Human Health Sector in the Blackfeet Climate Change Adaptation Plan

The Human Health chapter of the 2018 Blackfeet Climate Change Adaptation Plan (BCCAP) is one of eight chapters created for the first formal, multi-sector climate change adaptation planning effort in the Blackfeet Nation, following the process described here. This chapter was initially developed through face-to-face meetings with people in the health field in the community and then expanded in scope in consultation with the Blackfeet Environmental Office. It was revised through face-to-face, telephone, and email correspondence. The first two sections, observed impacts and expected impacts, are sets of working hypotheses about climate change that are based on day-to-day observations and/or interpretations of climate change literature (e.g. the Montana Climate Assessment). These hypotheses were formed for the purposes of assessing climate change vulnerability and then strategizing adaptation goals and actions. This and other sections of the plan will be revisited and updated periodically as action items are implemented and adaptation efforts produce insights for future planning.

Increased risks to human health, due to a changing climate, are becoming more prevalent and varied. Health research investigations are exposing increases in water, food, and vector-borne diseases (from mice, ticks, mosquitos, etc.), temperature-related illnesses and death, air-quality impacts, and health challenges related to extreme weather events.^1,2,3,4 Health challenges within the Blackfeet Nation are arising from increasing wildfires and extreme temperature and weather events. Heat exhaustion and heat related death, injury and death due to strong winds, or increased precipitation events and flooding (such as induced by tornados or other severe storms) may increase as the climate changes. Although scientific understanding of how climate change affects human health is advancing, our comprehension of climate-related health impacts is just in the beginning stages. Many Blackfeet tribal members understand that as the climate changes, so does human health.

Many Blackfeet tribal members understand that as the climate changes, so does human health.

Within America, medical and biomedical professionals are relating health challenges such as increased asthma, and allergic reactions and sensitivities, to climate change (e.g. The U.S. Global Change Research Program’s “The Impacts of Climate Change on Human Health in the United States”).⁵ Changes in climate impact human health directly and indirectly. Impacts are indirect when they are mediated by social, behavioral, environmental, and/or institutional contexts, which influence changes in exposure and health outcomes. It is important to consider that climate change threats can occur simultaneously, resulting in compounding or cascading health impacts.⁶

The Indigenous Peoples of America have been involved in promoting preventative and healthy lifestyles, climate modeling, and health projections since the beginning of time. As America’s First People, first stewards of the lands, waters, and first stewards of all other living things, indigenous people were the first physicians, first weathermen, first scientists, and first climatologists, etc. within our homelands. Many Amskapi Pikuni are conscious of the need for balance and historically chose to thrive in a meaningful way that benefited all living things. Thus, the traditional seasonal movement of the bands of people within each tribe not only was beneficial to the Niitsitapiiks (the Real People or Pikuni people), but also to the Natoyitapiiks (all flying things), Sakoomiitapiiks (all things living in or on the land), and Soyiitapiiks (all water beings), which includes the health of all.

It is important to understand that the Pikuni have been adapting to climate and population changes for hundreds of generations, so this is nothing new. It is also worth mentioning that members of the Blackfeet nation care about  our priorities. They care so much that the Blackfeet Climate Change Adaptation Management Priorities,⁷ a community research investigation featuring many community members’ voices, was included in the 2016 National Climate Assessment.

The focus of this initial Health Sector is on air quality and vector-borne diseases. It is a beginning, since climate-related health concerns extend more broadly than these initial two planning priorities. As we move forward, we eagerly look forward to hearing from our community in each of the areas covered within this plan. In this way, the plan will be strengthened as we expand on our understandings together. We will work together to build definitive Pikuni-relevant data that will inform and help improve our response to current and future health risks.

Observed and Expected Impacts

The following are climate related health challenges that are already beginning to occur within the Blackfeet Nation and worldwide:

Changing Weather Patterns are Increasing Some Species Populations

Changing weather patterns are increasing the populations of some species that carry viruses and diseases such as mice (Hantavirus), mosquitoes (West Nile virus), and ticks (Lyme disease). Climates changing means seasons changing. This means that geographic areas and seasonal distributions of the above vectors (things that carry disease or viruses), and the diseases they carry, will be altered. Rising temperatures are changing precipitation events (the rain patterns are changing), so there is more ability for mosquitos to breed and transmit West Nile virus, which is the number one mosquito-borne disease in the Blackfeet Nation and across the U.S. Around the world, the changing rain patterns are increasing populations of Malaria-carrying mosquitos and increasing other mosquito-borne diseases such as dengue fever.

These same weather pattern changes are beginning to expand the distributions of ticks. This is especially important to understand if you work outside or spend time in the outdoors, whether on foot or horseback. Ticks carry Lyme disease, which has infected more than one community member locally.

Changing Climate is Impacting Air Quality

Changing climate is impacting air quality by increasing wildfires, with forest fires expected to increase in frequency and severity.⁸

As the Pikuni people have experienced more frequent and intense periods of air pollution during fire seasons over the past years, we understand that air quality can be negatively affected even hundreds of miles from the fire’s actual locations.

Climate change poses an air quality threat, as it increases fire frequency and severity. High winds in our area, which some tribal members believe to be increasing in severity, coupled with drought, may exacerbate dust exposure. Wind has been a “friendly challenge” to the Pikuni people, as many believe the wind coming off the Miistaksis (mountains) cleans our air within the remaining homelands of the Amskapi Pikuni Nation. We are also now learning that the wind can carry particulate matter, as experienced during increasing fire seasons, as well as after Mt. St. Helens erupted in May of 1980, carrying ash 700 miles to Pikuni Country and depositing variable amounts across our communities.⁹

The health impacts of wildfire smoke particulate are especially harmful to children because as they breathe smoke in, their smaller bodies are less able to get rid of the harmful particles that are in the smoke. Children breathe more air per pound of body weight than adults, and are still developing, compounding the damage. Older community members are also at great risk, along with children, from smoke.

Smoke exposure causes many different health challenges. These challenges can include chest pain, faster heartbeat (due to heart working harder to get oxygen pumped to body via bloodstream), and wheezing; smoke exposure can also bring on increased asthma attacks. In addition to increased coughing and trouble breathing, direct wildfire smoke inhalation can cause sinus infection, headache, sore throat, tiredness and runny nose.¹⁰ Long-term smoke inhalation of PM_2.5 (Particulate Matter measuring 2.5 micrometers) or smaller, can cause cancer, lung disease, and cardiovascular disease.¹¹

The most damaging fire pollutants are the fine particulate matter floating in the air. If the air is hazy or smoky, then there is definitely particulate matter in the air. Particulate matter from fires is made up of microscopic solids and liquid droplets that form in the air due to fire and contain many chemicals, from sulfur dioxide to nitrogen oxides, and sometimes the highly carcinogenic BTEX chemicals (Benzene, Toluene, Ethyl-Benzene, and Xylene). Health and climate scientists understand that any particle smaller than 10 micrometers or PM₁₀ can be damaging to your health because they can get very deep into your lungs and some of these chemicals actually get into your bloodstream. Much of the fine particulate matter that is floating in wildfire smoke is less than PM_2.5.

The most damaging fire pollutants are the fine particulate matter floating in the air. If the air is hazy or smoky, then there is definitely particulate matter in the air.

To understand how small PM_2.5 is, the average human hair is about 70 micrometers, so the diameter of a single human hair is about 70 times bigger than the fine particulate that is breathed in when our air is affected by wildfire smoke! By explaining the micro-size of the particulate matter in smoky air, we can understand how this particulate matter can get deep into the lungs and lung tissue (alveoli), to cause damage even though we may not realize this is happening.

Again, increased prevalence of forest fires will heighten ash exposure and increase asthma-related health issues, as well as wheezing, elevated heartrate, coughing, trouble breathing, sinus infection, headache, sore throat, tiredness, and runny nose. Increased winds (coupled with drought conditions) have the potential to increase dust, from soil dispersions and lessen air quality.

According to a 2014 study by the OECD, air pollution is now the main environmental cause of premature death, surpassing both poor sanitation and a lack of drinking water.¹² Compared to all causes of mortality, particulate matter air pollution ranks 13^th, contributing to approximately 800,000 premature deaths per year.¹³

As a final reminder, long-term exposure to fine particulate matter over time can cause cancer, lung disease, and cardiovascular (heart) disease. Respirator masks can offer some protection from fine particles, provided they are labeled N95 or N100, however, they do not filter out hazardous gases (such as carbon monoxide, formaldehyde, and acrolein).¹⁴

Changing Weather Patterns are Causing an Increase in Airborne Allergens

Air pollution and airborne allergens, attributable to climate change, are currently responsible for premature death and increased hospital admissions.¹⁵ The most recent data assembled by representatives from the Environmental Protection Agency (EPA), the Department of Human and Health Services (DHHS), the National Oceanic and Atmospheric Administration (NOAA), the National Aeronautics and Space Administration (NASA), the Department of Agriculture (USDA), and the Department of Veteran’s Affairs (VA) projects “hundreds to thousands of premature deaths, hospital admissions, and cases of acute respiratory illnesses each year in the U.S. by 2030”.¹⁶

Airborne allergens (aeroallergens) include tree, grass, and weed pollen (especially ragweed), indoor and outdoor molds, and proteins associated with animal dander, dust mites and cockroaches. As growing seasons lengthen, the quantity and allergenicity of pollen increases, as does pollen distribution.¹⁷

Dust and high winds transport spores which can have negative health consequences, as some people are allergic to their pollen. Changes in plant phenology and community structure, and expected impact of climate change, could also lead to increases in plant-based allergens. With earlier spring and later fall seasons, plant-based allergen season may be extended.

As growing seasons for allergen producing plants such as ragweed become longer,¹⁸ and the areas that these plants grow in become larger due to changing weather patterns, increased airborne allergens will increasingly challenge health in populations,¹⁹ most especially children due to their immature respiratory and immune systems. The growth patterns of these plants are changing due to higher temperatures and the increasing carbon dioxide levels, which promote growth and release of airborne allergens.²⁰ Just as our Blackfeet community members have reported seeing savisberry and chokecherry bushes growing in different elevations than before, so too are allergen producing plants expanding their geographical growth areas.²¹

More frequent and intense drought can increase airborne soil dust, which can lower air quality and cause breathing and visibility problems. Responses include immediately seeking shelter, and staying low, while covering the eyes, nose, and mouth.²²

Climate change may reduce the mixing of indoor and outdoor air, as people close windows and doors to control temperatures in their homes or businesses. Reduced air mixing can increase concentrations of indoor air pollutants since they are not as diluted by outdoor air. Indoor air contaminants can include carbon monoxide (CO), fine particles (PM2.5), nitrogen dioxide, formaldehyde, radon, mold, and pollen. The majority of people spend 90% of their time indoors.²³

Changing Weather Patterns Impacts Some Populations Disproportionately

Some populations are disproportionately vulnerable to health issues from declining air quality as a result of climate change, including indigenous peoples. People with low incomes, children and pregnant women, older adults, vulnerable occupational groups (people who work outside, emergency response personnel) persons with disabilities, and persons with preexisting or chronic medical conditions are also more vulnerable (especially people with asthma, hypertension, diabetes, chronic obstructive pulmonary disorder, and atrial fibrillation). So too are people who live or work in buildings without air conditioning and ventilation controls.²⁴

Vulnerable populations suffer disproportionately from health challenges, as is evidenced within our own communities. Our rates of preventable death, caused by many environmental, social, or behavioral causes, are much higher than other ethnicities across Montana and nationwide. Indirect impacts to health are experienced when they are mediated by social, behavioral, environmental, and/or institutional contexts, which influence changes in exposure and health outcomes. This means that there are many factors that can either work independently or together to negatively influence health, as a result of climate change.  This is especially important for us to realize as we experience many community stressors, including trauma, generational trauma, compounding grief events, poverty, joblessness, lifestyles associated with the effects of residential boarding schools, violence, oppression, and the forced assimilation policies of past and current governments.

Indoor air quality, for populations that cannot afford indoor air filtering systems, is also expected to decrease as dust, particulate matter, and airborne contaminants increase, potentially leading to “sick home syndrome.”

In addition, vulnerable populations may live in homes with inferior quality building materials used to build federally funded housing projects.  These homes are more susceptible to mold due to higher water tables from changing precipitation events. Mold growth in homes can cause significant health impacts. Dampness indoors can increase mold, dust mites, and bacteria, as well as increase off-gassing of damp building materials, releasing volatile organic compounds and other chemicals.²⁵

Climate Change and Health

There is a significant need for governmental or private resources dedicated to climate-related health research. By extension, there is a local Amskapi Pikuni need to build long-term datasets that will quantify change in air quality and vector populations, as well as illness, disease, and mortality incidence due to changes in air quality and vector populations, in an effort to reduce disease and death.

There is a local Amskapi Pikuni need to build long-term datasets that will quantify change in air quality and vector populations, as well as illness, disease, and mortality incidence due to changes in air quality and vector populations.

Currently, needed advances in climate-related health data collection is limited by the lack of systems in place to evaluate connections between air quality or vector populations, and diagnosis of air quality related disease, as well as vector-borne diseases and deaths as they relate to changes in climate, worldwide.  However, as a sovereign nation the Blackfeet have the ability to create such mechanisms and to model projected climate changes and health impacts to improve quality of life and protect families and community from the increasing impacts of climate change.  This health section truly is just a beginning of understanding and learning how to reduce negative health impacts due to climate change. In working together, we have the potential to impact health in a strong and positive way.

Human Health Assessment

Negative impacts on air quality are already occurring, however, they are temporally-sensitive. Air quality impacts from climate change are greatest in summer. Vector populations are expected to increase in Blackfeet communities with a changing climate. Health concerns are predominately concentrated among human communities, both outdoors and in homes. Areas with fewer resources and more at-risk populations will require more attention, as will lowland areas more prone to bolder exposures.

Probability of Impacts to Air Quality and Vector Populations
High

Confidence
High

Potential Consequences of Impacts
Potential physical consequences are high.

Direct effects of decreased air quality will increase stress on people with asthma, increasing asthma attacks. The World Health Organization has tracked the causes of 3.7 million deaths related to outdoor air pollution, which include: ischemic heart disease (40 %), stroke (40 %); chronic obstructive pulmonary disease (COPD) (11 %), lung cancer (6 %) and acute lower respiratory infections in children (3 %).²⁷ People with compromised breathing or respiratory systems, older adults, and children, athletics and social activities will be affected by increased prevalence of smoke from fires.

Mold also affects community health, especially when water tables are high.

Direct effects of vector population increase are vector-borne diseases such as Hantavirus Pulmonary Syndrome, Lyme disease, and West Nile virus. The CDC reports that of all fifty states, Montana has the 7^th highest cumulative hantavirus incidence per state, of all fifty states.²⁸ Further, 36% of all hantavirus cases nationwide result in death. Glacier County, in which the Blackfeet Nation is located, has the third highest incidence of hantavirus in the state,²⁹ with all of these cases occurring within Blackfeet communities.

The Montana Department of Health and Human Services reported tick-borne diseases in Montana range from Lyme disease (most prevalent) to Rocky Mountain Spotted Fever (2^nd most prevalent in Montana), to Tularemia (3^rd most prevalent), to Colorado Tick Fever and Tickborne Relapsing Fever (both tied for 4^th).³⁰ Two deaths were reported in Montana (2016) from West Nile virus,³¹ a virus that infects humans via mosquito vector.

From a social standpoint, consequences are high.

Unhealthy air decreases the aesthetics of an area, impacting the economy by decreasing tourism potential. Tourism is a major economic driver in Glacier County. Highways may be closed by fire or low visibility due to air quality. Workforce productivity may decrease as the prevalence of illnesses like asthma and stomach problems increase.

Vulnerability:

Exposure
The exposure risk for air contaminants and vectors is high.

Sensitivity
Sensitivity is high.

Adaptive Capacity
The adaptive capacity is low.

Vulnerability
Vulnerability is high. Our population is currently considered an “at-risk vulnerable population”.

Risk:

Estimated Risk
The estimated risk is high.

Priority
Priority is high. This report is an adaptive plan providing information and suggestions to meet the immediate and future needs of this community.

Human Health Adaptation Strategies: Goals and Actions

Responsible Party
Indian Health Services and the Blackfeet Environmental Office are the responsible parties.

Purpose (Goals)
1) Increase air quality monitoring
2) Increasing monitoring of vectors and vector-borne diseases
3) Increase community awareness of climate-related health risks and adaptation techniques
4) Explore ways to possibly reduce mosquito populations near homes, schools, and places of work
5) Improve air quality in the Blackfeet Nation
6) Enhance medical service provision for people with medical conditions related to air quality or vector-borne diseases

Priorities
It is a high priority to make a unified effort to combat the health effects of climate change relative to air quality and vector-borne disease within the Blackfeet population.

Preparedness Goals: Strategies and Actions

Goal 1: Increase air quality monitoring

Strategy:
a) Create a monitoring plan for air quality, within the 7 sub-communities of Blackfeet Nation, to include increased sampling during fire season

Goal 2: Increase monitoring of vectors and vector-borne diseases

Strategies:
a) Create a monitoring plan for deer mice, tick, and mosquito abundance

b) Monitor vector-borne disease incidence within Blackfeet population, particularly hantavirus, tick-borne diseases such as Lyme, and West Nile over time

Goal 3: Increase community awareness of climate-related health risks and adaptation techniques

Strategies:
a) Educate and encourage community members to take steps to prevent exposure to air contaminants, allergens, and particulates.

Actions:
1) Increase health messaging to encourage people to stay indoors in a ventilated building when the air quality is poor to reduce exposure to particulate matter

b) Educate and encourage community members to take steps to prevent their exposure to vector-borne diseases.

Actions:
1) Teach community members how to prevent rodent infestation in homes and other buildings, including outbuildings and haystacks. Additionally, instruct property owners on the removal of surplus material piles on their property that are attractive to mice. Finally, instruction will be given on how to take precautions when opening buildings that have been unused for a while.
2) Distribute pamphlets that show the community how to prevent exposure to hantavirus.
3) Distribute pamphlets to the community about the 4 D’s of West Nile Virus prevention to help people avoid exposure (Avoid being outside at Dawn & Dusk. Use approved insect repellents (DEET) and wear long sleeves and pants (Dress) while outdoors to help protect against mosquito bites, and remove standing water near homes (Drain) to help decrease the number of mosquitoes near residences.) Encourage people to use window screens and air conditioning in summer months to help keep mosquitoes out of houses.
4) If mice droppings or nests are found in the home or outbuildings, follow recommended clean-up procedures.

Goal 4: Explore ways to reduce mosquito populations near homes, schools, and places of work

Strategies:
a) Investigate the risk and utility of encouraging bat activity near standing water (e.g. by using bat houses), since bats consume mosquitoes.

b) Investigate the risk and utility of managing mosquitoes by removing mosquito breeding sites and applying pesticides where necessary, while recognizing the potential ecological and human health costs of using these methods.

Goal 5: Improve air quality in the Blackfeet Nation

Strategies:
a) Improve infrastructure to promote high indoor air quality

Action:
1) Explore providing assistance for remediating homes and buildings damaged by water to prevent mold growth

b) Create tribal policies to improve outdoor air quality

Actions:
1) Regulate and reduce emissions of ozone precursors.
2) Promote using alternative transportation like walking and cycling to not only reduce toxic emissions, but also to achieve the co-benefit of increasing physical fitness.
3) Promote construction of community walking and cycling trails.
4) Promote tree planting in Browning, Star School, Seville, and Heart Butte, as well as within future infrastructure development projects, to help reduce particulate matter, ozone, and other pollutants.

Goal 6: Enhance medical service provision for people with medical conditions related to air quality or vector-borne diseases

Strategy:
a) Support medical providers offering immunotherapy treatment, which can help people with pollen allergies have increased tolerance.

Required and Existing Authority/Capacity

• Blackfeet Tribal Council, Blackfeet Tribal Honorary Council, Blackfeet Environmental Department, Blackfeet Tribal Housing Authority, Blackfeet Tribal Programs, Blackfeet Service Unit: Indian Health Hospital and Clinics, Blackfeet Water Resources Department, Blackfeet Tribal Health Department, Montana School District 9 Administrative Board, Blackfeet Community College Administrative Board
• Community effort to increase understanding of health issues as they relate to a changing climate i.e. air quality issues.
• Incorporate students from multiple disciplines at the local tribal community college, such as engineering, nursing, natural resources, etc.
• Contact Blackfeet scientists and researchers, and their collaborators, to develop climate related studies.
• The Blackfeet Tribal Business Council is the existing authority, maintaining the oversight of the health of the people, the homelands, and all life and resources within the homelands.

Partners and Potential Funding Sources

• Bureau of Indian Affairs
• Environmental Protection Agency
• National Institutes of Health
• Department of Health and Human Services
• FEMA- previous disaster and emergency service drills
• Brownsfield grant- Hazmat training is a potential source of funding

Funding Needs for Addressing the Estimated Impacts

Funding for a full climate adaptation community health plan.

Existing Programs that Contribute Towards Resilience

• Blackfeet Environmental Office
• Blackfeet Water Resource Department
• Blackfeet Fish & Game
• Blackfeet Area Indian Health Service Hospital and Clinics
• Blackfeet Forestry Department
• Blackfeet Department of Agriculture
• Blackfeet Land Department
• Blackfeet Tribal Health Department

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Go to the next section: Land & Range

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Literature Cited

Anderson, Jo, J.G. Thundiyil, and A. Stolbach. “Clearing the Air: A Review of the Effects of Particulate Matter Air Pollution on Human Health.” Journal of Medical Toxicology 8, no. 2 (2012): 166-75.

Barnes, C.S., N.E. Alexis, J.A. Bernstein, J.R. Cohn, J.G. Demain, E. Horner, E. Levetin, A. Nel, and W. Phipantanakul. “Climate Change and Our Environment: The Effect on Respiratory and Allergic Disease.”. The Journal of Allergy and Clinical Immunology in Practice. 1, no. 2 (2013): 137-41.

Caplins, L., and K. Paul. “The Blackfeet (Siksikaitsitapi) and Climate Change: Input from Blackfeet Community Members to Inform the 4th National Climate Assessment.” 2016.

Centers for Disease Control and Prevention. “Cdc’s Building Resilience against Climate Effects (Brace) Framework.” 2015. https://www.cdc.gov/climateandhealth/brace.htm

———. “Climate and Health.” 2014. https://www.cdc.gov/climateandhealth/effects/default.htm

———. “Hantavirus Disease, by State of Exposure.” 2017. https://www.cdc.gov/hantavirus/surveillance/state-of-exposure.html

———. “Wildfire Smoke.” 2017. https://www.cdc.gov/disasters/wildfires/smoke.html

Environmental Protection Agency. “Climate Change Indicators: Ragweed Pollen Season.” 2016. https://www.epa.gov/climate-indicators/climate-change-indicators-ragweed-pollen-season

Irfan, Umair. “Climate Change Expands Allergy Risk.” Scientific American, 2016.

Kelly, Frank J., and Julia C. Fussell. “Air Pollution and Public Health: Emerging Hazards and Improved Understanding of Risk.” Environmental Geochemistry and Health 37, no. 4 (2015): 631-49.

Montana.gov. “Hantavirus Pulmonary Syndrome (Hps).” 2016. http://dphhs.mt.gov/publichealth/cdepi/diseases/hantavirus

———. “Tick-Borne Illnesses.” 2015. http://dphhs.mt.gov/publichealth/cdepi/diseases/ticks

———. “West Nile Virus.” 2017. http://dphhs.mt.gov/publichealth/cdepi/diseases/westnilevirus

USGCRP. “Climate Science Special Report: A Sustained Assessment Activity of the U.S. Global Change Research Program.” edited by D.J. Wuebbles, D.W. Fahey, K.A. Hibbard, D.J. Dokken, B.C. Stewart, and T.K. Maycock. Washington, DC., 2017.

———. “The Impacts of Climate Change on Human Health in the United States.” edited by A. Crimmins, J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen, et al. Washington DC: U.S. Global Change Research Program, 2016.

USGS. “Mt. St. Helens Ash Eruption and Fallout.” 1997. https://pubs.usgs.gov/gip/msh/ash.html

Washington State Department of Health. “Wildfire Smoke and Face Masks.” 2014.

https://www.doh.wa.gov/Portals/1/Documents/Pubs/334-353.pdf

White House Office of the Press Secretary. “Fact Sheet: What Climate Change Means for Your Health and Family.” Press Release, 2016, https://obamawhitehouse.archives.gov/the-press-office/2016/04/04/fact-sheet-what-climate-change-means-your-health-and-family.

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Endnotes

[1] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”, U.S. Global Change Research Program.

[2] Centers for Disease Control and Prevention (2014), “Climate and Health,”  https://www.cdc.gov/climateandhealth/effects/default.htm.

[3] White House Office of the Press Secretary (2016), “Fact Sheet: What Climate Change Means for Your Health and Family,” Press Release, https://obamawhitehouse.archives.gov/the-press-office/2016/04/04/fact-sheet-what-climate-change-means-your-health-and-family.

[4] Centers for Disease Control and Prevention (2015), “Cdc’s Building Resilience against Climate Effects (Brace) Framework,”  https://www.cdc.gov/climateandhealth/brace.htm.

[5] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[6] Ibid.; (2017), “Climate Science Special Report: A Sustained Assessment Activity of the U.S. Global Change Research Program”, U.S. Global Change Research Program.

[7] L. Caplins and K. Paul (2016), “The Blackfeet (Siksikaitsitapi) and Climate Change: Input from Blackfeet Community Members to Inform the 4th National Climate Assessment”.

[8] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[9] USGS (1997), “Mt. St. Helens Ash Eruption and Fallout,”  https://pubs.usgs.gov/gip/msh/ash.html.

[10] Centers for Disease Control and Prevention (2017), “Wildfire Smoke,”  https://www.cdc.gov/disasters/wildfires/smoke.html.

[11] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[12] Frank J. Kelly and Julia C. Fussell (2015), “Air Pollution and Public Health: Emerging Hazards and Improved Understanding of Risk,” Environmental Geochemistry and Health 37, no. 4.

[13] Jo Anderson, J.G. Thundiyil, and A. Stolbach (2012), “Clearing the Air: A Review of the Effects of Particulate Matter Air Pollution on Human Health,” Journal of Medical Toxicology 8, no. 2.

[14] Washington State Department of Health “Wildfire Smoke and Face Masks,”  https://www.doh.wa.gov/Portals/1/Documents/Pubs/334-353.pdf.

[15] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[16] White House Office of the Press Secretary, “Fact Sheet: What Climate Change Means for Your Health and Family.”

[17] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[18] Environmental Protection Agency (2016), “Climate Change Indicators: Ragweed Pollen Season,”  https://www.epa.gov/climate-indicators/climate-change-indicators-ragweed-pollen-season.

[19] C.S. Barnes et al. (2013), “Climate Change and Our Environment: The Effect on Respiratory and Allergic Disease.,” The Journal of Allergy and Clinical Immunology in Practice. 1, no. 2.

[20] Environmental Protection Agency (2016), “Climate Change Indicators: Ragweed Pollen Season”.

[21] Umair Irfan (2016), “Climate Change Expands Allergy Risk,” Scientific American.

[22] USGCRP (2016), “The Impacts of Climate Change on Human Health in the United States”.

[23] Ibid.

[24] Ibid.

[25] Ibid.

[26] Ibid.

[27] Kelly and Fussell (2015), “Air Pollution and Public Health: Emerging Hazards and Improved Understanding of Risk.”

[28] Centers for Disease Control and Prevention (2017), “Hantavirus Disease, by State of Exposure,”  https://www.cdc.gov/hantavirus/surveillance/state-of-exposure.html.

[29] Montana.gov (2016), “Hantavirus Pulmonary Syndrome (Hps),”  http://dphhs.mt.gov/publichealth/cdepi/diseases/hantavirus.

[30] (2015), “Tick-Borne Illnesses,”  http://dphhs.mt.gov/publichealth/cdepi/diseases/ticks.

[31] (2017), “West Nile Virus,”  http://dphhs.mt.gov/publichealth/cdepi/diseases/westnilevirus.