 Hi everyone, dear colleagues, friends and welcome to the World Environment Day webinar organized by the Wonka Working Party of the Environment. Today, you know that today's World Environment Day, 5th of June, and this time's theme of the World Environment Day is beat plastic pollution. But as family doctors, we have not confined to that topic only as people who provide holistic and comprehensive care in this webinar. We are going to address some other topics as well, which are very important to us as family doctors. So we have three eminent speakers with us, and I'm very much thankful to those three high-profile speakers for joining us today. And all three are very good family doctors. And as you know, they are Professor Andy Hens, Dr. Catherine Pendrian, Professor Sonia Ritler. So those three are from three time zones, Sonia from Canada, Andy from the UK, and Catherine from Australia. Thank you very much for being with us. And I'm Sanker, I'm from Sri Lanka, and I'm the young doctor's lead of Wonka as well as the vice chair of the Wonka Working Party of the Environment. And we have Austin with me from Turkey, she's the chair of the working party on the environment. Austin, would you like to go ahead? Thank you very much. It is a privilege to be with you in here with Professor Sir Andy Hens and with Dr. Catherine Pendrian and Professor Sonia Ritler. I just want to introduce for some of us, maybe we don't know the background. For example, Professor Sir Andy Hens is formerly a family doctor and professor of primary health care. His interest in climate change and health beginning early 19th, he was a member of the entire governmental panel on climate change for three assessments and chair of the Rockefeller Lancet Commission on Planetary Health. On the interacademy partnership he and there were lots of academies worldwide working group on climate change and health. He is co-chairing the Lancet Headfinder Commission on Health in Zero Carbon Economy. The stage is yours. Well, thank you so much for inviting me to speak. So what I'm going to do is, first of all, I'm going to share my screen. I'm going to give you an overview really of the linkages between climate change and human health and then say something about the actions that we can take to reduce the impacts of climate change on human health. So as you know, human influence has heated up the climate over one degree centigrade 1.1 bit more than that global average temperature relative to the pre industrial level. And you can see on this slide on the left, what the temperature would look like if it was just natural fluctuations you can see that there are natural fluctuations related to the way in which the earth rotates around the the sun for example other factors. But what's happening now is well outside any natural fluctuation, and this has been shown to be unequivocally very clearly due to greenhouse gas emissions. The most important of these greenhouse gases of course is carbon dioxide shown on the right side, and you can see how that's fluctuated over 800,000 years or more. And the reason we know that is because scientists have extracted air bubbles trapped air bubbles from the ice in the poles, and they've extracted the gas to trapped atmosphere, and then it can analyze that for carbon dioxide and other trace gases. So we know that carbon dioxide now has gone up in fact it's now over 420 parts per million, much higher than it's ever been in the past and very rapidly increasing. Carbon dioxide is a long live greenhouse gas so some of it stays up in the atmosphere for 100 years or more even a small proportion probably for millennia. And we know that there's big disparities big differences in emissions per capita emissions so the top 1% of emission emitters. These are people living in high income countries, they are responsible for a 17% or so of the global greenhouse gas emissions and the next 9% or over 30%. So together, these 10% high estimators are responsible for almost 50%. And the bottom 50% of the world's population is responsible for only 12% of world emissions. There are massive injustices in terms of the causes and the consequences of climate change for human health. And this infographic taken from a paper that we wrote a few years ago summarizes the complex pathways by which greenhouse gas accumulation affects the climate. And then through a range of demographic socio economic and other environmental factors, these influence the magnitude and the pattern of risks. And you can see that through a range of exposure pathways and by the way these are not comprehensive there are some that are not actually on on this slide. These have an impact on a range of health outcomes from the most direct like extreme weather events heat stress, air quality from wildfires for example or increasing pollen due to increase them causing increased allergies. Water of course water quality and quantity food supply and safety, vector born disease distribution and ecology and then on the right here, these social factors forced migration, probably violent conflict as well, it's still quite controversial. And these have physical and mental health effects. So that gives you an idea of the range of different impacts that we can expect and we are increasingly witnessing. And increasingly it's clear that climate change is having an impact on health now. For example, we know that the extreme heat events in India and Pakistan last year were made much more likely as a result of climate change. We know that this had impacts on human health directly it also affected crop yield and so on affects it rainfall patterns wildfires, and we know that at a global mean temperature of two degrees centigrade, such a heat wave would become additionally an extra 20 to 20 to 20 times more likely. So, and also even hotter than these heat waves are right now. So you can see that we are heading towards an uncertain but very worrying future. And recent evidence has shown that we can attribute a portion of heat related deaths to climate change not due to natural variability. This slide in nature climate changes of two years ago showed using data from 43 countries over 7,730 sites that are more than one third of the heat related deaths of recent decades could be attributed to climate change. So even though we can adapt to some degree to climate change. Nevertheless climate changes is having an effect on heat related deaths at the moment, but you can also say that there are big gray areas on the map and that's where there's no data for much of Africa and Asia and we do know that temperatures are increasing of course, but we don't know precisely how many extra deaths, they're responsible for because we don't have the daily death registration data from those countries. We know that as well as causing increased death rates particularly amongst the elderly extreme heat exposure affects labor productivity so you can't work outside to the same amount that you can as a temperature gets hotter. So that will drive more people back into poverty. And we estimated that once you got to over to two and a half degrees centigrade heating, then over well over a billion people in some climate models could be experienced such high levels of heat stress that it would make it very risky and dangerous for them to work for at least one month of the year. And we know that some groups like pregnant women are particularly vulnerable this is some work that's recently published from the Gambia, showing that fetal heart rate increases at the end of a working shift for pregnant women working of subsistence farmers, and that's directly proportional to the thermal stress thermal stress to which they're exposed. So these women are particularly high risk. But wildfires have an effect on human health of an increasing number of papers showing this wildfire particles are smaller than those in particulate matter from urban sources they get deeper into the lungs they have a higher level of water at PM 2.5 in that total particulate matter compartment, and they seem to contain more oxidative and pro inflammatory components and on the right side you can see that there's an increase in cardiovascular and respiratory mortality in the few days following to wildfire smoke, and on the left at the map at the bottom shows you where wildfire related PM 2.5 pollution has been recorded in some cases extraordinary high levels of pollution over 200 micrograms per cubic meter. So that's extremely high levels, indeed. We know also the climate change affects the distribution the range transmission of many infectious diseases vector born food born and water born diseases, and through a range of different mechanisms then it causes new cases of infection in new places and probably more severe infections as well, and it may interact with host factors such as under nutrition and forced migration. So we can expect a heavier infectious disease burden all things being equal in a hotter world. And this is just an example of how the transmission or the ability to transmit the dengue virus has increased in recent decades as a result of heating of the atmosphere. And you can see for the two main vector species, Edie's egyptian Edie's albapictus, according to this paper by my colleague, Chris Murray and others. A couple of years ago you can see how that's increased over recent years and so dengue we know is is is expanding in its distribution just had a case in the UK of a woman who caught dengue when she was in France. The distribution of the vector mosquitoes in this case albapictus is expanding in Europe, other parts of the world. We also know there could be some very nasty surprises ahead. And one reason for that is because we're melting the permafrost. And as you melt the permafrost and microorganisms and viruses that have developed many adaptations to survive for millennia in the permafrost will be liberated. There's also toxins like mercury atmospheric chemicals and nuclear waste and other things trapped in the permafrost will be liberated as that's melted. We also know that emerging zoonotic diseases can come from deforestation with increasing climate change and deforestation. That's likely to increase the numbers of outbreaks of emerging zoonotic diseases. This is going to negatively affect food productivity food crop productivity as shown in the map on the right here the red area shows where productivity food crops is going to be decreasing. You can see that's much of the tropics and subtropics. There may be some parts of the world in the green where crop yields increase but we don't know how long that will be for. We also know that from the Ukraine, the terrible war in Ukraine that there are other factors that may prevent countries exporting their grain, and at the moment we see a situation, a perfect storm an imperfect storm if you like, where food prices are increasing around the world, and climate change will amplify those kind of impacts on the left, you can see the modeling studies of agricultural yields and you can see that the crop yields getting increasingly negative as the century goes on. This is only going to get worse, sadly. We also know that as well as physical health effects there are many mental health effects. So for example after exposure to floods and droughts, you get a high prevalence of major common mental illnesses, anxiety depression and so on. There is also this concept of solastalgia, which is the distress caused by environmental change, such as communities in the Arctic which have had to move because of melting ice. They've had to shift their whole communities. And we know that many young people are experiencing climate anxiety. Many recent studies have shown that nearly 50% of young people in the country's survey have expressed really quite severe anxiety levels in some cases, nearly half of them affecting their functioning such an extreme level so we are seeing more climate anxiety, as well as the directivates of climate change. What we need to do while there are two types of action, one is mitigation, cutting emissions and the other is adaptation, managing the risk of climate change impacts as far as we can, through better flood protection, better disaster management, better infrastructure upgrades, better early warning systems and so on. And mitigation is about cutting emissions. We'll hear later about need to cut fossil fuel emissions through clean energy and sustainable transformation energy efficiency but also the food system, which is responsible for nearly 25% of emissions, so healthy and sustainable diets. This is just an example of the kind of actions that can be taken to reduce heat-related deaths, taken from a paper by Olly Jay and colleagues a couple of years ago in the Lancet. What you can see is that we need better surveillance and early warning systems. The health sector has an important leadership role, but it has to engage other sectors. There needs to be targeting of vulnerable groups, distribution of potable water, pooling centres for vulnerable people in elderly care homes, for example, but we also need to address the problems in refugee camps, workplaces, mass gatherings and so on. And as well as working to improve individual responses to heat, we also need to work with those who shape the urban landscape because we know that greener cities are like to be cooler cities and like to be better for our health and reduce the urban heat island effect. And many buildings, of course, are heat traps and we need better passive ventilation, window shutters and so on. So one of the things that we can do in the short term to reach this target of 1.5 degrees centigrade, which is sadly rapidly slipping from our grasp. These are the things we need to do and we're not doing them, of course, no new coal power plants, stop selling fossil fuel cars, and I would argue, promote public transport and active travel, healthy, affordable, sustainable diets, renovating buildings, stopping deforestation and ensuring that industrial installations become low carbon. Of course, that's not happening at the need, the necessary pace and scale. This is the potential benefits from phasing out fossil fuels. According to a study we did some years ago, I won't say much about it because I know we're going to hear about that later but you can see from the map where these deaths could be prevented, much of Asia, including Indonesia, Europe, North America, less so in Latin America and Africa, it's not burning as many fossil fuels but of course if they go down a high fossil fuel development trajectory, the number of air pollution deaths will increase. And we know that air pollution, of course, is a major killer in terms of heart disease, stroke and other outcomes as well. Diets are an important contribution, more sustainable diets. In the UK, for example, we showed that if we could optimize the UK dietary patterns to meet WHO nutritional guidelines, we could reduce greenhouse gas emissions by nearly 20% and increase life expectancy by about eight months, something of that order. And obviously more stringent dietary change would produce even bigger benefits. We know that cities can do an awful lot, efficient public transport and active travel, universal access to clean low carbon energy. I've mentioned safe access to green spaces and housing improvements, water, sanitation, cooler houses. Not just a reliance on air conditioning, which is very energy hungry. And if the grid fails during a heat wave, of course then the heat exposure can be even worse. So there's a great deal that family doctors and public health professionals can do, working with urban authorities to help cities adapt to and mitigate climate change and our colleagues in Barcelona have developed this idea of super blocks illustrated in this slide on the right side where they suggest we could amalgamate nine city blocks, stop through traffic, plant more vegetation, allow people to walk and cycle safely. And they've suggested that if that were possible to scale up to the whole city of Barcelona that would prevent many deaths from physical inactivity and air pollution. We've also documented the national spaces, going on the left side of the slide, the dark typing is the good evidence and the gray is where there's questionable evidence. And then the public health benefits of the Paris agreement could be very major. This is an estimate across nine countries of ambitions, nationally determined contributions to put health at the center of new climate policies and you could see millions of premature deaths from air pollution, diet and physical activity could be prevented by the implementation of these nationally determined contributions in just the nine countries that were studied in this study. Obviously the ratio of different types of deaths prevented depends on the country. And then finally the healthcare sector itself will be hearing about that in the third talk. If the global healthcare sector were a country, it would be the fifth largest emitter on the planet. At COP26 there were 52 countries I think there's now 65 countries committed to building health systems which are more resilient and also low carbon and sustainable. And we have the WHO initiative the attached initiative and WHO guidelines to help support this transition. So in conclusion, climate change poses very wide ranging threats to human health and increasingly family doctors will be seeing their patients experiencing those impacts. There's big health benefits from adapting to the climate change we can't prevent and from cutting greenhouse gas emissions from mitigating climate change. We only have a very small carbon budget left less than 10 years that this is probably this is a bit out of date this this slide is probably about seven years now to get to 1.5 degrees and sadly I don't think we're going to make it to 1.5 degrees but we can still keep below two degrees. So as you can see, we have only over 1000 gigatons that's 1000 gigatons is a billion tons of carbon dioxide left even to keep below two degrees so how we spend that budget is going to be really important for health and sustainability. I will stop there and hand over to the next speaker but thank you very much for for listening. Thank you. Thank you very much ending for that insightful talk and you address not only the impact and the and the consequences of the climate change but also the solutions for this. Thank you very much. And we are fortunate to have you here. Before I go to the next speaker let me remind you that we, we are recording this webinar because we know that the timing and the time zones and even the Monday so the day is not very convenient for everyone so this will be on the one car YouTube by tomorrow. So you can share and disseminate and we can share our knowledge as well. Okay, our next speaker is Catherine, Dr Catherine Hendry is a general practitioner and epidemiology scholar in Australia, who has been involved in effort to address the health impacts of climate change for 15 years with work that has spent advocacy research and policy. Catherine has previously served as a member of the United Nations Sustainable Development Solutions Network for Australia, New Zealand, and the Pacific, and is a current member of the Climate and Health Alliance Research and Policy Committee. Royal Australian College of General Practitioners Climate and Environment specific interest group, and also in the one car working party on the one or two. Thanks very much. Thank you. Now the first challenge making sure I can share my slides successfully. Here we go. Fantastic. All right. Thank you everyone and thank you to Sanka and Austin for inviting me to speak. It's an absolute privilege to be joining you, particularly speaking alongside such to such imminent and accomplished speakers so hopefully my perspective from down under in Australia can can add something to tonight's conversation. Well, I said tonight to to to this conversation wherever and wherever wherever and wherever you are. And before I go on I'd like to also acknowledge it's something that's important that we do in Australia that I'd like to acknowledge that I'm speaking to you from lands that have been traditionally owned by the First Nations people of Australia and specifically the Wurundjeri and the Boon Wurund people, which is where I'm speaking to you from today. All right, so fossil. So why should family doctors care about fossil fuels. I think Andy Professor Haynes has addressed a lot of this but we'll see if we can fill in a couple of gaps. All right, so I think we've well and truly covered this and I won't spend long on it but but climate change is the great challenge of our time. We are absolutely on the precipice and running out of time, and we need to address this urgently. And as you've just heard, and as we address things in medicine. We don't just treat the manifestations of disease we absolutely treat the root causes and for climate change really that means addressing fossil fuels. It can be an unfamiliar space for a lot of us to get into to think that we need not just to be practicing in our clinics but we need to be thinking about broad societal issues, global issues, energy policy. But it's absolutely relevant to the health of our patients and to our broader role within our communities, preserving health care. If we think about our patients who smoke, if they come in with lung disease cardiovascular disease cancer, the cause is smoking and that's something that we need to address. If we think about climate change the manifestation that we have is a global health emergency. And the cause is emissions from fossil fuels, which is coal oil and gas, and that's the cause of disease that we need to address here. So a small amount on fossil fuels they're released by by burning and other processes can also be deforestation land use change and various things to provide us energy. And that's something that we've been doing very intensely since the Industrial Revolution. And when we burn fossil fuels coal oil and gas, a range of greenhouse gas emissions are emitted into the atmosphere. And as you've heard that we talk a lot about carbon dioxide but there are others, and they basically trap heat that's leading to global warming and fundamental changes to our climate with profound implications for human health. I'll briefly touch on scope one scope two and scope three just because as you get into this space you might start to hear more about them. And it can be handy to know those terms, but we don't need to get to bog down into that level of detail. So scope one emissions is basically the direct emissions from activities that we do onsite. And so if you're at a factory and you are producing something, the any chemical fumes that were released in that would be scope one. We talk about scope two, that's emissions from the energy used to power that process. So they're the first form of indirect emissions and scope three is all the emissions that are produced in the supply chain of anything we use. And in healthcare, if you were giving a vaccine, the scope three emissions would be all the emissions that went into making that vaccine. And that's how we think about emissions when we when we're trying to understand these and how we can reduce these. All right, so as you've also heard healthcare is part of the problem and I'm not going to go terribly much into this because you've heard a bit about it and our next week we'll be going to it in great detail, but it's important for us to recognize that it's part of the problem. The breakdown that you can see in that graphic is from Australia so globally healthcare is considered about four to five percent but there is a lot between countries and in countries like Australia it's been estimated to be more like seven percent. And while hospitals are a big part of the problem primary care is important as well. And I've circled some of the areas on that graphic where primary care is particularly relevant you'll see general practice in Australia is estimated to only be four percent. But if you look down pharmaceuticals so the medications we prescribe are closer to 20% and primary care has a huge role to play in prescribing. So we absolutely need to be part of the solution and recognize our contribution. Okay, so but not only of course the fossil fuels contributing to climate change, but they have direct harms to health and fairly significant study. And it came out relatively recently, estimated that air pollution from burning fossil fuels is responsible for one in five deaths globally, a significant a very significant amount. And, and it's probably been an under recognized area as local fossil fuel developments have gone forward. There really are impacts at every stage of life from low birth weight to pre term labor and asthma in children contributing to cardiovascular disease, cerebral vascular disease strokes, and, you know, diabetes dementia, a whole range of health impacts that are coming from the polluting impacts of fossil fuels on our land, waterways and soil. All right, but despite the contribution to climate change and despite the very significant local health impacts from pollution. Unfortunately, global fossil fuel production is still rising. So this is a report from United Nations and EP called the production gap report, where they looked at governments plans and projections for their fossil fuel use, and they compared it to the trajectories that we need to keep to limit warming, ideally within 1.5 although, as you've heard that window is rapidly closing, but, but as close as possible to 1.5 degrees, anything beyond that has rapidly escalating and unpredictable health impacts. So you can see the red line or the, the ready pinky orange line is the line of our current projections of our fossil fuel use. The blue is where we'd like to be at 1.5 and the green is two degrees. So there is an absolutely massive gap. The international energy agency has said that we don't need any new oil gas fields coal mines or mine extensions. And that's a, that's a, that's the international energy agency that's that's a, you know, authoritative body that specializes in energy policy. And they've just, you know, definitively said that we need to move forward with renewables in terms of new developments. But as, but nonetheless governments are projecting 240% more coal, 57% more oil, 71% more gas than would be allowed for the 1.5 degree target. And we're continuing to subsidize fossil fuels on an absolutely enormous scale. So the G20 countries alone directed about $300 billion in new funds to fossil fuel activities, just since the start of the pandemic. Because the World Health Organization was calling for a healthy recovery from the pandemic that focused investment around clean renewable energies that were consistent with a sustainable healthy and livable future. Okay, and I think it's I'll just quickly touch on gas because sometimes in these conversations and particularly where I am in Australia but in a lot of countries. And I think it's clear that gas is talked about as a clean transition fuel that's cleaner than coal and other alternatives. But really, we're past the point of using transition fuels, and there's a lot of misinformation in those claims as well. So, you know, burning of natural gas, it involves release of high quantities of methane, methane is incredibly potent, particularly in the short term so in the first 20 years of its life contributes 80 times more to CO2 CO2 is long lived in the atmosphere, but methane is a highly potent gas particularly in the short term. A lot of emissions from gas projects have previously been underestimated, basically because there's significant leakage or fugitive emissions. So a lot of the claims that gases in fact cleaner are overestimated or in fact just just downright false. And that, of course, like other fossil fuels there are direct impacts on health. So gas heating in homes can cause asthma decrease lung function, and does contribute to carbon monoxide poisoning I think we've had 15 reported deaths. And one study period within Australia as a well developed country with very significant regulations around these sort of things and we still have a notable number of deaths each year. So it's not an insignificant contribution. And unconventional gas from fracking has huge issues associated with the polluting chemicals that are used to frack the gas particularly with release into the waterways. So if we return to our smoking analogy with our fossil with a you know coal oil fossil fuels considered to be generally like smoking I think we can think of gas as a bit like vaping. It's been marketed and promoted as a healthy alternative that can fix our problems but in fact it has just as many issues. All right, so we absolutely need to urgently end our addiction to fossil fuels, they're driving climate change, and they're polluting our local environments. And, and, but we're still continuing to produce and increase them so it's absolutely an area for urgent action. All right, we won't dwell on that. Okay, so what can family doctors do about it well again you've you've heard some very insightful information already from Professor Haynes who has absolute wealth of experience on these issues but we'll continue to explore and what we can do as family doctors. So I think my list is similar but will briefly touch on building resilience and responding to climate impacts very briefly touch on personal carbon emissions and then we'll maybe talk a little bit about some of the opportunities for professional advocacy. Okay, so here are some photos from my colleagues in Australia. As you might remember that just before the pandemic Australia had some truly catastrophic mega fires that were unprecedented, although in Australia over recent years. People have become tired of saying unprecedented because we've had unprecedented heatwave bushfire and flood event after unprecedented event and unprecedented is no longer unprecedented in the new climate norms in Australia. It has contributed to climate change per capita, but we are also one of the countries that has significant climate exposure to extreme weather events. So, there's a picture of Dr. Michelle Hammersie who was involved in the response to the fires experience them herself as a local doctor in Australia and has shared her story as something that she can do to contribute to raising awareness about the health of climate change and what we need to do as a community. And she said being witness to the mega fires ripped through my community really impacted my thoughts and my practice. The health of our environment is directly linked to our health and healthy environment means healthy humans. And so she was directly involved in supporting her community and since then has really taken on the role as an advocate and quite inspiring. So, and another one of my colleagues Dr. Kim Lou, who is deeply involved in building resilience in her local community which is significantly affected by disadvantage and urban area and a severe urban heat island effect. She does a wide range of work around advocating with local state and federal government around improving climate resilience of her community and there she is running a workshop with community members, talking about some of the strategies that you heard earlier. And so she's also working with local people safe and checking on vulnerable people, ensuring their plans, particularly for the elderly living alone or people experiencing a significant chronic physical or mental illness. And that's something we can do in our role as family doctors as well. Okay, so we heard a bit about this so we won't touch on it. But reducing our personal carbon footprint is a really important thing that we can do as family doctors. And once you do it, it's really important to talk about it and talk about it in your practice as well as with your friends and your family. Okay, so professional admissions, this is what you're going to hear about in the next talk. So there's a huge array of things we can do in green general practice and also in reducing our professional carbon footprint education and training is a really important space. It's a very huge challenge for us as a profession, and we're not all equipped with the knowledge and skills that we need to take it on. So if you're at this webinar if you're interested and if you're involved in the medical education and training of your colleagues or your emerging family doctors, making sure that climate change, planetary health, sustainable general practice are involved in curriculum is a key area where you could make a substantial contribution. And as advocating with our professional organizations to make sure that the organizations we operate in are operating sustainably is a key thing that we can do to make sure that we're reducing our carbon footprint and again as a platform to advocate more broadly within the community. Events and conferences are a really important aspect. It's something we've been trying to start doing some work on in Wonka. And many family doctor organizations might be in a position where they can adopt a net zero target and actively work to implement that. Okay, now reducing the public carbon emissions or societal wide economy wide however you want to phrase it. And this I think really comes down to advocacy. And, and we have a really, really powerful role as family doctors to advocate on these issues and societal wide and as you've already heard from a very experienced advocate tonight. And I think what this looks like depends on where you are in your local community. Just last night I was on a teleconference with a group of pediatricians who are starting to lead a campaign against a major fracking development in their community which will have very significant effects for child health in terms of direct polluting impacts but also as a major climate bomb that will contribute. There are enormous quantities of fossil fuel emissions and basically and any prospects of a 1.5 degree target. So they've stood up and they've written to their local minister they're chatting to the media and they're starting to run a local campaign against it, using their position as as as as as child doctors and his family doctors that's that's something that that you may well be in a position to do if you're in a community where there are ongoing plans to develop fossil fuel resources. So that's a that's, you know, that's something that you might choose to engage in but even at a smaller scale having conversations with friends and family about the health impacts of climate change, supporting local climate, climate health campaigns, writing a letter to the media, building a relationship with your political representatives and talking about your concerns. These are all things that we can do. You can also divest from fossil fuels there's a link up there for a good website to start. So that involves a couple of things you can tell any institution where you put your, where you invest your resources that they should not be investing in the ongoing expansion of fossil fuel projects. And if they reach a point where that engagement you feels not not productive you can you can move your money elsewhere and tell them that's why you've done it. And of course building partnerships is key. All right, I think we're almost out of time. Here's some photos of posters of what we've developed in Australia with our college, communicating to people that climate change is a preventative health issue and linking them to resources so these are these are family resources for our clinics. And at a global scale there's very significant campaigns happening that you can tap into. They're run by the Global Climate and Health Alliance. The Wonka Working Party on the environment is very active and you can absolutely join on the website. And the World Health Organization really has taken a leading role with campaigns in this space, calling out that we need to end fossil fuel proliferation and subsidies for fossil fuels as well. All right, so it can be an overwhelming thing thinking about climate change but connecting with others and taking action really is a way to, you know, prevent and overcome that that sense of being overwhelmed and instead to to maintain hope and to be contributing and thinking global but acting global is a good motto to follow by. All right, so that's basically it for me. And if there are any questions I'm happy to take them otherwise I'm really looking forward to hearing from our next speaker. Thanks very much. The next question is not loaded to hear from you. Well, it is so sad that the fire is a fact of life while they're talking about environment and the other disasters. We do have earthquakes, for example, although we told we can just handle out but we just get as Turkey I am saying, lots of help from our neighbors and the neighbors over the seas like Australia. And as I see here, Professor Dr. Feliz are from Ankara University faculty of medicine has just said that there have been they are just structuring a curriculum about environmental health in their faculty. Fantastic. And also, there are the others like Emma Shepherd says that the slice was enthusiastic. Thank you very much. I do hope that there will be other questions but not to make Sonya just so wait, and there are lots of people just want to hear from her. I want to introduce Sonya. And here goes Dr. Sonya Wicklund Professor Dr. Sonya Wicklund is a family doctor in downtown Calgary, Alberta, prior to living in Calgary. She practiced in rural Montana in United States of America and rural Ontario. She is clinical assistant professor at the University of Calgary and has educational research interest in the indigenous women's health, obesity and planetary health. As we have got some curriculum about lifestyle medicine and planetary health is it is my university of economics faculty of medicine. I really want to know what's going on here while we are learning our practice in general practice. Thank you, Austin. Thank you very much. And thank you for inviting me to speak. Certainly, the two speakers before me have much more extensive background, but this will kind of give a talk about boots on the ground and what's happening, what we're attempting to do in Alberta. So just disclosures really quickly, because we typically do this I have a couple of research grants from the public health agency of Canada and CIHR, and a small honorary for a program around obesity management. And I'm full time faculty now with the University of Calgary with my rules. And similar to Catherine, we always acknowledge the lands that we live on now in Alberta so one of the projects that I have the privilege of being a part of is called McCoy-Oxcoy, which translates to the Wolf Trail and it's a wellness program for indigenous women. And this was taken a couple weeks ago when we were going to the what's called the majorville medicine wheel. So I live on traditional territories of the Blackfoot Confederacy, Soutena First Nation, and Stoning Dakota First Nation, and these women come from these First Nations. And it was visiting this medicine wheel, which Canada, you know, often has the view of being a young country, but the medicine wheels date back to 4500 years ago that they were first developed. And this is the view across Alberta from the top of this medicine wheel. So I just want to honor our indigenous peoples. So I'm going to spend time, I'm going to ground us a little bit in the Canadian context, remind ourselves about the trusted voice that we have as primary care providers. Talk about what evidence we have for bringing the community, examine our potential, and look through one approach, our approach. And then lastly, a little bit of discussion around navigating the question as to how do we get people to care. And I think Catherine touched on this a lot, but we'll maybe talk a little bit more. So here we go, Canada. So we, Alberta, particularly the province that I live in produces most of the oil and gas. And our, our biggest admission and admittance to the environment is the oil and gas sector makes up 26% in Canada and most of it is coming from my province. Transport 25% buildings 12 heavy industry 11 agriculture 10 electricity eight and the other seven and below. And this is actually information taken from NHS data because we don't have our own data. So it works well in Canada, but I just wanted to highlight. If you look at the second last column you'll see primary care. As Catherine mentioned, our highest impact is really in the scope three elements of medicines production and what we're prescribing. So the time and many Western countries, a lot more effort is now being put into greening hospitals, and that's very important because infrastructure energy buildings play a huge role in the impact. But in primary care, we can have a massive influence on how we communicate what's going on with patients, so that they can make changes in their own world, as Catherine discussed. And also how we view medicine and how we handle it on one one intervention. So the Canadian government we have set some targets we were somewhat late to the game considering we signed on to the Paris Agreement when we did, but our targets are to be 40 to 45% reduction by 2030. You'll see from the second line 1990 to 2019 our emissions have actually increased. So we are off target right now and we have a long ways to go to get back onto track. So similar to Australia were a big emitter, but we have been especially in Alberta we've been hit with many climate problems believe it or not that's not snow that everybody thinks of from Canada that's a hail storm in the middle of summer. And we've had the wildfires now numerous use in row similar Catherine saying we now are somewhat used to them but massive impact. And thankfully it's part of the thing that has pushed us we've had massive flooding here in Calgary. And just to mention the heat dome that we had in the Vancouver area, and to ground this back into talking about community care. The coroner's report. A year later really emphasize that the people who died from the heat dome were inside lacked air conditioning seems like in retrospect such a simple problem to fix. What's gone on with our narrative locally in Alberta, certainly denial years ago has been a big part of our climate change problem, but we move to acknowledgement and then recognition with these sadly disasters that it takes to make people realize that it's real and more solutions focused. And finally a government present government with quite a good carbon tax and good plan overall as long as we can follow through with it. But what's interesting now here we've moved into the third stage which is now kind of formal a bit of fear of missing out becoming an economic laggery because we're not actually investing in green economy as much as we should. And again Catherine highlighted that the difference of the money that's still being fed into the fossil fuel system versus into the green economy. So hopefully that's this fear of missing out is actually going to push us a step further. So sadly here back to Alberta are very large province. We just had an election one week ago in the party with the weakest environmental plan. One, the election. So we have lots to do boots on the ground talking to our patients. Looking at medical associations what's happened in Canada is we have lots of calls to action by our medical association. We did sign on to the COP26 health program in 2021. And importantly, our medical schools did make a planetary health pledge just last month. And what's significant for us in Alberta is that when our schools sign on to this part of signing on to this is a signing up for the fossil fuel nonproliferation treaty part of it is setting goals for net zero health care by 2040. So it will be a prong to influence the situation in Canada and become an advocate. So if you look at primary care, community care, we've all many of you on on in this meeting have probably done it for many years, and we value these long term relationships I always say to my learners. I love family medicine because it's kind of like going for coffee every morning with some great science thrown in there. So you become good friends and very trusted. Our barometer is well done and Canada show that health care and education do rank very high in the trust scale. And thankfully, although we hear from the far right and I'll have you look at social media. It only came out at 27%. And I think for us doing this work sometimes we feel overwhelmed thinking, wow, misinformation is everywhere, but we need to remember that the people are patients are community members they are listening to us. And so we need to take this to heart. So, the next thing that we kind of did as a group of Calgary and I always have to acknowledge our colleagues, but I have a wonderful team and it extends beyond this now, but we did a scoping review to take a look at what what tools were out there to support us to start our community clinics, because grounded in Calgary, I'm at a teaching clinic downtown. And I'll get into that in a minute, but we hope to help support all of our community clinics because we send our learners for four weeks out to rural practices, and for four weeks out to urban practices. We need to, we are a bit gifted and privileged to have more resources than obviously our community colleagues. And so we hope to create a playbook that will be can be actualized in the community. Going back to our scoping review, we wanted to identify toolkits and aids that that would help support sustainable health care. So we first did the scoping review of published in great literature. We looked at evaluating these toolkits, and we used a Prisma protocol extension for scoping reviews and reviewed 17,000 articles. Importantly, we do have some exclusion criteria that are more in the clinical care area, and that would be deep prescribing of medications you saw that how important medications are for the greenhouse footprint. So it's like stewardship, green prescribing and plant-based diets. The reason we excluded them is because none of the articles yet do a lot of correlations with how these can cut emissions. Now these articles are rapidly coming out now, and it's a very exciting area. Here are our results. There were 20 articles, 11 toolkits. The articles were very diverse. 14 of them really described a simple tool or aid, and most of them are just checklist wonderfully written, and it's kind of the early work in those calls to action. Three of the articles discussed carbon footprinting. So one of them looked at e-learning and how we can decrease our carbon footprint. One of them looked at the importance of following individuals, rurally, for example, for their specialist type of care, rather than having them drive to the city. And lastly, one looked at the carbon footprint in GP offices. And then there were six interventions for them were educational education, a very important part. One of these was a large open access. And the other articles were, somebody has hit their unmute. Marilyn, hi. And these are available at that link. Then the other articles talked about active transport education, general education as my education, and then one was a public and primary health care partnership action plan. Somewhat limited. I want to highlight, because this came out after our scoping review was completed some great work for community care, led by Rafaela, a family doctor in Brazil, who has produced excellent patient and clinic care case examples using a planetary health lens. And then I want to spend time on the tool kits. So three of the tool kits were primarily hospital based, which was in our intent, but we included them because they did address things on rural and smaller community care centers. So if it's applicable to you and you check on the scoping review, you may want to go to these two of the tool kits focused solely on the respiratory diseases. So all of them provided a decent background about climate change and health, and most of the focus was on cleaning up clinical operations, not as much on how we deliver clinical care that's greener, such as plant forward diet such as prescribing time in nature, and not using our vehicles but walking or biking. So two of the tool kits really shone through their well established and I'm just going to show you the list you can just cruise down it but you'll see most of them are from the Western atmosphere. And the links are there and we provide them in the talk in the paper sorry. And these, these tool kits highlighted many different areas and we've designed the paper that if you're interested in one of these areas, you can see all the resources that discuss the topic. There could be all the way from waste and recycling built environment procurement medical devices, educational things such as QI projects or medical education components to talking about social prescribing, changing water and food in the systems and anesthetic gases transportation and exercise. So many different topics are covered. We evaluated the tool kits following the work of Yamuda. Checking these four areas. Do they have a clear description of purpose. Yes, they all did. Were there evidence based elements. Yes, was there detailed implementation and this is where it became tricky. Most of them did not have details. One of them really shone through in this area. And then there was it was there a rigorous evaluation plan combining outcome and process measures. And again, a different one of our stars really shone through here in this area and to discuss these two stars. On the left, my green doctor.org was founded by Dr. Todd Sack, a US hepatologist. Very sophisticated, well developed he started this work back in 1995. Many tears that you can do. And his approach that he promotes is that if you have clinic meetings, start with just five minutes at your clinic meetings until you have increased momentum and you get people interested in topics and then if they decide to focus on one. They'll dive in deeper and they have developed modules for these topics. And then the other would be greener practice. And this again it's the green impact for health toolkit. It's really sophisticated has multiple tiers you win awards, doing various levels. You choose yourself where to begin. And importantly, just thought I'd highlight both of their main screens on their websites. Emphasize for community doctors finances matter. So the financial component highlighted there on both of them. So I think it's just, I think speaking, and I saw that Terry is listening on this talk so perhaps, perhaps afterwards he'll have some comments but Dr. Sack said, don't create a green team green teams will meet and meet, and perhaps not get anything done. So I thought that was super valuable and Terry said this is a long and challenging path to green and to discuss this, depending on where you're coming from. So find your allies early on, have a survey, figure out who these individuals are. So now for the last couple minutes I'll just talk about so here is my clinic it's on the left hand side, the view out our top floor window and this was when the wind was coming from the north with the wildfires a couple of weeks ago. So here's some of our staff and students, and our approach. So, four years ago when we started this work we were inspired by the students because as most of you will know it's been student associations nationally internationally that started this work, along with many individuals on this call in the, and the two proceeding speakers, and we were kind of flabbergasted that we hadn't done this work. And, and so we dived in deep and our pre work included resident led QI projects in the area of climate conscious inhalers, reducing sterile glove use, lots of packaging related to this reducing speculating use self swabbing reduction that we used on beds and turning off computers and lights. And we supported the undergrads to do a set of climate wise slides that are given in school under each specific topic. And we developed a workshop for the family medicine clerkship students where they teach each other about relevant planetary health challenges. We went on to write a policy brief for Alberta health. And then we completed our scoping review. And now we're working in three different ways we've started to collaborate across the rest of the university communities with the transdisciplinary work on campus. And this would be one health, our sustainability offices, engineering community health public health, and then in our community downtown like looking at that Barcelona action plan downtown Calgary in our building we have an urgent care plus we have many clinical projects and we're going to work and start very locally to build the social mandate for change. We envision, we envision projects, community based projects that will integrate our work into the community, also projects that just focus on clinical care and just greening our actual building and those on clinical care. And then lastly we have an opportunity thankfully to contribute to our School of Medicine strategic plan. So, what do we know we've we've given many seminars in Canada and nationally. So, sorry in Alberta locally and nationally to physicians and physicians lack education on training so as Catherine said, we need to really support education, all the way from undergrad to post grad. And then when we look at our projects, it's super important because this is a very critical time that we really look at the credibility of them, our capable of doing them and how compelling are they will they get us where we need to be soon enough. And importantly, we need to use our trust to move the needle. So to spend one minute on, if you're starting to green and you sort of pull up the scoping review to look at some of these toolkits and get the links to them. I'd also recommend this work by climate outreach, talking about the social mandate for change because it has really helped our team. And it also looks at why climate communication is difficult and divides it into nice areas that you can address when you enter into these meetings talking to your team. And I'll have you just peruse these. And then it talks about why we have this constant distraction. Things from the COVID-19 pandemic policy advances populism polarization opposition to climate policies and gives perspective. And he talks about the importance of this dialogue that we need to be understanding the impact of climate change, so that we can adapt to protect and we can mitigate but understand the vulnerabilities of people on the ground. So I'll pass through this. And I want to just highlight that's one of our patients sitting in the waiting room, looking at one of our infographics that we have upon the wall that help us communicate what we're doing. Thank you very much for taking the time to listen. Thank you very much. So yeah, and also there are lots of very very interesting discussion was going on in chat. It is a privilege to have Terry Campbell here too, because he's also the one that we talk about the inventor of toolkit that we could use. So by this way, not only this is an hypothesis it is something that we can use in our daily practice. If we get to sub can we move forward. It will be only just cheating to each other or just saying things that makes us to handle it and go on will do like to say anything Terry. Oh hi. So, I agree very much with Todd that really the most important thing is to get it on the agenda of meetings. If you don't get this subject on the agenda of meetings it never gets discussed. There's no experience going around to general practitioner meetings where you think people should know about all this. They don't. Recently I was in a UK GP trainers meeting very sensible people who would know everything that 50 people in the room that usually very sensible things. Only two people in the room had ever done their own problem footprint of their personal life, and only five people over that 50 had heard about the screen impact for health toolkit which has been going after almost 10 years. We think we are in this little bubble we think people sort of understand what's going on, but there's widespread ignorance. And so we have to be quite very aware that people, for one reason or another are not aware. And so there's still a huge amount of education that needs to go on with our particular toolkit 15% of the UK general practices had registered to use the toolkit at the last time. But of those 1500 practices, two thirds had not made any added any sort of achievements to the toolkit they may have done stuff but they haven't actually recorded it so there was only one third that it actually were sort of pressing ahead. Usually, that is just one or two people in a practice which has got maybe 10 doctors and about 40 other staff. So there's still widespread disassociation from this problem. And we really need to get it on the agenda so people are actually discussing about it and can't be ignorant about this problem going forward in the future. Thank you very much. We have some questions I think some burning questions for burning issues. There's one from, I think, April from Indonesia has a few questions for all three speakers. The first one to Andy. That tells that I really admire the innovation in Barcelona I think we really need that type of silos breaking innovation. What is your evaluation on the current state of silos breaking by a profession in medicine. What advice would you give to improve it. Andy. This is a really great question and it's a very difficult one to answer. We've been doing a big review of all the kind of literature on, you know, climate change co benefits for health and what we found is that most of the evidence is modeling as mathematical modeling studies so when you actually look for concrete evidence of implemented actions on the ground, you don't find as much as you would hope to. As Terry said with, you know, in general practice is some people you know that there's a big spectrum of interest and ideas, and only a small number of people really actively involved so we did find about 30 case studies of where we were very convinced that some implemented actions had results and benefits to health. And these varied from big national initiatives around renewable energy, in which to be honest the health professions hadn't played much role down to much smaller kind of more community based projects we found one on sustainable diets in schools in Sweden, but that wasn't I don't think it was initiated by family doctors more for public health professionals. You do find some around active travel actions around active travel there's a couple of examples in some New Zealand cities. Again these seem to be initiatives, more from public health practitioners and primary care practitioners. We found a nice experiment in Australia around retrofitting houses with insulation. And again this was in I think in Melbourne or suburbs of Melbourne, and they were able to demonstrate there was a reduced. The people who had this housing into insulation is a randomized trial, and they had reduced demands on the healthcare the primary healthcare system. Over the over the winter months in particular where they were exposed to cold temperatures so it did seem to have a beneficial effect also reduce the greenhouse gas emissions. So there are a few examples. There are not as many as we would like to see and I think what counts is really building up your local, your local relationships, so that you can work with the local city authorities, public health professionals, community groups and so on. So you can't mandate this from the top you know you can't impose it on people it has to grow from bottom up through good relationships with local decision makers in local government departments, from a range of professions, and I'd love to see more documented examples of that just as Terry said, thank you. Thank you. Thank you. Catherine there's a question for you. Interesting one in terms of promoting planetary health in education. What's your advice to manage the recipient's feeling of capacity to make meaningful impact within the current critical time frame and feeling of hypocrisy, because of most day to day lifestyles are still reliant to positive. Yeah, absolutely. I think it's these are really challenging things for us to come to terms with there's the overwhelming sense of the, you know, immense challenge and potential for, you know, really catastrophic health impacts that we face and as and as I was pointed out, it can be also challenging coming to terms with the fact that, you know, for for most of us we're contributing to that in our daily lives. I think, really, though it is absolutely critical to maintain optimism. We just have to. And there are different ways to go about that. I think a very simple ways that I think I mentioned is connecting with others who, you know, are going through a similar thing and concerned about these issues, and taking positive action so you're right you can be grappling with the fact that that you have emissions in your life and and perhaps another way to reframe that is well what are three things I can do to reduce those today. And if I can do those consistently once I've done those what are the next three things I can do and what are the next three things I can do so rather than sort of being paralyzed by by that sense that sort of negative feeling you're shifting it to thinking about positive actions that you can take. And I think we've heard a lot about family doctors and just, you know, people coming together to connect to connect with others to work through these things so we can often achieve a lot together. If we're talking about, you know, maintaining our well being our sense of hope and coming to terms with these things there's a lot of evidence also for spending time in nature. So, you know, turning off turning off the news and stopping doom scrolling on social media for a bit, and just having some mindful time around nature and green things is actually a really positive thing you can do as well. And personally for me, there are different ways that I go about this on different days. And there are days where it's the, it's the, you know, Lord of the Rings superhero it seems like there's no hope, but maybe there is still some hope story. And there are other times where we're doing a little bit of gardening as what I need. So I would encourage you to sort of get inside your own head and figure out what works for you but don't get too far inside your own head, you know, step outside and connect with people. I am going to post a little chat in a link in the chat it's a Australian organization called psychology for a safe climate they're a group of psychologists and psychiatrists, and they have a whole wealth of resources around this kind of stuff as well and I can see Sonya's going to handle I'm sure she's got some brilliant things to say. I just wanted to add one comment to answer the question to from a clinic perspective. So, as I said about four years ago some of our early resident led projects. They are kind of like, maybe gateway events to get your clinic moving to so we found it helpful something as tangible as the footprint of the meter dose inhalers being so dramatic and nobody knows about it like Terry saying, surprising how many people don't know about it, and it's something that you can do and so and our doctors can be competitive. 24 doctors for modules 20,000 patients, and we're now up at, you know, 8%, 9%, 10% reductions in those those inhalers that we're prescribing so we're moving the needle and it's a nice one to get people thinking. And in the conversation with the patient, they see these infographics and then you can talk about the other elements and yes in the context like framing before the meeting. Professor Haynes we were talking about, we have this finite time this finite planet so it can nicely lead to how even a small change like your inhaler makes a different because it's it's a finite package so it's just a nice gateway that I wanted to bring up. Interesting. Next question is also for you. I think it's about the cost of bringing your practices like the question is to give us more context in terms of investment. I want to share how much is the initial investment cost to bringing your practice and how you start funding, but you also inform the relative percentage to the total income. Do we need funds to bring our practice always. Yeah, so you know Terry you weren't a speaker but I might let you also answer this in the end because probably have more data around this. And I think it's wise, it hasn't cost us. These first steps have no impact cost wise. They just take time and effort and a willingness to do it to change something such as put solar panels on the building right now in Canada we have great incentives for putting up solar panels, and in Alberta, although we're a terrific producer of fossil fuels. We also have one of the best ways as individuals that we can sell the electricity would produce from solar panels onto the grid. So an estimate for example for, or for the roof of the clinic might be actually a return of 10 to 13% right now in Alberta. So the cost is not there and if anything we're saving. There will be some transition costs when we move away from single use products back to cleaning but most of those costs. The cost go down and there's cost savings involved in change. And Terry I don't want to put you on the spot but you might have a couple comments about cost. The difference with cost is it's very easy to start make savings quite quickly. People don't like to change, particularly when they're busy. And that's been a major problem. But when we started our particular program, we did a pilot and we showed that with just seven practices to start with and say to each practice for the very small talk that we were running at the time. We're running around about 1000 UK pounds a year, very small but it's recurring savings and recurring savings ends up being a lot of money. And I'm quite confident that practice is going along this particular route. Once they get into the hang of it into the rhythm of it actually saying, what are we doing will continue to save money because it just makes basic sense because they're buying less they're consuming less they're recycling and we're using more and all the rest of it and inevitably you will save money. It just makes it makes sense but it's just getting a lot of general practices in the UK are really not business minded. There were clinicians, we want to do this stuff. And so they haven't really been run as businesses so there's a whole hopeful thing that they have to sort of take on board. For instance, quite a lot of practices in the UK are not don't own their own premises they're in somebody else's premises so they're very dependent on their landlord doing stuff in terms of you know buildings and the rest of it. But you know there's no doubt in my mind but I can't prove it because we could never get research funding to do any of this stuff that it works. There is one, there is a research project which will be starting this year but it's taken three years to get funding for it. And that's just the reality of it, you know people are catching up now when we should have had the money for doing research four or five years ago. So the bottom line is like when you go through the toolkits you can see that there are a lot of things that does not cost anything. So there are things of course that you need some sort of investment again it's an investment. So that's what we are talking. Anything else? Any other questions? Well, as far as I saw there's no question but there are some opinions like Professor Dr. Filsak is here with us and she is from Turkey in Ankara and they were talking about to curriculum for the premise students. We have got the same thing but not all over the country and so as far as I know not all over the countries. But it is, as I said before it is very important to have a toolkit that means if you just give a tool to people to use it after their awareness we can just go a little bit forward to cost effectiveness is important. But while people or the landlords as Terry said would like to sell things to us we will be only consumers not only as a family physician but also also people who are living in our the same world, the global citizens. Yes, some of them are making some things but the other will be effect but everybody is affecting from that. But as and the size, the effect will be much more worse for the ones who are more vulnerable. So we are responsible all the things that we are made not only about our foods but also our carbon footprints. Is there anything you would like to ask or say? Dear speakers, because it is hard to find all four of you and also Terry and the others to be here at the same time so. Just if I could add a brief comment. I mean, I think we also ought to emphasize not just the savings to original individual practices, but also the potential to save resources for all the health system as a whole, because we know that quite a lot of what we're doing is quite wasteful. And we're launching initiative with something called the Bevan Commission which is an independent commission that advises the Welsh Government on the National Health Service in Wales. We've been launching a waste initiative and trying to combine kind of clinical waste with carbon waste, if you like. And so we know that there's a lot of waste in healthcare systems, a lot of medications that are prescribed and not consumed. Many older people in particular have polypharmacy with multiple medications, very doubtful how much they're actually benefiting from them all. We've all been into houses where we've asked them where they keep the medication you open the cupboard and you see all these pills that you've been prescribing and they never be consuming. And you know I think there's probably quite a lot of that out there. So I think we can also make a plausible case that some of these actions can help to reduce the cost of the health to the health care system. And we can also help to reduce the cost by better public health better primary prevention. So you know more sustainable healthy diets ultimately in the long run should reduce the burden from non communicable diseases as should, you know more physical activity so combining also clinical practice with kind of social prescribing, which has win wins for health and for the environment. I think can be quite a powerful argument. So encouraging patients to spend more time in nature, but also getting to question about their own dietary patterns or in physical activity, and so on maybe even the company that buy energy problem could be a win win kind of strategy for for health and the environment. Thank you. Thank you very much. Oh, it is a pity that we are just coming to an end. Terry says that prescription is so high. And also share decision making with proper informed contents from patients will reduce over investigation over diagnose and over treatment. Good evidence for this going back to my early nineties, but also helpless literacy education is important as you may remember the educated and well capacity people can choose what is going on for their lives if we are just the ones who are just managing with the landlords it won't be easy to just make sure decision making because we will be making the decisions which has been manipulated, although we told we choose. And this is another part of the story, I guess, but thank you very much again for this topic in this very, very important day and be with us and we want to remind again that this will this all course has been recorded. This is a course because server and the highest is with us catch country is with us and so you work with us and also Turkey up with us. And that's why this is also an educational part for all of us. Thank you very much again. Okay, so we call it a day. Thank you very much. Thank you very much for joining. Bye. Have a nice day.