to Mayo again and it's such a pleasure to have Dr. Alexander and Dr. Hague with us tonight talking about climate change and disability and the role of PM&R and also talking about disaster preparedness today. It's a really hot topic right now so we're really excited to have everybody here and we will have a question and answer portion at the end so please feel free to post your questions in the chat. We have Jenna, say hi Jenna, watching the chat for questions and we also have Mariana from Columbia signing in and we'll be you know tag teaming the Q&A session later so without further ado we're going to start with Dr. Alexander. Can you hear me? Hold on a second, I'm so sorry. We're going to have Jenna actually introduce you first. I completely forgot about that. She must have introduced our amazing guest. All right I have the honor of introducing Dr. Alexander. So Dr. Alexander is a podiatrist and after working for 33 years in rehabilitation and having difficulty trying to have professionals attend to the threats of climate change with regard to people with disabilities, she decided that traditional academic channels were insufficient to raise awareness. So on June 21st 2019 she and her team worked to start a walk from Campobello Island in Canada to Key West Florida to raise awareness regarding climate change and disability and bring together professionals and persons with disabilities in community regarding this important concern. Along the way events included multiple grand rounds at academic medical centers, a community walk in New York City with a presentation at the Oculus of the World Trade Center and a walk through city of Philadelphia with an event at the Love Statue. In Washington DC the First Day for Tomorrow event was held at the mall. In 2020 the mission transitioned to a virtual world. Sustainer Abilities became a 501c3 non-profit in 2019 and the Sustainer Abilities YouTube channel was developed. In order to promote green health care Dr. Alexander edited the book Teller Rehabilitation Principles and Practice with assistance from many advisory board members. Dr. Alexander also became editor-in-chief of the Journal of Climate Change and Health. In 2022 the Graham project the green route aiding healthy adaptation and mitigation was founded in memory of the untimely death of Graham Alexander. As SOA continues its focus on disability and climate change we also place a special emphasis on the benefits of a healthy environment working together in community to promote education about climate change and environmental justice and quality of life for all. Welcome Dr. Alexander. Thank you so much. I'm going to take over here and share my screen and I appreciate the lovely introduction and let me get rid of this little panel up top which is always fun to get rid of and start a slideshow. So I thank you all for joining tonight and I'm gonna move this down and we'll talk a little bit about climate change and can everybody hear me okay? Yes? Any issues? I guess not. All right I'm gonna move on here. So we're gonna talk about climate change and disability and it's amazing because this is such a huge topic and it's been so hard to bring attention to it. Things have changed over the past couple years and I'm excited about change. I'm not excited of the reasons for the change but I'm hoping I can share with you now a little bit and get you also interested in this topic. So climate change is the biggest public health concern of the 21st century and you may not think about it so much but it is going to be the biggest problem we deal with. It's going to challenge health care systems. It's already doing so around the world. From 2000 to 2018 heat mortality from extreme heat events already has increased 53 percent and there's 300,000 people roughly that died in 2018 from heat alone. Now that's a start. Heat is one thing that people experience in terms of climate change but there are many other things that people are experiencing and being in PM&R we always don't know all these things. So I want to talk a little bit about how climate change affects human health. One of the amazing things that happened to me as I got involved more in climate change was realizing how this is such a nascent field not only in PM&R but in many other areas. So we've got severe weather events which is kind of an acute climate change thing and we've got injuries and fatalities. One of the things that happens though in terms of these severe weather events is that people have not really attended to recently until recently is all the mental health issues associated with severe weather events. Once you've been through something like this you suffer from PTSD and what happens if you think about people in Puerto Rico that went through Maria and then five years later they've got another severe hurricane going on you've already got this built inside of you the mental health impacts. Air pollution. Air pollution is a problem it's been a problem for a long time but now with air pollution and the heat we have more extreme issues and it's known that asthma is worse now and cardiovascular disease. We've also got changes in vector ecology. We're seeing and will see in the future more malaria, dengue, encephalitis, hantavirus, rift valley, Lyme disease, chikungunya, well West Nile. Now people in the U.S. may not think so much about these things but people around the world and internationally are experiencing more of these problems. Increased allergens. I think probably everyone now has some type of respiratory allergy and then there's the water quality impacts. Of course when there are storms there are problems with clean water especially in many areas and cholera, cryptosporidiosis, campylobacter, leptospirosis, the harmful algae blooms many times we now see in Florida the red tides. All these issues are happening more now and will happen more. People in the global south and other parts of the world are experiencing more the issues of malnutrition, diarrheal disease and then we've got the issues of forced migration, civil conflicts. When we think about Syria and what happened in Syria more and more people are attributing these issues and these severe wars etc to problems with drought and the weather. Finally we get into the issues of heat related illness and this really brings up the issue of disability. People with spinal cord injuries for instance or MS, the elderly, these people are more susceptible and we've got to think about heat but also cold because it's climate change it's not just heat it's also cold and the thing is though many times people that you know you try to talk to they may not think that oh this is so important now but the reality is that we're all aging and as we all age and this means everyone here you might be in your 30s now but 40 years from now you'll be in your 70s and climate change is actually going to be worse. So those of us that are able-bodied now will likely have some type of disability in the future and this can be sensory, medical, mental, motoric, orthopedic, pain or sensory and one of the important things about disability and climate change is disability is such a broad term that we can't really lump the term disability and climate change together. As physiatrists we all took the Hippocratic oath right you want to try to help people well the key is that just like we think about cigarette smoking and how that's bad for people and there's issues about gun control people talk about we need to think about climate change because climate change is impacting people now and will in the future and as physiatrists we need to think as the world works to conquer climate change that we start thinking about inclusive mitigation and inclusive adaptation to climate change. So one of the things as was mentioned before was that I started this walk from Canada to Key West and one of the reasons I wanted to do the walk was because I wanted to get people living with disabilities and allow them to tell their stories about how climate change impacted that. Well walking 1250 miles and I've only walked so far to North Carolina, Rocky Mount because I stopped because of COVID but I am starting again in 2024 but one of the things I realized that you don't see people with disabilities on the street and of course if it's hot out you don't see people with that able-bodied out you especially don't see people with disabilities so one of the things I did was I took a break and went to Puerto Rico and this woman here her name is Gretel Dillon she is actually an industrial psychologist and she was the president of the United Spinal Association in Puerto Rico during Hurricane Maria and I went around interviewed a number of people that are Spanish-speaking and one of the you know one of the highlights I would say about whoops let's get rid of that one of the highlights that was really discussed with people was how in the time when there was no power there was no gas there were also no catheters so people living with spinal cord injuries were put in the situation where they had to share catheters so we can see how a lot of things happen when you're in disaster times and we've got to learn how to deal with that so I did a study back in 2019 just interviewing physiatrists and therapists working in spinal cord injuries about their impressions on climate change and I really do think that SCI is a bellwether because people with SCIs have the issue of poikilothermia so they're susceptible not just to heat but to cold so when we have those bombs right when we have the bomb cyclones and we have polar vortices now which we didn't have 10 years ago people are also susceptible to being frozen right if your heat goes out you can be frozen so it's not just heat it's cold so skin issues orthopedic issues neurologic issues affect people with spinal cord injuries which gives them mobility problems and disasters bladder and bowel incontinence causes the need for supply and 57 percent of professionals felt in 2019 that climate change had already impacted their patients health but SCI is one of many types of disabilities so if people have chronic medical needs that's another issue we have to think about people need devices which require electrical power right people need medications and supplies sorry about the slides people need caregivers and they need continuity of care and these are things you have to think about when there's a disaster and then there's other personal needs that individuals have based on their own individual medical diagnoses so everyone with a disability has different needs also we can think about the group of people with sensory disorders they may have difficulty with disaster awareness they may have inability to tolerate cramped shelters think about having a tbi or having autism and being in a shelter where you don't have space they may also have the need for devices with electrical power to caregivers and the other personal needs the only thing we don't think about when we talk about disability is that if you have a disability it's not just the only thing that happens to you there's other issues that can impact people people can be poor they can be from indigenous people's groups they can live in areas that are vulnerable to disasters and i'm so sorry i don't know why this is happening they will also um potentially have extreme temperatures causing imprisonment at home and they may have other concerns certainly the issues of depression pain addiction are associated with living with disabilities we talked a little bit of some other countries too well in many countries there's also just a lack of basic accessibility so take this lack of basic accessibility and put it together this lack of knowledge disability and climate change can be an extreme issue now if we take the other standpoint though and think about being physiatrists as a health care sector we also contribute to greenhouse gas emissions and in the u.s we're actually the biggest contributors and we contribute eight percent of the greenhouse gases in the country so if we put all this together we take care of people with disabilities we're supposed to help people not hurt people and this is a future problem that's only going to get worse we've got to start thinking about what we can do and what i would like to share with you today is this concept of seeing clear to combat climate change and i think it's important that physiatrists start thinking about this so see clear stands for being communicators climate leaders educators advocates and researchers and this is a journal of climate change and health it's an open access gold journal you can sign up for alerts on it i am the editor-in-chief so i guess i'm a little biased but if you sign up for the alerts it will be a great way to be educated about climate change and health and it's free education so why can physicians be climate leaders well physicians are trusted educators and we can educate people about climate change and bring our communities to the fight we can communicate with many different people we can communicate with our neighbors our leaders our colleagues in health care our networks our communities and you know what virtual and hybrid formats are great now because we can lessen our carbon footprint and it's important to strive for accessibility we can be part of the solution we have an opportunity now to ensure that rehab facilities can function sustainably and we can do this not only with people living with disabilities but people with medical challenges and with other people with other professionals finally i want to say that physician statements have recently been published by the aap and the isprm so this is now something that organizations are taking on and i show this picture because this is from when i did an event at the oculus of the world trade center and this woman here is now the director of fema these were two new york congress people and that was this man here was the director of the office of disability in new york so if you reach out there you can do things you may not have a background in something but if you have passion you can do it this is a group of people we had people from mount sinai we had people from myu we had people from columbia all and and from uh hofstra northwell all joining us on our day for tomorrow walk in new york and the idea of day for tomorrow is that it's a day for preparedness because there's earth day and people know about earth day but it's not enough you've also got to be ready when disasters happen which is going to be more what dr haig speaks about we also have this is suzy groves a podiatrist um i went to dc doing this and walked to dc and then interestingly i walked from richmond virginia to north carolina and this is this is january so you see what happens in january and one day it might be um you know hot enough to wear sleeves sleeveless and then the same week i was in north carolina and there was snow on the ground so the world changes day to day and that's the concept of day for tomorrow is you never know what's going to happen tomorrow there's a lot going on in terms of climate change we need to work as a team we need to work with people with living people with a lived experience of disability and we need to work with professionals so this is a slide kind of talking about day for tomorrow and the concept is that when disaster strikes neighbors are necessary and being in community is crucial crucial and so you want to know your neighbors as part of preparedness the other concept is that we need to create an awareness of a healthy built environment this is important this is something we don't have now we need to have this healthy built environment but we don't we have fast-paced schedules we're struck we have decreased activities we have decreased nature time these are all things that can help us deal with climate change and what we need to do is work together also to think about getting rid of fossil fuels to think about decreasing greenhouse gases and all these negative health effects. In terms of Day for Tomorrow, we actually had events that were held in Tanzania, people got together, and I would encourage this group to start thinking about Day for Tomorrow and joining people in Sustain Our Abilities in celebrating it. The other thing is research. Research is overdue about the impacts of specific disabilities on persons with different climate risks, and we need to study specific treatments in specific populations. One of the things I learned getting into the field of climate change and health is that there are a preponderance of ER docs, a preponderance of pediatricians, psychiatrists, nobody in PM&R. I was actually the only person I found in the area, and now getting into climate change and PM&R, it's great to see there's more young people involved. I've got a team of people. I'm so happy Nina and everyone here is getting involved with this, and this is something people are caring about. We've got a lot of work to do, though. We've got a lot of research. We've got things we can do in terms of communication, waste audits, I need a long public paper on waste audits and PM&R in the Journal of Climate Change and Health, something you can think about. We need to start having biodegradable supplies. We need to do more telemedicine, and we've got to start realizing we've got to be able to respond to emergencies. What about decreasing polypharmacy, increasing holistic care, doing nature in our care? What about nature prescriptions, which are now offered in different places, and even coming up with easier systems for cooling and heating people? Plant-based diets are good for the environment and for healthcare, and just moving the pendulum back. You know, that's one of the reasons I started walking is because we've got to slow down. We've got to do more personally, physically. We've got to work on promoting our health in other ways, and at the same time, we've got to start transitioning into a greener healthcare system, and rehab hospitals need to start joining the push. In the UK, the NHS has pledged to go carbon neutral. The VA has now pledged to do this, and there is the National Academy of Medicine has a call for this, and actually, one well-known physiatrist, Michael Bollinger, now moved into a sustainability role at University of Pittsburgh Healthcare Systems, and they have taken the sustainability pledge. So it's sustainability, and then don't forget the issue of recycling, right? We've got to recycle equipment. I've talked enough. There's a lot going on in disability and climate change. There's many different disabilities. People's functional needs are different, and people with disabilities are different than talking about people from a city or a community. People with disabilities don't live in groups, so we've got to think about how we can get out there and speak about these issues. We've got to think about the physical issues, motor, sensory, cognitive, functional, medical, socioeconomic concerns. We've got to think about these needs of equipment and realize that people with disabilities often have multiple concerns, and they often are ignored in disasters. Stories continue, and I am continuing my walk. There is a QR code up here in the corner. I changed the name of my walk to the Green Root Aiding Healthy Adaptation and Mitigation. I had a personal tragedy. My son died a year and a half ago. I wish he had been able to spend more time outdoors, but what I've realized is the outdoors would be healthy for everyone. And so my walk has now been changed to the Green Root Aiding Healthy Adaptation and Mitigation, or the GRAM, and I am starting again on February 24, 2024. And I'm going to walk from Rocky Mountain, North Carolina to Key West, Florida on roads with a purpose of showing people how our communities, our cities, our roads need to be safer, more accessible. And that's not just in the U.S., it's around the world. And this is from Nigeria, where they did a Day for Tomorrow celebration. So I hope you'll take a chance and look at what Sustain Our Abilities is doing, and think about in your own country, in your own community, in your own hospital practice, and even in your home, what we can do differently to help in this climate change concern. And on that note, I'm going to escape and stop sharing and turn it over to Dr. Haig. Yeah, thank you so much, Dr. Alexander, for sharing that. You've definitely given us a lot to think about, and I'm very excited even more now to get to the Q&A section, because you've made me think of even more questions to ask you. So thank you so much for sharing everything. All right, thanks for listening. Yeah, so just like Dr. Alexander said, our next speaker is the wonderful Dr. Haig. So Dr. Andrew Haig received his medical degree from the Medical College of Wisconsin, after which he completed a residency in PNR at the Ranked Rehabilitation Institute of Chicago. He was on faculty at the University of Vermont, then led an award-winning rehabilitation system in Northwestern Wisconsin, before rising to the rank of Emeritus Tenured Professor of Physical Medicine and Rehabilitation with a joint appointment in the Ross School of Business at the University of Michigan. With over 150 scientific publications, numerous NIH grants, and a textbook, his work has been recognized with the field's highest awards in teaching, research, and patient care, including 2019, the International Society for Physical Medicine Rehabilitation Hame-Ring Award, and the 2021 AAPMNR Distinguished Advocate Award. He currently practices in Middlebury and Wilson, Vermont as a PMNR specialist with sepsis specialty board certifications in pain medicine and neuromuscular slash electrodiagnostic medicine. Through Haig Consulting, LLC, he consults with hospitals, insurers, and governments, including co-director of the Vermont Department of Labor's Federal Routine Return to Work Grant. He is the president of the International Rehabilitation Forum, a not-for-profit organization that builds medical rehabilitation in low-resource countries. So, without further ado, let's welcome Dr. Haig. Hey, thank you. I hope you can hear me. Give me a thumbs up if you got me. Can you hear me? Great. So, first of all, thank you, Gina and Nina, and gang, for organizing this. It's really important going forward, and I'm really glad you could see forward that way. And Dr. Alexander, like, salute, holy cow, putting your money where your mouth is. This is how it happens, because if you personally commit. So, I'm hoping now that you can see my slideshow. Do you see my slideshow? Thumbs up? Okay, cool. So, you know, in our field, I know a bunch of the people online here, but you go to, oh, my disclosures, right? So, there we go. All these things that I do, it's all true. You know, if you go to another part of the scientific world, they'll say, oh, you're Sue Haig's brother. Well, when I was three and Sue was four, we decided we'd become scientists together. And Sue's gone on to be the president of the American Ornithologic Union, and got a presidential award for starting the field of environmental genetics. So, from our youngest years on, Sue and I have worked, I've banded birds with her, we've looked together, and she's been on the real bleeding edge of what happens with climate change, and saving the California condor, and all these other birds. And so, together, we've had this discussion over and over again about rehabilitation and the environment, and it's really pretty deep. There are other parts of our world where they go, oh, you're Tom Haig's brother, right? And after I became a spine specialist, my brother Tom decided to get hit by a truck and had a spinal cord injury. And Tom is the other half of the story, because what he's done with me, but also on his own, is gone to disaster places and helped out. So, if you're in Nepal, all the videos about how to deal with spinal cord injury after an earthquake in Nepalese are done by Tom and our young friend Raju Dhakal, who's the rehab doc, the only rehab doc in Nepal. So, between the three of us, we've kind of been chewing on this forever, because it's really the future of the world, and we worry about it a lot. So, I'm glad that the physiatrists here are talking about it. So, disasters are a funny thing. They are 100% predictable. This is the Neelam River in Bangladesh, in Pakistan, and it's on the left, and on the right, 24 hours later, basically, you have no more river, right? And I don't know that we could say that this was gonna happen on that river on that date, but there is a 100% chance that there's gonna be an earthquake in Pakistan, right? We just don't know where, and we just don't know when. And when you go back up to the top statement, disasters are 100% predictable, we have work to do, okay? When you get to the bottom statement, we don't know where or when, we have even more work to do, because we have to find ways to be prepared for things we can't quite predict. So, the story in Pakistan begins with my young friend, Farouk. They had an earthquake one day, and Farouk was just a resident, just a resident in the military residency, and so one day they had about 200 spinal cord injury admissions. You complain about being on call, just shut up and think about Farouk admitting 200 spinal cord injuries. They took over a women's hospital, they admitted these people. I don't know how they did this. They measured function on admission and discharge, they checked their Dopplers, they did all the stuff you would do as if you only had four admissions that night, right? Incredible. They had no deaths, and they had two new babies, right? Just an incredible story. And I read about this someplace in some obscure corner, and I emailed him and I said, you gotta write a paper about that. His response, I'm just a resident. I'm like, you're a better human being than me. So, you know, we wrote the paper, right? And so far, this has become the linchpin of the science of disaster rehabilitation, right? Farouk's experience as a resident is what really launched the rest of us into the field. Now, what's kind of cool about Farouk, because of course, I guess I was kind of his mentor, a few years ago, the group called AuthorAid named him the top mentor in all of science in low-resource countries, because he got the message. He got the message that I've gotta train the next generation. And so if you wander around at the ISPRM meeting down in Columbia, you'll see Farouk followed by a whole bunch of ducklings who are his protégés, which is just where we wanna be with this stuff, right? The sustainability of us. What they found was kind of, well, you know these pictures, right? You've seen these from like how many different countries? Can I count the countries where you've seen these pictures, right? But what they also saw was this. Is that the way you lift a spinal cord injury? Or is that, or is that, right? This is all of what happened in their earthquake and in many other earthquakes. Turns out Farouk Ngan did the study. You know, way one and way two, you have complete spinal cord injuries. You'd use the helicopter, you have incomplete spinal cord injuries. He also showed that if you're a quad, you die. If you're a quad, you die in an earthquake in Pakistan, right? Why? Transportation, right? So there's like, oh my gosh, this is crazy. You shouldn't have to die because you're a quad. Well, I ran into my friend, Janyan Lee, whom I've known from international society stuff. And there was an earthquake in Sichuan and it looked something like the picture up above. And the first time around, he was begging the Chinese government, please let us go, please let us go. We know those amputees. We know those crush injuries. We know those spinal cord injuries. And they were eventually like, yeah, okay, right? Second earthquake, it happens. And the first day they call him up and say, Janyan, get your people from Sichuan University. Sichuan University, no, Nanjing University. I'm forgetting the name of his university, I'm so sorry. And send them on the way. And he packed up his team and there weren't enough of them. So basically we have a controlled trial of people that got the rehab people and people that didn't get the rehab people. Guess who lived better, right? Rehab saves lives. And of course, what we learned here and with others is it's longitudinal. It's not enough to save a person with an amputation. They need a new leg in six more years, right? They wear out their legs because they use them, right? So Colleen is my third hero in this story. Colleen is a Canadian physiatrist. When she was a young medical student, she wanted to understand what happened with amputees in wars. So she hopped onto a truck in the middle of a war in Africa and got almost kidnapped and hijacked and saw what happened on the front lines with amputees. That's Colleen, right? She's a crazy woman and brilliant. There's a group called Healing Hands for Haiti. Jeff Randall and Colleen started it. Jeff Randall's an American physiatrist, Colleen's Canadian. And they've been there for years doing really sophisticated work on the ground, building sustainable models of training the locals, et cetera, not just the donors, right? Then they had an earthquake, right? They'd been there forever. They knew the language. Jeff could speak Haitian, right? Politics, healthcare system. There's an earthquake and all the do-getters came, right? And it drove me crazy because I saw a major university claim. We built the first rehab center in Haiti. And I'm like, who you been talking to, right? They didn't do their homework. Even worse, I actually intended to respond to this earthquake, but instead I went and I broke my arm. And I'm sitting there going, I know what's gonna happen. I know, and writing and sending notes and saying, please, you've gone through. And the Navy didn't listen to us. And they had this really cool hospital ship. And pretty soon it hit the newspapers, unable to have people leave because they can't walk and you didn't give them crutches, right? It's not about their acute healthcare. People were eating food and consuming resources in a hospital ship simply because they didn't give them rehab tools. You can't walk home unless you got a leg, right? And so you look at the irrationality of responses to disasters. And we really need to avoid that. And then there are a few of you folks who were in New Orleans and, right? We had this, an American city that's below sea level. Let's see if this is predictable or not. Yeah, it's kind of predictable that if your city is below sea level it's near the sea that you're gonna go swimming, right? Well, it happened. And really famous, really wealthy healthcare systems were completely shut down. And people with disability, some people with disability don't swim so well, as you can see in the bottom picture here, right? Predictable? Yeah, right? Well, so we ended up holding the meeting in Kayseri, Turkey. These funny mountains are in. And it was the first International Rehab Forum Conference on disaster rehabilitation. The NGOs are run by emergency people. They're really, they care about what they're doing, but they're really good at emergency. And because they never kind of remember the fact that the rehab doc consulted in the ER, right? At least I used to, in my little town in Northern Wisconsin, I'd be, you know, the helicopter land and I'd show up, right? They think of PM&R as what happens after they save all the lives. So it's not part of their job. It's after they save all the lives. So it's not part of their business or their expertise. Their funding and strategies were about saving lives, not saving livelihoods, not saving people afterwards, right? And they had no PM&R strategies whatsoever, okay? So I'll go back 30 or 40 years. The only other purpose person who had this story was George Kevorkian. He is culturally Armenian. And there was an earthquake in Armenia in the 1970s. And George, who's still alive down in Texas, responded and built the prosthetic centers, right? George is like, no, no, you can't just save the lives. You've got to build a prosthetic center. And those centers still exist in Armenia, okay? So they built national infrastructure to help with this. What we found at our little meeting was that the very next weekend or next week in Turkey was the ISPRM, the Global Society Meeting, right? We showed up at the meeting and the we, the 40 or 50 people that showed up at our meeting were flabbergasted. We wandered around this meeting, talking to people from Europe, from Asia, from South America. There were no Africans, don't worry. And say, well, what do you do about it? And we realized that nobody was focusing on this. The global leadership just hadn't seen the issue. So we're a really little organization. And even though I'm full of ego, we're not. We said, you know what? There's a bigger and more important organization to run this. So we handed off and started an International Disaster Rehab Committee for the ISPRM and the World Health Organization. That's now become the most popular committee in all of the ISPRM. And I gratefully have nothing to do with it except for I show up as a cheerleader because the people who are in the committee are people who've really been there and done that. And that's really what we need. We gave up. Yeah, okay. We handed the challenge to a larger, more powerful organization. Oh, by the way, I am in a parking lot in Lansing, Michigan on my way to Vermont. So pardon that. And we thought the ISPRM would be a better organization. For those who are going to ISPRM, the pre-conference is run by our group and by CARF International on how to build rehab in lower and middle income countries. So you drop into our conference if you want. So we formed that, I guess I said, we formed this, but the committee has gone on and written over a dozen of policy and research papers, organized response teams. You know, I wanna show Ferry and Boxer among many people, but these two in Australia have done what we Americans need to do. They've formed academic disaster rehab, okay? Not just working there to help out, but let's study it. Let's build a laboratory. Let's get the master's degree students. And they've actually gotten to the point where they have an emergency response team, which actually shows up in other countries, okay? And this is really what we need to do. Nobody in the US is really, really doing this. So rehab, things that you folks have to do in your local communities, and when your surgeons are going to Africa or when your internists are going to South Asia or something like that, you know, policy planning for disasters has to include rehabilitation. You need to get on the committee. The responses that we put out have to be pre-planned. You can't just wing it and decide you're gonna bring some fake legs, okay? The resources have to be ready. You have to think about that stockpile of, yeah, catheters the patients didn't use, the supplies that you need out there, and have some storage room in your local hospital that says when the disaster happens, even if we don't respond, these are things we can send off to our friends in Chicago who are gonna respond, right? And so it's not a waste of time to start to put together the resources you know people will need. The other thing that needs to be ready is information for the patients. So, you know, I don't speak Farsi very well, but if there's an earthquake over there or a flood or a man-made, human-made disaster over there, somebody needs to have the handouts about how to teach catheterization, how to do pressure sore relief, how to transport your family member who already has an important disability, right? And so having, you know, working with people, if you have any interest in another country, working with the media that is needed to spread the word is really important because the rescuers, especially in low-resource countries, will be coming without a knowledge of the language or the culture, right? So getting ahead of it is really, really important. And of course, what we all are striving for is the thing that trauma has, a professionally trained disaster rehab team that's able to drop their jobs and go, right? That's funded by the WHO, the United States government, the U.S. military. There goes the rock and roll car ahead of me, sorry. When you've got a team that's drilled together, that's worked on the things that I'll talk to you about in a minute, then you've got a winning intervention. They also have to be tied to the experts on the response in the first place, okay? And we'll talk about that. You don't just go to a country because your family's from there, okay? You go to the country attached to a major organization so you don't get in the way. It's really important. So the things that you all need to be trained in if you hope to respond to disasters, and let me pause for a second here. I guess Dr. Alexander hit the, I knew she would, right? These disasters that happen like earthquakes and floods have always happened, but we're gonna have more, right? We're gonna have more. And we're gonna have more human-made disasters like wars, right? This is gonna be more. And so we're gonna be, for the next generation, this will be part of your work in the world. So you have to be trained in a bunch of stuff, okay? You need to know how to get messages out to the rescuers day one, okay? If you're gonna be part of a team that's doing disaster response someplace, you're gonna be the one that says, don't take them in a wheelbarrow to the hospital. Don't move them. Don't cut off the leg without talking to me because I know how we can fit a prosthetic limb, right? Look for people that are confused because they might have a brain injury. And if we can identify it early, maybe we hang onto them and don't let them go out someplace and have a subdural and bleed to death, right? Rehab triage is, and I'm getting very basic about the bread and butter of what needs to happen here. But what happens is you wander around that tent hospital and you put a toe tag on everybody, says, too late, rehab, probably fine. And then you come back on day two and go, oh, it's not too late. Oh my God, they saved her life. Put her on the rehab team. And I'm saying toe tags, but you know, that there is a label that you put on every bed so that people identify the long-term goals and the fact that they can't be discharged without the rehab team getting involved, okay? And then maybe after the first week or so, you'll have people coming with severe backache, with a foot drop, with all kinds of things that won't require hospitalization. And there has to be a process to identify them and to make sure they know to come back when you finally have some breathing room, right? So within a week or so, you start, make sure that you tag people and say, you're gonna come back to us because you've got a foot drop, right? And then the other part that people miss a lot is they have to spend an inordinate amount of time staying alive, okay? These are dangerous places because of the flood or the earthquake or the hurricane. They're dangerous because of the water being polluted, okay? There are diseases you don't know about. Americans don't deal with malaria very much, but you better be prepared if you're in that place. There are people that are desperate and will kill you for food, okay? There are bad things that happen with crime in a disaster area, and you need to be in a place where you understand how to deal with that. And my friends who've really been there, done that, will say, you go home and you have nightmares. You go home and you have nightmares. There's PTSD. And you need to be able to go there and come home emotionally safe and come back to the real world where people are worried about whether or not you're gonna give them more oxycodone. And you're thinking about the person whose leg was cut off without any anesthetic, right? So you need to be able to preserve yourself for the future. It's really important to be ready as a responder. These organizations, and I just put up a couple of them, are now really much more interested in the rehab side of things, partly because of the papers that our team, that's not me, that our team wrote. And one of the things that you need to do if you're involved with them is to talk about planning sustainable local rehab from day one. Now, local rehab, unless you're moving there, is not you, okay? So you've got a liaison with these acute response organizations. The first weeks are when the money comes in, okay? And it kind of, I'm never comfortable raising money. But you know what? If you don't get money for the prosthetics lab in the first two weeks, it's never gonna come. So you have to be out there screaming and hollering for the funds that are needed to keep people going after this. You're looking locally at the people who are staying. And in one country, there's no rehab doctors. Let's build a training program. In another country, you have a physical therapist who is just a brilliant leader, and you anoint her and you make sure that she feels strong. And you say, you go talk to her, because she's staying. And you have to look at the leadership locally to make this work, right? What was happening beforehand? And then you need to really work with the local people in the region or the country about the people they're gonna need over the future. How many prosthetists do we need going forward when there are five times as many amputees as you ever had before? What schools will start training programs for PT assistance? What kind of facilities need to be out there? Where are they gonna start getting the plastic to make orthotics, right? And then we're getting to an end here. But what's really missing is an international global systematic approach to building this rehab infrastructure for disaster. We need to integrate it into every nation's disaster planning. It's nation by nation. The policies for human-made disaster, I wanna spin off on in a second. You mentioned Syria. I tried to get the International Societies Committee to respond to a rehab doctor who was in a refugee camp in Syria. And everybody's all excited. And then somebody from an unnamed company said, but we don't wanna get political because they were on the other side of the war, right? What's political about getting your leg cut off? That's just crazy. But that's what we have to deal with, right? Who pays for rehabbing the civilians in Ukraine? I was in Ukraine the year before talking to the trauma surgeons, right? And I'm sick every time I look at Ukraine. And you look at what's happening in Sudan and who's gonna pay for rehabbing the civilians when two different armies are fighting each other? What if they won't? Who's gonna take charge of things there? How do we respond to things like bombings, whether it's Boston or Bangladesh? What about that nuclear disaster? Finally, we get rid of our carbon footprint and we make ourselves a 40,000 year old nuclear footprint, right? And when there's another toxic train leak, what are we gonna do for the people in the community with lung disorders, right? So, it's gonna happen. Disasters will happen more because of the environment. We don't know where, we don't know when, which means you can plan ahead. There's our information. Contact me or contact the IRF if you wanna help out with anything we're doing or if I can help you at all. Thank you. Wow, that was just powerful from both of you. I'm just, I'm excited and I'm also like, oh my gosh, there's a sense of urgency I'm feeling now to actually get work done. And I'm just so pleased that both of you were here to talk about these really, really important topics. I know we have a shared document. So, I know that there are questions that have been coming up and I'm gonna hand it over to Jenna and to Mariana to head our Q&A session. Yeah, thanks so much, Nina. I appreciate you doing that. And thanks Mariana for helping me out here. We had a few questions in the chat, so maybe we can start here. Mariana, you were the first one to ask a question. Do you wanna ask yours? Yeah, that's my question. Okay, so the question is, how can healthcare providers and policymakers work together to ensure that individuals with disabilities have access to appropriate support and resources in the face of climate change related challenges? I guess I should take this one on. That is a huge question. And basically it is a, I would say it's a lifetime commitment. There are many people living with disabilities that work in their sphere, which is more environmental law and human rights. And they are pursuing getting to the table at the biggest forum for this, which is the community of practice meetings, the top meetings that the UN puts on. So, the way I started working on this as a physiatrist was I ended up collaborating with people around the world and started trying to work with people living with disabilities and realized that there's so much to do. And basically our goal is, what I'm trying to do is bring together physiatrists, bring together people in rehab, and then also bring together people living with disabilities to bring these issues together and start working in different spaces. What are these different spaces? Well, we became an observer organization in COP. So that was a big process. It takes a couple of years to get that designation. And I've gone to the COP meetings. I've gone to the meeting in Glasgow last year. I went to the meeting in Egypt. The next meeting is going to be in Dubai, not going. But basically it's getting there. It's talking to representatives from different countries. It's learning to be an advocate. It's learning to communicate. As an organization, AAPMNR, for instance, could join the Global Climate and Health Alliance, which is an international organization where people go together and try to lobby, first get help on the agenda. So there's so many different agendas. People are advocating for women. They're advocating for indigenous peoples. And you've got to have the commitment and go for the resources. And it's just a challenge. It's start in your hospital, your facility, start working with people. Think about having a day for tomorrow meeting. What we actually ended up doing at COP this year was we ended up putting on an event of a Nigeria pavilion. So the way COP works is there's different pavilions for different countries. And I had a woman living with spinal cord injury and a physical therapist that came to the COP meeting this year. And we went to the Nigeria pavilion and did something on disability in Nigeria and climate change. And it was great. We had about 50 people there from the government, but that's just one country. And what we're trying to do now is work together to get an international research project going on climate change and disability. Because I used to work in the field of sexuality. And if you think about sexuality and disability, every disability impacts sexuality differently. Well, the same thing happens with climate change, right? You know, there are common issues that people have, but then there's individual issues that people have. And so as a physician group, what we can add is looking at those individual issues. But it's a lot of talking. It's a lot of networking, you know, really getting out there and knocking on doors and meeting people that are in this area. One of the things I would say that we are putting on a, with the journal, I have instigated putting on a course called Climate Health 2023. And there's a number of people from different Ivy Leagues, backgrounds, countries involved with this meeting. We're gonna be having it at Hofstra University in Long Island. Adam Stein, who's a physiatrist, is actually quite into this topic. And it's going to be free for students and people in training. Internationally, it's gonna be available. So I encourage you to go look at that and really just, you know, get out there and we can work together and join us and get the topic more on agendas because it is very difficult. It's just a start. So I don't know, I hope that answers a little bit of your question. I could spend days talking to you about it. It's okay, thank you. Thank you so much for your information and for being a leader and giving us that information. Thank you. So the next question is from Lauren Shapiro. The question is, the FEMA Red Cross pamphlet on preparedness for disasters for people with disabilities and special needs was written back in 2004. Any thoughts as to how we convince them as to the need for them to update it? We've had so many major hurricanes since that time from which we have learned important lessons. IE three days of food is not an appropriate stockpile for many persons, particularly disabled persons who live on islands and flood-prone regions. So what do you think? Yeah, maybe I can field some of that. Each of you listening, and hi, Lauren. Lauren takes a lead in a lot of this, by the way. Each of you listening can focus on one thing and get it done, right? And so if that was, Lauren's caught a lot of things on her plate and she's doing them well. But if that's important to you, you're gonna have to become the expert. And it's really okay. Like if there's a resident listening, you can do this. You don't have to be a faculty, whatever. And you say, that's the problem, I'm gonna solve it. And then you're gonna dive in and say, well, who writes that stuff? Why don't they write that stuff? What's the committee? When's their meeting? Can I email somebody? Can I join the committee? And it's an airplane taking off, okay? It's no simple answer. Like I can't write them a letter and say, hey, you idiots, do it, right? There has to be somebody who's persistent and knowledgeable about how it works that just keeps hammering away at it until they get it right. And in so many areas of what we're all talking about, that's what happens is one of you becomes crazy enough to just take it on and don't get distracted by all the other stuff. Well, I would just add to that too, though. I think the thing you've got to think about, Lauren, is the statement, nothing about us without us. And I think that is a key thing that people living with disabilities bring up all the time. Andy, you've got your brother living with a spinal cord injury and Raju, right? When you approach organizations of people with disabilities, they really don't wanna talk to you if you don't have a disability. And I have to tell you that. What is really, what I found was when I went to the COP meeting, I went to the IDA group and I was part of this meeting. And basically, what I was asked to do was be the one that carried the microphone around. But my colleague, Amina, who is in a chair, was immediately asked to speak at different forums and that sort of thing. And so you've got to really partner with people living with disabilities and have them be interested in the topic. And I think that's a key thing. So that's one thing I would say too. You know, Marca, I wanna emphasize that back to you. I almost thought about saying something about your last comments because this is so critical. You know, this is both, I'm calling, I'm using the word they and us to teach. I won't talk about my disabilities, okay? But I'm using it to teach, okay? It's their problem, okay? They need solutions because they have a life to live with a real risk, okay? They are also the voice that people listen to. What are we? We're people who took organic chemistry once. So we're really smart about the front end, which is this is real science, this is really important. We can raise a flag to our consumers and say, you really wanna pay attention to this people and here's why, and I'm your doctor and I know it's true. And on the far end of their problem, we've got some technical knowledge about how to solve the problem, right? We know about how you can reuse catheters and we know about how you can cool off bodies. And the very center of it is the people with disability, both in terms of their power and in terms of, it's their problem and to the extent that they aren't us, if you're not feeling disabled this week, put it in the hands of the people who really have a stake in it and then become their advisors, right? Well, I think the other thing is though, as we all get older again, all of us have different types of disabilities, right? All of us potentially included in this discussion. And so, but it is important to really acknowledge that issue and think about that. And so it's sustain our abilities now. I've collaborated with a gentleman, Alex Guinness, and he has spinal cord injury, but went to college and then to got his master's degree in environment and then public policy. So you've got to start thinking about how do we let these younger people do the work? And that's why you're all here. We want you guys to take this all over, right Andrew? Please. I did wanna just add to that. I posted David McMillan's work out of U Miami. I wasn't sure if Dr. Shapiro, if you were familiar with his work, but I know that he, the thing that I just posted, it's actually a disaster preparedness manual for spinal cord injury patients. But again, I feel like it's very much geared towards people who live in Florida. And interestingly, I actually was just at the Abilities Expo and FEMA was there. And they gave me this like handout. I actually had to like go find it, but they have links. But again, when I was actually talking to the lady about specifically people with disabilities, I was a bit dismissed. She just said, just look on the website and just, what did she say? Adapt it to those individuals. Because yeah, so I was like, okay. And then she gave me her contact information and she then said, cause I was talking about having something for an international audience. He's like, yeah, just go to FEMA and you can adapt it for that specific country. And it just made me think, I'm like, but how can we really do that if we didn't do like a needs assessment, we don't know what that country really is facing. So I definitely think even within the United States, just regionally, like there, I don't know if we can necessarily carte blanche use like the same disaster preparedness techniques because Florida does not look like Colorado. So I just, I was kind of surprised by her reaction. So I think that's a really interesting question that Lauren had, because I feel like they need people to help them kind of rewrite it. And maybe make it more regionally specific within the US and then, yeah, maybe take some of the general ideas and then adapt them to other countries, but you need a conversation with that other country to really understand the issues that they're facing. So yeah, go ahead. I was gonna say, I don't know that other countries think that the United States is the leader in terms of this. And so I think we've got to be extremely cognizant of people with disabilities, living with disabilities and knowing about their disabilities, wanting to take the lead in these areas. But I agree, we had put on a course on climate change and disability with Columbia. I tried to just access it right now and they changed their website. So I wasn't able to do it. We did a course in English, which was four episodes. And we had one episode that was basically people telling their stories about living with disabilities. And I think that's really important, but it's also important to get the worldwide view. It's not the same thing living in Africa or living in Australia and living in the US. So it's really a matter of, this group of people has an interest in it. We've all got to collaborate. I don't think there's anybody in this room that wouldn't be willing to work together on a project. And one of the things we do wanna do is do something more so on climate change, but disasters is part of climate change. We're working to get a educational program for people with disabilities, created by people with disabilities. Cause I think that's a key. You know, it comes back to kind of the same theme. I guess this theme is coming in my head over and over again. We are at the beginning and we are at the execution, but we're not the center of Columbia or Brazil, right? We, meaning the global community can look at a country and say, you really need a disaster rehab plan, right? I think we have a moral authority that allows us to say, you really need, okay? You don't have, and you really need. They're the experts on what it needs to look like and what has to happen there. And then because we've all talked to each other, my team at the IRF have talked to each other. We sometimes have expertise in the execution which they might choose to use, right? So you do have a moral authority to say, this needs to happen, I'll help you. We certainly don't know how to tell Bangladesh how to do it. You know, I actually, I don't mean to promote my journal so much, but we did a special issue on the issue of collaboration. And there was some interesting articles that people might want to look at there. There's a study that's discussed about a, actually in, not in Bangladesh, I think in Malaysia, where Welcome, the Welcome Trust funded a project that was people in Australia working in Indonesia and they changed the groundwater systems and to improve the water. And they talked about and gave the background of how they were able to integrate people locally into the project. And it's a qualitative research study about how that process happens. So there are a number of templates that we're trying to get people to be able to share because that is a requirement more and more when you apply for these international grants. The key is to get local people doing the research and to, you know, promote them that way. And you can't do these things unless you really have buy-in from the community. So that's a key thing. Well, yeah, and you know, we're really behind in rehab medicine, okay? My friends and I put together the global health curriculum for the University of Michigan, pardon the muffler. And, you know, when you look at obstetrics, when you look at orthopedics, when you look at infectious disease, when you look at pediatrics, there are whole universities that have departments of, University of Michigan's Department of Obstetrics, their whole, every faculty member has got an MPH in global health. That's a gig, right? You want to go to Chicago, they're good at forceps deliveries or something like that. So there's academic expertise in departments in different specialties around the country. About two or three years ago, we had a medical student who was interested in global health had an MPH and had spent time overseas. He was the real deal. And he wanted to do a residency in PM&R. And he worked with us and did a survey of all the PM&R departments in the country. And he could not find a PM&R department that had any academic specialization. Now that's different from global tourism or one of us having to care about, Bangladesh is my favorite country for the moment. That's different from the university department that hires a bunch of MPHs and gets Fogarty grants and does stuff as an academic center, right? So the science of what we need to do is coming from the seat of the pants. It's not coming from an academic institution that is teaching us what to do in our specialty. That is anomalous compared to the other specialties in the world. That's really interesting. Very interesting. Jenna, do we have other questions? Personally, I just really wanted to ask this question of you guys while we, if you're okay with me taking a little bit more time. One of the things we talked about was trying to help make our rehab facilities function more sustainably, help them be more prepared for disaster relief. So, if someone wanted to just make like a QI project, we're in our own rehab facility, inpatient, outpatient, private or academic, like what would you suggest that we start to like, you know, do like a QI project to help our local area have like a disaster preparedness and or function sustainably? I would love to talk about sustainable development. So, a couple of projects that I've seen people do. Anita Lowe, when she was chief resident at Stanford, did a project looking at, she basically did a waste audit and did a waste audit looking in the outpatient area of how much waste there was in different procedures and compared people that use the pre-made kits to people that used individual kits. And she did publish it in Journal of Climate Change and Health, you can see it online, but we did that as a resident and I think that's a great thing to add because when you go into rehab hospitals, you know, most rehab hospitals, at least the ones I've been in, you know, people don't recycle, there's no push for so many things, right? We reuse things, there's so much waste. Another, I guess she's a fellow now, Alexandra, I think her last name's Fogarty, she did a, she's written an article, actually she's involved in, she's doing a spine fellowship now, so she does pain management and she did a study looking at the pain injections and what the carbon footprint was of different types of pain injections. So she actually did the full cycle in terms of that. And so I think this is what we're going to need to do is start looking at, you know, there's so many issues when you think about sustainability and rehab centers, right? You know, there's so many practices people have, they just make patients come back, they don't think about all the issues of how far they've got to drive. Telemedicine is really important. Adam Tenforty at Spalding, you know, he's a sports guy and he'll bring people in the first time, but after that, everybody that comes in for a follow-up visit is a telemedicine visit. So it doesn't even matter if you're close, you know, just on the other side of the city or far away, you're saving carbon, you're saving time, you're improving people's quality of life. So my own hope, and I would love to see one of you guys take this over and maybe Andrew, you could facilitate a conversation in this, is I do think CARF needs to start thinking about it. I think one of the CARF requirements has to be disaster preparedness, but also what are you doing about sustainability? You know, all these issues have to start getting taken forward. And, you know, my dream is to develop like sustainable catheters, right? Think about that. I mean, there's just so many other things we can do in healthcare. And then think of the issue of the prescribed nature prescriptions. You know, social workers write nature prescriptions for people. We did a study on nature prescribing in Canada where, you know, we could all prescribe nature to people. You don't need an MD to do that. And it's better than drugs. You're saving a lot of things. So there's a lot you can do, and that would be a great QI project for people. Yeah, I want to emphasize what you're talking about here, Marka, because I think this is so actionable and it requires some strategy. In other words, you know, waste in hospitals, right? It's a really big deal. I get frustrated with the work I've done to try to create change, right? So I write a paper on paraspinal electromyography and 15 years later, a fifth of the physiatrists are doing paraspinal EMG, even though we proved the hell out of it, right? Then we wrote a stupid paper comparing the number of rehab doctors in Africa to the number of rehab doctors in Antarctica, right? And it gets published in five journals and changes WHO policy, right? And so you need good science. Do not blow off the idea that studying this in a hospital is really important because you don't want to start with a bad basis. We're not a bunch of crazy people. Well, I am, but you're not. So you need the good science and someone needs to go out there and study it in a hospital and study it in another hospital and come up with the commonalities that occur across hospitals and write about it. And then there's got to be some pressure and strategy. And if CARF is a great idea, but why is everybody else going to copy what I'm doing is the question I always have. Why are they going to copy this if I write the paper? And for sustainability in hospitals, whoever starts doing the papers needs to start thinking about how to influence change across the country, not just writing a paper and getting tenure. So I do hope people take this on. There's some real studying to be done and then they just really need to hammer it home and make sure that every hospital in the country is embarrassed if they don't do it, right? Yeah. A lot of changes that are important. Yeah, no, those are, but thank you for answering that. That was something I really was really curious about to ask you. And if we still have time, I know everyone might be getting tired. So just let us know if like, you know, we're done, but, you know, Dr. Hay, you kind of mentioned this too about like, you know, running out of steam when you're fighting for a cause. So, you know, for anybody, Dr. Alexander or Dr. Hay, when you quote, like run out of steam, fighting for climate change, what would you say keeps you going? Heroin. What? You know, it's, I'm gonna answer that a little differently. I think the thing is that you've got to, take a break. You've got to do other things. You've got to look outside. Like I'm in Florida right now. And yesterday I found an alligator in a pond and I'm like, all right, I hadn't seen one in this town. So that's an exciting thing. You know, my life's dream was to go to Antarctica and see what Antarctica's like. And I have two kids that are into climate change. And that was our big, big expenditure. But seeing how beautiful it is and seeing all the things that you can lose in life is really key. Learning how to scuba dive a couple of years ago, seeing all the beauty there, all the things that may not be there for people. You've got to take a step back and you've got to, you've just got to push. It's hard. I've given lectures on this topic and I've gotten attacked. And, you know, it can be hard, but you just got to keep trying and realize how many people care about this and how important it is, not just for your future, but for your kids' future. And I think that's a real big, real big thing. And aside from my heroin, which I haven't used in many ever, anyhow, and Mark, I want to give a nod to the importance of having a balanced life. You have to do another stuff. We are coming back from school, right? And we've been biking every day and it's been kind of fun, right? You have to have your other life. If you don't, you're just too crazed. But the other thing is that within the context of your work, if you're doing global health work, if you're doing sustainability work, you know, you've got to find the place where you've got that grant. You've got to get the energy to write a grant so you get a half day free every week. You know, you got to start working on a career path. You need to get on the podium because even if you're a introverted person, the fact that you're the person talking at a regional meeting about it really brings energy back to you. It validates you. You begin to hear that other people think that what you're doing is worthwhile and important. So within the professional part of it, you need to, you're going to volunteer more time than you ever think to get anything done. Don't worry. But you also need to seriously think about the sustainability of your volunteer work. You know, can you get donations? Can you get your development office at your university to support little bits of grants, you know, so you can get other people involved? So do look at the things that feed your energy within your work as well. And it's typically time away from other clinical duties. It's typically just a little bit of recognition that people realize you're actually doing something special and you have to seek it out. You can't just hope that somebody notices that you're saving the planet. It just doesn't come as easily as you think. And I think on that note, I'm going to wrap things up. And just a couple of things that I wanted to say is based off of, you know, what you just said, Dr. Haag, about positioning our careers. Our next session is actually going to be during the summer. We're doing a summer series with actually non-physiatrists who are doing work in global health. And our goal is to, we also have a physiatrist who will be part of the discussion, but the goal is to really help, you know, residents and medical students who are interested in international rehab and global health to, you know, sort of design their perfect career in international rehab. So, you know, there's strategies to go about it. You know, we talked about a ton today, you know, getting involved in research, getting involved in policy. I myself have a policy background and I know how hard that can be. And especially just, you know, having to network and talk your mouth off, you know, until you're blue in the face and hopefully somebody's listening to you. But there are different ways to, you know, forge a path in global health. So that's something to really look forward to over the summer. It's our summer series. We're gonna have, I think right now we have two planned and then just sort of a side note, because I do think that, you know, we can't sort of forget the power of not just research, but, you know, I think Dr. Alexander, you're already putting yourself out there. One thing we did do was we did put together a proposal, very similar to the program at Columbia on climate change and disability for AAP. I know it's not our organization, but I'm just letting people know. So, you know, it's not just AAP Menard, but, you know, I think it's really important to put our faces out there in other organizations and non-physiatry groups because they don't, first of all, they don't even know what we do. And then here we are talking about climate change, you know, and they're like, wait, who are you? You know, so I think it's really important to one, get our faces out there, let people know what PM and our docs are and what we do and, you know, bring our expertise in climate change and disability. So I think those are really important. So for those of you who are looking to, you know, do projects or to, you know, perhaps, you know, speak at other organizations, that's just something to keep in the back of your mind. And the last thing I wanted to say is, just because I've been so, like, intensely interested in this topic, I've been, like, scouring, like, Netflix, Hulu, like, Apple TV for, like, you know, documentaries or even just, they don't have, they can be fiction, you know, fictional stories. And one of the shows that has just really gotten me recently is called Extrapolation. I believe that's what it's called. It's on Apple TV, but it's really interesting. It's all about climate change. So if you haven't seen it yet, it actually follows, like, a group of people who are, you know, going through, you know, the effects of climate change and the effects of climate change on their families and their, basically, their legacies, you know? So it's a really interesting, you know, thing to think about. Maybe that's another thing we can do is to do a documentary. I don't know, maybe ask, you know, the IRF and Sustainer Abilities to do a joint project, to do a documentary and, like, you know, put people on camera. And, you know, hopefully we can have more people listen. So really using social media as well, because, you know, the millennials and the Gen Zers who might be here, that's all they, you know, pay attention to nowadays. So I think that's another project to kind of put on the docket. But I am so pleased that, you know, this was such a great event. I'm so excited for everything that's to come. And we are here to help both of your organizations. So, you know, we'll definitely keep in touch. And for anybody who's interested in getting involved in these projects, please reach out to us. And we'll have, we'll send everybody an email about Sustainer Abilities and the IRF. And hopefully you guys can connect with them. So thank you, everybody. And thank you, Dr. Alexander and Dr. Haig. We'll see you in Cartagena. Bye-bye, everyone. Have a great day. Thank you. Bye-bye. Thanks so much.

climate change

disability

disaster preparedness

health impacts

inclusive mitigation

rehabilitation

assistive devices

collaboration

disaster response

FEMA

sustainability