Climate adaptation and resilience must account for context and culture

The health effects of climate change are unequal, so adaptation policies must prioritize the most affected communities.

Climate change is accelerating health disparities by intensifying pre-existing social and structural inequalities. Although much attention has been given to physical hazards such as heatwaves, floods and air pollution, far less focus has been placed on how these hazards interact with uneven social vulnerability, limited adaptive capacity and unequal access to healthcare. Marginalized groups, including low-income workers, women, older people and those in precarious housing, are disproportionately exposed and less equipped to respond to such events. These inequities are further compounded by global crises such as food price inflation, post-pandemic economic stagnation and population ageing. As these stressors converge, they are not only widening health gaps but also revealing critical blind spots in climate adaptation policy. Current strategies often presume uniform exposure and capacity to adapt, neglecting the behavioural, cultural and institutional dimensions of inequality that define real-world resilience. To build truly equitable adaptation, health systems and policy frameworks must centre the lived realities of those most at risk, not as afterthoughts but as the foundations of effective responses.

Intersecting health exposures and compounded vulnerabilities

Climate exposure is deeply structured by space, labour and social roles. The physical geography of risk, referring to where people live and work, is not accidental. Low-income populations are more likely to reside in urban heat islands and in homes with poor insulation, limited ventilation and inadequate access to public cooling infrastructure. These environments also frequently overlap with areas of elevated air pollution and scarce green space. Such spatial inequalities accumulate over time, increasing baseline vulnerability. Occupational settings further entrench exposure. Outdoor workers, including those in agriculture, construction and logistics, are routinely required to operate under extreme weather conditions without adequate protection¹. Empirical data from Tokyo, Japan reveal that during summer heatwaves, the highest rates of heatstroke consistently occur among older labourers without access to shade or rest facilities². Yet these occupational risks are rarely integrated into labour or climate adaptation policy, reflecting a systemic failure to regulate environmental working conditions.

Exposure is also shaped by cultural and behavioural norms that assign unequal responsibilities across gender and age. In many societies, women bear the primary burden of caregiving and food preparation, often remaining indoors during heatwaves in poorly ventilated spaces with limited mobility³. Children are similarly vulnerable, particularly in households without cooling or heating systems or access to safe communal spaces⁴. These roles are not merely personal routines but manifestations of socially assigned responsibilities that limit adaptive flexibility. Despite this, most climate adaptation strategies continue to rely on generalized behavioural assumptions, such as the ability to rest during peak heat or relocate during extreme events, overlooking the rigid social structures that constrain these options. Without explicitly addressing the spatial, occupational and cultural dimensions of exposure, adaptation efforts risk reinforcing the very inequalities they aim to alleviate. These dimensions are summarized in Fig. 1.

Fig. 1: Dimensions of climate-related health vulnerability.

Climate-related health inequality includes exposures and basic resources, adaptive capacity and system responsiveness and procedural and representational factors.

Spatial fault lines in a changing health system

Climate change is also exposing and accelerating long-standing weaknesses in healthcare infrastructure. The regions that are most vulnerable to climate extremes, such as heatwaves, floods and prolonged drought, often coincide with areas that already face fragile medical provision⁵. In these places, hospitals and clinics are frequently understaffed, outdated and ill-equipped to manage surges in demand caused by climate-related illness⁶. As extreme events become more frequent and prolonged, health systems are placed under recurring stress, stretching their capacity to respond and recover.

This stress is not only immediate. The impacts of climate on local economies, especially in rural areas that depend on agriculture and seasonal labour, can erode the fiscal foundation that supports public health services. When crop yields decline or economic activity slows owing to environmental instability, local governments collect less revenue. This weakens their ability to retain medical staff, upgrade equipment or sustain basic operations. In parallel, younger and healthier residents often leave these areas in search of stable employment and healthcare access in urban centres⁷. What remains is an ageing, medically vulnerable population with few options. The combination of reduced demand, limited revenue and rising needs creates a feedback cycle that accelerates systemic collapse.

Healthcare inequality is not only a rural problem. Within countries and even within cities, there are stark differences in healthcare access tied to geography, income and planning priorities. In many metropolitan areas, affluent neighbourhoods are better served by emergency response systems, cooling centres and public health outreach, whereas lower-income districts lack even basic protection⁸. Informal settlements and marginalized communities are often invisible to official climate health planning. As climate hazards become more spatially differentiated, the ability to access healthcare will increasingly define who can adapt and who remains exposed. Without targeted investment that aligns health infrastructure with evolving environmental risks, climate change will deepen territorial divisions in public health outcomes.

Adaptive health inequities in complex risk regimes

Adaptation to climate risk does not rely solely on emergency protocols or physical infrastructure. It is rooted in a deeper architecture of resilience, encompassing nutrition, mental health, social cohesion and institutional responsiveness. This broader configuration, often framed under the concept of integrated or systems health, is increasingly recognized as essential in managing complex, compound climate stress. Yet the ability to sustain such resilience is highly stratified. Adaptive capacity is neither uniformly distributed nor naturally accumulated. It is institutionally governed, historically embedded and profoundly shaped by intersecting social, spatial and economic regimes.

In a broader understanding of health, it is essential to consider not only immediate health risks but also long-term, indirect threats, such as those linked to diet and nutrition. Nutrition provides an entry point into the architecture of structural adaptation. Climate-related disruptions in food systems alter the availability and affordability of healthy diets, but the social reproduction of nutritional inequality runs deeper⁹. In many cultural contexts, body image norms, gendered expectations and economic precarity shape food practices that compromise physiological resilience. For example, chronic protein insufficiency among young women in East Asia is a result not of food shortage but of socially constructed restrictions on body weight and appearance¹⁰. Among older adults, particularly those living alone or in depopulating areas, dietary monotony, reduced food access and loss of intergenerational care networks result in heightened micronutrient deficiencies¹¹. These deficiencies, in turn, weaken immune responses and elevate vulnerability to heat stress, dehydration and infection during climate shocks. Nutritional resilience is not about caloric sufficiency alone; it reflects the entanglement of food systems, cultural norms and care structures under climate pressure.

Mental health and psychosocial integrity constitute another dimension of adaptive fragmentation. The cumulative stress of recurring climate events, uncertainty and loss produces both acute and chronic psychological effects, including climate anxiety, depression and trauma¹². Yet access to mental health services remains uneven, and, in many regions, stigma or infrastructural absence suppresses treatment-seeking behaviour. Social isolation, particularly among the elderly, migrants and informal residents, compounds this risk by severing information flows and emergency support networks^13,14. Adaptive capacity, in this regard, is shaped as much by cognitive and emotional scaffolding as by material protection.

Importantly, current adaptation policies often over-rely on behavioural rationality, expecting individuals to act when warned, to seek help when needed or to modify practices when advised. This presumes a uniform ability to absorb information, translate it into action and deploy resources. In reality, adaptation is constrained by uneven exposure to knowledge systems, legal precarity, distrust in institutions and lack of agency. It is not a choice but a structured response conditioned by one’s position in the social–ecological system. To treat adaptive capacity as a neutral or apolitical resource is to ignore its layered production through institutional design, cultural conditioning and material inequality. Without explicitly confronting the mechanisms that allocate resilience unequally through food, care, information and voice, climate adaptation risks reproducing the very stratification it claims to solve.

Reconfiguring planetary health resilience through a multi-scalar agenda

The climate crisis has transformed health resilience into a distributed privilege. Communities facing the highest exposure, be it to heat, floods, food insecurity or air pollution, are often those structurally deprived of the means to adapt. These include rural settlements with collapsing health networks, ageing industrial zones with decaying infrastructure, and urban peripheries excluded from core service delivery. Any serious adaptation strategy must begin by rebalancing these spatial inequalities. Climate-vulnerability mapping that integrates meteorological risk, demographic sensitivity and healthcare accessibility can guide the reallocation of investments, turning adaptation from a reactive measure into a corrective spatial intervention.

Yet resilience is not built through infrastructure alone. It is embedded in cultural logics and social practices that govern how people respond to crisis. Gender norms, food traditions, caregiving roles and intergenerational obligations shape both health behaviour and access to support. For many women, dietary restrictions and caregiving expectations during heatwaves limit physiological recovery and social mobility^10,15. For the elderly, climate messages may be inaccessible because of digital illiteracy or institutional distrust. Public health strategies must, therefore, move beyond universal messaging and embrace a context-sensitive, culturally literate approach to climate adaptation. Without this, interventions will reproduce behavioural inequalities instead of mitigating them.

The healthcare system itself must be reconceptualized as a dynamic institution situated within the broader climate–health interface. Rather than preparing for occasional surges, health systems must normalize compound crisis as part of their operational logic. This includes developing decentralized service models, anticipatory triage protocols, multilingual communication channels and mechanisms to reach those without formal citizenship or documentation. Institutional resilience is not merely about surviving shocks but about adapting in ways that expand inclusivity, flexibility and systemic awareness. The future health system must be designed not for stability but for continuous responsiveness under conditions of uncertainty.

At the policy level, adaptation cannot succeed without transforming the social protection regimes that shape everyday resilience (Table 1). Existing safety nets often exclude those most exposed to climate stress, such as informal workers, seasonal migrants, caregivers and the chronically ill. Social policy must evolve to accommodate climate-linked vulnerability through expanded eligibility, flexible entitlements and support for care labour, mobility disruptions and nutritional fragility. A just adaptation agenda is not simply one that protects the most at-risk, but one that actively restructures the institutional conditions through which health resilience is produced, distributed, and maintained. Only by reshaping these underlying architectures can climate adaptation become a vehicle for systemic equity rather than an amplifier of pre-existing stratification.

Table 1 Policy matrix for addressing climate-related health inequality