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Going and um proceed with the uh uh talk. So Sarah Phillips uh will be talking to us next. She's a consultant at King's uh College Hospitals in London. And um we're going to be talking uh a very topical uh subject at the moment. She is working in Gaza, but she's actually gonna present ongoing work and gather over the years as well. I'm very excited to hear more about that in about and you, Sarah. Well, thank you and thank you for um inviting me to come in, talk about a subject which I can get for about, especially in the last few. Um As far as I know, no conflicts of interest, although we have been supported or part of different um groups UK government. Um over the years. Um So trauma in Gaza, um I'm sure everyone knows where Pfizer is. Um what makes it different. We know that worldwide uh former makes up about 12% of the global burden of disease. And I suspect part of it's probably that certainly is at the moment. Um Its population is only 2.3 million, 75% of refugees, 70% below the poverty line. This is pre October last year, 30% then unemployed. Um It's been on the blockade uh since 2007. Um And therefore there's nothing gets in either by planned care or see, I think numerous escalations over the years um of varying intensities. The the these two pictures are actually of taken in August 2014 at the tail end of the, of the 51 day war, which at that time was the largest and the most. Um, and topic is actually the rehabilitation hospital. In hindsight, it's probably not a good idea to come below the rubble of something that's just been blown up. But, but that's time. And then that cycle of violence continued with the protest march in 2018 19. This was a conjunction of what the Palestinians called the, the catastrophe, which is the formation of Israel, but it was agitated a bit more by Trump deciding to open the US Embassy in Jerusalem. And what you can see there, there was quite a lot of injured, but actually there were over 7000 gunshot wounds which, um, limb injuries hasn't quite worked. Um, was, um, uh, over 6000 which 12 to 1500 required limb reconstruction surgery. And on the 14th of May 2018, which probably everyone's heard of now between two pm in the afternoon and 10 o'clock at night, 100 and 67 gunshot wounds came in. I would suggest that the four major trauma centers in London would have not coped with that. And then the cycle of violence continues with various different amounts of uh casualties. Um all ongoing. Before October 2023 there were 36 main hospitals within Gaza Ministry of Health and NGO Gaza would not like it to be described itself as a low to middle income country. Its set up and situation is very different. They have a very capable well educated workforce. There's a Palestinian medical border overseas. It's a combination of sort of training SAC and GMC. So it supervises the training, but it also registers the doctor have their own medical school. But the problem is there's been blockade. So there's limited supplies, often zero stock of those medical, there's limited budget, there's no orthopedic equipment budget and more technically demanding patients, whether it's orthopedics or cancer or whatever, they've always been reliant on trans clothing patients. Um So the challenge 16 years of intermittent conflict and ongoing blockade where there's lack of medical supplies, no orthopedic equipment budget capacity has always been limited during um hostilities at that time is unable to transfer patients out. Training is isolated and it's an of course and is an open prison. Um You cannot get in out easily. Prior to 2007, the senior medics would have trained in or the UK or some still were managing to train in um in the Arab States, but it's very difficult, completely reliant on humanitarian aid and donations and top of the maybe trauma they have this ongoing, of, um, cough injuries. What injuries do you see in conflict? Well, it depends a little bit on the mechanism. Um, and the type of warfare that's on blast, fragment, bone crush or gunshot. This is a gunshot wound throughout the ages. It's always with war, always predominated second world war with, it's, um, Falklands, whether it's Korea, whatever Ireland, the injuries of always, and it's almost deliberate. You, if you, if you kill a uh a soldier, a combatant, then you'll, um, that doesn't take a lot of work from the people you're attacking. If you kill someone, they're alive, that causes an awful lot more. Um This is with my ex R AMC, how on. So, uh did 37 years in the Reserves. But, you know, sort of when you're talking about conflict, wounding people if you attacking somewhere is much more. Um, yeah, it, it, it, it's, you know, it disturbs things about more than people. Um So it's perhaps not surprising with those types of injuries that limb reconstruction comes into its own, whether it's nonunion, munion, leg length, discrepancy, bone loss or infection. Um And I'm sure you all know about this method, but when you're talking about non unions, infection, bone loss, this is a method of treatment that comes into its own. Um, you know, with bone loss, you can uh get a frame on, you can acutely shorten, you can then lengthen and sport, then lengthened, ended up with a relatively straight intact leg afterwards. The difficulty is that we know that even with the in the NHS, this is both arduous and lengthy treatment, not just for the patient but also for the team. It's inpatient and clinic heavy. It is a big team at Kings. We have plastic psychology, physiotherapy, nursing, uh citizens advice. We have a, we have a assists advice advisor who paid for by my other charity and to advise patients on their benefits and their employment and their housing, et cetera, et cetera. And we have to start a charity to help support our NHS work. It's expensive. You need a stable environment, all things that you don't have in conflict and some and in other countries. So my other charities ideals, what it does is in its name and what I mean by name is a long term support, an awful lot of charities that um uh go in and out and that's it and then go back again. Um And as you'll see, not quite the case for us. Um The charities worked in it started in the V of Sarajevo by John Bevis, who's a, who was a retired orthopedic surgeon um and has worked in Northwest Frontier Pakistan and in Sri Lanka. And since, yeah, 2009 has been based in Gaza with a very short episode in the West Bank and we've done various projects um and worked with various partners over the years. But obviously, so for me, our biggest project has been a reconstruction project. And my first visit and when the project really started was January 2013. So you, you've been going there and I've been going there for 11 years. And um what have we been doing? Well, various phases. It started off with training fellowship. So the first phase 2013 to 15 was bringing three GZ and orthopedic surgeons, two kings for a period of time um to train with us to do limb reconstruction. And our rem which is basically was to train people, build a MDT in limb reconstruction. So patients didn't need to be transferred out. And that's what the various other bits were rudely interrupted by before uh 51 day war in 2014, but basically to establish a tertiary limb reconstruction service. But then also to improve the management of trauma within the other hospitals within, within Gaza. So basically what we mean by capacity building is it's building something or hopefully. So 4 to 8 visits a year in between times, virtual meetings, case conferences, advice whatsapp x-rays sent to you. What what do I do with this? So support throughout the time on the whole surgical principles. Well, limb reconstruction is always what is the limb salvageable or not? You know, do you amputate? Do you reconstruct? But when it comes to working in environments outside the UK or outside the developed so called developed world. There's other considerations, the number of patients facilities, whether there's going to be ongoing care. Then again, in a society that doesn't readily accept amputation, hardly religious, but also because OK, being able to get a decent uh prothesis is um difficult principles of er surgical bits. So, reconstruction, debridement, stabilization, restoration, sorry, restoration of soft tissue envelope, elimination, infection, and restoration of burning defects and um to fill the gaps. We've also been lucky. We buy our composites who have been very generous in donating um stimulant. Um We have tried using induced membrane techniques. We haven't always been quite successful with that. Our mainstay shortening and lengthening or all bone transport or combination of all. But the problem again is numbers time cost resources and even before October last year, antibiotic resistance, which was quite high. So what have we achieved? I think a little bit you need to read is the uh one season is this book. And so 10 years, we'd established a Gaza Li construction service and 2.5 1000 consultations, 630 operations. I'm the Quartermaster. I spent $3 million on orthopedic equipment, 33% reduction in patient transfer down training programs. We achieve something that we haven't even achieved even deeper, hasn't achieved as in the sac. Then recon is recognized as a speciality in Gaza that all trainees have to do. That doesn't even happen here. N da started to collaborate um considered by Moh as their most successful program. And also more importantly, it is enduring relationships with Palestinian colleagues. The sad bit is this, I think that that's a mis standing the limb reconstruction isn't, this isn't lovely weight show and went in and took a video especially for us because they helped set it up to show it's nonexistent. So index injury may 2023. I I'm not sure what the mechanism of is, it possibly was gunshot. Um But you can see that never a good start when you can see the other side of the leg and the person's um gown and side of the leg. Um So those are the x rays. So initial debridement and provisional stabilization with a very nice A X ray. Um uh and they've chewed off a little bit and then acute shortening and lengthening. So, so frame goes on short thing, then you lengthening there and in that leg im 2024. So conflict and only months. What's so special about this one team that we've taught and trained, that's what long term support is about life changes. So the present situation. So these are the figures sort of from about the 31st of May. Um Over 36,000 killed, 82,000, over 82,000 injured, majority of which are women and Children and elderly. There's an unknown number under the rubble, which is probably 10,000 or more, 78 to 80% displaced in hospitals, partially operational but overwhelmed, um partially operational. I think, you know, it's can't do, certainly can't do what they were doing before and, and they're overwhelmed with trauma. Um There are nine field hospitals but actually there are four that are not able to work field hospitals that have been set up since October. Um and these projections, this was projections from, I think from April March, April. So even if there had been a ceasefire, then there's still been these excess debts. Now, we haven't had an epidemic yet such, but you can see that um um I'm looking at at least 85,000 and it's probably hard in that, that you have if there's an epidemic. Um The main thing is 60% of water is contaminated and the plants, it is a surgeon communicate. Clinical disease has been at least 30 to 40 deaths for malnutrition. Um No mains, electricity, no drugs or medical supplies. Getting in crossing has been closed since the seventh of May and, and I'll get onto it and there's huge issues regarding that. We were going in through C and then MA A with the UN, how that is closed. So the significant access issue. So what have we been doing? So our role has changed. We are now recognized by the WH O as a specialist emergency medical team and we've been working at at a European G alongside the car and colleagues that remain, should add that. There's, you know, well, over 400 healthcare workers that have been killed, there's 100 and 24 in detention in Israeli jails and there's 50% of the 50 to 60% of the workforce can't get into the hospitals because either dead can't get there displaced or looking for food. Um So the five equipment, we've had four missions. So I went in January, we went on the second mission. Um, five was because we had, and there was no one to go and I was supposed to be there this week and the part was canceled because we couldn't get, and the two has just been canceled because the, you can't get in. So the UN has now started convoys back through Ker Slo it's two a week. There are only five places for emergency medical team working considering the number of emergency emergent need to go in to lie those who in there and get them out five or something. And you need to go for four weeks. That sort of stops most of us in the NHS. And, and you're only allowed to take two suitcases as 20 days each which considering you need to take it for four weeks isn't an awful lot. So I think it'd all come back thinner so we can't get, and we're hoping that things will change and we will be able to get that at the moment on hold. I think ma who is the, one of the other big UK charities is taking people? Um We do. Well, this is European Gaza in better days. It was built with money from the European Union. Hence its name. It was, it was a, it was pretty tidy, well organized hospitals had 250 beds that went up to 400 with the prefab, um, that was, um, built during COVID and that's what it looks like looked like in uh Christmas. And certainly February, I'm inundated. Well, over 900 to 1000 patients, 22,000 into the were at one stage 22. It's an internally distress. You couldn't walk down the corridors because people were sleeping in the corridors, either patients or family or whoever was living in the hospital or in the ground. You couldn't move around, um, was lessened when one thought the hospital was going to get attacked and they were worried they would end up in the mass graves like the people at NASA. And now she did. So it, it I got sent a video, it showed the corridors were deserted. That might be still the case now. But at its height, it was typical injuries at that stage, sort of traumatic amputation. Um, but uh infection and bone and soft tissue loss, there'll be some closed injuries, um because of crush injuries and things like that. But the majority that we were seeing or I was seeing were certainly, um, open injuries of the severest type and infection, not infection because of the acidities within the hospital. They often played a part infection because of the type of injuries, the delay in treatment, the numbers involved. And therefore the time it takes malnutrition, if someone's mo if someone starving, they don't have the resilience, you know, and, and think, uh, described it recently. I heard it's also you got it the tiger. You got a, it's basically that catabolic effect of severe injury, you need more pro don't eat less and you certainly don't need to be starved. So, what have we done so far? What we, the top picture is we don't always take yellow suitcases, but that's quite, quite good for some reason. So they cos they, you can see them and they get mixed up with other people. We were taking about 40 suitcases of um equipment over just through Cairo for, we've managed to get it through without paying any cost or consultations and 60 or so surgery over 300 nerve blocks. We have some of these, I was interested to hear about the nerve blocks we managed by these little, um, we bought this, um, ultrasound probe that you connect to an iphone and, and therefore the anesthetist was able to give nerve blocks when there's no analgesia nerve blocks are wonderful. Um, and then procurement, that's a very conservative estimate that bottom picture. It's my front room as I left it yesterday because we haven't got a warehouse yet. So, and then my colleague's front room looks the same and another colleagues front looks the same. We've got another gal. So we like Amir. We got to try and find a um a warehouse cos we can't get anything in it. So the first and challenge uh obviously huge patients, chaos, lack of basic and orthopedic appropriate staff to look after the patients. There's no system for follow up medical records. Are we try our best and we're probably one of the better groups regarding um ation, but we certainly can't do patient health notes at the moment. That's what we used to do. Um And obviously the security situation is just getting worse and worse you. This is um I who knows where this place is? This is uh the uh commonwealth war grave and uh Bala, this is whose family look after it. Just so the ceramic poppy does get everywhere. Who knows what's gonna happen? You just on hold essences and perseverance building, trust with partners, collaboration, not competition. I think that's one of the biggest things. You know, we've just seen everything that we've built in the last few years disappear. So many people to acknowledge. You can hardly read it so small, but there's quite a lot of things I should point out. Mm He is back home. Mm Help us with equipment. This wouldn't have happened without these two. So John Bevis, who um set up the charity idea and some of you will know Graham Groom he's seen in and start to lead on this project. And then finally, just to mention Aland Albert Adnan was our first um post 1000 fellow kings in 2013. Um Heent within six months, um he became the head of orthopedics at Al sh he was um detained and arrested in December 2023 died in Israeli detention. April 2024 that we've heard from other. So that's what they told me any questions. Thanks so much, Sarah for this uh heartfelt and a very uh moving uh presentation but also factual uh you know, things are happening there. I'm sure there are loads of questions in a room. We'll try and keep them shorter, stick with time, but uh continue the discussion again over lunch. Uh Jonathan and um Johnson, he's ak I wonder whether you link up with the upper limb side with him. He, I've chatted to him. No, John John's been a few times with us. I mean, you know, when I went back to the side of the volunteers, the dots are all in places all over the place um including Oslo. Um you know, John John's been a few times. They never understand what he's saying because of his Estan accent, but, you know, a great teacher and he's been a few times and he, you know, once, once a ceasefire. A lot of people find it difficult to go when there's hostilities and for lots of different reasons and, and we, we do have a significant number of people who want to come with us but just can't go in, I mean, I can't go and go for four weeks. I can go for two weeks, but I can't go for four weeks. So, you know, when the situation is changing the whole time, it's um it's very difficult to um to go for some people. And bottom line is our, our life insurance. We need to don't have a mortgage. A lot of people, he does a hand on upper limb, he does a hand and upper limb. And I wondered whether there was other people who go from kings who do that or it was. Yeah, we've got, we've got limb, we've got the plastics, plastics, people are all from kings. So, but then, you know, deep as goes um a almost went that he wouldn't allowed to invite the Israelis. Um And um we have people from Gloucester, Scotland all over the place. We're not just kings. So it is all over the place and, and we partnered with um Norwalk in the past and still do try to work with Norwalk. So they're based in O OK. Just I have one question, sorry. Um Just a question of sort of equipment you mentioned, you use stimulant and stuff like that. We, we have access to stimulant as well in our trip. Uh, some of it is out of date and, uh, I just kind of think of it a bit like, you know, uh, chocolate goes out of date but, you know, you, we, we discuss that with them and because they, at one point they did give us a whole part that was near its day and, um, and then it, and then it got nicked by Israeli customs. So, and we didn't get it back. So, so they're a bit more careful about that now. So they donated us quite a lot and, and, and the expiry date, the last, the last lot they gave was actually quite long. Um I mean, it will, you know, they said we can't tell you this officially, but it, as long as the packaging is intact, it will obviously last a little bit longer than it says on the pack. Um But they're very careful about that expiry date because every time they delivered it to Kings, it got lost. And so the reason why my room like that because we ended up having to have the syn stuff supplied there. All the bar composites had and Smith and nephew are just hanging onto it for us at the moment because we haven't got anywhere to put it. Last question, James. Well, first off, I'm very sorry for your loss. Um A few questions, I suppose one are civil insurgents in a war zone. More of a hindrance, civil insurgents in a war zone. More of a hindrance than the help because we don't necessarily actually have the background and gunshot wounds. I think, I think that that is, that, that can be an issue. I think it depends what kind of surgeon you are. I think if you work in a major trauma center and you see some of the stuff that comes through nowadays because they survive and don't d the roadside, you can adjust your, adjust your skills. I think there's definitely a problem because other fellows who are still in Gaza has said that some of the stuff that he's seeing and being sent, he can't believe some of the treatment that the orthopedic patients are getting. And, and that's simply just an experience from people who think that they can do things in a, in a war zone and it will be exactly the same as doing a yes. And it's not true. It's, it's different and you have to be slightly cautious. The other thing that I'm sure we'd all be very keen to know and how do you uh negotiate that time off from the, because that's something I think I I'd struggle with in terms of finding it, think of, um um I can think of better holiday dis it's annual leave, annualized contracts, it's and also annualized contracts. So I have a, so Graham case in point, he has a very annualized job plan and I have an annualized job plan. So it means that, um, um, one we do an annual leave. But as long as I do my annually job plan, I, and on the whole, I, every year since I've, I know my job, I've had to stop working clinical because I don't know that they often do something else. So, so annualized job plans help. But otherwise it's annually, I think it depends from trust to trust when we've had trainees come out, they manage to get it steadily. Pretty much. Can I bring in our next speaker who's hanging on the line from the US at the moment or continue this conversation if we can over? Thank you very much, Sarah, I'm sure. Ok, the, an ex speaker you can see in the corner there, um, is coming in from a different perspective to orthopedics, er, Professor Mahmoud BTA who works in, er, er, in Sussex and, er, actually has spoken to the B OA as well and some of you might have seen him, he's a leader in sustainability and also has done a lot of work from an ent perspective in LM IC outreach. Um, these are things that us as orthopedic surgeons that often, you know, relegate to this sort of like secondary, um, you know, consideration uh in our practice, but it's becoming more and more relevant and important to us, especially since resources are becoming so expensive and so scarce, so difficult to, to, to bring with us working on a more sustainable model is certainly something that is, you know, nowadays more relevant to LM IC orthopedics and any time. So, first is actually based in, at the moment on a conference or, um, work trip that he's doing where he's kindly agreed to come in for a live length, er, to talk to us about the environmental and labor, harm some surgical products. Er, mahmoud over to you and sorry about the delay. Uh We're trying to keep you time but we're doing fairly well, no problem. Um And thank you very much for asking me to join. Um So some of you may have heard some of this previously but hopefully is new to some of you, but I am trying to incorporate some of it into some of the relevance to work in low middle income countries. So, so my research interest is includes sustainable healthcare and in particular related to our supply chains for surgical products. And I'll come on to talk to you about that. But the other big aspect of the work I do is actually related to delivering um ear and hearing care um in low resource settings. So um I've, I've also worked in a number of different countries, so, so I understand the challenges but also what we can learn from um countries where of course resources are more limited and we seem to be more frugal with our use of equipment. So, next slide, please. So this is um something that I've been working on for some time. So when I was a junior doctor in sho I started to raise concerns about uh particularly problems with our supply chains. And this is an article I wrote in the British medical Journal in 2006. Uh click again, please. But also back then I was interested in the environmental harms. Um You know, we think that some people seem to think that climate change is a new idea. Um I think the first paper that described climate change was written by Guy Calender in the UK in 1932. This is nothing new. We knew about this next, please. Um We have produced in November last year, something called green surgery report. So this is sort of obviously uh a progression of my interest. So those of you are interested, you can freely download this. It gives you a detailed um outline of everything we can do to make er surgical career more environmentally friendly based upon current evidence. This is an emerging field and we're all learning as we go along. Next slide, please. I think one of the basic problems that we have I II in my view is the way that our brains work. We are obviously the most intelligent species in the in on the planet. But also arguably, I think the most destructive when you undertake functional MRI and look at where we have different aspects of uh intelligence. There are two types of thought. We have abstract conceptualization, which I think is obviously er, led us to progress to, to great extent in, in everything that we do by passing down knowledge, by having ideas of how we control the world and how we communicate with each other, those abstract ideas, um er er gives us um sort of what's called fluid intelligence, but we also have something called concrete intelligence, which is based upon our real world experience, which is also of course valuable because that's how uh you know, we embed ourselves, what we've learned when you do functional MRI the two thought process seem to very little, very little overlap. And I think this is one of the issues is that we have this abstract concept of where things are far away, where things are not visible to us. So climate change historically certainly has not been on the agenda because it just seems an abstract concept to us still it is today an abstract concept. But ii liken it to when people suddenly found out there were things called bacteria, the world just didn't believe it until the microscope, you know, then they started to see these things actually existed. So it's the same problem that we have and it's the same problem with our supply chains. These are abstract concept, things are really quite far away. Next slide, please. And if we look through human history and I'm not sort of you know, saying that everything was romantic but for the vast majority of history, up until about 200 years ago, we lived very much in harmony with our planet. Um, if you look at a lot of, er, existing cultures that are still following ancient ways, um, they in fact talk about our harmony with the planet. So if you meet the Inuit people, they talk about Inuit, the life force that binds us all together and they are very much into sustainability. I've worked with Aboriginal um people in Australia as well, they very much live in harmony with the planet. When you kill an animal, you must be grateful to its spirit for allowing you to do that and you do not harm more than uh than is needed. You do not take more than is needed. So this phenomenon of destruction of our planet is a relatively new phenomenon. Next slide, please. And I'm sorry to say that it was the British that really pioneered this approach. So back in the 18th century, uh what we found was that the feudal landlords um in England actually decide actually came up with the idea that product produce could be sold. Before that time, people in agriculture would make products that were just designed for local distribution within the um village or town where people lived um or, or obviously just serve their uh their landlords as it were. In fact the word er, er er, sorry, it, it what happened then was that people started to sell this food and this idea er, became er widely accepted and er spread across the world where we can extract everything we need, including money from our planet by monetizing and taking over our land. So I think it's now around 70% of all land is given over to farm next week. And this is of course, uh some of the end product of how we treat our planet. And some people say that this is of course shameful. Next slide, please. So how does this relate to medical products? And I'm gonna talk to you about the consumption of medical goods. Next slide, please. So medical goods in the NHS in England, we see this in our day to day is 10% of the carb footprint of health systems in high resource settings is due to medical goods. So we know that overall around 4 to 5% of the carbon footprint of the nation is, is due to um uh the NHS. So actually about one in 200 of all of our carbon footprint for the UK is due to medical products. It's worse in the US. It's around 8% and I'm currently in the US. I'm actually here to speak to a number of people about trying to get this country to uh sort of decarbonise its health systems and it was dominated by linear consumption. So it's been estimated at 73% of all products using the NHS are single use and look at the quantities 10 billion medical devices per annum. 592,000 different types. 240,000 tons of just clinical waste, er, produced every single year. Next slide please. And here's an example. 93 million drapes and gowns in the UK. The vast majority are still single use. Millions of metal instruments, billions of gloves and er, electrosurgical products and sting devices. I come in to talk about some of these next time, please. And those of us who work in low resource settings will recognize that it doesn't necessarily have to be this way. We don't really have good data, but this was a systematic review of the waste generated per in per um continent um per bed day. And you can see that of course, as you imagine that places like the North America are very um high resource, lots of consumption of uh waste um per hospital bed. Whereas places like Africa are very low, it's showing Australia very low there, but I'm not sure. I completely agree that that's true. Next slide please. And when we look at uh the factors in medical device procurement in LM IC, what do people actually care about? Um You can see that the main driver there is device cost in LM I as you'd expect. That's what they're interest interested in. Whereas we seem to have this fragmented um sort of purchasing and supply, er, issue where, what we buy in high income countries we don't pay for. And so it seems quite easy to throw it away as well as some uh unfounded concerns necessarily about infection risk. Next slide, please. Yeah, carry on. So what are the harms from this linear economy of medical goods? Next side? Well, I always look back to history. Sorry. There's been some reformatting of the sliders that come across which is why it doesn't look quite right. Um There's been some historical er if we look back through different approaches, we can see um to surgery, we can see that we have moved towards this linear economy. So I always show this example from Cassie THS data in the US she carbon footprint, different approaches to a hysterectomy. And we've got the more traditional approaches, a vaginal approach and an abdominal approach. But then we moved to laparoscopic approaches and robotic approaches. The carbon footprint is obviously the size of that bar and what we see on the right is anesthetic gasses. Actually, this is historical data because it was using a compound called desflurane, which you may be aware is a very toxic compound in terms of greenhouse gas emissions is now banned from this year in the for use in the UK, which is a great thing for us to be proud of. But the second biggest component there in red is the production and use of single use equipment. So as we've moved to modern approaches such as laparoscopic approaches, such as robotic approaches, we have an explosion in the use of single use equipment and it simply doesn't have to be this way. There are plenty of good quality, reasonable laparoscopic instruments that can be resharpened and used for years. But we seem to just like the fact that we can throw them away and robotics now are now starting to make a few products that are reusable. But you wonder why it wasn't that way to start with. Of course, this is the linear economy model where we take make and throw away. And this is the capitalist model of extracting what we can from our planet. Next slide please. When we look at goods in the operating theater and we look at what's the contribution. So these are our data. We looked at some of the most common operations. You can see that 68% of the carbon products use is due to single use products. And there's something for orthopedics there knee arthroplasty. Again, you find is a lot of single use products. We found that you could reduce this uh by 14% just by changing what you do. Now, we don't need some massive solutions in terms of technology. We just need some behavior change. Next slide, please. And it doesn't have to be this way if you looked at uh the carbon foot or cataract operation. This is the only example I've got from my LM IC and this is what we need more information of when we look at cataract. Well, when uh my colleagues have looked at a cataract operation performed in the UK, has a typical carbon footprint of an operation of 100 and 80 kg of carbon dioxide. That's the equivalent of driving from London to Edinburgh in a petrol car for the same procedure performed in India has a carbon footprints 30 fold lower. And that's because of they use highly efficient systems. They reuse almost all of their equipment and they report lower rates of infection after an operation than we report in the UK. So anyone who says, oh, you can't reuse things because of infection risk. It's simply not true. We need more data on these sorts of ideas. Next slide, please. So people often think that hey, perhaps if we recycle everything, everything is gonna be ok again, sorry for the formatting issues that have er er come across in the translation. If we reduce what we use, we will reduce, we will save 100% of the carbon. If we reuse, we know from a systematic review, you are typically gonna say between 38 and 56% of the carbon. No other strategy will get us that much carbon reduction than to reuse our. And that takes account of all the sterilization, all the decontamination. So um don't let any companies tell you otherwise because sometimes they'll tell you all, there's a carbon of reuse as well. There is, but it's still much, much better and recycling. We all like to do it and we like to think that it all goes off to some wonderful place where the world is gonna be saved. You typically will say 3 to 4% of the carbon if you recycle at home. So recycling is part of the answer. If we recycle everything, our planet will die, it's not enough. And in healthcare, it's very difficult because products are often contaminated. They're often multi component. By the time you've taken it apart, uh possibly cleaned it, you may save no carbon whatsoever. Next slide, please, we've got a lack of resilience. I don't know if you're finding that we've got things that are not available. Uh This is the number of products that are not available. It's getting better. But we, at our peak, we had nearly 1900 products um where products were not available in NHS uh for us to use. And if we stopped throwing things away, perhaps we would have more things available. Next slide, please. Of course, in low and middle income countries, they don't throw things away because they don't have these supply chains where they can afford to throw things away. What else? Plastics. So it's estimated 2% of global plastics are used in healthcare. And in the operating theater, we found uh my colleagues have found three times higher microplastics. I'm afraid microplastics are in every single indoor environment. They'll be around you as well. These are tiny little sharks of pla that are released of off every single plastic surface. Um, and they're, as I say, they're in every indoor environment. Unfortunately, they've been found in every single human tissue that has ever been sampled. They will be in our lungs, they'll be in our guts, they'll be in our liver. They're even found in our bloodstream. There's multiple studies now showing that they are very difficult for your body to remove because they are not natural compounds. So they sit in our lungs and our guts pro probably forever. Um When in the operating theater, we find three times higher levels and we think this is probably because of over materialization as we're opening more and more packets of things, pieces of plastic are flying up into the air, we inhale them, we ingest them. We also find toxic levels of um other compounds. So this is a compound called DE HP, which is a phthalate. It's used to soften plastic and the graph at the bottom there shows the DE HP levels coming out out of wastewater from a hospital in Denmark. The red line is the er permitted levels at EU and you can see the blue lines and the actual levels. These are highly toxic levels of DE HP coming out of water in a hospital. We don't know where they're coming from, but they must be from plastic additives. Um, um, so I hope none of you drink plastic bottled water because if you do, you are drinking an average of 240,000 microplastics per liter and you are of, you are drinking DE HP and despite what the companies say often at toxic levels, so please, I would say don't drink plastic bottled water. Next slide, please. What we also found is that when we outsource products, we get free market economics. So here's some bandages and support. So I think these are new supports coming off this er er production line in Mexico, what they're doing is they're being produced by different manufacturers. So the the the box on the right is actually a US er brand. Um er it was well known now no longer trading the box on the left is a local Mexican brand. Um you it's exactly the same product going into six different products, uh six different boxes. So this is what's called global value change where we outsource production to the lowest possible cost. Usually because we want these linear economies where we want to throw things away. When you want to throw things away, you want to make them as cheap as possible. And unfortunately, this free market economics carries a risk of labor abuse. Next slide please. So we tried to map these data and this was a paper that was published earlier this year were very difficult to find data on where products are being manufactured. But um uh we did manage to get some data from Norway next, if you just click again, please. And we had data from 29,000 items because Norway actually asked their suppliers to tell them where their prices would be manufactured as a condition of contract up until recently. You couldn't do that in the U in, in other countries in Europe because of eu regulations that I'm glad to say has now changed through some campaigning with that. I was also involved in um when we map those 29,000 items. Next, please, we find that actually um we map them to uh country of origin. Next, please. We find that, er, around half of products are actually manufactured in countries where we know there's a high risk of labor rights abuses. Um According to the IT UC uh uh um categorization. Next slide, please. So what are the incentives and barriers that lead to this uh linear economy? Next, please. And I think of it as three things. It is, first of all, a perceived risk of infection and usually it's a perception rather than a reality and this is something I'm gonna talk to you about. Second is the economic drives, we often think it's cheaper to just throw things away and I'm gonna show you that's simply not true. And the third is a lack of human and physical resource to allow us to reuse things. So we think uh if, if it's not easy to reuse something, it seems easier to throw it away. And that's a behavioral thing. Of course, next slide, please. I'm gonna show you examples where we have infection scares and that has led to us leading to overuse of uh uh over materialization. So the classic example is PP and of course, we saw this during COVID, but we've also seen this before. So when I was young, I remember uh growing up there was this new thing that was going to kill us all. It was called HIV or AIDS. And this was the, some of the advertising that we saw around AIDS was going to kill us all. Um And so what we found was a huge increase in the use of gloves. Of course, we know that HIV has not spread through skin to skin contact, but the use of gloves became routine in healthcare at that time. And then, er during COVID, we were told to wear all this PPE, the gloves, the gowns, the masks. I'm afraid to say it was all completely unrequired. We do not need to wear all this PPE and I've spoken to the World Health Organization need for infection control. He himself does not understand why we were told to wear all this PPE because we should possibly have been wearing masks and even that is questioned now. But the evidence now shows there was no advantage whatsoever from wearing any of this PPE, we should have been washing our hands and this massive increase in PPE was completely unjustified. Next slide, please. So PP increased during the pandemic, we, we know that it went up but even before the pandemic, we had 1.7 billion gloves per annum used in the NHS. And we placed end to end that would almost stretch the moon. I see carbon equivalent. Also we did the first carbon footprinting a PPE of driving a petrol car around the earth 8300 times. This is a huge amount of er, er, environmental harm. Next slide, please. But what we do know is 60% of glove use in the UK is inappropriate. People put on gloves habitually rather than thinking about why they're wearing gloves. Gloves are only required when we have expected contact with potentially infected body fluids or broken skin and inappropriate use is perpetuated by individuals and institutions and it actually puts patients at risk because gloves are not clean. Of course, they're not sterile gloves. So they actually spread infection rather than prevent infection. Next slide, please. What we also know is that we've got a new oil refiner under construction in Malaysia which produces 70% of all the world's gloves importing up to 300,000 barrels of oil per day from Saudi Arabia to help fund our um our cultural problems with putting on gloves. Next slide, please. But also there is a problem with labor rights abuses. So this is top glove, the world's largest manufacturer of gloves, which produces 2 billion gloves every year. And although the factories look ok, the realities are that these workers on the shop floor are migrant workers typically from Nepal and Bangladesh. And although it seems ok, the reality is that most of them, well, 40% of them have paid illegal recruitment fees typically around $2000 sometimes up to $5000 for this golden opportunity to come and work here because they're desperate for work, these fees are illegal. They should not be paying them, but the realities are, they're so desperate. They get um, recruitment agents that will um uh ask them to pay these fees next slide, please. Well, the reality is that they actually uh live er, that, that they've worker usually for at least three months without a single day off. Um because they're desperate to get um, er, the, the legal recruitment fees they paid back to them. So if you just click on, er, hopefully the other video will go. They also live in accommodation provided by the factory. Um I'm not sure that video is working yet. Thank you. Um And this is the worst accommodation I've seen but I've not seen any good accommodation. These workers were living in shipping containers for three years, their entire, er, contract um and their entire existence is to work in this um er factory um for 13 hour days. Seven days a week and live in this shipping container. Most of them have never seen any other aspect of Malaysia. And as you can see, imagine the mental health issues are severe. These are gloves coming into the NHS, these gloves are going everywhere around the world. This is some of the worst false labor that has been documented anywhere. Next slide please. And these are all the companies that have been found to be doing exactly the same abuse of migrant workers in the gloves industry and in fact, in other industries in Malaysia is endemic, you can read our report where we interviewed 1400 workers. Next slide please. Next slide, please. So with masks, if you just click on the video, it should go. Um We also found that some of our masks were produced using forced uighur laborer by in the northwest of China. I'm I hope some of you are aware of the genocide of the Uygur population. Um And this was uh they were being forced to produce of these masks where the uighur population are forced to assimilate into mainstream Chinese society and to give up their traditional ways at threat of physical and sexual torture. You can read the UN report into the genocide of this population which unfortunately, we have been funding through buying these masks. Next slide please. Textiles next slide please. 93 million drapes and gowns, as I mentioned previously and for knee arthroplasty and carpal tunnel two, the procedures we looked at and carbon footprint is a huge contributor when they are single use like slide, please. And this is something that is misconceived. So, the British orthopedic Association says drapes and gowns must be made of impervious material. Thin cotton drapes and gowns have no place in orthopedic surgery just to make you aware, cotton has not been used as a substance for, um, er, drapes and gowns for at least three decades. Next slide please. All healthcare textiles are unfortunately made of plastics, but they're made of plastics so that they meet these standards for liquid penetration and microbial penetration. So you do not need to worry that there is any risk of infection from reusing reuse is typically 55 to 75 times and has one third of the carbon footprint. Next slide, please. In addition, the performance of uh single use of reusable products is much better. Their tensile strength is much higher. Their burst is much lower and their linting for particle release is much better. So if you want a high quality textile that um actually reduces your risk of infection. For me, there is no question, you should be using a reusable product and I think there is lots of marketing unfortunately, from er, suppliers of disposable products that will tell you otherwise. And um I can tell you some adverts have been withdrawn by some of the suppliers of these uh products because of complaints made by me saying that this was false advertising. Next slide, please. The if you click again, the laundry sterilization standards are the highest in the world in the UK. They are all contaminated using steam sterilization. The same method that is used for your surgical instruments. So if it's not good enough for your textiles, it you shouldn't be using operating at all cos your surgical instruments undergo exactly the same process. Next slide, please. What we find is with disposable things. Some of the gowns in China we found during the pandemic were made using forced North Korean labor in China where between 70 100% of the salaries of these workers were sent to the North Korean State. So we are funding state sponsored forced labor. Next slide, please. Metal instruments. Next line, please. 52 million single use metal instruments perhaps not so much in orthopedics but in accident emergency and outpatient clinic. Sometimes we just throw these things away even bizarre things such as removal of sutures. We have 6 million single use scissors used in the NHS. Next slide, please. So what's the infection risk? And in the 19 nineties, they were inconsistent, inconsistent with inadequate sterilization. People were sterilizing the instrument, these instruments in the back of their room, not necessarily cleaning them, not necessarily checking the CL works. Click again. And what we find is w what happened was this thing called CJD with Prion disease with a risk of transmitting this Prion um and causing irreversible brain damage. And so what happened is we moved to this er throwaway economy and we got rid of a lot of our sterilization facilities. The older members in our audience will remember that we used to have sterile services in all our hospitals. And now unfortunately, we don't next slide, please. So it seems easy to throw things away, but that's simply er unjustified because in the 20 twenties, we have robust decontamination and sterilization with the highest standards of quality assurance in the world nobody has. In the last 70 years we think developed um er, prior disease from a surgery. In fact, we don't know of any prior disease whatsoever. So we've had these infection scares and we just change our systemss and we don't go back next night, please. Here's the production of those surgical instruments. So, 70% of the world's surgical instruments are manufactured in Pakistan. Unfortunately, using sweatshop labor, these people will typically work 13 days a week. Er, sorry, it's 13 hours a day, rather seven days a week, they get paid a peace rate. So they will work often, they end up in debt and uh as a result um will be e effectively in bonded labor. Um, their injuries are not unusual, sometimes quite serious, sometimes, er, life changing. I know of people who've had their arms pulled out and, er, by these equipment like slide please. Of the 50,000, laborers and 47,000 are Children. If you just click on the video, please. Some as young as seven, I've seen seven year olds working on grinding machines. Um but typically Children will start at the age of 12 to make these instruments that we throw away. Just to make you aware. A lot of your reusable instruments will also be manufactured in Pakistan. Pakistan can make cheapest chips. They can also make the highest quality instruments that often rebranded by companies er in Europe and sold to us as if they're made in Europe, but a lot of them will be manufactured in here. I'm told that 50% of our supplies er coming from Europe are actually manufactured here. Obviously, these are not the labor conditions that we would like to see. And so through our use of healthcare, we are damaging health globally, um human health, uh the planetary health as well as throwing away money. This is a sign of deeper problems with our supply chains. Next slide, please. So we've interviewed a number of these Children. They want to play cricket in the street. Um They want to go to school but they don't have that opportunity. Next slide, please. So industry next slide, please. We have marketing of fear. Here's an example. Here's a paper that talks about single use rhino rheoscope. This is something I use to look into people's nose. It eliminates a serious potential risk of prion transmission. Click again please. The reality is, there are no known cases of variant CJD being transmitted by anything. And that's the Department of Health's own assessment. Next slide, please. Uh, we are planned obsolescence. This is some drills. Here's system seven, here's system eight, I can't tell the difference but very soon the um, er, er, software to drive drill number seven will become obsolete. Hm. There's only one reason for that. It's, it's to continue, of course, with uh selling products. Next slide, please. Here's something. Yeah, keep, carry on. Sorry, here's something called a harmonic scalpel to help us electrosurgically dissect costs around 600 lbs single use. We throw it away which is bizarre. Um It can be made reasonable because if you just keep clicking, there are actually people who will remanufacture these um because they're so expensive big in the US. What we find is they change the tips with a pad. Um But that's not enough. They have to go inside the case. Uh Sorry, go back, go inside the case and replace the chip because the chip only allows single use and they have to put a new chip in that allows it to be used multiple times. This can be made reusable, but it's made disposable. That's 600 lbs a go cos we'll just pay for it. Next slide, please. Solutions to finish. So we need to try and reverse a lot of these uh uh misconceptions. Click again, please. I'm working with the infection prevention society to bring some sense and guidance to, er, click again, please, the perceived risk of infection and actually when you speak to senior people, infection control, they are very much behind the reuse agenda. Um they, er, the, there's misconception at local level rather than at national level. There are academics that will support this and we've released, guided in the green surgery guide saying you should reuse, uh you should, for example, use reusable drugs, you should reuse everything that you can when you've got the right processes in place. Next slide please. Economic drivers, we looking at whole system findings and what we find is every single example we've found so far reported of reuse saves money. That's er in the appendix in the green surgery report. Um er next slide please. And what we need to do is expand natural infrastructure for reuse and look at exploring new methods for sterilization, decontamination. For example, I'm looking at UV Light for decontamination. We've had introduced UV Light into my trust. Next slide, please. So why is this relevant to global surgery? Um for those um to, to finish? Sorry. II realize we're tight on time. The poor defined poverty is the inability to exercise control over their lives. So this was a big report by the World Bank and I would argue that climate change and labor rights are some of the biggest threats to poverty. Climate change will affect the impoverished more than any of us who I, well, we started to see that already for those of us that work in low resource countries, harvests are not coming in because of the change in the climate and labor rights are also the inability to exercise control of your life. So this is very much linked to poverty. Next slide, please. So what do we need? We need high durable, high quality durable products that can be reused. So that provides health system resilience. It provides lower costs and it protects planet and people next likely. And I think we need more than this, that we need North to South in terms of what we do in, in terms of leading the way to say we will not be throwing so many things away. Next please. We also need South to South learning because of course, um what we should be doing is with our supply chains. Uh Some of these products bizarrely will come into high income countries and then be sent back to low income countries. We have perfectly good manufacturer in low income countries and they should be selling directly high quality products, protecting workers, right? Um South to South. Next slide please. And on top of that, we need South to North learning. Those of us who work in low middle income countries recognize that what they do is often the right way and what we do is the wrong way. So we should be learning from them and we need more data to evidence that this is safe. Next slide, please. So thank you for your time and I'm happy to take any questions. Thank you very much for that. That was uh eye opening and uh very, very important environment. Any questions? Hi. Can you hear me? Yeah. Yeah. Thank you. And thanks for your talk. I saw your talk in um the B OA the last B OA. Um I'm actually Malaysian originally. Um And I just want to say, I think the um that's very sad, you know, the situation, but I think the illegal immigration has got worse since the pandemic. Um And the, the, the life that these immigrants come over, I know they've come over illegally is quite um it, it, it, it, it's poor, the, the condition. However, um there has been illegal immigration throughout through agencies, I think. And usually if you look at the countries, their currency is much lower than the Malaysian currency and Malaysia generally the rest of it, you know, the environment is fine. So, and also there's a religious link, I think. So what happens is these people, they come over and then they, they earn whatever it is however little it is, they send it back to their family. So they take a huge hit for their life to support their family. Um And Malaysia's export, I think I'm not sure if it's still the case but um factory products, um you know, latex rubber, things like that have um that's the biggest sort of export. Um And I think if it depends, there's a link so how much it's paid there, how much uh labor they can give. And if we just say, I mean, we have to be aware, we say we need to stop forced labor. But then those people who are coming over, they will have no income if they just stay where they were. You see, I'm not saying that this is right. This is not right. But is there some process? So for, for example, like say in Tanzania, when they wanted to stop female genital mutilation, the government provided an alternative income to the midwife say, for example, but here there's this whole process that is linked. So what's your thoughts on that? Sure. Yeah, it's um thank you. It's a, it's a complex difficult problem. Um Should we stop these migrant workers having this opportunity? No. Should we give them decent jobs? Yes, absolutely. So one of the biggest problems is the is, is the sort of lack of transparency. These people are paying fees and they should not be paying that and they should be paid a decent salary. And we could argue who's partly driving there and perhaps are, you know, drive to have the lowest possible cost because of course, we throw things away. But there's no doubt that there is abuse within Malaysia as well. So the the person who owns top has a personal wealth of about $4 billion. These people are not normal. However, we have worked. II didn't have time to talk about it. I worked with the five biggest governments, something called the five eyes um to sort of highlight this issue. This has led to some changes in Malaysia. In fact, the US banned that $50 million breach of contract because you should not be abusing your workers that's embedded within the UK law. But the UK government has shied away from giving them. In fact, I was involved prosecution of our government last year for buying ieg made using forced labor during the pandemic on which I warned them. So these are difficult, complex problems. But the idea that we shy away from it or that we say that this is just one of those things that I simply don't buy other questions, Mahmud. Um, you've given us one example of how anesthetic gasses have been discontinued and that's, uh, you know, a huge win. Can you give us an example of something in your practice that you changed? That you thought was a really big, big win. Um Well, there's wins at local level and there's wins that we need to do. So at local level. What have we done? We've stopped using disposable tourniquets, which is a bizarre thing to be doing. So we're saving 70,000 lbs a year because we reuse all these or, you know, we all know they're stupid. But we've to get that through. What else? We stopped throwing away instruments, outpatient and ophthalmology, 35 lbs and we move to a year. So I'm already those few changes. About 200,000 a year. We are, I tell you next month, we're launching a collaboration of four NH Trust in the UK that I'm saying we move to reduce and reuse across our, our, where we can and we're gonna invite others to join because I'm afraid they need some up here. But I think there's more than this. I think I need to mandate more things. I think there is absolutely no to go to prevent any risk patients. So I'm saying to the A I think we should be mandating all DRS and become reusable. Um so that we can say 60 of um car di the where about 90% of it just I don't think Austria has higher risks of high rates of infection. So I think we need to, I'm afraid stop the behavioral microeconomics that seems to occur where people make their own decisions about what to do. When there is clarity, there is no risk to patient safety, but there is definite risk to labor or planetary harms. We should mandate that change because they're mandated by a structure that doesn't listen to evidence we used to have in the private sector, we used to have these gowns taken away because somebody said, oh no, they're not good for infection control. No, there's no. Do you feel about using, using a non disposable? Can I'd love to making that happen in Sheffield? Sorry, making that happen in Sheffield. And I think it's the first thing that had unanimous support in a consultant meeting ever. So. Um Hi Mahmoud. A couple of questions. How would you deal with the situation when, when kind of in, in lower volume products if a company moves the goalposts as to how often a dressing needs to be changed or how often an implant needs to be changed? I'm just thinking, I have a couple of examples in my practice. So, negative pressure wound therapy, um I don't know if you use it much in ent, but the previous guidelines from the biggest company said that you change it every 5 to 7 days. And then at some point a year ago, they just changed it to 2 to 3. And now I am not allowed to leave this dressing on for 5 to 7 days because the company has moved s because now I'm going against company indications. So there's um it, it's a difficult thing. Um It's the same with scissors. So I don't know, I mentioned 6 million single use scissors, scissors because they're simply labeling level. So that says do not use twice as a two and a cross out. That means you cannot use it again, you can use it again, but you take the responsibility for it. So they, they the company, obviously, ob obviously, there's absolutely nothing wrong with using a pair of scissors twice, but the regulations say you can't use it twice. So I think there's two aspects to that. First of all, you need to go to the company and I encourage you to go to the company and say, where's your evidence for this? Can you explain it to me because I am actually concerned about the environmental harms of this. And um I want to be assured that your company is also assured about the environmental harms and right. And if I'd encourage you and I've done this, I'm afraid I'd copy in a number of your colleagues into such an email so that they have to formally respond to it in an open public written forum to explain why they have made that change. And I can tell you some companies have suddenly gone. Oh, actually, no, it's ok. The other thing is if you, if there is no evidence, you have absolutely every right as the clinical lead as the person taking the responsibility to go against that guidance, you are allowed to as long as you can justify it yourself. Obviously, you know, we take risks every day through surgery. I'm not saying take unnecessary risks, but where there's no evidence, you can make your own decisions about what's right. What I'm trying to do is actually create guidance. Um So I'm working with the Ent UK and I'm happy to work with other uh organizations. In fact, I've written to the British Orthopedic Association to produce guidance from the organization that says this is what we do. So I'm producing guidance on endoscopes using the nose where we say, hey, you should be using reusable and this is safe and about for wax removal. Bizarrely, people throw away all this equipment for wax removal, wax is not a toxic substance. Um So we are producing guidance that says, no, you reuse all your equipment and then people feel um safe because their organization has said that it's ok to do so. So that's what we need to move to as well. The dressing on, but I do leave the dressings on for longer because I've had many years of experience using them for longer. So that's not a problem. But the, the second part of that is that I do a procedure which is called osteo integration and the company um for amputees to enable them to walk. And the company have now changed the criteria for changing parts. Um So it used to be every eight years. It's now every three years. Uh And that will be at a cost of 20,000 lbs per patient to change the parts. And literally, I don't have a leg to stand on if I don't change them because that the rules. So I don't know how you get around that. Is that a government level thing? It probably is, I think if you, I think if you've got um evidence to say this is not right. So I go, go to the company and say, what is the evidence behind what you're doing? And again, ask that question, if they've got clear evidence, then that's fine. I imagine they don't, I've actually written to them and uh companies before and said, oh, I'd like to speak to your infection if it's around infection. Can you tell me whose advice you on your infection control policy? Of course, they have nobody because they're just marketing. Um I've also asked them who's advising you on your clinical um um outcomes uh policy. And of course, again, they usually have nobody. So if it's just based upon opinion, we need to challenge that because obviously, there's only one reason I think that they're doing it. And I, again, I'd encourage you to write to them and copy in your colleagues and get the evidence. And if there's clear evidence of planned obsolescence, this is what I call it. It's planned for us to throw things away. Then um do let me know, I'm happy to gather evidence. I'm on the clinical advisory board of the Green or N HSI can raise this. But I think within the specialty, you can also raise it because if you produce guidance from your specialty that says this is absolutely fine to continue or do whatever or raise the concerns that this is and obsolescence, then um I think the companies will listen because if their market, as in the whole of the market starts to raise concerns, then they will be worried that their brand reputation is under threat. So we've got to use our power in whatever way we can and we do hold power particularly if we use it collectively. Thank you. And on a similar theme, I guess to everybody else. So every time I go in the side room, I've got to put a really flimsy plastic gown on that that will probably kill a dolphin. Every time I see a patient. How do I get through to our infection control department? That is crazy. What do I tell us? Yeah. So you need, this is what we, this is what I mean by behavioral microeconomics, we have infection control, people making decisions when they don't understand their own specialty. So I work very closely with Jenny Wilson who's a professor of infection control and I met her a few years ago and I thought I'm gonna have to fight, but actually she was completely on board. She said this is utter nonsense. So there's actually National Guidance on this. So unless the only reason to wear a gown, uh or, or, or an apron is if you are at risk of splash. So things like diarrhea and vomit, that is what it is there for, to protect yourself from that. Otherwise there is no reason. So what I normally do is um ques politely question them there. If you're still meeting resistance, I then write an email because then it's a written documentation to say, hey, I understand that National Guidance is you should only be wearing an apron when there's a risk of splash. Can you explain to me why you think otherwise they then have to provide a written response and usually you don't get anything back and just stop wearing your apron because you can challenge them. And if they challenge you say, OK, I'll take it up, you know, to another level. I try not to be adversarial. I have to say my infection control team locally is very much on board with what we're doing. In fact, they're pushing things better than I am. But um the end of the day, you have to question these uh these sorts of ideas. So gloves are only to be worn when you're in contact with potentially infected body fluids. I only put on a single glove to examine inside someone's mouth or ti put on two gloves when I'm examining AAA wound that is not clean. Other than that, I never wear gloves. I wash my hands. I can't think of any time when I wear an apron and I can't think of any time where I wear a mask except when I'm operating. But even that has no real evidence I'm afraid. And unfortunately I'm trying to sort of battle this as well because unfortunately those masks, um just so you're aware are made of plastic and they release around 2 to 3000 microplastics doing a single use. We're inhaling all of those into our lungs. Um, and there's no evidence for them, except for implants, surgery. There is some evidence they may reduce risk. Probably we need to move to cloth masks because probably our body can at least break down cloth particles if they end up in our lungs. But there's lots of misconceptions I'm afraid. And what often happens is people just decide this is the way it's going to be without the evidence behind it. On a precautionary principle that isn't evidence based. But yeah, feel free to challenge it. And if I can help you then drop me a line. Other questions. Just 11 quick question. Sorry. Really fascinating talk. Um, I'm a hand surgeon. Um I don't like safety needles. Um, the safety guards on all the needles now are now bigger than the needles themselves and it's quite difficult to give injections. Um, I've seen more incidents with patient safety with disposable needles. There's a ton of plastic that is not required. Is there anything happening in that front? Can we go back to needles? I'm completely with you. I think it's nonsense. Um, you can do, you just say I actually, I think it's a higher risk and I don't want to use them because of that risk and that's the truth. Um uh But you, you do have to fight for it at a local level. There's also you're supposed to wear gloves to take blood. And actually our local team has said no, you don't because it, it is nonsense. I mean, I, II think it's a higher risk because if you put on gloves you can't feel what you're doing. So, at national level. Um, yes, maybe we could. But, um, yeah, I guess the, the problem is there's so many things that we need to turn over. Um I'm slowly working through them, but I want other organizations to come on board. So what we're doing is creating a standardized form where we say, hey, this is the guidance and here's the evidence. Um Here's the evidence of what of what they say, here's the evidence of the environmental harm and therefore this is what the guidance that we produce. So, like I say, I'm doing that with the ENT UK at the moment, but I don't, I'm not, I happen to be an ent surgeon by my interest is obviously not just the ent it's everything that we do. So I'd encourage others who want to participate in that process to come on board and help develop these guidance that we, we create. What I can do tell you is at government level, there's just not enough resource or expertise to do these things. So I've mentioned this to the NHS and they say, well, we, we haven't, we haven't got the either the knowledge or the, or the human resource to produce all these guidelines. So it needs to come unfortunately, from us and of course, unfortunately, we're all busy so it's difficult to know how to tackle these things. Ah, uh, just thanks again for not just inspirational but fantastic talk, which is great. I was thinking well into the night and after a few beers, uh, thank you very much for the effort because I appreciate how early it is over in the US just now. And uh thank you very much and go for lunch. Thank you. So, uh half past one, please. If we, we convene lunch. Thank you very much, Jim. It's probably not gonna take that long. We'll probably have an extra 15 minutes for lunch. 45 minutes you eat today. No, it's a sit down and be generous. You're interested in reusable gowns as that does it.