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So we watch out. She's a public health physician with a phd in infectious disease epidemiology. She spent 10 years working in the MS including the emerging and Infectious disease proposal. Writing her time among COVID-19 malaria and other infectious disease outbreaks. She's worked in sponsors, multiple and one of the program directors for the new Distance Learning Healthy Humanitarian Program. She remains MSF as clinical and advisor and follow competition with us. Thanks for giving me the blood. He is the president of the Royal Society of Medicine and Hygiene. He's previously worked in the G for, for Children and Sierra Leone for the Medical Research Council. He was the team leader in the Medical Research Council program for Aids. Previously, he was head of international activities and Population Health as well as well as a member of the scientific advisory committee for the WH O Sra Move for action to prevent AICs. He shares the sign of a group of research to help in humanitarian crisis and his chair of the Public Health. Ok, sorry. Uh Is that how you smoke if you like that? Ok. Uh well, thank you very much for that fulsome introduction. Um We're going to do this as a double act. Um uh I'm Jenny Wentworth and Ar Garvey is my colleague and we're going to be talking about outbreaks. So a few facts to start with, one of which is that our outbreaks are nothing new. We've always been vulnerable to outbreaks and no one is quite right to be worried in his situation here. He's in a really crowded situation, not only lots of people but lots of animals around him as well. And in close proximity, he's got a lot of rather peaky looking birds outbreaks emerge. They're often unexpected. We don't know what they are, we've not seen them before and this happens regularly. That top left panel just shows over a 20 year period, new uh infections that were recognized for the first time. Top right. This is pointing out that outbreaks occur everywhere in the world. This is a wor word cloud of er, reports to Promed uh the website that reports clusters of, of outbreaks occurring around the world for 2016. And you can see that it's everywhere. Bottom left is despite what you might think if you just read the press outbreaks occur very frequently. This is just the front page of a random edition of a bulletin that Wo Afro office put out every week about the outbreaks that they're involved with on the African continent. And in this particular week, they've got 46 events that they were following just in Africa uh one new event, one new outbreak, 45 existing outbreaks. Uh no events, one new event, 45 existing events and of those 30 were outbreaks and 16 were uh humanitarian crises or emergencies. And then bottom right government, I've always worried about outbreaks. This isn't something that is new and has come with COVID. This is looking at the UK National Risk Register held by number 10. Um just looking at the biggest risks for the the UK nation and you can see pandemic influenza right up there um with things like coastal flooding track attacks in crowded places, electronic attacks and so on now. Ok. So there's outbreaks occurring all the time all over the place and they're driven by a very wide range of different drivers. Some are due to the microbes themselves changing or adapting in some way. Others are because of wider environmental effects, things like ecological changes or changes in land use or climate, climate change. Others are more related to human behavior, things like international travel and commerce or direct uh human influences, technology, modern agricultural practices and so on. Others are just due to the sheer number of people that there actually are with a lot of crowding, with urbanization and with poverty, all of which will help to promote uh uh outbreaks. Human behavior is very often a key determinant of risk for for outbreaks. Immunosuppression can be uh an important factor if you think about things like um HIV and uh tuberculosis. There are good examples where a breakdown in immunosuppression has led to outbreaks public health services when they're working, you don't notice them and that's the measure of their success. It's only when they break down that you, you notice the effects and breakdown can often lead to uh outbreaks. Things like uh cholera or dips diphtheria or even trypanosomiasis can be due to breakdown in public health services. And then, and we'll touch on this a lot in this talk, humanitarian crises and conflict also can promote and allow the spread of outbreaks. No, every outbreak is different and everyone has its own particular characteristics and you have to look at those and learn from those um to control it and also thinking about other outbreaks in the future. But there are some uh standard frameworks that can be used for preparing and controlling outbreaks when they might occur. One is surveillance and this is really about signal detection and repo and reports because we want to know as early as possible that an outbreak is happening. Then we need to investigate to be sure this is an outbreak and what the characteristics are. And then the control needs to think about how can we reduce the spreading of this, the overall number of cases, but also the severity of the outbreak at the same time. So with surveillance, what we mean by surveillance is that there's the systematic collection chelation analysis and interpretation of data for action. There's two main different ways in which we do surveillance. One is indicator based and this needs a framework and it needs case definitions. And it's the regular collecting of health data, whether this is about deaths, uh confirmed diseases or just syndromes and to have a report of those so that you can identify when there's a surge in something. The other is event based where essentially there's the systematic scanning of traditional or social media or even just rumors to, to uh detect uh chat about potential outbreaks, which might be occurring, no regular reporting mechanism. But things like Promed that I showed you before is a good example of an event based surveillance system. Then if we get a signal that there's an unusual cluster or increase in cases that are occurring, we want to know is this an outbreak? So we need to know are these cases actually related or are they just similar but have different causes? Is it something to do with the change in the denominator or the numerator that we're looking at here? So for example, if there's been an influx of refugees from a country that might lead to uh many more susceptible people for an outbreak or is to enumerate a problem. And there's been a really interesting paper that everybody has read in the district medical team and they're now all knock out for this particular uh syndrome. Is it actually an infection? Even if you have got a cluster or is it due to something else? Is it a nutritional uh uh uh feature or is it poisoning in some way? Keep an open mind about where the outbreak or where this cluster might be arising from? Then if you think it is an outbreak need to investigate, to uh work out what actually is going on and to do that, you need clinical description of the cases that are occurring, talk to them and talk to the health workers and the family members about uh the case. What do they think caused it? Do they know other cases? And if so what's the link between them and what you're trying to do here is draw up a frequency table of clinical features and develop a line list of all the cases that are recurring. And that is the base point from which you can actually start to do some uh epidemiology. The other arm here is pathogen detection. Um The standard way is you transport samples to a reference laboratory that's slow, that may take several days till you get a result back and time really is of the essence in some outbreaks. So having ra diagnostic tests near real time, near patient uh is the ideal. And in some cases, you may need to do genomic sequencing or metta genomics to actually determine what the cause of the outbreak is. From all this, you should be able to do some descriptive epidemiology and from that to do some hypothesis testing, develop some control strategies and model what those, er, er might be and what would happen with and without those control measures. So practical features to think about, if you're wanting to, uh, investigate an outbreak, think about what supplies and equipment might be needed, think about the logistics and the operations aspects. You heard earlier about UK Med and the stress there about the operational arm of what's required, read the literature of previous outbreaks and control measures that have happened. This has probably happened before and there'll be a wealth of knowledge out there that you can uh go back to. Um and just as on the side of there, I bought a few copies of this booklet with me today. It's called um In Control. It's produced by the Robert C Institute and it's a practical handbook for professionals working in health emergencies internationally. And I've got a box there. So if any of you would like some afterwards come up and see me that will tell you about what people have done in the past. Um Before you go have a plan, w what are your priorities when you get there? Um Before you go, think about the team, um who is in charge, what different disciplines are going to be needed in the teams, what are their roles going to be and what's the expectations going to be? And you, you'll probably need epidemiologists, clinicians, microbiologists may need social scientists. But the other specialities that you might need here will differ depending on the out. And of course, you need logistics organization as well. And communications plan with outbreak control, you're looking to reduce mortality and morbidity and also to break the chain of transmission. So you need to find and treat patients, reduce uh infectious contact and reduce the risk of exposure. And what you need to do is going to depend on the nature of disease, the population, the context and the resources that you have available. And then what we're trying to do is put together a combination of measures that will work well together. So when you're doing that, you need to know how is it transmitted? Is this water based, is it, is it respiratory or whatever? How infectious is it? Does the infection start before people get symptoms or does that only come afterwards? That's key. How does behavior contribute to the risk and how does the context in which this outbreak occur affect both behavior and risk? How can you intervene quickly and effectively and importantly, recognize what the effect of your control strategy might have on the wider health system um that needs to keep running. You don't want to drain away from that. So you need to think about how you can minimize the effect on general health services. Communications I've mentioned there are two arms to this. One is the da daily technical reports which is providing information for action, use our unambiguous language. Acknowledge uncertainty when there is make sure this is seen as advice and not instruction. The other arm is public communication and doing this is essential. Even if you haven't got full information about the outbreak, you need to have credible explanations and address people's concerns and questions. It needs to be very clear that the policy makers primary concern is society's health and wellbeing. And the important thing is to test all your health messages with representatives of the communities who will see them. So they're understood and not misinterpreted. And as we move into the, the next section, I just want to reflect on three recent outbreaks that there have been um and the lessons that we've learned from them, one was the Ebola outbreak in West Africa 2013 to 15, which was the largest recorded outbreak of Ebola that we have seen. It brought three countries to their knees and made it very clear that the human, the the global public health community is not well equipped to deal with large scale epidemics. And this is an example of where an epidemic led to a humanitarian crisis. We thought we'd learned lessons from that. Um When we had Zika outbreak in Latin America, uh a couple of years later where there was a much faster international response and much faster research uh conducted into what was going on. I think what actually happened was this occurred in a part of the world in which there were relatively good health services and there was active research that was already going on. And so any international response could build on something that was already solid. Then we had Ebola in eastern D RC 2018 to, to 2020. This was a really difficult outbreak to get under control for two main reasons. One was that it was in a really inaccessible part of the world. And secondly, it occurred in an area where there had been a humanitarian crisis going on for 20 years with huge suspicion of, of strangers coming in and with something like 100 different armed groups roaming about in the region. And this is an example of where an outbreak is occurring in a humanitarian crisis situation. And finally, um COVID pandemic that um uh we've lived through. Um one of the major lessons here is that there really is very little global solidarity that exists at all. Um This graph here just shows you the uptake of, of uh of fact seen high income countries at the top, low income countries at the bottom there. Uh And what happened was that rich countries pushed their way to the front of the queue to make sure that they served their populations uh rather than those who might have been in greater need. And I think we'll come back to that anyway, over to Barga. Just that one. Yeah. Ok. Um It's super hot. So hands up if you've ever managed an outbreak before but in an outbreak situation a couple, ok. Everyone surely would say yes to COVID. But outside of COVID, maybe anyone who worked in a humanitarian situation. Anyone, where do you work in Kenya? Fantastic. Anyone else? Ok. So I wanna talk to you a little bit about um about what it's like to be in an outbreak situation, but in a humanitarian crisis. So this is a, is a map um that was recently produced of all outbreaks between 1996 and 2022. And that is an overlay of a map of all current human. This is the I CCS the IRC S uh humanitarian sort of watch list as it were the top 20 humanitarian crises in the world this year. This is for 2024. It's done at the beginning. So, you know, between Sudan and, and, and, and Aza, you know, we could, we could decide which one is number one or two, but certainly they, they rank the top 10 and then the next 10 are hashtags ongoing humanitarian response plans. You will see a huge overlap in where outbreaks occur. Sure many people think of humanitarian crisis given that there's not many of you who've actually ever worked in a crisis like that, gonna go give us sort of a brief overview of what, what I kind of mean when I say this, the terminology is, is pretty broad. Um And most people tend to think of conflict. But of course, increasingly we're realizing there's a lot more to it than that. And so if you look over there in the, in the, in the top corner, we know that climate change contributes to humanitarian crisis through a variety of different pathways with climate related disasters, driving almost 24 million people into displacement. But it's also those countries that are most vulnerable to climate change. Um that also saw 95% of all conflict related displacements um in 2022. So basically, if you look at the 15 top countries most vulnerable to climate change, 12 of those 15 have an ongoing humanitarian response plan. And so how does that work out while somewhere like Somalia where there's been severe shortages of water and and food and water and pasta affecting 2.5 million people driving 100,000 people into acute food insecurity in South Sudan, seeing 700,000 people displaced with the worst floods they've seen in decades. So undoubtedly the climate crisis is a humanitarian crisis but with profound implications for outbreaks and the climate sensitive infectious diseases down here on the bottom corner, the other side of things is the largest food crisis globally in modern history. Unfolding, driven by climate driven by conflicts, wrecking crops, but also for instance, stopping fertilizer coming through. Ukraine, 100s of millions of people are at risk of worsening hunger with around 260 million people in the stages of acute food insecurity across 53 different countries. Then if you look in the top corner, you'll see. And I haven't even included Hazar in this yet. But for the past two decades, forced displacement um has continued to increase worldwide. Um In the end of 2023 there was about 1 110 million people forcibly displaced. That's about 1% of this world's population of which around 40% of Children displaced people are much more vulnerable to in health threats, um particularly infectious diseases. And increasingly, we see human humanitarian crises as a sort of a triple threat of climate displacement and hunger. But going back to the idea of conflict, what we also see is that conflicts are lasting longer and they're becoming more deadly. So of those countries that I showed you in the first slide, the IRC watch list on average, they've experienced conflict for around 10 years and we're seeing increasingly governance and international humanitarian law being utterly disregarded. So you're seeing healthcare centers being attacked, healthcare workers increasingly being targeted. We're seeing water supplies being weaponized. We see women living near conflict just living near conflict have a three times higher risk of dying. So women are in, you know, disproportionately impacted um by what's going on. And so, and all of this basically means not only is there an increase in caseload, but there's also reduced sort of ability or capacity within the healthcare system to respond, making it the absolute knife edge when an outbreak occurs because there's just nowhere else to go. So when we talk about global sort of pandemics and, and outbreaks, the, the COVID hangover has been really profound for those of us who work in these settings. It drastically altered the scale and the geography of, of humanitarian need and it really challenged our models of response. Um And whilst lots of the world focused on getting making and getting COVID-19 vaccine, we saw the largest sustained decline in Children ch childhood vaccination globally in three decades. And that was particularly so as you can see there um in humanitarian crises much more effective than any others with supply chain issues, vaccine hesitancy. And this single minded focus on containing the pandemic that meant that other diseases went unchecked. And so what we then saw what we now see, you know, is that getting vaccines to be harder to reach populations isn't just about justice or ethics. It's also how security we're seeing measles outbreaks everywhere. We're seeing diphtheria cholera popping up all over the place pandemic related disrupt er disruptions and malaria prevention have led to an additional 13 million infections and 63,000 deaths. So this drastic rise in cases and deaths we see kind of again related to conflict, displacement and climate change. What's different about interventions in humanitarian crises on the face of it. Nothing right. You should do whatever it takes to reduce deaths to, to, to contain your outbreak. But actually, in reality a lot, because when you're in these situations, you need to do population wide measures as soon as possible. To achieve the most impact that you can as quickly as possible. You need to cope with reduced access and security. You need to rely on a workforce that's very small and often not quite as skilled and loads of other priorities at the same time. Um Apart from just your, your, your pants, for example, during the first Ebola outbreak, I actually was in D RC working on measles and malaria, which killed way more people than Ebola ever did. But no one for the funding we received for that almost negligible. We also had disrupted healthcare systems, really importantly, very limited data. So everything that Jimmy said is right, except in your humanitarian crisis, you've been always crossing my all of that off. So this is a little bit, I mean, I worked on that. So er population level measures, things like vaccination, water being absolutely critical, er different ways in which we, we combat accessing security from like big grab bags of drugs, using water in whatever way we can, having people just ready all our medics ready to run whenever we need to be with, with these bags. And we can see that this is what it's like having to circumnavigate a disrupted healthcare system, which is cholera in Haiti, Central African Republic, er Afghanistan Bangladesh. And this is just an idea of like, how can the, in these crises, how these things come all at once? So this is um in 2017, uh when 650,000 Rohingya crossed the border from Myanmar into Bangladesh to meet another 100,000 people who were already there in this refugee camp. We had an incredibly brutalized population, high degrees of rape and violence, no shelter at all, Horrible water in San uh high levels of malnutrition and then suddenly someone notices pseudomembrane in the back of er someone's so and that was the first outbreak of diphtheria that we'd seen in almost 30 years and actually very few of us knew how to deal with an outbreak. I dealt with cases before on an individual basis, I'd never dealt with an outbreak before and that was on top of measles outbreak and then a Hepatitis E outbreak. Oh, it never rains but it pours and this is the reality of the situation. And so this is some work done by a colleague of mine Francesco looking at all the many things you may expect in the first six months of a crisis. And a lot of this is how do you prioritize and what do you do first and what do you do next? And unfortunately, that's the situation in terms of data. So he looked at um crises uh in the first six months over a five year period to see what kind of data you had available to yourself to make decisions and you can see how late and delayed a lot of it is Jimmy, right. So that gives you a, a background into where we are with outbreaks and humanitarian crises. Um Clearly a lot needs to be done. So what progress are we making for that? Well, some of the recent advances have been around improving diagnostics. So, Multiplex PCR uh is now available in an increasing number of countries and national reference labs are able to do much more complex detection than they ever could before. And you all have seen with, with COVID but with other uh outbreaks uh coming up as well, l lateral flow tests for rapid diagnostics, some which can be self administered coming up uh as well. And that's all very valuable to being able to identify cases, case definitions that I talked about before can be really important. And in some cases, it's, it's critical to be able to see if you can improve the sensitivity and specificity of those case definitions during an outbreak in Ebola in, in West Africa, Ebola in Children was so nonspecific that at the start, it was almost impossible to differentiate Ebola from any other febrile illness that that Children may get. But over time, um it was possible to use the information that was coming in so that the sensitivity increased from less than 70% to over 90%. Much of the time people are using paper forms and Microsoft Excel for their spreadsheets uh for dealing with outbreaks um very 20th century technology. And we're trying to move forward with standardized case report form. And perhaps the leader here is uh something W OA spearheading called GO Data, which is available for uh electronic field data collection and I'll put the website there. Uh And that, that allows information to be input directly and analyzed directly and data depositories. Electronic ones also allow for improved epi uh descriptive epidemiology and to share much more widely than previously. Uh modeling is used much more in real time. You'll see that um uh uh modelers became the modern tooths Sayers in the UK during the COVID crisis. Um And genomic sequencing is used increasingly in real time. Um That's the first time was, was in Ebola outbreaks. And this again was used a lot for in, in COVID and also an increased emphasis on the importance of community engagement and community involvement. And a recognition more widely that dealing with an outbreak isn't just a narrow technical job for specialists that actually involves the help and involvement of communities if you're going to be successful. So thinking for the future, we need to do more to improve um the diagnostics that we have to have complex pathogen detection available in real time on location. Uh point of care tests, global sharing of the pathogen data and the risk assessment of that as well. And the development of new vaccines and new drugs. And one exciting example, there is a new experimental vaccine being tested. This is developed by the UK Vaccine Network and just released for testing and this targets Ebola Marburg and Lasser all in one shot. Um This case definition modification, improvement in real time should be possible and routine for the future. We can do much better in terms of virtual contact tracing and follow up of of cases using mobile phone apps and, and hotlines than we have been in the past. And we can do real time, open source modeling and sequence um information so that we can inform the response um uh much more effectively. But we also need to think about this issue of uh improved global pandemic preparedness and response and see what can be done to really develop much more global solidarity uh for the future. If we're going to be able to really control large scale epidemics for the future. And I'm sure Bar Gy will say something about me, what do we have? 10 minutes? OK. I know that you probably want to do questions on top of that after that or, or including. OK. So I might just, we might skip through some sides then instead um I won't even talk through the absolute headlines here. But I think when we're looking at as we're starting to think about pandemic preparedness and the challenges of outbreaks obviously as, as as as Jimmy says we need to start thinking about these signals, but importantly, how to integrate the different signals from community surveillance to event based surveillance, et cetera. So how do decision makers react to those? How do we ensure that communities are included in both the response and the surveillance systems? This is where they start, this is where they end, they have to be um part of the process by which we manage outbreaks. Um Jimmy's talked a little bit about kind of some of the molecular work um that needs to happen as well as the the much needed advancements in terms of um laboratory techniques and surge diagnostic capacity, very much a critical issue these days is one health and understanding that human animal um er environment interface um especially alongside climate. Uh a little bit about kind of stockpiling and resources right now. So we have as many of you may know there is an international uh global vaccine stockpile and we have this because of the unpredictability of um of of needs of academic needs and to and you know, and often to think about kind of how do we make sure we think about reemerging pathogens, how do we ensure that there's availability for epidemic response and that there's easy supply chains. Um And also in terms of kind of bioterrorism. Um the problem is is that they are chronically under supplied and we are short of almost every single one of these vaccines at present, I think at the moment, there is no cholera vaccine at all um in, in uh in in the global stockpile. And if you look at the key performance indicators that the ICG set themselves, you can see here at the bottom that II bring it out just how over the expected days they are. This is days since the first case is reported from request to round one of vaccine. And you can see that when you're doing an academic response 50 to 75 days is a very, very long time to start containing outbreaks, obviously um requiring safe and scalable case management. And those of you who been through the COVID epidemic will know all about kind of the critical importance of having PPE and protection. Um And and of course coordination. I wanna have one quick mention about epidemics and mistrusts. I think all of us now know post COVID how important myths and misinformation are um in West Africa as as as Jimmy mentioned during Ebola resulted in the death of about 11,300 people due to misinformation. This is an MSF care facility that was burnt down in D RC due to misinformation about what was happening there. Um And this of course is uh polio vaccine happening er in Afghanistan, Afghanistan still having many er er polio cases because of myths and misinformation around er the vaccine there. So I wanna end with this uh pandemic tiredness. I know is something that a lot of people talk about war, climate disasters, pandemics. Um I think we see the new latest news from the climate. Well, there is no room for wishful thinking anymore. Uh We know that global health emergencies will happen and that they require preparedness and a capacity for response. And I think what is certain is that we know pandemic threats will continue to emerge or what I wanna impress upon you is that full blown pandemics are a political choice. Um COVID-19 showed us the consequences of years of underinvest globally in public health and preparedness. And now the wh O is working towards a treaty to protect the world from future pandemics. And there's an early draft calling for regional vaccine production and technical knowledge sharing. I want you to look at the graph at the top. There, only 2.3% of the 13 billion COVID-19 vaccines administered took place in the 30 countries with a humanitarian response plan. Um You know, this is not again just ethics and justice. I'm showing you data here from COVID. It could be the same for any other disease that in global immunization leave spaces in which bacteria and viruses can replicate, unchecked, increasing the likelihood of new mutations or new variants. It's imperative that we prevent COVID-19 or any other vaccine preventable disease from becoming yet another epidemic of the less fortunate or the have nots. And I'm gonna be polemic here. I think it is frankly criminal that large swathes of our world have just not been included in global initiatives in vaccine distribution in access to diagnostics or to new treatments. Um And that humanitarian access also continues to be limited, not just to existing tools but also the development of new ones such as we're seeing with monkey pox. And of course, none of this is new for those of you who are as old as Jimmy. And I, we've been here before Ebola Zika even HIV for those of us old enough to remember the start. Um And it's really important for us to reflect after really critical events like this a few years ago, we lost a very great poor farmer. Some of you may have read his brilliant book about his life, Mountain Beyond Mountains. And he said this at ASTM H in the 27 in 2017, in the aftermath of Ebola, it keeps recurring again and again that when we have scientific progress, we have new vaccines, we have new diagnostics, we have new therapies and every time we fail to put together an equity plan. So for pandemic preparedness, I'd say first, we need the highest level of political attention on pandemic threats because they are overwhelming, they are complex and they have multisectoral impact and we need a leader led global Threat Council just to really sustain that pandemic readiness. We need two types of financing. Let's not combine these two. We need pandemic preparedness financing. And we need response financing because those are different things carried out by different people. COVID cost the world trillions. But we need to commit to just a fraction of that to protect parts of this world. And I think third and absolutely, we absolutely have to solve this problem of how we get equity and access to vaccines, tests and treatments wherever they are needed, delivered on time to save lives and to stop outbreaks. So, thank you from Jimmy and I, and it's a little plug if two plugs. In fact, if anyone is interested in humanitarian crises, we just set up a distance learning course at the, at the school for a masters. And if anyone's really interested in humanitarian health, Thursday the 16th of this week is the MSF Scientific Day. You can register online, I think in person is out, but please do come and register online. Come join us. Thank you so much for that. Inspiring talk. Both of you. Um We're going to in the interest of time we're going to start with in person questions first. If you can put your hand straight up into the air and we'll come to you. That's the ending. And I think the only comment to make is that um nobody's safe, that everybody is safe. If anyone else wants to put their hands up, they can in the meantime, just from our ones before the conference. And I know this could be a whole talk in itself. But it was the question was about climate change and its impact on global health. And you mentioned internally displaced people and you mentioned changing epidemiology of disease. But are there future challenges expected? I imagine? Yes, just uh short answer is, is, is yes, the question was about um climate change has has had to affect displaced people. Um changing of disease around the world. Can we expect more? Well, yes, we can. Um the world is continuing to, to war. Um CO2 levels are continuing to go up, the climate crisis is continuing and they seem to be heading straight for catastrophe and while we get there, then I get a chance for more displaced people and more changes in epidemiology. Um uh insect being able to get to parts of the world that they never got before. Um providing diseases to people who have got no immunity before I just going to perpetuate the risk that we, we have here. Um Plus we'll have more droughts, we will have more uh food insecurity, we will have more poverty associated with that and not only but severity of, I think that's enough. I think that's, I think that's right. I think it's, it's really important to recognize the interaction of, of climate of inequity and poverty. Um and for many other drivers of diseases, not just infections and all, but everything from malnutrition um to even trauma and, and, and certainly a Mr and II don't think there is a single disease fairly now that we can't see uh, how the impact of the through or indirect, uh means you first started.