Accelerating Decarbonization in the United States: Technology, Policy, and Societal Dimensions (2024)

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3 Public Health Co-Benefits and Impacts of Decarbonization ABSTRACT The energy system, which incorporates transportation, industry, buildings, and agriculture, supports daily activities that have both beneficial and adverse impacts on public health. The energy transition to a net-zero future provides an opportunity to address multiple health and energy challenges simultaneously. Numerous health benefits, also referred to as co-benefits, are possible with the energy transition, including improvements in air quality, water quality, physical fitness, and green space and living conditions. One of the primary benefits of decarbonizing the U.S. economy is preventing premature deaths related to fossil fuel production and combustion. It is crucial to minimize human health risks, including health inequities during the energy transition. The energy transition is an opportunity not only to avoid repeating past injustices and disparities but create a more equitable and health-promoting energy system overall. New energy policies and technologies come with potential tradeoffs for climate mitigation and health that must also be considered. To address and overcome barriers of the energy transition, the committee recommends health impact assessments be conducted during the development of transition programs and deployment of technologies to monitor the of health outcomes of decarbonization actions. Table 3-2 summarizes all the recommendations that appear in this chapter to support the inclusion of health considerations in decarbonization efforts. INTRODUCTION How we generate and use energy impacts our health in a multitude of adverse ways: from the environmental and health hazards associated with the extraction and processing of resources (Epstein et al. 2011; Healy et al. 2019), to the pollutants produced during power generation, and ultimately to the use of power and fuels in support of our daily lives such as through heating and cooling homes and buildings, public and private transportation, and operating medical technology. Air pollution, mainly particulate matter, contributes to an estimated 53,200–355,000 annual premature deaths in the United States (Mailloux et al. 2022; Vohra et al. 2021). The hazards associated with our existing energy system tend to disproportionately impact disadvantaged communities, 1 including ethnic and racial minorities and low-income households in the 39F United States and abroad (Agyeman et al. 2002; Healy et al. 2019; Lane et al. 2022; Mohai et al. 2009). Discriminatory policies can contribute to increased health risks for vulnerable communities that live near these hazards, even long after the policies have ended (Huang and Sehgal 2022; Lane et al. 2022; Wilson et al. 2008). To prevent further injustice, procedures for siting new energy technology and remediation of past damage must consider how risks and benefits are distributed with income and race and ethnicity (McCauley and Heffron 2018). Without active correction and the intentional inclusion of and 1 Communities that are marginalized, underserved, and overburdened by pollution and experience other socioeconomic burdens, such as low income or high unemployment. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 112 

consideration for affected communities, existing disparities will persist and continue the nation’s legacy of desperate and unjust health and economic damages—or even worsen inequities and create new disparities. In addition to the impacts of the current energy system, climate change has adverse impacts on health. These impacts include increased risk of premature death and exposure to extreme climate events and environmental hazards. This section provides background on current impacts of energy access and air quality on health. This section will also provide a brief background about the health impacts of climate change itself, but the focus of this chapter will be the health impacts from air pollution of fossil fuel combustion. Health Impacts of Energy Access Energy access is vital for health and well-being. Basic needs for adequate heating, cooling, and some life-sustaining medical equipment require reliable and affordable energy. Without energy, additional health hazards can arise such as lack of clean water for hygiene, and increased exposure to heat during heatwaves, which can exacerbate chronic health conditions (Jessel et al. 2019) and coping strategies during cold weather that increase risk of house fires (Carley et al. 2022). Climate change associated with fossil fuel energy sources may challenge reliable energy access, increase heat waves, and reduce access to clean water in many communities. As further discussed in Chapter 2, vulnerable populations are particularly at risk for limited energy access. Even households not identified as energy insecure based on income metrics may still limit their energy use, potentially risking more heat and cold related illnesses (Cong et al. 2022). The uncertainty and challenges of controlling energy costs can have mental health impacts, including anxiety, chronic stress, and depression, as well as physical impacts from the effects of heat and cold, and when households are forced to choose to spend their income on food or energy (Hernández et al. 2016). Finding 3-1: Energy access and affordability persist as barriers to low-income communities in achieving health and economic stability. Health risks include heat and cold stress, anxiety, increase of fire risk, and lack of reliable access to energy for medical devices. Health Impacts of Air Pollution While climate change mitigation is primarily focused on methods for reducing greenhouse gas (GHG) emissions, sometimes referred to as climate pollutants, the same measures to reduce GHGs often reduce many co-emitted “traditional” air pollutants as well. “Traditional” air pollutants include the six explicitly regulated by the National Ambient Air Quality Standards (also known as criteria pollutants): particulate matter (PM), sulfur dioxide (SO2), ground-level ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO), and lead (Pb) (EPA 2022a). These pollutants have distinct direct health impacts, typically via acute or chronic inhalation. Criteria air pollutants tend to be short lived (e.g., hours, days, months) in the atmosphere and exert much of their impact regionally. See Box 3-1 below for information about criteria air pollutants. In contrast, GHGs last from 12 years to thousands of years in the atmosphere (EPA 2022b) and exert global effects. GHGs include carbon dioxide (CO2) and methane (CH4). Some pollutants could be considered both traditional air pollutants and climate pollutants, including ozone, precursors to ozone (e.g., CH4), and black carbon, a component of fine particulate matter emitted from sources that burn fossil fuel. Clarifying the differences between traditional air pollutants and climate pollutants is also important for public perception and support of health-based decarbonization policies (Dryden et al. 2018). Furthermore, the transience of traditional air pollutants can be beneficial for decarbonization policies because immediate health co-benefits can be achieved from reduction of fossil fuel emissions and are highly relevant on a local scale. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 113 

BOX 3-1 Fossil Fuel Combustion and Criteria Air Pollutants Particulate matter (PM) is a complex mixture of particles derived from a variety of sources—including fossil fuel combustion, wildfires, windblown dust, agriculture, and chemical reactions of other pollutants like ammonia and sulfur dioxide. PM is one of the top environmental health concerns as it is estimated to contribute to as many as 8.9 million premature deaths per year globally (Burnett et al. 2018). Fine particulate matter (PM2.5), comprised of particles 2.5 microns or less, presents the greatest health concern, because it can infiltrate the lungs deeper than larger particles. Well-established causes of death associated with PM2.5 include ischemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lung cancer, and lower respiratory infections (McDuffie et al. 2021). Some fossil fuel combustion PM sources may be more dangerous than others, even after correcting for the mass of PM2.5 they produce, although more research is needed (Thurston and Bell 2020; Wang et al. 2022; West et al. 2016). Sulfur dioxide (SO2) is a gas released upon burning of fossil fuels, particularly from coal-fired power plants which emit 66 percent of U.S. SO2 emissions (EPA 2023a). Diesel combustion and industrial processes such as metal extraction, pulp and paper mills, and gasoline extraction also emit SO2 (WHO 2000). SO2 has been identified as a potential contributor to developing and exacerbating asthma (Andersson 2006; Casey et al. 2020; Gorai et al. 2014). Short-term exposure to SO2 is linked to an increase in asthma-associated emergency room visits and hospital admissions (Zheng et al. 2021) and is positively associated with all-cause and respiratory mortality (Orellano 2021). Ground-level ozone (O3) forms from precursors emitted from fossil fuel sources, particularly tailpipe emissions containing nitrogen oxides (NOx). While ozone in the stratosphere forms the UV-protective ozone layer, ground-level ozone (or tropospheric ozone) is a health hazard. Under favorable conditions of heat and sunlight, ozone is formed from the combination of NOx and either volatile organic compounds (VOCs), CO, or methane. O3 causes respiratory harm through worsening asthma and COPD and causing inflammation. It has also been linked to causing premature death from short and long-term exposure (EPA 2013). Nitrogen dioxide (NO2) is formed during fossil fuel combustion from oxidation of nitrogen contained in the fuel and/or from the reaction of N2 and O2 in air at high temperatures. NO2 and other nitrogen oxides (NOx) are often associated with traffic-related air pollution. NOx can interact with VOCs to form acid rain. NOx can irritate the respiratory tract, aggravating asthma and potentially causing the development of asthma (EPA n.d.(a)). Carbon monoxide (CO) is released from the incomplete combustion of carbon-containing fuels, often associated with traffic-related air pollution. Sources of indoor CO emissions include furnaces, gas water heater, gas stoves. In high doses, especially in enclosed environments, CO can cause fatigue, headaches, confusion, and death (EPA n.d.(b)). Although elevated levels of CO outdoors are uncommon, this can be an issue, particularly for people with cardiovascular disease, who may have a harder time getting oxygen to their heart. Lead (Pb) is a metal that can be suspended in the air and absorbed and accumulated in the body. Lead can cause irreversible brain damage, as well as damage to liver and kidneys, immune system, and reproductive system (EPA n.d.(c)). Since the EPA began phasing out leaded gasoline in 1973, lead levels in the air dropped 98 percent between 1980 and 2014 (EPA n.d.(c)). Lead can still also be found in soil and resuspended in the air, leaded fuels are still used in piston-engine aircraft, and lead is a pollutant from certain types of ore and metal processing. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 114 

In the United States, ambient air pollution, especially from fine particulate matter (PM2.5), is among the top environmental risk factors for premature death. Estimates may differ based on how pollution concentration is calculated, the number of health outcomes included, and the exposure response function used in the study (Pozzer et al. 2023). See Table 3-1 for a compilation of estimates from various studies. Despite the varying estimates of attributable premature deaths attributable to PM2.5, decreasing fossil fuel combustion is a key target for reducing PM emissions because it can be more easily controlled than natural sources. TABLE 3-1 Estimated Premature Deaths from PM2.5 Pollution in the United States: Total and Attributable to Fossil Fuels Total Estimated Premature Deaths Estimated PM2.5 Deaths Attributable Study from PM2.5 Emissions (thousands) to Fossil Fuels (thousands) McDuffie et al. (2021) 47 in 2017 N/A Thakrar et al. (2020) 100a,b in 2015 N/A Goodkind et al. (2019) 107c in 2011 N/A Fann et al. (2018) 121 in 2014 N/A Tessum et al. (2019) 131 in 2015 N/A Shindell et al. (2021) 191 in 2020 N/A Mailloux et al. (2022) 205 in 2016 53 in 2016 Burnett et al. (2018) 213d in 2015 N/A Lelieveld et al. (2019) 283 in 2015 e,f 194e in 2015 Vohra et al. (2021) N/A 355g,h in 2012 a Estimate includes primary PM2.5 and secondary PM2.5 precursors (NOx, NH3, NMVOC, and SOx). b Estimate attributes 99,900 deaths to anthropogenic PM2.5 from the transportation, electricity, food and agriculture, residential, and industrial and commercial sectors. c Estimate attributes 60,990 deaths to pollution from energy consumption. d Estimate includes mortality data from the United States and Canada. e Estimate includes ozone (O3) pollution. f Estimate attributes 230,000 deaths to anthropogenic PM2.5 which includes agriculture, residential energy use, and non-fossil emissions. g Estimate includes mortality data for long-term exposure to PM2.5 from fossil fuel combustion. h Estimate includes mortality data for populations older than 14 years old. A few studies evaluate the impact specific energy sectors and process have on the premature deaths and costs in the United States. For example, Penn et al. (2017) estimates that PM2.5 from electricity production, mainly driven by SO2 emissions forming secondary PM2.5, cause 21,000 premature deaths per year in the United States. Another estimate finds that human-caused PM2.5 emissions contributed to $886 billion in costs with 57 percent of the impacts attributable to electricity generation and transportation (Goodkind et al. 2019). Goodkind et al. (2019) also point out that air pollution from electricity generation and industry may be easier to control than PM2.5 emissions from road dust or residential wood burning. These health impacts do not include additional damages from other co-emitted criteria air pollutants. While there is a range of estimates owing to differing methodologies, the evidence indicates that a reduction in GHG emissions could have significant positive health outcomes from reduction in co-emitted air pollutants (Gallagher and Holloway 2022). A retrospective analysis, for example, found that between 2007 and 2015 the improvements in air quality from increasing replacement of coal generated power with PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 115 

wind and solar in the United States have prevented between 3,000 and 12,700 deaths and saved $29.1 billion–$112.8 billion (2015$) of health costs (Millstein et al. 2017). The benefits of clean air, especially reductions in particulate matter are large: the Environmental Protection Agency’s (EPA’s) cost benefit analysis of the Clean Air Act estimates that 85 percent of the economic benefits of the Clean Air Act can be attributed to reductions in premature mortality from particulate matter (DeMocker and Neumann 2011). For more information about the air quality impacts of certain energy sectors, see the Health Co- Benefits of Decarbonization section below. Current Disparities in Exposure to Air Pollution Decarbonization policies can reduce disparities in exposure to air pollution and create health and equity-related co-benefits. Effective policies will target households and communities experiencing the greatest harm. Low-income, racial, and ethnic minority households often live in older, less energy efficient homes, where energy efficiency upgrades would improve both the health and financial stability of the household (Lewis et al. 2020; Tonn et al. 2014). Furthermore, Black Americans and Hispanic Americans face excess exposure to PM2.5 relative to the pollution caused by their consumption of goods and services (56 percent and 63 percent, respectively) (Tessum et al. 2019). Increasingly, decarbonization strategies are location-specific, and at least one analysis reports that these are more effective than broad regional or sector-specific strategies, especially when trying to achieve multiple goals (Wang et al. 2022). Despite the regional and state variation, racial and ethnic minority groups historically have the highest national average exposure to all six criteria pollutants (Liu et al. 2021). The health risks are also disproportionate: people of color have higher rates of emergency department visits for asthma and other diseases (Nardone et al. 2020) and are more likely to be living with at least one chronic condition that enhances their susceptibility to air pollution, including asthma, diabetes, and heart disease (Erqou et al. 2018). The evidence of socioeconomic disparities in respiratory health may be, in part, explained by disparities in exposure to air pollution (Bravo et al. 2016; Liu et al. 2021; Ringquist 2005; Woodruff et al. 2003). The following sections examine the existing disparities in exposure to indoor and outdoor air pollution. Indoor Air Quality While much research on air quality centers on effects of ambient air quality, these same pollutants can be found in indoor environments. Residents of the United States are estimated to spend 87 percent of their time indoors (Klepeis et al. 2001), and while outdoor air quality influences indoor air quality, there can be greater variation indoors than outdoors (O’Dell et al. 2023). This means indoor air pollution can reach very high levels in some rooms or dwellings, with corresponding health impacts (Ilacqua et al. 2022; NASEM and NAE 2022). Indoor combustion (e.g., unvented gas fireplaces) can release CO and NO2 at levels higher than health-based standards, even when appliances are correctly operated (Francisco 2010; Lebel et al. 2022). A recent meta-analysis on gas stove use and asthma found that 12.7 percent of childhood asthma could be attributed to gas stove use (Gruenwald et al. 2023). A National Academies’ report (2022a) recommends researchers and practitioners engage disadvantaged communities in studies on indoor environments and in developing research priorities for indoor air quality standards. A better understanding of the factors impacting air quality indoors– such as the type of heating, cooling, ventilation, and filtration systems; building materials and maintenance practices; occupant density and housing type; and the source, proximity, and scale of outdoor contaminants—would be useful. Furthermore, the electrification of home appliances can improve indoor air quality and reduce the health risks associated with indoor air pollution. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 116 

Ambient Air Quality and Facility Siting Since 1982, the environmental justice movement in the United States has identified disproportionate siting of hazardous facilities, particularly sites for energy production and petrochemical facilities, near historically disadvantaged populations (Agyeman et al. 2002; GAO 1983; James et al. 2012; Linder et al. 2008; Mohai et al. 2009), with communities of color up to 75 percent more likely to live near pollution from the fossil fuel industry (Fleischman and Franklin 2017). Socioeconomic and racial disparities to outdoor air pollution are related to inequities in the proximity of communities to these environmental hazards (Brender et al. 2011). However, as noted in Chapter 2, disparities in absolute exposure to air pollution have been found to be larger for racial and ethnic groups than for income categories. For example, racial-ethnic exposure disparities to air pollution from emissions sources are found to be consistent across incomes and within urban and rural areas (Liu et al. 2021; Tessum et al. 2021). Furthermore, a study quantifying PM2.5 exposure disparity by emission type found that the industry, light-duty gasoline vehicles, construction, and heavy-duty diesel vehicles sectors are responsible for the largest emission disparities for Black, Hispanic, and Asian populations when compared to White populations (Tessum et al. 2021). Changes in passenger vehicle activity during COVID-19 lockdowns further also revealed disparities in impact of NOx emissions from heavy-duty vehicles (Kerr et al. 2021). Finding 3-2: Siting of electricity generating facilities and other large industries, as well highways and roadways with light- and heavy-duty vehicles in the United States has a legacy of disproportionately harming Black, Indigenous, and low-income communities through higher exposure to criteria air pollutants, especially PM2.5. Existing disparities in exposure to air pollution need to be recognized to ensure that the siting of decarbonization infrastructure does not worsen them during the transition. Redlining, Air Pollution, and Heat Islands The legacy effects of redlining—a 1930s process through which areas with high populations of people of color, older housing, and/or poorer neighborhoods were deemed hazardous for home loans— include increased exposure to urban heat islands (Hoffman et al. 2020), increased exposure to air pollution (Lane et al. 2022; Rothstein 2017), and higher rates of asthma-related emergency room visits (Nardone et al. 2020). The impact and occurrence of heat islands can be reduced through the strategic placement of reflective surfaces and green space. However, redlined areas often do not have these features and are therefore more impacted by the adverse outcomes of heat islands, especially heat-related mortality. Figure 3-1 shows a comparison of greenspace and the occurrence of heat islands within Richmond, Virginia. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 117 

a) b) FIGURE 3-1 Legacy impacts of redlining in Richmond, Virginia: (a) tree cover, and (b) summer temperatures compared to the city average. SOURCE: From The New York Times. © 2022 The New York Times Company. All rights reserved. Used under license. Adaptation to these adverse effects of redlining commonly lead to energy intensive actions, such as increased air conditioning to combat high outdoor temperatures (Abel et al. 2018). Furthermore, as shown in Chapter 2 (see Figure 2-3), redlining has caused air pollution exposure to persist in racial-ethnic minority communities despite the national decrease of PM2.5 exposure overall (Tessum et al. 2021). See the section “Built Environment Co-Benefits” below for more information about how the effects of redlining and the current energy system can be mitigated with the transition to a net-zero energy system. Decarbonization policies can reduce current disparities, with the most effective policies acknowledging these disparities and targeting emission sources causing the most harm (Tessum et al. 2021). Additionally, subnational analysis of national decarbonization strategies and their impacts show the importance of considering co-pollutant emissions when decarbonizing the electricity sector to reduce the inequities of PM2.5 exposures (Goforth and Nock 2022). That is, although PM2.5 has been identified as a risk factor for premature death, decarbonization actions that simultaneously target specific emission sources and reduce other criteria pollutions associated with fossil fuel combustion will support the reduction of air pollution disparities. Furthermore, siting of new energy facilities need to consider the health impacts neighboring communities will face and engage with communities to inform them of the risks and benefits of new energy facilities will be the most successful during the transition. See Chapter 5 for more information about engaging effected communities in energy transition decision-making. Climate Change and Air Pollution Intertwined Adverse health impacts from climate change are extensive and provide some of the most compelling motivation for climate mitigation. Although this chapter primarily focuses on the health impacts of the transition to net-zero energy, Box 3-2 briefly reviews some of the major health impacts linked to climate change. BOX 3-2 Health Risks from Future Climate Extremes Warming since 1850–1900 has increased the frequency and intensity of extreme climatic events globally, including extreme heat and cold, heavy precipitation, floods, droughts, desertification, dust storms, and wildfires (Diffenbaugh et al. 2017; Ebi et al. 2021), and climate change is projected to PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 118 

exacerbate this trend (Cissé et al. 2022). These climatic events cause significant human mortality and adversely affect human health (Alderman et al. 2012; Bressler 2021; Ebi et al. 2021; GCRP 2016). Health costs from premature mortality, health care, and lost wages during these events can reach billions of dollars (Knowlton et al. 2011; Limaye et al. 2019). Long-term negative effects include increased respiratory illnesses, vector-borne, water-borne and food-borne diseases, food insecurity, and detrimental mental health impacts (Cissé et al. 2022; Limaye and De Alwis 2021). As the intensity and frequency of heatwaves increases, death tolls and hospitalizations from heat are also increasing globally (Hayashida et al. 2019; Kollanus et al. 2021; Li et al. 2012; Limaye et al. 2019; Vogel et al. 2019). For example, in 2020, about 17,000 premature deaths were attributable to heat exposure (Shindell et al. 2021) and in June 2021, the number of heat-related emergency department visits was 69 times higher than during the same period in 2019 (Schramm et al. 2021). Adaptation to heat with air conditioning use requires more energy, which could in turn increase air pollutants from that energy use, leading to 5–9 percent increase in air-pollution-related mortality from building electricity demand (Abel et al. 2018), if fossil fuels continue to be used to generate electricity. Predicting the impact of policies on prevention of direct climate change health impacts, like excess heat related deaths or improved air quality, can be challenging. One study finds that, while air pollution impacts are more immediate, U.S. premature deaths from heat exposure increases from about 20,000 premature deaths annually in this decade to 100,000–150,000 premature deaths per year by 2070 even with U.S. and global decarbonization action (Shindell et al. 2021). Comparatively, the Climate Impact Lab’s Lives Saved Calculator,a which uses a damage function to calculate deaths and health costs of future climate change, predicts that globally 7.4 million annual premature deaths and $3.7 trillion in annual adaptation costs (e.g., building cooling centers, installing air conditioning) could be avoided if the United States achieves net-zero emissions by 2050 (Climate Impact Lab 2022). Increasing aridity is likely to lead to increased drought, dust, wildfires in some regions with associated health issues. Wildfires have increased dramatically in the past decades, driven in part by climate change, and continue to increase (Burke et al. 2021; Ford et al. 2018; Romanello et al. 2022). Wildfire activity is associated with premature mortality and increased hospital admissions for respiratory and cardiovascular incidents from smoke (Neumann et al. 2021). Rising aridity in the U.S. Southwest (Overpeck and Udall 2020) is expected to increase fine and coarse dust levels, triggering additional mortality and hospitalizations for cardiovascular conditions and asthma (Achakulwisut et al. 2019). Furthermore, drought, fires, and excess heat are likely to stress agricultural production, impacting food security, human health (including outdoor workers), and livestock health (Bezner Kerr et al. 2022; Gowda et al. 2018). Over half of all human pathogenic disease can be aggravated by climate change (Mora et al. 2022). Rising temperatures will increase water-related illnesses (Limaye and De Alwis 2021; Trtanj et al. 2016) and food-borne diseases (Cissé et al. 2022). Additionally, allergies and respiratory diseases, such as asthma, are also predicted to be enhanced by rising temperatures, which induce longer pollen seasons and higher pollen concentrations (Anderegg et al. 2021; Ziska et al. 2011) and increased CO2 levels, which increase the potency of aeroallergens (Bielory et al. 2012). Furthermore, climate change is expected to alter the seasonal and geographical activities of vectors, including mosquitoes and ticks, affecting the transmission of the infections that they carry, and may increase human exposure to vector- borne illnesses (Kraemer et al. 2019). In addition to impacting physical health, climate change-related extreme events affect mental health through multiple pathways: extreme events, heat, and climate anxiety. Extreme events can lead to depression and posttraumatic stress disorder (Lowe et al. 2019). Other consequences of climate change and extreme events, such as displacements and malnutrition, were also linked to several mental health problems (Cissé et al. 2022). Hotter days were correlated with an increase in self-reported mental health issues in the United States and globally (Li et al. 2020; Obradovich et al. 2018). Last, the view of climate change as an existential threat was suggested to increase levels of stress, anxiety, and hopeless, PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 119 

of particular concern for young people (Hickman et al., 2021; Ojala et al. 2021; Palinkas and Wong 2020). a To view the Lives Saved calculator, see https://lifesaved.impactlab.org/. Despite the extensive negative health effects of climate change, research shows the health effects from fossil fuel combustion alone are much larger than those associated with climate change. For example, Shindell et al. (2021) found health benefits from improved air quality outweighed those related to avoided climate change. Additionally, the economic benefits of avoided climate change, which includes the monetized impacts of avoided heat exposure and extreme weather events, have been found to be smaller values than the economic benefits of reduced fossil fuel combustion (EPA 2011; Markandya et al. 2018; Vandyck et al. 2018). However, there are decarbonization pathways that will directly address the impacts of fossil fuel combustion while indirectly lessening the adverse health impacts of climate change. For example, decarbonization pathways that increase green space may also reduce allergy and respiratory impacts, and mental health impacts associated with climate change. The rest of this chapter will focus on the health and monetized benefits predicted to follow from decarbonizing the U.S. energy system. HEALTH CO-BENEFITS FROM DECARBONIZATION Large health benefits come from the associated reduction in air pollution when fossil fuel combustion is reduced. For example, renewable energy sources such as wind and solar reduce GHGs and have the co-benefit of reduced ambient air pollution emissions relative to fossil fuel combustion. While reduced air pollution will likely provide the largest amount of health co-benefits, others, such as green space and infrastructure for active travel can yield additional mental and physical well-being co-benefits (Grabow et al. 2012; Nieuwenhuijsen 2021; Raifman et al. 2021; Younkin et al. 2021). This section describes co-benefits of decarbonization in for air quality, built environment, transportation, water quality, nutrition, and occupational health. Air Quality Co-Benefits As the country transitions to net-zero emissions and a majority of fossil fuel combustion is phased out, positive air quality health co-benefits are universally expected, although studies relying on different methodologies or modeling different policies show considerable variation. Some studies use models to assess how future policies and actions—such as phasing out fossil fuel combustion (Goodkind et al. 2019; Mailloux et al. 2022; Penn et al. 2017; Shindell et al. 2021), replacing some energy generation with emissions-free renewables (Abel et al. 2018; Driscoll et al. 2015; Prehoda and Pearce 2017), or increasing energy efficiency (Abel et al. 2019)—affect air pollutant emissions and subsequent human exposures. While estimates of the number of deaths avoided and health costs vary simulation modeling indicates that future decarbonization of electricity generation would prevent thousands of deaths per year in the United States. Shindell et al. (2021) find that decarbonizing in the United States to maintain a 2°C pathway could prevent 4.5 million premature deaths and 1.4 million hospitalizations and emergency room visits. Comparatively, Mailloux et al. (2022) predicts nationwide efforts to eliminate energy-related emissions across the electric, transportation, building, and industrial sectors could result in 53,000 avoided premature deaths per year and approximately $610 billion annual savings. Figure 3-2 depicts the projected decrease in ambient PM2.5 from the simultaneous removal of PM2.5, SO2, and NOx emissions from energy-related sectors: electricity fuel use, industrial fuel use, residential fuel use, on-road vehicles, non-road vehicles, and oil and gas production and refining. Other benefits of decarbonizing are also being quantified. In addition to $56 trillion to $163 trillion in public health benefits from 2020–2100, PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 120 

decarbonizing in the United States could prevent 300 million lost workdays, and 440 million tons of crop losses (Shindell et al. 2021) over the next 20 years. FIGURE 3-2 Projected decrease in ambient PM2.5 concentration from the simultaneous removal of PM2.5, SO2, and NOx emissions from energy-related sectors. The energy-related sectors included in this estimate are electricity fuel use, industrial fuel use, residential/commercial fuel use, on-road vehicles, non-road vehicles, and oil and gas production and refining. SOURCE: Courtesy of Mailloux et al. (2022), https://doi.org/10.1029/2022GH000603. CC BY-NC 4.0. Numerous studies have quantified health benefits for specific decarbonization policies, such as replacing fossil fuel combustion for energy generation with renewable options, and have found benefits vary based on region, technology, and methodology (e.g., model assumptions, extent of life-cycle assessment). For example, Wiser et al. (2016a) finds $77 billion–$298 billion in air quality and public health benefits will result from future solar energy use but acknowledges the uncertainty from existing estimates of GHG impacts and air pollution. Similarly, McCubbin and Sovacool (2013) estimate avoided health and non-health externalities for wind power plants in Idaho are between $18 million and $104 million and in California are between $560 million and $4.38 billion, noting the ambiguity is owing to emission rate and location, and estimate of effect. Impacts from the Infrastructure and Jobs Act and Inflation Reduction Act The recent major U.S. climate-change-related laws, the Infrastructure Investment and Jobs Act (IIJA) (P.L. 117-58) and the Inflation Reduction Act (IRA) (P.L. 117-169), have health co-benefits PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 121 

associated with many of the provisions in the bills. 2 Together IIJA and IRA invest in the nation’s energy 40F and transportation sectors through appropriations and authorization which will have direct and indirect impacts on GHG emission reduction goals. The health co-benefits from these investments include avoided premature deaths from PM2.5 and increased opportunity for active travel. However, a majority of the provisions have yet to be implemented and the true impacts of the bill cannot yet be reported. In lieu of a peer-reviewed analysis of the bills, policy analysis and previous estimates of potential co-benefits can help with estimating the health impacts. This section highlights modeling studies that estimate the health impacts of IIJA and IRA. The IRA and IIJA include appropriations that are likely to help both reduce GHG emissions and improve air quality (see Appendix H). The provisions include: appropriations for fleets of zero-emission medium and heavy duty vehicles, appropriations for light-duty EVs, and spending programs to reduce air pollution at ports; tax credits for electricity produced from renewables or new solar and wind facilities in low-income communities; appropriations for construction of renewable energy facilities and energy efficient buildings; spending programs for improving air quality monitoring for underserved populations and at schools and block grants for environmental and climate justice projects; and appropriations for clean energy projects, including the EPA Greenhouse Gas Reduction Fund which was modeled on successful green banks. Multiple groups have attempted to quantify the air quality co-benefits from the IRA. Rhodium Group’s analysis suggests that SO2 and NO2 emissions will be reduced from 2021–2030 from the IRA, as compared to baseline modeling without the IRA (Larsen et al. 2022). The implementation of IIJA and IRA have been identified as a key barrier to accessing the health and decarbonization benefits of the provisions. For previous climate-related policies, it has been observed that the monetized health impacts from air quality improvements have been found to either partially offset (Sergi et al. 2020; Shindell et al. 2021; Thompson et al. 2016) or exceed the up-front cost of implementing policies and funding incentives (Abel et al. 2018; Buonocore et al. 2019; Wang et al. 2020). According to a presentation from the REPEAT Project, the IRA could have health benefits of reducing 5,800 premature deaths from particulate matter annually by 2030 (Jenkins et al. 2022). Comparatively, Resources for the Future (RFF) estimate IRA policies focused on electricity generation will lead to at most 1,300 avoided deaths with an associated $12 billion–$22 billion in health benefits in the year 2030 alone (Roy et al. 2022). An NREL modeling report estimate the cumulative impacts of both IIJA and IRA may result in 4,200–18,000 avoided premature deaths and $45 billion–$190 billion in avoided health damages estimated reductions in SO2 and NOx from the 2023 to 2030 (Steinberg et al. 2023). Additionally, Energy Innovation indicated that the IRA could prevent at most 3,900 premature deaths, 100,000 asthma attacks, and 417,00 lost workdays in the year 2030 alone owing to corresponding reductions in air pollution, specifically particulate matter (Mahajan et al. 2022). The benefits of recent U.S. decarbonization policies are expected to continue beyond the modeled 2030 outcomes, assuming no changes occur to remove them. It is also expected that additional legislation will be passed to support a national net-zero energy system by 2050. Calculating the effects of policy implemented beyond 2030 increases the cumulative benefits. Other components of IIJA and IRA specifically target low-income, disadvantaged, and environmental justice communities, which could help with health equity goals. However, because most of the bills’ programs offer only incentives, such as tax credits, there will not be equitable outcomes unless the incentives are appropriately implemented and work as intended. For example, if incentives to electrify transportation and home heating are highly successful while simultaneously incentives to site and deploy renewables are not, air quality could decrease and fossil fuel use could increase through 2030. See 2 It should be noted that the IIJA and IRA are not equivalent in funding mechanisms. The IIJA consists of a mix of authorizations and appropriations while the IRA primarily consists of spending programs (appropriations) and tax expenditures. Appropriations are laws that provide money for government programs and must be passed by Congress every year in order for the government to continue to operate. Spending programs can allocate federal resources to projects and activities up to the amount of their appropriation. By contrast, tax expenditures typically have no limit on the amount that could be claimed by taxpayers. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 122 

Chapter 5 for more about siting processes. If incentives work as planned, improvements in air quality, active travel, and mitigation of climate change will provide substantial positive health benefits. Some provisions in both pieces of legislation may have additional health impacts from infrastructure that supports active travel, such as biking and walking. Provisions in the IIJA that can be used to improve active travel include: the Surface Transportation Block Grant program (§11109); Congestion Mitigation and Air Quality Improvement program (§11115); Safe Routes to Schools Program (§11119); Bicycle transportation and pedestrian walkways (§11133); and funding to increase streets for safe and accessible transportation (§11206). See the Transportation Co-Benefits section for more about active travel and related health benefits. Finding 3-3: Serious and widespread negative health consequences would continue from fossil fuel use under the “business as usual” greenhouse gas emissions projections. Recent climate legislation, especially the Inflation Reduction Act, will have direct and indirect impacts on U.S. emissions, mainly through air quality improvements. The improvements in air quality anticipated from implementation of the Inflation Reduction Act will prevent thousands of premature deaths and thus provide significant monetary benefits. Even larger health and monetary co-benefits could occur with further reductions in fossil fuel combustion and deployment of technologies to manage combustion emissions, both of which are supported by various Inflation Reduction Act and Infrastructure Investment and Jobs Act provisions to meet the net-zero emissions goal. Regional Variation Health benefits from emissions reductions will depend on regional factors, including weather, population density, and the type of emissions sources. For example, atmospheric chemistry with natural precursor emissions (like biogenic VOCs) can affect the formation of ozone. Wind speed and direction also affect where air pollution ends up. When densely populated regions are affected, the value of total co-benefits are larger because more people are affected; likewise, the underlying characteristics of the population that affect vulnerability to air pollution (e.g., the elderly, or children) can also affect the calculated health benefits. Lastly, regional variation in emissions sources can affect the co-benefit estimate—using wind or solar to replace a highly polluting coal-fired power plant versus a somewhat less polluting natural gas-fired plant. Health benefits from replacing existing electricity sources with wind, rooftop solar and utility solar energy in 2017 have been estimated across the 10 U.S. electrical grid regions (Buonocore et al. 2019). Figure 3-3 illustrates the results of the study, highlighting how different renewable energy technologies relate to CO2 reductions and monetized health benefits. As shown below, renewable energy deployment offers the highest health benefits in the Great Lakes Mid-Atlantic region, followed by the Upper Midwest, and then the Northeast. The main differences in health benefits are owing to the fuel type and corresponding emissions displaced, and size of the population affected. For example, the Great Lakes Mid-Atlantic electrical grid region (including the Ohio River Valley region) benefits from decarbonization as a higher concentration of coal plants would be replaced with cleaner energy, and substantial populations downwind are affected. Likewise, in the Northeast, gas and oil would be reduced, affecting the high population density region, resulting in high health benefits per ton of CO2. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 123 

FIGURE 3-3 CO2 reductions and health benefits per ton of CO2 reduced, by region and renewable energy type. NOTES: Red circle represents rooftop solar, green triangle represents utility solar PV, and blue square represents wind. Points for rooftop solar and utility solar PV overlap. Not all points are labeled to prevent overplotting. SOURCE: Courtesy of Buonocore et al. (2019), https://doi.org/10.1088/1748-9326/ab49bc. CC BY 3.0. Localized health benefits from future decarbonization efforts will vary by location. For example, between 32 percent and 95 percent of the health benefits from eliminating emissions in a region will PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 124 

remain in that region, with marked state-to-state variability (Mailloux et al. 2022), as pollutants easily cross county (Sergi et al. 2020) and state boundaries (Dedoussi et al. 2020). The regional nature of air pollution impacts has equity implications, as different decarbonization strategies may not bring emissions reduction benefits to all demographic groups at the same scale and/or pace (Goforth and Nock 2022). It will be important to consider both health and equity impacts of decarbonization technologies during this energy transition. Built Environment Co-Benefits The built environment encompasses residential homes, workplaces, neighborhoods, and metropolitan and regional geographies. Globally, 30 percent of final energy consumption and 26 percent of energy-related emissions come from the planning, design, maintenance, and disposition of the built environment (EIA n.d.). This section identifies the health co-benefits that stem from improving the two key challenges within the built environment: heat islands and energy use. See the Identifying Potential Health Risks section for more about retrofitting existing buildings. See Chapter 7 for more information about additional challenges that will be faced during the energy transition. Urban Green Space Local decarbonization and health action can reduce urban heat islands along with the GHG emissions associated with the energy demand for cooling. Urban heat islands can be mitigated with cool surfaces (e.g., roofs and pavement designed to help reflect rather than absorb sunlight) as well as green space. Cool surfaces can reduce urban air temperatures and up to 6 percent of GHG emissions, according to one study (Azarijafari et al. 2021; EPA 2008). However, the true reduction of GHG emissions and heat islands will be context-specific with some neighborhoods seeing less reduction than others. Creating green space in built environments can provide many potential benefits related to health and decarbonization, including reducing urban heat, reducing air pollution, and benefiting mental health. Green spaces reduce urban heat by increasing evaporative cooling, creating shade, and altering wind around buildings and this heat reduction has both energy and health impacts. Urban forests 3 in the United 41F States reduce electricity use by 38.8 million MWh annually, with the average reduction in residential energy use from trees estimated at 7.2 percent (Nowak et al. 2017). For health impacts, several studies indicate that green space, along with other sociodemographic factors, may decrease heat-related mortality risk (Choi et al. 2022; Gronlund et al. 2015). Additionally, greater tree canopy cover is associated with reduced ambulance calls during extreme heat events (Graham et al. 2016). However, a case study in Chicago demonstrates that a green roof on a new building did not create the same heat mitigation effect as the field the building was constructed on (McConnell et al. 2022). It will be important to identify the limit of green spaces in built up landscapes. Other potential co-benefits from green space include improved air quality, mental health, and stormwater management. Urban vegetation can also help remove air pollutants from the atmosphere. The EPA estimates that urban forests in the U.S. net annual sequestration is 37,580,224 metric tons of carbon (EPA 2023b). Green space also has been found to be associated with lower levels of depression, anxiety, and stress after controlling for many confounding factors (Beyer et al. 2014). Green infrastructure can additionally help stormwater management, improving water quality and reducing runoff (Kuehler et al. 2017). Considering the health impacts in total, a study in Portland, Oregon finds that one premature death can be avoided for every 100 trees planted, with older trees providing more value (Donovan et al. 2022). While creating green space offers multiple benefits, there are limitations and potential trade-offs involving green space depending on the specific choice of plants (Wolf et al. 2020). Many factors of how well vegetation can provide heat, air quality, water quality benefits, as well as the overall maintenance 3 Trees in cities and suburban areas. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 125 

and water usage required may depend on the type, diversity, and density of vegetation (Fineschi and Loreto 2020; Rambhia et al. 2023). Two potential disbenefits include increase in pollen, which can exacerbate asthma and allergies (Sousa-Silva 2021; van Dorn 2017), and emissions of VOCs, which may contribute to ozone (Drewniak et al. 2014; Sousa-Silva 2021; van Dorn 2017). Selection of trees that are known to be less allergenic or diversifying tree planting overall may improve urban health. Energy Efficiency Substantial health co-benefits can result from decarbonizing the built environment, specifically from energy efficient buildings. These co-benefits include improved mental and physical health, and reduced risk of dehydration and excess winter mortality in hot climates (IEA 2019). However, challenges exist in the implementation energy efficiency policies buildings. For example, the primary use of voluntary financial incentives requires extensive coordination to be successful (see Chapter 7). This report will examine the impacts of energy efficiency in buildings by exploring the sector most pertinent to health—the healthcare system. Within the buildings sector, the healthcare system contributes 8.5 percent of U.S. GHG emissions when estimates include buildings, purchased electricity, and supply chain emissions, which is nearly double the global average of healthcare emissions of about 4.5 percent (Eckelman et al. 2020). According to the Commercial Buildings Energy Consumption Survey, inpatient health care was the third highest energy intensity per square foot for commercial buildings in 2018, after food service and food sales, and was also the sector with the largest decrease since 2012 (EIA 2022). Note that chapters will discuss the emissions associated with electricity (Chapter 6) and the built environment (Chapter 7) as separate sectors in of themselves. The healthcare sector can act as a leader in promoting innovation for health, equity, and climate change. Many organizations have already taken steps to reduce GHG emissions and support health equity in this sector. For example, the Department of Health and Human Services announced the Health Sector Climate Pledge in April 2022 to encourage organizations to commit to lowering their GHG emissions and to building more climate resilient infrastructure (HHS n.d.). Within a year, more than 100 stakeholders— hospitals, health center, insurance companies, pharmaceutical companies, and so on—have signed the pledge. In addition to the commitment of federal health systems, about 15 percent of U.S. hospitals have committed to reducing GHG emissions (HHS n.d.). Addressing the full life-cycle energy demand from the health sector—from facilities and products (e.g., anesthetic gases), to electricity and steam sources, and ultimately to supply chains—is the motivation of the National Academy of Medicine’s Grand Challenge on Climate Change, Human Health, and Equity 4 as well as other initiatives within the health 42F care sector. Transportation Co-Benefits Like decarbonization of electricity generation, decarbonization of transportation can also have health co-benefits from fewer emissions. Transport decarbonization can also yield benefits through physical fitness. In addition to air pollution, transportation health considerations include physical fitness and avoided emissions from road dust. One study exploring reducing short car trips in 11 cities in the upper midwestern United States found that the combined benefits from improved air quality plus the added physical fitness benefits from making 50 percent of short trips via biking could result in a total of nearly 1,300 lives and $8 billion saved annually from avoided morbidity and mortality (Grabow et al. 2012). However, owing to the relative lack of research in transportation health co-benefits compared to air quality co-benefits, there are limited tools and literature to assess the immediate impacts of the 4 The National Academy of Medicine’s Grand Challenge on Climate Change, Human Health, and Equity seeks to improve and protect human health and equity through a multi-year global initiative. For more details, see https://nam.edu/programs/climate-change-and-human-health/. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 126 

initiatives. Furthermore, the health impacts of transportation modes, such as mass transit and active transport, can be challenging to model across large scales. Vehicle Transportation Several pollutants are associated with the transportation sector, particularly tailpipe emissions from fossil fuel combustion, including PM2.5, NOx, and ozone. One study estimates that 22,000 out of 115,000 deaths attributable to PM2.5 and ozone came from the transportation sector, with health damages costing approximately $210 billion (2015$) in the United States in 2015 (Anenberg et al. 2019). At a finer spatial resolution, many reviews have noted the near-highway health effects from motor vehicles emissions, especially in urban areas (e.g., Brugge et al. 2007; HEI Panel on the Health Effects of Traffic- Related Air Pollution 2010; Khreis et al. 2020). Studies have shown how decarbonization of vehicles, especially the electrification of the heavy-duty vehicle fleet, can provide significant health and equity co- benefits (Ramirez-Ibarra and Saphores 2023; Zhu et al. 2022) and will play a large role in decarbonization, given the large amount of GHG emissions from the transportation sector and the large percentage of transportation emissions resulting from passenger, freight, and other vehicle trips. However, even with a fully electric fleet, vehicles would still produce transportation-related pollution, especially coarse particulates, from brake dust, tire abrasion, and road dust (Liu et al. 2022; Timmers and Achten 2016). Active Transportation Active travel, including walking and cycling, can reduce emissions associated with gasoline combustion and improve health through increased physical activity (Castillo et al. 2021; Celis-Morales et al. 2017; Dinu et al. 2019; Hamer and Chida 2008; Kelly et al. 2014; Mueller et al. 2017). A systematic review and meta-analysis found that people who participated in active transportation had an 8 percent reduction in all-cause mortality, 9 percent reduction in risk of cardiovascular disease, and a 30 percent reduction in risk of diabetes (Dinu et al. 2019). For cyclists, a 24 percent reduction in all-cause mortality and a 25 percent reduction in cancer mortality was also identified (Dinu et al. 2019). Additionally, several studies find the health benefits of active transport are much higher than the health risks of traffic collisions while walking or cycling (Maizlish et al. 2022; Mizdrak et al. 2019; Mueller et al. 2015). Accounting for both avoided deaths from increased physical activity and additional traffic deaths, an analysis of multiple scenarios of active transportation infrastructure investments found the benefits of avoided deaths greatly exceed the costs of building the infrastructure (Raifman et al. 2021). In the United States, 52 percent of trips are less than 3 miles, with only 2 percent of trips greater than 50 miles (DOE-EERE 2022). Given the majority of emissions are from longer trips unsuitable for biking and walking, active transportation is likely to have a small impact on GHG emissions from transportation. Based on Bureau of Transportation Statistic data, doubling active transportation and public transit is likely to replace less than 5 percent of miles traveled in personal vehicles and a similar percentage of GHG emissions (BTS 2017). Nonetheless, the health benefits from active travel are substantial and health promotion priority for walkable and bikeable communities within transportation decarbonization planning is elevated because small incremental increases in routine exercise at the population level offer substantial health benefits (Mueller et al. 2017; Pedersen and Febbraio 2012). To what extent active transportation replaces personal vehicle travel depends on the regional planning and infrastructure. Examples of short-term changes of increases in bike lanes in some areas have demonstrated that large, rapid increases in cycling is possible when the infrastructure exists to support people’s ability to bike safely (Kraus and Koch 2021). Safety for cycling could be improved with physical separation for bike lanes, which one study estimates benefits would be 10–25 percent greater than the costs (Macmillan et al. 2014). Increases in mass transit ridership may also increase physical activity if PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 127 

replacing automobile trips. While riders of mass transit may not be active during a bus ride or train ride, 90 percent of transit riders walk to or from their transit stops (NASEM 2021). In the United States, this is a median time of 19 minutes of daily walking to and from transit (Hirsch et al. 2018; Xiao et al. 2019). Few studies have explored the equity implications of active transportation. People of low-income often rely on active travel owing to lack of vehicle access, and while they may benefit from physical activity there may be other equity concerns, such as lack of nearby access to healthy food or health care (Hansmann et al. 2022). There are also many barriers to active transportation including lack of safe street infrastructure (e.g., sidewalks, bike lanes, etc.), pollution exposure, exclusionary zoning, crime and policing, harassment, and racism (Agyeman and Doran 2021; Barajas 2021; Brown 2016). Some of these barriers can be overcome with equitable urban planning that considers the health impacts of and access to active transportation. However, the needs and constraints for each community will vary depending on their transportation needs and climate and health goals and thus active travel and transportation infrastructure decisions need to have at the local level. Water Quality Co-Benefits Water and energy are interrelated concepts: water is used within all phases of energy production and energy is required to pump and deliver water (DOE 2014). If the transition to net-zero is not completed with an intentional focus on impacts on water use and availability, the United States may risk increasing existing water stress 5 (IEA 2020). Although most studies of impacts of climate change on 43F water quality focus on the hydrologic cycle (e.g., increased contamination from flooding), climate mitigation strategies may also impact water quality, with corresponding health effects. Decarbonization may impact water quality directly via pollution or more indirectly through changes in water withdrawal and consumption, which affects the availability of quality water sources. Some current energy sources directly produce water pollutants. Steam electric power plants (powered by fossil or nuclear fuels) generate an estimated 30 percent of all toxic pollutants that are discharged into surface waters from industry (EPA 2015; Massetti et al. 2017). Toxic metals (including lead and arsenic) are of special concern in water, as they are consumed by fish and wildlife and accumulate to dangerous levels, and may be eaten by people in the community, with deadly effects on health (CDC n.d.). Mining and other extractive activities can also negatively impact water quality, as a result of acid mine drainage, contamination from tailing ponds, and pollution from oil and gas well runoffs (de Oliviera Bredariol 2022). Relatedly, some processes to mitigate and reduce water pollution, such as desalination, are energy intensive, expensive, and often come with environmental impacts related to waste management (Molinos-Senanta and SalaGarrido 2017; Shahzad et al. 2017). The reductions in fossil fuel use expected in a net-zero energy system could lead to improvements in water quality from decreased discharges of toxic pollutants. The electric sector in the United States is one of the largest withdrawers of water (removing and returning to a source, often at higher temperatures), although it consumes (removal without return) only 6 percent of the nation’s water (Cameron et al. 2014). Several analyses find potential for decreasing water withdrawals and consumption with increasing renewable use (especially wind and, to some extent, solar), although the extent varies by region based on the portfolio of technology (Barbose et al. 2016; Ou et al. 2018; Wiser et al. 2016b). Increased mining for the critical minerals needed for clean energy technologies could negate some of these potential water quality benefits, although there are recommended technologies and policies to mitigate environmental impacts of mining (IEA 2021). Likewise, agriculture for biofuels, mining and fracking processes can have adverse impacts on water quality. For example, runoff can contribute to excess nutrient contamination and algal blooms (see the below section Identifying Potential Health Risks). 5 For more information about the water-energy nexus and the predicted impacts energy transitions to net-zero will have on water availability, visit https://www.iea.org/articles/introduction-to-water-and-energy. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 128 

Improved Nutrition Co-Benefits Shifting from diets high in animal product, particularly red meat and processed meat, to more plant-based diets can reduce GHG emissions and improve health. This shift can also provide other environmental benefits, including improved water quality and decreased nutrient runoff. The EPA estimates that 11.2 percent of national GHG emissions from 2020 are attributable to agriculture with this sector’s electricity-related emissions accounting for 0.6 percent (USDA 2022). See Chapter 8 for more on the GHG and land-use impacts of agriculture. A realistic healthy diet, as defined by the Dietary Guidelines for Americans, could reduce U.S. food-system energy use by 3 percent, and, if further maximized for energy efficiency, a 74 percent reduction in food system energy use could be achieved (Canning et al. 2017). There are numerous significant health benefits of sustainable and plant-based diets (Gao et al. 2018; Tilman and Clark 2014) and for diets when meat consumption is reduced (Biesbroek et al. 2014; Scarbough et al. 2012). Most significantly, a decreased risk of all-cause mortality. For example, adhering to the EAT-Lancet Commission’s sustainable diet guidelines could prevent 11.6 million deaths per year among adults worldwide (Willet and Rockström 2019). Similarly, according to a UK-based study, following the World Health Organization’s dietary recommendations could also reduce deaths, improve life expectancy by 8 months, and reduce GHG emissions (Milner et al. 2015). Additionally, three prospective cohort studies in the United States found that a healthy plant-based diet reduced the risk of developing type 2 diabetes by about 20 percent (Satija et al. 2016). There are GHG trade-offs associated with all diets, including harvest emissions, transport emissions, and issues of food waste. Global transport of food accounts for 19 percent of total food-system emissions with high-income countries accounting for 46 percent of international food-miles and food- miles emissions (Li et al. 2022). Domestically, Li et al. (2022) found that the emissions from food-miles for fruits and vegetables were 0.61 Gt CO2e whereas the food-mile emissions for meat were 0.007 Gt CO2e. In comparison, the food production emissions for meat were 2.00 Gt CO2e versus 0.03 Gt CO2e for fruits and vegetables (Li et al. 2022). In addition to transportation-related emissions, roughly one-third of food in the United States is never eaten, representing a significant waste of resources and embodied emissions. See Chapter 8 for more information about reducing food waste to support climate mitigation. Current policies indirectly subsidize the costs of animal products and encourage the use of concentrated animal feeding operations (CAFOs) (Horrigan et al. 2002; Sealing 2008; Story et al. 2008). CAFOs enable a large and cheap supply of meat in the U.S. food system and contribute a variety of air and water quality issues, as well as increase the risk of emerging infectious diseases (Hribar and Schultz 2010). Because animal products produced by this system also cause environmental health impacts, federal spending on agriculture has not been optimized to promote human health (Mozaffarian et al. 2019). For example, current spending on corn and soy to support CAFOs outweighs spending on other fruits and vegetables. Policies must be modified to accurately include the health and environmental impacts in food prices (i.e., healthy and sustainable will also be cheap and affordable). The current system does not reflect “the true cost of food,” which would incorporate the cost of negative health and environmental externalities (Rockefeller Foundation 2021). Changes to the system need to consider the benefits of incorporating health and environmental impacts and the risks of heightening food security disparities with increased food prices. Finding 3-4: Shifting from diets high in animal products to more plant-based diets can reduce GHG emissions, especially methane, from food production and improve health. Plant-based diets are associated with a lower risk of type 2 diabetes, coronary heart disease, stroke, and cancer. Recommendation 3-1: Phase Out Incentives for the Highest Greenhouse Gas (GHG)-Emitting Animal Protein Sources. Congress and the U.S. Department of Agriculture should phase out incentives for the highest GHG-emitting animal protein sources, such as beef, and increase PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 129 

incentives toward sustainable, low-emission production of fruits and vegetables. This could reduce the risk for farmers, create greater access to fruit and vegetables, and reduce production and consumption of high-emission animal foods. Occupational Health Co-Benefits Moving to a decarbonized energy system will decrease jobs in industries with substantial health risks. Analysis of the comparative risk of severe injuries has found that fossil fuels jobs entail greater health risk (higher overall fatalities and higher fatalities per unit of energy produced) than jobs in wind or solar electricity, hydropower, and nuclear energy (Burgherr and Hirschberg 2014). For coal, accidents and fatalities occur primarily in mining, while oil and natural gas have the largest proportion of accidents (e.g., spills, leaks) during transportation and storage (Burgherr and Hirschberg 2014). Although accidents comprise a small portion of overall health impacts compared to ambient air pollution, they can have major impacts on local environmental health (e.g., the Deepwater Horizon spill). In addition to accidents, coal miners are at risk of lung diseases including pneumoconiosis and COPD from their exposure to coal mine dust (NIOSH n.d.(b)). The risk of lung diseases may persist for miners of the critical minerals needed to create some net-zero energy technologies. See the Manufacturing Net-Zero Energy Technologies section below. Maximizing Health Co-Benefits of the Energy Transition Any approach to decarbonizing the electricity sector will decrease co-pollutant emissions compared to a scenario in which no additional carbon policies are implemented; however, some of these approaches may be more effective and faster than others at reducing regional, racial/ethnic, and socioeconomic disparities in exposure to air pollution (Goforth and Nock 2022). Goforth and Nock (2022) note that, given the equity implications of these different approaches, decision-makers need to consider both national (e.g., total air pollutant reductions) and regional impacts of electricity sector decarbonization scenarios. Health impact assessments (HIAs) are intended to analyze how decisions affect population health, including health impacts specific to disadvantaged communities (CDC 2016). These assessments can identify key health outcomes that need to be considered during program design and evaluated after program implementation. HIAs also help build public trust and acceptance and support data analysis to understand the scale of health benefits and harms relevant for decision-making on facility siting and the stringency of standards (Nkykyer and Dannenberg 2019). The use of HIAs that support adaptive management will be critical for the adjustment of projects that are not on target or are creating unforeseen adverse impacts (see Chapter 1 about the critical role of adaptive management). However, health impact assessment tools would benefit from technological advancement to improve ease of use and speed of results. 6 44F Finding 3-5: Decarbonizing the U.S. energy system has the potential to provide substantial health co-benefits including access to safe active transportation options, reduced heat islands, and reduced air and water pollution. However, there are risks to human health that need to be avoided during the energy transition. To maximize health co-benefits and minimize health risks, public health experts need to be engaged early in the decision-making process and often to broaden the consideration of health and equity impacts into planning decisions. Furthermore, affected communities need to be considered priority decisionmakers and should be consulted for relevant decarbonization actions that may pose adverse health risks. The coordinated engagement between The EPA compiled a report enumerating the existing HIA tools and resources with the goal to generate a 6 comprehensive list for HIA practitioners to use throughout the process. For more information, see Pepe et al. (2016). PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 130 

experts and affected stakeholders will advance both public health and equity approaches of the energy transition. Therefore, successful decarbonization policies have to include selection criteria and formal evaluation with health benefits in mind, in addition to equity and efficacy for carbon emissions reduction. Recommendation 3-2: Increase Use of Health Impact Assessment Tools in Energy Project Decision-Making. Health impact assessment tools should be incorporated into the program design and evaluation processes of decarbonization policy with consideration for the full life-cycle impacts. The inclusion of health impact assessment into existing life-cycle assessments for decarbonization technologies will ensure that benefits and costs are considered. This will support adaptive management efforts by providing insight into which programs are not having the intended effects on public health. To support the increased inclusion of advanced health assessments in energy decisions a) Congress should allocate new funds to the Centers for Disease Control and Prevention’s National Center for Environmental Health/Agency for Toxic Substances and Disease Registry to add a Climate Mitigation Health Co-Benefits component to the existing state health department-level Building Resilience Against Climate Effects (BRACE) program. b) The Department of Health and Human Services Office of Climate Change and Health Equity should establish and convene meetings for a new interagency working group with the goal of developing a rapid health impact assessment tool to assess the health and equity risks and benefits arising from deep decarbonization and to mitigate risk to communities. IDENTIFYING POTENTIAL HEALTH RISKS OF DECARBONIZATION While decarbonization is generally expected to produce large positive health co-benefits, some decarbonization strategies could contribute to health harms. To understand the multifaceted benefits of decarbonization, it is important to consider the full life-cycle costs and benefits of emerging energy technologies, 7 including related to public and personal health impacts, in comparison to fossil-dependent 45F energy processes. Many energy technologies that don’t burn fossil fuels are associated with reduced exposure to pollution (Chapman et al. 2018; Hawkins et al. 2013; Lee et al. 2012; Romero-Lankao et al. 2022). However, some of these technologies can also create risks to human health and quality of life. One example is biofuels, which unlike wind or solar, still do emit some air pollutants and would require additional land devoted to agriculture for energy crops, which could have negative impacts on water quality, water availability, and food security (Hill et al. 2009; Luderer et al. 2019). This section discusses the adverse health impacts that need to be considered during the energy transition. Continued Combustion of Fuels A net-zero future will likely still require combustion of fuels for certain applications to maintain reliable and affordable energy services. For example, biofuels or low-carbon synthetic fuels may be required to decarbonize aviation and some heavy-duty transportation, and natural gas burning power plants with carbon capture and sequestration (CCS) may be needed as a firm source of power to back up a mostly renewable grid. Use of low-carbon synthetic fuels or biofuels and combustion of fossil fuels with CCS could reduce or eliminate net CO2 emissions, yet may still lead to release of air pollutants, including PM, NOx, and ammonia (NH3), that have the potential to degrade air or water quality (Driscoll et al. 2015; 7 For a comparison of the health benefits and disbenefits of multiple energy generation technologies and processes, see Smith et al. (2013). PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 131 

Tzanidakis et al. 2013; Veltman et al. 2010). In some cases, chemical- and site-related emissions from hydraulic fracturing, also known as fracking, have been linked to drinking water contamination and negative infant health outcomes, including preterm births, low birth weight, and lymphoma (Apergis et al. 2019; Currie et al. 2017; Hill and Ma 2022; Li et al. 2017; Schuele et al. 2022; University of Pittsburgh 2023). Net-zero-carbon fuels, either derived from biomass or synthesized from CO2 and H2, can emit NOx, CO, SOx, and PM when combusted. Implementing CCS on existing fossil fuel powered plants will require using more energy than an equivalent energy output of a non-CCS equipped plant, and could increase emissions of NOx, NH3, and PM throughout the fuel life cycle, depending on the source of energy to run the capture unit (Tzanidakis et al. 2013). At the capture location itself, NOx and PM emissions are likely to decrease because of pretreatments used to purify flue gas (European Environment Agency 2020) or system designs that integrate CO2 capture with NOx and SOx removal (Shaw 2009). One case study found that, with just the pollution control equipment required for the carbon capture technology to function, NOx emissions decrease by 10 percent, SO2 and filterable PM emissions by 96 percent, and condensable PM emissions by 46 percent (Brown et al. 2023). Depending on the carbon capture technology used, emissions of other co-pollutants, such as NH3 and volatile organic compounds, may increase owing to solvent degradation or reactions of the solvent and flue gas (Benquet et al. 2021; Gibbins and Lucquiaud 2022; Gorset et al. 2014; NETL 2020; Spietz et al. 2017). However, there are strategies for mitigating these emissions. See Chapter 10 for more about mitigating the emissions of criteria pollutants. In some cases, use of low-carbon fuels and biofuels and deployment of CCS may fail to maximize the health co-benefits and to some extent, impede decarbonization. 8 For example, large 46F subsidies on biofuels, particularly first-generation biofuels, could miss health benefits that would be obtained with other renewable energy options and contribute to worse harms via air and water pollution and higher food prices—while also failing to meet GHG emission targets (Lark et al. 2022). See Chapters 8 and 9 for more about biofuels and land use strategies. Increased production of biomass for fuels would require additional U.S. land devoted to agriculture for energy crops, which could have negative impacts on water quality, water availability, and food security. A systematic review found that 56 percent of 224 publications reported negative impacts of biofuels on food security (Ahmed et al. 2021). This finding was not significantly different based on which fuels derived from feedstocks directly compete with food production, like corn ethanol, versus inedible biomass. Additionally, the agriculture practices can lead to the contamination of wells by runoff containing excess nitrogen from fertilizer and animal waste. This can lead to methemoglobinemia (blue baby syndrome) and harmful algal blooms that often produce their own adverse health impacts and are associated with some cancers in adults (Carmichael and Boyer 2016; Temkin et al. 2019; Ward et al. 2018). Similarly, outfitting combusting facilities with CCS has fewer health co-benefits than decarbonization strategies that rely on retirement of combusting facilities enabled by increasing energy efficiency and increasing renewable energy use (Driscoll et al. 2015). While CCS could be targeted for industries where decarbonization is particularly technically challenging, its deployment could potentially delay retirement of polluting facilities where cleaner alternatives exist. For example, in 2020 Wyoming legislated that electric utilities generate power from coal plants with CCS, despite increased costs for consumers and increased pollution, rather than enabling a transition to renewables (Kusnetz 2022). Furthermore, data from a coal plant with carbon capture capabilities indicates a net of only 10.5 percent of CO2 emissions are captured, 9 and that for the same energy costs, wind and solar can reduce more CO2 47F 8 See Chapter 2 for more information about the environmental and equity concerns surrounding CCS and Appendix E for more information about challenges associated with other decarbonization technologies. 9 Jacobson (2019) determined the low net capture rates are due to uncaptured combustion emissions from the natural gas used to power the carbon capture equipment, uncaptured upstream emissions, and uncaptured coal combustion emissions. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 132 

without the air pollution (Jacobson 2019). Furthermore, CCS comes with potential environmental risks (Warner et al. 2020): • Contaminating underground sources of drinking water; • Moving radon closer the surface where it could affect businesses and homes; • Releasing CO2 to the soil or the atmosphere; and • Physical damage, such as landslides, sinkholes, and earthquakes Regulation can reduce risk, through site characterization, monitoring, and safe operational practices (Warner et al. 2020). (See Box 2-2 for additional discussion on CCS, environmental risk, and equity.) Finding 3-6: Decarbonization technologies that involve continued combustion, such as power generation with biofuels and carbon capture and storage, if focused solely on mitigating CO2, can potentially harm human health through continued or increased emission of harmful non-CO2 air pollutants, water contamination, and food insecurity. Similarly, the recent incentives for biomass fuels could have negative impacts on water quality, food security, and human health by encouraging the growth of feedstocks that compete with food production. Manufacturing Net-Zero Energy Technologies Increased demand for minerals, especially critical minerals, needed in the production of solar panels and batteries, for example lithium, nickel, cobalt, and gallium, could increase mining and the subsequent impacts from mining, including significant environmental damage and health risks from contaminated water 10 (Luckeneder et al. 2021; Martinez-Alier 2001). See Chapter 9 for more information 48F about the critical minerals and supply chain associated with electric vehicles. The mining of certain minerals categorized as critical for net-zero technologies is concentrated in a few places: 60 percent of the worlds’ cobalt comes from Democratic Republic of Congo (Brinn 2023), while lithium mining is highest in Chile, Australia, China, and Argentina (Dall-Orsoletta et al. 2022). Cobalt and lithium mining has “effects on human health and local biodiversity, water consumption, energy intensity, and conflicts with local and indigenous people” (Dall-Orsoletta et al. 2022, p. 5). Without equity-centered transition programs and attention to local labor and environmental standards and impacts, these mining activities could affect the health and quality of life of communities where they are extracted (Mayyas et al. 2019; Sharma and Manthiram 2020). Globally, the demand for minerals is increasing interest in mining in areas where mines have been closed as well as in areas with no prior mining activity. This has led to residents expressing concern about potential damage to their communities. See Chapter 12 for more information about recovering critical minerals from mine tailings and other sources. Many of these regions may lack adequate or updated mining regulations to protect public health and the environment (Healy and Baker 2021; NASEM 2022b). In February 2022, the U.S. Department of the Interior announced an Interagency Working Group on Mining Reform to inform potential updates to regulations and permitting (DOI 2022). Communities need to be informed about and involved in the process of siting new mines and related infrastructure. See Chapter 5 for more information about inclusive siting and development practices. The CDC’s National Institute for Occupational Safety and Health (NIOSH) is a research agency whose work is supported by five advisory committees that provide advice and guidance on topical areas, including occupational and mine safety and health (NIOSH n.d.(a)). NIOSH, in coordination with other relevant research groups, can 10 Analogous effects are associated with fossil fuel mining and extraction, and such activities are likely to decrease in a decarbonized future. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 133 

play a critical role in the assessment of the risks associated with decarbonization technologies, especially occupational health risks. Although this report focuses on the United States, the full life cycle assessment of health impacts needs to take into account international impacts. A transition to greater use of rooftop solar can reduce GHGs and water consumption; however, when considering the full life cycle of solar, the water demands and environmental hazards would likely be transferred to countries where the solar panels are being manufactured creating global health and equity concern (Frisvold and Marquez 2013; Vengosh and Weinthal 2023). Greater consideration is also required for the end of the life cycle of these in-demand materials, especially for metals which can be recycled but often end up in landfills (Reck and Graedel 2012; Seeberger et al. 2016). Specifically, 95 percent of critical minerals in lithium-ion batteries can be recycled at the commercial scale (Brin 2023). One way to mitigate mineral extraction and waste from solar panels and batteries would be to encourage manufacturers to develop standardized modules to enable easier recycling (see Chapter 9 for more information about mitigating mineral extraction). Likewise, the planning for the decommissioning and restoration of the sites of mining, natural resource extraction, oil and gas production, and fossil power plants is important for the renewal of communities and avoiding continued health harm from insufficient environmental remediation. Additionally, more mass transit and active travel could reduce the demand for vehicle manufacture. Finding 3-7: Some components for low-carbon energy technology show potential health harms for workers or the general population that must be mitigated and weighed against other expected benefits, especially the benefit of reduced life-cycle harms from fossil fuels, which include contamination during resource extraction or oil spills. Recommendation 3-3: Assess Occupational Health Risks Associated with Clean Energy Technologies. The Centers for Disease Control and Prevention’s National Institute for Occupational Safety and Health should assess health risks associated with the manufacturing and deployment of clean energy technologies. This assessment should characterize potential occupational health risks relating to the extraction of raw materials, the manufacturing and installation of technologies, and the final disposal of waste products in an approach consistent with life-cycle assessment practices. Furthermore, the analysis should also identify preventative interventions for addressing such occupational risks. Building Retrofits Unintended health risks may occur with indoor air quality when buildings have improved sealing against the air but can be managed with precaution. While generally energy efficiency retrofits provide health benefits, increased air tightness in homes could also increase concentrations of unwanted indoor air pollutants, including radon and VOCs like formaldehyde (Fisk et al. 2020; Symonds et al. 2019). Building retrofitters need to check for this risk in radon-prone areas, or buildings with older or damaged foundations, and add mechanical ventilation (Ferguson et al. 2020; IOM 2011; Rapp et al. 2012). Weatherization that avoids exacerbating indoor air pollution, combined with decarbonization, produces the greatest health benefits while minimizing the potential hazards. See Chapter 7 for more information about building retrofits and weatherization. Transportation Electrification For transportation electrification, the benefits depend on how energy is generated. The provisions in IRA and IIJA intend for electric vehicles (EVs) to be powered by a grid with mostly renewables, which would provide both GHG and health benefits. Even today, an average EV is lower emitting than an PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 134 

average internal combustion engine vehicle (ICEV) in every region of the United States; furthermore, more than 90 percent of the U.S. population lives in a region where the average EV is lower emitting that the most efficient ICEV when traveling at 59 mph (Reichmuth et al. 2022). However, increasing EVs without decarbonizing electric power would limit the health and GHG benefits of vehicle electrification, primarily shifting emissions from where the vehicles are driven to where the fossil power is generated (Brinkman et al. 2010; Nopmongcol et al. 2017; Thompson et al. 2009; Razeghi et al. 2016; Weis et al. 2015). Studies differ on the likely impact of vehicle electrification when paired with fossil-fuel intensive electric power, including at the extreme case of EVs fueled entirely by coal-powered electricity. Some studies estimating health impacts of EVs charged by coal power indicate 80 percent higher environmental health costs relative to an ICEV fleet (Tessum et al. 2014) while others indicate that coal-powered EVs still lead to health improvements relative to the average ICEV, given that transportation emissions tend to occur much closer to where people breathe than power plant emissions (Shindell 2015). Studies examining more realistic cases of EVs powered by today’s grid mix and likely future fuel mixes of the power sector generally show that EVs reduce both GHG and health-harming emissions relative to ICEVs (e.g., Funke et al. 2023; Peters et al. 2020). To fully reap both health and decarbonization benefits, transportation electrification must be accompanied by decarbonization of the electricity sector, as this report calls for. See Chapter 9 for more information about decarbonizing the transportation sector and Chapter 11 for more information about decarbonizing the U.S. electricity grid. Equity Considerations Decarbonization, public health, and reducing inequity cannot be accomplished by individual choices alone, requiring consideration of system-wide processes. While people can be asked to reduce their carbon footprint and better their health, this places the burden on individuals to overcome obstacles to these activities—especially challenging for those with limited time, money, and in areas where accessing energy efficient appliances, fresh vegetables, and safe biking routes may not be easy to access. This is also a challenge in wealthier, mostly white neighborhoods—even with newer, energy efficient houses, the larger size of these houses means that they still have high total emissions per resident, relative to Black neighborhoods, creating an “emissions paradox” (Goldstein et al. 2022). Systematic approaches to alleviating barriers are needed and health and equity impacts need to be prioritized over technological solutions through requirements for health- and equity-focused analyses during decision-making (Rudolph 2022). Such analyses must emphasize benefits to communities whose health and economic priorities have been met with resistance or misinformation from the fossil fuel industry (NASEM 2021). To improve health during the energy transition, the nation must be aware of both the costs of decarbonization technology and reduce inequity. SUMMARY OF RECOMMENDATIONS ON PUBLIC HEALTH CO-BENEFITS AND IMPACTS OF DECARBONIZATION TABLE 3-2 Summary of Recommendations on Public Health Benefits and Impacts of Decarbonization Actor(s) Responsible for Sector(s) Objective(s) Overarching Short-Form Implementing Addressed by Addressed by Categories Addressed Recommendation Recommendation Recommendation Recommendation by Recommendation 3-1: Phase Out Congress and U.S. • Land use • Health Ensuring Equity, Incentives for the Department of Justice, Health, and Highest Agriculture Fairness of Impacts Greenhouse Gas (USDA) (GHG)-Emitting PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 135 

Animal Protein Sources 3-2: Increase Use Congress, Centers • Electricity • Equity Ensuring Equity, of Health Impact for Disease Justice, Health, and • Buildings • Health Assessment Tools Control and Fairness of Impacts in Energy Project Prevention (CDC), • Transportation • Industry Rigorous and Decision-Making National Center Transparent Analysis for Environmental • Fossil fuels and Reporting for Health/Agency for Adaptive Management Toxic Substances and Disease Registry (NCEH/ATSDR), Department of Health and Human Services (HHS) Office of Climate Change and Health Equity 3-3: Assess Centers for • Electricity • Equity Ensuring Equity, Occupational Disease Control Justice, Health, and • Buildings • Health Health Risks and Prevention Fairness of Impacts Associated with (CDC), National • Transportation • Employment Clean Energy Center for • Industry Technologies Environmental • Fossil fuels Health/Agency for Toxic Substances and Disease Registry (NCEH/ATSDR), Occupational Safety and Health Administration (OSHA) REFERENCES Abel, D., T. Holloway, M. Harkey, A. Rrushaj, G. Brinkman, P. Duran, M. Janssen, and P. Denholm. 2018. “Potential air quality benefits from increased solar photovoltaic electricity generation in the Eastern United States.” Atmospheric Environment 175:65–74. https://doi.org/10.1016/j.atmosenv.2017.11.049. Abel, D.W., T. Holloway, J. Martínez-Santos, M. Harkey, M. Tao, C. Kubes, and S. Hayes. 2019. “Air Quality-Related Health Benefits of Energy Efficiency in the United States.” Environmental Science and Technology 53(7):3987–3998. doi: 10.1021/acs.est.8b06417. Achakulwisut, P., S.C. Anenberg, J.E. Neumann, S.L. Penn, N. Weiss, A. Crimmins, et al. 2019. “Effects of Increasing Aridity on Ambient Dust and Public Health in the U.S. Southwest Under Climate Change.” GeoHealth 3(5):127–144. https://doi.org/10.1029/2019GH000187. Agyeman, J., and A. Doran. 2021. “ ‘You want protected bike lanes, I want protected Black children. Let’s link’: equity, justice, and the barriers to active transportation in North America.” Local Environment 26(12):1480–1497. doi: 10.1080/13549839.2021.1978412. PREPUBLICATION COPY – SUBJECT TO FURTHER EDITORIAL CORRECTION 136 

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