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Thank you. So I'm going to follow up on the theme of work in progress.

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We didn't actually know what we were going to be talking about,

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but I'm also going to be talking a little bit about some of my more reflective thoughts.

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I will, so I will race through a bit of rationale.

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I get a sense of who's in the room, who just help, who is who is self-identify as working in the health sector, says.

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OK, so I'm going to race through that and it's a bit different.

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So I'm going to talk a little bit about just pre-empt where I want to get to talking a little bit about the Avengers where we left off.

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Yeah, I'm and the the ways in which the nature of the migration that is ongoing is influencing disease trends.

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I consciously used that these trends, not health trends, because we often conflate them.

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I will talk a little bit about our health system, health care system responses to some of those changes.

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And then I'll spend most of my time talking more around my reflexive thoughts around bolder thinking for bolder action.

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I'm going to give you a little bit of what kind of work that we've been doing

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in the last few years as the Research Initiative for Cities Health Equity,

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which I still lead. That's based in University of Cape Town.

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So this is the racing through it. So this is what we know about the urbanisation, right?

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This is not this is not new to, I'm sure everyone in this room.

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The world is overnight waiting about 10 years ago.

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For some more people live in urban and rural, the rate of urbanisation in Africa particularly more phenomenal than almost anywhere else.

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Importantly, it's not just urbanised, and I liked the slide you into the image of what we what we think of when we think about

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organising what the reality is often urbanised and pushed by high levels of inequity.

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Largely, what we see is a huge growing informality,

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and two thirds about two thirds of urban dwellers on the continent reside in the conditions of informality.

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So we know that this is rapidly changing. We know it's complex. And yet sometimes we try to think simply, OK, so how is this?

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What are the kinds of ways that this is impacting health?

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All we see in terms of the built environment is that we see these dense, informal settlements increasing.

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So making it easy for a disease to to transmit, but also importantly,

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increasing the risk of not non-communicable diseases through the food environment that we have

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access to through the ability to embrace active living that we see increases in obesity,

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the increase in diabetes, hypertension, etc. and these diseases coexist and without in multimorbidity,

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we see that we're pushing south to push the boundaries of human settlements that we see

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re-emergence of old quote-unquote infectious diseases and zoonotic disease outbreaks,

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which are then hottest control because they're in dense urban settings.

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We see an inadequate urban infrastructure, unable to cope with some of those demands and resulting in the persistence of

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infectious diseases in spite of what might be a slight of apparent development.

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So, so as you mentioned, I lived in Cape Town for for about 11 years,

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and I recently just moved back last year and I was I remember doing my public health,

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very strong training and a lot is improving in South Africa, and I remember thinking that was in the middle of the country.

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Why do we have a term like diarrhoeal season that makes the old start real, seasonal like this is this is this should not be just shouldn't be.

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We see increasing exposure of young people to these unhealthy conditions.

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So we see a lot of multimorbidity and multiple diseases happening at young ages and we way that we actually have.

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OK, so the second point, so that was the first point to second point, these trends in health, what we see.

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So this is looking at morbidity as measured by disability, adjusted life and so the years of life, not just instead of looking at mortality,

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because not all diseases, particularly chronic disease, don't lend themselves to understanding the burden of disease looking at death.

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So we. Look at years of life lost due to disability or years of life lost due to early 70s.

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So looking at the changes between 1990 and 2010 for South Africa.

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So anything above the line is up. Anything below the line is down, red is infectious, blue is non-communicable.

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Green is enduring violence. So without having to read any of the text, a lot of blue going up.

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Obviously, the spike of HIV aids because it's it's cost over the peak of the epidemic.

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Some increase and decreases in diarrhoea and respiratory infections, but overwhelming what we see in public morbidity across the board is abysmal.

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So that's the first point. The second point is speaking to the way in which the urbanisation has consequences on

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health is there are multiple villages that we did a study a few years ago looking at.

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So at the time, I was working in the primary care setting and doing HIV TB research,

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and there was a lot there's a lot of work to be done in integrating HIV,

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TB and I was looking at it all day and I was also doing some service provision in the HIV clinics.

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And when I realised that actually what I was doing in terms of what I was looking at, it just seemed to to be one aspect of the reality, right?

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So I started noticing that even though it was focussed on making your viral load and your adherence and looking at whether you had symptoms,

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signs of TB and integrating those what what, what it wasn't doing was taking your BMI and taking your blood pressure and seeing my body.

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And so I started seeing this anecdotally based on some of the symptoms patients I was seeing.

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I thought, I wonder, based on people who are already in in in care what, how much overlap they exist between them.

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So we just did a study looking at.

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Fourteen thousand, a number of of episodes over a nine month period in the clinic and looked at just so this is just the tip of the iceberg,

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is just amongst people who are receiving treatment for one of HIV, TB, diabetes, hypertension whilst they are all 70.

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At the time they were separate, they had the same problem so that we could look at the clinic folder.

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You can have a unique patient identifier, we can look at the prescriptions and look at Wolf.

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What do we see? So if I said anything else, but if I said, if I said HIV,

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given what you know about the way this disease is co-occur, what would what's the most common comorbidity?

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Well, I think TB is hypertension. Why?

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Because the presence of the patient health tension is just high in the population.

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HIV doesn't protect you from it. So if I to see some some indicators when it goes the other way around.

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So we saw that well, firstly, one in five had another one of those conditions already diagnosed.

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Remembering that at least we know from other studies that at least half of people with high blood pressure are undiagnosed.

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So, you know, just amongst people diagnosed, but interest in civil societies.

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We also had some indicators that this was happening at a young age.

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So if you look at compared the people on antiretrovirals, so this is the caveat is that HIV negative is not necessarily negative, but not on your own.

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But it was in the setting where screening was very high and that spectroscopy is completely ruled out for several years.

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What we saw that in particular in the 1835 already we saw is a huge difference in prevalence of treated diabetes,

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hypertension in HIV infected on average about that.

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But this is not so. It's just things happening at ages where we're not anticipating that.

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OK, so think about health system stress,

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maybe because then we have to do something right because these people are coming in to the clinics and seeing them regularly.

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We all this is familiar to a lot of people.

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Yes, this is a W.H.O. health system building block.

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So we think about health system spending in this.

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I think that Fraser came up a lot of pressure during the Ebola outbreaks and need to strengthen the health systems, right?

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So the W.H.O., the health system, building blocks, so so the liveried, the health workforce, the information systems,

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access to medicines financing, leadership and governance as a core foundation for what any health system needs.

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So when you're thinking about responsive health systems,

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where there's improved health and social financial risk protection and efficiency, that's what we think of.

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OK, take a step back. Theoretical situation as rising as it may be, because let me explain it was it surprised me.

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They might say a theoretical scenario.

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You have a certain area of knowledge of people living in conditions of normality in Cape Town, working in an administrator in government.

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So it's quite a base, isn't it?

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Well, overweight or obese non-smoker had 15 year history of HIV on Second Life,

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but really very well controlled, competitive loads of breath undetectable for over 10 years.

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So one of the early events that emerged in the emergency department visits the symptoms of a neighbour of mine,

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Michael Horseback, and further investigation shows undiagnosed severe heads into this less severe weather.

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And off it was. She was undiagnosed diabetes.

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Not sure. So in the scenario, it was complicated and resulted in mortality.

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When you look into the health system response, what are the kind of things you want to ask yourself?

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That's not rhetorical. And thinking about how to avoid this kind of warning system.

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Right, so what are the ways that we could pick this up, right?

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Sorry. Offering health checks, right? Would that would that have made a difference?

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Right. So questions like, well, first we because because you came in with the condition and she died, right?

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So could we have treated that better so that she received what was the what were the bad ones that were followed when they delivered in a timely way?

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Of right? Why was someone we see regularly who is very well controlled for the the disease that we thought would be the most important poisoned place?

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Why was her risk of cardiovascular disease not picked up?

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In what ways can we organise the health care delivery service delivery method, like you say, which is to be, we think health checks.

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We think not just about disease, but about different ways of bringing them together to integrate care.

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You know, thinking about the building blocks, how do make sure that we screen people all are is our health workforce?

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I would say with the criteria for diagnosis, et cetera, going through this building health.

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Reasonable. Yeah. OK. But I recognise this ball.

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That the real point. Everything. Do we react?

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It is in the entirety of our response to improving population health reactive.

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Then what's next? She was 39. Was it inevitable that she would be obese and have a high blood pressure?

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That was inevitable? And then all we can do is just pick it up because that's how that's how we think those are important.

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And I think we all agree that that was that those steps were vital.

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But is that all is that all? Is that this other case to say, OK, we've done that.

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That's all we need to do. The other thing is that we can't afford to do that at a population scale.

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We can't afford to just wait. I showed about I showed concepts of weaponization.

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So the context of the exposures that people live and work and socialise with and try and

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kind of thrive in a changing in ways that are not necessarily conducive for health.

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So the the need for health care is increasing.

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There was a recently published paper by some colleagues of couple months ago that looked at the cost of implementing primary care one to one,

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which is a kind of a basic package of primary care guidelines for cardiovascular disease in South Africa,

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and implementing it at 70 percent of what it should be would essentially bankrupt the health budget.

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Now I'm trying to get it. So do we just say that all we're doing is chasing the best we can?

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We need people chasing. They get me wrong. We need you because there's less burden as a burden of disease and those risk now.

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But if we all chasing who's thinking about how we can do things differently now.

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So, yeah, so so I'm thinking about why we don't.

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One thing I like about public health is that it's really quite obvious, right?

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All you need to do is fairly obvious like, you know, the when you take a step back.

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But then when you go into, well, why aren't we doing it? That's when it's wonderfully complex.

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So I started thinking about one of my frustrations because I started off in infectious diseases.

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And one of the things one of the big differences I've noticed about infectious diseases this is non-communicable disease

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is the kind of rage and anger that you can muster and kind of rally for infectious diseases that you just cannot for not.

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This is just you just can't get anyone just annoyed about the trends and people.

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The deli's people, you know, say, lets you do that.

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And it's not asking, Well, why is that and what is it about that?

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And and what would it look like if it was?

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What would a different scenario look like?

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And that reminded me of the notion of a counterfactual which I was exposed to in, you know, from epidemiology perspective, right?

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But I suspect that is not, you know, when you when you when it's your people, I guess it never really goes out.

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And I got to Netflix. So the psychological test is a sociological is not is not you.

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And I'm usually so I sort of reading around the counterfactual and just kind of exploring not just from the public health methodology perspective,

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but just sociologically and from the psychology perspective.

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What the what is it about thinking about things in the counterfactual that can help to change things?

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Help stop them, so when they of the counterfactual, obviously it's a difficult position of the reality.

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It can be a driver of change. It can result in space because it's just like, what if?

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What if, what if, what if we can't do anything but it can by exploring other options drive change, sometimes without the counterfactual.

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We're not inclined to take because it's just like, this is just the way it is.

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What can we do about the way things are now?

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So what happens if you don't like the way things are now? Talk, say some more of my readings of unexploded files.

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A couple of ideas around or thinking around the spot that are needed to set a counterfactual thinking.

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So I don't even think we there. I think we we accept.

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The first move necessary is that the current situation has to be something perceived as negative or out of the ordinary.

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Well, it is what it has always been this way. It's not this is not absolutely me, this is just how things are.

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So not exploring, not not going into that counterfactual is one of the things that I see.

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Oh, I recognise as potentially being the bonuses. The second is a direct link between cause and effect, side by side and public health.

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This is something that, of course, at the macro level loves me.

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But what if those links are diffuse and distant and you haven't reached the worst of it yet?

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What if you can't quite pinpoint this is what caused it?

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Because it's just a myriad of things. That's another we'd rather not think about.

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It also it's also helpful to be able to say how you or someone like you or

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somebody in a particular position can play an important role to make that change.

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And if you can't see that, then it's not. It's difficult to see a way through.

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Well, how do we deal with that in the context of a city where we have this complex adaptive systems?

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How do you do that in the context of health and mental health when the roles are not so obvious,

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where we see what we see is the tip of the iceberg and we don't see the determinants of health that drive it.

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So we see how they'll health manifest, but we don't see the run up to it, which largely happens outside of the health care sector.

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Some added complexities, I think. Then I kind of overlay that with additional considerations in the context of of rapidly going to snap again.

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So thinking about so a lot of the work I do at the moment is looking at the ways

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that the activity and food environments in cities can be harnessed for health.

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Right. So not just the individual level, you must do this.

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You must do that. When you know, I know you walk out the door and you are able to follow that advice in any way.

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Be able to do that. It's a very typical access who's building and sitting in the comfort of the impulses in the moment.

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Right?

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Huge youth population with very little in terms of a disaggregated data on exposure and outcomes across different settings, and they're not together.

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There is insufficient, in my opinion, regional sharing and exchange.

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So we all starting from scratch every time because we think about something we don't know.

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If someone tried this before in the similar context that it worked, why didn't they work?

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What was left to take on? I think this is an important city sensitive to that because it's a lot of different things.

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But I think it's is in the broader African context, the historical context of systematic exclusion,

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whether that was spatial because the cities are not there for the majority, whether it's social, whether it's cultural, whether that's political.

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We see that playing out in inequities in terms of how we see the circular migration, we see this unpredictable demand in services such as an influx.

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So I thought, well, in what ways can the conceptual thoughts kind of sports onto this?

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Well, perhaps those are Typekit glasses make it difficult to see, well, who's who's got a central side.

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Perhaps the lack of is that big data data that you can put together makes it difficult to see what is causing the effect side by side,

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even if they take a while to happen. If we have the data,

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perhaps you could see it's a little bit better than perhaps the perception that it's something you'd need to get out of the ordinary.

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If it's just kind of always been this way, this is what we have to kind of hustle through.

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OK, so that's basically my last couple of minutes of the way in which we can rethink a health service in the confines of the city.

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What does that mean? So it's not here.

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I mean, this is not a retreat, but it's just to share with you the handle's network in the health care and health aspects of health services, right?

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In terms of the exposure. We think about the, you know, the dimensions of access, what is available, accommodating.

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And I thought about that actually when you were talking about energy, you know, thinking about access,

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not just geographical and alive, but all these different dimensions in the intermediate outcomes.

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It's the way that you conceive of chronic disease control your episodic collection of health care towards improving place.

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Well, what if we thought about health services a bit differently?

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What have we thought about health care as being one part of health of the health service where

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you have the other sectors and access that play an important role but which are not visible?

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Thinking about this counterfactual spots thinking about your habitation.

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The planning or design of your place may be thinking about the kinds of exposures linking those,

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the kinds of exposures that have a downside and actually result in you increased risk of cardiovascular disease.

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Who who are the things to go to there? Whoever is responsible for the planning of the city when they've diagnosed with hypertension?

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Right, so lovable. But what what is the what is the exposure and how is that impacting 74?

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I mean, this is not exhaustive, but thinking about some of the this is just my things I'm interested in.

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OK. This is another way of putting it to say that again, when you think about health care,

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often we we interact with health care, health care at the top and bottom end of our lives and when things go wrong.

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But actually the rest of the time, this is our exposures.

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This is where we spend our time, if we lucky be healthy and the huge determinants of health outcomes.

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But yet we don't connect them in a way that in thinking about patient health, we need to.

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And we don't think about the systems for health that require reading together.

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The health care system with those are the systems that are important roles in control so that some

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of the thinking I think last night that I was informed of the my some of the work that I do.

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So this is some of the conceptual thoughts kind of linking my background.

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And so the research we've got ongoing at the moment looks to foster partnerships with a typical XS and XS who

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co-created some into the interdisciplinary research to build capacity for this kind of work and foster exchange.

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So we do do some health systems work of still doing some work looking at health system responses to HIV,

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NCD integration thinking in the context of adolescents at the moment,

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but also moving to the dark side to speak because they're looking at systems for health things.

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So we've got a couple of studies in a study in a couple of cities looking at health and housing policy and the ways in which governance.

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I really resonated with how the governance for health is out of whack, as I say,

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and looking at opportunities for integrating health objectives into housing policy.

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We're doing some work now average and with colleagues in also in Cape Town.

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And there's a kind of living in Kenya and in Jamaica looking at a little bit more

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around the diet and activity environment and the policies that govern them.

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Adolescents form a huge target group,

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important because I just don't think we can ignore them in the context of Africa and not just as a vulnerable group,

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but actually as agents to make that change.

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So, for example, one of the studies that we're looking at is exploring them as citizen scientists to actually work

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with them in the collecting data and the analysis and in the co-creation of these therapies.

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This is my last night. I put this here.

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This is your my test audience because I've only been met with his hands because this gives me a little bit of humility,

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because often we think about science, public health research.

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Yeah. He's a better health.

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But I think the reality is that we do it through other means and then if we if we if we do that, if we look at will the implementing acts.

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So that's in the public sector, the people themselves and in the private sector, there's kind of actually have the force to an implementing power.

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But if all the different levels and all with different complexities and all engaging with themselves in different ways,

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and I find it helpful to think about well in terms of thinking about public health and why we said, where does that sit?

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Where am I most comfortable? Where am I somewhat uncomfortable?

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I'm actually not doing a lot of work in and but when I look at it and when I think about it ideologically, I should be.

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So I'm trying to use that to drive the next and the follow on direction of of work.

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But his plans to ensure that kind of going back to say, Well, am I just kind of sitting in my sweet spot looking at the strong links?

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Or am I actually pushing a little bit and looking at where the evidence is weak and where we don't really play sufficiently?

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So that's where I'm at. Thank you.