Rebecca Haddock 0:02 Hello and welcome to the health system resilience and sustainability session. My name is Rebecca Haddock and I'm the director of the Debble Institute for Health Policy Research at the Australian healthcare and Hospitals Association. Together with Professor Alexandra Barratt from the University of Sydney, I co-lead the health systems resilience and sustainability theme within the network. Before I begin today's session, I would first like to acknowledge the traditional custodians of the land from which I'm joining you today, the Ngunnawal people, and pay my respects to their Elders past, present and emerging. Transforming the health system for greater resilience and sustainability requires consideration of the systemic and complex nature of climate change as a determinant of health. Attention must be paid to both patient level processes and the different framework requirements at each level of the health system. The healthcare system and infrastructure will need to adapt rapidly to episodes of extreme heat, bushfires and smoke, and infectious disease outbreaks and in turn made related increases in healthcare demand. Critically, the sector will need to substantially reduce its own carbon footprint to meet net zero emission targets. For these activities to be achieved, we will need to improve energy efficiency of buildings, reduce healthcare demand, medical waste, and excess testing, and use more virtual healthcare including telehealth. Currently, these reforms are challenged by fragmented and inadequately analysed data, solid health organisations and professional associations and specialist care that is disconnected from primary care with no national system for compiling and sharing actionable research evidence. Therefore, strong leadership within the health and research sector, supported by innovative evidence based and practice informed strategies that support the resilience and sustainability of a healthy Australia, will be essential to responding to the impacts of climate change on Australia's health outcomes. As part of the HEAL network, the health systems resilience and sustainability thematic will contribute to this leadership through three core activities. Firstly, we aim to assess the health system's vulnerability to environmental change and extreme events, including associated costs and adaptation needs, particularly over the long term and in regions most affected. Secondly, we aim to strengthen the resilience of the sector to extreme events and overheating and mitigate the sector's environmental impact through holistic health care interventions. And finally expanding on existing experience, we aim to pilot a national sustainable health unit to track health care's environmental resilience and footprint. So it now gives me great pleasure to introduce Dr Elly Howse, Research Centre Manager and senior research fellow at the Australian Prevention Partnership Centre at the SaxInstitute, who will be facilitating today's session. Over to you Elly. Elly Howse 3:11 Thanks so much, Rebecca. Hi, everyone. I'm phoning or calling in today from the lands of the Darkinjung and Kuring-gai people on the central coast. So just want to acknowledge those Elders past, present and emerging. So today we're going to be hearing from two fabulous speakers. And then we'll be having a panel discussion about the health system and environmental impacts of environmental change and climate and so on. So first, I'd like to introduce Dr Arunima Malik from the University of Sydney to talk about environmental footprints of health systems. So Arunima is an academic with the School of Physics and the Business School at the University of Sydney. And she undertakes big data modelling to quantify sustainability impacts. And Arunima has carried out a range of sustainability supply chain assessments of healthcare at the regional, national and global levels. Her research is very interdisciplinary, which is fabulous and focuses very much on the appraisal of social, economic and environmental impacts using input-output analysis. So, I'd like to invite Arunima if you've got some slides to share, and we'll get started. Arunima Malik 4:24 Thanks, Elly. So just stop, slide. Share. Yep, thank you for inviting me to speak today. In my presentation, I'll be talking about some of the work that we are doing at the University of Sydney in quantifying the environmental footprint of health systems. So what is the environmental impact when we look at the health system from a supply chain perspective? So the kind of the research that we do involves looking at upstream supply chain networks, starting with the healthcare sector. So the healthcare sector, of course, interact with other sectors in the economy, maybe in a food, resources, goods, energy and services. And if these sectors need to supply inputs to the healthcare sector, so for example, the health sector needs input of electricity. So where does electricity come from? If it's fossil fuel based, then coal mining sector needs to provide input into the electricity sector producing electricity, which eventually goes off to the hospitals. So from a supply chain perspective, when we do environmental footprint assessments, we look at the upstream supply chain networks. So starting with the demand by healthcare systems, for the different commodities or goods that they buy, and the sectors that are involved, and these sectors in turn interacting with other sectors of the economy so that they can sort of produce the relevant goods or service that is bought by the healthcare sector. So in terms of quantifying these impacts from a supply chain perspective, so looking specifically, in addition to scope, one and two, scope three impacts as well, which are hidden in upstream supply chain networks. We've done some assessments at a national level, we've done some regional assessments and also a global level. So in my presentation, I'll talk about some of the work that we have been doing in this space. So essentially, when you have to do supply chain assessments, you really need to consider: Well, what are the inputs that are being bought by the healthcare sector? And what are the associated impacts. And when I talk about impacts, I'm primarily referring to these indicators that we consider in our sustainability assessment. So they can either be emissions, so emissions embodied in the supply chains of health systems, or water embodied in the supply chains of health system or waste produced directly and also indirectly in the supply chain, or satisfying the different inputs that the health sectors are buyers from other sectors in the economy. So we know that the health sector, of course, spends money on a lot of things: electricity, equipment, food, and lots of other consumables. I've got dot dot dot here. So really, we know that the health care sector interacts with a range of other sectors, primary, secondary, and tertiary sectors in our economies. So what are the associated impacts of these interactions. We can do these assessments on these so called industrial ecology and virtual laboratories, which are essentially cloud computing platforms that we have been developing in collaboration with other universities. So it's about a seven or eight University collaboration across Australia. And these labs offer information on how different sectors of the Australian economy interact with one another. So if I pick the example again, for electricity, then electricity, of course needs input from the construction sector, from the equipment sector, coal mining or other sectors in the economy. If we need to mine coal, then when in turn need to interact with the equipment sector or the construction sector. For making equipment, we need electricity. So all these sectors in the economy are very much inter-connected. So the connections happening and these connections can sort of be visualised and also documented in the form of input-output tables. So these input-output tables we get from the ABS, which is the Australian Bureau of Statistics. They produce these tables on a regular sort of basis, we get these tables, and we feed the data into this IE lab platform along with information on a range of indicators. So emissions data from national greenhouse gas monitoring, information on water or waste employment. So how many jobs are created in the supply chain? So we have some indicators that we consider as positive indicators and some that we would rather not have so much impact for so for example, emissions. So these these labs that we have been developing, and there's one for Australia, which includes specific information for those drilling economy. There's a lab for Taiwan, there's a lab for China, Japan, US. So we have been developing these labs for a range of different countries around the world. And there is a global lab as well, which lets us know how is Australia interacting with other countries of the world and the sectors in countries that are producing other goods and services that we might import. So these labs, they offer a capability of constructing customised databases. So for the purpose of calculating impact for the health sector, we firstly identified the relevant sectors in the input-output tables that we will need to consider for such an assessment and we made a customised input-output table in the IE lab. We then integrated information from AIHW, which is the Australian Institute of Health and Welfare, and then produce these reports on health expenditure for Australia on a regular sort of basis. So we've got information on what the spending is for the health sector on hospitals, public and private, dental services, and other categories. So we have public hospitals, private hospitals, pharmaceuticals, dental services, community health, public health, other health practitioners, referred medical services and a range of other categories. So all this information we obtained from AIHW from the report that they publish and we integrated this information with the economic input-output model that we developed in the IE lab. So it's, it's a bit like saying that we have an economy, and we're trying to really see how the health sector interacts with every other sector in the economy. And we're trying to put a number to the impact associated with the demand in terms of electricity, equipment, or other consumables that the health sector buys. So this is a form of hybrid lifecycle assessment, where we have top down information and bottom up data that we integrate into the top down model. We did this first, at a national level. So this study was published a couple of years ago, looking at the national carbon footprint for Australia's healthcare sector, by taking the expenditure. So the expenditure again, from AIHW, so all the spending for these different categories, as per the definitions of AIHW. So we got the categories directly from the report on how they've defined these. So public hospitals, that's the expansion, for example, and expenditure for other categories in the health sector. We then integrated data, andthe indicator that we were interested in. So at first, we started off with emissions for this study. So we looked at the emissions directly. So this is the direct emissions factor. So impact per dollar, so kilotons per million Australian dollars for each of these different healthcare sectors, and the total impacts. So the total impacts take into account the entire supply chain network. So the supply chain tree on my first slide, where I had the health sector of the bottom and the different sectors of the economy, and that provide inputs to the health sector and other sectors that in turn provide inputs to the sectors that provide input to the health sector. So it's like suppliers, suppliers of suppliers, suppliers of suppliers of suppliers, and so on. So all those interactions get captured in the total impacts. So these are intensities per dollar, so direct intensities, and total intensities, and then the absolute impact in terms of direct and total. So if we look at these two figures down at the bottom, so we have these direct impacts from Australia's health care system, and the total impact, we can sort of quickly see that the total impacts are much higher than the direct impacts. And this sort of highlights the importance of looking at the supply chain impact, so impacts embodied in the upstream supply chains of the health sector. So after having done this study, we thought well, this was done nationally at an Australian scale. How is the health sector performing if we look at the different states within Australia. So then we thought that it would be interesting if we break this down further to do a regional study, where we have not just the national perspective as in the sectors interacting with one another at a national level, but the sector is interacting at a sector level. So there might even be interactions between the sectors in Queensland, with the sectors in New South Wales or Victoria. So we then developed a multi-regional input-output model. So this multi-regional input-output model offers information on different states. So we have a range of states featured in the model that we developed and the different sectors in those states. And we integrated data. Again, it was a hybrid lifecycle assessment, we integrated data on different healthcare categories into this multi-regional input-output database, and ran the assessment by creating a model which was quite a quite large model in comparison to the national model that we first started off with, and using that we looked at the impacts of different production layers. So we have, again, the supply chain, starting with the healthcare sector, and the demand of the healthcare sector, from other sectors in the economy. And those sectors in turn interacting with the rest of the economy for producing inputs, and so on and so forth. So we have that impact broken down according to different layers of production. So we call these production layers, which is which are the different layers if we look at the upstream supply chain network, so we thought, well, it would be interesting to further The breakdown the footprint, the total amount that we get from these environmental hybrid lifecycle assessments to see where exactly are these hotspots and how far away these are from the healthcare sector. So how far up do we really need to consider the impacts to get an understanding of the scope three impacts of the healthcare sector. So in terms of two indicators, for illustration, we have greenhouse gas emissions and water use. So greenhouse gas emissions, different layers of production. So these are layers where you have the immediate suppliers of the health sector, then suppliers of suppliers of the health sector, then suppliers of suppliers of suppliers of the health sector and so on. And considering these layers of production and plotting these in a cumulative sense, where you have your impact at layer three, which includes the impact of layer three, and layer two and layer one, so you can start to see when it starts to flatten out these impact. So looking at this, we found that for the greenhouse gas indicator, the key sectors responsible for the impacts, from a supply chain perspective for the healthcare sector, are mining, transport, agriculture and utilities. So utilities includes electricity consumption by the different health care categories. And this was done for New South Wales. So we looked at the regional perspective, and we specifically focused on New South Wales because the study was done in collaboration collaboration with New South Wales Department of Planning, industry and environment. So we thought we'll start with New South Wales, to see what the impacts are, and break this down further into different layers of of production. We also looked at water as an indicator in addition to greenhouse gas emissions. And here as well, we have agriculture. So that's, that could be food. So agriculture, which is a primary industry providing inputs for the production of food, which is then bought by the different healthcare sectors, for example. So agriculture, utilities, and health services. So these are some of the direct impacts happening within the health sectors and the indirect impacts in the supply chains of the health sector. So it includes both the direct and the indirect impact when captured from a supply chain perspective. In addition to looking at a regional perspective, so he's for New South Wales, and national perspective, so all of Australia. We've now started looking at a global perspective, and expanding this work for a range of other indicators. So in addition to greenhouse gas emissions and water, we're looking at PM. So the study was recently published in Lancet Planetary Health, where we looked at PM, NOx, SO2, so we're looking at air pollutants, malaria risk, which is caused by deforestation again in this from a supply chain perspective, nitrogen emissions, scarce water and of course, greenhouse gas emissions. At a global scale, we wanted to see what are the impacts when you consider the health sector in all countries around the world. So from a global perspective, we broke down the impacts according to the direct impacts, which are these darker bands for each of the different indicators. First Order impact which are direct suppliers. So impacts, if you consider the total footprint for the healthcare sector and you break it down, according to the direct impact happening within the different healthcare services or the First Order suppliers and the supply chain impacts. So looking at a global perspective, we can see that there are impacts happening directly of course, on the premises of hospitals, for example, or other healthcare categories, first order suppliers that provide inputs to the healthcare sector and higher order suppliers as we call them. So, all indirect apply upstream suppliers resulting in impacts. We also looked at trends over time. So, how is the footprint changing? So, if we pick one indicator, out of out of these ones in the paper, we present these trends for all these but just for illustration, if we pick just one indicator, which is nitrogen emissions, reactive nitrogen in water and in air, so if we look at nitrogen footprint, and we look at expenditure, so healthcare expenditure at a global scale, of course, has been rising from 2000 to 2015. The intensity is improving, which is a positive sign. So because of technological improvements, there have, has been a reduction in nitrogen emissions per per US dollar. So the intensity is improving as we can see, here, and footprint kilogramme per capita that stays fairly fairly constant, but the emissions are rising because of a rise in healthcare expenditure. So this this sort of shows that if you break down the footprint according to the drivers or the determinants, we can start to see that the footprint is increasing and that is primarily due to a rise in expenditure. Yeah, what are the findings been used? So, in collaboration with NSW Health, we, so this was a position statement that came out where some of these findings are featured. So, as a researcher, I'm glad that some of the work that we're doing is going in the policy space as well. And I'll stop it. Thank you. Elly Howse 20:39 Thanks so much Arunima. I'd now like to invite Professor Priya Rajagopalan, to speak about adaptation to overheating. The response from the built environment. And Priya, I'm just going to put your bio into the chat so you can start straight away. Thanks. Priya Rajagopalan 20:53 Okay. Thank you, everyone. And thank you for the opportunity to present into this. Today, I'll be talking about adaptation to overtaking and how the the VIC government has been wanting and how it should be responded to. So we have all the importance and significance of climate change and extreme hot days, which is predicted to increase significantly over the next few decades. This has got a huge impact on public health mortality rates, and a huge demand at the economy. We all know that although Australia has always had heat waves, bushfires and hot days, climate change is increasing the risk of more frequent and more longer heatwaves and more number of extreme hot days. You sure remember the extreme hot day events in the 2020-2013. That was phenomenal, and which actually caused many of the records to be broken, including the hottest day ever recorded for all over Australia, the temperature maximum, average maximum, was recorded as 40.3 degrees Celsius, And this prompted the Bureau of Meteorology, to change their weather forecasting chart, which was previously capped at 50 degrees Celsius. There is two more additions of purple, dark purple and the pink colour, and the temperature actually increased up to 54 degrees Celsius. So what is the impact of this on the built and beyond then. Let's look at cooling energy. So the problem of overheating becomes more significant when we move away from the coastal area. We all know that most of the cities in Australia they have been developed next to the sea. And in order to get the benefit from cooling characteristics of the sea breezes, but not everyone can afford to be living next to the sea. And then you move further inland, the temperatures are much higher, mainly due to the impact of the test. And this is a picture which is showing the distribution of cooling load. If you a reference office building, and how when you move away from the course how's the cooling load actually increasing. And you can see the northwestern part of Sydney, which has got around double, two times the cooling load compared to those who are living close to the coastal. And this actually equates on heatwaves, three times more mortality rate in this area compared to the costal areas of Sydney. And this is a study by the UNSW High Performance Architecture group, which is led by Professor Mike Santamouris. So the impact of the overheating and associated risk, they have a big impact on the old buildings like many of the Australian buildings are currently, you know, call it like a 1.5 star and retrofitted building and also the new building stock particularly. And it's not only in Australia, but this is a huge issue for the public health across the world. So what happens is the dense urban areas and inner city neighbourhoods they have limited open spaces for green areas which will actually trap the heat inside basically calling this as the urban heat island phenomena. And the heat wave incidents in previous years, right, one of the 2008-2009 extreme events actually, we have seen that the ambulance callouts for cardiac related illnesses were significantly increased. And the predictions actually show by, through model impact, they are expected, if this continued to longer periods, it's expected to lead to 2000 or so heat related deaths in Australia. So we all study, we all have experienced actually hot events and it has caused heat stroke in some people, but the problem is worse when in those people who have reduced ability to regulate body temperature such as older people, very young people or people with chronic illnesses. And if you look at your neighbourhood who I mean, there are, some of us probably happy living in tropical, hot arid climates, but people who live in temperate climates are more likely to be affected because they are not used to such extreme heat conditions. And also in cities with cooler climates or example, in Melbourne compared to Sydney or compared to Brisbane, the temperatures threshold where heat-related deaths begin to increase during a heatwave is lower. So that means Melbourne with a 35 degree could be equivalent to Sydney in a 38 degree, so we have to be a bit careful there. And also exposure to heatwaves earlier in the season, like sometimes we observe a huge waves is actually coming in before the start of December that has a greater impact on mortality because the population has not had a chance to adapt to those temperatures yet. So I'm just focusing on one particular cohort of this depending on which is people who are low income groups and the houses inhabited by them because this is where the biggest risk lies because most of the people who who are low income, they don't really have access to, you know, air conditioning, or high quality buildings. So and in addition, the low income households are typically associated with parts of the city with the higher land surface temperature, for example, in the inland areas in Sydney and Melbourne, which doesn't really have the cooling effect of the coastal areas. This is an example of temperature profile, which we measured during the summer in one of the vulnerable, heat vulnerable, local council area in Melbourne City Council and you can see they're trying to plot the temperature. The Bureau of Meteorology data stations, which is basically away from the urban environment, and how the temperature within the built environment actually can be up to four degrees Celsius higher. So most of the predictions and simulations which is happening, you've seen this Bureau of meteorology weather stations are actually under predicting the impact in the building. And this is a simulation study of taking a low income, unconditioned, residential building simi-typical design layout and see just focusing on, you know, three days of hot, three hot days, where the temperature in the first day actually started about 39 degrees Celsius and trying to plot this along with the temperature inside the bedroom, inside the lounge, inside the home etc etc. And what you can see here is even when the temperature is reduced enough in the first two days, during the night, it still goes high during the day, but what actually heated up it takes a long time to cool because of how the construction. There is no way to ventilate or there is no way to shape the walls or the windows from the extreme heat. So there are passive design strategies for example, building materials, insulation, appropriate shading, orientation, and lateral integration which can help protect older people against heat and heat related illness. However, you know, there are days, particularly in summer, where none of this natural ventilation or passive strategies will work and that's where we need to find some air conditioners to get that sort of thermal comfort for residents. However, a large number of low income groups don't have access to healthy residences. Elly Howse 30:08 Priya we might close there and jump to the panel discussion and talk a bit more about these. I just noticed that we've only got about 10 minutes left before the next room starts. So I might just asked Katie, Eugenie and Gerard to put on their cameras or, you have. Great. So joining us on the panel is Gerard Duck from New South Wales Ministry of Health; Dr Eugenie Kayak, from anaesthetist, I can never say that probably, and also Associate Professor Katie Bell, an epidemiologist from the University of Sydney. And I've just got a few questions for them. I think the first question for Gerard is about, um, how is the health system, I guess, planning to respond or is already responding to some of these issues that both Priya and Arunima and others have outlined, such as extreme weather events and heating, and so on. Gerad Duck 31:03 Look, thank you very much. Thank you very much for the opportunity to join today. Just wanted to acknowledge that on on Darwell country today in the Illawarra. So the New South Wales Health is responding in several different ways. I think one of the key things just to link into Arunima's presentation today is on that concept of the sustainability of the health system in New South Wales from an environmental impact point of view. So we've seen quite a bit of momentum behind that concept over the last few years. I think, the last 18 months, we've been somewhat sidetracked through the impact of the pandemic has really taken a lot of the headspace in resourcing away from this area internally within the Ministry of Health and across the health system. But I think we're rapidly turning back our attention to these areas. And I think there's some organisations within the New South Wales Health, sort of broader cluster that have really made quite strong commitments. I think there's going to be some discussion tomorrow in the New South Wales hub in a presentation around the Hunter New England Local Health District, for example, which has made a commitment to be carbon neutral by 2030. And so there's a lot of planning and implementation of those sort of things happening at a local health district level. Essentially, the one of the key sort of supply chain links for New South Wales health is an organisation called HealthShare, which supplies a lot of the food services, linen services and other support backup house services across the public health system and New South Wales Health. And they released a new strategic plan in the last couple of years, which includes an, a, one of the three pillars in their strategic plan is to be sustainable, and support the sustainability of the New South Wales Health System, really acknowledging their role in terms of the procurement role that they have across the system and how that impacts those supply chains and what we're delivering across the system. So those are just a couple of examples. I think also, I noticed in the last few weeks, there was the New South Wales Health solar power programme, was a finalist in the New South Wales Premier's Awards where there's been installation of solar across a whole range of health facilities across the state. And in fact, I believe one of them at John Hunter Hospital, which I'm sure you'll hear about tomorrow for people that join the session, is the largest solar installation in a health facility in the world. So look, there's a range of ways that New South Wales Health is responding, of course, though, there is much, much more that we can continue to do. Elly Howse 33:46 So I know that, you know, we've mentioned before that the UK has got their sustainable health care unit, which is part of the NHS, but Australia is a federated country. And, you know, health care is actually predominantly delivered by the states and territories. So I'm wondering Eugenie, if you've got any thoughts about what a sustainable health care unit might look like in Australia? Eugenie Kayak 34:08 Yes, um thank you. And I'd also like to acknowledge myself the Woiwurrung people of the Kulin nation that I'm on. And yes, yeah, excellent question. And Australia is not like the UK and the way our health care is delivered here does sort of, you know, present unique challenges. So not only do we have that the state's predominantly fund and run our public health system, but the federal government does actually fund our Pharmaceutical Benefits Scheme and our Medicare benefits, which include our GP funding and a lot of other funding. So it's a very complicated system and to throw that into the mix we also, of course, have integral to our health delivery private and not for profit systems, which they don't necessarily have in the UK. So DA has really advocated for a national unit like the UK has for almost a decade. But really, I think the challenges for one, we're probably insurmountable up until very recently, and I say recently being the last two years, primarily because we probably couldn't have had the right policies and regulations to cross all over those separate jurisdictions and entities that provide health. What's changed? Why do I think it's so necessary and possible now, and that is because over the last two years, there's just been such a change within healthcare with the in the people working within health care, right from the board members, to the executives, to doctors and nurses on the ground for change and for roadmaps and guidance on how to decrease our emissions. And therefore, I think, a well set up national unit, which was actually worked as providing the carrot rather than the stick, could really result in significant emission reduction targets for our sector. So from the beginning, you'd probably only have 10 to 15 people, like the NHS only did for the first 15 years, either in the Department of Health or in another health entity. And they would be people who could actually, like we've heard today, start by consistently measuring and giving a standardised guidance of how to actually measure our emission reduction targets because it's a bit hard to change what you're not actually consistently measuring. And also to provide guidance on the best sustainable models of care and evidence-based roadmaps for change. There's just such an appetite out there now to actually make a dent into our environmental impact from the healthcare system that I think it really would be possible to do that with the national system, which would work of course, with state based systems and private entities, including industry. Elly Howse 37:00 And I guess one part of this conversation is all also about keeping people out of hospital and from really costly, high carbon intensity procedures. I'm wondering, Katy, if you can tell us a bit about things like telehealth, which have been proposed as a low carbon alternative, what do you think about that? Katy Bell 37:19 Sure. Thanks Elly. And and I'd like to acknowledge that I am on the unseeded lands and the Gadigal people. So telehealth is a great example of a potential innovative new way of delivering health care that that could be a lot lower carbon emissions. But I think it's important that we need to have good robust comparative evidence for new delivery, like telehealth, to make sure that there's not unintended consequences that could potentially increase carbon emissions. So telehealth, for example, seems to be particularly beneficial for monitoring conditions that have already been diagnosed. But potentially, it might not be the solution for replacing all kind of face to face visits. That means that the doctor is more uncertain and ends up ordering a whole lot more medical tests and other health care which all have their own carbon footprint. Elly Howse 38:21 Great. And I might just get Arunima and Priya to wrap up and say a couple of things. With Priya we've talked a lot about the health system, but that's obviously really influenced by what's happening in other sectors, are there things that we could do in urban planning and housing that could actually reduce some of those, you know, that burden on the health system in an effective and cost effective way? Priya Rajagopalan 38:44 Yeah, so, we got a lot of this happening in the built environment. For example, the new National Construction Code census, which is proposed in 2022. And previously the housing and insulating system they looked at how the whole energy is just one total energy for heating and cooling and what happens is the the cooling energy is not really given enough importance, because of the the design is all around improving the during the cold climates. So what happens is even those 10 star, you know, the seven star houses, which probably, it has got a better energy efficiency compared to five star house. When you look at the performance during the hot weather, they are actually performing poorly compared to five star because of the but with new proposed changes to construction code, there is separate heating and cooling load limits, for which the suburb community pleading and also the climate science which they are actually using in this latest simulation that is also upgraded and also is Considering the future, bitter fires, which is somewhere you know, the climate change aspect is incorporated into that. And also there are these better apartment design guidelines, because apartments are something which was not really given enough attention because of various multiple reasons and over overheating in apartment buildings is a significant problem. But with the new proposed changes, there are more built to satisfy provitions for apartments, for example, providing overshadowing and also have some kind of landscape design and water management principles in the development, which is not yet compulsory but it's advisable for to reduce the urban heat island. So in addition to that, also, there are many councils, local governments, are doing a very proactive approach to have water sensitive urban design, and also have more community participation to actually monitor the information like how hot becomes inside the house. So having like really low cost, citizen science kind of engagement for people to monitor the conditions inside and then give, them actually provide evidence based data for these local councils to adapt and mitigate. If you want to provide a more open spaces, more greenery, more shading, and even retrofitting the houses with poor roof will significantly reduce the temperature inside and even reduce the energy consumption. So there's a lot building that currently the government is doing, which probably would be important in the coming years. Elly Howse 41:46 great, thanks, Priya. And just final thoughts from Arunima before we finish up because we have very rudely gone into Sharon session. So Arunima any final thoughts. Arunima Malik 41:55 Just really quickly, I would like to just highlight the importance of tracking emissions over time for healthcare systems. There are of course, a number of techniques that are out there and of course, they are now being put into practice in measuring emissions at a national, regional and global scale. And it's also really nice to see how this is translating now into policy. So Gerard mentioned the work that's happening in NSW Health and again, in collaboration with Dr Aditya Vas as well who was also one of the co authors for the regional study. So just really glad as a researcher to see how some of these techniques are translating into practice. And that's where I'll stop. Thank you. Elly Howse 42:35 Fantastic. Thanks so much to all of our panel and to our speakers.