundwater depletion; therefore, crop diversification or less water-consuming crops are considered to be alternative options for the region. COASTAL ZONE The coastal zone comprises 19 districts in southern Bangladesh and covers an area of 27,738 sq. km (Figure 4). It is a part of the flat Ganges Delta, which is intersected by large tidal rivers discharging into the Bay of Bengal. The 40 million coastal population is particularly at the forefront of climate change and natural disasters due to changes in temperature and rainfall patterns, increase in the frequency and intensity of tropical cyclones and storms, saltwater intrusion, and coastal flooding, which are threatening the lives and futures of the people living there (Saleh and Eklund 2021). Analyzing 22 years of data (1977–1988), the South Asian Meteorological Research Council (2003) showed that the relative sea levels in the Bay of Bengal have risen by 4.0 mm/year and 7.8-mm/year along the western and eastern coasts, respectively (Alam et al. 2018). It is predicted that rises in both the mean sea level and sea surface temperature will significantly increase the height of storm surges and increase areas of inundation along the Bangladeshi coast. The major impacts include a reduction in livelihood diversity, migration, and a high prevalence of diseases (Alam et al. 2018). Between 1891 and 1990, Bangladesh was hit by 700 cyclones (Shamsuddoha and Figure 4. Coastal Zones Chowdhury 2007). In 1991, Bangladesh was struck by one of the deadliest tropical cyclones ever recorded, which ravaged the offshore islands and the mainland coast. In recent years, two consecutive cyclones— Sidr in 2007 and Aila in 2009—had devastating impacts on both the physical and mental health of the coastal population (Kabir et al. 2014). Cyclone Sidr caused 3,406 deaths, while 55,000 people sustained physical injuries (Paul 2009). Heavy rains accompanying cyclones and tidal waves caused extensive physical destruction; casualties; damage to crops, livestock, and flooding in a total of 30 districts across the southwestern coast (Ministry of Flood and Disaster Management 2009). There were massive outbreaks of waterborne diseases, respiratory tract infections, and pneumonia. Children aged five years or younger were the most vulnerable (Ministry of Flood and Disaster Management 2009). Source: Original figure for this publication, based on About 2.3 million people on the the Bangladesh Delta Prosperity Plan 2100 (Ministry southwest coast were impacted by of Planning 2018). cyclone Aila, which caused massive 17 damage to infrastructure and agricultural lands (Baten et al. 2010). Approximately 50,000 people in Dacope Upazila in the Khulna District were left homeless as climate refugees (CRs) for over two years (Khan et al. 2016). The economic cost of Aila outweighed the impacts of Sidr and caused long-term suffering for the coastal people. Khan et al. (2016) determined the neurodevelopmental status of children born as climate refugees compared to their nonclimate refugee (NCR) counterparts. There were significantly more (86 percent) landless families among CRs compared to NCRs. Neurodevelopmental Impairments were three times higher in CR children (21.3 percent), compared to the latter group (7.4 percent). Specifically, expressive language and gross motor functions were the most significantly affected areas of impairment. The findings are of concern because in Bangladesh large populations are forced to leave their homes and become climate refugees annually. Postcyclone analyses in Amtali Upazila of Barguna District (affected by Cyclone Sidr) and in Koyra Upazila of Khulna District (affected by Cyclone Aila) showed that both cyclones had serious effects on the overall health status and the livelihood pattern of the affected population, increasing their vulnerability to diseases. The incidence of diarrhea, typhoid, skin infections, dengue, hepatitis, and other infectious diseases increased among the cyclone-hit populations, as did the risks of injury and death (Kabir et al. 2014, 2016). A qualitative case study was conducted on the perceived need for mental health support and the availability of such services in a cyclone-affected coastal area in rural Bangladesh (Hasan et al. 2020). It was found that cyclones had numerous psychosocial impacts on the population including acute stress disorder, sleep disorder, PTSD, generalized anxiety disorders, suicidal ideation, and depression. Children, the elderly, and women were perceived to be the most vulnerable. The study found that there was a visible gap in finding effective ways to provide affected people with the required mental health and psycho-social services. Abedin et al. (2019) investigated the impacts of climate change on water resources and human health in two villages of Shymnagar Upazila on the southwestern coast and found that the local community perceives climate change to have substantial impacts on freshwater sources and their health. More than 70 percent of respondents identified diarrhea, dysentery, and skin diseases as the main waterborne health risks that occur through climate-related safe water scarcity (Abedin et al. 2019). Over the past few decades, salinity has gradually intruded into the coastal areas, which has had significant impacts on the primary production system, coastal biodiversity, and human health. Salinity along the 720-km coastline has encroached more than 100 km inland into domestic ponds, groundwater supplies, and agricultural land through various estuaries and water inlets that are interlinked to the major rivers (Allison et al. 2003; Rahman and Bhattacharya 2006). Since 1948, river salinity in some of the southern districts has risen by 45 percent (Integrated Regional Information Networks 2007). Salinity intrusion is likely to increase in the future because of diminishing river flows, increased upstream withdrawal of water, poor water management and shrimp cultivation, and longer-term climate change–induced decreases in dry season rainfall and sea-level rise (Khan et al. 2011). According to the Intergovernmental Panel on Climate Change (IPCC), groundwater, crop soils, and many rivers are likely to become increasingly salinized from higher tidal waves and storm surges brought on by climate change (Parry et al. 2007). 18 Approximately 20 million people living along the coast, who rely heavily on rivers, tube wells, and ponds for washing, bathing, and obtaining drinking water, are now affected by varying degrees of salinity (Ministry of Environment and Forests 2006). The use of salinized water for household and drinking purposes was frequently associated with “feeling sick,” physical weakness, rough skin, and sores on hands and legs (Shohel et al. 2011). Further, hair loss, scabies, skin rashes, gastroenteritis, diarrhea, skin paleness, and skin allergies, especially among women and children, were reported (Paul and Rashid 2017). Consumption of saltwater was associated with an increased number of waterborne diseases, such as diarrhea and dysentery that primarily affect children (Warner et al. 2012; Paul and Rashid 2017). Moreover, salinity was associated with changes in menstruation of women and higher rates of miscarriage (Warner et al. 2012). A population-based case-control study in Dacope found exceptionally high sodium levels (mean 516.6 milligrams/liter [mg/L], standard deviation [SD] 524.2) in drinking water sources (Khan et al. 2014). Women consuming tube well water were at a higher risk of morbidity than rainwater users. Salinity in drinking water was significantly associated with an increased risk of (pre)eclampsia and gestational hypertension among pregnant women in this population. Hypertensive disorders in pregnancy are among the leading causes of maternal and perinatal death in low-income countries. (Pre)eclampsia is one of the top-five causes of direct maternal deaths and is associated with an increased risk of preterm birth and intrauterine growth restriction, together with higher childhood blood pressure in offspring, and future cardiovascular disease in mothers (Firoz et al. 2011; Macdonald-Wallis et al. 2011; Sibai 2002). In the same study area in Dacope, sodium concentrations in drinking water were strongly associated with blood pressure in adults after adjustments for confounding factors. For every 100 mg/L reduction in sodium in drinking water, systolic/diastolic blood pressure (BP) was lower on average by 0.95/0.57 millimeters of mercury (mmHg), and odds of hypertension were lower by 14 percent (Scheelbeek et al. 2017). The local population, therefore, is in dire need of safe and affordable drinking water with low salt content. HAOR AND FLASH FLOOD-PRONE ZONE The Haor 1 Basin, located in the northeast region of Bangladesh, is an important freshwater wetland ecosystem that consists of more than 400 haors sprawled across seven districts (Figure 5). The basin covers an area of 8,000 sq. km and has a population of about 19.37 million (BWDB 2011). Flash floods in the pre-monsoon period are a common water-related phenomenon that inundate the area every year. The Haor Basin is bounded by hills, and heavy rainfall causes flash floods, which ultimately discharge suddenly and with high flow velocity through downstream river networks (Hossain 2013). The severity of flash floods depends on the time and quantity of rainfall in the hills and the drain-out capacity of the main rivers. Studies reveal that the Haor Basin is projected to be under additional stress due to climate-induced changes in temperature and rainfall patterns (Suman et al. 2014). 1 A haor is a wetland ecosystem in the northeastern part of Bangladesh, which physically is a bowl- or saucer-shaped shallow depression, also known as a backswamp. 19 Both pre-monsoon and monsoon rainfall are predicted to increase in the future, with Figure 5. Haor and Flash Flood Areas subsequent increases in the volume of surface runoff, aggravating flood conditions in the region (Suman et al. 2014). Additionally, the Haor Basin is estimated to be sinking between 4 mm and 2.1 centimeters (cm) annually because of the down-thrusting under the Shillong Massif (Reliefweb 2019). This sinking means that annual floods will become even more extensive and will be exacerbated by sea- level rise. Flash floods and heavy rainfall are predicted to cause severe damage to crop and agricultural land, which impact the quality and quantity of the harvest. Large sections of the local population are likely to be impacted by the loss of livelihood and food insecurity (Suman et al. 2014). The livelihood of the Haor population is almost entirely dependent on agriculture and fishery. Crop production practices and economic activities of the farmers are quite different from those in other parts of Source: Original figure for this publication, based on the country. Boro rice—a winter rice the Bangladesh Delta Prosperity Plan 2100 (Ministry of Planning 2018). cultivated in the Rabi season (November to June)—is the main crop for the area (Khan and Mia 2012). Economic opportunities during noncrop seasons, which can extend between five to six months, are quite limited. The Haor Region produces about 20 percent of the country’s total staple food (rice) and provides the livelihood for 20 million people, who are extremely vulnerable to environmental degradation and climate change (Rabby et al. 2011). Despite the Haor Region’s economic and ecological significance, the poverty rate is substantially higher there compared to the national average (national average: 24.3 percent vis-à-vis Kishoreganj: 53.5 percent and Netrokona: 34.0 percent) (BIDS 2016; BBS 2017). Several studies show that early or pre-monsoon flash floods, even just two to three weeks preharvest, can destroy Boro paddy, leading to irrevocable economic loss, poverty, food insecurity, malnutrition, and short-term out-migration (Kamruzzaman and Shaw 2018; BIDS 2016; Khan and Mia 2012). In recent years, seasonal flash floods in Sunamganj District and other haor areas have begun, on average, 15 days earlier than they did 30 years ago, leading to farmers getting less time to harvest their crops (Kamruzzaman and Shaw 2018). Between 2000 and 2004, Boro crop areas in the Sylhet Division were partially or fully damaged by flash floods, with losses amounting to about 570,000 metric tons of rice (Ministry of Environment and Forests 2012). More recently, in 2017, a major flash flood in Tanguar Haor, which supports livelihoods for 70,000 people, submerged a considerable area of agricultural land, leading to significant losses of crops (Hossain et al. 2017; Rahaman 2016). 20 In 2012, an estimated 320,000 people in the Haor Region were affected and in need of assistance due to early flash floods, and about 3,000 shelters were partially or completely destroyed (ReliefWeb 2019; SFB 2019). Almost 60,000 people were at-risk from food insecurity along with postflood scarcity of safe drinking water, contamination of pathogens and microbes, and unhygienic sanitary conditions (Hossain et al. 2017). Sarma (2011), studying the socioeconomic vulnerabilities of people residing near deep Haor areas and their dependency on its natural resources in Nikli, Kishoreganj District, report that 71 percent of households were effectively landless, of which, about 55 percent were absolutely landless. About 78.9 percent of Haor households suffered from food insecurity because of mono-crop cultivation, seasonal unemployment, and natural calamities. During floods, most families in Haor temporarily migrate to nearby schools that are used as temporary shelters for several weeks, where they face further food shortages and a lack of basic sanitation facilities. Many displaced people resort to sleeping under the open sky for extended periods, increasing their susceptibility to infectious diseases due to unhygienic conditions. The adverse human health impacts of floods are complex, wide-ranging, and difficult to attribute to the flood event itself. However, numerous health risks are associated with population displacement, loss of health workers, and loss of health infrastructure including essential drugs and supplies (SFB 2019). In the short to medium term, health risks of floods include drowning, infected wounds, poisoning from snakebites, electrocutions from power lines, skin-eye-ear infections, poor mental health, communicable diseases like acute respiratory infections (ARIs) and acute watery diarrhea, and starvation (ReliefWeb 2019; SFB 2019). Epidemiological studies have demonstrated a marked negative relationship between diarrhea and the physical growth and development of a child. Each day of illness due to diarrhea produces a weight deficit of 20–40 grams (g), while “catch-up growth” often does not occur in malnourished children, increasing their risk of developing more serious diseases (Patwari 1999). In the long term, chronic diseases, disability, and stress- and poverty-related diseases including malnutrition have been recorded in the Haor Region (SFB 2019). Women are particularly vulnerable as the scarcity of transportation in flood-affected areas and disruption of communication services impede access to health facilities for antenatal, deliveries, and postnatal care (ReliefWeb 2019). There is a strong relationship between crop diversity, diet diversity, and nutritional outcomes (Uddin 2019). Children living in the Haor Region are one and a half times more likely to be stunted than in other parts of the country (BRAC 2018). The overall prevalence of stunting 2 among children below five years of age was 46.6 percent in the Haor Basin (compared to 30.9 percent nationally), while the prevalence of underweight 3 was 44.5 percent, compared to the national average of 22.6 percent in 2018 (BRAC 2018; World Bank 2022). A recent study found that nearly half (48 percent) of the total primary school–going children in the Haor areas of the Kishoreganj District were wasted (compared to 9.8 2 Stunting, a marker for long-term undernutrition, is defined as being 2 standard deviations below the mean of the reference population. 3 Underweight, a marker for short-term undernutrition, is defined as being 2 standard deviations below the mean of the reference population. 21 percent nationally), 4 40.5 percent were underweight and 38.0 percent were stunted (Khanam and Haque 2021). The likelihoods of stunting, wasting, and being underweight were higher among female children than their male counterparts. A higher number of children in the family and delay in giving complementary food after six months were found to be associated with higher odds of becoming malnourished. In contrast, increased meal frequency and solvency with land ownership were found associated with reduced odds of becoming malnourished (Khanam and Haque 2021). Seasonality remains an important issue in malnutrition. Higher levels of malnutrition in the summer months are perhaps related to restricted access to food. This matches the flooding season, which can lead to increased diarrheal diseases, which in turn is linked to the rising prevalence of malnutrition (ReliefWeb 2019). Though floods may not directly and immediately impact nutrition, they increase vulnerability and lead to a rise in undernutrition in a short amount of time. This is further compounded by factors such as inadequate hygiene, lack of private and safe spaces for women to breastfeed or feed children, and limited access to nutritious food. Epidemiological studies show that chronic malnutrition leads to multiple health complications and diseases, which are responsible for about 64 percent of the total 7.6 million under-five deaths worldwide, as reported by the World Health Organization (Lardner et al. 2015; Liu et al. 2012). The phenomenon, known as the “developmental origins of health and disease,” is well-documented and signifies that poor nutrition of adolescent girls and pregnant mothers can lead to an intergenerational cycle of undernutrition resulting in child growth failure (Barker 2004). The role of episodes of undernutrition in the fetal period and in childhood is increasingly recognized as a risk factor for the development of certain noncommunicable diseases (NCDs) or for NCD risk factors in adulthood (Mwene-Batu et al. 2021). URBAN ZONE The urban areas in Bangladesh include seven districts spread across the country, covering an area of 19,823 sq. km in total (Figure 6). Urbanization is occurring at a rapid pace and the urban population is projected to grow more than 50 percent by 2050 (United Nations 2014). The urban centers face a multitude of challenges related to rapid population growth, unplanned development, land conversion, falling groundwater levels, and pollution (Zermoglio et al. 2020). These factors, along with rising sea levels, erratic rainfall, and heat waves, cause damage to economic activities, houses and infrastructure, and human health (Zermoglio et al. 2020). Currently, about 55 percent of the urban population lives in urban slums, where they experience a wide range of deprivations including substandard, overcrowded, and unhealthy housing, and scarce and subpar access to health, sanitation, water, and waste disposal services (Uddin 2018). The ever-expanding megacity, Dhaka, is a hotspot for climate risks and is among the top five most vulnerable coastal cities in the world (OECD 2007). It must deal with floods and waterlogging repeatedly each year (Dasgupta et al. 2015). In recent years, extensive water logging from May to October has become a common and recurring 4 Wasting is defined as having a weight-for-height ratio 2 standard deviations below the mean of the reference population: https://www.who.int/health-topics/malnutrition#tab=tab_1. 22 problem causing adverse social, physical, and socioeconomic impacts (Subrina and Chowdhury 2018). Recent major floods have worsened in terms of depth and extent of inundation and duration, especially in fringe areas, where many of the urban poor reside. With the evolving climate, characterized by heavier and more erratic rainfall in the Ganges-Brahmaputra-Meghna (GBM) Basin during the monsoon season, the situation has Figure 6. Urban Areas deteriorated further (Dasgupta et al. 2015). The risk of flooding is heightened by concurrent encroachment of floodplains or retention areas (Thiele-Eich, Burkart, and Simmer 2015). At the same time, groundwater levels are depleting due to overextraction for drinking water and irrigation, while surface water quality is compromised due to increased water pollution, ad hoc waste management, industrial effluents, fecal sludge disposal, and increased use of chemicals and pesticides. Dhaka city has an extensive, but not fully effective, sewage network linking to ponds, lakes, and canals, which flow into the surrounding river systems (Alam et al. 2011). During extreme climatic events, such as floods, fecal-oral transmission is heightened, leading to significant off-season outbreaks of diarrheal diseases in urban settlements. Floods churn the water, bringing sediment and Vibrio cholerae biofilm attached to particulates into the surface water, thereby enriching the V. cholerae population (Alam et al. 2011). Source: Original figure for this publication, based on Bangladesh experienced numerous disastrous the Bangladesh Delta Prosperity Plan 2100 (Ministry of Planning 2018). flood events between 1987 and 2007, causing many diarrheal deaths in the cities as waterborne diseases spread in epidemic forms during postflood periods. During the diarrheal epidemics in the three most severe floods in Dhaka—1988, 1998, and 2004, V. cholerae was the most commonly identified cause of diarrhea, followed by rotavirus (Schwartz et al. 2006). Compared to nonflood periods, individuals presenting during flood-associated epidemics were older, more severely dehydrated, and of lower socioeconomic status (Schwartz et al. 2006). During the 1988 flood, diarrheal disease was responsible for 35 percent of all flood-related illnesses and 27 percent of 154 flood- related deaths in a population of more than 45,000 people (Chowdhury 2017). A systematic review reported that floods and storms are associated with a range of health impacts including poisonings, wounds, gastrointestinal infections, and skin or soft tissue infections (Saulnier et al. 2017). Leptospirosis and diabetes-related complications also increased postfloods. The majority of diseases occurred within four weeks of floods or storms. In August 2007, extreme floods in Dhaka city was accompanied by an unusually severe diarrheal outbreak that resulted in a record-high number of incidences (Alam et al. 2011). 23 Analyses of diarrheal data for three consecutive years (2006–2008) and regional hydroclimatology over three decades (1980–2009) indicated that the pattern of cholera occurring in Dhaka was associated with flood waters transmitting the infectious clone circulating via the fecal-oral route during and between the dual seasonal cholera peaks in Dhaka. It was concluded that circular river systems (that receive the sewage effluent of approximately 21 million inhabitants) and flood embankments along the city’s border likely facilitate the transmission of infectious V. cholerae throughout the year. This leads to sudden and off-season outbreaks in Dhaka's densely populated urban ecosystem (Alam et al. 2011). Another study estimated the effects of rainfall and temperature on the number of non- cholera diarrhea cases in Dhaka and found that the number of cases increased, per week, by 5.1 percent for every 10 mm increase above the threshold of 52 mm of average rainfall over lags between 0 to 8 weeks (Hashizume et al. 2007). The number of cases increased by 3.9 percent for every 10 mm decrease below the same threshold of rainfall. Further, cases increased with higher temperatures, particularly in those individuals with a lower socioeconomic and sanitation status (Hashizume et al. 2007). Similarly, floods can potentially increase the transmission of dengue. Standing waters caused by the overflow of rivers act as breeding sites for mosquitoes and increase the potential for exposure of flood-affected populations to dengue (Hashizume et al. 2012). The incidence of dengue, a mosquito-borne infection that causes potentially fatal complications like dengue hemorrhagic fever (DHF) and dengue shock syndrome, increased dramatically in recent decades. Approximately 2.5 billion people living in tropical and subtropical urban and semi-urban areas are now at risk, and more than 50 million dengue cases are estimated to occur annually. In some Asian countries, DHF is a leading cause of hospitalization and death in children (WHO 2021b). In Bangladesh, sporadic cases of dengue were documented between 1964 and 1999. The first outbreak occurred in Dhaka in 2000, and since then, cases have been reported every year with clear seasonality, suggesting that weather factors play a direct or indirect role (Rahman et al. 2002; Hashizume et al. 2012). A number of studies investigated the relationship between climate and dengue across several locations in Dhaka and concluded that high temperatures and rainfall both increase the risk of dengue. Hashizume et al. (2012) explored the effects of river levels and rainfall on hospital admissions for dengue at 11 major hospitals in Dhaka. Strong evidence of an increase in dengue incidences at high river levels in Dhaka city were found (Hashizume et al. 2012). Hospitalizations increased by 6.9 percent for each 0.1 meter increase above a threshold (3.9 meters) for the average river level over lags of 0 to 5 weeks. Conversely, the number of hospitalizations increased by 29.6 percent for a 0.1 meter decrease below the same threshold of the average river level over lags of 0 to 19 weeks. In Dhaka and Chattogram cities, the mean dengue incidence was 31.62 per 100,000 and 5.76 per 100,000 population, respectively (Islam et al. 2018; Mahmud 2021). The incidence of dengue cases was found to be significantly associated with the monthly mean temperature, total rainfall, and mean humidity. The low-lying topography of the country, subject to frequent flooding and waterlogging, makes secondary cities extremely vulnerable to climate change as well. For example, Khulna and Chattogram cities are located at the confluence of several major rivers and streams and on the Bay of Bengal coast, which increases their vulnerability to hydro- meteorological hazards like cyclones and tidal waves that impact people, economic 24 activities, and health of the urban population (Zermoglio et al. 2020). Both cities experience frequent waterlogging during extreme rainfall events. In the Khulna city corporation area, more than 90 percent of households are affected by waterlogging during late monsoon due to unabated encroachment of perennial waterbodies and filling up of ponds for infrastructural development (Murtaza 2001; Sarkar 2021). Rising temperatures, more intense precipitation and subsequent flooding, and more frequent cyclones and droughts, coupled with population growth, are expected to have negative impacts on Khulna city’s water availability and quality (Zermoglio et al. 2020). Both surface water and shallow groundwater are impacted, reducing the availability of fresh drinking water. In May 2020, Cyclone Amphan allowed river water to freely flow inland into Khulna city. This resulted in excessive flooding and sustained waterlogged conditions (Roy et al. 2009). The destruction of water and sanitation infrastructure as a result of submerged roads and housing during floods led to restricted access to sanitary toilets. More than 30 percent of the affected population continued to suffer as late as September (four months since the event) (UKAID 2020). Tidal bores not only affected the quality and quantity of the harvest but the food stocks of affected households were also damaged, reducing food consumption and increasing food insecurity (UKAID 2020). This is especially concerning because undernutrition among children continues to be a key concern in both Khulna and Chattogram cities. As previously stated, there is strong evidence that children who suffer from stunting are at increased risk of infectious diseases like malaria, diarrhea, and pneumonia (Saha, Chattapadhayay, and Richardus 2019). Waterlogging has particular implications for women’s and children’s health. First, poor access to sanitation facilities and living in knee-deep water increases the risk of infections, especially for menstruating women. Women and children living in shelters may be subject to gender-based violence (GBV) (UKAID 2020). Further, children suffering from undernutrition and stunting may experience higher vulnerability during waterlogging, as reduced meal intake is one of the primary coping mechanisms of affected households (Uttaran 2020). Khulna city’s migrant community and squatter population are mainly spread out in the urban slums, exacerbating the challenges faced due to water quality and availability (Zermoglio et al. 2020). Since 2005, there has been a huge influx of rural-to-urban migrants in the city. Approximately 79 percent of the 400 migrants settled in Khulna cited livelihood insecurity as the primary reason for displacement (Rahaman et al. 2018). About 12 percent reported fear of recurrent natural disasters; while 23 percent of people reported that they migrated due to poverty (UKAID 2020). The migrants settled in overcrowded urban slums with limited access to amenities, including water, proper hygiene, education, health care, and social services. Most of the slums are situated in low-lying, flood-prone areas that are highly vulnerable to frequent floods due to poor drainage systems. Rahaman et al. (2018) noted that migrants are at increased risk of health issues, including food and waterborne diseases like cholera, diarrhea, typhoid, and hepatitis, with diarrheal disease being the most common. 25 RIVER SYSTEMS AND ESTUARIES The river systems and estuaries cover an area Figure 7. River Systems and Estuaries of 35,204 sq. km, and 29 districts fall into this zone (Figure 7). The livelihood of the riverine population is essentially dependent on the river and its resources. In turn, they are frequently exposed to a host of issues including floods, sedimentation offtake, subsidence, tidal fluctuation, sea-level rise, floods, and river erosion (Ministry of Planning 2018). About 50,000 Bangladeshi households become homeless each year due to river erosion (Ministry of Planning 2018). Recent trends in the riverine areas indicate an increasing frequency of floods. The adverse impacts are intensified further when devastating floods and riverbank erosion occur together in the riverine areas (Kutub et al. 2017; Hossain 2012). The result is the loss of productive lands and other natural resources of the riverine households, and the associated threat to their livelihoods and food security (Alam 2017). Data on the long-term health effects of climate change on the riverine and char 5 population in Bangladesh are limited. Snake bites and Source: Original figure for this publication, based on drowning are common phenomena during the Bangladesh Delta Prosperity Plan 2100 (Ministry of Planning 2018). riverine flooding. Snakebites appear to be a neglected public health problem and one of the major causes of morbidity and mortality in many rural tropical areas (Rahman et al. 2010). Worldwide, around 5 million snake bite cases occur every year, causing 100,000 deaths (Reza et al. 2015). A study in the riverine districts of Sirajganj and Pabna found high incidences of drowning (27 percent), snake bites (51 percent), and snakebite-related deaths (14 percent) during floods (Reza et al. 2015). The estimated incidence density of snake bites was 623.4/100,000 person-years (95 percent confidence interval [CI] 513.4–789.2/100,000 person-years) (Rahman et al. 2010). Meanwhile, over one-quarter of deaths among one to four-year-olds were due to drowning in 2003, which increased to 42 percent in 2011 (Rahman et al. 2017). Hossain et al (2021) assessed the perceived impacts of climate change on the riverine island dwellers. They reported increase in the frequency of floods, severity of riverbank erosion, drought, and rising disease outbreaks to be major concerns associated with climate change. Further, all respondents encountered several health-related issues during different seasons, including cold and cough, fever, skin diseases, and diarrhea. 5 Char is a tract of land surrounded by the waters of an ocean, sea, lake, or stream; it usually means, any accretion in a river course or estuary. 26 In Bangladesh, flood vulnerability and gender are strongly related. As with most water- related disasters, poor rural women are more adversely affected than their male counterparts, as they lack equal access to basic rights and opportunities for self- protection, social protection, and social capital (Hofstede and Hofstede 2005; Saleheen and Huda 2001; Cannon 2002). Physical injury (25 percent), shortage of food (89 percent), diseases (85 percent), malnutrition (91 percent), lack of clean drinking water (84 percent), unemployment (64 percent), sexual harassment (35 percent), crime (16 percent), and shortage of clothing (89 percent) and fuel (84 percent) were reported among women in the flood-affected study areas. The diseases included increased incidences of cholera, dysentery, skin ailments, and diarrhea. Another study looked at the challenges related to menstrual regulation and postabortion care at both the facility and community levels, and the care-seeking patterns of pregnant women in Belkuchi Upazila during the 2016 flood (Ray-Bennett et al. 2019). The main challenges at the facility level were a lack of services and a shortage of medicines, equipment, and trained health workers. At the community level, people faced displacement, high rates of self-diagnosed spontaneous abortion, and a lack of treatment for postabortion complications. Miscarriages, unsafe abortions, and postabortion complications significantly impact both maternal mortality and morbidity. The psychological impacts of spontaneous abortion on women are also immense. Women may experience grief reactions similar to those after the loss of a neonate; there may be continuing feelings of sadness, inadequacy, and fearfulness as well as impairment in the relationships with their spouse and children (Stirtzinger and Robinson 1989). Generally, women with lower socioeconomic status are at a higher risk of spontaneous abortion (Zheng et al. 2017). It is important to address the lack of availability of health care services, especially for pregnant women, during floods. Health care facilities that are critical for providing care are often adversely affected by floods. For instance, floods can cause structural failure, such as damage to infrastructure, medical equipment, power supplies, means of communication, transportation methods, and water supplies, which can inhibit the operation of health facilities (Ray-Bennett et al. 2019). Therefore, constructing flood- resistant health infrastructure and training health workers in menstrual regulation and postabortion care is critical, so that these services can be made available during natural disasters. CHATTOGRAM HILL TRACTS The Chattogram Hill Tracts (CHT), which cover an area of 13,295 sq. km and have a population of 1.6 million, comprise the three hill districts of Rangamati, Bandarban, and Khagrachari in the southeast region of Bangladesh (Figure 8). The CHT is geographically distinct from other parts of Bangladesh and is mainly characterized by very steep and rugged mountainous terrain. Most of the population lives in small, scattered habitats, which are difficult to access because of the hilly and remote terrain (UNICEF 2019). The CHT is one of the most disadvantaged and isolated areas of Bangladesh. The population, which is mainly tribal, is frequently confronted with the loss of forest and vegetation cover, landslides, droughts, cyclones, and flash floods (Gunter, Rahman, and Rahman 2008; Ministry of Planning 2018). 27 Climate Change has dried up many water resources in the CHT, forcing thousands of people, particularly the tribal population, out of their traditional settlements (Mahmud 2021). The habitat has grown increasingly hostile over the years due to the climate change crisis. Currently, one in five of the tribal people in Bangladesh are estimated to be victims of climate change–related disasters (Mahmud 2021). The environmental hazards include long spells of droughts, receding groundwater levels, and soil erosion. People often have to migrate from one valley to another and settle deeper into the woods. CHT is at the bottom of Bangladesh’s social deprivation index. There are significant disparities in access to, and use of, basic services such as health among the various CHT communities (UNICEF 2019). The CHT’s remoteness, poor Figure 8: Chattogram Hill Tracts communication, and unique socioeconomic characteristics have made it difficult to provide social services to its inhabitants. Health care centers are located far away from remote villages and there are transport challenges in reaching them (UNICEF 2019). Many children in the CHT live in dusty and undulating terrain that is susceptible to landslides and can become dangerously slippery during the monsoon season. In the Rangamati District, it is necessary for villagers to travel by boat to get their children to school or receive health care (UNICEF 2019). The availability of safe drinking water is a major concern. According to a survey in the Bandarban and Lakhhichori areas of CHT, approximately 60 percent of people face water scarcity during natural disasters (Nadiruzzaman et al. 2020). Agricultural lands in the CHT are affected by prolonged periods of drought, increasing Source: Original figure for this publication, based on food insecurity, and threatening livelihoods. the Bangladesh Delta Prosperity Plan 2100 (Ministry A good number of hills are not producing of Planning 2018). crops that were traditionally cultivated, while water sources, around which the hill people usually establish their settlements, remain dry even through the monsoon months (Mahmud 2021). Many hills become infertile after only five or six crop yields, which also forces the inhabitants to migrate to adjacent locations. Very few studies have explored the health consequences of climate change and water resources among the population there. One study looked at the perceived impacts of climate change on the CHT population and found that 80 percent of the respondents believed that climate change or natural disasters substantially increased disease prevalence (Nadiruzzaman et al. 2020). During floods, the frequency of waterborne diseases increases in flood-prone areas, and communities suffer heavily due to the lack of medical infrastructure. Approximately 57 percent of the respondents believed that 28 sources of water had reduced over the past 10 years due to over-extraction from tube wells and deforestation. Other reasons include rock harvesting, rising temperatures, and heavier rainfall. To cope with water scarcity, 55 percent of respondents collected water from other villages, the burden of which usually falls on the women. Kabir et al. (2018) studied the effects of climate change on the psychological health of the CHT people (Kabir 2018). Drawing from 125 in-depth interviews conducted between January 2015 and October 2016, with community members and local and regional health professionals, it was found that impacts of climate change can be felt at both the individual and community levels, with health outcomes ranging from psychological distress, depression, and anxiety, to increased drug abuse and suicide rates (Kabir 2018). Globally, very little attention has been given to the mental health impacts of climate change. Some recent literature indicates that climate change and related weather events and environmental changes can profoundly impact psychological well-being and mental health through both direct and indirect pathways, particularly among those with preexisting vulnerabilities or those living in ecologically sensitive areas (Bourque and Willox 2014). Although there is still limited knowledge about the connections between climate change and mental health, some evidence indicates that impacts range from psychological distress, depression, and anxiety, to increased addictions and suicide rates (Bourque and Willox 2014). 29 CONCLUSION AND RECOMMENDATIONS In Bangladesh, a country with over 700 major and minor rivers, water resources are intricately linked with climatic factors. Climate projections suggest that freshwater resources will be strongly impacted by an increase in floods, salinity intrusion, groundwater depletion, and droughts, with far-reaching adverse consequences on human health. Diseases due to water scarcity and quality continue to be one of the leading causes of death in Bangladesh, particularly among children. The analysis explores how climate change affects the quality and quantity of water and impacts the health of populations in the six ecological zones of Bangladesh, which have been categorized by the Bangladesh Delta Plan 2100 (BDP 2100). The BDP 2100 makes this distinction to identify and prioritize investable sectors for action to reduce climate risk and environmental losses in the vulnerable areas of the country. The analysis identified a range of health impacts associated with water-related natural disasters and the lack of freshwater resources in the country. The impacts are inequitable, with disproportionate effects on the most vulnerable populations including women, children, communities living in the Haor and the CHT, and the riverine population. The six ecological zones will each face unique health challenges because of their distinct regional socioeconomic, geographic, and climate differences. As such, there is now an increasing need to formulate zone-specific actions to adapt to the impacts of climate change. The main findings and recommendations are as follows: Barind and Drought-Prone Zone Risks: In the drought-prone Barind tract, poor water quality, coupled with high temperature and high prevalence of severe dust during drought periods, cause various health hazards. The region is likely to see high rates of malnutrition and mental health problems among the local population if no adaptation measures are put in place. Droughts have been associated with outbreaks of waterborne diseases, as well as an increase in circulatory- and respiratory-related diseases in the region. Moreover, droughts have the potential to severely compromise agricultural production and fish cultivation, thereby threatening the livelihoods of people in the Barind tract, where a majority are already living in extreme poverty. A crucial relationship exists between Boro rice production and groundwater depletion in the northwest, especially in the Rajshahi District. Depleting groundwater levels, especially in the summer months, significantly reduces cropped land and food production, exacerbating poverty rates and food insecurity. Recommendations: The northwestern region has recurrent poor food consumption scores compared to other regions of Bangladesh, and per capita GDP is far below the national average. To address food insecurity, major adaptation strategies need to be put in place. Crop diversification or less water- consuming crops can be alternative options for the region. Providing microcredit to affected communities and drought-mitigating social safety net programs can be prioritized. Implementing multisectoral nutrition-sensitive programs can improve nutrition awareness and address nutritional deficiencies among vulnerable sections of the population. 30 Coastal Zone Risks: The coastal population in Bangladesh are at the forefront of climate change and natural disasters—driven largely by rising sea level and saltwater intrusion, increased frequency and intensity of tropical cyclones and storms, and frequent coastal flooding. Heavy rains accompanying cyclones and tidal waves cause extensive physical damage, casualties, damage to crops and livestock, and flooding. The major impacts include a reduction in livelihood diversity, migration, and a high prevalence of diseases. Waterborne diseases are the main health risks associated with climate-related freshwater scarcity. Cyclones were found to have numerous psychosocial impacts including acute stress disorder, sleep disorder, PTSD, generalized anxiety disorders, suicidal ideation, and depression among those affected. Meanwhile, very high levels of salt in natural drinking water supplies have been found, which have been associated with high rates of hypertension in adults, and the risk of (pre)eclampsia and gestational hypertension among pregnant women. Neurodevelopmental impairments were found to be three times higher in climate-refugee children (who were displaced by Cyclone Aila), compared to their nonclimate-refugee counterparts. Recommendations: Given that coastal populations are confronted with high salinity exposure, it is imperative to develop and evaluate affordable approaches to providing safe water with low salt content. Further, enhancing resilience and improving access to and the quality of water, sanitation, and essential health care services including immunization and psychological support during natural disasters will substantially reduce the disease burden among the coastal population. There must be specific action plans and initiatives to address and support the mental health of the affected population. Optimum antenatal care of pregnant women, as well as their offspring within refugee situations, needs to be ensured to prevent developmental impairments and poor quality of survival. Haor and Flash Flood-Prone Zone Risks: In the Haor Region, flash floods in the pre-monsoon period inundate considerable areas of agricultural land and subsequently significant amounts of crops are affected. The basin is projected to be under additional stress due to climate-induced changes in temperature and rainfall patterns. The available days for cultivation have reduced on an average by 10–15 days compared to 30 years back—which significantly affects rice production. The Haor population is at risk of food insecurity along with the scarcity of safe drinking water due to contamination of pathogens and microbes, and unhygienic sanitary conditions. The immediate health risks of flash floods include drowning, injuries, infected wounds, poisoning, skin-eye-ear infections, communicable diseases, and starvation, while the longer- term impacts include chronic problems related to mental health and nutritional deficiencies. Epidemiological studies show that chronic malnutrition among children leads to multiple health complications and diseases, which are responsible for about 64 percent of total under-five deaths worldwide. Recommendations: Haor farmers need to adapt with diversified crops and short-duration rice varieties. Methods like cropping on floating beds may help with double cropping in a single year, which can increase livelihood opportunities for farmers. It is important to put a stop to the existing leasing system of Haor water bodies and make proper arrangements for creating alternative income- 31 generating activities throughout the year. Early warning systems, especially for downstream inhabitants, need to be developed and strengthened to allow farmers to assess risks more accurately. Farmers can be provided with emergency rice storage platforms to avoid damage to crops. Further, low-cost and robust village protection systems using local materials can be built to protect against floods. Multisectoral nutrition-sensitive programs for Haor communities can also be implemented to increase nutrition awareness and address nutritional deficiencies. Urban Zone Risks: The urban centers across Bangladesh face multiple challenges due to rapid urbanization, falling groundwater levels, and pollution. These challenges intensify the impacts of rainfall and heatwaves, causing damage to natural resources, economic activities, houses, and infrastructure, as well as loss of life. A majority of the urban population lives in urban slums with scarce and insufficient health, sanitation, water, and waste disposal services, which impedes sustainable development in urban areas. Floods followed by waterlogging severely impact the availability of fresh water in the cities. Floods have been associated with massive diarrhea outbreaks of cholera and rotavirus diarrhea in urban areas. Similarly, floods can potentially increase the transmission of dengue, as standing waters caused by the overflow of rivers can act as breeding sites for mosquitoes. Recommendations: Given that a large section of the urban population lives in urban slums, it is crucial to improve their access to water, sanitation, and essential health care services, as well as the quality of health care that is available to them. Strengthening communicable disease monitoring, surveillance, and response, and increasing public awareness and outreach programs will significantly improve the health status of the urban population. The frequent dengue and malaria outbreaks need to be addressed through comprehensive disease surveillance systems, integrated vector control and management through community awareness, implementation of early diagnosis, immediate treatment, and effective patient referrals through trained personnel at all levels of health care facilities. River Systems and Estuaries Risks: The riverine population in Bangladesh are exposed to a myriad of problems including floods, sedimentation offtake, subsidence, tidal fluctuation, sea-level rise, floods, and river erosion. Drowning and snake bites—a neglected public health problem and one of the major causes of morbidity and mortality in many rural tropical areas—are common phenomena during riverine flooding. As the population gets displaced frequently, women, in particular, are susceptible to reproductive health problems and diseases. Studies have found that among displaced populations, rates of spontaneous abortion and postabortion complications are high, highlighting the importance of providing better access to health care, especially for adolescent girls and pregnant women, during natural disasters. Recommendations: It is important to increase the availability of health care services, especially for pregnant women, during floods. More resources can be 32 availed to strengthen primary health care facilities that are critical for providing care, for example, through stronger infrastructure, increase in medical equipment, ensuring power supplies and communication means, as well as transportation and water supplies. Increasing the number of health workers and training them in women’s health, especially, menstrual regulation and postabortion care, is crucial so that these services can be made available during natural disasters. Providing mental health counseling and support to displaced populations must be prioritized. Chattogram Hill Tracts Risks: The CHT Region and the population living there are distinct from other parts of Bangladesh, being one of the most disadvantaged and isolated areas that frequently face landslides, droughts, cyclones, and flash floods. Very few studies have explored the health consequences of climate change via water resources among the population there. Some literature indicates that climate change and related weather events have profoundly impacted the psychological well-being and mental health conditions of the CHT population. It is important to gather more evidence on the health impacts because of the high vulnerabilities of those living in ecologically sensitive areas. Recommendations: Because of the extreme vulnerability of the CHT population, more health centers in the remote areas of the CHT can be built, specifically addressing the health issues of women and children. It is important to improve communication and transportation means to reach remote areas to enhance coverage of basic services in the areas of health, nutrition, education, protection, water, sanitation, and hygiene promotion. Providing psychological support through counseling programs to disaster-affected and displaced populations, particularly in the remote areas of the CHT is important. In addition to the above zone-specific recommendations, enhancing the overall resilience of the population against the adverse health impacts of climate change is key, especially focusing on vulnerable sections of the population including women, children, and communities living in the char, Haor Region, and the CHT. Improving climate resilience involves assessing climate risks and vulnerabilities and taking steps to better cope with these risks. Public health is committed to evidence-based practice, and as such, it is important to apply an evidence-based practice framework to climate change adaptation to ensure that customized action plans are developed for each zone. To support this, the research capabilities of the Institute of Epidemiology, Disease Control and Research (IEDCR) and other national organizations need to be strengthened. There is a lack of guidelines for reporting climate change health impact projections. Realizing the goal of an evidence- based approach will require systematic, coordinated efforts among various stakeholders, including researchers, practitioners, and policy makers. Strengthening national data systems will ensure the production of better statistics to help the government track progress, to make sure decisions are evidence-based and also to strengthen accountability. In particular, the Bangladesh Bureau of Statistics (BBS) has a key role to play, and therefore it is essential to strengthen national statistical capacities 33 and modernize data systems. Ministries need to find ways to work together and create partnerships and synergies to generate and curate the data. Further, there must be monitoring and evaluation at the national level, which will require institutional coordination, both horizontally and vertically. 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Perine. 2020. “Climate Vulnerability Assessment: Impacts On Health Outcomes in Secondary Cities Of Bangladesh.” United States Agency for International Development Adaptation Thought Leadership and Assessments (ATLAS), January. Zheng, D., C. Li, T. Wu, Tang, K. 2017. “Factors associated with Spontaneous Abortion: A Cross- Sectional Study of Chinese Populations.” Reprod Health 14 (33). https://doi.org/10.1186/s12978- 017-0297-2. Zug, S. 2006a. “Monga-Seasonal Food Insecurity in Bangladesh-Brining the Information Together.” The Journal of Social Studies, 111–17. ———. 2006b. “Monga-Seasonal Food Insecurity in Bangladesh.” NETZ (Dhaka). www. bangladesh.org/pics/download/S_Zug. 43 ANNEX 1: SUMMARY OF CORE STUDIES INCLUDED Impacts on water Zone Study quality and Health impacts quantity Dey et al. 2011. Drought, reduced Substantial proportion of tube wells rainfall, lower turned dry; people had to collect groundwater levels drinking and domestic water from far distances to meet basic requirements. Increase in temperature and prevalence of severe dust during drought periods compared to normal years caused various health hazards including dysentery and diarrhea due to unsafe drinking water. Alam et al. 2021. Drought Only severe and extreme drought in the short-term drought periods Barind and affected mortality. Long-term drought-prone drought was not associated with natural cause mortality in Rangpur and Nilphamari. In Dinajpur, mild and moderate drought was associated with circulatory- and respiratory-related mortality. Iqbal 2014. Drought Drought-related seasonal food insecurity in the northwestern region of Bangladesh is a recurrent phenomenon. The study identified demographic and socioeconomic factors that could help lessen food insecurity and protect livelihoods. Khan et al. 2016. Cyclone There were significantly more landless families among climate refugees (CRs) compared to nonclimate refugees (NCRs) (p value = 0.0001; OR = 1.86, 95% CI: 1.37–2.51). Neurodevelopmental Impairments (NDIs) were three times higher in CRs (21.3%), compared to NCRs (7.4%) (p = 0.0001; OR 3.83, 95% CI: 2.16– 5.21). Expressive language (p value 0.002; OR 2.86, 95% CI: 1.46–5.57) and gross motor functions (p = 0.007; OR 2.27, 95% CI 1.22–4.20) Coastal were most significantly affected areas of impairment. Kabir et al. 2014. Cyclone Sidr Prevalence of diarrhea, skin impacts diseases, dengue fever, hepatitis (jaundice), and other infectious diseases increased after the disaster. Risk of injury and death increased during the disaster. Children and adolescents were most vulnerable, facing serious health problems including in mental health. Kabir et al. 2016. Salinity, scarcity of Lack of pure drinking water safe drinking water aggravated spread of waterborne diseases in affected areas. Prevalence of diarrhea, skin 44 diseases, typhoid fever, and jaundice rapidly increased just after Sidr. Hasan et al. 2020. Cyclone impacts Cyclones had numerous psychosocial impacts on the population including acute stress disorder, sleep disorder, PTSDs, generalized anxiety disorders, suicidal ideation and depression. The survivors had specific needs for receiving support. Children, the elderly, and women were perceived to be more vulnerable. Khan et al. 2014. Salinity impacts High blood pressure, (pre)eclampsia in pregnant women significantly associated with salinity in drinking water. Adjusted risks for both increased in a dose-response manner for increasing sodium concentrations (300.01–600 mg/L, 600.1–900 mg/L, 900.01 mg/L, compared to >900.01 mg/L, compared to <300 mg/L) in drinking water: (ORs 3.30 [95% CI 2.00– 5.51], 4.40 [2.70–7.25], and 5.48 [3.30–9.11] (p-trend, 0.001). Scheelbeek et al. Salinity impacts Drinking water salinity were highly 2017. associated with BP after adjustments for confounding factors. Furthermore, for each 100mg/L reduction in sodium in drinking water, systolic/diastolic BP was lower on average by 0.95/0.57mmHg, and odds of hypertension were lower by 14%. Abedin et al. 2019. Safe water scarcity Diarrhea, dysentery, and skin diseases were the main waterborne health diseases. Shohel et al. 2011. Salinity impacts Due to salinity of domestic ponds (44%) and underground water (18%), respondents walked two kilometers or more (61%) for fresh water. They were exposed to saline water for 5–7 hours (51%). Waterborne diseases like dysentery, diarrhea, and skin diseases were common among respondents. Prevalence of waterborne diseases were found statistically significant with the respondents' education (p < 0.000) and involvement in shrimp industries (p < 0.000), which can be reduced through sustainable use of alternative water and desalinization process. Rahaman 2016. Decreasing rainfall, Impacted crop production and rising temperature, fisheries: Decreasing crop Haor and flash frequent drought production (25%), reduced fisheries floods (21%), loss of forest ecosystem (16%), loss of biodiversity (16%), 45 loss of cultivable land (13%), and loss of personal belongings (9%). Flash floods Flash floods severely destroy Kamruzzaman and standing Boro rice just before Shaw 2018. harvesting almost every year. Sarma 2011. Flash floods About 71% of households were found effectively landless, of which about 55% were absolutely landless and 17% households were migrants; and 78.9% Haor households suffered from food insecurity mainly because of landlessness, mono- crop cultivation, seasonal unemployment, and natural calamities. Hossain, Nayeem, Flash floods Considerable area of agricultural and Majumdar 2017. land was submerged by this flash flood and eventually a significant amount of crop lost. Consequently, almost 60,000 people are at risk of suffering from food insecurity along with scarcity of safe drinking water due to contamination of pathogenic water microbes from unhygienic sanitary condition. Khan and Mia 2012. Flash floods In Rabi season Boro is the main crop and damaged by flash floods due to unavailability of controlling measures. Hashizume et al. Rainfall and river The study estimated the effects of 2012. levels river levels and rainfall on hospital admissions for dengue fever at 11 major hospitals in Dhaka. Hashizume et al. Impacts of rainfall Number of non-cholera diarrhea 2007. and temperature cases per week increased by 5.1% (95% CI: 3.3–6.8) for every 10mm increase above the threshold of 52mm of average rainfall over lags 0–8 weeks. Number of cases also increased by 3.9% (95% CI: 0.6– 7.2) for every 10mm decrease below the same threshold of rainfall. Ambient temperature was positively associated with a number of non- cholera diarrhea cases. Urban Schwartz et al. 2006. Floods During flood-associated epidemics, Vibrio cholerae was the most commonly identified cause of diarrhea. Rotavirus was the second- most frequently identified flood- associated pathogen. Islam et al. 2018. Climate variability Mean dengue incidence was 31.62 (SD 28.7) per 100,000 in Dhaka whereas it was 5.76 (SD 11.7) per 100,000 population in Chattogram. Incidence of dengue cases was found significantly associated with the monthly mean temperature, total rainfall, and mean humidity in Dhaka; though in Chattogram, the significantly associated factors were monthly total rainfall and mean 46 humidity. Alam et al. 2011. Floods Results of the analyses of both diarrheal case data for three consecutive years (2006–2008) and regional hydroclimatology over three decades (1980–2009) clearly indicate that the pattern of cholera occurring in Dhaka, and not seen at other endemic sites, was associated with flood waters transmitting the infectious clone circulating via the fecal-oral route during and between the dual seasonal cholera peaks in Dhaka. Ray-Bennett et al. Floods Main challenges at facility level are 2019. lack of services and shortages of medicines, equipment, and trained health workers. Main challenges at community level are displacement, high rates of self-diagnosed spontaneous abortion, and lack of treatment for postabortion complications. Hossain et al. 2021. Floods, river erosion Results reveal that increasing frequency of flooding, severity of riverbank erosion and drought, and rising disease outbreak are the highest indicators of climate change perceived by riverine island (char) dwellers. Almost all respondents encountered several health-related issues during different seasons, where prevailing cold and cough River systems and with fever, skin diseases, and estuaries diarrhea are the leading ailments. Kutub et al. 2017. Floods Women suffer from physical injuries and are often evicted from their dwellings due to floods. Difficulties in finding adequate shelter, food, safe water, and fuel for cooking, as well as problems in maintaining personal hygiene and sanitation, prevent women from performing their usual roles at home. Despite these extremely difficult circumstances, they demonstrate considerable fortitude in their attempts to cope with floods by selling assets, moving toward high places, storing dry food, social networking, borrowing money, collecting safe drinking water, and managing household activities, etc. Reza et al. 2015. Floods In Sirajgonj District, 140 drownings were reported and 49 snake bites. Furthermore, among 49 cases of snake bites, death occurred in 14.3% cases in Sirajgonj District. Shahzadpur, Shirajgonj Sadar, and Ullapara were the most common reported upazilas for drowning cases, which were 27.1%, 15.0%, 47 and l4.3% cases, respectively. Kabir 2018. General climate Drawing from 125 in-depth change impacts interviews during January 2015– October 2016, with community members and local and regional health professionals, an overview of climate change effects on psychological health of people living in the Hill Tracts are presented. Impacts can be felt at both individual and community levels, with health outcomes ranging from psychological distress, depression, and anxiety, to increased drug abuse and suicide rates. Chattogram Hill Gunter, Rahman, and Increased droughts, Both tribal and nontribal populations Tracks Rahman 2008. floods, landslides are highly vulnerable to climate and cyclones across change–induced increases in the two population droughts, floods, landslides, and groups cyclones. Nadiruzzaman et al. Reduced rainfall, Frequency of heavy rainfall (≥ 2020. drought, rising 89mm) in Bandarban is decreasing temperature annually. Data demonstrates a trend toward increasing temperature. In winter, annual decrease was observed for wet spells for more than 1 to 2 days. These changes had negative impacts on household agricultural production, access to water for drinking and domestic use, job loss, and exposure to a myriad of environmental challenges. Source: Output from literature review conducted by authors. Notes: CI = Confidence interval; OR = Odds Ratio; mg/L = milligrams/Liter; mmHg = Millimeters of mercury; PTSD = post-traumatic stress disorder; BP = Blood pressure; SD = Standard deviation. 48 The government of Bangladesh’s (GoB) Delta Plan 2100 (BDP 2100) disaggregates Bangladesh’s 64 districts into six ecological zones based on hydrological characteristics and climate risks and deems 58 districts to be “extremely vulnerable” to the effects of climate change. The heterogeneity in the water crisis across the different hotspots presents unique health challenges. This paper summarizes the effects of altered quantity and quality of water on human health for each of the ecological zones and provides recommendations based on the findings. Climate change continues to deteriorate the quality and quantity of water in Bangladesh and is one of the leading causes of morbidity and death. The consequences are particularly pronounced for pregnant women and children. There are substantial regional variations in the effects on health, driven by the country’s topological attributes, such as groundwater depletion in the Barind and drought-prone areas and salinity in drinking water in the coastal regions. To address these challenges, it is imperative for agencies such as the Institute of Epidemiology, Disease Control and Research (IEDCR) and the Ministry of Health and Family Welfare (MoHFW) to build research capacity and upscale comprehensive disease surveillance systems to monitor trends in existing and emerging communicable and noncommunicable diseases, and to rigorously evaluate the efficacy of disease prevention and control programs. A set of zone-specific health policies and actions needs to be formulated under the aegis of the MoHFW in collaboration with relevant GoB stakeholders (such as the Bangladesh Bureau of Statistics, academics, practitioners, and policy makers, underpinned by credible evidence. 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