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Hello everyone. Welcome back from the lunch break for our first session this afternoon. I'm delighted to be chairing this important session on maternal health and heat. I think this topic is a great example of something that those of us living in the UK in England, Scotland thought is a particularly important issue for us. But climate change is changing that for those of you who don't live here in 2022 we had three heatwaves over the summer with temperatures of 40 degrees being recorded in England. We have had nine of the 10 most hottest days in the country in the last 24 years and the trend is for increasing average temperatures. So really making this global issue local as well, despite the growing evidence of the impact of health on pregnancy outcomes, which I'm sure our speakers are about to detail. Pregnant women have not been consistently included in heatwave planning as at risk groups in the UK. In fact, they weren't even there all before 2021. This is an equity issue because the pregnant women who are most vulnerable to the adverse effects of heat are vulnerable for other reasons of poverty or pre existing ill health. So to tell us more about the current evidence and potential interventions related to heat and maternal health. It's my pleasure to introduce Professor Anna Bunnell and Dr Yohara Idris who are both joining us online from the Gambia. Professor Burnell is a professor and academic clinician who brings together her knowledge of clinical medicine physiology, maternal health and epidemiology to work on the nexus between climate change and maternal and child health. She works particularly in West Africa and importantly on the co design of sustainable interventions to reduce the health risk of heat in vulnerable populations in NICS. Dr Idris is a research clinician and study co ordinator working with Professor Burnell on the heat in pregnancy study to evaluate the effects of climate change and heat stress in pregnancy and the path of physiological and biochemical pathways associated with adverse pregnancy outcomes in pregnant women in the Gambia. So I'll hand over to our speakers now and just remind you to submit your questions as we go through and I'll bring them to our speakers in the Q. Thank you. Thank you very much for the instruction and it's a real pleasure to be here with you today. Although it online we are calling in from the Gambia in West Africa and sorry not to be able to join you in person. If for any reason, we don't get to your question and you want to contact us afterwards, then please feel free to drop myself or Dr Idris an email and we'll be happy to discuss any aspects of our talk further. So I wanted to start by presenting this slide from the most recent IPCC report and really highlight two important points from it. One is that the climate scientists are very good and that unfortunately, we are following the trajectory and the slopes that they predict looking at the greenhouse gas emissions. The other point is that although they've been very good at predicting the climate models, what we find from the most recent report is that actually the impacts are being felt at a lower temperature than was initially thought. So in 2014, the extreme weather events, for example, were predicted to occur at a higher temperature than what we see in reality come 2022 and ongoing. Um and just to add to what has already been said about the current state of the climate. So we all know that 2023 was the warmest year on record. In fact, many people say that welcome to the coolest year of your life because we know that every year going forward, we are breaking heat records on heat records. The average temperature has already exceeded the Paris agreement of 1.5. Although we can't say for certain that that has properly exceeded it until we have a further trend over the next few years. And we see records being broken in multiple countries. And multiple continents year on year. So I wanted to um coach this place, this discussion that we're gonna have on this statement from the UN where they state that climate change impacts are not gender neutral. And I would like us to bear that in mind as we go through presenting some of the evidence base around the impacts. But also as we start talking about what solutions and what interventions could be affected And why do we think, why do we know that climate change impacts disproportionately affected, affect women? And it's not to do with physiological or biological vulnerabilities. It's actually to do with some of the social and economic vulnerabilities that come with women having less access to agency and decision making and disproportionately making up the percentage of the global poor who are living in extreme poverty. So this is just a visualization to give an overview of the impacts of climate change on health more broadly. So we tend to try to divide it up into direct and indirect effects, although some pathways don't fall neatly into that. And so extreme weather events would be classed as a direct effect of climate change. But things like changes in vector borne diseases, exposure changes in food security would be on the indirect pathway. And then these, these different um direct and indirect effects obviously can then have a whole host of different um health impacts going forward. I will focus and this talk will focus mainly on the impacts of extreme heat. But it's important to bear in mind that often with climate events, these are happening as compounding events. So you see drought over a number of years followed by an extreme heat event, followed with crop failure associated with this, all of which made much more likely due to climate change. So they do not happen in isolation. So like I said, I'll focus on the extreme heat and the health impacts. Um and where, what we know at the moment around how it impacts on m uh maternal health. So this is a study that was published last year from sorry, in 2020 last year, in 2023 from a group in India where they looked at occupational heat exposure. And I think this really also speaks to this affects the fact that heat affects disproportionately affects those living in poverty. So this was focusing on women who work during the course of their pregnancy and they found an increased risk in um all cause adverse pregnancy outcomes. So that's miscarriages, still any fetal loss, um low birth weight and preterm birth. And what was interesting is that they found this big rise in the Tympanic temperature that they did when they looked at the working shift. So somebody working at the beginning of the day versus the end of day, and they saw this increased risk of dehydration in these women. And this is going to lead into some of the discussions that we have around. What are the mechanistic pathways that are associated with the adverse outcomes and heat exposure. So, there are lots of studies now. Um the most recent kind of collated evidence shows that there's over 100 environmental epidemiological studies showing the adverse impact of heat on a whole host of different pregnancy outcomes. Um All the way through from congenital abnormalities to people lost to preterm to preeclampsia and gestational diabetes. Um I've just picked out two to give an indication of where the the amount of association that you see. So the top graph gives you the um uh results from a meta analysis that uh looked at the impacts of heat waves on preterm birth and found a 16% increased risk of preterm birth in those exper er exposed to uh heatwaves. And the bottom graph is from a study that was conducted in South Africa looking at the risk of developing preeclampsia and showed that if women are exposed to early heat in the first few weeks of pregnancy, this then increased their risk of preeclampsia later. And this feeds into some of the pathways that we are exploring in terms of epigenetic changes. So this is the visualization that we put together to try to summarize where we're at with our knowledge based around um what is actually happening and why most of this is based on animal data or very small numbers of studies. And so there's a big knowledge gap still to really understand why it's happening. But what we do know is that if you're exposed to heat in different time points in your pregnancy, you have different outcomes. So those that are exposed in the first trimester um are increased risk of congenital abnormalities. There's evidence that epigenetic changes occur and different protein expression happens. Whereas those that are exposed later in pregnancy have this increased risk of stillbirth, pre preterm birth and small babies. And just to um feed into this, the, the reason how we develop those sort of our understanding of this is is based around some of our pilot data from the Gambia. So in this uh this study, we looked at pregnant subsistence farmers and what we found was that there was a large um heat stress exposure in the pregnant farmers just working in their day to day activities, including those that um uh in and this is this is data from 2019. So obviously, it's only got hotter since then. And when we looked at the maternal physiology, what we found was that again, you see this rise in core temperature from beginning and end of working shift, we saw a link between the heat stress exposure of the mothers and the fetal heart rate. And we saw a link between the umbilical artery Doppler and the heat stress exposure where those that had an adverse pregnancy outcome had a different response to the umbilic um to the heat stress in terms of their placental uh abilities and then moving on from just looking at adverse birth outcomes. There's a growing body of evidence looking at maternal morbidity as well. So this is a study from the US where they took different definitions of heat waves and linked it to 20 of the top maternal morbidity conditions. So that's hemorrhage, pulmonary embolus or sepsis, for example. And as you can see, you get a big increase in the risk as the heat wave days go on over time. And there's ongoing work now to try to expand this work in other settings that hopefully will give us a clearer idea of what's happening and it's not just the physical effects. So there's been a fair number now of qualitative studies to understand how these impacts on mothers. This is a report from Sindh Province in Pakistan where they spoke to them about not only working, living in the extreme heat, but also this compounding problem of the extreme floods that they experienced. And the women experienced grief, despair, stress and fear as they thought about their environmental stressors and that they were trying to live with another maybe yeah, less well explored, but it sort of rising in the awareness is this link between extreme heat and intimate partner violence. Um And this is a recent report from the UN where they looked at um the using the health and demographic data, they looked at the risk of, of intimate partner violence and heat exposure and found that in certain parts of Sub Saharan Africa, you're at more risk and in particular, you're at more risk if you're younger and if you're from less, less, well economic groupings. Um And I will hand over now to Doctor Idris to give a bit more, uh give a talk on our ongoing work here in the Gambia. Ok. Thank you very much, Doctor Anna Bon. Uh It is my pleasure to join the call. Uh Ana Bonia has sent the stage and the on the an has set the stage and the uh the available evidence is on maternal heat exposure and the advanced pregnancy uh uh outcome and uh and our previous work in the Gambia. So I'm going to be talking us to the pathophysiology mechanism of acute and chronic he failure on maternal and fetal wellbeing. Uh This is a welcome trust uh funded. Uh This is a welcome trust uh funded study that is we started in 2025 go up to 2027. So our approach include uh five work packages starting with a systematic review. In this review, we uh set for available evidence is on the part of physiology of uh acute and chronic exposure. And, and then currently uh this work has been completed and hopefully in the night in the time to come, we're going to publish this work. So the one of the second work packages. The acute heat chamber study. This is a work that has been cut that has been that that was carried out in uh Greece. So, uh pregnant women were recruited and then trialed into heat chambers, heat chamber at the physiological to see the effect of acute heat exposure on their physiology. So, this is also a work that has been concluded and then publication uh will soon be out on this uh aspect. So currently what we are doing in the Gambia, it is C is a crony heat exposure uh on the cohort of pregnant mothers. So in this aspect of the story, we are recording pregnant mothers in two regions of the Gambia with geo variable geo chromatic characteristics. So this is where I'm going to dwell more to talk to highlight more on our ongoing work or what we are doing on the ground. Also, we are also doing a placenta work along uh with this uh recruitment at the end, a bone is going to talk to us on the potential uh adaptation and intervention options uh that we can carry it out to uh kind of avoid the impact of extreme heat Asian. So our recruitment side has two location in the Gambia and the BCAA which is uh coastal region which is very cool, which is relatively cooler temperature. And then we have the center which is the hottest part of the Gambia. So these two regions have a GE variable geoclimatic characteristic, especially temperature. As you can see from the figure on the right, the temperature average temperature, monthly temperature in basi can go as high as 40 degree, 45 degree while in the the average monthly temperature is below 35 degrees. So we are going to be recruiting about 800 m into this study. Uh One third of which we come from Brian, which is the inland uh the coastal region and then the remaining proportion we come from ba. So our study visit uh we have five distinct study visits. So interpose on this visit is the monthly uh home visit by our feed uh workers. So the first study visit is the enrollment visit where we recruit these mothers in collaboration with uh some clinics in the centers where we are carrying out the study. So at enrollment, we are going to assess the gestational age of the participant and make sure that the gestation is below 28 weeks of gestation. So once the participants fulfill this criteria, she is going to be enrolled into the study following the scan. And then at this stage, we also collect some data on social demography, clinical and obstructing data. And afterwards, then we schedule her for subsequent visit. So in the second visit, the week 28 visit. So prior to this visit, we uh uh visit, the participant comes to deploy some to deploy some other devices that we are going to be used for monitoring the uh heat exposure and the physiological stressors. So after five or six days of uh deploying these devices and attaching those devices to the participant. Uh at the completion of the 28 week, then you come to the clinic where we will conduct the obstetric scanning and then con collect some etor clinical and blood samples. So basically at that stage, so subsequently, we wait for the next visit, which is going to be visit at week 35. So at visit, week 35 prior to this visit, the field worker, we also repair the same procedure of visiting the participants houses, attach or deploy this uh devices we are using for heat exposure monitoring. Then subsequently they come to the clinic at the same, we repeat the procedures and with 28. So after we 28 visit, we go to uh delivery visit. Once the participant visit the hospital for delivery and immediately the participant deliver, we collect uh the delivery data, the bad outcome, we measure the the charts and data, collect the blood samples and then placenta sample afterward. The next visit, which is the fifth visit. Uh The last clinic visit is the postpartum visit where the child is brought to the clinic. And we conduct uh we will conduct neonat uvea assessment scale and then also collect some blood samples at this stage. So the interpose in these visits as earlier. Are you that we have the uh monthly home visits, which is going to be carried out by our feeder assistant. So and in this visit, we uh uh kind of collect uh data on maternal recent illness. And then maybe we as the in the last one week, what is what illness that she experienced? So also the heat exposure related questions, sleep, uh uh quality and quantity question and then for security and and also what security at this stage in each of the uh monthly visit, we collect this data. So our heat exposure mapping, we are going to be using some devices related to heat stress and the air pollution devices and the no noise pollution devices. Currently in the field, we have deployed the heat stress on devices, both ambient and the personal device, uh strength device. So we have been deployed in the field but for air pollution noise pollution devices, uh this hopefully we're going to deploy them in the field. They come in November, hopefully. So I'm going to be touching us to uh concentrate more on the heat uh strength devices. So here is one of the device we use as part of the environmental or ambient uh monitoring device. So this device is mounted in the regions or the locations where we are our participant embassy. And so and then the devices is recording the environmental temperature, the humidity pre baretta pressure, wind speed deal and the heat point. Subsequently, we are going to model the data using the multilinear uh line user creation. So here is the personal uh monitoring device that we deployed to the feed. And then at each of the base 28 at week 28 and 35 visit. As IE as I earlier highlighted, we are going to be attaching these devices to the participants. So uh subsequently, the device on the left is going to be measured in the temperature, the humidity and then the dew point and the heat index. Why the device on the right is going to be monitoring the physiological uh stress or such as the heart rate, respiratory rate, the P the ma or the mother level of physical act and then the sleep uh physiology. Subsequently, we are going to download this data and then uh uh save them in the database for subsequent analysis. So the marginal uh health and wellbeing questionnaire, as I earlier said, uh we visited the murders month on a monthly basis where we assess for illness. And then we preceding four weeks, we also uh administered the wh 05 point to this participant. We also uh conducted sleep survey where we assess for sleep quality, frequency, quantity and quality. Then also the food security, the water assets, food diary and tax uh diary. So the tax diary, you just ascend the mothers about the activities, what they have been doing throughout the days. Have you been to the market? What kind of activities they have been? Carried out. So the fa health data collection uh at each point in time at, during the enrollment visit with 28 visit to 35 visit. We are collecting data on the fetal wellbeing. So we do this by uh conducting an ultrasound scanning on the mother where we measure the head c the the the fetal head circumference, the biparietal diameter, abdominal abdominal circumference and femur and to determine the condition that each at each point in time. And then to also check for the future wellbeing at this at the week 28 and 35 visit. We are also conducting our blacker artery do to assess the placenta block to one to us uh to for assessment of any placenta insufficiency. So at uh delivery, we assess for the bad outcome both on the mother and uh and on the feet on the neonates on the mother, we assess for maternal complications related to pregnancy such as uh postpartum hemorrhage. We have a duration, we assess for duration of labor, the duration of labor and any other advance uh uh pregnancy related adverse outcome. So, and for the fetus, we are assessing for the ab score. We also assessing the physical development of the gi and measuring the weight, the length and head circumference. So at this stage in time, we also collected by some biological samples such as we collecting the matinal blood. We're also collecting the placenta samples as a a uh uh earlier said we are going to be doing some epigenetic analysis on the placenta samples. At this time, we also call it the cold blood sample. So at uh postpartum visit, the childs are going to be well, the the child, the the neonate are going to be brought to the clinic. We are going to be assessing there for United Assessment to assess for uh the the fetal neurodevelopmental level at this stage and also the motor and then some reflexes at this stage. So we also assess for feeding behavior in the neonate, the frequency of feeding, the duration of feeding and other uh uh other areas related to the feeding. So we also assessed the sleep quality, the child, the frequency, the duration uh both day and night. Then we also assessing the physical development at this stage. Also by conducting the at tropometric measurements such as the height weight and the the head circumference. And we also assessing the vital signs, getting the pulse rate, respiratory rate and then the degree of uh maybe the blood level is a check in for the PCV or the hemoglobin level. So we finally we carry out the final blood sample for the child where we'll be collecting uh uh the hip prick sample. We do hip prick sample at this stage and also we'll be collecting a vaginal swab sample and sorry apology. We'll be collecting a rectal swab sample for microbiota at this stage. So I was taught the outcome for both for the mother and the child. For the mother, we have a history and the sleep quality and quantity, the wellbeing, full security placenta function and some uh inflammatory proteins or biomarkers and also the placenta epigenetics. So these are the marginal uh outcome of the study we're expecting. So for the fetal, we're going to be a certain fetal growth restriction, fetal loss, pre birth, low birth neonatal behavioral assessment. And our study output will be immunology and coos we have a phd student or two phd student to be looking at this area where uh and then we also have uh another phd student that will be doing some lab related work on inflammatory proteins and biomarkers, placenta physiology, molecular and epigenetic studies. So at this stage, I'm going to hand over to doctor to continue with the discussion. Thank you. Thank you. Sorry. I have five minutes to very quickly talk a little bit about the evidence based action on heat. And I divided this broadly into government action, public health measures and individual changes. So um in terms of government actions, I think we all have heard many over the years that sort of move towards trying to green the urban environment and how, how much benefit there is from that. And there's actually strong evidence that if you do greener city, you can increase the the quality of the air, you reduce the air pollution exposure, you can reduce the heat exposure and also improves physical activity and stress levels. So then I was interested to understand whether or not there's evidence of this specific for maternal health. And what we find from some of the larger studies is that they on a split where they've looked at greenery as an interaction term and found that those that are exposed to more greenery have less effect of heat. And this study is a study from Spain where they did basically that they had four different regions and they looked at how the effect of exposure to green space, altered fetal growth. And what's interesting is that you only see the effect of greenery in the lower socioeconomic groups, not in the higher or middle. So whether or not it's itself in and of itself beneficial or whether it's part of a wider commentary, maybe on the economic disparities in regions. I think there's, there's, there's, there's sort of like question marks about how it, how it would actually work and there's clear compounding between the heat and the air pollution exposure when it comes to green greenery. So I think the verdict isn't quite out there as it turn to like a hard clinical benefit of greenery. But there's no doubt that um it's it's beneficial in other respects. Um Something I just want to very briefly touch on is the heat health action plan. So, as we already heard um in the introduction that pregnant women were only recently included in the as a vulnerability group. And I just want to take this time to highlight the fact that heat health action plans are fantastic. They have shown to work in terms of reducing mortality, overall mortality from heat waves. But if pregnant women are not included in the planning phase, then they may not be effective for pregnant women and the lives that they are living. For example, if you are responsible for collecting water for your household, and our advice is you need to drink more water, then actually the burden is then just falling to the women to then collect more water to allow everyone to deal with the heat. Equally, the access to cooling centers may be prohibited depending on the setting and the gender availability of the different cooling centers. So it's I think it's overall a very good thing to think about, but it risks widening the disparity and the inequality between groups as well. If it's not done carefully and leading on from this. This is an example of when it has been done very well. So this was a study that was done in Pakistan where they used community health workers who are often female and accessed the low income did a cluster randomized controlled trial of low income communities in Karachi in Pakistan. And they found that with a simple educational intervention, they managed to reduce all cause hospitalization visits during the heat waves. The last few things that I wanted to bring to your attention is things that are a little bit maybe less obvious and on the cutting edge that we don't really know as yet what this is going to mean. So this is a paper that was published last year from Shanker at all. Again, using data from Pakistan where they use data from a clinical trial where women were identified pre conception, supplemented with micronutrient supplementation. And then they used the data from the trial to understand how extreme heat affected those women. And what they found is the women who were supplemented with micronutrient supplementation. Pre conception were protected against the effects of extreme heat in the first trimester. So if you weren't supplemented, you had a reduced length of gestational age Z score if you were exposed to heat. But if you were supplemented, you didn't see that. Conversely, this is a study that we are just um we just finalized and will be published shortly. We also used a a randomized controlled trial, nutritional intervention study to look at how nutritional interventions and heat exposure interacted in terms of growth. And what we found was that in pregnant women supplemented with protein energy supplementation in the final trimester had a worse impact of extreme heat versus those that received either standard care, iron and folate or micronutrient supplementation. So there's complexity around the interaction between um nutritional status and heat exposure um that hopefully will become um a bit clearer going forward with, with new work. And finally, I just wanted to highlight this, which is a bit of a theme around um economic impacts of heat. This is a study that was done in Ghana where they gave unconditional cash transfers. And this is a subsequent secondary analysis of this cash transfers looking at the link between heat expos C and low birth weight. And what you can see is that those who were given the cash transfers had no effect of heat on their risk of low birth weight. Whereas those that were not given the cash transfers, you can see an increased risk if they're exposed during their pregnancy. I um have the final note which is um around female empowerment and education. So this is often touted as a weighed as a as climate action. And the reason why it's thought to be a, a strong advocate for climate action is that women are extremely strong advocates as we see, especially with our youth leaders. Today, there are a lot of extremely powerful young women coming forward, pushing for climate action. But if you, if you increase women, girls education, then they get more reproductive choices. They have more agency in their choices going forward and they can also then access the green market, which is as we know, growing rapidly. Finally, I'd say a huge thank you to the teams. Um Both our current work on gaps and, and the other work that, that, that we presented earlier, um our collaborators from the University of Cambridge and the Fame lab and the funders. Welcome trust. Thank you very much. Thank you both very much. So, got some questions coming in. But just before I go to those, I'm going to use the chairs prerogative to ask. It's really interesting to hear about the pre conception, micronutrients and the benefits of that and then potentially not of the protein. And I wondered, given you also presented the potential different outcomes related to heat exposure at different time points during pregnancy, whether you had any early hypotheses about the pathways for those? Yes, thank you. That's a great question. So actually, the micronutrient supplementation study, they also then looked at some epigenetic changes and found almost 1000 differentially expressed genes in those that were exposed to heat versus not exposed to heat. So we hypothesize that if you are, there may be some protective mechanism at that early stage of pregnancy around your epigenetic changes if you're supplemented with the micronutrient supplementation. Whereas at later pregnancy, we know that if your so your heat, your heat strain is a combination of your environmental heat, stress exposure and your internal metabolic heat production. And so when you give people high energy protein energy supplementation, what you're doing is actually increasing their internal metabolic heat production. And so that's what we think mainly happened in that situation where they're then increasing the heat production in those that are supplemented with protein energy and it possibly just tips the heat stress, overall heat stress into negative impact on the fetus. But like I said, it's very new those findings and I think there's definitely a need for studies to collaborate those findings. Great. Thank you. So I have a question here from Valentina, who's asking about the devices worn by women? How are you ensuring that they'll wear them all the time? Are data synchronized or do you download when you meet them? And have you thought about any resistance fear or doubt about wearing these devices? Yes. Also a very good question. So we we have a little bit of experience with using devices from previous studies. And that's kind of why the one that we chose is the one that we settled with. So we thought that to expect a woman to wear a device for five days straight, that's on the chest or like, you know, like around the abdomen would be untenable for people. So that's why we ended up choosing the risk device despite the fact that it maybe isn't quite as accurate in a lot of ways compared to some of the other devices that you can get that measure elsewhere. So as part of our kind of initiation of the project, we do very extensive community sensitizations and during the community sensitizations, we meet not only with pregnant women and the healthcare workers in the villages and the clinics, but also with senior members of the community. So Al Carlo, the head of the community, both men and women. And at that stage, we would, we address many of the questions and queries. They have. One of the queries was around the device and was around. What does the device do? What's it recording? Is it recording me? So at that time, we were able to allay a lot of the fears around what the device was actually doing. If people take the device off, then it will just not record during the time that they've taken off. So we will just miss that data. But we are regularly checking in on them to make sure with the field team, we're doing the best that we can to make sure that we have robust data. But we accept that this is a pragmatic observational study where people are living their lives and there will be some data loss. And is this relatively novel in the fact that you've got individual level measures of temperature? Whereas many of the studies I've seen before have been sorry, geographical measures of temperature to correlate a geographical exposure with an individual. Whereas you're going to have some individual measures like how unique is that? Yeah, it's, it's I don't think it's completely unique, but it's definitely more common in say the occupational health setting versus the maternal health setting. So I think we're one of a few studies that are currently. So the well trust funded a call looking at heat exposure in maternal and child health. And so there are I think four or five cohorts and we all have quite similar methodology including individualized environmental monitoring. So that's one of the plans is to look at how well the individual monitoring correlates with the weather station data and also how well it would correlate with the satellite data to give us an indication of how accurate are our exposure measures? Yeah, great. And another question saying it's so good again to see the theme of taking research data and using them for advocacy and policy change. So do you think this should be a core priority for global health researchers? And how can we better design research to impact policy? It's a big question. Um Thank you. I'm not sure I'm gonna do a very good job of answering it. Um I, I've long been a believer in advocacy, but I do think it's quite a personal, personal commitment and a personal passion. And so I wouldn't want to kind of tell everybody that that's how you should be doing it. Yeah. So I'm not sure how I feel as a sort of like statement that this is how we should be. I think for me personally, I feel an obligation because I live and work in a place where I really see the impacts of the climate crisis on women and in particular on women who have very little choice in avoiding those exposures and So I feel like an obligation to speak up on their behalf. But I feel like that's quite a personal decision in terms of how to make research more relevant to policy. Then I think it has to be a round table discussion between researchers and policy makers to understand really what it is. What is it that policymakers need to see to then change their decisions to fit the health profile because the IPCC have been throwing out their reports year on year showing the impacts of the climate crisis and how harmful it is for health. None of this is particularly new or shocking and yet the ultimate policy changes aren't happening. So II, yeah, that's all I can say on that. Thanks. Thank you. So we've got two minutes. I ask one last question. You talk there about some of the community sensitization work you've done around the devices. And Wendy's asking whether there's a qualitative component where you'll be looking at women's views and perceptions to the adaptive behaviors and how they'll be engaged in developing those mitigation strategies. Yes, absolutely. Thank you. That's a great question. So I didn't present it today. But we also have another study that's happening in Pakistan, which is a cluster randomized controlled trial of heat intervention bundles. And the idea is that we would try and use some of the learnings from that study to bring to the discussion board around the qualitative work on what interventions could work So what we would like to do is take the evidence base that we're creating from this cluster, randomized controlled trial of we're doing structural interventions, educational interventions, community interventions, see what works and then try and discuss it in this setting to see what would be appropriate, what would be feasible, what people would actually want here going forward. So that's completely embedded within the project as well, going forward. Great. Well, thank you very much. We will wrap it up there. Um If you'd like to give a round of applause for our speakers. Thank you so much for your presentations.