In Africa, as elsewhere in the world, climate change looms as a profound health challenge in this century. Socially, politically and economically mediated ('tertiary') effects will probably be the most significant consequences of climate change, substantially exceeding the probable burden of its direct effects and infectious diseases. Climate change will decrease crop yields in many low-latitude areas, decreasing food security in many countries, including those in Africa. Under-nutrition will worsen, aggravated by diminished economic growth - one of the most widely predicted consequences of climate change. Furthermore, migration will increase, which will stretch and could even overwhelm health systems in destination areas, in addition to sapping donor locations of the financial and human capital they could use for further development. Mass migration heightens the risk of conflict, as does resource scarcity caused by climate change. Consequently, the capacity of states to meet the expectations of their citizens and impose law and order could further decrease, incentivising unscrupulous leaders to initiate or sustain conflict to enhance their support base. In summary, health systems on the African continent will be severely challenged by the increased demands caused by climate change, while their capacity will be diminished by its direct effects, reduced economic growth, additional migration and conflict. Adaptation is frequently treated as the best climate change response, but it is especially difficult in poorer countries, where even general development is threatened by these challenges. Reliance on adaptation would exacerbate the health gap. Global climate change mitigation is the surest way to preserve health, in Africa and elsewhere.