Good morning, everybody. My name is Saaj Savool, and I'm one of the speakers here. So we have, like, five speakers combined in, like, four talks, which will be about 15 to 20 minutes each. And we have Dr. Rosemary Sokas. She is actually joining us remotely. She is the moderator for the panel. And she is sitting near Georgetown University in D.C. area, a couple of hours ahead of us. And I'll give the mic to Dr. Sokas. Dr. Rosy, take it from here. Thank you, Saaj. Thank you so much. Can you hear me? Yes. We can. Okay, great. So I'd like to welcome everyone to Session 214, Occupational and Environmental Health in the Developing World, which is co-sponsored by the International Section and the Section on Underserved Occupational Populations. As Saaj said, I'm moderating remotely, and we're so fortunate to have him in the room as an in-person moderator. It's going to be my pleasure to introduce all of our panelists now in their order of presentation. We request that you hold questions until all have presented. So Dr. Saajat Sabol is the Program Director for the Occupational Medicine Residency Program at the University of Pennsylvania. He's faculty with the Perelman School of Medicine, and he's the Medical Director of the Penn Presbyterian Hospital's Occupational and Employee Health Division. Dr. Sabol has been heavily involved in COVID-19 surveillance in the workforce and vaccination planning, and has particular interest in the vaccination efforts in low- and middle-income countries and equitable access in high-income countries. Dr. Stephen Odonkor is a Fulbright Scholar and Senior Lecturer and Research Scholar, as well as Coordinator of the Public Health Programs at the Ghana Institute of Management and Public Administration. Dr. Odonkor's research interests include environmental and occupational health, water quality, microbial source tracking, antibiotic resistance, pollution, and sanitation. He is a visiting professor to several universities in Ghana and also at Rutgers University. Mr. Amos Mbore is the Director of Environmental and Occupational Health at the National Public Health Institute of Liberia. He's an environmental and occupational health practitioner with over 15 years of experience working in the field in Liberia. He holds a Master of Public Health degree from the Vrije University in the Netherlands. He's an Adjunct Lecturer at the University of Liberia College of Health Sciences, Department of Public Health. Dr. Benjamin Vannem is Advisor to the Director General of the National Public Health Institute of Liberia and Senior Researcher. He obtained degrees in General Chemistry and General Medicine from the University of Liberia, a Master of Medicine degree from the University of the Watersrand, and Master of Business Administration from the University of Maryland University College. He has served as County Health Officer, Program Manager of the National Malaria Control Program, and of the National AIDS and STI Control Program. And he conducted studies that led to the change in malaria treatment policy in Liberia. He led an effort to provide hepatitis B vaccination to all healthcare workers in Liberia, and he also lectures in the Graduate Program in Regional Planning at the University of Liberia. And Dr. Brian Davey, who is also presenting in person, is the Health and Safety Director for the World Bank Group. He's a South African physician who holds a Doctor of Medicine degree from the University of the Watersrand with postgraduate qualifications in research physiology and occupational health. He has held various positions in the United Nations system, including Head of Health and Safety at the Organization for the Prohibition of Chemical Weapons in The Hague, Medical Director of the United Nations in New York, and Director of Health and Safety at the World Bank Group, where he has been deeply involved in leading the World Bank Group Health and Safety response to the COVID-19 pandemic. So with that, I'll turn it over to Dr. Sabol and looking forward to these wonderful presentations. Thank you, Dr. Sokas, and I hope the audience will remember all that because we're not going to repeat that. Okay, I was nicely done. So the first presentation, as Rosie was saying, is on COVID-19 vaccinations, like the disparities globally, and then looking at it also within the high-income countries. So we'll be, like I said, that's what we will be doing here today, the global disparities and then the high-income countries, and also like to look at some of the recommended strategies to help improve vaccine distribution and acceptance. So the World Bank sort of assigns this like criteria of like anywhere from low-income to high-income nations, and as you can see, the 10 percent of the world population lives in the low-income, or what we call the poorest nations, and then about the 15 percent is in the high-income, and then your 75 percent in between. So population-wise, 85 percent of the world population is in non-high-income countries. This is a graph. It goes over about 16 months, and this looks at the – this is, by the way, by World Bank looks at the COVID-19 vaccinations, and this is doses administered per 100 people or individuals. And – sorry. So as you can see, the upper-middle and high-income countries are about 200 doses per 100 people, which by many vaccine criteria is like a fully vaccinated, and then going to the bottom of the screen, you can see the low-income countries is way down, so maybe 15, 20 per one – doses per 100 people. So why did the high-income countries got the majority of the vaccines first, you know, most of the vaccines, most of the commonly used vaccines were developed in those countries. There are in the research and development departments, the production, it was all there, and then they had, obviously, the financial resources to purchase the millions and millions of doses. And just to give you an example, by March of 2021, and just as a reminder, the vaccines were offered, it was like in early December, at least in North America, and in about those three months, Canada had purchased five times the doses it needed for its population. U.S. had purchased twice the population. So what about rest of the world? And so, there's another stat, like by April of 2021, this is again like the four months since the vaccines were available, 1 billion vaccine doses were administered globally, and of those, about half were in the high-income countries, which is, again, you're 15 percent of the world population. And then the low-income countries had received only, like, it was just less than half a percent. So then came COVAX. I mean, COVAX was already there, but then they took this initiative to support equitable distribution of 2 billion doses by the end of 2021 to the low- and lower-middle-income countries. And this was, the initiative was, like, mainly by Gavi, which is the Vaccine Alliance, and then SEPI, WHO, and then the distribution was mostly done by UNICEF. And they coordinated efforts, international resources, but keep in mind that most of the funding that they received was by or from high-income countries. Here's a graphical representation where you can see the European Union, the U.S. pledging, you know, just between them, like, 1.5 billion doses. And the darker blue that you see is the vaccine doses already delivered to the nations, and the lighter blue is, like, pledged, announced, and on their way. So this graph is from March 2022. Remember, it was, like, April 22 or March, April 21 when COVAX said, like, 2 billion doses by the end of 2021. So they are actually at, this graph shows that about over a billion have been administered or delivered, and they're close to 2 billion right now. So even with COVAX and also organized globally and had, like, you know, WHO, UNICEF supporting, there was still, the supply initially was limited. One reason was most of the higher-income countries were purchasing the vaccines, but then that got better once there was more and more populations vaccinated in those nations, then the lower-income countries received more and more vaccines. But by early this year, still, the poorer nations only had received, 8% of their population had received one dose, but still, it was better than 0.4% several months ago. And then, also, it was not just, like, not having the vaccines available. There was also, like, the poorer nations, their infrastructure, you know, getting the vaccine to the patient or the individuals. Some of these vaccines were, like, delivered by the time they got to their destination. They were too close to their expiration dates. So these photographs show, like, you know, millions of doses were unfortunately discarded because they were either expired or too close to their expiration. And then, you know, there were other factors, like, within those countries, the lower-income countries that they just could not handle the vaccines. So it wasn't the availability of the vaccines, but it was also how to deliver it to the end-user. This is, again, a more, this is, like, from three weeks ago, this graph, and you can see the orange is, like, one dose, at least, given, green is two doses, and then comes the booster. So, I mean, it's better than where we started over a year ago, like, you remember the 0.4% for the low-income countries, vaccinated individuals, and then we saw 8%, and now we are, like, at 5%, 15%, which is good, at least for the one dose. And I mean, forget the booster. I mean, you have to be fully vaccinated first to have the booster, and sorry, I pressed the wrong button. So, they're, like, under 1% if you look at the booster doses. And then, we'll look at some of the disparities within high-income countries, and I'll just give an example of maybe two or three countries here. In the U.S., the initial vaccine rollout was, you know, it was offered to the public. It was based on what the work was, where they worked, their age, and any comorbidities. There was no, like, socioeconomic status or any such thing, so, but, like, the scheduling was mostly electronic, and so, that first-come, first-served online scheduling mostly favored individuals, like, with that access, reliable transportation, you know, flexible schedules, like, where they could take time off from work and go and get vaccinated, and then there were also the reasons there, like, for the unvaccinated individuals, why they couldn't get it. And this timeline, I'm not going to go over, but just to show, like, within the first 14 days, there were two vaccines which were available in the U.S., and within the first 10 or 12 days, 1 million doses were administered, so the vaccine was there, and this, I'm, again, like a busy slide, but just showing this to have an idea on, like, the different phases, and then, again, like, who would get the vaccine, and who would get it first, so even here, like, the socioeconomic status, or, like, for example, I underlined a couple of criteria which were, like, you know, in phase one that they should get the vaccine. This is another study. This is called the ZO COVID study. This was by the King's College in London and Massachusetts General Hospital here in Boston, and they looked at 2 million individuals in the two countries, so in the U.S. and U.K., they found that racial and ethnic minorities were more hesitant or unwilling to receive a COVID-19 vaccine compared to non-minority groups, and also they found, like, unlike in the U.K., in the U.S., the minorities or, like, here, like, the Blacks in the U.S. who wanted the vaccine were less likely to receive it than whites, but the clarification here, the reason was not that they did not have the vaccine available. It was just, like, their access to or their availability to get the vaccine. Okay, and then, again, the same point here, that lack of access to the COVID-19 vaccine among minority populations in the U.S. was more the willingness, the lower willingness to get the vaccine rather than the availability of the vaccine, and then over time, it improved, and the gap in the graph on the next slide, you will see that this improved. Initially, the difference was, like, 14 percent between the Caucasians and the Afro-Americans here, which Afro-Americans being the highest minority in numbers, and that got better to 6 percentage points, and then similarly, like, between whites and Hispanics, the difference initially 13 improved to actually Hispanics getting more vaccines than the white majority, and this graph just shows, like, the differences more, like, earlier on, and then there was a lot of catching up and very positively, so things got better. This is for Australia, the Australian indigenous population, and the blue, what you see is, like, from their census a few years ago, but then the orange is, like, the number of vaccines that they received, and you can see the, you know, the clear difference, but they did pretty well. I guess in a matter of, like, four to six months, the difference between the aboriginal and, like, the minorities there in Australia was, like, they received 46 percent of their population received a vaccine as compared to the rest of Australia, where, like, 76 percent, but that got better in a matter of, like, six months without reaching to minorities, and then that was the difference was, well, the vaccines given were, like, from 46 percent that jumped up to 73 percent, and the last maybe three or four slides are on the, this is, like, strategies to help those who are, don't have access to vaccination or do not have the, that acceptance to vaccination, so this is, like, research-proven methods, you know, this is by a study done by CDC over several months and looking at several states, different communities, different socioeconomic status and professionals, professional status, and so they came up with, like, these 12 strategies to help increase vaccination. So, just briefly, like, they said to have, like, vaccine ambassadors, which are, like, trained community members who can disseminate health information, medical, and I remember, like, when the vaccine came out, this was, like, again in December, January, and, you know, I also worked with, like, a group of physicians as, like, a more, like, a social organization where we had, like, a couple thousand of doses, and we went to, like, we stood outside of stores, and, like, we went to, like, some of the markets and churches and some other places or worships to reach out to the communities, those who would not otherwise go to a health facility. Medical provider vaccine standardization, that there should be, like, by default, like, you go to the doctor and they ask you about the vaccine, no matter what's your reason for that visit, they ask you for a vaccine and encourage you to have the COVID-19 vaccine. And then medical reminders, motivational interviewing, which is, like, patient-centered conversations to increase patients' or individuals' participation, their motivation to get the vaccine. Financial incentives, yes, it's there, and there were, like, some of the, I guess, communities or cities, they gave, like, small incentives to have the vaccine. It wasn't that too big of a campaign, but I remember, like, a gift certificate to a restaurant or a free drink. And then school-based programs where students, families, faculty, they can get vaccinated. And then there are a few more, like, home-delivered workplace vaccination. I mean, I was obviously heavily involved in this. I mean, we have our work for a hospital system, university-based, and we have, like, about 35,000 employees. And then we had, like, vaccine clinics, like, day and night, and for the employees initially, but then we offered it to their families, we offered it to the communities. And we have, at a great success rate, like, for the 35,000 employees or so who were fully vaccinated are, like, 98%. Booster is, I mean, it's getting there, but, like, the 98% of the employees are fully vaccinated, or they have been, like, for, I would say, at least a year now. Okay. Well, so, in summary, there are inequities, disparities in vaccine distribution, acceptance globally, and within countries, within communities, within jurisdictions. Low-income countries are still far behind in achieving adequate COVID-19 vaccination, in spite of, like, significant efforts globally. Like, we looked at, it was, like, still under 15%, as compared to the rest of the world, which is, like, 70% or more vaccinated. And there is evidence-based strategic approaches that should continue to get our world fully vaccinated. Thank you. Thanks so much, Saj. I want to apologize. I think Dr. Udankar is having trouble getting onto the Zoom. So, if there's a way to help him, that would be great. And we can go straight to Mr. Mburi, who I know is waiting in the wings right now. So, if you could just go ahead and we can go straight to Mr. Mburi, who I know is waiting in the wings right now. So, we can hear from our Liberian colleagues, Mr. Mburi and Dr. Vonem. Next, please. Okay. Thank you very much. Is our slide available? Again I don't know if we've got someone supporting that, but I will bring them up if you just want to get started, Amos. I'll get, I'll try to do that. Sorry about that little delay, but we will go with our next live presentation with Dr. and in the meantime we'll try and fix the other two speakers. Thank you. Thank you, Saj and thank you, Rosie. Good morning and greetings to colleagues that have joined online. I wonder if we could ask the technical folks to put on the live presentation. Yes, indeed. So we're changing tack slightly in this session and I'll be talking about the particular issues faced by Global Occupational Health and Safety Department as over the last two years we have been challenged with the support of our staff across the globe and I'm sure that many of you in the room have been in exactly that position. This COVID pandemic has certainly presented challenges, but also opportunities that I'll expand on a little later that are truly unprecedented. So the World Bank Group is the world's premier development organisation, has a huge investment portfolio really across the globe and all the little red dots on the map are places where we have offices and staff and if you look down at the bottom on the left you can see the numbers. So 50,000 plus clients really of a health and safety department that at any moment in time can pick up the phone and call for assistance and of course as COVID rolled out, reverberated and echoed across the globe there was truly not a moment in the last two years that there weren't at least a couple of offices or a region experiencing a surge and a problem that had to be dealt with in an occupational health sense. I hesitate to put numbers in place, I think the numbers of cases that we've had to manage across the globe are clearly cases that have been brought to our attention as employees, there's no obligation to report illness, we do encourage our staff to do so, but what this does show is just the distribution of cases and once again what we saw and what we still are seeing is that when there's a surge in a particular area it flows over into our staff, so where COVID is surging we are busy. The mission statement that guides us in our department is an ambitious one and we strive and the official statement as you see is to protect and promote the health and safety of staff wherever they may be and then bringing in the occupational element, taking account of their individual status, their working environment, their operational environment and the job demands, so clearly many varying demands and as in any large population a huge variety of personal risk levels. Now our directorate is organised into three main functional domains. We like to address those domains in an integrated sense, bringing all three sets of skills and strengths to bear on any particular problem, so tackling the occupational health and safety side of things, the personal health and wellness which obviously the COVID challenged us a lot on and then of course the mental health and wellbeing. But if I do just put up how our organigram has been constructed, I wanted to highlight two additional functional areas that in fact we have dedicated people to serve in and that is the critically important area of managing field operations and with a challenge of this extent, you really do need people that are thinking only of how to bring all these elements together and to deploy them in a coordinated and effective way, informed by continuously updated data because as I'm sure all of you know, there is almost too much data available about COVID but finding the relevant data that can guide you in your decisions is quite a challenge. But on the right side, the function of communications I think has never been more important for occupational health physicians. Many occupational health practitioners are used to dealing with patients, used to using in a clinical sense stethoscopes and prescriptions and dealing with individual problems but with a problem like this you're dealing with behaviours and mass groups and education and if you don't have a very advanced communications capability and a digital platform that allows you to project those messages in a continuously updated and accessible way, you're going to struggle. So I think we had already been thinking in these lines before COVID but COVID drew a whole lot of bold lines under the importance of that particular function, so much so that we now consider that as an independent function within our health and safety directorate. A couple of background considerations that really formed a backdrop for everything that we did on a technical level. One is we are an international organisation, so that is where we are represented around the globe. Our offices have the status of embassies, so technically in a legal sense we're not subject to the laws and provisions of the countries and we can make our own decisions but of course we are obliged to be good citizens and as far as local health regulations, although we may not be legally obliged to follow them, we certainly do our best to do so. It would not be the right thing for our staff or our functions to become a source of index cases or super spreader events, but we also are a specialised agency of the United Nations along with World Health Organisation and WHO is the premier and guiding health organisation in the UN system, so WHO guidance also forms a very strong foundation of where we draw our guidance from. These are often not the same. You find differences and there are challenges, so I think in COVID we saw that very much with World Health Organisation taking the global population perspective, but from our perspective as a headquarters in Washington DC, we were taking guidance from CDC and every one of our offices was taking guidance from their local authority and those were often very varied and it was hugely useful to have our own professional network of United Nations medical directors all faced with the same challenges who were and still are meeting regularly, we meet every week at least once, to just sift through all these different guidance sources and come up with something that makes sense for our particular population. The other issue that really drives everything we do in the UN is the mantra of stay and deliver, so the UN is in many cases playing a huge part in assisting countries to meet the challenges of the pandemic, whether it's financially such as the World Bank development projects or as with many of the health groups actually providing and resourcing health facilities. So the ability to stay in place rather than have the luxury to just remove people when the health challenges become severe, that is very much behind what keeps our functions going and in two particular areas, being able to bring into play medical evacuation to move patients to a destination of higher care in another country if they became critically ill. You can imagine that was a huge challenge at the beginning of the pandemic to actually find a destination willing to accept a critically ill infected COVID patient when you know what happened to world travel regulations and entry permissions. That was a huge problem at the beginning and also global vaccine access which we'll talk about a little more. But also briefly just mentioning is that if you are going to have your own programmes as an organisation, you do have to think quite hard about issues of equity and take vaccines for example. Many parts of the world and the developing world where we are most active simply did not have access to vaccines until a later period of the pandemic. And for any organisation that is going to try to bring in vaccines for their own population, they're going to have to think hard about how to deal with the equity issues, optics issues, particularly if there are health facilities that don't even have access to vaccines. But of course that's helped when you are considered as part of the response and in many parts of the world our staff were in fact considered as first responders. And often our approach would be to share the benefit and to not only look after our staff but to make sure that some of the resources we were bringing in were also used for first line care in critical health facilities. But that is a challenge to think about if you tackle this sort of thing. So this slide just contains a conglomeration of the issues we had to confront and that kept us very busy and still are doing so. But of course as for everyone adapting initially to all these functions in a remote fashion, what a huge step that was, but also astounding how quickly everyone adapted and how functional we were able to become and I'm sure you all experienced that too in the remote world. So much so that we're struggling a bit to get people back to the office now that they've become so used to how convenient and easily you can function in a remote way. I've mentioned already how important it was to be up to date and we actually had and have a number of staff dedicated to simply scanning the literature every day, both the academic literature, also the public health literature, the guidance resources, CDC, WHO, because of these constantly changing guidelines that we needed to be on top of and still need to use to guide our responses and to put all of that into tangible and effective and practical risk management plans. And of course when you're doing this for your organisation and your international, you can't just rely on the local authorities for vaccination policies, masking policies, distancing, etc. So you're constantly having to pull all the guidance together, communicate it and have it working and relevant for your particular staff. And countless communications events, town halls, meetings, whatever you call them, every week our staff were involved in these sessions with staff across the world and huge amounts of training, but we also became a logistics department where in the early days, and I'm sure you all remember well the transition from masks are no good to masks are everything, but then not being able to find them and for us having to set up procurement and supply chains, crossing masks and then particularly during the tremendously distressing Delta surge that we experienced probably the worst impact of the pandemic, oxygen concentrators and once they became available, test kits. But really our health department became a health logistics department, all of which was on top of the normal case management and care, which is what was our primary function. So this, as I say, was probably the period of time that our group was stretched more than ever before, but that came with huge opportunity and I don't think there's ever been a period where we have received more invitations to sit at the highest levels of the organisation. The organisation needed us. We sat at board meetings, at executive director meetings and had a visibility of how important occupational health that I think was unprecedented and we're still reaping the benefits from that. So although it's been massively challenging, I think COVID has presented an opportunity for the field of occupational health that has never existed before. So a little bit of how we started putting it all together. We first had to come up with an office status framework because clearly things are different in all the different offices. So we came up with clear guidance on tier levels, guided by indicators that were important, but also by work modalities that were required depending on the particular business of the group. All of that fed into a table that gave people an idea how to decide what tier they were in and how they should function when they were in it, but with very much flexibility down to ground level to allow the local offices to make their own decisions within that framework of decision making. We also found that we needed to come up with our own way of interpreting and managing all the risk data. This is our current version that went through a number of iterations and in fact we have a number of our staff who were key developers of this in the audience. But we did come up with a way of integrating regionally and locally sourced data into a simple red, green and yellow type risk indicator that then could be tailored back, flexibly of course, we didn't use it written in stone, but to guide the various decision making efforts. I have to say that in recent times this type of approach is becoming less and less useful because it worked when nobody was vaccinated and everybody was facing a similar type of risk. But as we've progressed, individual risk has become so much more important in fact than community risk in making worksite decisions. So beyond tracking our office status and having access to this type of information for each office to make decisions, we've also introduced a number of individual risk management tools so that an individual can go into a well-structured platform and feed in their own health data, there's a version for travel where they're travelling what sorts of stops they have, where they can titrate their risk profile themselves to the guidance of the organisation and then make informed risk decisions that they can discuss with their managers and just make it a little easier and not have 50,000 people calling my office to say is it safe for me to travel. I cannot stress how advantageous it was to be within a group of organisations with similar challenges but also with considerable influence. And through the United Nations we participated and cost shared in a number of programmes that really were the foundation of being able to keep our functions going. In particular one major programme which became known as FLUDD, first line of defence, but which aimed at strengthening local facilities, the local UN clinics, bringing the expertise, equipment and protocols in place that they needed, but also coming up with a model of care that guided how much equipment was needed, how we would think about medical evacuations, how we would think about how much, for example, vaccine was needed in a particular area or how many ICU beds we had to negotiate for or how ready we had to be to evacuate people if such things were not available. So that was critically important. But switching to the topic of vaccinations, if you as an organisation make the decision you're going to do it yourselves and take responsibility to procure, supply and administer vaccines, there's a whole list of issues you have to think about because you're then operating outside of the national, one, logistics capabilities, but two, medical legal framework and that can be quite a big one that certainly kept our legal department involved in and busy for a while, because most vaccines today still are available on emergency use authority rather than fully approved, which then, if you procure and administer yourself as opposed to under the umbrella of a national programme, takes away your access to the many countries have structured liability management processes that take the liability off individual providers and organisations that might be administering. So if you make the decision to go outside of that, it's a big decision from a medical legal point of view. You have to think hard about liability, waivers, et cetera, et cetera. But also then you need to set up yourself, all the supply protocols, the cold chains, you need to train people, you need to take your clinic and say, how do you do a vaccine clinic in a safe way? You have to think about how you document this and how you can translate a vaccine certificate into a travel document, big challenges, so as I say, this was stretched the wings of our department as never before. The result of this across the UN system was very encouraging and in fact the UN managed to procure and supply nearly half a million doses to over 72 countries. The figures at the bottom are our World Bank Group current figures in our headquarters in Washington. We've achieved 96% coverage as an average across our country offices, 84%, but 10% have still not submitted, so it's probably closer to 90 and I think by any scale that's a very encouraging level of vaccination. I'll bring the vaccination picture together with the evacuation picture at the end, but one of our biggest problems at the beginning, to tell people either to travel to or to stay in a country when there is a substandard or suboptimal medical infrastructure, you have a duty of care to be able to get them out of there again if they get critically ill. This simply wasn't possible in the first few months because all of the commercial providers simply were unable to fly COVID-infected patients. But working together with our UN system and particularly with the World Health Organisation, we were able to come up with a management system utilising commercial transport providers but using the combined negotiating power of the UN Secretary General, the World Health Organisation Director General, to actually achieve access in many countries. And overall, up until last week, in fact over 350 evacuations were managed, 20 of them in my own organisation, and that truly took the pressure off in some of those early months when we were struggling so much. But bringing those two stories together, this progression on the blue numbers are showing you the number of cases we experienced in any particular month. The little red blocks are the number of times that we had to critically evacuate seriously ill people that needed higher care destination. And you can see that since October, despite going through the Omicron wave and having more cases than ever before in the last quarter, we in fact only had the need for one medical evacuation and that was a very specific patient with very specific and severe comorbid risk factors and a fully vaccinated person. But I think that is a perfect illustration of some of the challenges we had at the beginning but how later on it has become easier in fact. And as we move to this new normal, and for those that may just be listening, I just made the inverted commas, the new normal that I don't think we all fully understand yet is deciding how far we can go living with all these cases we're experiencing, but so gratifyingly not causing such serious illness as we experienced at the beginning. So that has really just been a lightning quick tour of some of the challenges faced by a global occupational health directorate. I hope we've managed to get some of our other colleagues online who are going to talk about other aspects of medical care in the developing world. I'll be happy to take questions and comments when we get to questions at the end. So thank you all. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thanks, Brian. And our next speaker, Dr. Gabori Amos. He'll be joining us from, he's in Mondrovia, Liberia. They're about six hours out of us. Yes, hi everyone. I'm still waiting for my slide. Can you share my slide for me? Yes, your slides will be up in a second and I'll be advancing those slides, Dr. Gabori. Okay. Okay. Your title slide is up. Yes, hi everyone. I'm Amos Gabori from the National Public Health Institute of Liberia. I'm the Director of the Environmental and Occupational Health Program. This presentation is going to be co-presented by my colleague, Dr. Benjamin Bond, who is currently on the field, but he will join us remotely. Next slide. Yeah. Next slide. So Liberia is, as you can see, Liberia is located on the West Coast of Africa. It's a post-conflict country. We have a lot of ties, long history with the United States. Next slide. The Occupational Health Program in Liberia is structured from the national level to county and district levels. In terms of legal instruments, we have a National Occupational Health Safety Policy, which was developed in 2010. There is a draft Occupational Health and Safety Guideline, which has been finalized. We are awaiting validation. Currently, we have a focus on workplace safety inspection, especially looking at the manufacturing industry. In the healthcare sector, we are focused mainly on IPC, which is infection prevention and control. As a matter of fact, Liberia was one of three countries that were partly hit by the Ebola virus, the outbreak of 2014 to 2016. Following that epidemic, we thought that we needed to pay attention to the healthcare industry. So most of our interventions have been focused on infection prevention and control, especially the use of PPEs among healthcare workers. We pay little attention on intervention program in workplaces. And then we do have a Decent Work Act, which has been put into force or monitored by the National Public Health Institute of Liberia in coordination with the Ministry of Labor. Next slide. So, like I said, the history of Liberia, Liberia has a long history of Ebola. Also, it's good to highlight the fact that we are a post-conflict country. We fought a civil war, which destroyed most of our infrastructure and our systems. Following the situation of the civil war in 2003, we were also recovering from that civil war when in 2014, we were hit by the Ebola epidemic, which claimed over 11,000 lives in Liberia, Guinea, and Sierra Leone, with Liberia recording over 4,000 deaths. Our economy has been impacted negatively as a result of the Ebola outbreak. So, just to also weigh in, recently with the coronavirus disease, which also affected all of the world, we are also suffering from that impact. There's issue with private sector growth, there's issue with agricultural production, leading to concerns about food insecurity. There's cross-border issue with trade and also restriction movement. All of these were also experienced during the Ebola outbreak. We lost an estimated one, I mean, Liberia is expected to have lost a lot of healthcare workers in the pandemic that we are currently facing. But if we go back to the Ebola outbreak, we lost about 192 healthcare workers. And if you know Liberia is a resource-limited country, we do have a significant shortage of the human resources in health. So, losing about 192 of them was a huge, huge blow to our healthcare sector. Mainly doctors, we lost a good number of doctors and nurses. But it's good to highlight that the environmental health staff that we work with during the Ebola outbreak, we did not experience any death among them in terms of infection, none of them got infected. And that is strongly linked to the occupational health and safety measures we ensured that they follow, especially the use of PPE and also disinfectant. This is something that we thought to share with the global community. Next slide. Next. Okay, so also of interest, we did a hepatitis B intervention in Liberia. The issue of hepatitis B is becoming a growing concern, especially among healthcare workers. We also have other occupations that are also experiencing it but among healthcare workers, we thought that there is a need to focus on the prevalence. You know, there is a need for prevalence study, even though we haven't done that. So currently there's no prevalence study. Anecdotal evidence suggests that there's an increase in hepatitis B infection among healthcare workers. Next slide. There will be globally, the global estimate is 17.55% of the global population is infected with hepatitis B. In Liberia, we thought that we could conduct a study to look at how prevalent the infection is, but that study, the most recent study, which was part of the laboratory, the rapid test survey did not get complete. However, one study ranked Liberia at 55 for people living globally with HIV, which is hepatitis B virus. In terms of the pre-qualification of donors in the screening process, 19.7% of that was pre-qualified, especially when it comes to plasma fluorescence program tested positive for HIV, HIV infection. Next slide. So what have we done? When we got this data, we thought that we needed to move quickly and be able to do something to prevent the further infection of healthcare workers, especially those who will be taking care of patients. So we established an infection prevention program for hepatitis B, although there is no definite data within the Ministry of Health. So in the occupational health safety guidelines, we have included the issue of healthcare workers being vaccinated against hepatitis B as a major requirement. Next slide. So Enfield and the Ministry of Health in 2017, 2018, thought that we needed to pilot the vaccination of healthcare workers against hepatitis B. The beneficiary that were targeted were 16,500 healthcare workers, including administrative and support staff. In terms of vaccines, we procured a number of doses, around 5,000 doses were procured through Brifos and Probitas and Enfield. The storage transportation administration was done by the expanded program on immunization, which is the EPI Division of Administrative Health in collaboration with Enfield and the Public Health Initiative of Liberia, Enfield. Next slide. So in terms of coverage, the initial data that we looked at during the pilot study out of the doses that were issued out to the counties, we thought to share these data from three major hospitals, which included JFK Hospital, the Jackson, James David Hospital, and then that of the Redemption Hospital. For the Jackson, for the JFK Hospital, it took a total of 914 beneficiaries who were during the first round were coverage of 100%. And then for the JDJ Hospital, which is the James David Hospital, we reached 280 beneficiaries. That was the plan for round one, first round. But in terms of actual people that were reached, we reached 231, which is 83% coverage. For Redemption Hospital, 550 beneficiaries were targeted for round one, but actually we vaccinated 417 healthcare workers. Next slide. So the other data could not be presented because of the COVID interruption. So the remaining counties, we are still collecting the data. Maybe in subsequent conference, we'll be able to share the updated version. But in terms of final result and conclusion, there was initial reluctance among a few of the healthcare workers, but due to the outbreak of COVID interruption, the expansion to the other facilities were also impacted. Coverage for the second round of the same facility, only one round was about 73%. So the second round, we were only able to reach 73% in one of the three facilities that were mentioned earlier. There are still some vaccines in store, but some have expired. These are issues that we have found. And also it is possible to provide HPV vaccine to all healthcare workers. This is a target that we are looking up to. Data from the rollout phase is not yet available. Like I said, I have been in discussion with the EPI director, the expanded program organization director. And what we have planned is they are bringing in additional vaccines so that it can become a routine program as new healthcare workers are joining the employment in the health sector. They are vaccinated against hepatitis B. This is happening with the medical school students. So all medical students that get ready for their clinical year, in terms of their clinical rotation has screened for hepatitis B virus and possibly are vaccinated and hopefully should meet the vaccination requirement. Next slide. So in terms of recommendations, the intent of the exercise was to influence government policy to make hepatitis B vaccination as a requirement for employment in the healthcare sector. This recommendation has to some extent been implemented or is being implemented in the guidelines that we have revised. We have included that as a requirement. And like I said, medical students are now required to do hepatitis B screening as well as making sure that they are vaccinated. Other healthcare facilities have already started ensuring that. For Enfield, for example, we have ensured that the laboratory technicians are screened and vaccinated against hepatitis B virus. We've done that for a number of them. So this recommendation is already in swing. The next one is even though the exercise did not end as intended, the discussion of making a routine requirement for employee needs to continue. This is happening. So we hope that our EPI police can have the vaccines in country. Those vaccines, those doses will be deployed to the countries to ensure that healthcare workers that are joining the employment of the healthcare system are vaccinated against hepatitis B. Lastly, the results from the exercise to inform the MOH and the World Health Organization which is working towards current. So yeah, basically we hope that this exercise, although the data is not big enough, but we think at the end of the day when all of the vaccine report is available, those vaccinated should be enough to be able to inform both the WHO and that of the ministry I have on the needs for routine immunization of vaccination, of the hepatitis B virus. Next slide. So there are other diseases of interest that we thought we could share to inform the body as to how Liberia is focused on those diseases of interest, Ebola virus disease, vaccine, which is under investigation. We have talked to have conducted pilot study looking at three counties that are bordering Guinea. We recently, Guinea reported a case of Ebola. Thankfully that case was, that outbreak was contained. However, Liberia thought that we could have piloted the vaccination of the healthcare workers so that they could be better protected against Ebola virus disease. This pilot vaccination did not continue because of several challenges, but we do hope that this is something that we can look at in the near future. Also, there is an ongoing vaccination of healthcare workers with the COVID vaccine. The data that we have seen show that a good number of healthcare workers have been vaccinated. This is something that we will also share in the future. Although initially there was hesitancy among healthcare workers, but recent data shows that most of the healthcare workers are now willing and have taken the COVID vaccine. The other area of interest, disease of interest that we are looking at is the issue of Lassa fever. So we do have Lassa fever as a priority disease among our epidemic diseases. The need for healthcare workers to be vaccinated will be high if the vaccine is available. Currently, there are prophylaxis that are available and we have deployed them in our healthcare system. So healthcare workers that are deployed in infection prevention control unit or isolation units are provided these prophylaxis so that they don't get infected or even if they were to be infected, at least the infection will not be able to treat them so badly. Next slide. Thank you very much. Okay. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. You can do it, right? Okay. If you want to, yeah. Yes. Great. Yeah, we see your slides. All right. Great. Great. All right. Thank you. So my name is Timonodonko. I'm from Ghana. And I will be sharing on artisanal mining in Ghana, the operational health and environmental challenges that are associated with this. So I will, this will be my other presentation and I will just have a quick introduction. We'll look at health impacts of mining in Ghana, environmental impact of mining, and then we'll provide some conclusions. All right. So mineral wealth is an important asset that can be used to stimulate and enhance economic growth and spare infrastructure. And this is well known, and the World Bank makes allusion to this. In fact, in Ghana, mining has played a substantial role in the country's developments, and which is second only to South Africa in terms of gold production on the African continents. But recently there has been an upsurge of small scale mining which locally has been termed Galamsey. And this Galamsey mining is carried out at an individual level. And this is done mostly by the poor with very little technical know-how or machinery. Whilst we know that over 10 million people worldwide are directly engaged in small scale mining, with another 10, 80 to 100 million people directly or indirectly dependent on the production of these activities for their own survival. It's obvious that most of these individuals are not miners by choice, but they so find themselves in mining. In order to survive. And it has been seen in different ways as a way by which people, particularly the young, want to have a daily living. And small scale mining has also been viewed with different perspective by different groups, by different countries and so on. We know that the International Labour Organization has defined small scale mining as less intense and operated with basic or low level machinery. In Ghana, when we talk about a small scale mining which we refer to as Galamsey, it involves mining of gold by technique. And this technique do not actually contain some substantial expenditure by individuals or groups. They have made up some of the technical knowledge and they have made up some ways that we are able to do this mining. You have another five to 10 people coming together to do this. But the challenge is the release of some harmful substances into the environment as they carry on with their processes. Indeed, one report estimate that five tons of mercury is released from small scale mining operators in Ghana each year. And this most often gets into water bodies, into farmlands, among others. While there are no exact figure for the number of small scale miners in Ghana, it is actually estimated that approximately you have 100,000 Ghanaians who are engaged in the mining industry, where it accounts for 41% of the country's foreign exchange and the leading foreign exchange. So the question then is, what is the health of what we've been talking about so far? And indeed, the impact of the small scale miners, which are referred to as Galamsey, is very, very challenging. And it is something that a lot of people has actually been concerned with. And the study done by Akin and Steven, they did indicate that mining... Yeah, it looks like we are back on. We'll... Yes. Sorry, I think I went out of order. So, as I was saying, a study by Akin and Steven indicate that mining remains one of the most hazardous occupations in their wealth, both in terms of short term and long term. And it's a very, very important issue. And it's a very, very important issue that we have to address. So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we have... So, in Ghana, we had... So we had a catastrophe that occurred which hit a town in Ghana known as Nkampungfin in the central region, where numerous people were buried in the Galansi Pit when it caved in near Dauphin River when they were doing their mining activities. And we had over 100 miners who lost their lives in that disaster. And reports stated that about 136 Galansi or mechanics who were working the pit when the accident occurred. And this was in June 2010. And we had about 13 bodies that were recovered by rescue operation. And this was actually hampered by the gushing water from the Dauphin River. Another incident also occurred at a castle near Kukukukum in the Ashanti region, where we have at least 12 Galansi operators were trapped in the Kulas Pits. Later on, we have nine bodies retrieved from the pit. And the Ghanaian Times, a state-owned newspaper, reported an increase in the cases of disease, kidney disease. And according to one expert, Dr. Mwakua Atau, who is the head of renal unit of the Kofuanote Teaching Hospital, the use of mercury by the illegal miners is a contributive factor to the increase in the kidney diseases that have been found to be happening within the area. So health incidents, again, in the mining sector. There was a study in five selected communities, Sanso, Anyem, Anyumankrom, Akumpi, and all in the Obwasi municipality, on mining activities near the Angloga Ashanti operation site. And Angloga Ashanti is one of the major gold producers in Ghana. And they tried to check on their health impact and found that residents suffer from diseases such as malaria, skin disease, diarrhea, fever, colds, and catar. And in that study, they found that the residents in the communities around these mining areas, they found that malaria accounted for about 42% of the diseases that were reported. And this was followed by respiratory infections, 27%, and skin diseases, 17 from 17%. Again, fever, diarrhea, and other symptoms were reported by 13.6% of the respondents in the study area. And the highest occurrence of colds and cough was also found at one of the places called Anyum, where 37.1% of the respondents presented with this. And Anyum in particular is located very close to the Angloga Ashanti OPP site, where rock blasts and topsoil removal with heavy machines are usually prevalent. So the Center for Environmental Impact Analysis in 2011 published a report on the human health risk assessment and epidemiological studies from exposure to toxic chemicals. And this was done in Takwa, which is also a municipality around the Cape Coast area. And in that study, it was found that oral injection and dental contact of water and soil sediment samples, as well as oral injection of cassava that has been contaminated with elevated levels of toxic chemicals, such as arsenic, carbon, carbon, among others, led to elevated levels in both blood and blood serum of residents. So you have these chemicals that are used for the mining, released even onto farmland, and they end up in the food, like cassava that the locals were eating. And when they did the experiment, they found that there were high levels of arsenic and carbon, and other sources of metals in the inhabitants in the area. Now, there is another dimension that has become a growing problem that has been associated with these small scale miners in response to the health challenges that are faced. So you have the use of drugs and alcohol, which has become a big problem within the mining areas. And these miners or workers have used it with the notion that it will stimulate them to work very hard. So you have illicit drugs, such as marijuana and cocaine, and then some alcohols which the workers use heavily in order to help them to do their work. And this has resulted in a lot of health related problems like mental disorders, skin problems, among others. Within these health workers, as they try to use these drugs to help them to work harder. Now, having talked about the health impact, I quickly want to talk about the environmental impact, the impact of this mining in the Ghanaian environment and how it is ongoing. So in Ghana, contamination of surface and groundwater bodies are particularly being experienced. And the majority of the small scale miners, which I said refer to us as I say in Ghana, they wash their products from the oil into rivers and other water bodies that serve as sources of clean, potable drinking water to the mining communities. Others also release mine tailings directly into rivers. And this introduces large amounts of suspended solids and contaminants directly into the aquatic habitats. And this is of major concern and threat to human and animal life. The Ghanaian Council for Scientific and Industrial Research has revealed that many mining communities in the western region, for example, are at risk of health related issues from heavily polluted water bodies by small scale mining activities. And the challenge here is that water is not really available. It's not all that. Only about 25 to 30 percent of the population have access to plentiful water. So most often they rely on water from rivers. So you can see two pictures I share with you. One is a river on the left and then the right you find activities of these small scale miners. Their activities actually send a lot of chemicals and then debris into the river. So this ordinarily is a river that is very clean, that previously people could take water from, fetch water to use and so on. But it becomes so decorated with metals and then with some earth and so on as a result of the activities of these small scale miners. So what you find here is a typical community where small scale miners are trying to mine gold. The other challenge also that is associated in terms of the environment has to do with land degradation. And those who are involved in the small scale mining are found to be responsible for destroying about 13 percent of the total land forest in Ghana. A study that was also previously conducted shows that surface mining results in about 58 percent deforestation and a substantial 45 percent loss of farmland within mining conception in the western region of Ghana. And this is very important because communities in these areas are basically farming communities. So once they lose their farmland, they lose their livelihood and then the water and food around them also gets contaminated. And that has become a big challenge. And this land degradation has also resulted in threat to biodiversity conservation with devastating effects on soil, leading to increased soil temperature loss, depletion of nutrients, soil erosion, among others. And you would also find out that most of the mining concessions are found around forests and agricultural land. And then also where you have human settlement. And these derive farmers' access to their lands and so on. So here you are. This is a typical farmland that has been destroyed by the activities of the small scale miners. So their entire farmland is gone and they leave their lands not to be claimed and off they go and people lose their livelihood. In conclusion, I want to say mining is a very important thing to Ghana's economy and provides employment for many people. However, it is not mining as often as negative impact on health and environment, such as increase of malaria, skin diseases, diarrhea, fever, colds, catar, also pollution of water bodies by chemicals such as arsenic, mercury, carbon from refining of mined minerals. Again, contamination of farmland with heavy metals and other substances that deplete farmland, reducing food productivity due to infertile soil and reducing wildlife due to deforestation of forests, which are habitat for many animal species, is also of concern. Therefore, reforms are needed to regulate the small scale mining sector and to curtail ubiquitous environmental problems that it so presents. And that brings me to the end of my presentation. Thank you. Thank you. Thank you, Dr. Orankar. So now I guess we timed well. Thank you for your patience. I know we had a couple of airways glitches, but we caught up well. So we have a few minutes for questions. We have Dr. Davey here and myself, and then we have two speakers online. And is there a microphone for the questions for the online audience or remote audience? There's really no remote audience, unfortunately. They're going to have to be able to see this afterwards. So in person is great. And if you could just relay the questions to anybody who's answering online, that would be great. All right. So, yeah, I have a mic here. If anybody has a question, let me know, and I'll come over to you. Yes. Go ahead. Thank you. Rick Albon, CMO, Optimal Health. A question really for Brian on vaccine hesitancy. Certainly in the U.K., there was a significant cohort that was a challenge with vaccine hesitancy. I'm very interested to know, with that diverse geographic distribution you had, if you found any particular patterns and, you know, what you did perhaps to try and overcome that. Thanks, Rick. Yes, indeed. And I think you attended the session yesterday where we talked about the survey done across the U.N. system that, in fact, was done last year. And overall, we saw significant vaccine hesitancy numbers pretty much similar to other populations. And we were not immune to the misinformation, disinformation, and personal concerns. What we did find, though, as we went further, that as the vaccines actually became available and as the practice started to pick up and as people saw their colleagues going forward and also seeing the good examples set by managers that then talked about it, it really did pick up. And although I would like to say we might take credit for some of it, we did a lot of information sessions, talking, just listening to people and creating opportunities for people to discuss that sort of thing. I truly think the momentum that eventually built up probably took root and may well have been the greater number. We also, I think, are relatively fortunate to have a well-educated population that does have access to information. So once we were able to get the right information out, I think it was easier. We do have some problems still. We do have some folks who just do not want to get vaccinated, and that is a problem in determining ongoing vaccine policy in the workplace, because right now in our headquarters we still require people coming on site to be vaccinated, but we do have a voluntary attendance program. So crunch time hasn't come yet, but sooner or later it will be mandatory for people to come back. And then some hard decisions are going to have to be made on vaccine mandates. Although looking around at the moment, I think it's becoming less and less prevalent everywhere you look to have either government or organizational mandates in place, but rather protection tools in place and more reliance on individual responsibility, individual risk assessment, and individual decisions on what they're doing. But I think many of you, I'm sure, are facing those same problems. Thanks, Rikard. Yes, sorry, just Dr. Andrijan Marjanko. I worked in Qatar for two years and then I came back to Australia, and our death rates per capita are in the vicinity of 200. Well, as the US and the UK, your death rates per capita are in the 3,000s, really quite high in comparison, so ten times higher. And partially it's because we, Australia held it out, but in Qatar it was a different story. But individual responsibility I don't think had anything to do with it. I actually think individual responsibility can be harmful. And I just ask why you think those differences are there, and especially here in the US, you see a large disparity. In Utah, fairly low death rates per capita, and Vermont as well, while as in some of the southern states, quite high death rates. And I'm fascinated by the incredible difference in death rates internationally and within the USA. Yes, you're right, and I really don't consider myself enough of a population health expert to give you a clear answer to that. I think there is huge variance in the way in which protective measures have in fact been viewed. And I find it quite interesting that in some cases you get people who believe in things as opposed to hear about things and make a decision to use them or not. So you believe in vaccines or you don't believe in them. You believe in masks or you don't believe in masks. And that type of belief identity tends to become associated with certain population groups and political groups. I think that's probably got quite a lot to do with it. China, for instance, is very low death rate. I don't know how much people believe it, but there's no individual responsibility there. So in a way, I think that individual responsibility can be offered. Weighed against the individual responsibility is the employer duty of care. So if you are actually requiring people to come to the office and there is risk in that environment, you have to think about then what do you need to put in place. But for how long can you live with a voluntary presence in the office? And that depends on the functions that are being done. And different functions are going to have different approaches. Even within the UN system, that is being approached differently. So, for example, the UN Secretary to New York at this moment does not have a vaccine mandate in place and is requiring people to come back. But they have chosen particular occupational groups where they require vaccination. So putting it forward as an occupational health measure, so drivers, for example, or people at frontline service desks that are in regular close contact with others, doing a risk assessment of that particular job and then applying the vaccine requirement to that may be a route that other companies will take. I'll just add to that answer. That's very well explained. But the individual responsibility, individual awareness, individual acceptance, I mean, that's very important. Now, earlier I was proudly saying that 35,000 employees that I'm in occupational medicine or employee health with and the 98% rate of vaccination, so that's great. But then all like six hospitals have mandated that vaccination. Now, on the other side example, booster shots are not mandated in all six hospitals. One hospital is in a different state where it's mandated. So their booster rate is like 91%. And five hospitals where it's not, it's like hanging around 50% to 55%. Warren, you have a question? With your permission, I'd like to do a little commentary if I could. Do that on the microphone then, please. I've got the microphone. I'm sorry. I don't have the vocal cords, but I've got the microphone. I think if we're going to do an analysis of COVID vaccination, we're looking at it from the perspective, a Western perspective. In actuality, as of October of this year, 7.3 billion doses of vaccine were given. Almost half of those were given that were the Chinese vaccines. Geopolitics is important to take in analyzing what's happened with the vaccination program. Most of the Chinese vaccine was donated early on to developing countries as a means of goodwill, if you want to call it that. And having many friends in Southeast Asia, I can tell you what the response was. The first vaccines to show up on the scene were the Chinese vaccines. However, many people were suspicious of the value of the vaccine, and they wanted to wait for Western vaccines in many places in Southeast Asia. The first Western vaccine to show up was the AstraZeneca. It took a while for Pfizer to come and such. But people would say to me, I'm going to wait for the Western vaccine. It's accepted for travel. It's accepted for whatever. Unfortunately, you had to pay for the Western vaccine. And for the average person, it was pretty expensive. So you had to make an appointment in Thailand, for example. You had to make an appointment, sometimes weeks in advance, pay in advance, and wait to your vaccine time. A lot of the people couldn't afford that, so a big portion of the population got the Chinese vaccine. It took a long time to get the Western vaccine, but it was pretty widely used. A country like Cambodia, that has a very good relationship with China, it was given for free, widely. But in other countries, Vietnam, Thailand, you had to pay for it. There's some evidence coming out now. The Chinese and the Russian vaccines are different. They were based, in some cases, on research being done with coronavirus vaccines that were switched over to COVID, which is a coronavirus. Or other means. The Western viruses are mRNA viruses, mRNA vaccines. There's some data now that the Chinese vaccine folks that were vaccinated are losing immunity faster. So in January and February of this year, in Thailand, the COVID epidemic was pretty dramatic. Part of it's because of their government and the way they handled it. But in any case, when we look at it from the West, we don't necessarily take into account the geopolitics. And I would just encourage you to include that in any analysis for future, because we're going to see this again. I'd like to also comment on the mining. I'm the section head for environmental health, and we're trying to make environmental health a field of medicine that you can make a living at. So I'm going to tell you a story of a project that I developed, I was working on, right before COVID. With all due respect, Warren, it's timed, like 10.31, so this room will be needed for the next presentation. But thank you. And the first comments that you had, definitely I'll keep that in perspective. Thank you so much. Thank you, everybody. Thank you.

occupational health

environmental health

COVID-19

vaccine distribution

disparities

acceptance

World Bank Group

Health and Safety Department

communication

data analysis

risk management

collaboration

coordination