 It has many distinctions for a long and prosperous career in public health. He's going to talk to us this morning about public health emergencies, the common thread. Thank you very much. Thank you. Okay. It is a real honor to be here because it's the kind of audience I really like to talk to. Because actually I am going to talk to you about what's coming in the future. I've talked about public health emergencies for a long time. We're the ones who have coined that term many years ago. But along the lines of, you know, when we look at prices, disasters and all the rest of the stuff, actually as students, as scholars in the field, we tended to focus in on each one and sort of memorize what we knew about it and things like that. And no one ever talked about a common thread. Many of the events that boom happened over with, things like that, don't really have a big, if any, public health component. But the real disasters that we talked about, hard scale ones, things like wars, pandemics, as soon as a pandemic happens, it's a public health emergency. I'll tell you the reason why. But it is important and it really makes your life a bit more sane if you approach these as public health emergencies. We all get caught up as professionals with certainly the citizenry, media, politicians in the emergency phase of things. But it is clear that all large scale kinds of crises, more people die from the preventable public health aspects. I have what we call indirect indices, measures that they do from the direct. So that's what I'm going to talk about. But I've done this in various ways. Knowing, hiding out from Christie, the audiences, I decided that rather than talk about the years of war that I've been in, it's all turned out to be public health emergencies and learned a great deal from it. I'll just really touch on it briefly and then go really into the emergencies of essentially the future humanitarian crisis. I think that's very, very important. Because the wars that we've been through, especially in the last three decades, will pale compared to the events that are on our dose plan. Now, I am a physician. I've been trained for pediatrics. I'm a board of pediatrics, pediatric emergency medicine. I was a professional chairman of emergency medicine. I'm also a psychiatrist, so I can read your minds. And a few things. Obviously, I have a public health degree and I'm a tropical medicine. Now, I did all these things because I wanted to do international health. There was nothing to guide me. When I started going to do things international, I recommended, oh my God, I really need to know something about that. And I guess my own obsessive-compulsive behavior that I decided was just not learning something about mental health, becoming a psychiatrist was going to be important. And if I wasn't 70 years old, I would be going back and getting a law degree but just an international one. Because you do all of those things. And I was actually trained by the Swiss NCRC in international health care. We used all of what I had just told you. But we have training programs now. We do do a very good job. And so we now, if you look at, from the health side, we look at Harvard, Hopkins, and Columbia, and the major ones that we send people to or have to establish more mentally than others. And we can't get enough of you. But we're graduating about 200 a year to call themselves a humanitarian profession. About a decade ago, there were about 100,000 people who claimed that they are a humanitarian profession. Management to logistics, to health, communications, things like that. Now we're a little bit shy of 200,000. So I will tell you that if, with some of the large events and some of the ones we anticipate, which I'll talk about, we can field enough people to manage about 100 million people. And that's going to be a real stretch. It certainly has the potential to cause more problems than just that. But so let's save the questions to the end and sort of write them down as we go along if you have anything to pick from the questions. In some ways, it's almost a survey course. So I want to be sure that you understand and understand the common thread. Understand the differences between direct and direct measures in disease. It's extremely important. And certainly understand where you have to concentrate public health. I was telling Amy, or I think it was, that a number of years ago, I was interviewed from the Lancet on a live phone. I interviewed somebody that published the answers. One of the questions asked me was, what do you think the most exciting field for the future is? Some questions like that. I said, follow up. I think they all spell off their chairs. So that was about six, seven years ago. I think if they asked me a question again, the centers, they wouldn't be surprised. It is also interesting too that most medical specialties like internal medicine, pediatrics, that began back in the 30s as special areas. In about 12 to 15 years, there was then a bevy of interns, or pediatricians, and then even surgeons, and then, as a matter of fact, emergency physicians who, after they got the boards, they decided something was missing. And so a good number of all of them, in fact, would get the public help. Now, Johns Hopkins, a lot of faculty, also, about now, it's about 12 years ago. But Hopkins had nothing to do with this, but all of a sudden they realized that there were a large number of students coming in, getting their masters in public health. That were Cotms, they were lawyers, they were engineers. So they themselves knew that there was something about what they do, what they were planning to do, especially if it had some global impact, that they knew that they needed to get some grabbing in public health. So some of the other people know more than people do. The other thing too, I'll talk a little bit about this, but I have to tell you right now, I don't know how you define public health, but even when I got my MPH, I felt that there was a majority of people thinking that it was about water, sanitation, sanitarians, and whatever. As a matter of fact, you need to understand that most of the people out there in the world, especially in politics, still think about it. The definition of public health is change, change in the law. Right now, when we talk about public health, public health is what allows a village, a town, a city, a nation state, and now a local community to function. It's transportation, it's communication, it's economics, it's governance, it's public safety, it's judiciary, it's all of those things. When you think about it, when any of them measure whether they're successful or failing in their endeavors, and certainly all the UN agencies use public health indicators to measure their success. So it's something that's very unique about public health. And so that's extremely important for all of you to recognize. So anyway, let's get back to the... What's the dominant in our attention for the last three decades? Event conventional wars, things that cross borders. The internal complex of emergencies, if you don't know what that means, the events that happened after the post-colonial era in all of these countries that that were trying to become independent. Primarily started wars over territory and resources, over the internal, not covered by international law, so we have to find very inventive ways to get involved with peacekeepers and peace enforcers and things like that. And then asymmetrical warfare, which is entirely different, and that's what's happening in Iraq. I was the first Minister of Health in Iraq. I worked for Colin Powell and I planned for the issues we had in the futures of Iraq. Task Force is 17 of them. And quite honestly, we predicted everything that happened. Real difficulties and unspecified. So a lot of what happened was that the situation didn't have to happen. But the main thing is that I was the first one to go in, the first different. The Baghdad was still under fire, simply because the looting had occurred. The Department of Defense had moved my slide about that. But I declared it was a public health emergency. And I was stepped on by a bill that's not and after we finish this talk we'll certainly understand if you don't already know probably one of the most egregious public health emergencies is indeed Iraq. But in a way, all of these things have dominated our attention. And quite honestly, there are a number of articles even now to talk about the fact that the attention to the U.S. because it has some real leadership in the world and the delay probably caused considerable problems in efforts in things like climate change but many other issues because of the attention. But remember, as I said, these conventional wars and all the rest of the stuff are measured high, see it on television with steps, right? And those are direct, okay? Those are direct measures. We need to understand that if we look at all wars the number of people who die from the violent who will be shooting the direct deaths is rarely over 11%. So, just hold on to that as we have to go along. Public health emergencies are disasters that adversely impact the public health system and infrastructure. Protected infrastructure. Take it for example, turn on a faucet, take a shower and drink the water with some insurance, okay? Some insurance. You know, I mean, there's so many things that we have going. It's automatic. It's also terribly underfunded. So when things happen financially, where do they pull a lot of the money from? Public health departments. But one of the big problems in this country is the fact that public health is on political appointees and so you often don't have the transparency that you might in other places. We tend to measure along water sanitation, food, health and shelter. So the protective threshold is destroyed. Where? In war. That's why we measure it. We can go in and see the response when the public health infrastructure system is destroyed. We can see how rapidly things happen with morbidity and mortality and things like that. So we know an awful lot from the wars. It can be overwhelmed. Katrina, public health system going on not recovered. Well, the southern part of Iraq which was where the Shia were, you know, that's where during the first version of the war most of what was destroyed was Saddam-Semayek and we covered that. So when Iraq, the southern part of Iraq the Shia areas, Basher, up to almost Karbala in the south of Baghdad had terrible, terrible health and disease. Infant mortality rate under age 5, mortality rate you all, that's not foreign to anything. Baghdad was different. Fairly sophisticated. It was called the Relical Pearl of the Middle East and people actually came with lots of surgery. Not much in the way of public health and infectious disease things but because people wanted to make money from these things. And then what turned out to be the Sunni Triangle had a different set. And then Kurdistan, which had been helped and assisted since the end of the version of the war had wonderful health industries and we're building nursing schools and medical schools. So there was no one health indices but that was never recovered. And so they had the worst ones in the south or denied. And one of the things we know with the last three decades of internal complex emergencies is that we've had ethnic groups, religious groups, and genders that have been denied protective infrastructure. With that, mortality morbidity is higher. We measure these things as indirect, preventable excess mortality often is usually the preventable ones. But to tell you the truth we have fairly good statistics about the direct. Despite the fact all the controversy about the Iraq Mortality Study which is certainly heavily involved and believe it or not we're going to try to close the circle. We're going to do the third Iraq Mortality Study. It's already planned. But we do not have very good figures about the indirect mortality. So public health emergencies can occur in war and conflict. There's large scale natural disasters and certainly sometimes natural disasters. We're just giving an example, Katrina and Indian Ocean tsunamis. Naturally current epidemics have been and as I said a pandemic as soon as it happens is a public health emergency because there is no country in the world that has all the resources required just on full time. One of the reasons why we have an international health regulation which is a treaty that requires all countries in the United Nations to have surveillance systems and this and that because it is necessary for control of the pandemic. It's also one of the grand experiments in any deliberate biological, chemical radiation type of things. But also you need to understand what's really different about especially with the asymmetric kinds of issues that we have written about. But inequities, poverty, injustice, oppression, racism, religious movement, they all have a tremendous impact but that impact can grossly measure how it adversely affects the public. Because you wonder gee I'm doing this right these are all the things that deny through these elements people from essentially getting public health protections. So I think that would be the end of that. So we entered the 21st century because globally the public health infrastructure systems most of them disappeared and many happened. And they were pretty good most of them. Declined or failed to keep patient the demands of every member of Obama saying we want to put money into building up the public health infrastructure systems. To tell you the truth we'll be getting everybody back and it will go deficient dwellings, aged infrastructure and tied really to the third point unavailable infrastructure capacity response. If indeed there is a crisis right now it's handling a lot of population issues with a crisis on top of it that's when it shows us out of the head. So years ago actually in the 70s I wrote in one of the papers that disasters keep governments honest by defining the public health and exposing its vulnerabilities. Think about it everybody thinks it's fine. Katrina comes and exposes the public health yes of course and the vulnerabilities despite the fact that for over three decades good scientists have been telling them to fix the levees or bring back the wetlands. Wetlands are essentially horizontal levees and that's why they put verb loans up there when they destroy the horizontal and ecological environmental changes Haiti as I said is an absolute environmental ecological disaster and you have to study Haiti because there's nothing that can be done you know so a hurricane comes through it's Florida and maybe 10 or 12 people by direct effects you got hit in the head by piece of roofing and things like that the same hurricane goes through Haiti directly kills 10 or 12 people over the next two weeks between 3 and 5,000 people die in Haiti because of flooding, mudslides etc. and why do they have the mudslides and the flooding in Haiti in those restaurants what? they cut down all the trees they have 2% of the original trees so there's no roots to contain and there have been trying to get the trees back you say did it 20, 30 years ago it continually failed is that a man made or a natural disaster a man made it started with Spain the French did it they all cut down all the trees they make boats and it bought back in 17, 1800 that's where it started okay and it is continuing so these are the future ones we have some remnants of these and that will continue in some variation of the theme we're going to talk about biodiversity prices post conflict environments climate change large scale natural disasters pandemics, megacities globalizations and emergencies of scarcity that is what my generation is leaving your generation thank you we just didn't think you'd have anything we couldn't cure everything so let's talk about these things first off you know about conventional warrior studies and cross forward the whole UN Charter is written for cross forward wars it has absolutely no applicability you can curse the UN and all the rest of the world but they are limited by their charter and they can't do anything because it really has nothing to do with the kinds of conflicts and things like that so you can't look at the charter genocide, peacekeeping peace support bought in by other organizations so it has nothing to do with modernity so we certainly do need to have more charter it is unfortunately countries like the United States who continually bought the changing charter so it has become somewhat beneficial but the conventional wars have changed we now have asymmetrical workers so think of a rapid but the intent there was we certainly have it in Afghanistan but now we don't have a general who is saying well I think we are going to try to protect the civilians as winning we certainly sort of tried to do that with a surge on Iraq the point is that all the humanitarian organizations the UN including me said this is not a conventional war but they can't play more conventional warfare the important point is is that this is where the intention has been put on the warfare these other two this is an article I wrote in Lancet the security issues are just out of the military it is for everybody in the entire country and so who has war deaths in any group 25,000 Iraqi soldiers have died 150,000 one group and another studied 600,000 have died and the other thing that is just as important is the fact that as long as it goes on it produces a prolonged public health it is terribly egregious they are not going to make any headway if you just focus on that and this is pretty elementary the military is just now understanding this so some examples the war started and started and ended essentially April 2003 but the first new Iraqi minister of health came on in April 2004 and what his first act was was to start a surveillance system is that a surveillance system sort of basing the public health so we do not know how many people died before that time we do not we certainly did not have death certificates which of course are elementary there and just to start was seeing how many civilians died and common health issues of a year and really more than that in 2004 the fledgling ministry of health along with the international community request developed a ministry of health report that showed that public health was actually a major concern what that is is that they most surprised most of us that other than there were more people died from public health causes then from if you have not heard this why is it because it got absolutely no progress but some indices the health is we started off with about a 22% chronic malnutrition so that's chronic malnutrition means that kids have had malnutrition for quite a while it's not acute malnutrition so you run up to 28% that's a very big jump but the infant mortality rate is extremely important it's what we call composite indices and the infant mortality rate has very little to do with antinatal prenatal and postnatal mortality of infants it measures governance it measures communication it measures education it measures capacity to have laws and a whole bunch of other things so the infant you can have the best antinatal program or prenatal program and postnatal program but if you don't have these other things the infant mortality rate is always going to be quite high so we call it a composite indicator and good governance is one of the most important things if you haven't read the book by Andrew Price, the health of nations now Andrew and I just got finished talking he is a political scientist by training and his hypothesis was that infectious diseases the capacity of a government to handle infectious diseases was the most sensitive indicator of governments they couldn't find anything else that was as sensitive now he said why not earthquakes other disasters specific components of a government take care of but infectious diseases like an epidemic or a pandemic requires coordination, unprecedented coordination collaboration of all government concepts so bringing it back however to a war kind of situation the infant mortality was actually quite acceptable however now it is among the four highest death rates worldwide so they share it with Liberia Afghanistan and Sierra Leone quite a commentary so it does measure the fact that the whole governmental system is falling apart and so water, sanitation, shelter, food all of that is actually worse than it was prior to the war so he said a public health emergency most conflict environments you need to know that again this blue line here is a number of direct deaths that happened during the war after a bit the system and the infrastructure destroyed we start seeing the indirect deaths the preventable ones don't have the shooting stops slowly the direct deaths go down but the indirect deaths continue to go up and they continue to go up and do not come back to the baseline for almost a decade so this is what we call the decay function extends up to 10 years may even be longer because a lot of these countries go back to war but if you look at Central Africa studies that looked at the wars between 1999 and 2005 that the indirect deaths during the conflict period made up 71% and they range anywhere from the 60s to the 90s in the Congo if you remember less Robert's excess mortality study he showed that between 2 and 4 million people died during a full month period in the Congo and he said, ah it's terrible and of course all the TV showed 837 to this that and the other but only 10% if we take the lowest confidence but lowest 2 million only 10% of those people died from the shooting a majority 90% died from malaria malnutrition dehydration etc all preventable public health issues 6 months after the shooting has stopped the indirect deaths went up to 83% dropped down in this study to 45% in 4 years who are these people? primarily women, children, mental health all members of the population but these are the most vulnerable because the public health infrastructure doesn't come back so if you want to know what is the most dangerous time it's the transition period which can extend from years after the war has stopped that's when death rates go up and you're saying why don't we hear about this when war is cleared over the non-governmental organizations take off the donors take off the UN takes off the money isn't there and we forget about it all of these things we say in the humanitarian community we talk about the two ways anything we do is try to improve the access and the availability of health and when that's worsened during this post-conflict time every country whether it's Afghanistan, Katrina Croatia suicide depression, alcohol, drug rates go extremely high a lot of them are out of work males and IDPs Croatia you know anything about the Yugoslav war Croatia was the one country that sort of came out of it not going too back I mean they all did but a few people know that after the declaration was signed the accord was signed people went home soldiers went home there were 700 suicides gender-based violence I hope all of you have heard of this a lot of writings why don't we do it it's the intimate partner race essentially that is one of the most sensitive markers of community breakdown and economic and fiscal and security there are other things that are going on but we use these as proxy indicators to tell us that there is something wrong in the society it goes up tremendously after anymore so Congo Iraq, Katrina we can put all of them in so you have some natural disasters in work a number of girls in school in that period afterwards this is a terrible financial threat and even globalization now the financial threat a lot of those countries never had to pay for their kids schooling but now they do so who doesn't go to school is the girl in the family and the study just in Lancet out of Afghanistan was a surprise of all but it showed the fact that the mortality rates were higher and the reason being is that they weren't going to school and in most of these countries the only health care is done during that time so you're going to see other nature and epidemiology is in charge I'm quite sure that I was an epidemiologist but one of the things that this is part of the study that we've done and for the first time since before we have less declared wars than any other war so you have less deaths the blue one due to conflict but what we have is we have more people living in post-conflict environments the ones we've forgotten about okay it's over with let's go on for the next thing because we're just emergency NGOs that's what we do but what we did is and there are a lot of different state departments and other kinds of programs that look at these countries forget about it you've got to go to the country and you've got to ask the people the people said there is still violence going on various levels of intensity but what we found was that all post-conflict countries still had some level of conflict so it's quite a myth post-conflict environment but the difference between the populations of war and post-conflict is actually getting blurred with this low level of conflict intensity so people don't see where something changes them so it doesn't mean that there's really peace out there and I don't know how many of you have done anything internationally but you talk to the state department talk to the military especially and so they sort of judge the countries that they're either permissive that the military and community can go in there not permissive that they can when the war is over and then semi permissive so we've got these terms to describe something that quite honestly people haven't even tried to understand or recognize nobody really wants to know that recognize the war is still going on now we looked at 303 countries 28 currently going on since World War II in 1949 World War II present time and what we found there were a number of things to be measured case fatalities casualties political disruption social disruption etc etc and there's 10 different levels but the yellow one is level one still something going on but the least what you see is that conflict plus 10 years we did conflict plus 5 years so the end of the conflict when there was a declaration of something 5 years and then 10 years the majority of countries there's still levels of conflict why this here well this was post World War II in Germany and in Japan and other countries that were involved but why this big area here why we don't have a big area there the countries today the post-conflict countries today mass and post nuclear yeah I mean World War II destroyed really there's nothing left of it but peace came back the reason is that they didn't have weapons not only do people have weapons when the war is over with they have increased weapons and we see the pieces they militarize so we sell them weapons if you have weapons and the monopoly of weapons weapons are going to be used so we don't have any history with that and it's what we call the monopoly of force the other thing too is that we're finding the same kind of events that were called terrorists or whatever during the war time the same events but now for political reasons they call them criminality or banditry and if you remember just recently the U.N. general for Sudan said the war is over with everybody said why I don't have a minute a second I don't think it is and he even said in his speech he said well there's just now some banditry going on well of course I hope you do but the confounding variables and what you study here the number of violent events the level of forces and the available weapons and that's what makes quite honestly most of the different the predictors of going back to war returning to conflict is just plain stagnation of health and economics and here we go with the infant mortality rate again because it is the most sensitive indicator and worsening infant mortality rate and I don't know how many have any of you done international missions and you know what we talk about the emergency threshold but the next thing about studying this kind of study is that we take the epidemiology that you study and we use it every day where it's in our conversations it's in our plans and everything but we have an emergency threshold which is greater than two per ten thousand a day of deaths and if that emergency threshold was there at the end of the quote war and it still is there and the public health system isn't adequate to take care of that it's one of the reasons for returning to war also these wars that have been evolving your history for so long that are now not on the radar screen they have less than ten percent of the resource space to work from and simply do a recent conflict that's one of the main reasons to go back to war because they don't know anything else and the thing is it was never really fixed so 47 percent of the conflicts we've had over the last three decades returned to war within a decade and if you look at Africa it's over six months not very good. Now the point is is that this is the first time since 1994 that we have less declared wars even though as you just learned now this is unpublished that we have still levels of intensity but the point is is that this is the first opportunity we have to do something about it and most of it is bringing back the public health infrastructure these are countries that had it before that is why they're leaving so they're just clean especially people who could leave which was many of the interesting crises you need to understand that we have in the globe areas of biodiversity that are extremely important for the environment and the ecology and that's where those are places that contain the majority of the world's plants and vertebrates right? Biodiversity hotspots and this is strict criteria is where the habitat for greater than 100 species of vascular plants have lost at least 70% of their habitat that's an effect on the entire world okay? and it should be a great concern so I don't know how much you can see here so this is South America in the United States here we are the big biodiversity area all the crops are grown the only country that the entire country in the wide biodiversity area is New Zealand and I just got back from speaking a lot I'll tell you a little bit about it but you can see these areas and that's where most of us rely on our crops and our animals and all the rest of the stuff that we treat it with because it's always a balance but the darker spots are where we have had major wars and the unfortunate thing is that major wars have often occurred where the biodiversity because they want the resources they want that territory okay? now that's changing a strict criteria I want you to pull onto that as we go but what we know is that 80% of the major conflicts that I was just talking about occurred in 23 of the 34 most biologically diverse areas if we look at Iraq and you're not hearing about a gang but for the last two years they've had major droughts major sandstorms the bio only 13% of all of Iraq is arable land that's between the tigress and the Euphrates river if you've ever been there or flown over it it's one of the worst deserts and all of a sudden you see a river and then zoom these date palms of all the rest is all active absolutely amazing but that is all disappearing also the attitude is the tigress and Euphrates river come from Syria and Turkey in the north and what are they doing? they are damning them very much like China they may call river okay and we're the essentially the rice bed for all the major plants okay and so the salinity is now coming in from the sea so we have an environmental emergency right now so as some people have said well I guess they'll use the oil money to buy food and that's not at all unusual okay or money harvesting all the great timber and cambody and condom lizard drugs in Afghanistan southeast Asia Latin America okay when other things should be grown proliferation of small arms when they have the small arms we can shoot all these in so there's no balance now where hunters used to have heard about the groceries but now our supply of small animals and the lingering post conflict and kind of fighting just failed recovery of those areas that are not going to survive Oceania where I do a lot of work and you're part of it east coast they have six of the 34 months spots and the unfortunate thing is that has a very very poor worker of extinction about plants and animals you are going to be dealing with this more than you realize all of these are tied together climate change well think about the what's called the boundaries framework threshold for seven environmental indicators climate change, biodiversity global cycles of nitrogen the fresh water availability ocean acidification CO2 emissions the point is that these three have already gone over the tipping point scientists will say we don't know whether we can bring it back but any change of any of these affects the other certainly the fresh water sustainability is over the top in many areas of the world so this is extremely important and that's what we're really concerned about but setting off mass migration is a mass conflict from these reasons Lake Victoria if you've ever been there about 10 feet in six years rising temperatures diminishing rains I was telling Deli because I go back I remember in Nairobi and in Kenya I could walk around any time of the day or night and just talk to the people I can't actually tell you in the hotels as soon as you step out there are monstrous mega cities entirely entirely different but tropical diseases their vectors change first as it gets warmer they can reduce more because it's warmer during the time they're producing and so their vectors are moving from tropical to subtropical to non-tropical what are the arguments during the Bush administration was the fact that well there's no indices to tell us how something's going on with climate change well Mark Keim who has worked a lot for CDC in Polynesia has looked at and found that if you've ever been to Polynesia I haven't had to go back after many years islands that I remember now all you see is some just palm trees but you can stand there for a year on the coast and say I don't see the water coming any higher the point is if you need to build the physics and the water seeps under the island first disrupts the roots and coconut farms and taro and whatever so it stops their growth these are all the polygons have an endemic vitamin A efficiency but now we're seeing starvation for the first time so starvation is the sentinel proxy of climate change at least for Polynesia challenges are quite different with each island but essentially increased severity of the tropical cycle because it's warmer water so it can go firm general sea level rise natural effects with increased acidification of the sea and that's from the CO2 and warming the coral reefs and eventually a lapse of those ecosystems the migration pattern is different than what you saw in wartime in Iraq in Afghanistan, Africa but by 2050 and probably going to be for that night about 75 million islanders will be forced to relocate as I said I'm a professor in Australia and they say it's our responsibility they're already making plans to take the islanders but this is 75 million out of 900 million that are also people around the world that are affected by this so it's a difference here this is regional rather than international so we talked about the refugees this is a different issue but they will be indeed refugees primarily driven by drought and soil degradation but the first move is villas to villas this is what we've seen in Africa they call it crept after our living it's like people over here people over there, things like that it's interesting the Africans are talking about moving more to Mediterranean and seasonal sort of moving to back and forth depending on the conditions and that happens in Mexico and China China has, and this is their their not fit for human habitation this is land that's just essentially turned over to desert over 150 million need to be moved mainly from water shortages so a lot of when all the factors started on the east coast and a lot of great jobs for young adult males a lot of people said oh, they came for the economy no, they left the young adult males left central China because there was no super dust storms and a lot of the springs from the aquifers have decreased and that's what's happening in Africa you see the climate say in Victoria but really what's way underneath is what's going on so that's a big concern which we might not get that so you get things like this Shenzhen is one of the economic zones outside of of Shanghai and if you go there you say it's more water than any place in California and it's really quite great contributing to modern jobs and things like that this is all a shallow land of the area that was then going to become Shenzhen and this is it 25 years later so all the blue areas the dark blue areas, the urban areas just the white ones there are just new urban development just spring up like that now the point is that they'll say we're going from the economy then you go there and actually China's places I go back almost 40 years and they're during Canada and the square and certainly during Milestone and whatever but it was really a very rural place and there's a lot to be humanitarian but they will tell you we had to build this because Shanghai was one of the most dense dense different than population areas in the world but they didn't they were infrastructure public infrastructure now I was speaking in Shanghai and they said we're going to drive you it was about a three hour travel northwest so another big highway it never used to be in the car now they're all in the place but anyways they get off the road because they wanted a certain direction but I don't know if the drive was not lost and we went around we went by some guard things and then we drove in and all of a sudden I would all look like this and they're in front of me with a type of bus it was this massive, massive city but it was like a neutron bomb and it hit it and a neutron bomb won't destroy the buildings but it was killed the people everything was new there were pharmacies, there were schools there were apartments, everything everything was okay massive, not for miles and miles and miles they were nervous as hell because I wasn't supposed to be there they finally got out finally got the thing we didn't say anything about it generally we were reminded because they said don't say anything about it don't say anything about it and I said well what is it and it was the city of Kong which they said in about two months several million people will be moving there so their response to because you just there is a limit isn't there to the infrastructure and the water and all the rest of the stuff and so their answer is to build new cities and they be one of the best things as we know now of all the developed countries Australia is the most developed the most vulnerable so they had rising temperatures low rainfall, bushfires like crazy, severe droughts but winter rains in the west just like with Perth which now the mosquito breeding is going on so Brisbane did have some dangy, the 80s mosquito is now spreading all over it's spread down to New South Wales and things like that but dangy and Ross River fever and L.A. dosis haven't spread yet that's what we expect in the next decade so this is the concept that happens as long as you imagine this in Katrina, you all know who's talking about but about the public health people in the Department of Health in New Orleans were treated in outbreak investigation during the hurricane one committed suicide one died in a heart attack but New Orleans never had a lot of fun so their entire surveillance system all the things that tell you about the epidemiology and the population et cetera, et cetera was done on paper so when the floods came that paper turned into pulp so after Katrina they had absolutely no baseline epidemiology and what's the Department of Health without that the citizens however and if you remember the Times which continued throughout the entire hurricane and after this they started to have more obituaries and the citizenry said why all these obituaries and complained to the fledgling Department of Health Department of Health turned to us Harvard and went down and did a study and found that a year after this is excess mortality again the indirect there was a 47% increase in the people who died in New Orleans since the hurricane that's unprecedented because the public health system is disrupted I'm not unable to provide basic surveillance and of course these were not even good but 2.5 billion internally displaced but do you know that? that's more than the people internally displaced in Sudan and post tsunami in New Orleans so it's 10% of the total in the ocean tsunami more money than gone Clinton getting all the money the money has gone to economics because the economic theme is if you improve the economy everything else will follow then the health system will get better and the education system gets better they had people on the beaches within 5 hours after this but of all the countries that were hit by the tsunami 3.5 now 4 years after this large gaps in shelters, sanitation portable water, health facilities and shelters that was not no attention despite all that money was given to them so 20 to 25 years before the real decision of New Orleans is whether the city should survive there should have been built in the first place 38% fewer hospitals in New Orleans this is the worst 56% fewer inpatient psychiatric patients to read that last sentence the last psychiatric hospital last psychiatric bed and all of New Orleans closed this sentence were things getting better there's still about 32,000 kids who have never returned to school so those are this is called Katrina Payment because you have to have indices globalization how many of you remember Alma Otter or at least study it what was Alma Otter anybody well that's what it was Alma Otter all about there was a declaration that everybody can have health care the health indices so it took people like you who back in the 1950s just how many people are dying they primarily focused on women and children they said this is appalling so this was the Alma Otter which essentially they said by the year 2000 we'll have equity in terms of health and they were really moving towards that the wars, the conflicts everything just stopped it but the other issues was run by W.H.L was it also said look health and education is a human right so this is what was emphasized why this should be done well that failed now we're certainly before this economic crisis World Bank has essentially dominated things and as I said their mantra is we can improve the economy everything else will follow now as a W.R. Wilson scholar in DC it was not far from the World Bank became very very a good student of it but also increasingly critical some recent articles on that back me up on this but if you look at it there is no public health component to this and very little they said well we have an epidemiologist from CDC we weren't doing anything but there's no health and human right component they feel that health is a responsibility that's what McCain said in that interview where Obama said it's a human right when McCain said it's a responsibility nobody asked well what do you mean by that the responsibility term comes from the World Bank meaning that if you have a job or whatever it's your responsibility to get it companies will also provide helping but that just didn't work and during this time gang this is the most important thing there's been a net reduction in expenditures public health health education whatever because in these cities where a lot of this the economy has been outsourcing and going to all of the health care was public health dominating now they built new hospitals do it in India but you can go here and get your bypass done but the population can't but during that time there was enough coming from the Hoffers to try to maintain these public health facilities laboratories, clinics, hospitals whatever but even that there was nobody was putting money in to keep them maintained just running because they said they'll all be replaced by the private sector so the financial crisis happened and guess what we've got a health tragedy worse than we did before and in these cities we have a large number of we don't know who they are but we think they're mostly young adults who are hoping that they will get a job and so where do those people know they move to the disaster prone areas in those cities so during this time we've had increase in health inequities and a widened gap between the haves and the have nots the haves being those that didn't have a job but guess what this is important the have nots have returned to those 1950s health indices so we gained absolutely nothing over those 40 years but as I said it's an invisible population in these mega cities we don't know the numbers we don't know who they are if you go to Lagos in Nigeria it's primarily women who are widowed or single with three to five children who were escaping rural Africa remember 67% of the population in Africa are now living in urban cities in rural Africa rural Africa just abandoned but they go there for the security many of them have been raped they get to the city looking for social services for themselves and the children they're not there they can't return return to prostitution understanding the subject so we don't know where they are it's important for us when we go out we know where they are so the demographics have to be done and quite honestly do we have NGOs and UN working big time in the cities absolutely nothing so this is a quote from many of these cities not from us in the humanitarian committee health for many has become a major security issue so this is coming from their own matters in China they're being very transparent on this but they now have a million at least minimum newly unemployed primarily in adult males who are sent by their villages to add jobs sending money back to the villages they're out of their jobs the villages don't want them to come back because they might take the few jobs they have away so they're sitting there unemployed and no help and what they call in China mass incidents is not being getting increasingly violent you need to understand that the one country in the world for decades not just recently but for decades has more mass violent incidents than any other country has but you don't hear about it because they also deal with it equally there's a lid put on the right of way people come through the shadows and take care of it and that's what's happening so they're having less control over it and this worries them but again we don't know the demographic so we just don't that's going to be up to somebody in public health to really not only figure out who these populations are but what are the two ways access them really good so the contradictions of globalization are you have the beautiful there and then the shanty towns so in California, New York Washington DC four to six percent of the population are considered homeless are urban squatters and these cities 78 percent is that a problem? is that a potential conflict? yes do we know how to deal with it? do the police know how to deal with it? military is actually hard on how to deal with it in a very conventional way which will do nothing to cause more conflict so nobody is really paying attention this is a major public health problem and the reason being also that you have to think beyond the courses that you're taking public health is the most composite discipline and it's multi-disciplinary what do you like or not so I'd rather I can understand why the economists so what we're seeing now the urban slums is we have the highest underage five mortality rate and the highest infant mortality rates urban shanty towns about one in a million growing about 25 million every year in the Asian countries they are growing about 1 million in every six months sanitation is being ignored and infectious diseases are becoming more prevalent remember other natures in church and I've been putting this up for years but this shows that we have more people living in urban populations in rural populations but it was supposed to happen somewhere around 2015 but it's about five to seven years ahead and that's what we're also finding in other issues that we're measuring in kind of changing emerging diseases it really really is a wonderful time to be a virus and you need to understand why why do we have the 70 emerging and re-emerging diseases the point is I mean if you go to Guangdong province in China you want to study SARS you want to study ADN influenza it's there it's where very very dense human populations live in very very dense and so it's a real setup but we just have too many people but it's not so much the population it's the density of the populations so in Guangdong province remember this quote Guangdong province moved from Guangdong province to Hong Kong and then to SARS went to 10 to 40 countries in 10 days that's pretty awesome the other thing is we have if you're looking at the H1N1 we're talking about the Mayor and New Zealand the aboriginals in Australia why didn't more people the indigenous people in Mexico around here these are people that genetically don't have any influenza A background to them to provide that because they never got it they were almost isolated but the other thing is that we just can't blame it on that it's also access and availability so they got sicker didn't have access and so more of them died because of that so the grand experiment here and please until somebody read about this read about the international health regulations which became intriguing in 2007 because what has been done with that may end up being the health regulations for climate change food shortages for all of those things it is working but it is the grand experiment density is like pornography I don't know how to define it but I know it when I see it and here look at all these things it goes way back there this is in Asians now most people say gee how do you get a hot dog or a hand in the ring people in public health ask what where are the toilets where the toilets are but is that a public health problem for you but remember the population doesn't understand so we got a lot of this is Polynesia but Rick Bissell in the 1970s said of all the large scale natural disasters floods and hurricanes are the only ones that change the ecology and this is what's happening it changes the ecology it changes the ecology consistently but what happens is that believe it or not Polynesia is becoming urbanized because they're all in one area population growth density then increases contaminate and pollute home water storage wells coastal areas and of course increased bacterial contamination that would be the easiest question on a public health exam last thing this is the one this is energy water and food we are now getting intense of the conference and this is probably one of the most interesting but the most dangerous of things that are emerging in farmers essentially land has been taken away from poor people from farmers from mines or growing other things that are not indigenous so the impact on the poor people and the fragile states are the greatest they are once and last lack social protections the reason why you have those courses in public health and also the political and institutional means to resolve it plus the fact that food prices have gone up about being 3% meaning that poor people spend 80-90% of their bigger income just in food think about it okay it's 10-13% okay so interesting these study Guatemala it's been one of the poor countries but it's also got a big guard population rich people hotels and all the rest of stuff about 50% of the children in Guatemala are currently not in their system how the meaning is gone and the Mayan the Mayan 80% of those children the issue is for a long time now they haven't had the money to buy the food and now with the financial crisis it's all in the tipping point so has Guatemala been on our radar screen now we've been concerned with countries who will look and shooting each other so this is a different kind of situation and how do you begin to control this okay increasing resource competition in countries and it's becoming aggressive especially in countries that already in half for decades require their food from imports who are South Korea, Japan China and a range of Middle Eastern countries they've always had to bring in food they feel that they have the right to purchase and produce energy the city oil or whatever South China Sea Caspian Sea but now we have countries investing in farmland and foreign countries and farmers have no political voice a lot of instances in the country because it increases the coffers in the countries but anybody know the case of Madagascar this happened in one of our developed countries it would be all over for a 60 minutes date on everybody would talk about it and I think one of the most interesting things is I don't have a single hand raised in this class Madagascar is a very poor country it has a lot of arable land that has never been touched and so of April of this year South Korea after a lot of negotiations got a 100 year no cost lease on half of all the arable land in Madagascar they were to grow corn because corn is the main staple in South Korea and also palm oil which is a biofuel it sounded good in the beginning because they said oh think of all the people that we will employ then it got a little bit deeper and deeper and deeper including the fact that guess what when you lease that land there was no cost because they said oh the economy will grow you also have the rights to all the water and that's as much water as it's obtained by Hoover Dam so when this was found out the populace went out their arms political coup and the first act by the guy that's in there now stopped this but it is all over the place and when I was in Auckland remember when I told you all of New Zealand is a bio-universe area while you fly three hour flight from Sydney which they were just going to have a little dust storm it's mostly deservisional to New Zealand and it is just emerald green and it rains a lot emerald green and just in the tax amount that I was telling you the Japanese just purchased two big islands purchased this swap land it's all because of this the water to all the bio-universe areas and bio-universe so is this it's already becoming a conflict issue and so it really rather than rather than looking at it in a global way because we do have enough land to feed the entire population of the world if indeed it's approached not by individual nation states but by globally so we have a very fragmented approach to global health we don't even really have global health because it really will require no institutions that are in the process of public health redeployment humanitarian assistance certainly has moved from rural to urban areas to the humanitarian community it's not prepared to protect the urban or the system I spent a good part of my life teaching people how to build defecation fields pick the trains refugee camps it's not there anymore how do you start building a well here we do not know how to defend public health and we certainly do not know how to handle the emergency of scarcity because the approaches militarized everything like that if people rebel are they then terrorists to the stand how do we I mean this is the human right it's at least expected but we're not prepared for this but the way in which we provided we're missing out on public health disasters keep governments honest by defining the public health exposing the vulnerability that was what I contributed because that was what my generation didn't the disasters defined it exposed it, reacted on globally, scarcity climate change, water energy and food will define now the status of countries public health solutions deforestation has got to stop but reduction growth rates that's a big thing reduction in growth rates what is step number one it's empowering women empowering women is not popular in most of the countries when I worked when I worked old conjurer and he said if you just do one thing only one thing only one thing if you just educated women you'll see immediately that the mortality rate in children will go down and you don't touch the children just do that and it's true it's true now we've been interrupted by all these what it is just as true then is enough ensuring social protection so take those courses of public health very seriously because they've got to be combined with the other things you do in public health medicine decrease the carbon emissions because it's what's produced in the acidification of the sea and populations and you'll hear these terms populations are called to identify their learn how to reduce them so the word on the street now adapt and there's now money for adaption and the money for adaption should come the development countries field the money for adaption should come from the rich countries so the word is adaption, adaption and that will redefine just how resilient populations are some will leave some the important thing if this doesn't work we have to have strong mitigation policies and plans so last thing that you need to know that is I'm sending this article I've sent it all over the world because it's so good but you've suffered from expertise that's just too narrow in content research process interaction, different classes global health and public health is now very integrated it's interdisciplinary multi sectoral and it addresses the needs of multi ministerial issues leaving public health research the policy makers and practitioners who are poorly prepared to interpret strengths and weaknesses of integrated research so I can recommend it and I have the way I told you to the UC system starting out at UCSF they didn't understand what it really meant to do more to more vertical silent kinds of research that's not what we're talking about and again global health is a composite field so even if you don't have an institute for global health your global health curriculum your departments have to reflect so the conclusions public health must take precedence over politics it cannot be driven by political orders and political interference and influence on public health has increased exponentially over the last 20 years because and more so in the last 7-10 years because governments know that they have to control public health and the indices and the measures and that's not what we should be public health must be seen as a strategic and security issue I've been saying this for many many years but the this is it says 1973 but the closest thing just happened this year in the G20 global impact and vulnerability act which is measuring many of those things that I just did so last slide is