1 John H. Chafee Memorial Lecture on Science and the Environment Climate, Poverty and Health: time for preventive medicine Larry Brilliant, MD MPH Founder, Seva Foundation and Executive Director, Google.org Presented at the 7th National Conference on Science, Policy and the Environment Ronald Reagan Building and International Trade Center Washington, D.C February 1, 2007 2 The significant problems we face cannot be solved at the same level of thinking we were at when we created them. Albert Einstein Thank you Ambassador Benedick and thank you Peter Saundry for that kind and generous introduction. 3 Senator Chafee, members of the Chafee family. Friends and colleagues: thank you for giving me the opportunity to be with you this evening and to present the 7th annual John H. Chafee Memorial Lecture on Science and the Environment sponsored by the National Council for Science and the Environment. I particularly want to thank you for coming to listen to me since most of you know much more than I do about climate change. That puts me in a terrible spot to begin with. One never wants to face an audience that knows more than you! But not only do I face an audience that knows more about climate change: what about the previous six Chafee lecturers? ; As I read through the first six Chafee Lectures and I realized who has spoken from this stage before – it has humbled me and inspired me. Thank you for giving me a chance to follow such an all-star lineup of deep thinkers on the issues of science and the environment. Fortunately for me, the theme of this year’s conference is integrating environment and human health so at least I have a chance to make a contribution on the other side of that equation. .. But I can tell you that these two worlds—of health and the environment---are not always the best of friends, and they will need a lot more integrating in the coming years. I was in Davos and I attended many meetings on global health on one day and many others on climate change the next day. I did not see a single other soul who attended both sets of meetings. The fields are inexplicably segregated even as the subjects are inextricably linked. Coming from epidemiology and preventive medicine, THIS SLIDE FROM THE 2001 IPCC SYNTHESIS REPORT WAS VERY INSTRUCTIVE TO ME. (slides) 4 It suggests that global warming and especially sea level rises are what we would call ―lagging indicators‖ of climate change. We may learn more tomorrow when the IPPC report is released, but most of my climatologist friends tell me they make they think that a certain amount of global warming—say between 2 and 3 degrees Celsius--- is unavoidable, is locked in as it were from the sins of our past. And an even greater disproportionate rise in sea level is also locked in, so that even if we stopped carbon emissions today, we will still suffer from its effects for years to come. But this chart only shows what would happen in later years to sea levels. We need a similar analysis of what would happen to climate-accelerated diseases like malaria and the newly emergent zoonoses and what will happen to the water and land inundated by salt water. But one thing is clear: in addition to heat and sealevel changes, there will be equally unavoidable effects on health and welfare as a direct consequence of global warming already locked into our future. Tonight, then I want to discuss with you some of these probable ―locked in‖ health and welfare effects of climate change. Some of them you will either know or already intuit. For example, that there will be a litany of new emergent communicable diseases. We’ve seen many of them recently: zoonoses like bird flu, SARS, monkey pox, West Nile. But old adversaries like malaria will resurge putting as many as a billion additional people at risk. And as the rising of the seas impinge on coastal communities, making lands uninhabitable, it will create refugees in nearly every continent. Salt will become a new reality to deal with in agriculture as sea waters flood agricultural lands, leading to diminished harvests. In many places water will become contaminated with salt, reducing available drinking water even as our thirsty and hungry population is on course to increase beyond the 9 billion mark before it levels off. There is still time to act---but we are in the stage that my professional calls secondary prevention and climatologists call adaptation and economists call risk mitigation. By whatever name we call it, we need to think together tonight and for the future, of how to 5 make decisions that will minimize the pain and suffering of our brothers and sisters, and especially the poorest and most vulnerable amongst us. As I look around this room and see leaders from so many walks of life, I share with you the most difficult challenge: decision making under conditions of uncertainly. How much global warming, what is the timeline for climate change, how much sea level rise--- these are the uncertainties. But I can tell you that prudence dictates we now must plan for the health and welfare consequences of these changes because we know, directionally and qualitatively, what they will be. In my field of preventive medicine, we identify primary, secondary and tertiary prevention distinct from disease treatment. Not to put too fine a point on it, but primary prevention measures are ―those intended to prevent the onset of a condition.‖ including things like vaccination that literally prevent disease1. Secondary prevention usually consists of those things which prevent disease for people who are still asymptomatic but who have already developed preclinical disease. in these patients are incubating disorders, similar to the situation with global warming, in that the stage is set, the process of warming---or of disease—is cooking or incubating, but is not clinically apparent.‖2 Screening tests followed by disease mitigation are examples of secondary prevention. Early detection and early response can ameliorate the natural history of disease and minimize suffering. We can argue semantics, but we agree that we face warming of 2 to 3 degrees, sea level rises of many inches or some feet, and health and welfare conquences that we need to better understand. We are in the area of secondary prevention, alreadybeyond the least 1 The U.S. Preventative Services Task Forces’ Guide to Clinical Preventive Services (2d edition, 1996) (pp xli) 2 The U.S. Preventative Services Task Forces’ Guide to Clinical Preventive Services (2d edition, 1996) describes secondary pp xli 6 expensive remedies and into more costly, more dangerous, and less effective preventive interventions. And that is what I want to explore with you tonight: what are these remedies, these secondary preventive measures, and in what venue do we discuss the most controversial of them, in what forum do we debate the costs and benefits, and indeed how much will they cost—and what is the cost of doing nothing at all. As Dr. Jack Geiger, then of Tufts medical school and one of the founders of Physicians for Social Responsibility was quoted as saying “The poor are likelier to be sick. The sick are likelier to be poor. Without intervention, the poor get sicker and the sick get poorer”. Today he might add: “The poor get sicker and the sick get poorer, and as the climate crisis deepens, without intervention, there will be many more sick, and many more poor”. And with that in mind, I am not talking to you on behalf of Google or the Google Foundation or the Seva Foundation, I am talking to you out of my experience as a doctor, an epidemiologist and a specialist in preventive medicine to offer some suggestions for ways to prevent the worst consequences of climate change. But a fair warning : some of the things we need to consider are bitter pills, hard medicine. I myself do not ideologically like a lot of the medicine I prescribe. As a late- blooming environmentalist, I wish my conclusions were different. As a scientist, I wish the data were better, the conclusions more evident. As a wannabe social philosopher, I wish we could any of us think our way out of our current dilemma. 1.0 Bangladesh: the canary in the coal mine==and the rise of the seasLet me start off with a country where I lived for a short time thirty years ago. Bangladesh was the 7 country with the last case of Variola major in nature, a young Bangladeshi girl named Rahima Banu, who developed a classic smallpox rash on the 17th of October, 1975. SHOW SLIDE OF RAHIMA BANU I was fortunate enough to be part of the successful WHO smallpox eradication program and to visit her on Bhola Island just as she was recovering. At some metaphysical moment, when Rahima Banu exhaled the last smallpox virus out of her lungs or when the last virus fell from her scabs---because there were no susceptible hosts to continue the chain of transmission- the Variola virus died harmlessly on the Bangladeshi soil. Thus ended a chain of transmission for a disease which began thousands of years ago in antiquity, killed over half a billion people in the 20th century alone, and was now eradicated. Bangladesh was not an unlikely place for the mixed distinction of being the last country with Variola major . It is a very difficult place to live. SHOW SLIDE OF SMALLPOX HISTORY But since then, there has been some good news out of Bangladesh. Now that he has won the Noble Peace prize, everyone knows Mohammed Yunus and most of you know the history of his Grameen Bank. SHOW SLIDE OF GRAMEEN Certainly it is one of the great success stories in economic development. Just under 25 years ago, after leaving Vanderbilt University, Yunus started the bank (which means ―villager’s bank‖ in Bengali) . Over the past 25 years, it has lent money to nearly 6 million in Bangladesh, nearly 96% of whom are women, with a loan recovery rate of 99.45%. 8 Millions in Bangladesh have been given a loan and hope. And speaking of hope, one of Yunus’ hopes is that over the next 100 years, the Grameen Bank will reach every corner of Bangladesh and provide self help to every Bangladeshi. But Yunus’ dream and the growth of the Grameen Bank are on a collision course with global warming. Bangladesh has a population of nearly 150 million, the majority of whom live at or just above sea level. For that reason, Bangladesh is one of the countries that would be hardest hit by even small rises in sea level. It is ironic to call Bangladesh ―the canary in the coal mine‖ of course, because unlike the original canaries which were used to test coal mines for toxic gases, this new ―canary‖ will be affected if coal—and other fossil fuels--- continue to be burned in quantities sufficient to contribute to the sea levels rising from global warming, and to inundate its coastal communities. Millions have died over the previous century from floods Bangladesh has such high population densities in coastal communities that almost anything that causes a rise in the seaswould be a catastrophe—and indeed a 2000 study by the World Bank suggested that a 1-meter rise in sea level, in addition to the devastation of physical infrastructure, would flood half of Bangladesh's Riceland with saltwater3. Come along with me now for a flight over the terrain of Bangladesh so you can experience some of the topography. Hang on because the flight might make you a bit dizzy as we are zooming in from space to sea level. This story is about —how deforestation ―upstream‖ in Nepal and erosion led to Himalayan melts and floods that had a devastating effect on our canary, Bangladesh. GOOGLE EARTH SLIDE SHOW . 3 (See map p 36 in Ch 2 of Eco-Economy.) 9 The overthrow of the Ranas in 1950 effectively opened Chitwan to immigration, which was then facilitated by the malaria eradication efforts of HMGN/USAID during the period 1954 to 1960 (the disease was officially declared eradicated in 1960). From 1950 to 1960, the population of Chitwan District nearly tripled. The spreading settlements caused the disappearance of almost two-thirds of Chitwan's forests during the decade, and numerous wildlife species were almost eliminated through hunting and habitat destruction. The rhino was hunted especially intensively for its enormously valuable horn (in 1981, up to US$17,000 kg-1; Martin, 1981). Until the 1950’s the malaria-infested belt of thick tropical jungle of the Terai was an effective barrier to marauders from the south, and forest cover was actually promoted to increase the effectiveness of this shield. Malaria eradication, using DDT, and supported by HMGN/USAID was successful during the period 1954 to 1960 and the disease was officially declared eradicated in 1960. From 1950 to 1960, the population of Chitwan District nearly tripled. The spreading settlements caused the disappearance of almost two- thirds of Chitwan's forests during the decade t as large areas of the forests were cleared for agriculture. This deforestation significantly contributed to natural disasters in the monsoon season – with severe soil erosion, landslides, and floods -- in the Gangetic plain of India and Bangladesh thousands of people each year are reported to be killed by floods alone. 4 Tens of thousands of cubic meters of topsoil are washed away into the swollen rivers and streams, and deposited into the Bay of Bengal. With global warming these natural disasters will come at such a scale that thinking of it overwhelms me -- as you all know so well, increasing global temperatures are causing the thermal expansion of sea water and the melting of icecaps. Sea level has risen 4 to 10 4 Source: Natural Disaster Relief Act 1982: To Manage Disaster - By Lekh Nath Pokharel 10 inches this century and is predicted to rise another 6 to 37 inches in the next century. A doubling of pre-industrial CO2 concentrations to 550 ppm may result in a sea level rise of greater than 40 inches – one meter. Donald F. Boesch of the University of Maryland Center for Environmental Sciences has estimated that for each millimeter rise, the shoreline is swept away an average of 1.5 meters. If sea levels rise by 1 meter— Bangladesh’s coastline will retreat by 1,500 meters, or nearly a mile5. If we don’t mitigate the effects of global warming, Mohammed Yunus’ hundred year goal may be washed out, literally. Without food, without land, Bangladeshis would be forced to migrate by the millions. Will their Hindu neighbors graciously accept these millions of Muslim climate refugees? And it won’t be only Bangladesh who are at such risk of course. There are currently 46 million people around the world who are at risk due to flooding from storm surges. With a 50 cm sea level rise, that number will increase to 92 million. Raise sea level 1 meter, and the number of vulnerable people becomes 118 million. A recent study for WHO by scientists at the University of Wisconsin takes those numbers even higher, suggesting that flooding as a result of coastal storm surges could affect the lives of as many as 200 million by the 2080s.6 A 1 meter increase in sea level will be enough to flood 1% of Egypt, 6% of the Netherlands, 17.5% of Bangladesh, 30% of Shanghai, and 80% of the Majuro Atoll in the Marshall Islands. Here closer to home, Lester Brown estimates losses of 14,000 square miles of land in the United States with 1 meter sea level rise. Large portions of Lower Manhattan and the Capitol Mall here in Washington, D.C., would be flooded with seawater during a 50-year storm surge. As you all know so well, whatever design is ultimately chosen for the 9/11 memorial in New York could be inundated if not by rising sea levels, then by storm surges. A recent study estimated the costs of adapting to a one metre sea level rise in the 5 http://www.earth-policy.org/Updates/Update2.htm 6 http://www.news.wisc.edu/11878.html 11 United States would amount to US$156 billion (3 percent of GNP). The majority of the world’s nations don't have this kind of money to spend. Whatever variable you examine: drinking water, floods, crop yields, nutrition, malaria, the effects of climate change on human health is expected to devastate poor countries, tip countries at the margin into poverty and wreck social and economic havoc on even the very richest amongst us. Let’s take safe drinking water. Today, 1.2 billion worldwide lack access to safe water and 2.5 lack proper sanitation and 5 million die each year from waterborne diseases; by 2025, with current climate projections, it is expected that the percentage of world population living in countries under water stress will increase from 34% to 63%. A report from the World Wildlife Fund estimates that with an increase of 2 degrees’ warming, an additional 3 billion people will not have access to adequate drinking water, and with 3 degrees of warming, the number at risk increases to as many as 3.5 billion.7 In addition, competition between drinking water and agriculture is already intense. It will grow more so. Agriculture consumes about 70% of the world's available water, but experts say that, where there are competing demands for water, small farmers are the first to lose their supply. The world’s poorest rely on their ability to grow crops for their own food supply: estimates are that 815 million to 1 billion are chronically undernourished, 95% in developing countries; but climate change will make it worse.8 Two scientists in India, K.S. Kavi Kumar and Jyoti Parikh, assessed the effect of higher temperatures on wheat and rice yields. When they looked at temperature change alone, a 2-degree Celsius rise led to a decline in irrigated wheat yields ranging from 37 percent to 58 percent. Even when they combined the negative effects of higher temperature with the positive effects 7 From World Wildlife Fund: http://www.wwf.org.uk/filelibrary/pdf/2_vs_3_degree_oct06.pdf [attached to email] 8 http://www.iied.org/pubs/pdf/full/9512IIED.pdf 12 of CO 2 fertilization, the decline in yields among the various sites ranged from 8 percent to 38 percent. This is a huge loss of food in countries already under stress of food shortages. 9– Yet this crisis will be even compounded as the world’s water supply becomes salty as a result of sea level rise.10 The bottom line: the climate crisis is predicted to contribute to a doubling of the number of us without adequate food and water, with the highest burden on the most vulnerable amongst us. Jack Geiger was right: the poor get sicker, the sick get poorer. 2.0 Climate Change, Mosquitoes and Malaria In 1968, smallpox was the 4th disease considered for eradication by the World Health Assembly, the decision-making body of the WHO. Three previous efforts at disease eradication had already failed: malaria, yellow fever and yaws. Two of these, malaria and yellow fever, are mosquito-borne diseases. We have never eradicated a mosquito born disease other than in regional geographical areas where we mostly eradicated their mosquito vectors; attempts to eradicate yellow fever were abandoned when it was learned 9 Lester Brown, Plan B 2.0 http://www.earth-policy.org/Books/PB2/PB2ch4_ss3.htm 10 Current at risk for water shortages: http://news.bbc.co.uk/1/hi/world/1887451.stm 13 that monkeys could contract the disease and form an animal reservoir for yellow fever. The global malaria eradication program was making progress until the mid 1960’s when DDT was outlawed, a delicate subject to address in a room full of environmentalists, but about which we will talk more later.. Malaria is the worst mosquito-carried killer, causing an estimated 1.5 to 2 million deaths per year. Malaria contributes the highest percentage (>80%) of the climate-related disease burden in Africa. The physiological relationships among climate, vectors, and pathogens are only partially understood. Malaria provides a good example of how potential climate change may affect environmental and vector-borne diseases. Surveillance systems and epidemiological data on malaria exist in some of the regions most susceptible to climate change, allowing future monitoring to move from speculative to causal relationships. According to Guerra and Snow, et. al. in 2005, there were 3 billion people at risk of malaria mostly from P. falciparum and P. vivax11. That means that approximately 45% of the world’s population is within the zone of malaria transmission today. Mosquitoes are hot weather insects that have fixed thresholds for survival. Anopheline mosquitoes and falciparum malaria transmission are sustained only where the winter temperature is kept above 16°C (61°F). Climate changes affect malaria prevalence in three ways: 1. Extending the range---latitude and altidude 2. Extending the seasonality---eg. 6-9 months in Kwazulu-Natal 3. Rapidly increasing after extreme weather events—rates went up 5X after 2000 floods in Mozambique. Clusters expanded in the Horn of Africa after flooding in December and January. . Nearly one billion more people----15% of the world’s population--will be brought into the susceptible zone, bringing the percentage of the world's people within the susceptible 11 Guerra, C.A., Snow, R.W. & Hay, S.I. (2006). Mapping the global extent of malaria in 2005. Trends in Parasitology, 22(8) : 353-358. 14 zone to 60% or nearly 4 billion people. In 2005, there were roughly 300 million cases of malaria per year, of which 1.5 to 2 million result in death, mostly in children and mostly in Africa. This is likely to increase substantially. If global temperatures were to rise 4 degrees C, according to the World Wildlife Fund12, the impact could be an additional 50 to 80 million cases of malaria worldwide each year. But it does not take anything as dramatic as 4 degrees C increase to cause an increase in malaria; even light warming may contribute to malaria resurgence due to a phenomenon known as ―biological amplification‖. Mercedes Pascual et al13. report that a half-degree rise in temperature may be a factor in the increased incidence of malaria in the East African highlands. They estimate that the biological response of mosquito populations to warming was found to be more than an order of magnitude larger than the measured change in temperature14. 12 http://www.wwf.org.uk/filelibrary/pdf/2_vs_3_degree_oct06.pdf [attached to email] 13 ―Malaria resurgence in the East African highlands: Temperature trends revisited‖ by M. Pascual, J. A. Ahumada, L. F. Chaves, X. Rodó, and M. Bouma (see pages 5829–5834) 14 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1458622&rendertype=figure&id=f2 15 Figure 1: The average global temperature begins to pull away from the long-term average in the second half of the 20th century. In the past decade the mean average temperature has increased by about 1 degree Celsius. As a general rule, temperatures decrease on average by 6°C for every 1,000 m of elevation gained. Many cities in Africa are situated more than a mile high, historically high enough to remain free of malaria. High-elevation locations such as Nairobi or Harare may become vulnerable to malaria epidemics because the malaria parasite may be able to survive in the warmer conditions anticipated (IPCC, 1996) at higher elevations than the current limits. Projecting into the future, Ebi et al. (5) have compared climate suitability maps for malaria in the topographically diverse country of Zimbabwe and found that the projected warming from global climate models would make the country’s entire highland area more likely to be hospitable to malaria by year 2050 (Fig. 2). 16 Figure 2: The linear fit shows that as the average annual global temperature from 1984 to 1998 gradually increases, the number of cases of malaria in India from the vector P. Falciparum increases as well. (source of data: Jones, 2006, Kakkilaya, 2006) 17 To summarize: Climate change will alter the prevalence of malaria in the near future. Will it also alter the priority we give to this ancient scourge? Malaria is the weakest of the three sisters of the Global Fund, after HIV AIDS and TB. But when as many as 60% of humanity lives in malaria endemic areas and deaths double, will we look at it differently. Today, any talk of ―eradication‖ of malaria is met with some derision; the costs are too high, the tools are too few, they saw. We must plan for a world dominated by malaria if we are not willing to raise the E word. And how much malaria will it take before we look again at the pesticide poisons like DDT? If we wait long enough, that day may come. 18 Map 1. Global distribution of malaria transmission risk, 2003 (WHO) 19 Cases of malaria, by year, 1989 to 2003 The question that we should ask is this: if global warming is going to cause an acceleration of malaria, shouldn’t we accelerate our attempts to eradicate malaria? An editorial in the British Medical Journal called Roll Back Malaria ―a failing global health campaign15‖ before taking into consideration the effects of climate change. If we think that malaria is not under control, and it is not, and we think that climate will catalyse a global explosion---isn’t this exactly the problem we need to solve? BMJ 2004;328:1086-1087 (8 May), 15 doi:10.1136/bmj.328.7448.1086 20 Writing about DDT, here is where doctors and environmentalists need to talk. The British Medical Journal editorial says: And what about the third tool, insecticides? Here we need a re- think. The Persistent Organic Pollutants Treaty aims to completely phase out global use of (DDT), while many donor agencies will not fund any malaria control programs that use this insecticide. But is effective,9 with a remarkable safety record when used in small quantities for indoor spraying in endemic regions.10 DDT, a "dirty word" in the malaria world, must surely be reintroduced into the conversation on rolling back malaria. The current ―Roll Back Malaria‖ program, begun in 1998, is not an eradication program and does not pretend to be one. Its stated goal was to halve the number of cases of malaria by 2010, but today, with 3 more years to go, the annual incidence of malaria is higher than at the start of the program. Bed nets and indoor spraying and Artemisia are helpful elements of a control program, not an eradication program. . I said in my opening remarks that the environment and health—or rather the ardent environmentalist and the practitioner of public health---have not always been the best of friends. One poignant story about this revolves around the malaria eradication program in South Asia, which by all accounts, had achieved terrific results using DDT to kill off the malaria mosquito problem. Malaria was declared eradicated in Nepal in the 60’s (we’ve heard how that encouraged population movement and deforestation with sad unexpected consequences). India was close to eradicating, but not as close as Sri Lanka which was down to a reported 17 or 18 cases in the mid 1960’s just as Rachel Carson’s Silent Spring alerted environmentalists to the dangers of DDT. This is hugely controversial topic, even the dates and times and facts are in dispute. But the USAID pulled funding from the use of DDT, and malaria soared in Sri Lanka until it reached as many as 2 million cases a year. This is not to simply say that we should blindly bring 21 back DDT as many mosquitoes are now resistant to it in any event; however, we have two stories---malaria eradication in Nepal contributing to deforestation and then to floods in Bangladesh; and a ban on DDT contributing to a resurgence of malaria in Sri Lanka and elsewhere. We need to study these cases, understand not only the proper role for eradication of malaria and for pesticides, but to learn well the lessons of unintended consequences. 3.0 Climate, weather and disease Malaria is only one of the communicable diseases which comprise burdens on the developing world. Today, despite dramatic improvements in sanitation, clean water, and modern advances in science and medicine, over a quarter of the deaths worldwide remain the result of infectious diseases. In developing countries, infectious diseases are the leading cause of death— responsible for one in every two deaths. In fact, it has been estimated that every hour, 1,500 people die from an infectious disease, over half of them children under 5 years of age16. Many infectious diseases either are strongly influenced by short-term weather conditions or display a seasonality suggesting that they are influenced by longer-term climatic changes.17 Climate can directly impact disease transmission through its effects on the 16 Institute of Medicine, Microbial Threats to Health, Smolinski, Hamburg, Lederberg, eds. 17 Patz JA, Graczyk TK, Geller N, Vittor AY. 2000. Effects of environmental change on emerging parasitic diseases. Int J Parasitol 30(12–13):1395–405. 22 replication and movement (and perhaps evolution) of disease microbes and vectors; climate can also operate indirectly through its impacts on ecology or human behavior.18 To be transported over relatively large distances from one host to another, many microbes must be borne passively through moving air or water. Some pathogenic microbes, such as those causing coccidiomycosis, are picked up from the soil and carried by dry, dusty winds19 ; some opportunistic human pathogens can apparently survive transoceanic transport in dust clouds20 ; and others, such as cryptosporidiosis, may be washed by heavy rains into reservoirs of drinking water. 21 The fact that local and regional climatic factors clearly influence disease emergence has led scientists to suggest that projected global climate changes will have a very important impact on infectious disease emergence. Indirectly, if global climatic change were to result in reduced food availability, thereby producing undernourished human populations more vulnerable to disease; its impact on infectious disease could be dramatic. Likewise, if social disruption, economic decline, and displaced populations were to emerge as a result of reduced food availability due to global climate change, the emergence and spread of infectious disease would likely be substantially impacted. And if all the above issues are not enough, now we must be concerned about the potential ―bioweaponization‖ of zoonotic diseases, particularly by individuals or groups either acting alone or with sponsorship by a foreign government. Zoonotic agents have a number of attributes, including their potentially large impact when released into a human or animal community, that makes them especially suitable for use as weapons. Ironically, 18 NRC. 2001. Under the Weather: Climate, Ecosystems, and Infectious Disease. Washington, DC: National Academy Press. 19 Schneider E, Hajjeh RA, Spiegel RA, Jibson RW, Harp EL, Marshall GA, Gunn RA, McNeil MM, Pinner RW, Baron RC, Burger RC, Hutwagner LC, Crump C, Kaufman L, Reef SE, Feldman GM, Pappagianis D, Werner SB. 1997. A coccidioidomycosis outbreak following the Northridge, Calif, earthquake. JAMA 277(11):904–8. 20 Griffin DW, Kellogg CA, Shinn EA. 2001. Dust in the wind: Long range transport of dust in the atmosphere and its implications for global public and ecosystem health. Global Change and Human Health 2(1):20–33. 21 Alterholt TB, LeChevalier MW, Norton WD, Rosen JS. 1998. Effect of rainfall on giardia and crypto. J Am Water Works Assoc 90:66–80. 23 continued advances in biotechnology, while offering great promise for improving human health, may concomitantly make it easier for terrorists to manufacture and deploy effective biological weapons. In the final analysis, it cannot be predicted which zoonotic pathogens are likely to emerge next or cause the biggest problem. Given the obvious link between human health and pathogens that circulate in domestic animals and wildlife, we must be alert to pathogen flow in any of these areas. SLIDE SHOWING 30 NEW EMERGING DISEASE AND THEN SHOW WHAT A PANDEMIC WOULD LOOK LIKE 4.0 Increasing population, industrialization, conspicuous consumption i rising seas in the poorest areas of the world We have an overpopulation problem, but it is not as most of us expected when I was a professor of international health 25 years ago. In fact, on the human population side, we have dodged a bullet. We used to teach that the world’s population was growing so fast that it would not level off until it passed 20 billion, an unsustainable level for our beloved planet. It was a time of neo- Malthusian prophets, like Paul Ehrlich, who wrote the famous book ―Population Bomb‖ which predicted that the earth would run out of food in the 1980’s and 90’s because of a crush of population two decades ago. But now it looks like the human population will stabilize in the range of 9 billion. We should say ―only 9 billion‖ .We owe this to the demographic transition, from a world with high birth rates, high death rates and very high growth rates, to a world of lower rates of growth, birth, and death---largely due to3 programs: 1. improvements in public health particularly child-survival programs 2. family planning programs themselves 3. education of women, and economic gains in developing countries 24 But, while population planners over-estimated the number of people, they all markedly underestimated the weight of people. The weight, height, consumption, amount of domestic and wild animals produced, the GDP, and or overall burden per person on the atmosphere and on the earth. There are indeed ―only 9 billion‖ but might consume more than the 20 billion we had expected.. We have an overpopulation of protein, domestic animals that are the source of proteins to improve human diets, and human-animal contacts have increased dramatically as the barriers created by rainforest and jungles have been cut destroyed. In China, 3 decades ago the human population was 1 billion, today it is about 1.3 or 1.35 billion, an increase of 30-35%. But 3 decades ago, the population of chickens was in the millions, today it is 15 billion. And other animals raised for food have increased proportionately, including hogs, ducks, cows, and exotic animals like civet cats. In the same three decades, we have seen over 30 new diseases, some of which could kill millions of people with one or two bad gene mutations or one or two unfavorable environmental changes or changes in the interplay between this rapid growth in domesticated animals, humans and the environment. After 20 years of industrialization, two-thirds of the world's most polluted cities are in China, threatening urban residents with illness and disease. Acid rain, polluted rivers and inadequate sewage treatment have left half the rural population without access to clean drinking water, says the World Health Organization (PDF). As peasant farmers take the brunt of this, unrest often follows. On April 8, villagers armed with iron bars vented their frustrations toward polluters in the rural Fujian province by attacking factories they say were fouling water supplies, according to Hong Kong's South China Morning Post. 25 Similar protests are frequent. The Guardian reported that riots over land, water and environmental issues averaged 230 a day last year. China's government recognizes the problem, and its latest Five Year Plan for National Economic and Social Development calls for "building a resource-efficient and environmentally friendly society" by reducing pollution and energy and water use. . This unchecked pollution from industrialization takes its toll on China's neighbors as well. In Korea, giant clouds of "yellow dust" -- a putrid mixture of industrial pollution and dust from the Gobi desert -- regularly cross the border, causing breathing and skin ailments. The problem is fueled by deforestation and greenbelt degradation. With its dependence on coal-fired power plants, China is among the world's most extravagant energy users, spending 2.4 times more energy per unit of gross domes China has done something amazing, historic. They have taken 300 million people out of poverty and propelled them into the middle class. The problem, however, is that there are another 300 m, and then another, and then another 300 m waiting in line. To keep this movement out of poverty, and keep stability, China needs 9 10% growth rates, which means cheap energy. Who will pay the surcharge for more expensive clean energy? It is one of the most daunting challenges in the world toay. . 26 4.0 Thirty new emerging communicable diseases –effect of climate change Humans today are pushing every conceivable ecological boundary. We are displacing animal habitats, importing non-native species when we move or migrate, feeding meat products to herbivores, dining on exotic predators and experimenting with animal hybridization, xenotranplantation and precursors to bio-terrorism in a world made smaller by staggering advances in transportation and global commerce. In the early 1900’s the top 10 killers in the US were infectious disease, since then the United States has gone through the "epidemiologic transition," a change in the pattern of disease from waves of infectious epidemics to death in old age from chronic diseases caused by genetic roulette and "lifestyle illnesses" such as over-consumption. One unintended consequence of this transition is that we have ceased our society's realization 27 of the priority of public health and infectious diseases and have forgotten that humans are only one species of many sharing a rich and effervescent viral stew. Now, in rapid succession, come torrents of emerging infectious diseases called "zoonoses," or diseases that "jump" from their usual animal hosts to humans. SARS, mad cow disease, and monkeypox are newly emergent zoonoses, as are Ebola, Marburg, Lassa fever, Hantavirus, and almost certainly the HIV/ AIDS virus. Older zoonoses include anthrax, plague, salmonella, and rabies. Swine flu, the influenza pandemic that killed more than 20 million people in 1918, was a zoonosis. We are obviously and legitimately worried about pandemic avian flu today, in 2006, but it is a single pixel on a very large canvas. The pressure of the world's population, which has grown from 1.6 billion in 1900 to more than 6.5 billion led to human settlements in areas that were once jungle habitats. 28 HERE IS A SIMULATION OF WHAT ANY PANDEMIC WOULD LOOK LIKE FLU OR ANOTHER The way we raise poultry, beef cattle, and swine has changed dramatically to meet the souring demands for animal proteins in an era where the number of farms raising animals has declined. Increases in feedlot sizes have led to more animals raised on the same size or even smaller farm – and not without consequences. The increased manure and wastewater produced can overwhelm a watershed’s ability to assimilate the nutrients contained in the waste, resulting in reduce oxygen levels and cause fish kills and toxic algal blooms. Pathogens in manure can also represent a food safety concern, especially when used as fertilizer or spread on pasturelands. Cryptosporidium, Coccidioides, Giardia, E. coli, Salmonella, Campylobacter, and Listeria have all been linked to human disease from fecal contamination of food and water, some of which has involved antimicrobial-resistant strains. Just this past year most of the United States avoided fresh spinach for several months as a result of E.coli traced to contamination of agricultural fields by nearby cattle waste. In addition, a number of human activities undertaken with the best of intentions may have harmful potential. For example, the food and farming industries increasingly use antimicrobial agents and other types of drugs to boost the efficiency of food-producing animals and to prevent certain troublesome organisms from reaching consumers. Use of these chemicals probably enhances the proliferation of antibiotic-resistant microbes. Xenotransplantation, the use of nonhuman animal cells or tissues in humans for therapeutic purposes, may inadvertently introduce new zoonotic infections to its recipients. of the Pathogens transmitted by mosquitoes and their arthropod allies sicken millions of people each year, cause inestimable morbidity in humans and animals around the globe, and remain major barriers to social and economic development in much of the tropical world. 29 As mentioned earlier, vector-borne diseases continue to emerge in new areas and/or to resurge throughout the world, even in areas where they were previously controlled. The emergence and reemergence of vector-borne pathogens are linked to changes in temperature, wind speed, and relative humidity; the amount and diversity of vegetation; and the presence of alternative hosts. In particular, global warming could theoretically result in dramatic alterations in the incidence and distribution of vector-borne diseases. The movement of goods and people can also support the movement of vectors, allowing them to become established in new areas. Probably the most notable public health example of such events is the dissemination of Ae. aegypti throughout the world (Tabachnick et al., 1985). After domestication and adaptation to humans and human environments, Ae. aegypti apparently spread to coastal areas of Africa, and was then transported throughout the world in sailing ships. Presumably Ae. aegypti, as well as yellow fever virus, was introduced into the New World on slave ships. Ae. albopictus, the Asian tiger mosquito, likely entered the United States via shipping (Moore, 1999). Aedes spp. eggs can easily be transported in such objects as waterlogged tires to new areas and hatch upon exposure to water. The large shipping containers used to transport so many products provide excellent environments for the transport of mosquito eggs. Adult mosquitoes can be spread much more quickly throughout the world in the cabins or other areas of airplanes (Lounibus, 2002). Traveling mosquitoes can also rapidly introduce new genes, leading to the emergence of epidemiologically important vector phenotypes in new areas. Traveling viremic humans can easily disseminate dengue virus to new areas via jet travel, and with the establishment of the mosquito Ae. aegypti in tropical and subtropical areas, can readily introduce new and perhaps virulent virus genotypes into susceptible populations. These same areas are also at risk for introduction of yellow fever virus, which is likewise transmitted by Ae. aegypti. Between 1970 and 2000, seven cases of yellow fever in unvaccinated travelers from the United States and Europe were 30 reported.22 It would appear to be inevitable for yellow fever to be introduced into new areas, such as Asia, with potentially catastrophic results. Global health has had great successes: Rockefeller Foundation on hookworm and vaccine preventable diseases. WHO and the eradication of smalloox and again are close to eradication of polio and Carter Center and others close to eradication of guinea worm. Child survival rates are up vaccination rates are up malnutrition is down. In many ways, these are very good years, in many ways thanks to the vision not of governments but of individuals like Bill and Melinda Gates and those who inspired them like Bill Foege. CONCLUSIONS You have been very kind to indulge my thinking out loud tonight. You’ve heard my clinical impressions, my diagnosis of the inter-relatedness of climate change, health and welfare, and stability of our planet and our species. Climate change will affect the poor and the sick more than the healthy and rich. There are many inter-related loops between health and poverty and climat change. Good health care for children saves lives, parents choose to have fewer children, population growth slows down, the effect on the climate mitigates. The poor try to emerge from poverty through rapid economic development using more use energy and consuming more, there is negative pressure on climate, negative effects on sea levels, salting of ground water and agricultural lands, with adverse affects on health and poverty. More hotter winters, less insect die off, more vectors to carry more diseases. Increased populations of humans leads to increased populations of animals with decreased green barriers separating humans and animals leading to more rapid spread of zoonotic diseases. And the cycle will continue until we solve some first order problems. 22 Monath TP, Cetron MS. 2002. Prevention of yellow fever in persons traveling to the tropics. Clin Infect Dis 34(10):1369–78. 31 There may be a question if there is time for primary prevention of climate change, but if we act soon, we still time for secondary prevention, to make sure that ―adaptation‖ is as palatable as possible. Now if I may be presumptuous I would like to offer a lucky seven prescriptions which arise from that analysis. Secondary Prevention: 7 Prescriptions 1. Reduce population growth through improving child survival, educating girls, making contraception a real option by creating jobs and choices. 2. Prioritize global health efforts not only by today’s impact, but factor in climate change 3. Increase global disaster preparedness 4. “Manhattan project” for cost effective desalinization processes and other clean water programs 5. New agriculture for a brackish world 6. Study the unintended consequences of past interventions and learn from them. 7. Radical new funding methods for “secondary prevention,” “adaptation,” or risk mitigation 1. We need to reduce population growth. Even though we dodged the bullet of Paul Ehrlich’s population bomb and it looks like will top off at around 9 to 10 billion people, we eat like were there were 20 billion of us and we underestimated the carbon footprint and environment effects of ―only‖ 9 plus billion of us. And the best way to control population is through increasing child survival, educating girls, and making both the knowledge and availability of condoms and birth control tools. And even better would be to make jobs available for women and make choice a real possibility. 32 By far the most important of these is increasing child survival. In a community in which childhood death rates hover near one-third, most parents will opt to overshoot their internal targets on their own most desired family size. They will have replacement births, insurance births, lottery births---and the population will soar. It is in counter-intuitive, but eradicating smallpox and vaccine preventable disease, diarrheal diseases and malaria are the best family planning programs yet devised. Fewer childhood deaths, lower fertility rates. More disease, especially affecting the poor, will raise IMR and child mortality which in turn will raise fertility. I know that the data from Africa appears to contradict the child survival hypothesis. But outside of war torn countries and before the AIDS crisis, almost every sub-Saharan African country dramatically reduced infant and child mortality over the past 40 years. If we go deeper into the data, we see that that families who are secure about their children surviving into adulthood opt for dramatically smaller familes. And yes, there is a lag time. We don’t want to throw our hands up and accept a new lifeboat ethics for a renewed Malthusian scenario of higher fertility, reduced food security and higher death rates. We need to intervene to break this cycle if there is evidence that it is beginning. The problem in sub-Saharan Africa is that many countries are experiencing high infant and child mortality rates due to war related emergencies, HIV/AIDS, and the widening gap between the few rich and masses of the poor. Much of Africa (not just Darfur) are in constant complex emergencies – and the effects of climate change will only make it more complex, more difficult to sort out, more difficult to stop violence and out-migration away from tortured areas. Increasing child survival, educating girls, making birth control and life control options available are some of the most astute investments anyone in the world can make in response to climate change, but also in response to the call of reason and morality. 33 2. We must change the way we think about diseases to factor in the impact and timing of climate change. I used to teach health planning and consult with governments on how to plan their health resources. Looking back, we made plans for a static world. We never thought through planning as if we were adjusting our bow and arrows to allow for the wind. Golfers understand this. Sailers do, too. But from now on, we have to adjust all our planning for the trajectory over time of the effect of global warming. Triage in medicine is a hard word, usually the hard choice of battlefield medics and emergency rooms doctors. But we all have to make resource allocation decisions even if not so dramatic; if we believe that some diseases will be catapulted into dangerous prominence by climate changes to become pandemics or explode in virulence, we need to factor that into the risk-cost-benefit decision that health planners make. Nowhere is an once of prevention more vital than in the case of communicable diseases. Those diseases that a more careful analysis suggests will become pandemic with climate change in the 2 to 4 degrees increase need to be adequately resourced, including improved alert and surveillance systems. Special emphasis should be placed on mosquito born disease such as: malaria, dengue, Japanese encephalitis, and water born diseases such as cholera, polio, and guinea worm; and the emerging zoonotic diseases such as bird flu, etc. If we believe that rising temperatures will spread the risk of malaria to over a billion new susceptible, we need to put malaria eradication back on the table and do a real gut check on the risks and benefits of using poisons like DDT and other pesticides to kill off mosquitoes before malaria becomes pandemic at levels not seen in generations. DDT is a very emotional issue for many and not without reason; however,it is a poison that outlives us. But we first need to ask ourselves when it becomes, I am sorry to use this term, the lesser of two evils compared ot resurgent malaria. Not easy choices, but we ignore the debate at mortal peril. 34 3. We need to plan for disasters in greater number and greater severity than we have seen in the past. The trend toward more weather related disasters is clear. The likelihood of novel emerging diseases and new epidemics seems high. It is hard to imagine that there will not be increased dislocations and refugees. Less clear is that the water wars or conflict whose origin lies in disputes over dwindling natural resources like Darfur have only just begun. The 230 riots per day reported by the Chinese government; the increasing likelihood of massive migrations from low lying areas and pandemics, droughts, and floods. We need better tools for early warning, for event management, and for collaboration amongst the many and diverse governmental, UN, and NGO agencies that constitute the disaster response community. Surveillance must be the first link in the chain of public health action. Most of the surveillance systems for infectious diseases are passive in nature, relying on the routine collection of clinical reports, laboratory data, and other measures to indicate an aberration from the norm that might indicate an emerging disease threat. Some active surveillance systems have been developed around specific disease agents. One such system is the global influenza surveillance system. To cope with the genetic variability of influenza, the World Health Organization (WHO) maintains a network of more than 100 laboratories that constantly survey influenza viruses, and this information is then analyzed in four reference centers. Based on these efforts, WHO makes annual recommendations for those virus strains to be included in the current vaccine in order to stay abreast of genetic drift or, more tellingly, major antigenic shifts. Still, improvements are needed in our ability to detect and respond to emerging zoonotic agents or any infectious disease threat, particularly those that appear suddenly and are capable of spreading over large areas. Finding and assessing smaller outbreaks or scattered cases of disease, or finding large outbreaks at incipient stages, is the real challenge. Other factors may help anticipate when and where disease may be likely to occur for more targeted surveillance, and perhaps more importantly, help groups of NGOs and UN agencies collaborate on event management, sharing of data and resources, and avoiding confusion. We need to 35 get much better at responding to and managing disasters. One such effort is the INSTEDD consortium funded by Rockefeller Foundation and Google and supported by100 technology companies and disaster response organizations. If you are interested in this project, you are encouraged to join. 4. Today we talk about ―peak oil‖. If we were meeting here in 10 years, I don’t doubt we would be talking about ―peak water‖. We need a Manhattan project to invent better desalinization methods. To a large degree, the climate crisis is as much about salt as it is about heat. There is a wonderful Urdu expression ―namak haram‖ to be unfaithful to your salt---to fail to pay heed to the one who gives you salt, something like don’t bite the hand that feeds you. But we need to take care not to be unaware of salt’s potential devastating effects on water for drinking and growing. Salt has always been a double edged sword---vital for preserving food, deadly for killing the ability to grow it. Roman soldiers were given salt rations as part of their salary which were called ―salarium argentum‖ the forerunner of the English world salary. But in the second century BC, some historians believe the same Roman soldiers sowed the lands of Carthage with salt so it could not sustain agricultural crops to insure that there would be no sequels to the third Punic War, as the salted land and salted water of Carthage could not sustain raising a new army. 5. Likewise, we need to invest in agriculture that will survive salted lands, perhaps even if that means bio-engineering of food. We need a Green Revolution in Africa and one that is ready for a brackish world. Rockefeller and Gates have announced major innovative collaboration on bringing a Green Revolution to Africa, and how prescient they are. But just as in anticipating the trajectory of malaria new resurgence, we need to be sure that we don’t dismiss Genetically Modified seens, GMOs, for purely ideological reasons. 36 I can’t believe I am saying this, and I feel like I am ―namak haram‖ when I speak to you about DDT and GMOs and I certainly worry about cross fertilization and letting the genie out of the bottle; but we have to look objectively at the data, which tells us that our children will inherit a more salty world and we need to have agricultural products that thrive in brackish water. And we should not forget hermetically sealed containers to store and prolong the life of food and understand make sure the unintended consequences of our science do not disenfranchise small farmers. We need hi-tech solutions that are pro-poor. I know the new Green Revolutionaries are considering all of these problems and they dserve all of our open minded support. 6. We must be very careful of negative externalities and unintended consequences of well intentioned interventions--- The last green revolution decreased bio-diversity. The malaria eradication program in Nepal led to in-migration, cutting down trees, erosion and flooding which caused devastation in Bangladesh; the banning of DDT in the US led to a resurgence in malaria deaths worldwide; it is possible that using corn for ethanol fuel instead of for food could lead to food shortages. We don’t want food scarcity and high prices of grains to be added to the other pressures moving us towards a world where as many as half of us don’t have enough food to eat. Pandora’s Box has been opened by globalization, industrialization and new technology, and human caused climate change. We need to be careful of what we wish for. 7. We need radical and creative ways to fund secondary prevention. 37 Traditionally, preventive medicine isvery difficult to fund because the rewards of prevention do not return one to one to those who pay for it. HMOs don’t like paying for prevention because they don’t know if today’s subscriber will still be in their system when they age so the economic benefit of that pneumonia vaccine will go to the next insurer while the former one bore the cost. It took decades for the primary payer for the costs of tobacco related disabilities—taxpayers—to understand that they would reap the economic benefits of strong intervention. But there is no better investment than preventive medicine. The eradication of smallpox from the world cost $150 million and the annual benefits in savings are in the tens or hundreds of billions, but at the time of the campaign it was hard to convince policy makers of the positive externalities. When we eradicate polio world wide, the savings from health and disability care in the US alone are estimate in the tens of billions. So how do we fund secondary prevention or ―adaptation‖ or risk mitigation to reduce the calamitous effects of global warming, particularly on the poorest and most vulnerable amongst us? First, we have to overcome the disconnects among the health, development, and climate communities. Secondary prevention or risk mitigation requires these to be integrated. In addition to the disconnect between those in the health and the climate crisis communities, there is also a disconnect between those in development and in climate – the Millennium Ecosystem Assessment clearly showed that we cannot continue to ―develop‖ in ways that undermine the planet’s natural ability to sustain life. We will not be able to reach the Millennium Development Goals because it will cost us so much more to human engineer the provision of clean water, storm protection, and soil productivity than if we allow nature to do it herself. Development funding must have at its core a focus of restoring our ecosystems, thereby protecting us from all of the consequences I have outlined in this talk tonight – 38 Climate Climate change is a development issue; climate change is a health issue. Climate change is the most urgent threat we face from our destruction of the earth’s natural systems, and at the same time that we restore the composition of our atmosphere by reducing greenhouse gas emissions, we can also restore other ecosystem functions, thereby alleviating poverty and protecting our health. To finance this restoration, let us move development assistance to prioritize a holistic approach to address climate mitigation, adaptation, and otherwise restore our ecosystems. Beyond public financial flows, this must also include the redirection of private sector financial flows – many private financial institutions have adopted new guidelines for more sustainable lending practices, but these look at mitigating the negative impacts of development projects – what about proactively funding projects that bring development and health improvements while also restoring our natural systems? These projects often take a more creative, locally-driven approach. Some of the best projects I have seen in this arena came from NGOs and small businesses in the developing world at the Development Marketplace of the World Bank of all places: solar water pumping and drip irrigation in Benin; water filtration in Nigeria using the local moringa tree combined with slow-sand filtration; and soil reclamation by cattle ranchers in Bolivia – that also increased their productivity. Second, let us continue to adjust our own developed world policies and work with the developing world to jointly deploy clean technologies to market and to create new sustainable businesses. Brazil’s ethanol market demonstrates the potential massive upside of cleaner energy approaches – yet even its program has had its negative externalities pushing soy farming further into the Amazon wildlands, increasing conflicts with indigenous communities. ,Let’s learn from the past and build a better more robust approach for the future; we should not run away from biofuels because of some unacceptable practices such as the rainforest destruction in Indonesia for palm oil plantations – but let’s create market demand for sustainable products by identifying them as such. For instance, when Europe establishes a biodiesel trading platform for moving product to market, let’s label and track biofuels to its source and only 39 allow those that meet sustainability criteria to take advantage of that trading platform, penalizing those that use inferior practices. The private sector must be the majority player in meeting these challenges, but capitalism does not yet integrate nature’s value, so we have to help it to do so. Which brings me to cap and fair trade practices: let’s raise the bar on the carbon markets to more holistically benefit the planet and humanity. The world is moving to a more serious response to climate change through Cap and Trade systems. The global carbon markets already move massive flows of capital for climate mitigation. Legislation like California’s new law to cap greenhouse gas emissions and similar legislation pending in other states and perhaps federally will add to those flows, again by funding a variety of primary preventive activities – mitigation. The voluntary greenhouse gas credit market has had mixed results even for ensuring the value of the claimed greenhouse gas reductions themselves, with minimal focus on benefits beyond. But what if some or all of the ―grade‖ or quality of an offset – in voluntary and in mandatory markets – were not only its effect on primary prevention, but secondary as well----in other words, give extra value for projects that also help those most vulnerable to prepare. We must value and pay for assistance to adaptation now, but the adaptation funds that have been established by governments are entirely inadequate and under-funded. The criteria for such projects will establish guidelines and metrics for adaptation benefits, and drive private financial flows to those most in need. Projects like this include regrowth of mangrove forests (for hurricanes) and wetlands (for floods and tidal surges); or projects and practices that improve crop productivity and resistance; the reforestation of native forests for creation of sustainable livelihoods and water storage; the funding of low energy desalination plants and the provision of sustainable, resilient, and lower cost energy services; and the alleviation of health threats through the provision of sustainable energy services for medical clinics or programs to eradicate or ameliorate those diseases on a trajectory to become pandemics because of global warming. These multi-benefit approaches address not only immediate needs, but also put in place more robust, long-term solutions. And these projects should not be limited to the developing world; our own low-income communities here in the United States have some of the least efficient housing, highest 40 air pollution, greatest vulnerability to increased energy costs, and high unemployment. Green building projects such as energy efficiency retrofits, renewable energy installations, and green roofs all provide opportunities to reduce greenhouse gas emissions, improve local air quality, and create new jobs – not to mention also lower electricity prices as well as improve student learning and productivity when incorporated into schools and workplaces. - --------------------------------------------------------------------------------- ENDING My fellow stewards. Someone once said that human beings are the first evolved species claim the title of sentient beings because we among all animals know the finitude of our mortal existence. We enter a new world now, as we can see that live on earth is rapidly reaching –a cross roads. We must choose life. And we must do so while preserving the values that we hold so dear. There is still time for mitigation. There is still time for adaptation. There is still time for prevention. 41 I’m optimistic. I think that we have have time on our side, not against us, because we can see the trajectory of change. We know that we face difficult choices, but we also know that there are amazing opportunities as there were in the pre-industrial and industrial eras. It took courageous investors to bet on the Transcontinental railway and the underseas cable; it will take courageous investors to be get on desalinization technologies, and malaria vaccines and better pesticides and childhood vaccination programs and girls education and all the primary and secondary preventions the importance of which society is just begining to understand. But there is not a lot of time, as you in this room know better than I do. My great hope is that there are organizations like NCSE and people like Ambassador Benedict and many others in this room tonight who have spent your lives and a career fighting for the environment in the earlier battles in what is now clearly than a war to save our favorite planet. Thank you for what you have done and what you continue to do……and thank you for allowing me as a latecomer to this battle to join you today. It is a distinct honor to be with you. Thank you.