CFR Public health Dr Sanhita Chakrabati (13.12.2022)



This teaching session explains the importance of understanding health policy and how it impacts the services provided to patients. It covers the concept of policy-making, determinants of health, considerations such as inequality, and how policy can be utilized to address public health problems. Through discussion, lectures, and case studies, the session will explore the importance of health policy in creating a more equitable and healthy society.
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Public health Dr Sanhita Chakrabati

Learning objectives

Learning Objectives: 1. Understand the distinctions between declaring a policy, implementing a policy and how policy pertains to health and medical care. 2. Identify different types of policy makers and the levels at which policies are made. 3. Describe the factors to consider when making decisions related to policy and how they can have a positive or negative impact on the health of a population. 4. Explain why it is important to be aware of policymaking and how policy is implemented, as a doctor and a health professional. 5. Describe examples of policies and strategies to promote improved health and well-being, such as legislation, taxation and labeling, and how they are used to promote health and wellness in a population.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

doctor and also, until a few years ago, a family doctor as well as working clinically until a few years back. So I've That's the wrong. That's the wrong fly set, because I've given that one. A couple of weeks ago, the one I sent through to the CRF med school about 20 minutes ago should be the right one. It's called understanding health Policy. I don't mind doing the other one, but some people may have heard it before. Okay, bear with me one moment. The temp. Any on who wrong one again. Is this it know you've gone back to the other one? The old one. It's the one that's called understanding health policy. You showed it just before. So I'm going to talk to you about health policy, partly because not many people teach about it and partly because I think it's really important that medical students and doctors, for that matter, understand enough about how policy is made to know why they're working the way they're working, um, for their whole careers. So I'm pretty sure it's important stuff. Uh, and I hope to talk a bit about it in a way that you'll find not boring because people talk about help us. Oh, gosh. It's not about doing things to patient's. Well, ultimately it is. But health policy is at higher levels. They're talking about groups of patient's and how decisions are made. The treatment and care that a country or a local area makes available. Two people living there. So hopefully if I interesting. With a bit of luck, Claudia will manage to get the right slides up in a moment. Um, that should be fine. Okay, Well done. Right. Okay, so here we go. I've just said we're going to be talking about health policy, so hopefully you will all realize, uh, and hopefully probably most of you know already. Why? Why? It's important to know about health policy, uh, wherever you live and work. Uh, and for that matter, any other kind of policy making, uh, that we'll stick with health policy because that's the name of our shared endeavor about medicine and health. Okay, next slide, please. I'm gonna be talking about health policy, and I'm going to use the pandemic as an example as a case study, and I use the pandemic for lots of examples and case studies for lots of different subjects. Uh, so it's as good for policy as for lots of other things. And then, as I said before, hopefully time for questions. So on we go, please. Next slide. What do we mean by a policy? Can anybody as as, uh, yeah, great. Stay there. Thank you. Anybody want to tell me what they understand by policy? Okay. In any context you like. Please, um, mute yourselves and have a shot. I don't have to be that bold or courageous to talk here. There's a quite a small, select group, and I'd love to hear from some of you. I If you're willing to speak, just please, just speak up. Nobody wants to tell me. All right, I'll go on, then. All right. What do we mean by policy? Let's have a look. Oh, wrong way, I think. Thanks. One. That's it. OK, so policy really is about making decisions, Okay? And you can make a policy decision. So a policy is about what to do, and you can hear it's the same route as political. So these are decisions that are decided at any level international, national, regional or local. That's going to affect the people, the lives of the people who are in that area or living in that area. Um, one of the things and it can be about anything. Okay, so we're going to talk about health policy decisions that are made about anything to do with health. And I would include healthcare in that the things that will affect the lives of people who are living in the area, whether it's a country or whether it's the world or a small village or a town. So, uh, the one thing I always remind myself and suggest that everybody remembers is a big distinction between policy decisions and policy implementation. Okay, so, for example, the government can make a decision about a policy, but whether it actually becomes reality is dependent on how it's if and how it's implemented. So quite often, particularly with governments and their decision making, they may well say we are going to do some facts or why, Because this is our policy. They may not decide to implement it, so it might never happen, and that's probably quite a common finding. So our country, for example, might say we're going to increase international age, but actually they may decide a few months later to decrease and not implement that policy at all. In fact, possibly do the opposite. They might have a policy to put lots of lots more money into running health services, but when they look at the budget, they might decide. Actually, they can't afford to do that, so that doesn't happen. It doesn't get implemented. So it's always really important between a policy that's declared, has definitely decided property and actually what happens. So it's worth remembering that. And then So how is policy made and by who anybody want to have. I guess at that work, I go at that one. Not really. Okay, I think it's probably Is this a slightly new subject to most people think that it possibly is unless anybody's worked in health policy of the government, uh, or or in local government? But possibly it's something that we don't I don't necessarily get very involved with, but that's why I think it's really important that, but we spent a bit of time on it, okay, so how's policy made policies made by people who make decisions and they can be at government leg? Also, it could be government ministers. Governments. Generally they can be, uh, so that's about discussion's that go on in a Parliament would ever come to your in or if it's not in a democracy, could be a decision, a policy decision made by an individual head of state who decides that this is one is right there, country. Or it could be a decision made at a very local level in a town or a village, and by whom depends on the structure of the decision making arrangements in that area or in that country. So quite often, policy will be made by politicians, which is the name of the The root of the word is inseparable, but not always. Okay, can I have the next one, please? So, health policy, let's dig down a little bit about that. Health policy isn't only meant isn't only made by the Ministry for Health or the Department of Health or in the England. We have a department of health and social care at the moment changes. They change their names every little while, but ministry Ministry of Health is common title the determinants of health. As you know, from a public health perspective, much broader, then the responsibility of a particular ministry health. So people involved in setting policy at national level in departments like employment and education uh, and it defense and many most others are including very much financial decisions. So the Ministry of Finance, the Treasury have huge impacts by their decision making their policies on the health of the population because of all the different determines for health much broader than simply those that provided through the Ministry of Health, which are largely healthcare and have public health services directly provided. It's quite a common, uh, term little, uh, that's been been used certainly the last few years in the UK and internationally that we should be moving towards where health appears in all policies. Health has should be a consideration in any policy. So if you got to have a new transport, what we see, for example, the new in to decide where, uh where and how green. For example, Transport is going to be that the the the implications for people's health become quite clear. But we don't always think of health in terms of policies. Outside of specifically health policy. There just a reminder that she applies across the board, so just that already healthy will seek frequently a consequence of all of these different kinds of policies. Economic, education, social, agricultural, defense and others are just mentioned transport as well, but others as well and, of course, fiscal policy, overall economic and financial policy. So it's a consequence. It's also a determinant. So we need to be really careful, as far as possible, that health features in all of these policies people at the grass rings. I don't have that much influence over how these policies are made at national international level. But it's important to know that we can lobby for that. And we can look for political parties who say yes, health, the health of the population is important, and we need to consider health in all of our policies. And increasingly, those left and right leaning parties are beginning to understand that concept. Okay, and just to mention something about inequality, and we're going to talk about any problems. Have you already had a lecture on inequalities in this this term? That's any qualities. Do you know we haven't Not yet. Okay, so they're really important. Maybe I'll come back and do that Maybe one of my colleagues is going to do it. So if you introduce a health policy, it can make things better for some people, but worse for others. And that's always. And that means that there's going to be inequity, inequality between the way that policies impact on people, UH, which is really important. So some policies will help to improve the health of the whole population. Some will help to improve the health of for the poorest people more than the people who are who's health is best, which are usually the richest, the most affluent people society, and that will narrow inequalities between those with the most emotion the least and other policies can widen those inequalities. I'm not going to talk about that now, but just something to be aware of. We could maybe pick up some examples as we go through. I think you probably pick up that when we talk about the pandemic, so but please remember that one next one. Okay, this is a lovely color picture, but it's also really good, I think, to look at how policy is created and how it's used. Uh, and there's an organization called the Nuffield Council on Bioethics who created this as part of A Was they published this rather as as part of the report many years ago on obesity, interestingly, and how how they should be policies to support the population, being more likely to be of a healthy weight and not unhealthy weight. So what they did was create this ladder. If you look at the bottom, it's case of just watching and waiting and see what happens. And then you gradually think in terms of policy, what could we do? Say, say, your national government say you okay, you could just make sure that people understand people know that they've got access to information and education about Let's use eating for a moment about healthy, healthy doubt. You could go one step up the ladder and say, You know what we could do? Make put things in place to enable people to change the way they think about what they buy. Uh, we can provide labeling, which is better to show people what's perhaps more healthier than other food that's less healthy. We could make healthier choices the next one up, the easier option. So perhaps the price structures the taxation structure of the country would be of influencing people's choice of food. And as you go up into the green, that's where we're getting to incentives and then disincentives. So you put tax. Some countries have put sugar taxes on certain foods so that people are more likely to choose the things that are lower price and less unhealthy. For example, in that one, uh, then you can move up to actually regulate and restrict what people have access to, and finally you can say no. Actually, we're only going to offer the healthy options, and I don't think there's a country in the world that's considered that. But you could start to think for some foods or for some, just talking about obesity, Remember, but a certain things you could start to eliminate choice. You can start to ban things, and that's certainly around the tobacco. That's the roof that's been taken right the way to the top, but not banning completely banning in certain environments in certain circumstances. So just to show you I think it's really useful. If you ever talked about policy, the level of intervention could be anything from not very much at all to really heavy legislation. Can you have the next markets? I should have said at the beginning. If anybody doesn't understand something wants me to explain it. Just please take yourself off mute and and shout or put something in the chat and hope that Claudia will with or somebody will get to catch it. We're happy to be interrupted. Okay. So good practice in policy making. You need to understand what the problem is that you're trying to solve. No point in having a policy for no particular reason. Okay. You know, the policy could be well, we'll paint all the roads white. But unless you've got a good reason to do that, why bother? It's going to be a big, expensive job to do. Probably won't work anyway. They will get dirty. No point. So you need to understand what it is you're trying to create policy to achieve. You should. This is about good practice. You should normally have an understanding of the evidence base. Uh, what what the needs are of the population. So we're into public health territory and what works the evidence based for particular intervention, and then create a policy on the back of that in reality, not always easy as well. Talk about the pandemic. We didn't have much evidence at the beginning, hardly anything at all of the pandemic. So the evidence had to be based on people's understanding and modeling of what is likely to be effective. But by and large, ideally, you want to be basing your policy on the needs of the population and knowing, as far as possible, what's likely to work in terms of a policy, you really need to have people involved. So stakeholders, including the people who are affected by your policy, that's the general public to a very large extent. And a lot of the good policy would be co created, uh, and based on what's going to be acceptable to people, it has to be affordable. Uh, and that's in a very elastic turn. Affordable because it depends on the view, the view of both the government or whoever is making the policy and those people who are going to be on the receiving end of it as to what is affordable, and it should be acceptable, ethical, equitable and transparent, clear for everybody to see. It should be timely. That means it's going to be accepted by the people because it's something that there clearly is a need for. Okay, that's that's not always the case. But this is good practice. It's just to be sustainable. So it shouldn't be, uh, something that works one day, and then by next week, you can't do it anymore. So when you're setting policy should be something that you have to look forward and say, Can we future prove this policy? Is it going to be useful, valuable and effective a little while down the line or a long way down the line? Depending on the nature, you should always check out that you're going to have a look at it every so often to review it to evaluate it. Is it doing what we set out for it to do? And finally, is it? That's part of the review? Is it producing better outcomes for the people affected by the policy? Is it doing what you set it out to do? Okay, I hope that's reasonably clear. Next one, please. Thanks. So this is just quite a nice way of describing all of that. But you set out to identify your your problem. You look at all the options using the evidence available as to what might work. You set, you develop your policy, and then you put it into law. Or you could decide to implement it in whatever way you do in your jurisdiction or in your village, and then you've implemented and it's a circle. Then you need to make to see whether you're having an impact on that problem and keep going around that circle to review that policy and look at others. Next one, please. Okay, some examples. Yes. Please keep going. We'll know before you do. Actually, Yeah, that's I was gonna I'm gonna talk very briefly about tobacco control because it's one of the best known policy areas in public health. Anybody want to talk about anything else? Anybody want to ask about to suggest any other policy areas in, uh, in health or in public health? I'm going to be talking about the pandemic as my little was a case study. But I'm going to have a quick one slide to talk about tobacco policy. Anybody wanna mention any other areas of policy that they're particularly worried about or excited about? I gave you a thought before about obesity and food policy. Okay, let's keep going. Thank you. Alright, Next one, please. Tobacco control. Okay, So the sort of things that we do for tobacco control if you look at back at that ladder of intervention that I showed you before the colored ladder with the with the rainbow colors on it, taxation is quite it's high up because that's something that has to be put in place by official authorities. If you as a as a corner as a corner shop decides to tax people to to put the price up on tobacco products. But nobody else does, then all you're going to lose business. So that kind of decision has to be taken at a higher level to have some impact on the population. The other things that happened in have happened is restrictions. So taxation on tobacco has been around for many, many years, several decades, Certainly in the UK, uh, and probably most other countries, but not quite all. The next thing that happened was restrictions on sense. So you can't sell tobacco in this country and many others two Children, and you can if you do that, I said I said shopkeeper, you can be fined quite heavily. So the next thing that came along it was people realizing at the time the people most impacted by the evidence that smoking was harmful to health at the very beginning were doctors. And that was largely because the original research about the impact of tobacco smoking on lung cancer was carried out in doctors. So they felt that they were really personally as a as a cohort. They were really impacted by the findings of, uh, Richard doll and his colleagues all those years ago. So smoking hospitals of something that came up quite early on, uh, and most hospitals put in place various kinds of restrictions, uh, usually tax smoking areas and now no smoking indoors on premises at all. Very few hospitals and have have got no areas with people smoke out out of doors that if you have done health warnings on packaging, I'll just go through quickly. These are national nationally dictated, uh, advertising bands came in gradually sports sponsorship bands. Uh, workplace smoking came in much more recently. Uh um, and restricting of smoking in enclosed places once the evidence was really clear that this was affecting people through 3rd 2nd hand smoke, passive smoking. And it took many, many years of effort on the part of our public health leaders sent me in this country to make sure that those policies became enacted, uh, and implemented van. No smoking of in cars in Children we have in in England. Many countries don't yet have that particular ban. It's quite a difficult one to police because people don't miss. There aren't enough people to watch out and to report of somebody smoking in a car with Children. Plain packaging came in following evidence most in initially, mostly from Australia. They did a lot of the original initial work on the impact of packaging to reduce, uh, cigarette consumption, which is really interesting and effective. And then, most recently, we've got regulation on access to so not sold the Children, although clearly they are brought by Children. But in most jurisdictions that actually banned, but they still managed to access them. Uh, because quite often, although I talk about band quite often, it's a voluntary agreement by the industry rather than legislation. So the regulation is quite weak in many countries around access to electronic cigarettes and also about where they are used. So in some places they ban of their uses. The same matches, that of cigarette, but not in all. So that's the sort of little summary of several examples of where tobacco control has been has been introduced over series releases over about 40 50 years. Uh, of different health policy elements that have added up to the current situation where access to, uh, and the ability and the and being permitted to smoke, uh, ordinary cigarettes has become much, much more restricted. Uh, and far few people smoke fewer people smoke than they did 50 years ago. Uh, so next one, please leave tobacco there. I think have the next slide, if you can manage it. Thank you. Okay, so in a pandemic, you don't have the luxury, Do you? Of no policy making that right? I don't think I'm going to ask you why. Because it's kind of obvious. So it's pandemic becomes an emergency situation. So it's different in terms of policy making, but it's also really interesting, Which is why I like to use that, uh, that could have the next record, please. Okay. So how do you think that pandemic might impact on policy making and health policy making and its implementation. And all of these things are likely to make a difference, aren't they? To how you implement policy? So how do you make priorities? What is the purpose of health policy and during the pandemic? How urgent is it really, Whose responsibility is the policy and its implementation? Does it need law? Or if there's something that people will just do and what is the process of developing, taking and implementing policy? All of those things I thought about anyway with any policy, but they all came to the fore with with the introduction of A with the announcement with the pandemic, and different countries have dealt with them differently. So just to to draw attention just typically, though, which is the one country in in the developed world where legislation wasn't used to to, uh, to introduce restrictions on the way that people behaved or the way that, uh, that we lived our lives, the management of the pandemic, hardly any legislation. Do you know the one country that stood out from all of the others in the certainly in the developed world? In the in? Yeah, in the Western world. You wouldn't want to tell me which one It was country that's quite known to be very open in three countries. And it didn't surprise us in a way. But it was really interesting to watch their management of abandoned because it was just so different from everybody else's. No. Sweden. All right. No lockdowns. Very little restriction movements. Restaurants stayed open throughout school. Stayed open throughout. Really pretty interesting models to compare with most and rested the developed world, just just to mention it. Okay, I'm really sorry about that. I hope that you're still here. Yeah, and I back my apologies. Okay. Are you still Are you still seeing the screen? Okay. Uh, can everyone see the screen? We're still here. They're doctor. Okay. Nice apologies. I fell out. I got kicked out or whatever. Okay. All right, let's move on quickly. So my apologies. I hope I don't disappear again. I'll come back in on my phone if I do. Um, okay. Honestly, aims during the pandemic. Okay, next one. Let's just rush through with this a bit, and then we can have a conversation. All right, So we're we're trying. So most countries have similar aims. But who knows? So this country was it about prevention, containment, eradication or elimination? Herd immunity, population protection. Protecting the health care system in the UK we had this rhetoric for several months in 2020. Protect the NHS. That seemed to be the biggest concern of government protecting the economy, though protecting incomes or simply controlling the pandemic, which really is encompassing lots of different things. Um, but hopefully people understand, just to say quickly, uh, people get confused between eradication and elimination. You might want to think about that a little bit. Eradication usually is. The term is used about removal of the disease from the planet. And the only disease that that has applied to so far is, uh, small pox. Elimination is where a country goes out to say we will. We have no, none of this particular disease within our borders. Uh, just so that you know that you can I'm sure you'll get more of more detail around infection control and communicate disease control. Um, okay. So I'm just looking at, uh, that claudia's messages coming up. Yeah. Please interact. Please shout, uh, and talk. Okay. I'm going to carry on if you're happy with this. Okay, So how do we How was preparedness and all of that? So preparedness is about the policy, really very quickly had to be decisions made, which would made with expert advice, but ultimately by political decision makers. So we had to be prepared, and all of this should have been available and ready in advance. That's the whole paired point of being prepared. And as a country, we were quite ill prepared. Sadly, other countries were better prepared. We had had a very good preparedness plan that had been shelved several years ago before the pandemic lobby book pandemic. Other countries had adopted our plan and not shelved it. So they did much better in 2020 than we did. Um, and all of this will come out in public inquiry, maybe at some point or other. But what we should have been prepared for was, how do we How do we know somebody's got the disease? Have we got testing ready? And will we have it really rapidly in place and be able to roll it out and make sure that people can access testing? Have we got availability of self care for people safe care for people who get really ill from the disease. And in this case, obviously most people have had very covid quite smiled, Lee. But a minority people have become really sick. Needs to go to hospital. Do you think in advance about how that care would be provided, including keeping the carers safe? Carers I by by which I mean anybody looking after somebody who had a severe bout of covid who were in danger of getting a severe. But did we understand how to do contact tracing? So we understood how at the at the early stage, the disease could have been contained. Did we think about quarantine and isolation? Do we think about where to where to place people who when you had the infection, would it be better to have better quarantine facilities? Did we think about how other sectors would react? Education. So did we know that we were going to think about shutting out schools? Did we think about the food supply chain that actually there would be a run on certain types of food and empty supermarkets? Uh, and did we think, probably really critically about the role of the Treasury How much funding would be needed to support the country during the pandemic. And all of those things became really important as we went in as we we found ourselves deeply into the pandemic. Was it clear what people should do at different levels and to what extent was their international coordination? And the international health regulations had been put in place several years before and they've been updated during the pandemic. So if anybody wants to read more about international health regulation, clearly you can do so. International policy, uh, collaboration between countries in terms of managing infectious diseases. Okay, next one, please. So some of those were done better than others. Uh, in any countries in particular, my experience is that we've been more mostly in in England. Okay, So the elements of policy, this is not this is just to give you some examples of feel for it. Preparedness. Did we have really good stocks of personal protective equipment in the UK? The answer? Sadly, no, not enough. We had to go rushing around the world at very short notice. Trying to get enough. We had front night staff in health and social care who were not protected. Did we pre prepare for lockdowns kind of and social distancing? We sort of explain that, and politicians were very visible explaining that these things were going to be necessary. Four. Part of the public health response to the pandemic. Do we have the way of putting in place quickly implementing developing policy and implementing the testing and contact tracing ization? We have policies that changed very rapidly in the first few weeks of the pandemic. Unhelpful. But eventually we came out with something that worked reasonably well. But at the beginning, it was very messy, Um, and and not well coordinated at all, certainly not well planned. We had pharmaceutical interventions, very few at the very beginning. So not no, no drugs that were going to be impactful on people who had covid. We were dependent on non pharmaceutical interventions, very much like social distancing, possibly about face coverings and so on. And washing hand washing was a very big non pharmaceutical intervention. Gradually, drugs have come aboard, as you know, uh, but at the beginning there was no policy because there was no evidence of anything that worked. Was health were health and social care prepared with hindsight, not at the beginning. There was all of our services were very close to becoming overwhelmed. And in many countries, particularly that the early pictures from Western European countries, many of which were healthcare services, were overwhelmed, not many of which, but some, some of which. So, uh, did we look at putting in place preparations for those people who were going to be at greater risk than others? We couldn't because we didn't know who they're going to be turned out, we learned very quickly who who was most vulnerable, Uh, and that was in particular very elderly people and people with reduced immunity. But we didn't know at the beginning, and that wasn't planned for vaccines. A lot of effort went in from the very beginning of pandemic. Once the virus had been identified to create vaccines and the UK joined with many other countries on huge collaborative international efforts to develop vaccines which were very successful evidence, as you know, and border controls, different countries reacted very differently. UK was very, very slow, very late to decide to make a policy decision about border controls. Eventually did so, but very late after we'd imported a lot of cases that create began to create a very big first wave of the spring of 2020. So there's the kind of things that countries could be prepared for and the variable responses that I've just described from our experience and you may well be able to describe them from your experience to anywhere where you were aware what you've read and what you've heard and what you've experienced in whichever country you've been. So can I have the next one, please? Okay, so one of the things I said at the beginning is you've got to have stakeholder engagement for a policy to be implemented successfully and effectively, and part of a lot of that is about communicating with with people, uh, and that communications got to be clear, transparent, consistent. I'll be honest. People have got to believe what's being said to them, and they got to understand that, actually, it's good for the community as a whole to do what you're being asked to do. And ideally, you want really to see the people in authority as role models you would be able to see. Oh, they're behaving in that such a way. So it makes sense or mean to behave in that sort of way or my family to behave in that company, my household, my community. Um, the perception of benefit is really important. Um, and where, for example, some countries, not in the UK, where not so much in the UK, where there was an understanding that very elderly people particularly vulnerable, there was a very good understanding that those people had to be protected, um, and and looked after in this country, we didn't do so well, Uh, that's partly, uh, cultural issues, but it's also about housing issues where people are living in very crowded accommodation, incredibly difficult. A lot of people had enormous concerns and great distress about trying to protect the elder, the older generation, those people who are most vulnerable, even though they were living in close, close proximity to those people. Really very problematic, very distressing for people to try and protect people and then found that they were being infected because maybe somebody was going out to work in a job where they were exposed themselves or they were using public transport where there was a lot of virus transmission, uh, in crowd ID paces and then taking that home in their people that they loved at home who were involved with the group, the oldest generation they're in. Their households were becoming infected, uh, and similarly in, uh, in nursing homes and residential homes, looking after very elderly people had huge ways of people becoming infected, uh, and dying as a result of mainly staff to a lesser extent at the beginning and pandemic visitors being allowed into those homes without any protective equipment. And as for leaders, can I see the next slide, please? This is just as an example. Okay, so, autumn 2021 we had quite strict, uh, restrictions in place around, uh, facial wearing face masks, face coverings, Uh, in indoor place is So this is a It was a vaccination center in London. Lots of people, hundreds of people coming every day to get their vaccinations. And one day, one of our colleagues was, uh, was was working there and was visited by the then Prime Minister's. Probably you can recognize him, and you might recognize that something different about him the more the other people there. Yeah, you can see yourselves. You don't have to tell me Okay. So, unfortunately, his role modeling was like what was needed. Okay, let's just to give you an example of policies around face coverings as well, we're on the subject. So march this year, many countries by then had no policies about face coverings just to show you where some countries had partial so policies where there was restriction. All face coverings in some places is under certain circumstances, Um, and in some countries requirement to where face comes, it just showed the variation, which depends to some extent on the state of the pandemic at the time, as to the number, the the amount of virus circulating in a particular population. But also it depends on the views of the particular government as to what is effective, uh, and also how restrictive they wish to be on their population. Remember, this was after we'd had vaccines in many countries for more than a year. So quite often in their countries with high vaccine uptake regulations, restrictions had were being markedly reduced, but not in every country. And of course, some countries have had even up till now very, very low vaccine coverage. And we're behaving again. If you look at Africa. The difference in policies between different countries, even though vaccine uptake is university quite low. Uh, it's just it's interesting to see that what those differences are. Okay, the next one, I think, is just a bit of a comparison. Yes, this is, uh, just a week before last, um, and shows you again. Different picture again. Where Russia can see has introduced more requirement for face coverings than than it had back in March. Um, and different countries have done different things depending on their their view of the policy. So Australia has lifted its restrictions that it had back in March, whereas other countries have either left left the same or increased in some in some instances, but just to show you vast differences, Um, And if you're ever interested in, uh, in looking at our world in data Absolutely brilliant website. If you like to look at these kind of pictures, you can ask anything you want about the pandemic across the whole world or in individual countries. Uh, brilliant websites already recommended. Uh, that's just on the site. Next one, please. Moving quickly. Okay. This is just example. Sorry. The slide doesn't read very well of how we've had different policies regard to face coverings in the UK I will stop. Uh, let's move on quickly. Thank you. Lessons learned. Uh, this was something. We had an interim report from the UK government, uh, in October last year to say, sciences, not enough. It's absolutely critical, but it's not enough. And we often get that with public health measures and public health gem impact that sciences essential but not sufficient on its own. You need to have different ways of getting people to change their behaviors and to and to react to situations in order to improve public health. Just an interesting example that next one, please, I realize. Sorry. Lost in five. Yep. Keep going. Okay. So looking at how do we know whether policies have been successful? So in relation to the pandemic, looking at a number of people who died has been probably the most common thing to do across the world. Then it's been quite difficult to to compare because different countries have used different definitions or they or they have got different quality of data to say. Actually, how many people have died due to covid itself or died during the pandemic for other reasons which may have not been covid related. So there's been quite a lot of differences in that quality of that data. But we think the execs deaths are floating around this sort of level in both America and the U. K. A few in Denmark and interestingly, uh, very compliant countries which these populations unknown to be very engaged with government and and very compliant, a great deal of trust between people and policymakers, which makes a big difference. And Brazil has, you know, has been one of the countries where been a tragic the higher number of deaths. So the number of cases has been looked at as a measure in the first wave number of ventilated patients, lots of different ways of looking at successes of different parts of this public policy to contain or to to control, the pandemic to manage the pandemic and broader terms. Um, compliance vaccine rollout later on. Clearly, the uptake of vaccine varies hugely between countries. Um, and the generosity of some countries to offer provide vaccine to, uh to low income countries been very variable as well, and the impact on the economy and services health services and other services and on other sectors has been huge. And all of these has been Look, they are being looked at in terms of judging the success of policy to manage the pandemic so briefly, rapidly on these, I think we're nearly there. So excess deaths just to show you differences between countries. This is don't forget. It's about what can be retrieved from accessible data. So some of the data, as I said, is much more reliable than others just to give you a picture. And I've kept Sweden in down there. Look, they've done really well and their their data is probably pretty reliable. Okay, next one, please. Thank you. And just this is in the UK the medical director of the NHS in England. Sorry, England said. If we can keep deaths below 20,000, we will have done very well back in the at the very beginning of March 2020. And the number of deaths in the UK is about 200,000, and the vast majority of those in England So we've not done well. Will we do better next time? Should we take more notice of policy? So that's it for me. I'm sorry. I haven't. I was hoping to leave those of time for questions, But clearly, I have not managed to do that. My apologies. And, uh, thank you very much for joining me. Thank you, Doctor, for your time. You went through it very clearly and slowly anyway, so we've got the message. Okay. Hope it was abuse to you. I hope it was interesting. Happy to have your feedback, please. Then I know whether you want it again or something different. Okay, Thanks a lot. I think you've got somebody else coming on now. Hope you. So I better disappear. That right? Thank you, Doctor. Yes, OK, great to have. Thank you for having me and all the best to all of you. I hope things go well for you. Take care. Thank you, Doctor. Take care. Thanks a lot. Bye. Thank you. Thank you, everyone for attending. Please do feel in the platform so we can continue our lectures as well. And I'll be posting. This is difficult. And the next link for the lecturer to thank you guys