 Hello and welcome to our plenary session. My name is Alan Abelson. I'm a family doctor in Toronto. And part of the working party on the environment with Wonka. It's my absolute pleasure today to introduce the plenary speaker, Professor Sir Andy Andrew Haynes, who's going to talk about safeguarding human health in a time of environmental change. Perhaps Andy's greatest credential is that he was co-founder of our Working Party on the Environment in 1995 at a meeting of Wonka in Hong Kong, where he and I started the working party. But let me talk about his broader commitment to this discipline. He was Dean of the London School of Hygiene and Tropical Medicine and his Professor of Environmental Change and Public Health there. And I want to go into great details about his role there. He was a general practitioner in North London for many, many years. And more recently, his work in terms of climate change, he was a member of the UN Intergovernmental Panel on Climate Change, the IPCC, the working group that worked on the health effects of very, very influential policy work and gathering the evidence for the second and third assessment reports and the fifth assessment report. And importantly, he chaired the, in 2014-15, the Rockefeller Foundation together with the Lancet Commission, the Rockefeller Foundation and the Lancet Commission produced a commission on planetary health that was published and really was the founding document for the whole movement of planetary health. So I want to, with great respect, introduce Andy to talk about safeguarding human health in the time of environmental change. Thank you, Andy. Well, thank you so much. It's a great honour and a pleasure for me to speak to you today. And my title is about how we can safeguard human health in the face of multiple environmental changes. As we've seen in just the last week or so, we've been very much engaged, of course, in climate change and health with COP26 in Glasgow. And that's really brought to the collective consciousness of the world the importance of addressing one of these changes, which is climate change. So in my talk, I'm going to draw on some of the work we did a few years ago on the Commission on Planetary Health, but also I'm going to focus particularly on climate change as the main example of these multiple environmental changes that are confronting humanity. So my first slide really illustrates the scale of the challenges and people have called this the great acceleration because it's acceleration in terms of the human impact on the environment. And on the left, you can see the socioeconomic trends that are driving these changes in the world's environment, the global environment. World population has increased, of course, dramatically, particularly since the middle of the last century. The economic enterprise, the global economic enterprises increased also very markedly since the middle of the last century. So real global GDP is now, this slide was made a few years ago, it's well above 70 trillion, of course. Energy use has increased, it's been powering the economic growth, which has resulted in human progress. We've seen increases in urbanization now with the majority of the world's population living in cities. In order to grow the food to feed this world population, of course, there's been an increase in fertilizer production and consumption. We've dammed about 60% of the world's rivers in order to irrigate the land and to generate hydroelectricity. And many other changes have occurred as well as illustrated on the left side of this slide. So we have seen genuine progress. We've seen reductions in poverty, absolute poverty has reduced, although, of course, there's still a lot of inequity around the world. And in some countries, inequities have actually been increasing, particularly as a result of COVID. We've seen an increase in life expectancy of over 20 years since the middle of the last century, although, of course, COVID has resulted in some countries in a reduction in life expectancy in the last year or two. But this progress, this inequitable progress, has come at a cost. And the cost has been borne by the earth systems. And that's shown on the right side here. You can see how greenhouse gases like carbon dioxide, which is a long-lived greenhouse gas, have accumulated in the atmosphere. It's the most important of the greenhouse gases, about 70% of the heating so far has been due to carbon dioxide. And of course, about 15% or more of it stays up in the atmosphere for a thousand years or more. We don't know how to get it out in a kind of cost-effective and efficient way at the moment. So that's a legacy we're leaving to future generations. But other gases as well, methane, which is a short-lived climate pollution, very, very contributes substantially to global heating. It's also increased as a result of changes in land use, increased livestock, gas leaks and so on. Many other earth system trends are shown on this slide. I won't read them all out, but you can see that oceans are becoming more acidified. The temperature of the planets now warmed 1.2 degrees centigrade. We've reached now since pre-industrial times. So there's already been a lot of heating of the earth's surface. There's been more over the land than over the oceans and some parts of the planet have warmed up quicker than others. The Arctic, for example, has heated up more quickly than much of the planet. And we've exploited really about 40% of the world's land to grow food. And so there's really a limit. We can't really exploit any more of the land, particularly if we want to protect biodiversity loss. Many scientists have suggested we're moving into the sixth grade extinction where we're losing biodiversity and unprecedented rate. Perhaps it's 100 fold or perhaps more times greater than pre-human existence. So what we're seeing then is we have said genuine, although in that inactable progress, but that's now threatened by the undermining the damage to the earth systems, which ultimately, of course, I helped depend on these vital earth systems. So this has led to the concept of planetary boundaries advanced by Johan Rockstrom, Will Steffen and colleagues. And this is a paper they wrote in 2015, which shows us these described outlines these different planetary boundaries ranging from climate change, biosphere integrity, ecosystem change, freshwater use, nitrogen and phosphorus flows, acidification of the ocean, loading of the atmosphere with aerosols causing air pollution and so on. Depletion of ozone, the high level ozone, the stratosphere that protects us against ultraviolet light. That's the one good bit of good news that that does seem to have stopped and the ozone hole is is healing to some extent. There are many novel entities, lots of chemical pollutants, many of which we don't understand the full cost of consequences of those pollutants. So you can see these very widespread changes that are impacting on human health now and will increasingly affect human health in the future. I'm going to focus particularly on climate change, but against the background of these multiple environmental changes which interact in ways that we don't fully yet understand. This slide just illustrates how these multiple factors can affect under nutrition. So here are the pressures on the left side here, everything from freshwater use, land use chains, climate change and so on, overfishing. And these are how they affect these states like the climate rainfall temperature, extreme storms and so on sea level rise, air pollutants like ground level ozone, not to be confused with the stratospheric ozone which is high up in the atmosphere and protect us against ultraviolet light ground Soil and so on. These affect loss of biodiversity, pollinators are very important for many crops and they obviously influence food plant diversity, the content, the nutrient content, as we put more CO2 into the atmosphere, the nutrient content of many crops declines. So all of these factors result in declining crop yields, declining nutritional quality of crops, reductions in fisheries and seafood, and all of this can increase the risk of course of under nutrition people crops and obviously fruit and vegetables as well. We know that the causes of this degradation, much as least certainly in terms of climate change are very inequitable. So the richest 10% of the world's population are responsible for almost half of the total consumption related carbon dioxide emissions, whereas the poorest 50% are responsible for only about 10%. So the profound issue of climate justice here, those populations that are going to suffer the most from climate change are least responsible for the emissions that have caused climate change. And that's something we need to bear in mind when thinking about the challenges of climate change. Now climate change has a range of impacts on human health. They're summarized in this slide. It's rather complex slide, but let me take you through it quickly. So these greenhouse gases cause rising temperature, rising sea levels, increasing extreme weather events, and through many demographic and socioeconomic and other environmental factors, these moderate or modulate the way in which climate change impacts on human health. And some of those are summarized in the slide. The climate change then affects a range of different exposure pathways. There are these very direct pathways like extreme heat stress, for example, storms, extreme storms, floods, droughts, wildfires, and these all affect human health through a range of pathways here. But heat is an obvious impact, but also air quality, wildfires affect air quality, of course, water quality and quantity affecting a whole range of infectious diseases here in freshwater systems, but also some extent in the oceans as well, these harmful algal blooms. So food supply and safety, as I've already mentioned, these can affect under nutrition, but also increasing the risk of food poisoning and other diseases related to contamination of food chains. Vector-borne diseases like malaria at the edges of the distribution or dengue or other vector-borne diseases here. There are impacts that are mediated through social economic systems like increasing poverty, displacement or migration of populations, and increased in conflict probably as well. So you can see the effects are quite complex, mediated through a range of pathways, and it's likely that some of these indirect effects will be at least as important, perhaps more important than some of the more direct pathways. So increasingly, thanks to advances in science, we can detect and attribute the health impacts of climate change to human-induced climate change. So they're not due to natural variability, we can increasingly separate the natural variability from the human-induced climate change. And this image on the left here shows you what the climate would look like without anthropogenic or human-induced climate change, which is along the bottom here, and with a climate change, human-induced climate change. You can see that these lines are diverging, and as I've said, they're about 1.2 degrees centigrade apart now, and that's a global average. You can also see that some events that are happening now wouldn't have happened without a human-induced climate change. So if we look at the Siberian heat and fires in 2020, these were virtually impossible in the climate pre-1900. They wouldn't have happened without human-induced climate change. So we can say with confidence that human-induced climate change is indeed having effects on human health and human societies more broadly now, as well as in the future. A recent study, very important study in nature climate change using data from over 730 sites in 43 countries, showed that more than a third of the total heat deaths between 1990 and 2018 could be attributed to human-induced climate change. In other words, they wouldn't have happened without climate change. But as you can see from the map, there's big gaps in the data. So there's no data for much of Africa and Asia, and we need to fill in those gaps because this estimate could be an underestimate. We just don't know because the vital registration systems in these countries are not robust enough to allow us to make credible estimates. So this is probably a conservative estimate. We've also seen a number of other effects, so as well as causing increased death rates amongst the elderly and so on, when you expose them to extreme heat. There are also effects on other groups. And this is one group. This is a pregnant women's subsistence farmers. This is some work that's just being submitted for publication led by PhD student Anna Bonnell working in the Gambia in West Africa. And you can see her there with Gambian colleagues working literally in the field with pregnant women's subsistence farmers to measure the extreme heat exposure that they're working under at the moment. Of course, ideally you should take shelter. You could work under shady conditions. That's not actually possible for many of these women. And what worried me when I saw this data was the extreme heat exposures. So this is the wet bulb global temperatures is measured by this instrument here. It integrates temperature and humidity and some solar radiation. And what you can see is that some women are already working extreme heat exposure, this orange and red here. If they were elite athletes, they would be told that they shouldn't compete above a wet bulb global temperature about 28. So many of them are working hard in the fields whilst they're often, whilst they're pregnant, sometimes advanced pregnancy, because they don't have any choice they have to feed their families. So they're already at unacceptable levels of heat stress and that can only get worse in years to come so it raises the question of to what extent will be possible for populations like these to adapt to create a heat. We know also that heat exposure is amplified in cities. This slide shows you how the daytime and the nighttime temperature increases over urban areas that can be modified somewhat by green space so green space helps to cool cities. Water to some extent as well in the daytime but in the nighttime, the heat is radiated so it compensates for that with water. But the green space does cool cities in the day and the nighttime and there can be big variations between the city and the surrounding countryside but also within cities as well, depending on the kind of services. So the surface, the road surfaces of course are dark, they absorb the heat and then they emit it again at night. And so painting buildings white for example can help to reflect some of the heat. And there are big socio economic differences so often in poorer neighborhoods. There's increasing heat exposure because they have less green space and that's been shown in a number of studies for example in the US and the UK. We also know there's increasing wildfire risk to health from climate change so those of you working in areas where wildfires have occurred will be aware that these produced large amounts of air pollution. This recent papers in Lancet Pantry Health explored the impact on health of these wildfires you can see that in some parts of the world they cause extraordinary high levels of air pollution with PM levels, even over 200 which is extraordinarily high because in some parts of California, parts of Southeast Asia for example. So big exposures of populations to wildfire smoke which we believe is more toxic than your kind of average urban particulate air pollution has a lot more oxidative and pro inflammatory components and causes an increase in mortality and death rates as you can see for several days following the exposure to this wildfire smoke, as shown in a recent paper led by my colleagues, Antonio Gasperini and Anna Visero-Cabrera, looking at data again from a whole range of different sites. So wildfires again an important risk to health, not just to physical health but also mental health as well. We also know that infectious diseases are changing so these are the effects of climate change which we've already seen, already observed on the two vectors of dengue, EDs in Egypti and EDs albapictus and you can see how their own capacity their ability to transmit dengue has increased over recent years, this is a mathematical models of their vectorial capacity and you can see how it's changed since the middle late of the last late years of the last century, how it's increased steadily for these two different disease vectors, so they're increasingly able to transmit dengue around the world and that's responsible probably for some of the increases in dengue that we've seen. But it's not just the infections that we know about, there may also be some nasty surprises, this has been a couple of workshops and also recent paper in nature climate change, suggesting that as the permafrost melt there could be a number of emerging threats to health. So these microorganisms called Methuselath microorganisms they have adaptations that enable them to survive for many millennia in permafrost as you melt the permafrost these organisms may be released. We don't know what the impacts for human health are we don't fully understand what these organisms could really do we know that some organisms that are dangerous to human health like crostridia and so on, could be released. Also as radioactive waste, toxins like mercury and so on could also be released as the permafrost melts so these are just examples of some nasty surprises that may be ahead. We know that climate change affects not just physical health but also mental health. There are some common increases in common mental disorders. And there's this condition called solastalgia which is the kind of grief due to environmental change when people see their familiar environments changing around them. And for example, Arctic populations that are forced to move their villages because of melting ice, or farmers that lose their livelihoods due to increasing droughts. Some of the reports just recently shown here on mental health and climate change about useful summaries or for state of knowledge. But they do also emphasize the potential benefits of climate action for mental health so we know that many young people are experiencing climate anxiety, and that could simply seen as a rational response to an uncertain and risky future. And these both of these reports raised the point the important potential benefits of getting involved in climate action, which I'll mention in just a moment, these may have benefits for physical and for mental health. So, it's important for those of you working on the front lines in populations affected by extreme events to realize these mental health effects, but also we need to capitalize on the benefits of action. So how are we now up to COP26 well COP26 was a mixed picture wasn't it I mean there were some advances we saw Cole mentioned for the first time many of us expected to see Cole phase out agree but unfortunately the wording was changed to cold phase down which is not sufficient. We do see for the first time acknowledgement of methane as a short lived climate pollutants and the importance of cutting methane quickly. So that's a positive thing. We did see a lot of mobilization of the world community. A lot of mobilization of NGOs around climate and health to a greater extent we've seen in the past and the health community was better represented. But health was still not at the center of the climate change negotiations. In terms of where we're going. Well, we've already experienced 1.2 degrees warming, as I've said or heating, we might say. If we're very optimistic we could get to 1.8 remember the Paris agreement says 1.5 or that's the preferable option the preferable target, but if not then well below two degrees so we could still get there. But the real world action based on current policies takes us well above two degrees and the full implementation of the targets embodied in these nationally determined contributions which the countries have to have to submit under the Paris agreement takes us to about two and a half degrees so we're still well shorter where we want to be but it's still feasible at least to keep us below two degrees if we act promptly and if we build on that some of the contributions of COP 26 as we move towards COP 27 in Cairo. The steps that need to be taken for a 1.5 degree world or read them all out but you can see that we need no, we mustn't have any new coal power plants, we stopped selling fossil fuel powered cars before 2035 have to include aviation and shipping. We need to stop deforestation move towards best practice and agriculture number food and agriculture 30% of emissions, and we need to have all new building zero emissions for 2020 well that's clearly not happening. It gives you some idea of the really the step up we need in order to reach 1.5 we need to reduce greenhouse gas emissions by 7% every year in order to keep to 1.5 degrees so that's going to be very, very tough very difficult. So in the light of all this we need to build climate resilience we need to both adapt to those changes we can't prevent, but also cut emissions so we need to take actions to reduce greenhouse gas emissions that cause climate change by moving towards sustainable transportation clean energy and adaptation which means better flood protection, better infrastructure, better disaster management, more resilient health care systems. These two communities often don't work together, and increasingly we need to integrate mitigation and adaptation. So for example if you just adapt if you just put say put in air conditioning, you increase demands for energy increase burning and fossil fuels, increase air pollution. You just have to put the heat somewhere so you pump it outside and that means your cities outdoors will be hotter. So we actually need to have policies that synergize between mitigation and adaptation. Climate resilient health systems will require action to all these different building blocks of health systems summarized in this slide. The health work workforce will need to become more aware of climate change. We need to reduce the vulnerability of our vulnerable populations the elderly, those living in poor housing for example, those who suffer food poverty. We need to ensure that essential medical products and technologies can be provided at the lower environmental footprint through robust supply chains. We need to ensure that our health systems can withstand floods, droughts, extreme heat, for example, and the health financing needs to be linked to that at the moment, very limited amounts of climate financing actually devoted to health. So the health sector is not being funded through the climate financing, and the climate financing by the way is not enough. So the countries said they would give 100 billion, but they haven't done so, particularly the donor countries. This just gives you one example of how we can respond to climate change. This is about heat action plans and a very recent Lancet article. And this shows you how the health sector needs to lead responses to extreme heat needs to be increased surveillance and early warning systems here, working with the meteorological community. We need to have community response plans with cooling centres, distribution of clean water, targeting of vulnerable groups like the elderly, people living in informal settlements, refugee camps, even sporting events, for example, which can put people at higher risk of heat stress and strain. And successful strategies will involve integrating individual interventions, buildings, so having cooler buildings with green roofs or shutters to prevent ingress of extreme heat, and landscape and urban strategies like planting, having more green space in cities. And it's by combining these different approaches, we can have the most effective adaptation systems, but there will be of course limits to those systems. There's also big benefits to human health as we move towards a net zero carbon economy. So for example as we move towards renewable energy we stop producing air pollution from fossil fuels. We think about 3.6 million premature deaths a year are due to fossil fuel burning, the air pollution from fossil fuel burning. Also, there are many other deaths from household air pollution from burning solid fuels in houses about 7 million deaths altogether, about 20% due to pneumonia, 20% stroke, 34% from heart disease, 90% from chronic obstructive pulmonary disease and a small portion from lung cancer. So when you see patients at high risk or suffering from these diseases, one also needs to think about whether air pollution is contributing and what you can do to reduce exposure to air pollution, including of course moving towards a clean low carbon economy. The food system, as I've said, a major contributor to climate change about 30% of emissions, and the Lancet, the Lancet Commission some years ago proposed this diet, the planetary health diet they called it, which would, if it was taken up, would create a sustainable food production system, reducing greenhouse gases, reducing water demands and demands for fertiliser could prevent, according to their estimates, perhaps 10 to 11 million premature adult deaths a year and lead to a sustainable food system by mid-century. So this diet, some people were found it controversial, it's proposed reductions in animal products, particularly red meat, which of course responsible for a lot of greenhouse gas emissions, but also adverse effects on health. But also, and importantly, increases in the consumption of fruit, vegetables, whole grain, carbohydrates and so on, cereals and so on. So it did involve substantial dietary change. One limitation of course is whether this diet can be afforded. And we know that in many people around the world can't afford sufficient fruit and vegetables. So that needs to be addressed. But certainly when you're talking to patients, you can emphasise the both the health and the environmental benefits of consuming more fruit vegetables and in high consuming populations cutting red meat. A lot that can be done the cities, a lot of action at the subnational level, and a primary care professionals of course in many cases that can work with local governments to accelerate some of these changes. Using the health argument, accessible and efficient public transport and active travel, walking and cycling. We know many people, many of your patients do not take enough physical activity. So if we can get safer walking and cycling that will help to reduce the risk of conditions like diabetes, heart disease, stroke, and so on reduce also the risks of obesity. And using public transport of course is much preferable than dependence on a private car. So universal access to clean low carbon energy I've already mentioned, safe access to green spaces can improve mental and physical health and of course more resilient housing and energy efficient, better access to water and sanitation. These are all actions that can be implemented at the city level, local community level. Nature based solutions, we're recognising they're increasingly important, not as an alternative to cutting out fossil fuels but as an. They provide perhaps one third of the cost effective climate mitigation by so intact forest for example, take up carbon dioxide. And there are a range of different nature based solutions from minimal intervention, keeping ecosystems intact, moderate interventions such as agroforestry and extensive interventions such as new ecosystem so for example green roofs would be one example of those. So it's important in implementing these nature based solutions that they're done, not imposed on local communities but done with a full engagement and consent of indigenous people, for example, often the custodians of these spaces, forests and other intact ecosystems are a society in a fair and effective way, maintaining biological and cultural diversity and contributing to the achievement of many of the sustainable development goals so they can be beneficial, but how they're implemented is going to be important, and they're not in turn alternatives to cutting fossil fuel emissions. We're also recognising the carbon emissions from healthcare are a really important contributor so if the global healthcare sector was a country, it would be the fifth largest emission on the planet. We know that from the work of healthcare without harm contributing to four to 5% of greenhouse gas emissions and in some countries like the US, it's closer to 10%. So where do these emissions come from well this is the carbon footprint of the National Health Service in England, you can see that more than half of these emissions actually come from the supply chain medicines medical equipment and other supply chain issues, some of it comes from of energy in buildings. Some comes from anaesthetic gases like desflurane or metatocin halers which are climate active. And so some of these are due to the acute sector. As shown in the right side of this slide you can see where the contributions come from, but some comes from primary care. So for example, the prescribing much pharmaceutical prescribing takes place in many countries in the primary care sector. We're seeing a necessary policy poly pharmacy, choosing low impact pharmaceuticals where possible for example, powder dose aspirin halers rather than those with propellants that contain powerful greenhouse gases these can all make make an impact. So this lot we can do through healthcare systems. The NHS in England is committed to net zero emissions by 2045 even for these supply chain emissions and we've seen a cop 2650 countries commit to resilient climate resilient and in some places net zero healthcare systems as well. Moving in conclusion to what Wonka is doing and what you can do. You'll be aware that Wonka has been a leading voice really in arguing for planetary health for the integration of health into the care of natural systems and this declaration summarizes many of these care key points. We all have to learn more about the links between natural systems and health, respond to emerging health challenges communicate with patients preparing practices for possible extreme events, providing patients about important co benefits and benefit their health, their family's health and the climate and planetary health more generally leading by examples. We know that healthcare professionals are the most trusted professions around the world. Be active in advocating we've seen a lot of leadership from the healthcare professions. You may remember that representatives of 45 million health professionals route to the leaders of the of the G seven last year urging them to take a much more active role in climate change mitigation. And of course there's the, there's the Wonka working party on the environment, currently being chair very, very effectively by Enrique Barros and we definitely like to urge you to, to take note of what they're doing and if you feel motivated to join these activities. These are some of the educational resources that are available, the green impact for health toolkit from the Royal College of GPs here. And this wonderful course on planetary health for primary care, launched by colleagues in Brazil, last year with Wonka, and the work done by our labels and colleagues on on the training the trainer around air health, how that can benefit reducing air pollution. So business usual is not going to work, because we are heading. If we're not careful to real serious and potentially catastrophic impact of environmental change on human health and so it's really important that the primary care sector is advocating and taking a leading role in moving towards transformative changes that will take us towards a much more equitable resilient and sustainable economy and health care system of course, as well, rather than merely trying to have incremental change and business is useful so this is my last slide. It's really tries to summarize the role of primary care professionals in climate action as important role in mitigation cutting emissions, both through personal example, also through professional collaboration, working with the health care system. Also talking to patients and community groups and so on about the co benefits. And there's an important role in adaptation of resilience as well by ensuring that practices are more resilient to climate extremes that our patients are vulnerable patients are vulnerable and protected during these extreme events and working with a range of different actors in our local community to increase the knowledge of and the awareness of the impacts of climate change on health, and also what needs to be done about that. And with a positive message, of course, there's great threats and challenges ahead, but there's much that can be done. And the primary care community one curse they can a leading role. The primary care community is really on the front line of this climate and environmental emergency. And there's lots that can be done in primary care integrating this with current practice. So let me leave you with that positive message. There is much to do. But we in primary care can play a really important leadership role in advocating and catalyzing the changes that we need to see to protect our patients, families and future generations. Thank you very much. Thank you so much Andy that that that's, that's what I expected from you because over the years your, your work has been so consistent and so motivating to us. And I think it was again today. I would just like to point out that this plenary, the significance of this plenary happening right now. Wonka has decided, and I want to congratulate them to to have a have a plenary session on planetary health. This is, this is the first time that has happened. It means that the climate emergency that that that has been declared that is accepted has been accepted by the World Organization of Family Doctors and that this issue has been elevated to the point that we should have a plenary and that's that's very significant and I want to congratulate Wonka and encourage the the executive Wonka and the members who are listening and the broad membership of Wonka to to take up this challenge that Andy has has has offered us this challenged us and and to move with it. There's lots that can be done. A couple of points I want to make. Following on my my position. I like, I like the idea in terms of encouragement to talk about outrage and optimism. Optimism yes we must stay we must stay positive we must be active. We must stay hopeful, but, but, but mixed with that, we must stay outraged we must use our, our outrage our anger, our despair to motivate us. This is a wonderful combination. And I think we will be pushed the young doctors in Wonka the young doctors of the world will push us will make us respond with both outrage and optimism. I want to pass the microphone to Enrique, who's been sharing the working party over the last number of years very very successfully and very lots of energy. In fact with outrage and optimism I would say, and just ask him to say a few, a few words, and then we'll open to questions and comments from the audience hopefully. Enrique. Thanks a lot, Alan, and thanks for everyone watching. It's really a pleasure to have Andy Haynes with us, who's been working so hard on these issues and bring his bringing his family doctor experience when addressing these environmental changes. I also want to thank Alan for being the provost of our working party for so long and making all this possible, when many times we only have two or three people in the room. It seems that the times are calling for an environmental look for family doctors around the world. So I just want to make a few comments. When we started talking about planetary health as a central issue for family doctors. I remember having a meeting with President Hoey at the time, and Andy Haynes and Dr. Hoey said she was very pragmatic, which I think is is a very important aspect. She said, well, Enrique, yes, this is important, but family doctors are already very overburdened. And I gave a lot of thought on that. And my answer was that, and please Andy and Alan correct me if I'm wrong, but my answer was that basically family doctors that practice the good medicine, evidence based medicine are already doing planetary health care. Because we need to be highly effective, highly efficient with the energy and the supplies that we have. And perhaps primary care can be one of the most effective ways to promote climate change mitigation as we reduce the more high energy intensive services from hospital-centric services. As in my country in Brazil, that's quite easy to see. We need to move away from a more hospital-centric model. And it's one of the most important ways to promote equity, health equity, as Barbara Starfield used to point out. So I think we need to be very pragmatic. I think we need to make sure that the climate change community, the international community that fights climate change, they must understand the role of primary health care, the role of universal health care, and the role of family doctors in promoting mitigation, adaptation, and resilience. And of course, one of the questions is, what is the role that Wonka wants to play in this? I see there's a major role. It seems that Glasgow COP, the recent COP, I think it's 26, sorry if I'm mistaken. It's seen more and more a central issue of the central issue of health for climate change. And I think that in the future, we may see health as perhaps one of the center issues, one of the center motivators to mitigate and adapt to climate change. So I want to leave it there. And I would love to hear some questions from the audience and further comments from Andy Haines. Thanks. Thank you, Enrique. I am waiting for somebody in the audience to raise their hand and pose a question. But I think what I will do in the absence is ask Andy to talk a little bit more about his experience at COP26 and the health community and where he thinks Wonka should fit into that community. Thanks very much, Alan. Yeah, so I was at COP26. I've been at a number of COPs now. I would say that this was the conference of the parties which the health care community was the best represented. So there were large numbers of health care professionals from many different countries. And there was for the first time a pavilion, rather small pavilion, compared with some of the others, but there was a pavilion run by WHO, which had a whole series of I think over 40 meetings on health during the 10 days or so of the conference of the parties. That was definitely very welcome and much higher profile of health. There were many other health events as well outside that pavilion. And also there was a conference. WHO hosted a conference offsite at Glasgow Caledonia University with the Global Climate and Health Alliance and with other key players as well on climate change and health. I think that conference was certainly was available online and maybe still is. So there was a lot of activity that that's on the plus side. But on the negative side, it was my impression that the health community was often talking to itself was talking to each other. There was a lot of attempts to lobby delegations to get them to include health in the final communique and to raise the profile of health, of course, in the nationally determined contributions in the negotiations more generally. At the end, I think health, the word health only appeared once in the final community for a communique if I remember rightly. And that illustrates the fact that although there was a gradual appreciation that health really should be at the center of climate change negotiations, it still hasn't penetrated to the heart of the negotiations. And that was certainly done in the run up to COP 27 in Cairo, particularly working with our colleagues in Sub-Saharan Africa, well in North Africa as well, to ensure that health is much more embedded in COP 27 than it was in COP 26. And I think there are the two areas that we know about of course climate change adaptation is going to be really important. Many of our African colleagues, very concerned about adapting to the climate change that we can't prevent. There's not climate funding climate adaptation for health, much more emphasis on the resilience of health systems in the face of climate change so that's going to be important. But of course we can't forget the importance of those high emitting nations, decarbonizing their economies so rapid decarbonization, moving towards clean energy moving towards net zero health care systems and so on these other sectors that I've mentioned. So I think we can move forward on these twin paths really the adaptation and the mitigation, working in tandem working in an integrated way together. And hopefully at COP 27 we can have even more impact than we did at COP 26 and and health will really be seen much more at the center of discussions and negotiations. I'll stop there but I'm happy to answer further further questions. Thanks Andy. We do have a question from the floor. And the question is wanting to know about changing prescribing habits and what family physicians can do. And I'll just pick up on the, the one topic that Andy mentioned which is is totally within our grasp right now, which is switching from a meter dose inhalers for asthmatics and COPDs to dry powdered inhalers. The MDIs or the puffers that that we prescribe every day have a significant footprint carbon footprint, which would, which would be significantly reduced if we switched over. There's some concerns about in many countries with funding of dry powdered inhalers. They often not funded they're not on on the formulary. So that's a problem but that's definitely easily accessible and a significant thing that that we could do. Let me ask Andy and there and I'm aware of articles in in recent family physician journals just about to be published in Australia and the UK and in Canada on this so this is this action this is this is starting and it's, it's one thing easily within our grasp, but Andy can pick up on and take that that idea and then the idea of further prescribing further. Yeah well I'd also like to bring in Ricky and as well because you know he's seeing on a patient's on a day to day basis so I know he tackles these kind of issues in his consultations but so one of the issues is of course wasted medications and we know that many medications are just not taken as prescribed. So, ensuring better adherence to medications stopping the prescribing of unnecessary medications are important reducing polypharmacy, where that's potentially hazardous to patients but also damaging to the environment. Do our patients always need to be on so many medications particularly those elderly people, often adherence is a problem anyway so looking rigorously at that prescribing habits and trying to reduce unnecessary prescribing is really important. And then I think, perhaps collectively we should be doing more to work with the pharmaceutical industry. Because we know that procurement policies are really important and certainly the NHS in England is going to be working with the pharmaceutical medical equipment industries to support them in decarbonizing their supply chains. So incentivizing that kind of action through procurement policies which would maybe bring in climate impact assessments, as well as kind of cost the routine standard issues around costs of medication which of course are very important. I think that could that could be really useful and we are seeing an increasing number of pharmaceutical companies getting interested in this area and working even working collectively to try to develop better standards better metrics for measuring the environmental footprint of pharmaceuticals, but also working with their supply chains and I was sitting next to a very senior executive in a well known pharmaceutical company actually at a dinner in the periphery of COP26. And he informed me that that company, they get their supplies from 55,000 other companies so they have extraordinary themselves, they have extraordinary diverse supply chains. So they can't work individually with each of those companies but they need to establish guidelines good practice support for their supply chains to incentivize them to decarbonize their activities so they have a big multiplier effect potentially. And we can work with them I think constructively to promote much lower environmental impact pharmaceuticals and of course emphasizing prevention may mean that we need to less use less pharmaceuticals in the first place if we can get people walking cycling eating reduced air pollution exposure, etc. But let me hand over to Enrique because he has a lot more recent experience in this than I do. Well thanks Andy. I guess there isn't much to add, except for perhaps mentioning that I've been successfully trying to introduce some some talks with my patients about planetary health. And it doesn't take long, perhaps we can do a workshop about that in the future. I would just mention, try to comment on the on the on the word that you said about the health talking to the health sector, talking to each other or to its own audience in Glasgow. And, well, that may be the case but only in Glasgow I don't see that happening around the world. And I think that family doctors still have a long ways to go to understand fully what that represents the threat, and what they can do. I think there's a large role for the grassroots movements, sparking from family doctors. And once doctors around the world understand this issue, it would really spark a very powerful movement. And COVID is very is a very good example for what the health sector can do to to advise on, I mean, even even lockdowns, which would be, I would never imagine that such things could could exist. We should not underestimate the need to talk to ourselves. I know you're doing a great lot, Andy, but I think we cannot overemphasize this. And just talking about prevention and the role of family doctors again, I've been talking a lot to students about polypharmacy. And the Brazilian doctors look a lot to the US as a role model. But sometimes we forget that one of the leading causes of death in the US is the excess use of polypharmacy and medical errors. And we should move more to primary care integrated approach, at least in Brazil and probably in other developing countries as well. So again, here's a key role for primary care, avoiding polypharmacy and avoiding the footprint of procurement, health procurement. So, if you want to comment again or Alan, if you have any more questions. Yeah, I just, I just wanted to pick up a professor Bob mash, who's at Stelenbosch University in South Africa who's actually hired a lecturer in planetary health in his department, and a professor asks the question, which I think you could you could pick up on Enrique and Andy. Is there a difference between strengthening primary health care in Africa and building climate resilient plant, planetary health care systems in sub Saharan Africa, which is very much in line with what you were saying so please carry on and comment on that Enrique and then Andy. Oh, okay. Well, I remember talking to Andy, perhaps in Wonka Rio a few years back, and we were discussing about about how this issue of climate change is central, and how how we should be very proactive in talking about climate change. And I remember a very important warning that Andy said to me he said, Well, listen, Enrique, we, we have to really understand that when we talk about climate change when we talk about planetary health, we're really talking about the core here that is health equity. And I think that's, that's the main message that family doctors can understand and can be proactive about. So when we talk about developing countries. Of course, that one of the most important issues to make a better climate resilient population is having a strong primary health care based universal health system. And I see that in my practice. So a lot of vulnerable people would be would be much better off if they if they have a family doctor even with low resources that really can help a lot with blood pressure or with good evidence based advice like taking, taking good hydration when they have diarrhea. Sometimes I have patients here that are not very clear on that. So sometimes very simple advice evidence based advice can make a huge difference. So maybe, maybe we can research more on that and make more clear cold benefits for climate resilient populations and more primary health care, stronger primary health care. And yet, would you like to also comment on this. Well, just very briefly, I know we're running out of time but and I do see that developing strengthening primary health care in sub-Saharan Africa has to be integrated with climate resilient primary health care systems but you can't have a climate resilient primary health care system if you don't have a functioning primary health care system. So the two need to be integrated very much. And many of the things we need to do to create greater resilience of primary health care systems to climate change are going to be good in any event so it's about strengthening supply chains. It's about having a resilient energy system so that you don't get disrupted by grid breakdowns of grid so using mini grids to provide renewable energy and so on. And so so many of them are kind of win win strategies that would benefit primary care if we didn't have such a thing as climate change. So integrate it rather than considering it as something separate. And then the other point which I wanted to address because Rick Patelio asked a very important point was COP26 a cop out. So in the questions he says, you know, there are more fossil fuel participants than almost any other group at COP26. I think it's very important to be realistic. And the cops are very imperfect processes you know they affect the kind of political structures of the world as we know it. And we know that many of the fossil fuel industry has strong vested interests and they have a lot of political power. And the COP the conference of the parties reflects that reality. So if you're looking for a perfect process you won't find it at COP but the question is, is it better to keep negotiating or not and my view is, it's an imperfect process but we have to keep it going. We have to hold countries to account as far as we can, but we shouldn't put all our eggs if you like into the COP basket in other words we shouldn't think that the COP is going to solve all our problems because it won't. And so what's really important is to continue much of the work that's going on at the community level from primary care professions professionals for example, this work around the decarbonization of the health sector, reaching out to other sectors cities for example working with local governments to support them in implementing policies cleaner transport systems, clean energy and so on. These are all important. So don't abandon the COP process because it's imperfect certainly is imperfect and we have to lobby for a better process, and less of these vested interests, but we won't be able to prevent them completely from having some influence. And it's really important to supplement or complement the COP process by other activities from from the ground up if you like, working mobilizing healthcare professionals, working with local decision makers working with local communities and influencing of course our national governments. Thanks Andy. That's a perfect way to end I think I think we're running out of time. And I want to thank Andy and Enrique and all of you and end with this with the note about Andy's Andy's call to action. There are imperfect, imperfect structures, but within our own countries, we can organize as health professionals to influence the politicians and their, their commitments to the nationally determined commitments which they will have to review every year and that's to be done within our countries, and as an international organization within Wonka organization of family doctors, please please please keep your energy, keep your outrage going keep your optimism going. And let's work together please be in touch with the working party and the environment. The youth, the young doctors movements the rural movements, the education groups, let's work together and and make changes in our practices in educating the next generation of doctors, and in influencing the policymakers as a health community. To end I want to thank Wonka for introducing Andy, but I want to thank Andy for responding and coming and delivering such a powerful focused and practical challenge to us all. So thank you everybody for for attending and let's keep the good fight going and at the next Wonka International in two years time, we will be back and we will see where we are. Thank you everybody.