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SCI Care: What Really Matters
SCI Care: What Really Matters
SCI and the Climate Crisis: From Impact to Action
People with the lived experience of SCIs are one of the most vulnerable groups of in the world-both to the extreme heat and weather events which have increased in frequency because of climate change. Although health care professionals have an opportunity to educate their patients about actions they can use to protect themselves during these extreme weather events, many feel unprepared to discuss the topic. Moreover, health care professionals are beginning to experience moral distress about their inability to take action regarding this existential concern. The webinar will include participants from three continents and multiple disciplines. We will use the interactive platform mentimeter to facilitate the interaction of participants, expressing their feelings about climate change and about sharing their actions.
The opinions of our host and guests are their own; ISCoS does not endorse any individual viewpoints, given products or companies.
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Good evening, afternoon or morning, uh, wherever you are watching this webinar. I'm Dr. Janis Jonisiotis from the National Rehabilitation Center in Athens, Greece, and chair of the Climate and Health Special Interest Group of ISCOS. I'm very pleased to welcome you on this webinar on spinal cord and the climate crisis from impact to actions. In this webinar, we will cover a wide range of topics related to climate health in spinal cord injury. And the purpose is to increase awareness for people with lived experience of spinal cord injury regarding climate and health, and to provide information to healthcare professionals how to educate their patients. And we need the interaction of the participants to express their feelings about climate change and about sharing their actions. I'm here with members of the government panel of the special interest group. I would like to present you in order of appearance. So I have uh Professor Markali Alexander, please, Markali. Markali Alexander is a physical medicine rehabilitation professor in a rehabilitation hospital in the USA. She changed recently her affiliation, and I need to see. Then we have um uh uh Ingebor Jirgens, a PRM physician from uh Norway. She is associate professor and on the Faculty of Health Science, Department of Nursing, Vit Specialised University in Norway. Then uh our member Carla Silva, which is a pharmacist from the UK, Southport Hospital, Mercy and West Lancashire Teaching Hospitals, and finally we have our professor Taslim Udin uh from uh Bangabandu Sheikh Muyu Medical University in Bangladesh. So uh I will uh start immediately with an introductory presentation and uh then Mark Ali uh will follow. So can you please see my slide? Please inform me if you can see the slide. Thank you. So, climate change and spatial core injury are two distinct topics, but they can have interconnected implications. People with lived experience of spinal core injury are one of the most vulnerable groups to these events. Although healthcare professionals have an opportunity to educate their patients about actions they can use to protect themselves during these extreme weather events, many feel unprepared to discuss the topic. What is climate change? Climate change refers to long-term alterations in Earth's weather patterns and average temperatures caused by human activities. It involves the gradual increase in the planet's temperature due to the buildup of greenhouse gases such as carbon dioxide in the atmosphere. These gases trap heat from the sun, leading to range of effects like rising sea levels, more frequent and intense extreme weather events, alternate precipitation patterns and shifts in ecosystems. Among other things, extreme weather becomes more frequent and intense. There are deeper and longer lasting drows, wildfires spread faster and wider, glaciers and sea ice gradually melt, oceans rise, and some areas have more intense cold snaps. These are pictures from my country, from my actual from my region, Attica, in Mandra, flash flood event uh which turned turned urban roads into fast-flowing rivers. As you can see, 20 people, 23 people died. And this is a big wildfire uh recent also in Greece, in my region Attica. Also, 104 people died in this wildfire. And recently in Pedel, in the same region, one people was dead, and Greece experienced its hottest June and July at that time. Excuse me. This figure provides 10-year estimates of fatalities related to extreme events from 2004 to 2013, as well as estimated economic damages from fifty-eight weather and climate disaster events with losses exceeding one billion in US dollars. These statistics are indicative of the human and economic cost of extreme weather events over this time period, and climate change will alter the frequency, intensity, and geographic distribution of some of these extremes, which has consequences for exposure to health risks from extreme events. Trends of future projections for some extremes, including tornadoes, lightning, and windstorms, are still uncertain. In fact, the United Nations Human Rights Council passed a resolution on climate change and the rights of individuals with disabilities in July 2019. The resolution acknowledged that individuals with disabilities are among those most negatively impacted during emergencies experiencing excessively high rates of morbidity and mortality while also being among those least able to receive emergency assistance. How climate change and SCI relate to each other. First, with the extreme weather events. Natural disaster reviews confirm that SCI occurring disaster settings, but high-quality, event-specific data for hurricanes, flood storms, wildfires, and snow ice events are remarkably limited and often overshadowed by earthquake data. And this is a nice review recently published from uh uh uh from some people, some scientists uh regarding uh affected by climate change and extreme weather uh with key findings, many important key findings, and I I advise you to go and read this review because it has very important information. This is another publication from Sapiro and colleagues regarding extreme storms, and the authors concluded that pay that patients in high-rise buildings may become trapped if elevators do not work, for example, propelling wheelchairs through storm debris or flute ware is physically difficult and risky, and personnel working in medical centers are unfamiliar with the care demands of this population. Physician offices and unpatient therapy facilities may be closed for several weeks, disrupting both usual SAI care and treatment for storm-related medical conditions. Second, the health the health care infrastructure. Climate change can strain healthcare systems and infrastructure, making it more challenging for individuals with spinal cord injuries to receive appropriate and timely care. Extreme weather events can disrupt medical facilities, limit access to health care services, and exacerbate resource shortages, affecting the availability of necessary treatments and rehabilitation for spinal cord injury patients. The access to mobility and adaptive devices, climate change impacts can also indirectly affect individuals with SCI by influencing the availability and accessibility of mobility and adaptive devices. For example, rising temperatures can make it more difficult for people with mobility impairments to navigate urban environments if infrastructure lacks proper accessibility futures or if extreme heat poses health risks. And finally, psychological impact. Both climate change and spinal cord injuries can have psychological consequences. Climate change-related events and disasters can lead to mental health issues, including post-traumatic stress disorder, anxiety, and depression. Similarly, individuals who have experienced a spinal cord injury may face psychological challenges due to the life-altering nature of the injury. SCIs may become climate-jailed and forced to remain indoors for long periods of time due to weather extremes, which could lead to even greater morbidity from depressions in persons with SI, which was pointed out by Mark Ali Alexander previously. The two key components of climate action are mitigation and adaptation, and I'm going quick over this because they will be analyzed in the uh later on. So, the mitigation, ways of mitigation is public communication campaigns, uh, patient education efforts, climate advocacy, inclusivity for those living with disabilities and collaboration. And mitigation strategies for climate change in spinal cord injury are all these evidence-based actions in health and lifestyle, energy conservation, waste and supply chain and advocacy and planning. Adaptation strategies for climate change, spinal cord injury, how we adjust our care to a changing climate, a climate resilient living with uh waste with heat management, power backups, water and sanitation, home environment, health care, and evacuation plans. And I finished with this nice survey published uh in 2019, which included uh 125 respondents, rehabilitation professionals over six continents, and almost 60% believed that climate and weather changes influenced their SEI clients' health and well-being. Almost 60% reported that extreme heat spells had an impact on their clients' health. 75% reported that they had not taken action to educate patients, and 85% were interested in learning more about extreme weather and climate concerns for their clients with SAI, meaning that many scientists have an interest in this direction. So this was my final slide. And uh I think uh now we can uh pass to the next speaker, Mark Ali Alexander. Mark Ali, please can you please share your slides?
SPEAKER_06:Sure.
SPEAKER_05:Hi everybody, um so good to see everyone, and I will now share my screen and let's get this going.
SPEAKER_06:So good to see many old faces or young faces. Just get to the slideshow, it doesn't want me to here we go in the beginning.
SPEAKER_05:All right, well, a lot has happened since I got involved in climate change um wholeheartedly. And I thank you, Yanis, for asking me to speak, and I appreciate that everyone else is here, and I'm really happy to see that there is so much interest now, and there's about 40 people in the audience on this topic because it really has been a and will continue to be a struggle to bring attention to climate change and particularly climate change and SCI. And I'm so happy that there's some. Okay, let's see if I can advance this now. I'm so happy that there are more papers out there, et cetera. But there's a lot, a lot of work that we still need to do. Back in 2019, 2020, um, I took a journey and I kind of left clinical practice and started working in climate change and disability. I really wanted to bring attention to spinal cord injury because I think people with spinal cord injuries, um, as in that article we published back in 2019, are like a bellwether for climate change. I think people with spinal cord injuries have more health impacts from climate change than potentially people with any other diagnosis. And there may be a lot more information available about renal disease or heat strokes or the impacts of pediatrics, on the birth of um belief, um, and especially on infectious diseases. But people with spinal cord injuries have so many aspects of their lives that can be impacted. Back in 2019 or 2020, I started the Journal of Climate Change and Health. And one of our first editorials by the team, we developed this um acronym, which is C Clear. And uh Yanis had the title of this talk, so I thought I needed to circle back and talk about C Clear and what that means and how we can all um get involved, and not just we, but you, you in the audience. Um, and on the right there, I want you to see um if you wanted to look at the QR code, please um go to the website. Um, my journey has taken me from doing a walk to starting the organization Sustain Our Abilities, which is where Yanis and Ingeborg and Carla and uh Taslim and I met to actually expanding more into an organization now called the Climate Health Society. Um, because I realized how important it is for those of us in spinal cord injury or rehabilitation or people that care about people living with disabilities to work in the greater audience, and that more than anything, we need to communicate about what's going on and really come out there and be leaders in this space. So C Clear stands for communicators, climate leaders, educators, advocates, and researchers. And as we've traveled through the years, we've done a lot of everything. Um, and I I really appreciate that the people in this room um are here, and I hope that all of you start thinking about this C clear as what you can do in climate change. Obviously, right now it's not a good environment for people that are worried about climate change. Um I live in a country that I wish I not, well, I wish I could live with any or in any of your other countries right now because I am in fact very devastated about what's going on with our country's leadership. Um, right now we're communicating with each other, which is great. And right now, COP is going on in Brazil. Um we've gone to COP a couple times in the past, um, couldn't go this year. Um, but it is really important that we all continue to communicate. So with the C, we're all communicating today about climate change. We should also talk about it to people in our communities, our patients, our family members, and communicating leads to being a climate leader and community. And day for tomorrow is something that many of us have done before and shared in our communities. This was an event we had in Philadelphia years ago, and um, we also had events in Africa. I see Amina that's on the phone has had um on the call, has had events. I know Injeborg, uh Yannis has had events, and we've got to communicate to people um what's going on in climate change. Um as part of sustain our abilities, and I think many of you may actually be sustain our abilities members. I hope you all are. Um, we ended up eventually creating a book which just was published this year called Climate Change and Disability: A Collaborative Approach to a Sustainable Future for All. And as we think about spinal cord injury, I think we all should understand that people don't just have spinal cord injuries, they have other aspects to life, right? We all come to the plate having an area we live in. We all have some type of sexual orientation, we all have some economic status. We may come from a lower middle income country, we may come from a wealthy country, we have a different background in that we may be employed, we may be unemployed. If we're in rehabilitation, we could be in different rehabilitation disciplines. And the other thing is when we think about the issues of the disasters that Yannis brought up, where you live has some indication of what kind of disaster you're experiencing. So the overview that we started with in the beginning now needs to be expanded and to grow. And so this book and the journal is a part of that expansion. And I invite all of you really to follow the Journal of Climate Change and Health. It's a gold open access journal. So if you sign up for the notifications, you get free education. And we've had 275 articles submitted so far this year. So the breadth of information that you can obtain is really incredible. One of the things about the book, and I also want to I want to give a shout out here to Dr. Udine, um, who is from Bangladesh and such a leader, and Taslam actually provided this picture, which became the cover image for the book. And I don't know if he's going to speak about it. Hopefully he will, but this person here on a banana raft in a flood actually had a spinal cord injury. And so I think this brings attention to what our constituents, patients, clients, whatever we call them in the area we work, um, are living with. So medications, bladder, bowel care. So you can really see how this situation impacts people so much. So I'm gonna promote this bottom, the uh climate health society now. And again, I'm gonna, I hope you know you become members, especially if you're a member of Sustain Our Abilities. Because last year I didn't discuss, I did um, we were lucky we had little funds, we were able to have a booth, and we did have, we do have about 500 people that are members of Sustain Our Abilities and can be free members of the Climate Health Society. Um, the society is free for students, it's free for people from lower middle income countries, and for those that are from developed countries, the cost is$100 US, which is pretty low when it comes to society charges, not as low as this cost, but um compared to other ones in at least in um our country and I know other countries around the world, it is low. Um, and we are trying to spread this education. Um, we're spreading it through the journal, yes. Um, I am personally stepping down as journal um editor at the end of the month, so I can devote my energies to the society. People that are society members, now the journal is the official journal of the society. So people get a discount in their APC. And we are going to have a meeting um for all people interested in climate health adjacent to the big COP meeting next year. For those of you that aren't really in the climate change space, COP is decided the year before where the location will be. So the location next year will either be in Australia or in um Turkey. And uh we're we're planning for either location with our friends and colleagues to work on getting this meeting going, which will also be hybrid. So the point is that when we talk about sustainability, when we talk about spinal cord injury, we're going through C clear, right? We're communicators, we're climate leaders, we want to be educators. Being an educator means you know what's going on out there, and so it's not just one lecture about SCI, it's learning completely about what's going on in this field. Hybrid meetings are part of the solution, right? I'm so happy that Isgus has adapted and is having these meetings. I hope that all their annual meetings become hybrid. Um, again, our physical location will be pending. And then the journal again. Please think about the journal. Um, start reading the articles, and also we really need reviewers. This is a great way to advance your academic careers. And I know that uh Taslim also, he is a great um publisher. He has an article in the journal on disability and LMICs. This is a shout-out to our friends from this was in actually Tanzania, um, and when we had a day for tomorrow event. It's not a picture from the wonderful event that Amina held in Nigeria, but again, I think the key here when we talk about climate change, and I'm worried about it now because of how badly the field has been affected by the US current president and the people around the world that have followed, is that we do need to continue with our advocacy. And Day for Tomorrow was part of advocacy. And also, if we look at this picture here, this was actually at the World Trade Center. Um, we know how the world changes. We know that there's been changeover in New York City about how things are. This was not the World Trade Center, it was the it's called the uh Oculus, which came in on the property. But this woman was actually the director of FEMA in the United States until the administration changed. This man was a gentleman in charge of um disability in New York City. He's now in charge of disability rights for Walmart. Um, if anybody's ever heard of Walmart, and these were a couple congressmen, and of course, that's me, and that's my husband. So we've got to keep pushing forward. We've got to keep up our endurance and work together. Um, on the research side of things, I do want to indicate here, I really think we have a long way to go. I've been lucky to um really learn about research by getting involved and launching the journal. But, you know, one of the things that I find is very disappointing in ISCOS is that we're not on the annual meeting agenda. Every year we put in for courses, and every year our courses turn into posters. Um, and you know, I think this topic needs to not just be a course, but to really be highlighted for once. We deserve to be on the agenda. This is the future, and it just can't be, you know, curing spinal cord injury. Years ago, we did more than just work on curing spinal cord injury. And I think we've also got to think about the bottom, one of the bottom issues there is about ethics of care and really taking care of people in LMICs. Um, in terms of spinal cord injury, we need research on these areas we talk about, the plant-based diets, doing things sustainably, maybe braces that are out of sustainable materials, using catheters over or having catheters out of sustainable materials. Same thing with wheelchairs. We could actually make, if we think about it, wheelchair parts that are interchangeable, loaning things rather than purchasing things, and thinking about sustainable systems of health care. I think these are all important areas. And the more we can actually get climate change on the ISCOS overall agenda, the better we will all be. Um, and again, I'm putting in our pitch here. I really would love to see you guys join the Climate Health Society. And if you are a member, you can get involved. We are going to have a Sustain Our Abilities Committee, which is focused on disability. And this is open. This is the way for individuals that are grassroots members to get involved. Not you don't have to be part of a big organization, a big university. Just if you care, we watch it. And what about the next year? And this is Isgas, and I've had a lot of fun with a lot of you throughout the years. And so I thought about what we need to do now because CClear came back from years ago, and I was giving a talk recently at the American Public Health Association. And, you know, there's a lot of distress going on in the field of climate change. Um, I think there's a lot of solistalgia. Some of you may not know that term. It's a term for caring about and wanting the way the earth used to be. And there is a tremendous amount going on in the psychological aspects, um, new disorders being discussed, et cetera, more information on the renal issues, et cetera. But we also need bars. And I thought that would give some of you a chuckle. And what that acronym is now, I'm saying we need better adaptation, resilience, and solidarity. Why? Well, we always need to do things better, right? Life is one continuous quality improvement. We've got to really look for the future and try to make ourselves and the world a better place. And the world right now, in climate change, we talk about mitigation and adaptation. Well, we need more than just mitigation now, because what's happening now is really screwing us in the future. Um, things aren't going to get better. We've lost the 1.5 degree um, you know, target that they had from the Paris meeting. So we need adaptation. So we need to come up with ways where our patients, especially our patients with spinal cord injuries, but also ourselves can adapt to living in a warmer world. And that may mean a lot of things. It may mean cooling gusts, it may mean telehealth, it may be electric vehicles, it may be, you know, learning more about how we deal with extreme heat or extreme cold. But we've got to get out there and start doing some research on it. And then we need to be resilient. It's pretty hard in my situation where I decided to change my life and focus on climate change and to know so many people that just after years lose their jobs. We've got organizations in the US like USAID just being dropped. We've got NIH being decimated, we've got so many issues, and it's really important. To work on resilience. Years ago, Klaus Kulting, who I see is on this call, and I did a course at both an Asia meeting and in Discuss meeting, and it was on maintaining your passion in SCI. And this is also something that people in the climate change field need to do. Finally, I want to say one thing is we need to say stay in solidarity. If people divide us, we lose. If we stay together as a team, we can win. So wherever we are, and whatever we do, and for those of you that are listening to this, please let's all work together and stay in solidarity. And on that, I'm going to stop speaking, and I'm available for any questions. And this is my email. Please feel free to write to me and would love to, you know, team up and work with you on this problem.
SPEAKER_02:Mark Ali, thank you so much. It was a wonderful presentation. You know that you have inspired a lot of us in this direction in climate action. I don't see right now any questions in the QA section. So if you can you stay with us or you will leave?
SPEAKER_05:I do have to go. I apologize.
SPEAKER_02:I'm definitely happy to may I ask you some one question, just one question. What are uh two things, two things to do for uh uh for uh SAI specialists? What are the uh the first things you uh they come up to your mind for uh SAI specialists can do uh in order to help persons with spinal cord injury regarding climate and health?
SPEAKER_05:Well I think the first thing is to talk um and bring it up, right? Talk about disasters, talk about heat, and really have people with spinal cord injuries realize that this can be as dangerous to them as as anything, right? If you go outside and you have a spinal cord injury, I you know, I really wonder about people that live in India when it's 115, how do people with spinal cord injuries um get by? And you know, I that that is something I wonder about. And then, you know, the issue of the floods. If there is a flood, you know, um people with spinal cord injuries are going to be the ones that have the hardest time. So I think it's really important that we discuss these issues with our patients. You know, we're all rushed, I think, in healthcare, no matter where we are, probably. Um, we have less time to spend with people, um, but we can, you know, if we bring things up, we can start the conversation. Um, and that has been done in other specialties, so there's no reason we can't do it too. Taslim has a question, it looks like.
SPEAKER_02:Yeah, thank you very much. Thank you very much.
SPEAKER_05:Thank you very much, thank you very much, oh just shut off one of your devices.
SPEAKER_01:Okay, okay. Uh uh truly it's a it's a great presentation. It's a it's a great presentation now for the shower of physicians, therapists, social workers, and many other groups. So uh any any uh any special uh suggestions for iscuss community or our members so that we can be sustainable and we can uh work for the adaptation of our LCA family members.
SPEAKER_05:Again, I think the most important thing for ISCAS is to realize that this SIG exists. I do think it's really important that we get a position paper out there. There have been position papers out there for ISPRM and some of the different rehab organizations. Um I think the presidents have changed. I know there's administration issues, but I think it's very important that we get a position paper out on the topic. Um, it's great that people are writing review articles out now, but a lot of these articles are just opinion pieces that are getting reviewed. And um, we need to move beyond opinions. We need the society behind us, we need the society to say this is an issue, and that will help get the providers out there. Um, the more Yanis brings this group forward, and Ingeborg and Carla and you and the others involved, I think the more we will come up with for the constituents. And I would say, you know, there's no magic to being the leader of something. A lot of times, people that, you know, some of your students, Tusley, may have great ideas. And I think that we're at the point where when young people reach out to us and we can grow those ideas, I think that's an important thing. Um, all of you know, you and I are uh are more of the senior people here, and we've got to really work to help the younger people take over and lead these things. So I think, you know, um it's it's all, you know, when you're having your meetings, I know you're a great speaker and you're out there discussing it. I I hate to see that we all go to these meetings for a couple of days and spend all that carbon and that sort of thing. But, you know, we're dealing with bigger societal issues, right? And so we've got to um, I guess, in a lot of ways, educate people and make it part of spinal cord injury care. It should be part of, you know, all the credentialing that people have. There should be a chapter in the spinal cord injury books about this. It should be on our agenda. If it's on other groups' agendas, why isn't it on ours? Why are the neurologists talking about it? You know, that's how you learn about things. We know that Parkinson's is impacted. We know that stroke is impacted. We we've got to take all these other issues and start dealing with them too. So it's a baby step thing, and but we can do it. It's a step-by-step, right? We're a lot further than we have been.
SPEAKER_02:Mark Ali, thank you. While you were talking, some questions came in some comments. I would like to discuss a little and ask you about it. So there is a comment. Uh Lisa Scales, things are changing but extremely slowly and mainly due to patient requests rather than companies. Example, catheters made with recycled items. But that again she says is uh another issue. And that's and that's correct because we know that uh PMR specific emissions or waste that at the moment, for example, healthcare rehabilitation, probably generates a lot of waste due to its numerous procedures, lengthy in patients' rehab states and heavily reliance on this disposable equipment like catheters, root care supplies, and so on, which raises uh carbon uh uh carbonate emissions. I believe it is a correct comment. Would you like to say something more?
SPEAKER_05:Absolutely, it is a correct comment. Um, and I again, you know, I'm pushing the society, but I think this is a way to bring people together. I know a couple people in the rehabilitation field particularly interested in sustainability. I saw I also took a course on sustainability um at from a company called 1.5. The issue is yes, spinal cord injury is very resource intensive. The question is, how do you change that? And it's not likely. Now, some of the country companies will say, and maybe somebody in this room can reach out and we can do a presentation, they would want to do it, but some of the countries do have a um commitment to being you know carbon neutral or promoting these things. On the other hand, that gets balanced with selling products, doesn't it? So we did have, when I was in charge of spinal cord series and cases, we had a point-counterpoint on the topic of catheters. And so it gets back to how do we bring this to the table and discuss this? We're not just gonna change it unless it does come into the halls of viscos, unless it gets in the halls of other places. So I think that's what we're up against now. So it it's it's harder than it was, but it is so important. You know, I have to tell you a little story. Um, the journal I started, you know, we're we're accredited with all these different journal companies, and we had an impact factor, and our impact factor is like 3.6, and our site score is 7.9. So our impact factor is you know higher than spinal cords, I think, right? But we applied for PubMed um at the end of last year. And guess what? PubMed is run by the United States. In particular, it's under NIH, which is in um, it's in the National Library Madison, which is in the National Institute of Health. And we still have not received a determination on the journal for PubMed accreditation. So we've got to, you know, do everything in every direction we can. Anybody any other questions, Yannis?
SPEAKER_02:Yes, yes. Uh I would already know Serifaha Moody considering infrastructure constraints, what innovative and sustainable strategies can ensure effective access to continuous professional development for medical staff in Africa? And how can the impact of these programs on the quality of care be measured?
SPEAKER_05:Well, I think one of the issues for Africa that um I've thought about for years is the uh Project Echo group, that we, in fact, we wanted to get this off of the ground, but we never really had the manpower. Project Echo does telehealth um education of people um and has different topics. Um, I think telehealth is a big important thing for the for the continent of Africa. I also think that when you are working in Africa, what you may be able to do is you don't have the um if you're working in just spinal cord injury in Africa, you don't have the negatives of climate change, right? Climate change is very um negatively looked at. But you do have um, you know, people would be interested in just improving services in Africa. And I think there's an a way to develop more volunteer programming and education programming, maybe not people on the ground, but maybe more volunteer programming. The other thing I would say is that um if I was based in Africa, I would uh be looking more towards getting funding from organizations like Welcome Trust, um, and or if I was in Bangladesh, because these organizations really target LMICs. Um, so that's kind of some of the thoughts I would have. But I would also say um talk to each other. I think there's a number of you on this call from Africa, and and uh working together as a team is so important.
SPEAKER_03:Yeah, right.
SPEAKER_05:And I know that you know Klaus has done a lot in Africa. I know Amin is here. I don't know whoever just asked that question. I think you should all collaborate too, and we'd love to collaborate with you.
SPEAKER_02:There are some other questions from Africa. If we have time, we need to proceed now. If we have time at the end, we will continue with the questions. But uh thank you so much for being here today with us, Markali. And I would like now to proceed to the next speaker, uh, who is uh Inge Borg Irgens, uh PMR physician, assistant professor from uh Norway. Inge, would you like to share your screen and start your presentation?
SPEAKER_00:Uh yes, I will.
SPEAKER_02:Thank you.
SPEAKER_00:Okay, are we up here? You can see it? Can you see my presentation?
SPEAKER_03:Yes. Yes, Inge.
SPEAKER_00:Okay, great. Yeah I will talk about climate change and complications in in spinal cord injury. And that is we know that uh a spinal cord injury interrupts motor sensory and autonomic pathways and impairing mobility and increasing heat storage like during warm seasonal temperatures due to the compromised autonomic control of both uh vasodilatation and sweating, and also the recognition of uh body temperature. See if I can how do I how do I change pages here? It won't change. Why? Yeah, I think I I think my screen it's showing the whole Oh nothing is happening here Okay here so now I found the button and yeah persons with uh because of this spy persons with spinal cord injury are more vulnerable to to high like hypothermia and its adverse effects. And however, information regarding how persons with spinal cord injury perceive warmer seasons and whether thermal discomfort during warmer seasons restricts routine activity still remains anecdotal. And we know that like impaired autonomic nervous nervous system, we will have for for people with with spinal cord injuries, especially those who have an injury above the C66, will have interrupted the signals from hypothalamus and that controls the body's response to to both temper temperature and temperature changes. So if I now uh press at the right. Oh, that's great. So I will just go through this uh this uh line I I uh had uh at you at the previous uh slide here, because uh puzzles with spin cord injury are unequally vulnerable to overheating during warm seasonal temperatures and heat waves. And as I said, because of the interrupted autonomic pathways that control sletting and blood flow below the lesion, there will be an affection. So heat dissipation is reduced and heat storage will increase, especially in people with a higher lesion and unlike tetrapedia. So clinically this can present as a persistent high core temperature, dizziness, fatigue, tachycardia, impaired cognition, syncope and in severe cases heat stroke. So practically overheating reduces comfort and daily function, like walking, transfers, self-care, and is commonly reported by people with spinal cord injury as having a greater negative impact on life during warm seasons than for pairs with a non-spinal cord injury. So prevention and immediate management is important. We should or people with spinal cord injury should prioritize avoidance and early cooling. They should use air conditioning during heat waves when possible. And when not available, use cooling vests, wet wet towels to limb and trunk, and use misting sprays and shaded outdoor routes. However, it's easy for me living in a developed country to say this these things. It's not as easy for all people to manage this. We also have uh the um uh impaired thermal regulation because climate change driven uh droughts and low indoor humidity increases skin dryness. And for people with spinal cord injuries, skin is already vulnerable because of the sensory loss and altered microcirculation, and also the reduced ability to shift position and all these are risk factors for pressure injury. Okay, and I also should say that poikilotomy or a loss of normal internal temperature regulation describes how body temperature can drift toward ambient temperature in people with high spinal cord injury. And again, due to the autonomic dysregulation, impaired sympathic outflow absent or reduced sweating and ultra peripheral vasomotor control means that these patients do not maintain the usual homostatic responses to environmental temperature shifts. Or it's wrong to say patients, people are a much better word to use. And then we have uh like burning and uh heat sources, wildfires and also smoke, because climate change increases extreme heat episodes and wildfire frequency. So the wildfires create both direct burn hazards as well as indirect risks like smoke inhalation, reduced air quality and disrupted services. So people with spinal cord injury face several intersecting vulnerabilities due to them sensory loss, which reduces awardness of localized heat or skin contact with hot surfaces and further mobility limits that rapid will make them able to evacuate from hot zones as well as respiratory comorbidities and exposure to smoke, which can be significant. So wheelfires and extreme heat also threaten power supplies that run essential medical devices as well as cooling devices. And then we have the cold weather and hypothermia risk, which is much more common for us living up in the north. And cold exposure is also hazardous. Individuals with tetrapegia and high cervical lesions have blunted vasoconstriction and reduced shivering or muscular heat production, and this is mechanisms that normally protect against cooling. And as a result, they can feel uncomfortable, have reduced dexterity, impaired cognition, and show greater reduction in core temperature during mild cold exposure compared with controls. And even moderate outdoor cold or poor heated indoor environments can produce clinically relevant hypothermia in susceptible individuals. Yeah, and then we have the the flooding and extreme precipitation and mobility barriers because increased heavy precipitation events and flooding create immediate physical hazards and longer term disruptions like loss of housing and interrupted care, damage to mobility equipment. So wheelchair users and people with spinal cord injury are disproportionately at risk during fluids because of inaccessible evacuation routes, lack of aquatic capable wheelchairs and interruptions to electricity for medical devices and pumps. Flood water also increases exposure to pathogenins and can contaminate skin wounds and pressure injuries, raising infection risks. So what to do then? After floods, damaged housing and long delays in repairs often make homes less suitable for return. Preparedness actions map accessible evacuation options in advance and store essential supplies in waterproof containers at reachable heights. It's it's easy to to just number these things up, but it's not so easy in real life. And and so is the security of or insulate of electrical medical equipment which should be kept with backup batteries and portable power. So I will just uh summarise the adaptation strategies that Janis talked about in the beginning here. The ideal thing is that clinicians should document lesion lesion levels, autonomic dysfunctions, equipment dependence, baselines, skin status and social supports because this forms the basics of a seasonal or emergency plan and also ensure adequate heating and cooling as well as backups. We should install accessible detectors, eliminate trip hazards and store supplies and backups in accessible waterproof locations if possible. Oxygens should be registered, ventilators and power dependent devices with local utilizers, emergency services. This should be maintained in spare cushions, battery and repair contexts. Further maintain regular skin inspection schedules and also pre-identify accessible shelters and accessible transport, conduct drills with caregivers and prepare a grab and go kit if possible. And also connect with local disability organization if possible to ensure caregivers and neighbors know how to help you and push for inclusion of disabled voices in municipal disaster plans, which is difficult even in Norway. And also teach recognition of hypo and hyper athermia signs and steps for cooling and warming, steps for wound infection signs after flooding and safe use of heating and cooling devices. And also promote accessible infrastructure, prioritize power restoration for people dependent on medical devices and targeted public health messaging during extreme weather events. Like in Norway, we we are more and more people are using sun electricity. But when we have winter and and darkness six months of the year, it's not always easy to fill up these equipment so so that we will have the needed power. So it's not easy and will not be easy, but we should do what we can to stay at least prepared on some levels. So stay prepared and thank you.
SPEAKER_02:Great. Thank you, Ingeborg, for this comprehensive presentation of all the health problems in spinal cord injured people regarding to climate. And uh we move forward to the next speaker, our next speaker, Carla Silva from the Southport Hospital in the UK. Carla, could you please please share your screen? We will have uh all the questions at the end.
SPEAKER_04:Hello? Um can you see my shared screen?
SPEAKER_02:Yes.
SPEAKER_04:Yes, okay, fantastic. So um um first of all, thank you for everyone for um attending. Um I am summarizing on this presentation the role of the healthcare system on climate change, what has been uh the management plan so far, and gonna highlight some of the actions we can uh we can take. So healthcare accounts for almost five percent of the total global greenhouse emissions. Uh this might may seem not much, but if if it was considered a country, this it would be rated as the fifth biggest emitter. So maybe we should remind ourselves of of that. Um some of you might have heard of the um greenhouse gas protocol. So this is a framework for um measuring and managing greenhouse uh gas emissions, and it is widely used by organizations globally, including the healthcare um uh organizations, to support climate action and and sustainability uh efforts. This um framework um identifies three scopes and pathways through which there is a contribution for uh climate change. So we have direct emissions uh that corresponds to like scope one, uh, and involves things like the hospital fleet, like the cars and ambulances and so on. Um, and then we have indirect emissions, um, which can be due to like subcontracts, um, as is the case of like purchased uh electricity. And we also have emissions secondary to the delivery of care itself, including drugs manufacturing, uh waste management, um patients transport and traveling and and so on. So on the management of its impacts, healthcare needs to address things from all the way from reducing overall greenhouse gas to developing more green-friendly uh products, which is a big scope. Um this picture um embodies and represents these three scopes of action, and it um identifies also the decarbonization actions that we can put in place. So, yes, if if possible, we should consider redesigning our our facilities. and and optimize the the hospital fleet. But this together with the electricity accounts only for 29%. On the other side, we can also focus on the 71% of scope three through things like low carbon medicines and better waste management. So we can consider optimizing our procurement methods, like the way we buy things for the hospital. We can consider single use versus circular economic economic model with better sustainability. Can consider the the company or or drug carbon uh footprint on the decision making like um when you're choosing uh a car on Hoover you have the option to go on an electrical car or you can go on a diesel car. And you can make that choice. And by the way I have no financial interest on Hoover just as a disclosure. So we can also choose drugs which packaging from the manufacturer also facilitates the daily individualized unit dose and automation as it is known to be the most effective stock management form because it highly reduces um um waste uh related to to to drugs this picture um is here like just as a representative of one of these procurement shifts so the artist uh Maria Kojik has depicted herself like surrounded by all the equipment used at her own cancer surgery one surgery on the right you can see the reduction that was possible after switching to a different surgical package one might say well it's not that much but we can see the difference and this accumulated times as many uh theater um interventions we have it will make a difference so this is just one of one one one um uh example one um other aspect um is um so-called like low value health care so actually some references say that up to 30% of healthcare uh provided can be wasteful low value or duplicative so it is worth to think evidence-based medicine prescribing and diagnostics so in the practical world what exactly can you do on your clinical role um and well these examples examples I'm bringing is just because I these are some of the most commonly prescribed um worldwide um so where the oral root is available for HAMER patients we can see that what difference it can make uh the switch between you know intravenous uh to oral root uh if you look at paracetamol this switch itself uh it's um represents a 16-fold reduction uh the same thing can be said in regards to antimicrobials as as an example I've I I brought here like a moxicillin and clevelinic acid for which we have a 38-fold reduction and when you think for how long our patients are on RSetamol and for how many courses of antibiotics they have well the earlier switch we made with the biggest impact uh we can get in in the end of the of this patient's um the this person's treatment um the monitoring bloods can also be another critical area to look at we know that most cut carbon emissions are actually at the point of sample collection mainly due to the um consumables and we know how difficult it is for spinal patients to to bleed so so um if we can plan uh monitoring bloods in a way that we can reduce the sample taking and and also the transport associated with with with the sample because sometimes the your sample might be actually be taken to a totally different location and need to be driven there.
SPEAKER_01:So if we can organize things in in a way that we we facilitate this and we streamline this we obviously we can get a better um result in less and less emissions um also if if you look at monitoring levels um just as as another example we should think why are we taking the levels is this for is it for safety is it for effectiveness um also depending on where you're practicing do you have um you know access to a pharmacokinetic department are you using a nomogram for this particular um uh person is am I looking at a one of those like a um like a gentleman uh before a catheter change um or am I actually planning to start this to stop treatment uh anyway will this result uh actually change my decision making um so having worked in different countries I'm aware that the protocols on how managing these things can be quite different um and obviously I have to say well follow your local protocol um but it is worth thinking why why are we um proceeding in a certain way uh the diagnostic images are also a big um contributor um with the CT and MRI obviously like leading the list so we should also be thinking a bit more thoroughly and more more consciously and on how we request these uh the these uh diagnostic images so as a uh take a home messages for my presentation just as a summary so healthcare is responsible for almost 5% of the global greenhouse gas um we can but we can optimize procurement and stock management we can reduce low value healthcare um we can utilize evidence based medicine and consider more often the intravenous to oral switch bloods and images diagnostics thank you thank you Carla I'm always enjoying your presentations and uh we'll proceed to the final presentation from uh Professor Taslim Udin from Bangladesh uh Professor Udin please may say you can share your screen thank you very much uh it's uh late evening here and uh do you hear me please yes Taslim please proceed okay uh so it's late evening here uh I'm sure globally good morning good afternoon so uh thank you very much uh already uh three three uh speakers and uh uh makali uh they spoke on the issue it's great that uh so my part has become easier and as Karla mentioned uh the people with disability especially the person with uh uh spinal cord injury they really contribute uh very little in uh global warming and uh the climate change but they suffer hugely uh in the changing climate so uh what actually we are getting in this uh station uh because uh um it's it's uh it's great to see the people in this room and uh the people are joining here in the agenda of climate change disability health issues and especially persons with spinal cord injury and we are here to find a way out or to find an adaptation of the persons with uh disability they are impacted with the uh climate change and in um uh in the Nepal earthquake 2015 we have seen about 200 persons with spinal cord injury and uh when uh they have impacted because Nepal has a changing climate and at this time uh how this disaster affected the persons with the changing climate we have seen that and uh during our last meetings with uh Society of physical rehabilitation medicine our international society of physical rehabilitation medicine and of course our national society meetings we have seen a great number of people with uh huge interest they are participating in this uh changing climate and how they are impacted with this uh the impacting the uh person with disability especially spinal cord injuries and um uh the because the um the person with disability and uh climate vulnerability are mostly affecting in different regions of the world so my topic is uh uh really it is the uh on the uh uh you know this uh changing um globally disparities across um LMICs and the developed developed developed countries so climate hazards are really intensifying global and social inequalities uh individuals with SCI face heightened uh risks due to multiple risks at as the our uh earlier uh speakers have mentioned clearly and persons with disability experience significant higher mortality uh during natural disasters especially in the low resource countries and we need to be resilient and uh we need to be uh talking on the issues uh change this one to yeah so if we consider uh a uh publication with the World Bank that person with disability face four times higher mortalities in natural disasters and persons with SCI face multiple difficulties due to their sensitivity due to sensory or mobility issues and the climate climate uh events disrupt access to emergency care uh to the medications and to the habilitation services disrupting the electricity water the financial strain and the limited uh transportations in different contexts both in the developed or developing region so if we see the natural disasters and the changing climates from wildfire to hurricanes tornadoes earthquakes floods and landslides uh we have uh seen as i have told about some of the earthquake problems that we have attended during Nepal earthquake 2015 and we had several landslides that follows uh mostly the floods uh in Bangladesh also uh the uh the how because their persons are poor their uh they they are they live in a poor housing and uh so most of them in in the on the uh hillsides of the um uh country and say the they suffer more and uh well people with aging uh here as we have seen in hurricane katrina more than 75 years uh age they comprise half of all storm fatalities this is an alarming issue and we need to learn from these examples uh so that we can uh really work for the resilient uh in the future see the mechanism for intensification of the inequalities how these uh uh uh uh issues happen there are three main issues one is the differential exposure increased sensitivity and limited adaptive capacity how the differential exposures are uh it is because the vulnerable groups open live in areas more exposed to climate risk as just I have mentioned in the uh uh uh landslides uh even often located in flood plains in urban heat islands or with less green space or near polluting facilities and highways increasing their exposure to extreme heat flooding and uh air pollution and the second point is the increased sensitivity that is their disadvantaged population including the elderly children pregnant women and those with the pre-existing medical conditions that they chose the different conditions and so the prevalent in deprived communities are more physiologically susceptible to climate change impacts like heat stroke cardiovascular and respiratory illnesses and infectious diseases and then the third number is being limited adaptive capacity this is because of again three issues the financial constraints access to services and social and political factors the financial uh constraints are mostly seen in the uh uh developing countries where the uh the the the they often lack savings they don't have insurance coverage or the financial means to relocate the improving housing uh insulation or to purchase cooling systems or other adaptive measures and access to services that means they have limited access to health care they have limited access to even early warning systems or essential services during a crisis that we have seen during even in pandemics. The social or political factors that is mostly in the covering the developed and as well as the developing countries because of the isolation language barrier and lack of political power can hinder their ability to advocate for their needs to access available support. So these are the factors important for hazardous intensifying existing health and social issues. Other environmental vulnerabilities for persons with spinal cord injury are deep spread, infections, dehydration water contamination increases the risk of skin breakdown and pressure injuries power failure that our earlier speakers have noted these issues that intermedical routines and equipment such as wheelchair coutumes and all the ventilators degrade even the extreme heat that we have seen in different publications. And one example is here how the environmental vulnerabilities cases the Bangladesh heat waves inaccessible cooling centers because the extreme heat in Bangladesh evaluating cooling projects this is uh situated in a such a situation in such places uh the the the the people with disability cannot uh uh uh afford to go there or they don't have any facilities to move from this place to that place and even in the US or in Europe uh because of the US wildfire smoke worsening respiratory complications that we have seen and in Europe there are where deadly heat waves exacerbating health instability so if multiple varnalities increase the risk of health impacts for any person be the pregnant women or the person with disability and aging population the poor or displaced Bangladesh currently houses uh uh the largest number of refuses from our neighboring countries so they are the displaced people they are suffering hugely and we uh we are running a project over there uh hopefully we will be able to publish the the uh disability rates and their sufferings in the displaced population and of course the children and elderly also suffering at the vulnerable communities of course the actual the changing climate when any any uh sporting event going on they are also vulnerable to uh uh impact on climate changes and uh of course the poor people they work in outdoors in agricultural workers or our other mineral workers they they they are the environmental decays so well uh of course there are the policy gaps and the climate action uh most of the LMIC's emergency plans lack funding for disability accommodations they they they just look for a general um uh way they don't care uh for the special need population this is really important and absence of evacuation protocols for wheelchair users uh and the marginalized populations lack of training for first responder on disability intrusive response this is really important and we need to talk on this on the policy gaps so that uh uh we uh we we can have a resilient uh uh uh adaptation uh fragmented coordination between ministries handling with health health and disaster management because multiple stakeholders are there everybody is working and if they do not work in a concert and in a one particular point it is really fragmented it remains fragmented and it really uh does not work so we need to talk on these issues and again inaccessible climate resilient infrastructures uh this is a real important because uh our uh uh donors donor countries they uh they work on these resilient infrastructures but they that really um remain inaccessible cyclone shelter hospital and raised roads oh they like ramps or leaf so it's very difficult to get people uh accessible and persons with small cord injury cannot reach eight distribution centers after disasters there's no way that they can that uh uh they can access to these uh uh eight distribution sites and there is no universal design is really applied in LMIC infrastructure projects most of the projects are okay uh from ADB or from other sources so they just do on their own ways because uh person with disability or person with uh working with the disability they are not really consulted while doing all these things we need to um accommodate these people while making a policy and uh of course uh two other issues are food security and mental health this is really important because uh these are the compound health impacts um uh and uh heat related illnesses uh infectious and uh hood borne diseases mental health issues disruption to health services all these are the heightened anxiety related to evacuation challenges and caregiver shortages of course these are the issues with loss of assistive devices increases psychological distress while this 2024 Bangladesh flood we were attending as uh emergency medical team we have seen one health loss that is a great issue that many of the elderly persons having multiple medications they have lost their prescription so while I was asking okay what are the current medications you are taking oh doctor I forgot I have some 20 plus medications because of my diabetes because of my hypertension because of my heart issues so I forgot and I lost the prescription in the blood water so it's a it's a real health loss and loss of uh other uh their mobility devices as well so I will be uh uh summarizing my talk soon the other issues in this part if not in the even other uh developed part of the world the cultural stigmas and climate awareness is really the really a problem because uh the state the the this leads to social exclusion during climate preparedness activities and in South Asia part of the world cultural norms affect who receives help first during disaster there is no cultural issues and person with disabilities are often left out of early warning systems stigma reduced risk community support and who is post-disaster health outcomes these are the issues and person with disabilities and climate change in Nepal uh um humanitarian impacts and uh for inclusive climate action this is a good attempt example of uh inclusive um uh uh disaster uh regional iste and the response system so I want to conclude here with a few words that um we have been uh with all the uh presenters here and uh I must thank uh uh arranging such a very important webinar thanks participants and uh uh of course we need to go we need to talk we are to be communicative we are to be leaders of climate change health disability and sustainability we need to be resilient because climate change is imposed disability uh disparities for individuals with uh uh spinal code injury there are uh environmental risks that disrupt medical rudeness that assisted devices and basic safety so the policy and infrastructure gap hind that safe evacuation and resilience especially in the developing countries and of course that I have told these uh stigma and the exclusion from preparedness systems worsen post-disaster outcomes and uh we need to build a climate resilience inclusion planning universal design disability aware response and strong cross sector coordination thank you very much thank you for kind attention thank you thank you uh you may also go to the can we stop sharing please uh you may also go to the chat there are some very useful uh comments uh Amina Adu is making a very important comment regarding the backpacks uh who are very important uh in case of an emergency for persons with disabilities and spinal cord injuries uh you may read all the comments also in the chat so while you are thinking uh regarding uh some uh questions uh I need to go to find out the Mentimeter we prepared previously but I cannot see it my screen is black why do you have any questions please if you can write your questions in the chat from the panelists do you want to add something while we are preparing the Mentimeter Carla would you like to add something okay can you see the multimeter yes okay right so let's go what can SI specialists do about climate change it's a cloud you may write what you are thinking of you may use the code or you have to use the design I leave it for a couple of minutes what can SI specialists do about climate change barcode you can use the barcode or you can use the code at menti.com Educate and prepare of course that's correct preparations and educations are very important we heard about it other ideas can be leaders or advocates of course as a specialist must be leader and advocates as Mark Ali pointed out uh before education again yes it's coming strong other ideas uh use evidence based medicine evidence based
SPEAKER_00:medicine yes we are some however we are we are lacking research in this direction there are a lot to be a lot to be a lot we need uh more research in the field we need more research in the field other ideas do you have any other ideas educate and prepare educations can be a climate leaders leaders advocates okay let's wait a couple minutes maybe some other days are coming please respond freely photograph gaps in axis that's new interesting photograph gaps in axis okay let's proceed to the next slide climate change preparation guidance for people with spinal injuries do you have any ideas in the comments previously there were some uh solutions Amina Du wrote some solutions regarding the eight participants only eight participants joined Menti you can join also with a barcode if you want if you find it easier no guidelines for three day pack yes three day pack is very important what will be included in the three day pack medications catheters some food some water informed patients challenge informed patients challenge okay inform patients challenge what is this sorry I can't understand this ink applicability of solution what do you mean by that can you write in the chat knowledge that they are we can discuss this later okay give leaflets about cling oh that's easy a good idea let's go to the next slide so the next the final slide is what is actually your specialty in order to understand what who is joining this webinar please tell us our specialty it's very important to to understand who who took part in this webinar till now we have uh PRM physicians and other that means no PRM professional or for other physicians okay 5050 now please continue to vote yeah actually PRM physicians physicians can offer a lot because they can offer basic interventions and comprehend the physiological mobility and psychological elements that raise the risk and also they can also advise patients about the elevated risk of for example cardiovascular disease and respiratory compromise in these situations something is in the chat okay we have also nurses from the UK so increasing applicability of already eventually okay okay and we have some other physicians okay great so uh from the panelists would you like to add something from the remaining panelists because I I cannot see Taslim anymore so we have I have only Carla and Ingeborg with me at the moment so would you like girls to say something to the audience yeah I can say something uh first of all thank you uh for for attending this webinar and thank you to you Yanis for organizing it it's always a pleasure to participate with you uh we saw in the Mentimeter uh uh what you people think we should both be prepared of and and how we should stay prepared and I think that is something we should keep on working on uh I like the idea with this uh three days it's uh so easy to get hold of and and maybe that could be uh something important for people to to survive for three days so I think and also I think education is super important both for for healthcare personnel but also for for people in general and for the politicians uh they should know what people with disabilities are facing in in uh during the climate crisis and climate changes so so maybe that should be uh one of the jobs in the future for us not only to inform people but also the politicians so thank you so much I agree and I believe it uh it will be also important to add maybe to know where to find these people to help them to have uh some kind of uh registries of these people uh because there are no registries at least in Greece so it is also very important because in uh in case of an emergency of a disaster uh these people uh need help so we need to know where to find them so Carla would you like something to add i um well I think a lot have uh has been said and I think we have like lots of um um inspiring um presentations and how to be a leader on on this subject um on my um part of let's say if I can uh add on is remember that as we are all part of this system we and although we do feel like we're a bit that we don't have maybe a lot of power to make the difference and to impose this diff this these these changes because most of them are at a more political level um there are little things that we can always like do on either because you're part of a committee and you can always try to raise awareness for these things and on little details on our own hospitals and our on our own organizations highlight that maybe sometimes there are there is a different way to look at things and there's a different way that we can make things a bit more um sustainable a bit more like uh climate friendly uh so I believe that we all have regardless of either if you're a nurse if you're a doctor we all have our own role to play on it so I think we're all a we need to be like a big team of of leaders thank you thank you so we need to finish here so I would like to thank uh all the attendants but especially the panelists uh the members of the government panel of the special interest group of iscus of uh climate and health uh Carla Silva Ingeborg Taslimudin Mark Ali Alexander all are the members of the government panel and uh thank you for attending this uh webinar tonight so I would like to say goodnight from uh Athens and thank you so much for attending bye bye thank you