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Thank you very much. Good morning, everyone. I hope you had a fantastic first session. I'm Hassan, I'm the Global Health and Senior Vice President of the Royal College of Obstetricians and gynecologists. And I'm really privileged to be chairing this session. And my colleague, Professor Campbell is also going to be co chairing with me. So this is an important part of the I feel. So for me, it is a big issue that a lot of countries are suffering from, which is conflict. I come from Sudan. And as you know, the situation in Sudan now is grave, unfortunately, Sudan doesn't make the news. So if you start to look at the BBC or sky news, first page, second page, third page, you are lucky if you find anything about Sudan maybe on the fourth page or you have interest to look in the African news. But I've just come recently actually from Jordan and there was a discussion about the situation in Gaza, which is obviously a horrible situation but actually reminded people that actually there are more women and Children died in Sudan since April 2023 to date compared to Gaza and Ukraine combined, but Sudan doesn't get a mention. Now, one of the issues always we have with conflict is the displacement, the, the damage to the infrastructure. Um And I, my father is a uh was, or my late father was a Maslo fal surgeon and he had kind of a hospital that really cares for people from displacement areas and so on which built as a charity. But I heard now that it's actually been occupied by the militia and they're running it as a center for their kind of intelligence. So these are the kind of the things will happen in these areas. Now, I was actually presenting the day before yesterday in Kolkata, a talk about maternal mortality. And it's really interesting when I looked at the um the fragile state index that there are nine countries were assigned as very high alert and they were Yemen, Somalia, South Sudan, Syria, Democratic Republic of Congo, Central African Republic of uh and then Chad Sudan and Afghanistan and guess what's common among all these countries, war and conflict. So I think it is very clear that this is an area that we really need to see how we can solve these issues and how we can make a difference obviously, if we can stop the conflict. But during the conflict, how can we help our women? So I think, and babies, I'm really privileged to be asked to present to you today, the two speakers. So the first is Dr P, who is a consultant in obstetrics and gynecology at Imperial College. She has a special interest and global maternal health. And actually, I was just discussing with Piper lots of ideas that we have and hopefully we can develop through the Royal College as well. She worked extensively with medicines, Sans Frontieres in Pakistan, Sierra Leone, DRC, Nigeria. And she's also worked, she actually runs an important part of David Knott's Foundation since 2012. So I think pa is in a fantastic position for us to tell us today how we can solve these problems. Thank you very much for inviting me to speak in this amazing building and with all these amazing speakers before me, I feel slightly imposter and but I'm going to talk to you a little bit about the maternal health care challenges in conflict zones. And as Dr said, my background is working for MSF. Initially, I was in the DRC in Congo, which was an active conflict zone. It definitely didn't feel like it at the time to me, but we knew that there were three militia in the small area that we were working with. And we were very aware of where the militia were and where the fighting was on a daily basis. I then went up to the north of Pakistan on the border of Afghanistan and EMF had started work there because of the refugees that had come over after the Afghan War at that time, there were still a lot of refugees, but also there were ultra strict Islamic fundamentalists in the area who were militant and suicide bombing was commonplace. And so that's why MSF continued to be there. Following that. I was in Sierra Leone, which although it was a long time post the civil war, it was still a post conflict zone and we had the Liberian refugees were still based opposite the hospital we worked at. But as the introduction says, really, I'm an obstetrical gynecologist and Imperial in ST Marys where I've got an interest in education and simulation. And so I've had the opportunity to work all the world doing that. And more recently as the OBS and Gy lead for the David Knock Foundation where we've taken a course called Hostile Environment surgical training all over the world. And they've worked in all sorts of places and I was with them in Yemen before COVID and then more recently in Ukraine in October and the organization has worked all over the world, but we were in Libya as well. And really, you know, everyone in the room knows that maternal mortality is the most divergent of all public health data. And there is a super complex interdependency of factors that lead to good maternal health care and well being. And I liked this that I found the other day, maternal health is a social issue, maternal ill health and disability are not just medical problems but outcomes of complex interplay of eco social forces, lifestyle and exposure, an individual led factor, individual level factors and all of these are affected by conflict. And we've been talking for years now about the three delays model. And we know that every single part of this is affected by conflict so that when you're looking at maternal mortality globally, and this is a couple of years old. Now, this data, but the global rate for maternal mortality was about 210. And in conflict and post conflict zones that's doubled, over, doubled to about 530 maternal mortalities per 100,000 and a bit leading on. From what Dr Shehata is talking about, this is a slide of where conflicts actually happened and this is from 1989 to 2018. So obviously, we're missing quite a lot of data from the recent things that have happened in Gaza and Ukraine. But you can see the distribution of conflict and as Dr Shear says, the distribution of is definitely not the distribution of what happens in the news. And you can see that that Belt of where conflict is occurring is the obstetric Christian Belt. It's the maternal mortality belt. It's the Belt of countries that have a lack of access to education and health care and it's where you find conflict as well. And actually this is from the Uppsala Conflict Data program. They've been registering organized violence since the Second World War and this is their latest infographic of where conflicts happened in 2023. And clearly, there's a big overwhelming increasing size in Ukraine and Gaza. But I think it's important to know that's very much not the kind of the distribution that is globally happening and how organized violence is occurring on a daily basis throughout the world. So when we're talking about conflict and mortalities in conflict, you can use the direct and indirect kind of model of maternal mortality and actually direct mortality through conflict is quite rare in the maternal mortality space. Now, when the guys were working in Syria, there were people, there were snipers that were picking out pregnant women and that was part of a direct mortality. But actually, historically, been quite rare for direct mortalities as in conflict associated mortalities to be associated with maternal mortality. But actually over the last 10 years and really, it started in Syria that hospitals became a target and it's an undeniable weapon of war at the moment is to bomb hospitals because that disenfranchises your whole civilian population. And actually, what we've seen from Syria and onwards is that hospitals are becoming more and more a target. And in the Ukraine, there's been a couple of maternity hospitals that have been specifically shelled in the recent kind of couple of years. And so the vast majority of the mortalities happen from indirect mortality. And I think Zainab will talk about this a bit more later on. But these are the things that are very difficult to measure. And they're all about the kind of breakdown of health systems, lack of food security, water supply and shelter and how those contribute to excess mortality. And they've estimated about 75% of the mortalities in conflict are due to these indirect, these indirect events. And actually, Ben David recently produced, this study showed that actually looking at women and women of childbearing age and Children and their risk of mortality dependent on where they lived and whether they lived within 50 kilometers of the conflict zone. And they found that there was a direct relationship between the intensity of the fighting and the mortality rates of these women of childbearing age and E and in Africa, they found that the risk of death of a woman with, with um within childbearing age was three times that if they lived within an intense complex zone, within 50 kilometers of an intense complex zone. But sexual and reproductive health care as we've talked about this morning, isn't just about maternal mortality and the barriers to this that are increasing. Your mortality rates in conflict are very much about the disruption to healthcare services. So if you're thinking about buildings getting bombed, roads, being unsafe and not having adequate power supply, thinking about women that fear of seeking health treatment and the reduced uptake of things that naturally keep you safe. Like contraception services decrease, you get an increased rate of unplanned pregnancies. And with that, you'll get an increased rate in unsafe abortions and the mortality from those and mortality in terms of neonatal and maternal mortality all flourish in these kind of environments. The most vulnerable people in society will be over affected in conflict compared to the people that are least vulnerable. As we see too often. With maternal healthcare, the poor and vulnerable, poor and vulnerable and this is exacerbated in the complex zones with fighting and conflict. Obviously, you get a displacement of populations and we know that pregnant women preferentially displace themselves. So, about 75% of displaced women, displaced people or women of reproductive age and Children and about one in five of those will be pregnant. But so the important thing about this is the first intervention when you're dealing with any conflict or humanitarian crisis will always be a Cesarean section. So the most important thing, even though you're an orthopedic surgeon and you want to go and fix limbs when the hospital set up, the first thing they'll need to be able to do is a Cesarean section. And that's why when we go overseas and deliver training at the front line, then we are very much focused on these general surgeons being skilled at delivering safe cesarean sections in maternity care. The response to the sexual reproductive health is to try and maintain and decrease mortality and morbidity in crisis affected populations. And this is a very busy slide. But the inter agency working group has set up this misp program which you guys probably have heard of quite well. But it's about tackling all of those different aspects of sexual and reproductive healthcare that we know contribute to mortality. So soon as your crisis happens, you are intervening in terms of contraception care, post abortion care, safe abortion care, reducing transmission of HIV infections like that. And you're looking at safely delivering women and neonatal care as well. And this misp is embedded within it is about population size and the and the signal functions that the who suggested for basic essential obstetric care and comprehensive care. So depending on your population size is you get some kits and the kits will be delivered. And in terms of that, you'll be able to deliver your basic emergency obstetric care. If you've got a population of 30,000 or if it's much bigger, then you'll be looking at comprehensive care with cesarean sections and blood transfusions. And just thinking about specific examples. I'm not talking about Gaza today, but obviously Gaza is a, is massively on everyone's mind. But I think my colleague will talk further about that. So I felt that I would talk about other things. But in the Ukraine as the war broke out prior to the war, they were improving their maternal mortality in a systematic way. It's a very advanced healthcare. But at the beginning of the war, about 50% of the population in the eastern Ukraine didn't have access to basic health services. So the pregnant women from there were displacing themselves and getting themselves to other areas which were government led and much safer for them. But in turn, that was overwhelming, the services that were already there. There was a, they estimate about 120,000 pregnant women displaced themselves during the conflict and 20% of them obviously will need emergency obstetric care. There's an increase in domestic violence. And as I said previously, the kind of direct attacks on the maternity hospitals and the most recent UN report in Odessa has increased complication rates by about 12% for the maternity care that's delivered in that part of the country. The Yemen Civil War is something that's quite interesting to look at in terms of outcomes of maternal mortality. It is an ongoing conflict between the houthis and the government led forces which obviously is ongoing now. But you can see that around the time that the conflict happened, you can see a massive change in the percentage of maternal mortalities that happened across the country and the east of the country which is less populous and and quite calm in terms of conflict is very, its maternal mortality is about 70 which we know from our Sustainable Development Goals. That's what we're all aiming for. But if you go to Hou and around the areas where the front line is, the maternal mortality at that stage is about 330 which is significantly bad maternal mortality rates throughout the country, directly related to the instability in the area. And in a lot of these areas, you have a kind of humanitarian equation that a midwife and a surgeon will replace the job of an obstetrician. And that's why it's really important that we go out and deliver training to people that are delivering front line care to pregnant women and we're just helping them, supporting them with their techniques that they're already doing. And so that's a little bit of an introduction of the, of the complexities of maternal health care in conflict and what we're doing in the setting of things like the David Knock Foundation to kind of contribute to that. Thank you. Thank you very much. Can I remind everyone that if you want to put your questions through the questions on the app, please? I would be really grateful. Our next speaker is Zaina Jadine. Zaina is a nutritionist and epidemiologist at the London School of Hygiene and Tropical Medicine. Her research is dedicated to improving the health of women and Children with a particular focus on those affected by conflict in the region. She's interested in validating tools that reflect insecurities and quantifying health and nutrition inequalities and evaluating the impact of various assistance interventions. We look forward to your talk. Thank you so much. Uh Good morning, everyone. Uh So I'll be talking a bit about assembling informations for maternal and newborn health in conflict and really reflecting upon, to be honest this year. So as Doctor Hassan mentioned, uh I was actually doing a phd at the London School of Hygiene with the Supervisor Ona Campbell, who's also sitting here. And actually, we were trying to understand and extract electronic information about Palestinian refugees in all five areas where they reside. So Lebanon, Syria, West Bank Haza and uh Jordan And in order to really understand one of the aspect, what was, what is the effect of exposure to conflict on access to antenatal care, but later on on um birth outcomes, so increase stillbirth and try to really distinguish and get this effect size. And during that in 2021 the person who was extracting the data, uh bombing was happening from Israel to Gaza and he still extracted the data for us. Fast forward to October 7 October 7 was devastating with the attack from Hamas on Israel that led to a lot of casualties that later on uh led to a mass uh escalation from the Israeli army in Gaza. And we've seen the news in the past year. And this really put me in a situation where I thought I was drowning and I was like, didn't know what to do. Especially given that I had 50,000 women and 50,000 Children in this data set that are in Gaza. And so I want to reflect on three big things this information and understanding background and reflecting upon it this year projections that we've come up with and really data collection in the middle of conflict. And actually I will start with the information and background, but I will start with Sudan, like Doctor Hasan was mentioning, Sudan has multiple reasons why it's not in the news. But also one of them might be that there is limited health information system before the war, Challenges in preparedness and preparing conflict, understanding stocks and planning is essential. And we know that there is more than 100,000 women that are pregnant, more than 67% of the hospitals are not working in Sudan. But the information that I was able to find was mainly from that food. And one of the reasons why is because wh O has historically been doing a Hira system, which is a he health in information system in Sudan that we were able to understand a bit what's happening currently in Sudan. And we have some percentages of EOC and EOC services. But we cannot really find this information in where a lot of the world is happening. And going to Gaza, actually, Raza had very good health information systems before the war. And we know that there are currently 50,000 women that were pregnant in Gaza. This was known at the beginning of the war and we knew that there were 100 deliveries per day that were happening and expected to happen. What Raza was able to do was to track very well. The attacks on the healthcare system and the decrease in hospital functionality over time. And you can see in orange the decrease but also what Raza had was very good mortality tracking from hospitals. And this has allowed it actually at the beginning of the war, when people were questioning the number to release lists of everyone who was killed and we took this list and we analyzed them. And you can see that in fact, in terms of mortality, more than 60% were actually women and Children. But it is important to note that we play this aspect of a perfect victim and the idea that women and Children. But in Chile, also men are included in this. And you can see a perfect pyramid here that represents the population of Aza that were killed and that was in October. But what good health information system also to help you is actually this this result. And this analysis was actually used by the uh South African team that was raising uh the concept of punishment of crime of genocide that's currently happening in Raza. And they put in this application and they used the, it's to push that what's happening in terms of mortality in the international course of justice. So basically, I'm emphasizing that investing and putting uh resources in health information systems will help in, in, in understanding and uh and planning. But also will help in advocacy and um regardless in whether we talk about climate change or conflict or not, necessarily just talking about conflict then moving forward in the projections. So, um as I told you, we reached a phase, we knew how much people were dying from mortality and trauma, but we really did not know in Feb, in December, what was happening in all different disease areas. So how many people will die from infectious disease? How many people will die from NCD S? And so we, we put in a situation where we wanted to do projections of what would happen in different scenarios in the ward. So as I mentioned, Raza had like at that point, there were attacks on the hospitals happening, there were mass uh movements of the population. And we wanted to understand if a cease fire happens, what would be the mortality from different causes of diseases from if an status quo happens or if an escalation happens? And these are the three scenarios that we wanted to project. We have a full report that includes all the different causes of mortality, but I would just focus on maternal. But we did look at all the others. Um So in terms of maternal and stillbirth death, what actually helped is that it was the only model that we had a projection for that was ahead of time. So in all the others, we had to basically in three months come up with new models for entities s for um nutrition that was major and we're still trying to fix them. But having good models that work and research beforehand helps us also advocate and automatically use this data. So we use the life safe tool that actually looks at services to actually save lives. And we did the opposite. We looked at how many lives would be lost. And so we changed the services of antenatal care. So women are not able to go to antenatal care. Women are not able to go to health facilities, breastfeeding. Uh As we know from Lebanon and Syria and other conflicts. Uh when uh what happens, breastfeeding sadly decreases. And this also puts more stress on on the Children or infectious diseases using infant formula. And all of that uh as our previous uh talkers were talking about water and wash and how important it is in health facilities. We reduced that also but also increased food insecurity. So, and we did this and this is very detailed to talk about the different vaginal assistance. But the idea is that before the war, 99% of women were delivering in a health facility d if a cease fire happens, we know that not all hospitals are working, we put 90% we put uh 70% in case of an escalation of women delivering in hospitals and we projected what would happen. And so these are just the maternal results from the nontrauma related mortality. And uh the pre war line that's in gray shows what would have happened in Gaza in normal times. And then in, in purple, uh you see the escalation with the attack that happened in uh and um we start October, November, December, January and the projections would branch branch out into these three. Sadly, we have moved into an escalation scenario and we see around 60 women uh who would be uh mortality from the indirect effect as from the projections. But that also reflects actually a huge reversion in the maternal mortality ratio in Gaza. So we were at 23 per 100,000 live birth. In a case of a cease fire, it would have been a double and that means it's going back 10 years and the healthcare system or even more than 10 years, actually 20 maybe. And in an escalation scenario, it's going back to levels of 1995 in. And actually, it's a reversion of health care system and all the improvements that the system has been made. And what I wanted to say also is that these projection can and have been used for advocacy. So, visualizing Palestine in collaboration with Jewish Voices for peace have used our projection the total number from whether it comes from um uh NCD S and different aspects. And they actually uh showed that that, that if a continued war happened versus if a cease fire happens, how many lives would we save? And it's actually 74,000. And um just talking about some of the projections that they've done that they've used also is including infectious diseases, uh NCD S and uh women and Children that would be saved. So my second message is really about advocacy and about using objections for planning but using good methods and all these projection rely on good studies and good evaluations. And so all of that is fed and helps in during conflict. Finally, I wanna talk about data collection during conflict. So as you can imagine, data collection in general is hard, but in middle of a conflict, it becomes even more difficult. One of the reason is because of you are basically going to one place and asking uh where you have access to, where are other places where there is a lot of uh war happening to uh in it, we do not have information. So there's a bit of a selection bias of what you understand in a war. And that is really like mapped what you an exercise that uh we did um uh back uh in actually a while back to actually map different reproductive uh newborn uh maternal indicators um and data available from Gaza. And the and the darker the light is, the more data and indicators were available in Syria in Syria. And so next to it is was the population of Syria and I don't know if you can see, but back in here, there is, there was a lot of war there happening and attack. But there is little information uh on indicators and this is the fragmentation and the that we get in war that we get a small picture from an area and li from others. But in fact, it's um it's a se selection bias that gives us a bit of an understanding of what's happening. But also also there's the ethics of it. So you call these women in the middle of a conflict zone to ask indicators about breastfeeding, where in fact, they, they need hospitals, they need supplies and you're not able to give them. And there is that ethical dilemma that you and agencies also have to, to, to, to work in and M MSF and other agencies. And so I think one of the things from Syria actually and from that a bit I reflected upon is in conflict, the need uh need of triangulating data. So not choosing data from one source only. And so uh at the beginning of the war in Gaza on the seventh of October, they were in the UN agency that provides assistance and primary health care for Palestinian refugees in Gaza. They were around 15,000 women that were registered to be pregnant and they decided uh actually in April and May to collect data on what happened to this pregnancy, but they only got 60% response. So they didn't get most of them, but they got 60% response. But what you in this response, there was a lot of questions but one that I will focus on is mortality. And from this survey, we knew that 25 women were uh actually um killed uh by Israeli attacks. But what we did also is triangulate these data. And do you remember the first data set of basically I mentioned about the listing and that the ministry has released. So we use that listing, but that listing became more and more harder to track mortality. So there is an undercount because every time there was an attack on the hospital, the hospital was not able to basically provide data. And so we use these lists actually and the expected delivery date of the woman. So we knew that she was expecting to deliver on the uh uh 11th of November. And we basically matched them to see when mortality happened. And in fact, we were able to match 118 and the overlap was around 1818 only. And so what we're talking about here is from traumatic death and nontraumatic death. And so we're talking about pregnancy related mortality that was in uh 2020 around 23 to around 850 to 900 per 100,000. And that's within one year. And that's just not talking about the long term effect. But also I want to talk about qualitative data that I am a quantitative epidemiologist, but also sometimes understanding that these women and qualitative information might be the most uh one that pushes for advocacy maybe. And usually I would uh this woman talked, usually I would have blood test and see the baby on the ultrasound. But now everything in my life has become impossible. The other thing that people talked about is this attack on the hospitals, whether Syria, whether Ukraine we've seen this happen over and over and uh this has huge implications for newborn health and for uh maternal health. First of all, this was when the fuel was not coming to a sh hospital and uh five out of the 37 babies died because of lack of um a lack of electricity in these hospitals. And these are preventable death we're talking about. But also there is uh the doctors talking about using blood. Uh so some are forced to resort to mass hysterectomies to control postpartum bleeding because there was no blood in in in the hospitals anymore. These were used for trauma. And so the resources were very, very limited and also the attack on hospitals that has documented that led multiple hospital to completely stop working. And in the interview that I told you about using the survey that did the survey. There was a lot of open text and I didn't put some of them. But if you read some of them, they were written in Arabic was about the experience of this woman who was in the hospital while the bombing was happening, she had ac section, she had to go to another hospital to have restitching of the C section. There were also a lot about Children dying from suffocation because of the dust. They were also, it's all quality, but it's also all informs us about how horrible the attacks on hospitals are for maternal health. And this is a system that relied on hospital delivery, not on home deliveries. So this is not something that they, they had, they had to completely try to mitigate all of that. And finally, I want to talk on actually the healthcare s health care uh doctors. So around 800 health care uh workers have been killed uh 4% around of the specialized medical system and medical doctors. But I wanna reflect on doctor, doctor uh was an OBGYN doctor. Uh she worked first uh in the hospital, then moved to the UN agency because she believed that she wanted to work on referral systems. And she was seeing that a lot of C sections is increasing and that we need to have good measures for referrals for C sections. Doctor CIN was killed with her uh at end during her house at the beginning of the war. And uh and she's one of many that were killed during that war. And so also reflecting on the impact of war on, on doctors and nurses and midwives and the whole health care system. And that has been trying to do referrals but was not able anymore to put up systems. And so basically talking about money uh data collection is mainly talking about triangulating data from different sources. And I wanna end with this, I this thing that also I reflected upon a lot this year is that we have also this idea that health care information systems are important and investing them in them is important for advocacy. Uh projections is also helpful data collection during conflict and in in conflict and other types, we all need advocacy for different reasons. But then war becomes more eminent because there's a need for humanitarian assistance. But also talking about the understanding the effect of the war in general, like going back and looking at um what, what's the effect of the war on stillbirth and all these studies help us during conflict to plan. And these are different part of the pieces including also what I mentioned in terms of MP and interventions during war and having these plans. But also actually before you talking about a Mr Raza had in some hospitals, 70% resistance and uh and uh and we, it's very well documented and so all of these different pieces hopefully will help us rise to challenges that we're talking about. And uh I know I was a bit very pessimistic but in terms of like, hopefully it helps us rise to all these challenges. Thank you so much. Thank you very much. Excellent talk and thank you very much as well. We have a couple of questions actually. So please forward your questions. So we have 15 minutes to ask some questions. So I'm going to ask actually um uh for the the compelling talks both of you um highlighting the need of information system before conflicts which you mentioned in particular about Sudan. Is there any kind of UN or other groups that could lead on this? I mean, is there a particular kind of context or toolkit that people can use in kind of preparing for, to have some preparation before conflict? Um You can answer from there. Actually, it's easier. OK. Uh So um so when the war breaks out, there is something called the health clusters and nutrition clusters and this is the cluster system that automatically starts in different places, Sudan had a health cluster before the war but uh to talk about systems, so wh O put out, put one that's called, that's called hira uh which is a, a resource mainly on an understanding different hospitals. So they had that in D but they didn't have that in uh the other aspect is also uh one that the wh O also does is called ears that tracks more infectious diseases. But also it, it is not really dependent on only relying on uh UN systems. So this really all relies on the UN doing this. But actually there is possibilities of using the National Health Care systems. And so if there is investing in them doing digitizing of them, the same concept that was talked before uh doesn't always need to rely on the UN. And part of it is that dependency in humanitarian settings, actually, that's not always good on, on UN um and UN staff. And so it's also like preventing and coming up with system. And actually, just to say like on has its own different one that was an electronic E health system. If you want to look at it, it's very, very detailed. So there are different ones that are available. Thank you very much. I have a question for you. This is from uh thank you for your presentation. Have you considered introducing a form of to shift to low cadr health care workers alongside training, also training of grassroots birth pregnancy, health care companions across these settings in order to have a widespread of skilled support in the case of emergency. Sorry, what was the beginning of that question? So mainly about whether you have a kind of a system of teaching, sorry, two minutes, teaching low ca or low skilled workers. So there will be kind of more what we call community workers in order to improve outcome. Have you considered that? And do you have any experiences with that? So in terms of kind of skilled birth attendance and things like that, I know that the kind of global narrative was anti that and then it's become more pro the kind of upscaling of people that are providing the health care to the populations that need. Personally, my experience is more about increasing the kind of capacity of the surgical capacity of people that are delivering surgical care. So it's quite a niche thing, but it's a niche thing that we think you can build on in the format that you can deliver in a meaningful way without kind of much higher level involvement from other agencies that are around. But there are engagement. I don't know, you probably know about specific examples, but there are lots of high level organizations that are building capacity on that kind of grassroots lower and middle income countries type. Thank you. And Professor Wendy Graham is asking, is there any positive kind of examples that you can quote, is there any optimism of how something has improved? There's a lot of anecdotal kind of talk about the, you know, people feeding back about using their skills to deliver safe care to people in the front line. I think it's important. We talked about the ability for tech to influence in a massively positive way and you can access people that are kind of doing surgeries through whatsapp and kind of encourage and sort of and be able to support and deliver that kind of training. But in a very remote capacity, just accessing the front line with what's happened and things like that. Thank you very much. I think our time is over. Thank you. I know.