Hello, this is Gilbert back again, and we're going to now look at some of the various forces that are driving population vulnerabilities, and this is part of our attempt to look at to what are the emerging risks, what are challenges for the future, and also what are the opportunities we have in the humanitarian community to block some of these vulnerabilities and reduce some of the hazards and some of the disasters that have happened to our populations. We'll also talk about how these forces interplay with each other to amplify or, in some cases, to reduce risks. And then we'll talk about how health services are likely to be affected by these forces that are responsible for the emerging risks. I've tried to indicate here some of the key areas that are responsible for the emerging risks and the problems that we're facing and challenges for the future. So we have population changes, we have food and economic factors, we have changing disease patterns, we have the fragile states, and then we have something that's going to complicate all of these, and this is the ongoing climate shifts that we're experiencing already and which we will see accelerating for the future. So let's start with the demographic forces. The demographic forces can produce some changes in demands, and they can increase instability. And this is an example in the population pyramid here of the youth bulge. So here's a population of a country where the population 10 to 20 or 25 years of age is the largest single element in this population pyramid. And in one level, this is quite a good thing because if you have plenty of employment for people and you have an economy that's booming, this young demographic element is really something that's going to drive development of the country, and this happened in China, it happened in South Korea, even happened in the U.S. But on the other hand, if you're in a stagnating economy and you have a large number of quite well-educated people coming online that now don't have employment, then this produces a lot of tensions, and this is probably one of the factors that contributed to the Arab Spring. A large population in mid and late middle age is becoming increasingly dependent and increasing economic pressure. So, if there's not a strong economy, this population can put big demands for health care without a large contribution back to the economy and this can potentially produce difficulties for countries as well. A number of countries are facing these kind of issues, particularly in the Far East, and it's uncertain how these issues are going to be addressed. Fertility is another issue of concern. The fertility rates increase stress on land and agriculture production. And so you can see from this map the various levels of fertility around the world, and high levels in South Asia, certainly in Afghanistan, but certainly throughout Africa, very high levels in Central Africa, Madagascar. In the Americas, the population growth has diminished. We look at population doubling times, that is, how long does it take for a country's population to double? We can see for the U.S.A it's 116 years; for India, it's 36 years. India is already the most populous country in the world, and you can think about how can this country manage a double population in 36 years. How is that going to potentially create unrest and tensions and potential difficulties for disasters in the future? Korea, China are high; DR Congo, 21 years; Gaza, 15 years – so every 15 years, Gaza is doubling its population. The population doubling time for Russia is never. In fact, we are in a situation where the population is generally decreasing as consequence of illness, of age, of lifestyle, and other patterns, but that produces its own potential for disasters in the future. When we look at the U.S.A, the population doubling time, 116 years, should point out that this is a combination of both fertility and for immigration. So, multiple factors play into this doubling time for the U.S. We look at demographic trends, again, that are potentially causing the root of disasters and stresses for the future. Economic growth is in the urban areas, so urbanization is an important area. Populations leaving villages and small towns now leaves these towns with a diminished capacity to cope. So if they're faced with human or naturally caused disasters, then they're less able to cope with this than they might have been in the past. A rapid urban population growth is not always matched by rapid growth in housing and infrastructure, so this creates a high level of susceptibility for populations. In the photograph here, you could see rapid population growth in the Philippines – very diminished housing resources in urban Manila and great stress on the population there. The expectations of urban migrants are often not met, and this causes political instability. These urban migrants can become very vocal in their demands for services and their demands for resources. Then we look at economic forces, economic disparities. These drive migration but they also create political tensions, and these political tensions that arise from migration are very carefully monitored in China. Nevertheless, in this graphic we see there's a huge difference in GDP per capita – this is a few years old, but it really hasn't changed probably that much. Coastal areas are the subject of many migration patterns, have a much higher GDP per capita, so that attracts people there, leaving hollowed-out areas in the interior. There's been a long history in the US of economic migration driving social and political change, and sometimes these have been violent and destabilizing matters. If we look at another indicator of economic inequities, it's the Gini coefficient, and this measures the difference between the wealthy and the lower quintiles in a population. So we can see that the dark red areas in this graphic are populations that have high Gini coefficient. So areas like Brazil, areas like Southern Africa are areas that are associated not only with big income disparity, but also poor health status and social tensions. They also occur in countries that have already high political fragility, so we can see that those can contribute potentially to the future instabilities in these particular regions. The photograph shows a number of casual laborers in the Gulf area watching a wealthy Dubai citizen taking his expensive yacht up Dubai Creek, and this is the kind of tensions that one sees in a number of countries. Then we see the issues of remittances – and this is an interesting area that is now becoming increasingly important: the amount of money that's being moved by people working in one country sending money back to another. These remittances weaken the receiving country's economy because it prevents them from encouraging development of their local resources, their revenues, and it creates a lot of social stresses where much of the able-bodied force is outside the country, not in the country contributing to the economy. There's also a loss of employment in the wealthy state, although the wealthy citizen probably would not do any kind of menial work that the people remitting the resources do. But it also affects not only employment, but it also affects the minimum wage in the country. So, the remittances and migrant labor has an impact and potentially could contribute to stresses and tensions that can predispose to crises in the future. Technological disasters and pollutions are an increasing risk from economic development, and many of these industries as they develop in middle-income countries are not being monitored appropriately. We have the example of Bhopal, we have the example of the extensive oil pollution in Niger Delta in Nigeria, and we also have an example of the Chernobyl nuclear reactor and the great long-term consequences that that has. The industrialization in these countries have an increasing risk of industrial disasters. And the capacity for early warning and the capacity for early response are limited in these areas, so we can't look at more and more of these technological hazards in the future and potential disasters based upon them as well. Then we have the issue of climate change, and many parts of Asia are going to be inundated potentially with a two- to three-meter rise in sea level. The countries that are at highest risk are countries like Bangladesh, countries like coastal area of China and in Vietnam. In this map of China, we see the areas that have highest population density. These are also areas that are only a few meters above the mean sea level in these zones. And so but we could see a rise in the sea level could potentially inundate many of these highly productive industrial areas. At the same time, a trend that we're seeing everyplace is migration to urban areas from rural areas, and many of these urban areas into which people are migrating are at high risk of flooding as well with a rising sea level. Also with the climate change, we're seeing the potential for a development of more severe storms, and we're already seeing this pattern emerging. This map shows where the storms are located in the world, and a rise in the sea temperature is going to give a rise to many more of these severe storms. So the kind of typhoons that we see that involve the Philippines, that involve China and Vietnam and particularly areas of Taiwan and China and in Japan are likely to be affected. We're going to see that in the US with the tropical storms forming off the coast of Africa that come into the US during hurricane seasons. So, the trend we've been seeing so far is a substantial increase in the number of tropical storms in the last 30 years. Then we see the impact of climate change on food security. And in the map here, we see a projected impact of global warming on agricultural yield. Some parts of the world will see a decrease in production, and this is going to affect particularly places in Sub-Saharan Africa. Unfortunately these are areas where the fertility remains highest as you remember from the graphs that we saw earlier, so we're seeing a decrease in the food production at the same time increase in population. So, potential for extended malnutrition and extended mortality from food insecurity is a real problem there. But there are going to be other parts of the world where food production may actually increase. So there'll be parts of areas in Northern Europe and in Central Asia and parts of the United States that will be positively affected by this with an increase in food production as the climate changes. Then we have the risk of emerging or reemerging diseases. And since 1947, there have been hundreds and hundreds of new diseases that have occurred, many of these coming from animals. As the range of vectors are changing, we're going to see more areas subjected to diseases that are carried by insects. We're gonna see diseases are gonna be affected more by population mobility, and this was a factor in the Ebola outbreak. The population in West Africa that was affected by Ebola was much more mobile than the population in Uganda that constituted many of our previous outbreaks. And we also see that the capacity of the health system to combat these emerging diseases is going to be seriously limited. We see this with Zika; we see the problems that occurred with Zika and our inability to get a good approach to managing Zika. And we saw that with Ebola and the many problems that were involved with Ebola. Now from the international community, Doctors Without Borders and many other charities did an amazing job in managing Ebola, but this really stretched their capacities and if we were to see another outbreak like this or a larger outbreak, this would probably exceed the capacity of the international community to really monitor these. And we see in the photographs one of the consequences of Ebola, the bodies being taken from coastal areas in Liberia and being buried in a safe manner to break the chain of infection with Ebola. Now, emerging diseases are also a problem because of air travel, and here we see a map of air pattern. So, a disease that could emerge in Southeast Asia could be spread to Europe and to North America fairly quickly. As some of you might remember, SARS, which was a major infectious disease, breaking in China quickly picked up in Singapore and also in Toronto, in Canada because of the air travel. Then we look at the fragile states. This is the 2015 Fragile State Index. But you can see where the fragile states are: in Southern Asia, to some extent, certainly in the Arab Peninsula, we see this in Central Africa and through much of Africa. These are also areas that are susceptible to climate change for agriculture. They're also potentially affected by emerging diseases so we can see an additive effect that can cause problems with disease and conflict and war as a kind of combined series of disasters due to fragile states. Here's a chart that shows state stability and per capita GDP. So you can see here that poor countries have a higher risk of collapse than richer countries. So, poorer countries have other issues as well – so we're going to continue to have instability in this sector of the population. So here we're going to talk about the health consequences of conflict. We see the loss of facilities, and in the photograph is one of the destroyed hospitals in the Balkans during the war there. There's gonna be a major loss in health staff that occur from conflict: some are killed, some migrate, or some are just so traumatized by conflict, they just drop out. Budgets that are normally designated for health are going to be diverted to military costs. Clinical skills of practitioners are going to become rusty. They will not have access to continuing education, they may not have access to internet or to medical journals. Populations are killed, they injured, they are migrating to other areas as a consequence of the conflict. So, they may take their diseases with them, and the locations they go to, they may put great stresses on remaining health services in these areas. Violence becomes a way of life – it becomes a method of problem solving. So, this is something ingrained in the way that populations deal with problem solving conflict. Now just some key points to emerge as we're thinking forward about the potential disasters, the potential conflicts, potential instabilities, and stresses for the future. We have to understand the public health consequences, that these are central to planning for the future. So when we think about the potential disasters in the future, we have to think about what are the public health consequences, how are we going to cope as public health practitioners with these events, and how are we going to address the needs of populations? Some emerging risks can be addressed through better prevention, but we have to think about those. In many ways, our chance to reduce the consequences of climate change on public health consequences are slipping away from us now, so we may have to be more aggressive in how we think about preventing things for the future. Increasingly risks are advanced, so we have to develop these methods that can cope and that we can develop methods that will build resilience in populations, and some cases it's almost too late for that. Much can be addressed through national level, at policy level, develop policies and procedures, but that requires a very proactive, forward-thinking policy, and that's our great challenge in political environments. However, we also know that there are a lot of public health measures that can be done at the local level. And in many ways, when national policy making is paralyzed, then we need to focus on local public health measures and local ways to identify vulnerabilities and to reduce risks. Projecting the changes and the needs for health services and planning for these is an important area. As we see, populations move. As the populations' need changes, then we see changes in vulnerabilities. And how do we project for this and how do we plan for this? This is critically important. And then, finally, we need to develop more effective response mechanisms for the disasters that will occur. Now, technology offers us many options here, and we've done much better in that. Populations are much better informed now than they were a few years ago, and we have much better communications which we can use to reduce risks and to encourage people to seek alternate approaches when disasters occur. So we have many options for the future, but we have many liabilities as well. So planning for the future is critically important, and there are many options and many new tools that we have at our disposal.