Climate Change and Health Seminar Series: "Climate Change and Urban Health: Opportunities for Research and Action”

Transcript

• 00:00(indistinct)
• 00:03<v ->All right.</v>
• 00:04Hello, everyone.
• 00:05Hello, everyone.
• 00:08Great.
• 00:08Thank you, everyone for coming
• 00:09and thanks for folks joining online.
• 00:13Today, it's my great pleasure to introduce our speaker,
• 00:18Dr. Ana Diez Roux.
• 00:20Dr. Diez Roux is Director of the Urban Health Collaborative
• 00:26and a Distinguished Professor of Epidemiology
• 00:29at Donsife School of Public Health at Drexel University.
• 00:33And from 2014 to 2023,
• 00:37she was the Dean of the Donsife School of Public Health,
• 00:41originally trained as a pediatrician in Argentina.
• 00:46She completed her public health training
• 00:49at Johns Hopkins University School of Hygiene
• 00:52and Public Health.
• 00:53And Dr. Diez Roux is an internationally renowned scientist
• 00:58for her research on the social determinants of public health
• 01:01and the study of how neighborhood physical
• 01:03and social environments affects health.
• 01:08And her research area includes many,
• 01:11including the social epidemiology.
• 01:13So for the students,
• 01:14you might already read Dr. Diez Roux's paper
• 01:17on the overview of social epidemiology.
• 01:20And also including urban health,
• 01:22the topic of today, health disparities,
• 01:26environmental interactions,
• 01:28environmental health effects, et cetera,
• 01:29using multi-level methods and a complex system approaches.
• 01:35So she's currently the Principal Investigator
• 01:38of the Wellcome Trust Funded Grant called SILUBA
• 01:42and the NIH-funded Drexel Center
• 01:46on Climate Change and Urban Health.
• 01:49And she has many, many awards.
• 01:52I'll just name a few,
• 01:53including the Wade Hampton Frost Award
• 01:57from the American Public Health Association,
• 01:59the Award for the Outstanding Contributions to Epidemiology
• 02:03from the American College of Epidemiology
• 02:06and the Ruthman Career Award
• 02:09from Science Society for Epidemiological Research.
• 02:13She's also an elected member
• 02:15of the American Epidemiological Society,
• 02:18the Academy of Behavioral Medicine and Research
• 02:22and the National Academies of Medicine
• 02:24and National Academy of Sciences.
• 02:27So without further ado, let's welcome Dr. Ana Diez Roux.
• 02:37<v ->Thank you very much.</v>
• 02:39It's a real pleasure to be here
• 02:43visiting the Yale School of Public Health
• 02:45and learning about all the exciting work
• 02:47on climate change and health that's going on here.
• 02:51Look forward to learning and sharing with all of you.
• 02:54So today I thought I would do,
• 03:00oops, am I pressing the wrong button?
• 03:05<v ->You might.</v>
• 03:08<v ->Oh, okay.</v>
• 03:11Okay.
• 03:12Oh, there we go.
• 03:13Okay, so today I thought I would do three things.
• 03:18Frame a little bit why an interest on cities
• 03:22is fundamental to public health
• 03:25and also to understanding the impacts of climate change
• 03:28and acting on climate change
• 03:31to prevent the health impacts of climate change on health.
• 03:35I'll share with you work that we've been doing
• 03:38as part of a large international collaboration
• 03:41called Salud Urbana America Latina,
• 03:43Urban Health in Latin America
• 03:45as sort of a foundation for new climate change related work
• 03:51that we are just launching
• 03:53and tell you a little bit about our plans
• 03:57for Salud Val Climate,
• 03:58which just launched a few months ago,
• 04:00as well as for our very new center
• 04:04on climate change and urban health
• 04:05that was funded also a few months ago by NIH.
• 04:10And hopefully generate some discussion
• 04:12about what we need to do to address effectively
• 04:17the impact of climate change in urban areas.
• 04:20So probably it's not necessary to remind people
• 04:24in this audience why cities are important to public health
• 04:28or to understanding the impacts of climate change on health.
• 04:31But I just wanted to say a few words about this.
• 04:35First of all, as you all know,
• 04:36urban environments continue to grow
• 04:39and have a major impact on climate change.
• 04:43It's estimated that by 2030,
• 04:45over two thirds of the world's population
• 04:47will live in urban areas,
• 04:48but most importantly,
• 04:49the majority of the growth that we're seeing
• 04:51will happen in lower and middle income countries
• 04:54is happening in lower and middle income countries.
• 04:57As you may know,
• 04:59cities contribute a large proportion
• 05:01of global energy related carbon,
• 05:03but can also be places where we can find policy solutions
• 05:09that make things more efficient
• 05:12and that actually reduce the climate impact.
• 05:15And so urban policies present major opportunities
• 05:18for climate mitigation as well.
• 05:20Urban areas are also especially vulnerable
• 05:24to the adverse effects of climate change.
• 05:26And this is because many urban areas are coastal,
• 05:30they're often particularly,
• 05:32especially in lower and middle income countries,
• 05:34they're often characterized by rapid growth,
• 05:37poor planning, high density,
• 05:39inadequate and precarious housing, poor infrastructure.
• 05:42They have very high levels of social
• 05:44and health inequality.
• 05:46Urban areas are very diverse in race
• 05:49and ethnic background and social class.
• 05:51And that creates a lot of sources of inequality.
• 05:55And for all these reasons,
• 05:57adaptation policies are obviously very important
• 06:00in cities as well to mitigate the adverse effects
• 06:03of climate change that has already happened.
• 06:06And last but not least,
• 06:07urban policies can support both mitigation and adaptation.
• 06:12Some of them are actually can address both things
• 06:15sort of at the same time
• 06:16and have health and environmental co-benefits.
• 06:20And so for this reason,
• 06:22robust and actionable evidence showing the impact
• 06:25of things that cities, many cities are already doing,
• 06:28showing the impact of these things on health
• 06:31and the environment is important to continue to advocate
• 06:35and also to support action.
• 06:41All these reasons,
• 06:44it's important to think about,
• 06:46to focus on urban health
• 06:47and the impact of climate change in cities.
• 06:51And I wanna spend a little bit of time telling you a bit
• 06:57about an urban health, a global urban health study
• 07:00that has been in place for several years now.
• 07:05We were funded back in 2017,
• 07:06originally by the Wellcome Trust
• 07:08as part of a big initiative they had called
• 07:10Our Planet, Our Health,
• 07:12which was not explicitly climate focused,
• 07:14but it was focused on environmental sustainability.
• 07:17And so a number of the foundational work
• 07:19that we've developed as part of this initial funding phase
• 07:24is what we'll be leveraging to do the climate related work.
• 07:27So I wanna spend a few minutes telling you
• 07:29about what we've done so far in SALURBAL
• 07:32as an example of a really, from my perspective,
• 07:37very special multi-country collaboration,
• 07:41which I think we really need to do more of.
• 07:46Hopefully that will become clear
• 07:48as I tell you a little bit more about the study.
• 07:50So the study has the ambition, SALURBAL,
• 07:54of creating the evidence base needed
• 07:56to make Latin American cities,
• 07:57but also other cities,
• 07:58because we think that there's a lot that can be learned
• 08:01from Latin American cities
• 08:02that is relevant to cities worldwide
• 08:04to make these cities healthier, more equitable,
• 08:06and environmentally sustainable
• 08:08with the idea that these three things
• 08:10are interconnected and entwined.
• 08:14Also, and this was new,
• 08:16certainly for me as a researcher,
• 08:19I have led a number of projects,
• 08:22but it was very rare that the funder
• 08:24and required an explicit objective
• 08:27to engage policymakers and the public.
• 08:30And so this was actually part of the grant
• 08:32from the very beginning.
• 08:33I think we're seeing more of that now.
• 08:37Certainly NIH is doing more of that now,
• 08:39which is something that was not very common before.
• 08:41And so engaging policymakers and the public
• 08:44in a new dialogue about urban health
• 08:46and urban sustainability
• 08:47and its implications for societal action
• 08:50was a very, very important part of the project
• 08:52from the very beginning.
• 08:55Also creating a platform or network
• 08:57that will ensure continued learning and translation.
• 09:00So we have worked very hard to engage the region
• 09:04and to engage investigators
• 09:05from the Latin American region in the study
• 09:08in a very meaningful way
• 09:09so that it's not just about send us your data,
• 09:12we'll analyze it and then publish papers with it.
• 09:16And last but not least,
• 09:18really a desire to really respond
• 09:21to the needs of the region,
• 09:23which is characterized by high urbanization
• 09:25and a high inequity among the highest in the world,
• 09:28but also to draw general lessons
• 09:30that could be applicable to other regions.
• 09:33So this is the SALURBAL team.
• 09:35It's coordinated by the Urban Health Collaborative
• 09:38at Drexel University,
• 09:39Dornsife School of Public Health in Philadelphia,
• 09:42but it includes a number of partners across the region,
• 09:46most of them in Latin America.
• 09:48We also partner with the Pan American Health Organization.
• 09:52And the initial formulation of the project of SALURBAL
• 09:56had four aims.
• 09:59One was to really use observational data
• 10:02to identify city and neighborhood drivers of health
• 10:06and health inequities.
• 10:08A second aim was to do policy evaluation.
• 10:11So to identify opportunities to do natural experiments
• 10:16or quasi experiments to try to characterize
• 10:19the impacts of actions that cities
• 10:22were already taking in the region.
• 10:25So this was done, we funded six of these
• 10:28after a competitive RFA process
• 10:30in several different cities of the region.
• 10:32So it was very focused on partnership
• 10:34between the research institutions in the countries
• 10:37and mayor's offices or other local partners
• 10:42that were actually doing the intervention,
• 10:44but trying to do it in a rigorous way.
• 10:48We also had an aim that was focused on bringing
• 10:53sort of a systems thinking lens
• 10:55to understanding the drivers of urban health
• 10:57and also the impacts that policies might have.
• 11:00And so I won't tell you a lot about this,
• 11:05but we did employ both more qualitative approaches
• 11:08such as participatory group model building,
• 11:10which is sort of a systems inspired way of thinking
• 11:13about increasing understanding of the drivers
• 11:19of urban health and what policies might work
• 11:21in the context of complexity.
• 11:23And then actual some simulation models,
• 11:25I'll tell you a little bit about that
• 11:26'cause they can connect to some of the climate work as well,
• 11:30including agent based models.
• 11:32And last but not least our policy aim,
• 11:34which was really about policymaker engagement.
• 11:39And so really we were really about science,
• 11:43but also impact and also inclusion,
• 11:45inclusion of the region in a meaningful way
• 11:48in all aspects of the study.
• 11:52So SALURBAL includes our sort of our city universe
• 11:56is all cities of 100,000 or more people
• 11:59in the 11 countries that are represented in the study.
• 12:03So it's not all countries in Latin America,
• 12:05but it's a large proportion.
• 12:08And this figure shows the population of the cities
• 12:11by country, Argentina, Brazil, Chile, et cetera.
• 12:14And what I wanna highlight here is that,
• 12:17of course we include smaller emerging cities,
• 12:20but also the big metropolis.
• 12:22So that there's a high, a lot of diversity
• 12:25in the characteristics of the cities that are in the study,
• 12:28which is a very, very important fact it turns out
• 12:34because it helps us learn more
• 12:37because it allows us to contrast very different cities.
• 12:41But it also recognizes that we need to,
• 12:45when looking at urban issues,
• 12:46we need to think about not just the huge cities,
• 12:49which is what people immediately think about,
• 12:51Sao Paulo, Buenos Aires, Mexico City,
• 12:53but also thinking about the many smaller cities
• 12:56that are growing rapidly across the region.
• 13:00The SALURBAL data resource we compiled,
• 13:04working with the countries,
• 13:06we compiled a range of data, including health data,
• 13:13physical and built environment data
• 13:15and social and economic environment data
• 13:17across all of our cities, 371 cities,
• 13:21but not just for the city as a whole,
• 13:23but also for smaller units within the city,
• 13:26which we call sub city units,
• 13:28for example, if a city is composed
• 13:30of several municipalities,
• 13:31we have disaggregated data for municipalities,
• 13:34but also even smaller neighborhoods within the cities
• 13:37to allow within city comparisons.
• 13:40And we have, this is of course,
• 13:41longitudinal linkable to other data resources.
• 13:44And there's also a public data dashboard
• 13:48that we recently launched called the SALURBAL data portal,
• 13:52where we make available the data
• 13:53that we can make publicly available.
• 13:56And that also includes a number of interactives
• 13:59to help with some of the dissemination efforts.
• 14:02So this is a really, has been a huge effort,
• 14:08lots of information.
• 14:10And I just wanna highlight,
• 14:12we have 11 countries, 371 cities,
• 14:14almost 1500 sub cities and almost 250,000 neighborhoods.
• 14:20So I wanna share with you a few select findings
• 14:25from the study in four key areas
• 14:31that are relevant to climate impacts.
• 14:33And these are areas that we will be building on
• 14:36as part of the new phase of SALURBAL climate
• 14:41to understand better and to also take us
• 14:44in slightly different directions,
• 14:46which I'll share with you.
• 14:48When we talk in a few minutes.
• 14:50So health inequities across and within cities,
• 14:53air quality and policy drivers,
• 14:55sustainable transportation and mobility
• 14:57and temperature impacts on health
• 14:59as well as flood exposures.
• 15:02So a big goal of SALURBAL was to make
• 15:06urban health inequities visible,
• 15:10to spur action.
• 15:13This is not news that there are health inequities,
• 15:15but the magnitude and presence of these inequities
• 15:18has not been as visible in the region
• 15:21as perhaps it has in other contexts,
• 15:23particularly in higher income countries.
• 15:26So one of the first things we did
• 15:29was characterize health across our cities.
• 15:32And so here you see a map showing life expectancy
• 15:36at birth for men in 363 cities.
• 15:41And one thing that was very striking to us
• 15:44was that there's a huge difference in life expectancy
• 15:47across different cities.
• 15:48And you can see in some cities,
• 15:50the life expectancy for men is close
• 15:53to what it was in Afghanistan at the time.
• 15:55And in other cities, it's close to what it was in Germany.
• 15:59So huge heterogeneity in life expectancy.
• 16:02And it turns out that the social environment,
• 16:06which is a social environment index
• 16:09that the study created,
• 16:10which includes measures of education,
• 16:13crowding, water and sanitation,
• 16:15no surprise is the strongest predictor
• 16:17of differences in life expectancy across cities.
• 16:20Now, it wasn't only life expectancy,
• 16:23but also the causes of death differ across cities.
• 16:26And this figure shows proportionate mortality
• 16:29for several major causes of death.
• 16:35Each line, each vertical line is a city
• 16:38and they're sorted by country, as you can see here.
• 16:43And they're also sorted by one of the causes of death,
• 16:47which is violent injuries, which
• 16:48is this green at the bottom.
• 16:50So you can see here, for example,
• 16:52how for violent injuries, even within countries,
• 16:54there's also enormous heterogeneity
• 16:56in the proportion of deaths that
• 16:58are due to violent injuries.
• 16:59Now, if we sorted by other causes of death,
• 17:01you would also see a lot of heterogeneity.
• 17:06But this is one example.
• 17:09And we found, of course, that several social indicators,
• 17:13social and economic indicators
• 17:14were also strongly related to violent injuries
• 17:19across our cities.
• 17:22We also did additional analyses
• 17:24looking at heterogeneity within cities and life expectancy.
• 17:27This kind of thing has been done a lot
• 17:29for high-income countries.
• 17:30I'm sure you've seen maps of this,
• 17:33but it has not been done
• 17:34for lower and middle-income countries
• 17:36very much at all.
• 17:37And so, first we looked at subsidies for the larger cities,
• 17:43and then we've been looking in more depth
• 17:47at smaller areas or neighborhoods.
• 17:51And just describing these inequities
• 17:54and looking at select indicators
• 17:56that might be associated with them.
• 17:58And I'll show you later,
• 17:59but this kind of work has got huge media impact
• 18:04in the region, which we were quite surprised by,
• 18:07but I think motivated a lot of discussion.
• 18:11And of course, climate change is operating
• 18:14on top of this inequity already,
• 18:17and which is something
• 18:18that I'll talk a little bit more about
• 18:20when we talk about sort of what our next steps are
• 18:22in terms of looking at the equity impacts of climate change.
• 18:27The other area that I just wanted
• 18:29to share a few findings with you
• 18:31has to do with evidence on air quality and its drivers.
• 18:36So one of the things that we looked at was PM2.5 levels.
• 18:38Of course, we found a lot of heterogeneity.
• 18:42These are, each dot is a city,
• 18:45and they're categorized by country.
• 18:47So a lot of heterogeneity in annual mean PM2.5.
• 18:53Very high levels of exposure.
• 18:55I mean, even using the old WHO standards,
• 18:58which is when we first published this paper,
• 19:00the new standards hadn't come out yet.
• 19:02Almost 60% of the population lives in areas
• 19:05with levels above the standards.
• 19:07And if you use the newer standard, that's even over 90%.
• 19:11And we also looked at what city factors are related
• 19:14to having higher or lower levels of PM2.5.
• 19:18And we found that there are several policy relevant factors
• 19:23like motorization, traffic congestion,
• 19:26policy amenable factors that are strongly related
• 19:29to higher levels of PM2.5.
• 19:31And in contrast, for example,
• 19:33greater access to public transit
• 19:35was related to lower levels of PM2.5,
• 19:37as was more green space.
• 19:39Now you may say, well, this is obvious.
• 19:41We already know this.
• 19:42And I think to some extent that's true,
• 19:43but being able to demonstrate this
• 19:45across the Latin American cities
• 19:47also got a lot of attention in the region
• 19:49because it shows that there are things
• 19:52that cities can actually do
• 19:54to impact these very high exposure levels.
• 19:59Another pollutant that we looked at, of course,
• 20:02which has a lot of connections to climate change is NO2.
• 20:06And of course, NO2, we looked at variability
• 20:10across much smaller areas
• 20:11because of the spatial heterogeneity,
• 20:14even across small areas in NO2.
• 20:17And so this is examples of neighborhood levels of NO2
• 20:21in two of our cities,
• 20:22Buenos Aires and Quetzaltelango in Guatemala.
• 20:25And again, we observed a lot of heterogeneity
• 20:29across neighborhoods, but very high levels of exposure.
• 20:32So of the almost 236 million people
• 20:36who lived in the cities that we studied in these analyses,
• 20:3885% lived in neighborhoods
• 20:42with NO2 levels above the standard.
• 20:44So very high levels of exposure here as well,
• 20:48and higher NO2 levels also linked to traffic congestion
• 20:54and less neighborhood green space, for example.
• 20:59So in thinking about the impact of climate change
• 21:02on these cities, the impact of climate change
• 21:05on these pollutants, but also interactions
• 21:07between things like temperature and these pollutants,
• 21:09of course, become very salient
• 21:11in terms of understanding the impacts
• 21:12and also understanding the health inequities.
• 21:18SALURBAL also had a major focus
• 21:21on healthy and sustainable urban mobility,
• 21:23because this is a big issue in the region
• 21:26because of the very high levels of urbanization,
• 21:30but also because the region has been,
• 21:32Latin American region has been a source
• 21:35of a lot of innovative thinking around urban mobility.
• 21:38One prime example is Colombia, for example,
• 21:42Bogotá and several cities in Colombia
• 21:44have been at the forefront of thinking about strategies
• 21:47to deal with urban mobility.
• 21:51So we were very interested that our partners
• 21:54were very interested in this.
• 21:57And so we had a big focus on this.
• 21:59Of course, the region is experiencing
• 22:02very high levels of motorization.
• 22:03I mean, the levels of motorization are rapidly increasing.
• 22:08This is just one example, a 30% increase over five years.
• 22:15And this has had a major impact
• 22:18in how urban commuting happens in the region.
• 22:22Anecdotally, when I go back to Buenos Aires,
• 22:25and I take a bus that I used to take from my home
• 22:28when I was a resident at a big children's hospital,
• 22:30the ride used to take like 25 minutes.
• 22:33Now it takes like an hour and a half
• 22:35because there's so much traffic, so many cars.
• 22:39And motorcycles have also increased dramatically,
• 22:42especially since the pandemic.
• 22:44And so this is a huge health issue for the region.
• 22:49Traffic-related mortality is a major source of mortality
• 22:53in the region, among the highest rates in the world.
• 22:57And so we looked at the relationship between city features
• 23:01and traffic-related mortality,
• 23:03and of course found that cities with more public transport
• 23:06have lower traffic-related mortality
• 23:08and higher traffic mortality
• 23:12is linked to more isolated urban development.
• 23:15Again, factors that are policy amenable,
• 23:17and you can start to see sort of the health
• 23:19and environmental co-benefits
• 23:20because the same factors are emerging
• 23:23across analyses looking at environmental outcomes
• 23:26and health outcomes.
• 23:30It turns out that in the region,
• 23:32urban mobility is also linked to health behaviors.
• 23:35We had some intriguing results looking,
• 23:39using some survey data showing that more time commuting
• 23:42and delays in traffic were linked to worse diets
• 23:46and more depressive symptoms.
• 23:49This also got tons of press in the region.
• 23:51It's a very interesting, I think, way,
• 23:55brings in things that people don't usually think about
• 23:57how commute can be affecting behaviors
• 24:00that then relate to non-communicable diseases
• 24:02in ways that you might not have anticipated.
• 24:07As part of one of our policy evaluation studies
• 24:12and that AIM2 that I mentioned
• 24:14where we're doing natural experiments,
• 24:17the team in Colombia led by Olga Lucia Sarmiento
• 24:20who is co-PI of the SALURBAL Climate Study now with me,
• 24:26they partnered with the city of Bogota
• 24:28to evaluate a new public transportation initiative
• 24:32called Transmicable which is an extension
• 24:35of the BRT which is this bus fleet
• 24:41which travels through dedicated lanes
• 24:43and extension into the outskirts of the city
• 24:45which tend to be much poor areas
• 24:49through a cable car system.
• 24:52And so they did a really nice quasi-experimental design
• 24:59where they compared the neighborhood
• 25:01that received the intervention
• 25:03with a matched neighborhood
• 25:05that was not receiving it at the time
• 25:07but was scheduled to receive it later in time.
• 25:10And they found that the cable car had a number of benefits
• 25:16of course, reductions in trip time
• 25:18but also increased leisure time,
• 25:21something we don't think much about
• 25:22but that is probably quite important to health,
• 25:26reductions in inhaled pollutants,
• 25:29more physical activity among users,
• 25:31improvements in health related quality of life
• 25:33and also reduced perceptions of insecurity
• 25:36and reduced community stigma.
• 25:38And so thinking about the climate implications
• 25:42of these kinds of things is also something
• 25:45that is very important to build on.
• 25:51So this idea of leveraging urban mobility initiatives
• 25:55to address, to both mitigate and adapt to climate change.
• 26:03We have also used simulation models to build on this
• 26:08to really try to understand the impact
• 26:12of different policies under various scenarios.
• 26:15Agent-based models are very good
• 26:17for looking at conditional effects.
• 26:19So what happens if one policy
• 26:21is combined with another policy?
• 26:24They have a lot of challenges
• 26:26which we can talk about if you're interested in that
• 26:29but this is one example of an agent-based model
• 26:32that was developed also for the city of Bogota.
• 26:34So it's a pretty abstract model
• 26:36but informed by certain characteristics
• 26:38of the city of Bogota to make it sort of illustrate
• 26:42sort of an exemplar of a Latin American city to some extent.
• 26:46And we use the model to look at congestion taxes
• 26:50and fare policies, which were two things
• 26:53that the city was actively considering
• 26:56as part of transportation initiatives.
• 26:59And I don't have time to get into the details
• 27:03but the model allowed us to examine
• 27:06the independent and combined effects of both policies
• 27:11and major conclusions were that to reduce time poverty
• 27:15among lower SES people, fare policies were needed.
• 27:18Fare policies are expensive
• 27:20but the cost can be offset through combined implementation
• 27:22of a congestion tax.
• 27:24So this was sort of the bottom line of the results
• 27:28which some aspects were surprising, but that's because,
• 27:32I mean, that's what you expect with an agent-based model
• 27:34to show you things that you wouldn't necessarily predict.
• 27:37And part of it is driven by the fact
• 27:39that in many of the cities,
• 27:40a large proportion of the population actually walks a lot.
• 27:44So it's very different than US cities
• 27:46where very few people walk.
• 27:48Well, in these places, a significant proportion
• 27:50of low SES people walk because they have no choice
• 27:53but to walk and they walk very long distances.
• 27:56And so paradoxically, when you do fare policies,
• 28:03you may see reductions in walking time
• 28:05but that can be a good thing,
• 28:07not necessarily a bad thing, right?
• 28:09It's all a question of balance.
• 28:11So these are some of the nuances that can emerge
• 28:13when you do these kinds of analysis.
• 28:15So thinking about how this can be expanded
• 28:18to incorporate climate change
• 28:19and answer questions relevant to climate change policies
• 28:23is something that we're also thinking about.
• 28:27We've also been looking at health impacts
• 28:31of some climate change related exposures.
• 28:34Of course, temperature is a critical one
• 28:37that we have focused on as part of the initial phase
• 28:41of SALURBAL through an ancillary study
• 28:43led by Daniel Rodriguez at Berkeley.
• 28:47And we, for our 371 cities,
• 28:51we looked at the relationship
• 28:53between temperature and mortality,
• 28:55similar to what has been done
• 28:56in many high-income countries.
• 28:58Some of you may recognize these kinds of figures
• 29:00that show the distribution,
• 29:03the histogram of the distribution of temperature
• 29:06across days in a year,
• 29:07and then the relationship,
• 29:09the relative risk for temperatures,
• 29:12various temperatures compared
• 29:14to the minimum mortality temperature
• 29:16for the particular city.
• 29:17And so we've created these,
• 29:19we've done these analyses
• 29:21and created these figures for all of our cities.
• 29:24And found similar to others
• 29:27that about 6% of deaths can be linked
• 29:29to non-optimal temperatures,
• 29:32temperatures below or above
• 29:33the minimum mortality temperature.
• 29:37The proportion is higher for cold than for heat,
• 29:40primarily because the days at cold temperatures
• 29:44are much more, so it's an attributable risk.
• 29:47So the prevalence of the exposure impacts
• 29:51the attributable fraction a lot.
• 29:55But when we looked at the steepness of the curve
• 30:00associated with cold and hot,
• 30:02we found that the steepness was much,
• 30:05for the most part,
• 30:06much more significant for hot days overall.
• 30:09So a one degree centigrade increase
• 30:11was linked to almost a 6% increase in mortality.
• 30:17Signaling that as temperatures continue
• 30:19to shift towards the right,
• 30:23we're likely to see significant increases in mortality.
• 30:26Of course, adaptation may kick in to a certain extent,
• 30:28but that's something to evaluate.
• 30:32But at the same time,
• 30:33there's a lot of heterogeneity across cities.
• 30:35You can see this in these pictures here.
• 30:37Now, some of it is due to the distribution of temperature.
• 30:40So depending on the temperature distribution,
• 30:42the shape of the curve is gonna be different,
• 30:44but there are also other factors
• 30:46that may be affecting these,
• 30:48even within similar temperature distributions
• 30:50that may be buffering or enhancing the impact of heat.
• 30:54And so that's one of the things that we wanna look at.
• 30:57We've delved into it a little bit,
• 30:59and I'll show you that in a minute,
• 31:00but there's a lot more to do.
• 31:04We also created sort of aligned
• 31:06with our dissemination and strategy.
• 31:09We also created an interactive app
• 31:12where people can take a look for their city
• 31:17and explore these curves in more detail for their city,
• 31:21including how many deaths were attributable to heat
• 31:25during X period or other aspects
• 31:28that they may wanna look at.
• 31:31So we did look at some effect modification
• 31:33of the excessive death fraction for heat.
• 31:39And one of the things that we were very interested in
• 31:41is greenness.
• 31:42So we found a little bit, but not a very strong signal.
• 31:46It's something that we wanna look at
• 31:47with more spatially resolved data,
• 31:51because this is done at the city level.
• 31:54So we found that for arid climate zone cities,
• 31:57there was a little bit of a signal,
• 31:59confidence intervals are including the null here,
• 32:01but we found a little bit of a signal
• 32:03that higher greenness was associated
• 32:06with a lower excess death fraction.
• 32:11Sorry, this should say excess death fractions
• 32:14stratified by greenness level.
• 32:17There was also some signal that effects were stronger
• 32:21when green space was more distributed
• 32:24as opposed to when it was all centrally located
• 32:26in one part of the city.
• 32:27This is something we wanna look into.
• 32:28This is very important policy-wise,
• 32:30because you can recommend greenness,
• 32:32but where, how should it be distributed in the city?
• 32:35And so some of these cities are quite green
• 32:39because they have green in the periphery, for example,
• 32:42in the peripheral areas, which are not very built up.
• 32:45And so this may be, it's not really telling us much,
• 32:51and we need to sort of look into this in more detail.
• 32:54So one of the things that the Berkeley team
• 32:56has done actually, because they have led
• 32:58a lot of the exposure characterization on greenness
• 33:01is developed a large suite
• 33:03of very sophisticated greenness measures
• 33:05that we hope to explore more in the next phase of SALURBAL.
• 33:09We also looked at effect modification
• 33:12by area SES, area socioeconomic characteristics,
• 33:16and we did not find very much, actually.
• 33:20A few signals, for example,
• 33:24higher secondary education in the city
• 33:27was associated with less excess deaths due to cold,
• 33:31but for heat, we didn't really find very much at all.
• 33:34In fact, even some paradoxical findings
• 33:36in the direction opposite to what we had hypothesized.
• 33:39So we really wanna look at this at the neighborhood level,
• 33:43because we really think,
• 33:44there's a lot of temperature heterogeneity
• 33:47within these cities.
• 33:48So even that we're not capturing differences in temperature
• 33:55within the cities, for example, at night, for example,
• 33:58which we know varies a lot,
• 34:00and we're not really capturing effect modification by SES
• 34:04at a finer level, at the neighborhood level.
• 34:06So we think we might see more if we do that.
• 34:09This is at a very high level of aggregation.
• 34:12So in some ways, it's not surprising
• 34:14that we weren't seeing very much yet.
• 34:19We've also looked at ambient temperature and birth weight.
• 34:21This is another area that has received a lot of attention.
• 34:25And these figures show the prevalence of low birth weight
• 34:30by temperature across cities in three countries,
• 34:33Brazil, Mexico, and Chile.
• 34:34And as you can see that in Brazil and Mexico,
• 34:38we saw the expected relationship,
• 34:40higher temperatures,
• 34:46more low birth weight.
• 34:50And for Chile, we didn't see much at all.
• 34:53In fact, the opposite,
• 34:54but you can see the temperature distributions in Chile,
• 34:57of course, are much more shifted towards the left.
• 35:00So, and this is a huge analysis,
• 35:03there's about 15 million births across 165 cities.
• 35:06So we're continuing to explore this.
• 35:07This shows the result by month of pregnancy.
• 35:13And you can see for Brazil and Mexico,
• 35:15especially in the latter months of pregnancy,
• 35:18the effect seems to be a bit stronger.
• 35:20For Chile, we see nothing at all.
• 35:24So looking at effects of climate change
• 35:27on infant and child health is a huge area,
• 35:29I think that we need to focus more on.
• 35:34Very recently, and this is a work under development
• 35:39led by Josiah Kephart,
• 35:40we're looking at flood exposures and across our cities.
• 35:46This is almost 45,000 neighborhoods
• 35:50in 276 cities from eight countries.
• 35:53And we observed a very clear patterning
• 35:57by neighborhood SES of exposures to floods.
• 35:59Whereas the lowest SES neighborhoods
• 36:01clearly had more experienced more floods
• 36:04than higher SES neighborhoods
• 36:07with a quite remarkable dose response.
• 36:09Actually, I was quite surprised to see this.
• 36:12And we've also looked at, this is all preliminary work,
• 36:16odds ratios of neighborhood flooding
• 36:18associated with neighborhood features.
• 36:20And we see, of course, the education signal,
• 36:23higher education, less floods.
• 36:26Greenness is associated with more floods.
• 36:28This may have to do with the peripheral location
• 36:31of these cities, we're not sure.
• 36:32We need to explore this.
• 36:32Coastal neighborhoods, of course, a huge effect.
• 36:36And so we're following up on
• 36:39some of these exposures as well.
• 36:43Distance from the city center,
• 36:44neighborhoods farther from the city center,
• 36:47greater risk as well.
• 36:50And so our next phase is to look at the impact
• 36:54of these flood exposures
• 36:55on some of the health outcome data that we have.
• 37:00So this is just a quick summary
• 37:03of some of the SALURBAL findings relevant to climate change,
• 37:09large inequities in health across and within cities,
• 37:12especially across small areas.
• 37:14Pre-existing, which of course will be further,
• 37:18it's very possible they are magnified by climate change
• 37:22and also by climate change exposures
• 37:25and also interact potentially
• 37:28with climate change exposures.
• 37:31Substantial air quality issues,
• 37:34substantial exposures and policy relevant factors
• 37:37linked to levels.
• 37:40Multifaceted impacts of urban mobility on health
• 37:43and a great opportunity for intervention.
• 37:45Many across Latin America,
• 37:47there's a lot of interest, for example,
• 37:49in electrifying bus fleets as a policy initiative.
• 37:53Many of the cities are highly dependent on bus fleets.
• 37:57And so that has, you can think of multiple,
• 38:00multiple climate and health connections there as well.
• 38:04So I'll tell you a little bit about what we're planning
• 38:07for the future as part of SALURBAL Climate
• 38:09and temperature and floods
• 38:11really as emerging health threats in the region.
• 38:16So these are the things that we're building on
• 38:18with SALURBAL Climate.
• 38:20I also wanted to share with you
• 38:22some of the dissemination work that we do in SALURBAL.
• 38:26This shows data briefs and webinars.
• 38:29So we produced a number of data briefs
• 38:32just describing our data or key aspects of the data
• 38:35or highlighting problems in the data
• 38:37like mortality statistics
• 38:38and encouraging strategies to improve.
• 38:42We also did a brief in collaboration
• 38:44with the Ubuntu Center
• 38:45at the Dornsife School of Public Health
• 38:47on race and racism in health data,
• 38:52under-emphasized areas,
• 38:54certainly in the region that deserves a lot more attention.
• 38:58And we also do dissemination webinars
• 39:01in Spanish, Portuguese, and English.
• 39:05We've also done policy briefs
• 39:07which are more targeted at specific policies
• 39:10and in-person events.
• 39:11Here's one policy brief on the Transmicable study
• 39:15that I showed you.
• 39:17And we do a lot of,
• 39:19each of our meetings has a policymaker day
• 39:23in which we engage with the local teams
• 39:26to talk to local officials
• 39:28about the study and what we're finding.
• 39:32And media, as I mentioned,
• 39:34I just wanted to highlight,
• 39:35it's been really interesting to see
• 39:38the things that got traction.
• 39:40Certainly the differences in life expectancy across cities,
• 39:43a simple descriptive analysis got huge impact
• 39:47as did the very high NO2 exposures
• 39:50and also the temperature impacts on mortality
• 39:54and low birth weight
• 39:55also got a lot of attention in the press.
• 39:57So there's clearly a lot of interest
• 40:00in the public in these topics.
• 40:05One of the things we wanna do
• 40:07as part of SALURBAL Climate
• 40:08is do more specific outreach to journalists specifically
• 40:12and perhaps, and we're also even planning up some workshops
• 40:15with journalists to facilitate understanding
• 40:19the information and its implications.
• 40:24And we also have,
• 40:27we partner with a number of different organizations,
• 40:30intergovernmental organizations,
• 40:31Pan American Health Organization,
• 40:33we've attended meetings of a network of mayors
• 40:36that PAHO hosts.
• 40:38We've also developed a really great partnership
• 40:41with the Inter-American Development Bank,
• 40:43which is a development bank in Latin America
• 40:45that supports a lot of transportation and housing work.
• 40:49They actually did a documentary on our study,
• 40:51so you can watch it there.
• 40:54And also with other non-governmental organizations
• 40:57like the World Resources Institute,
• 40:58we recently got funding to work with them
• 41:02in a small number of cities to use data.
• 41:06The goal is to get used,
• 41:08put together some data quickly to impact action
• 41:12in a very short timeframe.
• 41:14So which is that study is just about to launch now.
• 41:19So that brings me to SALURBAL Climate,
• 41:21which I wanna tell you a little bit about.
• 41:27We were renewed by the Wellcome Trust just last November
• 41:33after a competitive process to continue SALURBAL
• 41:39with a focus on climate change and health.
• 41:41And so our goal is really to leverage and expand
• 41:46the SALURBAL team, the data resource and the partnerships
• 41:51to generate new and also context-relevant knowledge,
• 41:55which is very important to support action.
• 42:01And support actions to prevent
• 42:02the further health impacts of climate change
• 42:04and also protect from changes that have already occurred
• 42:07and to build regional capacity
• 42:09for continued learning and action into the future.
• 42:12And of course, this is very aligned
• 42:14with the work that we've already been doing in SALURBAL.
• 42:18And so we have four aims,
• 42:20which I'm gonna tell you a little bit about.
• 42:23The first aim is to generate locally relevant evidence
• 42:27on climate change and health equity impacts.
• 42:29Because locally relevant evidence is a part,
• 42:32as we've seen in SALURBAL, is a powerful driver of action.
• 42:35And there's a lot of evidence that data
• 42:39from the Latin American region is very lacking
• 42:41in terms of climate change and health.
• 42:43What are we gonna do?
• 42:44Well, we're gonna document the magnitude of exposures,
• 42:47just descriptive information, how many cities,
• 42:50how many people are exposed to heat waves across the region
• 42:53or how many people were exposed to air pollutants
• 42:59linked to wildfires over the past X number of years.
• 43:02Descriptive data globally,
• 43:04but also by measures of social disadvantage, for example.
• 43:10So just describing exposures
• 43:12and also looking at health impacts as well, of course.
• 43:16So going beyond heat to also look at floods, air quality,
• 43:20interactions of air quality with other things,
• 43:22wildfires, drought and storms,
• 43:24and also with a strong equity focus
• 43:26because inequities are so important in the region.
• 43:30So we're going to leverage and explore,
• 43:32leveraging and expanding the existing SALURBAL resource
• 43:35and disseminating findings by building on the data portal
• 43:38that we have and using interactive tools, webinars,
• 43:43and stakeholder engagement.
• 43:46So that's the first aim which we've already started on.
• 43:53A second aim is to look specifically
• 43:55at mitigation and adaptation strategies.
• 43:59Why?
• 44:00Because many cities in the region
• 44:01are already taking innovative actions.
• 44:03Sometimes it's not because of climate change,
• 44:05it's just for other reasons,
• 44:06but taking advantage of those actions
• 44:08that they're already taking to evaluate them.
• 44:11And because we've seen that evidence on policy impact
• 44:14is really needed to support policy change.
• 44:17And so we will be investigating the health inequity impacts
• 44:22of planned and feasible mitigation or adaptation strategies.
• 44:25So things that are already in the works
• 44:28or things that are really feasible in the region,
• 44:30not pie in the sky things,
• 44:32but things that can really happen.
• 44:33And we're going to be using two complementary approaches
• 44:38for this health impact assessment
• 44:42in the sense in which it's described by WHO,
• 44:44which is a stakeholder engaged, equity focused,
• 44:49ex-ante sort of evaluation of a proposed program or project.
• 44:55And so we'll be doing that in two locations initially
• 44:59in Santiago and Bogota.
• 45:01Both cities have proposed important
• 45:05urban greening corridor kind of projects.
• 45:09And so the institutions in both Universidad Catolica
• 45:15in Chile and the Universidad de los Andes in Bogota
• 45:19are working with their cities on this.
• 45:22So this gives us great depth
• 45:23and we hope to develop a methodology
• 45:25so that this becomes sort of an exemplar approach
• 45:28that can then be used in other cities.
• 45:30And then combined with that comparative risk assessment,
• 45:35which is sometimes also confusingly called
• 45:37health impact assessment,
• 45:38but we try to keep them separate.
• 45:40Comparative risk assessment,
• 45:41which is more of a modeling exercise
• 45:44across multiple cities using existing evidence
• 45:48tried to estimate the impacts of a particular policy
• 45:51like electrifying bus fleets
• 45:53using evidence from other sources.
• 45:54It's a very quantitative modeling exercise.
• 45:58And so one gives us more depth,
• 46:00the other one gives us sort of more breadth.
• 46:02And so that's what we are planning for our second aim,
• 46:08which is really about policies.
• 46:13Our third aim, which was not a name
• 46:16in the prior version of SALURBAL,
• 46:19but which we have made a name in SALURBAL Climate
• 46:22because we did so much of it and it's so important
• 46:26is field building and capacity strengthening
• 46:30because local perspectives are critical
• 46:32to rigorous science, we think.
• 46:34We think we can't get the science right
• 46:36if we don't have the regional scientists involved.
• 46:39That has been very clear in SALURBAL, I think.
• 46:42And because local researchers are best positioned
• 46:44to influence local policies.
• 46:45And so we do a lot of informal and formal training
• 46:49in this next phase of SALURBAL.
• 46:51We are formalizing some of the things
• 46:53that we did more informally in phase one,
• 46:55including researcher training,
• 46:59strengthening institutional capabilities
• 47:00to lead and conduct research
• 47:03and capacity strengthening for policy actors
• 47:06in civil society.
• 47:07This is kind of that workshop on journalists
• 47:09is one example of that.
• 47:11And so we'll be doing this by targeting individuals
• 47:14through funding for early career researchers.
• 47:17We are also launching something
• 47:18we call the SALURBAL Fellows
• 47:20through which we also hope to engage scientists
• 47:23from groups that are underrepresented.
• 47:28Institutional capacity building.
• 47:29So the institutions, many of these institutions
• 47:32have limited experience submitting and managing grants.
• 47:36And so we support them in many ways for that
• 47:40and we'll continue to do that as part of the next phase.
• 47:44And also more societal activities and public engagement.
• 47:48And our fourth aim is similar to the first phase
• 47:53of the project to support policy action more generally.
• 48:00Ensure that research addresses local priorities,
• 48:03deliver findings effectively,
• 48:05and strengthen capacity among stakeholders
• 48:08to advocate for policy change.
• 48:09So we have a number of strategies that we're using here.
• 48:12Information sharing, capacity strengthening
• 48:16for researchers on how to communicate with policymakers,
• 48:19for policymakers on how to understand the data
• 48:23and particularly their policy implications
• 48:26and other stakeholders in terms of how to interpret
• 48:29some of the findings, as well as some specific policy
• 48:32and community engagement activities
• 48:34through a bunch of different things.
• 48:38So these aims are of course all interrelated
• 48:42and reinforce each other.
• 48:46And we've just got started working on this a few months ago.
• 48:50So the team is really, really thrilled.
• 48:53And last but not least, I wanna tell you a little bit
• 48:56about our new center.
• 49:00So it's 10 of, right?
• 49:02Am I seeing that right?
• 49:03There's some glare.
• 49:05Yeah, so I just, a couple more minutes and I'll be done.
• 49:08So I just wanna tell you a little bit about our new center,
• 49:12which is very aligned, of course,
• 49:13with SALURBAL, but also builds and expands on it.
• 49:17And so really our ambition here is to leverage
• 49:20the power of cross-city comparisons,
• 49:22not only across SALURBAL, which I've already told you about,
• 49:25but also across work that we have been doing
• 49:28at the Urban Health Collaborative in the United States.
• 49:31As one example, we have a partnership
• 49:34with the Big Cities Health Coalition,
• 49:36which is an organization that brings together
• 49:40the health departments of the 35 biggest US cities
• 49:43and we've done a number of things with them over the years,
• 49:46including a data dashboard and consultations
• 49:49on various topics.
• 49:50And so we really want to expand the work with them
• 49:53to encompass climate change impacts in these cities
• 49:56and policy implications, but also to think about
• 49:59how all this kind of fits together
• 50:01and how we can learn across the region
• 50:05about impacts and about what works.
• 50:08So our center, which is focused on creation,
• 50:14translation and dissemination of evidence
• 50:16to support urban policies to address the health
• 50:17and equity impacts of climate change in cities.
• 50:20We have an administrative core,
• 50:22a research capacity building core,
• 50:24community engagement core,
• 50:25which is a policy engagement core really in our case.
• 50:29It's really about working with policymakers,
• 50:31some public engagement too,
• 50:32but primarily our community, our policymakers actually.
• 50:36And a research project,
• 50:38which I'll tell you a little bit more about in a minute.
• 50:41And this is a partnership with the Institute
• 50:45for Transportation at Berkeley, led by Daniel Rodriguez,
• 50:49who's also part of SALURBAL, INCAP in Central America,
• 50:52Instituto de Nutricion de Centroamerica de Panama
• 50:55and several institutions in Brazil.
• 50:58And it's an exploratory center, as you know,
• 51:01it's a three-year project that we're really trying
• 51:03to leverage all the strength
• 51:05that we already have in urban health
• 51:07and add to it a climate focus.
• 51:09That's why there's a lot of emphasis on capacity building
• 51:13so that we can bring our expertise in health equity
• 51:16and urban health, learn from climate experts
• 51:19and think about how we can move,
• 51:21work together to improve the evidence
• 51:24and support meaningful action.
• 51:26The research project, which is led by Usama Bilal
• 51:31is really just building on some of the data I showed you
• 51:36earlier on neighborhood differences in health
• 51:38to understand heterogeneity in the impact
• 51:40of extreme heat on mortality across neighborhoods
• 51:43in selected cities in four countries.
• 51:45And so, we're interested in characterizing
• 51:48not only differential exposure to heat across neighborhoods,
• 51:51but also differential effects.
• 51:53So the effect modification piece.
• 51:56And so we have a number of aims
• 51:58from examining heterogeneity in effects by neighborhood
• 52:01to looking at the moderating effects,
• 52:03decomposing the impact of differential exposures
• 52:07versus differential effects
• 52:08and really develop sort of an exemplar or a paradigm
• 52:11that can then be applied to other exposures
• 52:13and other cities.
• 52:16And last but not least,
• 52:19this is sort of our ambition
• 52:21with both of these projects,
• 52:23SALURBAL Climate and the CCUH,
• 52:25the Center on Climate Change and Urban Health,
• 52:28we want to deliver data and evidence
• 52:31that's locally relevant.
• 52:33We want to support policy evaluation,
• 52:35capacity strengthening,
• 52:37and last but not least,
• 52:39meaningful policy impact that bridges the Americas.
• 52:44And that's it.
• 52:46Thank you so much for your attention.
• 52:48I look forward to your comments.
• 52:53<v ->Thank you so much.</v>
• 52:54So because of timing,
• 52:56I think we can have two very quick questions.
• 53:00So if any students have any questions,
• 53:03please feel free to raise your hand.
• 53:05We do have a lot of questions from online as well,
• 53:08but due to time, we'll just pick one.
• 53:10<v ->Okay, sure, go ahead.</v>
• 53:13<v ->Anyone wants to ask?</v>
• 53:15Yeah, please.
• 53:16<v ->Well, thank you so much for this insightful information.</v>
• 53:20And well, I am not actually doing a research,
• 53:23a research review about how the green space
• 53:26affects childhood obesity.
• 53:28And you just mentioned that we need to pay more attention
• 53:32on the cities.
• 53:33And I may be misunderstood by the mention
• 53:35that the cities might be isolated by roads more or-
• 53:42<v ->I think I may have said that the green space</v>
• 53:45is on the edges of cities.
• 53:47So it's not, it doesn't necessarily mean
• 53:50that there's a park nearby where people live.
• 53:52So I think thinking about the distribution of green space,
• 53:55I'm not sure if that's what you're referring to,
• 53:57but that's what I recall.
• 53:59Sure.
• 54:01<v ->So there's multiple questions online.</v>
• 54:03I'll just pick one from Freddie Morgan.
• 54:07Greetings from Chicago and congratulations on presentation.
• 54:11What would it be for sustainable transportation
• 54:15that would improve air quality in Latin America,
• 54:19knowing that each country has its own characteristics?
• 54:22<v ->What would be a sustainable?</v>
• 54:23You want my opinion?
• 54:24Get rid of cars.
• 54:26That's my opinion, (laughs) as much as possible.
• 54:32<v ->That's a good one.</v>
• 54:33Then maybe take another one.
• 54:34<v ->Yeah, sure.</v>
• 54:35<v ->So a very impressive work from K through 9.</v>
• 54:40She's asking about the publication of ZLUBA
• 54:44is both in English and some in Spanish.
• 54:46It's pretty rare for journals to facilitate the publication.
• 54:51A journal article (speaks faintly).
• 54:58<v ->Yeah, so that is a big challenge.</v>
• 55:00So there's a lot of pressure, of course,
• 55:03to publish in the top ranked journals, which are in English.
• 55:07So this is something we've discussed in the study a lot
• 55:09about should publications, where should they go,
• 55:12particularly for junior researchers?
• 55:14And there's no easy answer.
• 55:16I think over time we will see more journals
• 55:18in other languages.
• 55:19Unfortunately, I think right now it's still the case
• 55:23that a lot of the work has to be done in English.
• 55:25We translate, our meetings are multilingual
• 55:28and we do a lot of things.
• 55:29All of our dissemination is in Spanish and Portuguese,
• 55:33but a lot of the publications,
• 55:34we have published some things in Spanish
• 55:37and certainly the briefs are all multilingual too.
• 55:40But scientific publications, that's still an issue,
• 55:43I think, yeah.
• 55:44<v ->Thank you.</v>
• 55:45Thank you so much.
• 55:46Thanks again.
• 55:50And for students do not forget to sign the sheet
• 55:52and thank you all for joining online.
• 55:55Thank you.