Welcome, everyone, to the National Education Curriculum in Emergency Preparedness and Response for Preventive Medicine Residents. This is the 10th webinar in our series. We are pleased to have all of you here today. And before we move forward with our 10th webinar presented by Dr. Clifford Mitchell, let me just provide a brief housekeeping overview. Next slide, please. Just a brief overview. Please feel free to attend these webinars and ask questions to the faculty. You can post the questions in the Q&A or the chat, and we will try to answer all of your questions towards the end. We will also post a survey link during the Q&A session for you to complete. Please complete your evaluation feedback and help us improve. This is a pilot series that we're excited to offer. As always, you can continue discussion on this topic and other topics of this webinar series on ACPM Pulse, an online discussion and community forum that we've launched for our members exclusively. And as you may have just heard, this webinar will be recorded, and ACPM will send you the instructions to access the recording. Next slide, please. Without further ado, it is my distinct privilege, pleasure, and honor to turn over this lecture to Dr. Clifford Mitchell. Dr. Mitchell, over to you. Thank you very much, Ms. Bailyn, and it's a pleasure to be here with you all today. What I'm going to do today is talk a little bit about food, housing, and water insecurity in the context of preparedness and prevention. First, a little bit about myself. I am a physician. I'm the director of the Environmental Health Bureau at the Maryland Department of Health, where I have been since 2006. And prior to that, for 14 years, I was on the faculty at the Johns Hopkins School of Hygiene and Public Health, now the Bloomberg School of Public Health, where I was the assistant director and then director of the Occupational Medicine Residency Program. Here in the Environmental Health Bureau, our responsibility is the physical environment as it relates to public health and preventive health. Our sections include food protection, housing, and other issues, some regulatory programs, a lot of epidemiology associated with environmental and occupational health, and a number of other programs. I'm going to take some time to share my experience with you, as well as some thoughts about how to think about food, housing, and water insecurity in the context of prevention. Now, before I start, I will say that I have no disclosures or conflicts of interest. So without further ado, let's get started. So as I mentioned, the objectives for this webinar are that by the end of the presentation, you should be able to describe public health regulation and control of food, housing, and water under normal conditions. Then you should be able to prioritize the key elements of these systems to assess and maintain immediately before, during, and after an emergency and understand how recovery takes place in that context. And then finally, understand how physical needs and priorities may shift over time and what the implications of that are for preparedness. So let me start with a discussion about pre-event planning and preparation. Now, I will just say that as we discuss the whole issue of preparedness and prevention, it's very important to understand how the public health department organizes itself with respect to these activities. First of all, our office of preparedness and response, which is where the planning function takes place, works very closely with subject matter experts and the subject matter folks in each of the areas. So in infection prevention, our infectious disease folks work very closely with our preparedness and planning section and with the state's emergency management coordination function. Similarly, in environmental health, we work very closely with our preparedness and planning colleagues in understanding and exercising for a wide variety of events, everything ranging from fixed nuclear facility drills for radiation discharge, all the way to climate change, all the way to acute events, improvised explosive devices, infectious disease outbreaks, H5N1 influenza, Ebola, and so forth. And in each of those, we talk about the pre-event phase, the event phase, and the post-event response and recovery. Now, you've already heard a lot about some of these topics in some of your earlier webinars, so I'm not going to spend a lot of time talking about those except to talk about how each of them affects the context of basic needs, including food, water, and housing. And as we talk about this, I also want to emphasize, and you'll hear about this a lot in this webinar, that we don't do this by ourselves. This is very much an integrated function that depends on the public health role working and interacting very closely with our colleagues in the Department of the Environment, or whatever in your state it might be, DEP, the Department of Environmental Protection, or DEQ, Environmental Quality, our housing departments, non-governmental organizations, and others. So let's talk a little bit about the context of the pre-event phase. So in order to understand how we think about response to events, one of the things that's important is to understand how normally regulation of these items, food, housing, and water, these basic needs, how do those take place, and what is the role of public health in that normal regulation? So as you can see, if you look at the issue of food regulation in most states, food regulation is a complex, multi-agency event that involves oftentimes the health department, the Department of Agriculture, in some cases, natural resources, and also very often local health departments. And in some states, in many states, there is a divide between, for example, agriculture and health, where agriculture may do on the farm and raw agricultural product, whereas the health department may be responsible for food processing, food manufacturing. Local health departments are oftentimes involved in licensure of food service facilities, the facilities that interact directly with retail of food to the consumer. By contrast, housing and water depends on the state. In many states, public water supplies and systems, the larger water supplies and systems, and wastewater are regulated by environmental departments. Private wells that serve individual households may be regulated by a health department, by an environment department, or they may be controlled locally. And wastewater is often a complex undertaking, depending upon whether it's individual septic systems, on-site water systems, or large public utilities. And in housing, where generally speaking, the health department on a day-to-day basis is frequently less involved than in food or water, housing is often under the control of licensing agencies, local zoning and planning boards, state housing authorities, and then code enforcement. And public health in many states will be involved in housing if there are specific housing issues like mold, where some states have mold programs, radon, and so forth. A lot of that day-to-day housing decisions about health are actually built into code, and so health departments are less involved, although they may be very involved in things like subdivisions, plat, approval, and so forth. As we look at that integration of the regulatory functions, it's important to understand that basic structure, because in the immediate and then post-disaster response, all of those agencies are going to play a role and have to be able to work together. So, let's talk a little bit about how you think about the pre-event planning for a disaster, whether it is a, and we'll talk both about acute disasters and about slow-moving disasters. One thing is that as you think about basic needs, and all of these, food, housing, and water go into this category of basic needs, you do need to think both about the community as a whole, and then you also need very much to think about vulnerable populations. Now, some of those will be by virtue of medical needs. For example, thinking about patients who are on renal dialysis, they have very, very specific requirements for water quality, which need to be thought of beyond, over and above the context of the general community need. Congregate populations, whether they are incarcerated, or they are in group home facilities, or housed, for example, in skilled nursing facilities, or in congregate facilities for other populations, those all require some special consideration in the pre-event phase to understand what they may need. And then, in terms of thinking about, in the pre-event phase, both the acute event and then the long-term event, we're always thinking about, so what are the short-term needs going to be, and then what is the long-term need going to be? And I commend to you resources like the AFTO Food Emergency Regulator Pocket Guide and other guides that are paper, portable, and when the lights go out and there's no internet service, you are still able to hold in your hand and use as a checklist for pre-event planning. So I mentioned a little bit about the whole issue of who's involved, and this just shows you the very, very many number of agencies, parties that are involved, from federal support through FEMA, the Federal Emergency Management Agency. Overall, the state plays a coordinating function, and oftentimes that's a Department of Emergency Management, which coordinates all the state agencies, including, in our case, the State Health Department, and by extension, through the State Health Department, local health departments. Similarly, our colleagues in housing or environment or agriculture, we all work together in the State Emergency Operations Center before the emergency happens, during, and then after in the response and recovery phase to ensure that communication, which is absolutely critical and the key part of this, is as efficient as possible. And then there are a host of community resources that we're always thinking about and that are really going to be the first responders and the boots on the ground. If you think about the first hour after an acute emergency, be it an earthquake, fire, whatever, that is your local utilities, local government, local health departments. Those are all the people who are first and foremost on the scene. They are the people who need to have a resource behind them, the State Health Department, other state agencies, et cetera, that they can call upon as they respond. So this is just illustrative of both the complex nature of the reason for incident command and the importance of effective communication. So let's talk a little bit about a couple of planning examples, and I use these in part because I think they represent kind of the range of different emergencies that we need to think about preparing for. So in the case of wildfires, unfortunately with climate change and the warming of the planet, we are seeing, and as you are all aware, we are seeing a lot of an increase in wildfires. And we'll see an example in a moment of sort of how you think about wildfire response. But in an interesting survey that I'll show you data for, you can look at wildfires in California and see from the recovery how needs change over time. This has very big implications for the planning function and for planners because they need to think about this shift as they think about at what point in the disaster response and recovery are they going to need to have access to different kinds of resources. Power loss due to any kind of event which leads to significant power loss. As you think about that, it's a very, very good example of how to think about the integrity of your food protection system. Obviously, as refrigeration is dependent upon electricity, you need to think about what happens if you have significant power loss. How are you doing that communication? How are you thinking about maintaining the integrity of the food protection system even as you do lose refrigeration? And the AFDO food emergency response guide has some very helpful information and guidance as you think about structuring response and structuring resources, either temporary refrigeration or dry ice supplies or other kinds of things. And then floods and sewage backup are good examples, unfortunately, of the sort of long-term recovery that can happen or be necessary. And we saw these with floods in the Midwest over the last several years. And we are seeing this in other locations as well. And again, the planning function for this needs to be cognizant not just of the basic needs themselves, but also things like, do you have contracts in place for cleanup and decontamination or alternative water sources? And we've seen time and time again, as we've responded to these emergencies, that the biggest obstacle that we have is not predicting that the needs are going to be there, but ensuring that we have just-in-time procurement, just-in-time services that are available. Because the last thing anybody wants to be able to do or wants to have to do is to design a procurement in the midst of a disaster to obtain a service that you had high degree of confidence was going to be necessary before the disaster occurred. This is a slide that I adapted from a very nice article from Snyder about surveys of residents who were affected by the California wildfires, the recent wildfires, not the most recent, but prior to that. What this shows is how basic needs, food, water, housing, and shelter, in the immediate aftermath of the wildfires shown there in blue, shifts and decreases over time while at the same time mental health, behavioral health issues, which are much lower down on the scale at the initial phase, relatively speaking, than basic needs. However, as you think about the percentage of the population as the disaster or the event persists, you see a significant rise in the need for behavioral health specialists to address mental health needs in the survivors of the wildfire. This is just an example of the kinds of considerations in the pre-event phase. Now, as we shift to the intra and post-event phases, first the immediate response and then the post-event and long-term intermediate and long-term responses, there are more considerations that take place, which again should be reflected in the pre-event planning. The first I already mentioned is that almost always the first people on the scene will be local responders. Our function at the state level and the function of public health at the state level is that we are in most cases not the first responders, but we are the subject matter experts, coordinators, and disseminators of information, as well as the collectors and integrators of information who in the context of emergency operations center and incident command will look at what's happening locally. Then, for example, in the case of food, we assess power loss impact on refrigeration and then drinking water availability as we see whether or not regulated public water supplies are in fact operational. In the case of housing, one of the first things that we need to do is assess the availability of housing, either whether the housing structure is intact to begin with or whether the population has been displaced and needs housing elsewhere, or unfortunately, in cases where you have a widespread impact, if you have to displace an entire population, how are you going to house them in wherever they end up? That really does depend on the extent of the event. In the case of water, we look at, as I mentioned, first the large public water supplies, which supply significant portions of the population, and that's where we try to ensure that those systems are working first and foremost, as well as the wastewater management systems that are linked to them. Then, when you start talking about distributed systems, if they are small transient water supplies or unregulated supply, unregulated private drinking water wells, those are going to be last on the list to be triaged. In many cases, that will be left up to homeowners in the immediate aftermath to assess their own integrity and the operational status of their own water supply. We will provide guidance in terms of whether or not people should even use those water supplies, but that will not be part of our assessment until much later on. All of this is coordinated through the Emergency Operations Center. Now, as we move into the post-event intermediate and long-term response, a couple of things. The first is, in most cases, while the public health department is not first and foremost on the scene, nor is it in many cases the most active of the agencies in the intra-event, it becomes very important post-event in the intermediate and long-term. Public health plays a very, very important role and sometimes a leading role with other agencies. So, I want to talk a little bit about some examples that I think illustrate the complexity of thinking about basic needs in the context of some of these intermediate and long-term response activities. So, let's start with a discussion from the COVID-19 response. Now, I don't have to remind you, I suspect that COVID-19 was challenging and it was particularly challenging in the intermediate and long-term responses because of a variety of factors. In the context of housing, we saw how congregate settings could not be isolated from community health. So, part of what we observed, I spent a lot of time with both congregate settings, including group homes, but also I spent a lot of time during COVID-19 working in our correctional institution, working to try to prevent outbreaks and disease in the incarcerated population. I think any of you who had similar experiences or talked to people who had similar experiences will hear that we tend to think of the inside-the-wall environment and the outside-the-wall environment as being very distinct, both in terms of housing and particularly in terms of things like workplaces. And what we learned during COVID is that there is no separation, really, between the outside-the-wall and the inside-the-wall with respect to housing. We saw in many instances that you had workers who were going back and forth to their homes. We had issues particularly with congregate settings where workers were working very closely with vulnerable populations, and there was a great deal of concern about how you prevent the spread of disease, which is on the outside in the community, from making its way into the congregate setting where transmission could be even more complex and difficult to control. In the context of food and food protection, we saw severe disruptions and challenges, again, partly because, as you know, the United States is now a net importer of food, and we have a very, very structured and concentrated food manufacturing and food processing industry, which during COVID we saw some of the challenges with in areas like meat packing, where the density of the working population and the difficulty of separating the outside from the indoors made it really challenging for workers in that industry. And then COVID-19 in the context of water and wastewater, we saw how monitoring wastewater for COVID-19 using newer genetic techniques actually led to a National Wastewater Surveillance System, which is now looking at a variety of other potential exposures, such as MPOX and other possible infectious disease risks, as well as non-infectious chemical contaminants. And that certainly represents an opportunity to do surveillance in a new way, and a somewhat unique way, particularly in areas of the country or the state where testing of individuals and healthcare may not be as readily available. Wastewater monitoring represents a real opportunity to look at pooled samples and see how it is that the population is being affected by an infectious agent. At the same time, we also saw how the issue of wastewater management and concerns about whether or not COVID would survive and could potentially threaten people working at remote distances through the water supply was something that we really needed to think very carefully about. And we have seen that before. As you know, many years ago, we saw this when we've had contamination of public water supplies that have led to the dissemination and transmission across wide areas. And so this represents, I think, for us, a real challenge thinking about, in the context of a disaster, how do we ensure that these basic needs are being met? And how do you, as a public health physician and a preventive medicine specialist, provide guidance to other parts of the system as to how to adequately protect those basic needs? Another example that we are unfortunately seeing more and more, not just in the United States, but also obviously across the globe, are increasing numbers of droughts. And droughts like COVID-19 represent not an acute disaster happening at one moment, but a gradual disaster that happens over many months and years. And here, we see how when you alter the terrain for basic needs, you can actually not just think about the planning from a point of view of a response and recovery, but in some cases, you may actually just be talking about a response that leads to the inability to sustain life in an area for a prolonged period of time. So in the case of housing, for example, we have seen how in areas of drought across the globe, when you get to the point of having displaced populations where there's no longer adequate water, no longer adequate food, we essentially lose the ability to sustain the population in an area. And that then results in a displaced population. And you are probably aware that we are seeing long-term migrations from areas of the globe where droughts are now more severe and more commonplace. And with that, we see those long-term displacement issues, not just in the areas that have been affected, but also in the areas where that migration is taking place. So we are seeing that everywhere across the globe. And as you think about your role as a preventive medicine person, a lot of what you will be dealing with, I suspect in the years to come, is thinking about these larger population shifts and how we accommodate those as part of our own response to disasters, not in our own geographic area, but remotely causing these population shifts. You'll see in a minute, in another example, how this exact same scenario can play out when we talk about radioactivity. So with this, I do want to emphasize that when we talk about these long-term disasters or preparing for this kind of disaster, this again is an example where the role of public health cannot be divorced from discussions with our colleagues in the state who do things like environmental quality, climate change, housing, because as we see these large population shifts and the needs that they bring with them, we have to be ready to accommodate those. And a lot of the discussion that's taking place as we think about climate, for example, is to think about how, as we see areas in our own state coastline that become inundated or are flooded, as we see those populations who live along the coast having to move, we are inevitably going to be facing more and more of these kinds of planning scenarios where the issue will be, how do we adequately prepare for potentially a significant multifold increase in the population requiring services? I mentioned that there are other examples of this kind of problem. For those of you who remember Three Mile Island in 1979, Chernobyl in 1986, or Fukushima Daiichi reactor in Japan in 2011, the exact same factors that we looked at with drought can be seen here. Displacement of the population, a lot of secondary mental health impacts, long-term displacement issues, and long-term issues related to agricultural lands. Now, here, part of the role of public health is, as opposed to drought where there's not much intervention to do, there is ongoing monitoring and surveillance that should be taking place from a radiological point of view in the event of, for example, widespread contamination of agricultural lands following a large-scale nuclear disaster. It's really important for preventive medicine physicians to have a very clear understanding of how to do monitoring and surveillance of these physical parameters so that they can, together with their environmental colleagues, recommend to decision makers and policy makers and provide crisis communication and ongoing risk communication for the eventual return to previously contaminated or uninhabitable areas. This, in and of itself, is a huge exercise in risk communication. It's also a huge exercise in terms of thinking about how it is that you look at the role of the public health physician in interpreting complicated data such as background versus contaminated areas of agriculture where using protective action guidance from the Nuclear Regulatory Commission and EPA, you have to be able to translate these very complicated concepts of radioactive decay, half-life, and so forth into risk communication messages that will be understood by policy makers, the public, and others in a way that helped them to formulate appropriate responses to the ongoing emergency and eventually reach a point where they can recover and return to lands that were previously had to be abandoned. So that's an example of not just the need for the public health physician, preventive medicine physician to be able to look at data and think about the health implications, but also to be able to take complicated environmental monitoring data, surveillance data, et cetera, understand it and be able to convey information about those data to a wide variety of audiences with very different goals and understanding. So finally, I want to talk a little bit about specific populations at risk. You know, we saw, we have seen over and over again, and I've alluded to some of this already, that as a preventive medicine public health physician, you're thinking about the entire community, but you're also thinking about the most vulnerable and those with greatest risk. And those risks may be for any one of a number of reasons. But in the context of acute emergencies, it is really important to think about the lessons we've learned from the very many unfortunate disasters that we've encountered and how we can do better in the future. So for example, in the World Trade Center response, one of the things that we saw is that people who were the first responders and even the second level responders. So the first responders obviously being emergency personnel, firefighters, police, et cetera, but even the secondary responders, including, for example, those who were doing emergency response hazardous waste operations and emergency response, people with HAZWOPER certification, the skilled trades, the electricians, the welders, the people who were responsible for demolition. Those were people in the post-event response who really needed to have particular attention paid to them because their exposures were ongoing, significant. And I was involved in some of the work and know many of the people who worked in the World Trade Center monitoring program, the monitoring programs for firefighters, for skilled trades and other workers, as well as people living in the area who were exposed. All of those populations who were sort of occupational populations, and we talked about this in the context of COVID-19 as well, really required some special thought beforehand. So putting on your occupational medicine as opposed to preventive medicine, and I think of those as really two sides of the same coin, it's really important to think about the specific needs of working populations in the context of emergencies. And it's not just the emergency responders, it's also the people who are in after the emergency responders to clean up, respond, control, do search and rescue, and so forth. In the context, we talked about this in the context of COVID-19, people who live in congregate settings are at certainly increased risk for many kinds of disasters. They tend to be less mobile, they tend to, or not mobile at all, they're in close quarters, so anything involving infectious disease, particularly anything involving bioaerosols, can put them at much increased risk. And so you need to think about, for those populations, you need to think about their basic needs, housing needs and shelter, and then how you're going to manage with those needs in terms of ensuring that the people who work there, the workers, as well as the people who live there, have what they need to be able to respond. And in those, in some cases, pre-placement of resources may be very, very helpful. And then finally, congregate settings, and I mentioned this at the outset, things like the needs for renal dialysis patients, people who are hospitalized in intensive care units, people who are in cancer treatment centers or bone marrow transplant units, people who are immunocompromised, all of those are specific populations that, in the context of an emergency, you as a preventive health physician need to be thinking not just about sort of how do I do this for the community as a whole, but with your particular and specific knowledge, you need to be able to think about how to protect those vulnerable populations from what can be some of the most severe consequences. So that's a sort of an overview of thinking about basic needs in the context of prevention and preparedness. I have listed a number of references for you of different resources. I would also obviously add to this list things like the Radiation Emergency Management Guide, REM, which is available through the National Library of Medicine, and obviously a large number of resources from FEMA, all of which I would highly recommend to you. So with that, I'm happy to answer questions if there are any, Anita, in the last couple of minutes. Yes, absolutely. Thank you once again, Dr. Mitchell, for that wonderful, wonderful lecture. So much incredible information. We have received a few questions. As we go through these questions, again, a reminder to the attendees to please submit your questions to the Q&A or the chat, and we'll get to as many of them as we can until 8 o'clock. So the first question is, how has your department handled, and what is your role in the overwhelming avian flu and the poultry industry in Southern Maryland? How is it affecting workers? What are its consequences and effects on water runoff and animal waste? That's a very important question. So here in our state, we are learning from, unfortunately, but also coordinating very closely with our federal partners at the U.S. Department of Agriculture, and this is a combined response of our Department of Agriculture, our Department of Health, and local health departments. We have had a couple of broiler houses that have had infections and have had to be depopulated. We exercise and have exercised regularly with our Department of Agriculture, USDA, and all of the folks who are involved. We have had an avian influenza response plan for years, anticipating that this was going to happen. So the pre-event planning for this is now being utilized, and we are witnessing firsthand the value and the importance of doing that planning, because thus far, fortunately, we've seen that we have not had any, to date, any recognized cases in humans in our state. That is not to say that there's not risk. We know from other states that there is risk, but we have been very careful and thoughtful about how we provide personal protective equipment, work with our industry, and again, it just shows the importance of effective communication, a lot of pre-planning, and pre-exercising. Thank you, Dr. Mitchell. Next question. When you are talking about pre-event, post-event, event and post-event, are you using the Hayden Matrix Framework? Thank you. I'm glad somebody was paying attention during injury prevention in the School of Public Health. It is very much the framework that I use, and obviously, the Hayden Matrix is a very useful concept for thinking about the various opportunities for intervention in the physical environment, the biopsychosocial environment, and so I very much find that that is a helpful way and a helpful construct for thinking about disaster management. It's not the only construct, but I find it particularly useful because it's relatively simple and it's relatively simple to explain to other people who are not necessarily public health professionals. Thank you, Dr. Mitchell. Next question. What are your thoughts on the ongoing water runoff after fires, washing heavy metals, et cetera, from the destroyed materials into the water supply? So we are living in an environment and living in a society in which we have constructed a lot of things that are combinations of heavy metals, plastics, complicated polymers that tend not to break down, or if they do break down, break down into toxic gases. Our chemical environment is complex. There's no way of hiding from that, and when you stress that environment by fire or flood, you are unfortunately going to move that material from a place where it's bound up in a structure of some kind to a place where it's not likely to be as bound up. I think that we have witnessed various versions of this in sludge ponds when they become mobilized, in coal facilities when those sludge ponds get wastewater is released, and we see it in disasters, other kinds of disasters. I think the only thing you can say about that is there's some things that you can do about that from a planning phase if you change the nature of the material that you're building with. That is a very complicated, expensive, long-term thing to do, which is hard, but which may ultimately be the way we solve that problem. In the short run, at least understanding where the material is going, which is very much a collaboration between not primarily the health department, but emergency management and the environment department, to understand where that's going, and also to understand from a public health point of view how it may become either immobilized in various media so you don't have to worry about it, or much more complicated, how it may become mobile and then potentially bioconcentrate. We've seen examples of that in things like PFAS, where we know that there are concerns about sewage sludge and then uptake by agricultural products, and then bioconcentration in animals, just as we've seen with mercury and other heavy metals. I don't have a really good answer to that except to say that at the end of the day, what we build with and what we use in commerce and our products, eventually we are at risk of having that stuff mobilized. Thank you, Dr. Mitchell. Final question. It actually says, not a question, but a comment. Certainly drought, especially draining of the Ogallala, is a significant threat. I hope I pronounced that correctly. However, I think the remarkable and under-recognized financial precarity of American grain, soy, feed farmers is a more immediate and potentially catastrophic threat to the US food supply. Any thoughts about this? No, it's a very good point. I don't mean to diminish the sort of not natural, but economic disasters that can befall vulnerable populations. We know that agricultural markets, that it's difficult to be a farmer because you are not only dealing with the natural environment, but the economic environment as well. I do not at all, I think, I have an incredible respect for our farming communities and farming populations and I think it's not one versus the other. I think that the challenge for us from a public health point of view is to realize that ultimately humans need food to survive. We need agriculture in order to have food. Whether the threat is that people are leaving agriculture because there's no money to be made and they have to stop, or that we are depleting groundwater resources to the extent that you can no longer have arable land, either one of those is bad for the population as a whole. It behooves us to think about both of those things as we're planning for how to maintain a healthy agricultural community. Thank you, Dr. Mitchell. Okay, I think we have one more question. Do you anticipate greater vector-borne disease, such as Zika virus, spreading further north toward the mid-Atlantic states as climate change progresses? You know, it's a very good question. We know that in sort of the long-term trends, we are seeing mosquito-borne diseases moving farther north and arthropods as well. And so the short answer to that question is yes, but it's a somewhat nuanced answer because yes, there are sort of long-term shifts in, for example, mosquito-borne disease and the kinds of mosquitoes that we're seeing. What is also true, however, is that it's not simply a matter of climate. It's also a matter of things like land use patterns and other kinds of factors that affect for any given population or any given area, whether or not they're at risk of those mosquito-borne diseases or not. So I'd have to say the sort of global answer, large-scale answer is yes, but if I'm talking with or working with a specific group of individuals or communities or areas, then it's not a one-to-one that as the climate changes, those folks are definitely going to see increases in malaria or risk of malaria. That's mediated by a lot of other factors. So understanding that I think is important. Thank you, Dr. Mitchell. As of now, we don't have any other questions. Dr. Mitchell, if I can please request you to move to the next slide. And again, as a reminder, we still have a couple of minutes if people want to submit questions and a link has been posted on the chat for you all to submit your feedback on this excellent lecture. Thank you again. I will leave with this. We do have our penultimate webinar coming up on February 27th in exactly two weeks. Think Outside the Box, Healthcare Triage and Disaster Management Planning. Again, this would be featuring Dr. Eduardo Sanchez, Chief Medical Officer of Prevention from American Heart Association, but he's previously been the Commissioner of the State of Texas and other roles in the state of Texas. And so we hope you can join us then. Until then, thank you all very much. Have a good evening and I'm going to stop the recording.

emergency preparedness

preventive medicine

food insecurity

housing insecurity

water insecurity

environmental health

public health

crisis communication

climate change